Are we over- or under-diagnosing ADHD?

I am often confronted, in my professional setting and personal circle, with the question “Why should we medicate normal behavior? He is just an active boy.” I have observed, more than in any other field of medicine, that everybody has strong opinions to express when it comes to mental illness. The validity of the conditions themselves is questioned, as are the credentials and intentions of providers.

Attention-deficit/hyperactivity disorder (ADHD) has been proposed to be a mere social construct. While there might be truth to the fact that a misfit between a person’s cognitive abilities and current societal demands may cause difficulties, ADHD-like symptoms emerge following post-infectious encephalitic conditions and exposure to neurotoxins, highlighting the necessary presence of neurological dysfunction underlying the symptoms.

Naturally, the long-standing debate about ADHD treatment has been amplified by social media, often stripped of the scientific evidence to inform it. Arguments can be made to support both sides. ADHD medications are the most to second most prescribed medications in children and adolescents for extended periods and studies have shown that a diagnosis of ADHD cannot always be ascertained in medicated children.

Most diagnoses are made by busy clinicians, with limited time and expertise for a comprehensive assessment. On the other hand, the vast majority of children with ADHD are neither diagnosed nor treated. Some experts have even called on making “cognitive enhancers” (many of which are ADHD medications) widely available to optimize functioning, akin to using caffeine which billions of people consume.

But would we be doing society a disservice by emphasizing productivity at the expense of wellness? And would this amplify existing inequities? Away from the philosophical or ethical debate, for a parent of a child struggling with a learning disorder (which is different from an intellectual disability) or for an adult with long-standing academic or professional struggles, providers must screen for ADHD.

A thoughtful discussion with an informed clinician will help determine, collaboratively, how to establish the diagnosis and manage it. In the words of many who have seen treatment work: “It is like night and day!”

Admittedly, it is difficult to distance oneself from the stigma surrounding mental illness and the fear that one might be doing harm. But, getting educated about the condition, away from the cacophony of the internet, is imperative for well-being. It is unjust to withhold care for chronic pain, and it should be no different when it comes to cognitive distress. Not doing something comes at a cost. It is imperative to keep in mind that most people who are struggling would just like to feel better; proving a point is not their priority.

By Chadi Calarge, M.D., Thomas S. Trammell Research Professor in Child Psychiatry, Baylor College of Medicine, Texas Children’s Hospital, Child and Adolescent Psychiatry

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