Controversies Surrounding ADHD
Is ADHD a true mental disorder?
The fundamental area of controversy related to ADHD is whether or not this collection of symptoms should be considered a mental disorder. Although there are documented brain differences and significant evidence of impairment in daily functioning in individuals with ADHD, there is a large school of thought that views ADHD "symptoms" as simply an extreme expression of normal human behavior. These experts use the term "neurodiversity" to describe genetic brain-based variations in behavior (e.g., someone's ability to concentrate or to remain calm in emergency circumstances). The neurodiversity argument suggests that because a large portion of the population shows these types of behaviors to one degree or another, then ADHD is not actually a disorder. To some, the fact that many "normal" people show ADHD behaviors, combined with knowledge that a wide range of disorders create ADHD-like symptoms suggests that ADHD is not a true mental illness.
People who argue that ADHD is a true disorder agree that individuals vary greatly in their activity levels and their abilities to attend to complex material. However, individuals in this camp argue that most people with high activity levels and a tendency towards impulsivity do not experience significant interference with their daily functioning as a result. Problems associated with ADHD clearly interfere with a person's ability to successfully function in their environment. The presence of significant impairment places individuals with ADHD uniquely at the extreme end of what is considered "normal behavior"; therefore, this disorder is indeed a mental illness. The argument over the appropriateness of the ADHD diagnosis will likely continue among professionals for some time to come.
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Is ADHD a neurologically or psychologically-based mental illness?
Many experts agree that ADHD is a neurological disorder that can be influenced by environmental factors. Despite research that has demonstrated differences in brain structure and function between individuals with ADHD and "normal" subjects (described in a later section of this paper), some experts continue to suggest that psychological factors are the primary cause of the disorder. Although some research suggests that psychological factors can be important determinants in the severity of the disorder, most research suggests that ADHD is biologically based. Even so, the debate will likely continue on this issue.
Are ADHD prevalence rates accurate?
Another area of ongoing debate revolves around ADHD prevalence rates. Many experts believe that the diagnosis is not given often enough, and that current prevalence rates actually underestimate the true rate of ADHD in the population. These professionals think that many people who have symptoms are never evaluated or diagnosed. So, even though there has been a recent dramatic increase in the number of children and adults diagnosed and treated for ADHD in the United States and the United Kingdom, current rates do not accurately reflect the proportion of people suffering from this disorder.
Other professionals believe that current prevalence rates of ADHD diagnoses are distorted by diagnostic errors and problems with assessing symptoms. The diagnostic criteria for ADHD are fairly general. Therefore, it is possible that various types of disruptive behavior and/or learning disabilities are mislabeled as ADHD, particularly the Not Otherwise Specified (NOS) category. In addition, there is not an objective ADHD assessment tool that measures all of the symptoms listed in the DSM-IV TR. The primary methods used to assess ADHD are either self-report questionnaires or clinician-rated behavioral observations. Both types of assessments are subjective and may be influenced by feelings, values, cultural norms, and opinions. People who are providing self-reports or observing behaviors may be unduly influenced by the idea that ADHD is increasingly common, and endorse symptoms that reflect this diagnosis. Or conversely, the vagueness of the DSM categories and subjectivity of the assessment tools may lead to an underestimate of true ADHD prevalence rates if people are misdiagnosed with other disorders or try to avoid being diagnosed with this label.
Other researchers speculate that changes in the modern world make ADHD symptoms more easily observable. For example, our world is filled with electronic gadgets such as computers that require more focused effort and active concentration than was needed in the past. Increasing environmental demands for focused attention make it appear as if there is an increase in the number of individuals with ADHD. In other words, the current rate of ADHD is similar to the past, but previous environments did not draw attention to these symptoms.
Still other people argue that the rate of ADHD has actually gone up significantly in response to contemporary lifestyle changes, such as decreased physical activity, unstructured play time, and time spent in a natural environment. These researchers believe that as our society moves further away from the natural environment and spends less time engaged in physical activities, more people will demonstrate impulsivity, restlessness, and hyperactivity.
Another factor affecting prevalence rates involves the use of diagnostic labels in children. Some people are reluctant to label children as mentally ill, particularly if it leads to giving them medication. This type of thinking can decrease the number of children referred for evaluation, thus lowering the rate of children who are diagnosed with ADHD.
In addition to various opinions regarding ADHD prevalence rates, research has demonstrated that in some areas of the country, white males from affluent families make up the majority of children diagnosed with this disorder. This has led to concern that ADHD is becoming a fad diagnosis. In many other communities, with a more multi-cultural population in poor and rural areas, the diagnosis is not being given nearly so often. The exception occurs in many Native American reservation communities, where ADHD is a very common diagnosis for even very young children. It is unclear whether gender, socioeconomic status or racial biases influence prevalence rates. More research is needed before any definitive understanding will be available.
Should medications be used to treat children with ADHD?
The use of psychotropic medications (i.e., medication used to treat mental illnesses, regulate mood and control behavior) with children is another area of controversy. In the United States, psychotropic medications are a widely accepted means of treatment for ADHD symptoms. Physicians, rather than psychiatrists, often prescribe medication, even when the child or adult patient has not been officially evaluated or diagnosed by a mental health professional. As previously discussed, the need for an accurate diagnosis is critical. Without an accurate diagnosis, the physician cannot be certain that the child truly has ADHD as opposed to other diagnoses with similar symptoms. Utilizing medication to treat the wrong diagnosis can cause serious complications, including a worsening of symptoms.
At least partly as a result of physician involvement, the use of medications to treat ADHD grew from .9 children per hundred children in 1987, to 3.4 per 100 by 1997. Interestingly, the number has not continued to rise significantly since then. Many professionals and lay people alike are concerned about today's method of prescribing psychotropics. Although physicians can be quite helpful in providing routine ongoing care, they are not specifically trained in psychiatric disorders and are not generally considered competent to provide the initial diagnosis. Other professionals argue that general practitioners often have increased knowledge regarding ADHD, and this allows a greater number of people suffering from these symptoms to obtain competent care and the most effective treatment.