I remember sitting in Ms. Smith’s sixth-grade class, in full daydream mode, as she droned on and on in the background. Suddenly, Ms. Smith declared, “Now that I have explained this assignment, I want you all to get right to work on it.” My classmates immediately started working diligently at their desks with paper and pencils.
I had no idea what the assignment was because I had been daydreaming through the entire explanation. Trying to remedy the situation, I walked up to the teacher and whispered, “I don’t understand what we are supposed to be doing.” Ms. Smith immediately became irritated. This was not the first time I had asked her to repeat instructions.
“I just spent several minutes explaining the assignment. Weren’t you listening?” she demanded in an angry whisper.
“Oh, I was listening, but I don’t think you explained it very well,” I whispered back in a sad attempt to deflect the blame.
“OK, I’ll explain it one more time, but that’s it!” Ms. Smith hissed in an impatient tone.
Standing up close to Ms. Smith, I took in details about her that I had never noticed from my desk. I could see her scalp through her curly blond hair, and she had an alarmingly large nose. Even worse, she had huge pores. “Man,” I thought, “you could actually store things in there!”
Just as this thought occurred to me, Ms. Smith said, “There, now I have explained the assignment to you twice. You should be able to do it perfectly at this point.”
As I walked back to my desk, I realized I had not heard a single word of Ms. Smith’s explanation. I had been too busy admiring her pores. I returned to my desk and drew pictures until it was time for recess. It was many years before anyone suggested that I may have a form of attention-deficit disorder.
In Essential Psychopathology and Its Treatment (2009), Jerrold S. Maxmen, Nicholas G. Ward and Mark Kilgus estimate that 5 percent of Americans have some form of attention-deficit/hyperactivity disorder (ADHD), which is more than 15 million men, women and children. These numbers are slippery, however, because ADHD often goes undiagnosed or misdiagnosed.
Many challenges exist when it comes to getting a proper diagnosis for ADHD. I will examine several of them in this article and provide some suggestions that can help improve diagnostic accuracy.
Attention-deficit/hyperactivity disorder is a misleading term. People who have this disorder might actually have very intense focus when they are interested in a particular topic, sometimes spending countless hours engaged in a favorite activity. This presentation is at odds with the attention-deficit part of the term and can cause diagnosticians to erroneously rule out ADHD as a diagnosis. Also, many people have “ADHD, Predominantly Inattentive Type,” which often does not include hyperactivity among its features. In fact, a person with that diagnosis often has hypoactivity.
In other words, a person with ADHD may have moments of excellent attention and absolutely no symptoms of hyperactivity — behaviors that completely contradict the very title of the disorder. In an attempt to remedy this, Edward M. Hallowell and John J. Ratey, in their 1995 book Driven to Distraction, suggest it would be a good idea to change the term to Attention Inconsistency Disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) can be misleading when it comes to ADHD. The writers of the diagnostic manual seem to imply that only children have this disorder. They list ADHD in the “Disorders Usually Diagnosed in Childhood” section, and the descriptive criteria include statements such as “Often leaves seat in classroom or in other situations in which remaining seated is expected.”
Only about one-third of children with ADHD grow out of the disorder. The rest take it into adulthood. In addition, a lot of people are not properly diagnosed until adulthood, when they may have symptoms that look different from the ones described in the DSM. Adults with this disorder might be quick to get angry or frustrated, often start projects and then abandon them to start other projects, self-medicate in an attempt to manage their symptoms or have a history of underachievement despite possessing a significant amount of talent and enthusiasm.
There is no valid test for ADHD. This is a really interesting issue. As mentioned earlier, many people with ADHD have very good focus when something interests them. As a result, they may get curious when you present them with a test. In those moments, their attention increases and they perform like people who do not have ADHD.
To complicate matters further, pharmaceutical companies created some of the ADHD scales. One test in particular has been the subject of lawsuits because it is suspected of being designed to provide marketing information to drug companies. Counselors might want to question any scale developed by people who profit from an affirmative result. If tests are used at all for diagnosing ADHD, it is important that counselors take the results with a grain of salt and consider them as only one of many available pieces of diagnostic information.
People with ADHD are not always the best historians. They may report that they don’t have a problem in one area or another, when the people around them might tell you something very different. Diagnosis is best when it combines feedback from family members, school records, records from past therapists and the client’s own self-reporting. It is also helpful to get to know a client over
the course of a couple of sessions before making a diagnosis because the client may behave differently or recall different information from one session to the next.
Several disorders (for example, bipolar disorder) look quite a bit like ADHD but require a very different course of treatment. Those other diagnoses must be ruled out before assuming that a hyperactive and/or unfocused person has ADHD.
Environmental and circumstantial factors can mimic ADHD symptoms. We live in a society that bombards us with far too much stimulation, much of it competing for our attention at any given moment. We might also have past traumas that distract or upset us. Relationships can have a similar effect. The chaos of office politics or a dysfunctional family, for example, can reduce focus and create mood instability. Rule out these factors by seeing whether the ADHD symptoms are present in different environments and whether they have been present since childhood.
Certain people could receive secondary gain from this diagnosis. For example, a teacher having trouble managing the behavior of a particular student might feel more comfortable attributing the problem to ADHD rather than to his or her own classroom management skills. In addition, clients might falsely present with symptoms of ADHD in hopes that it will increase their odds of receiving disability benefits or other entitlements. Be sure to consider possible secondary gains that clients might experience before making your determination.
ADHD has a high rate of comorbidity, which can confuse matters. People with ADHD might also have substance dependence, depression, anxiety and/or learning disorders. It is easy to diagnose clients with these more obvious disorders while missing the underlying ADHD. A mindful, informed diagnostician will keep an eye out for contributing/coexisting factors, including ADHD.
Substance addiction/dependence can disguise or mimic ADHD. As just mentioned, it is easy to be distracted by the issues associated with addiction and to miss the underlying ADHD, which can be a significant contributing factor to the addiction. Conversely, people who are using or in withdrawal from substances often exhibit anxiety, hyperactivity or distractibility that mimic ADHD. In the case of substance abuse/addiction, it can help to delay the diagnosis of ADHD until the client has experienced several months of sobriety.
Diagnosis is complicated by the fact that some medications used to treat ADHD have a high abuse potential. This could possibly motivate some clients to feign ADHD in order to get drugs. At the same time, people who legitimately have this diagnosis might be denied treatment by mental health professionals who suspect these clients are drug seeking. It is important to consider both scenarios when making diagnostic decisions.
Diagnosis potentially can lead therapists to overpathologize their clients. The goal of diagnosis is not to condemn a person or to give him or her an excuse to fail in life. The goal is to identify the most effective treatments available to help a client address identified problems.
Hallowell and Ratey argue that it may not be accurate to refer to ADHD as a “disorder.” For example, the very elements of ADHD that disrupt life can also cause a person to be spontaneous, creative, intuitive and intelligent. When clients learn to manage the dysfunctional elements of ADHD, they can then also benefit from its positive elements. It is important to identify, celebrate and access these strengths as part of treatment.
Mike Hovancsek is a supervising professional clinical counselor in Ohio. Contact him at firstname.lastname@example.org.
Letters to the editor:
I have a book coming out this spring called Toddlers & ADHD. It’s about distinguishing between normal development and clinically significant symptoms in the 1-5 year old population. I talk about normal temperament, ADHD indicators, and differential diagnosis. I discus treatment options for this age range and helpful strategies at help the child self-regulate. In any case, I have quoted you from this article and introduced you in the book with what you have in your bio in Counseling Today. I hope this is ok!