Why we should eliminate the diagnosis of ADHD

I’m reluctant to write a post about ADHD.  It just seems like treacherous ground.  Judging by comments I’ve read online and in magazines, and my own personal experience, expressing an opinion about this diagnosis—or just about anything in child psychiatry—will be met with criticism from one side or another.  But after reading L. Alan Sroufe’s article (“Ritalin Gone Wild”) in the New York Times, I feel compelled to write.

If you have not read the article, I encourage you to do so.  Personally, I agree with every word (well, except for the comment about “children born into poverty therefore [being] more vulnerable to behavior problems”—I would remind Dr Sroufe that correlation does not equal causation).  In fact, I wish I had written it.  Unfortunately, it seems that only outsiders or retired psychiatrists can write such stuff about this profession. The rest of us might need to look for jobs someday.

Predictably, the article has attracted numerous online detractors.  For starters, check out this response from the NYT “Motherlode” blog, condemning Dr Sroufe for “blaming parents” for ADHD.  In my reading of the original article, Dr Sroufe did nothing of the sort.  Rather, he pointed out that ADHD symptoms may not entirely (or at all) arise from an inborn neurological defect (or “chemical imbalance”), but rather that environmental influences may be more important.  He also remarked that, yes, ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

I couldn’t agree more.  To be honest, I think this statement holds true for much of what we treat in psychiatry, but it’s particularly relevant in children and adolescents.  Children are exposed to an enormous number of influences as they try to navigate their way in the world, not to mention the fact that their brains—and bodies—continue to develop rapidly and are highly vulnerable.  “Environmental influences” are almost limitless.

I have a radical proposal which will probably never, ever, be implemented, but which might help resolve the problems raised by the NYT article.  Read on.

First of all, you’ll note that I referred to “ADHD symptoms” above, not “ADHD.”  This isn’t a typo.  In fact, this is a crucial distinction.  As with anything else in psychiatry, diagnosing ADHD relies on documentation of symptoms.  ADHD-like symptoms are extremely common, particularly in child-age populations.  (To review the official ADHD diagnostic criteria from the DSM-IV, click here.)  To be sure, a diagnosis of ADHD requires that these symptoms be “maladaptive and inconsistent with developmental level.”  Even so, I’ve often joked with my colleagues that I can diagnose just about any child with ADHD just by asking the right questions in the right way.  That’s not entirely a joke.  Try it yourself.  Look at the criteria, and then imagine you have a child in your office whose parent complains that he’s doing poorly in school, or gets in fights, or refuses to do homework, or daydreams a lot, etc.  When the ADHD criteria are on your mind—remember, you have to think like a psychiatrist here!—you’re likely to ask leading questions, and I guarantee you’ll get positive responses.

That’s a lousy way of making a diagnosis, of course, but it’s what happens in psychiatrists’ and pediatricians’ offices every day.  There are more “valid” ways to diagnose ADHD:  rating scales like the Connors or Vanderbilt surveys, extensive neuropsychiatric assessment, or (possibly) expensive imaging tests.  However, in practice, we often let subthreshold scores on those surveys “slide” and prescribe ADHD medications anyway (I’ve seen it plenty); neuropsychiatric assessments are often wishy-washy (“auditory processing score in the 60th percentile,” etc); and, as Dr Sroufe correctly points out, children with poor motivation or “an underdeveloped capacity to regulate their behavior” will most likely have “anomalous” brain scans.  That doesn’t necessarily mean they have a disorder.

So what’s my proposal?  My proposal is to get rid of the diagnosis of ADHD altogether.  Now, before you crucify me or accuse me of being unfit to practice medicine (as one reader—who’s also the author of a book on ADHD—did when I floated this idea on David Allen’s blog last week), allow me to elaborate.

First, if we eliminate the diagnosis of ADHD, we can still do what we’ve been doing.  We can still evaluate children with attention or concentration problems, or hyperactivity, and we can still use stimulant medications (of course, they’d be off-label now) to provide relief—as long as we’ve obtained the same informed consent that we’ve done all along.  We do this all the time in medicine.  If you complain of constant toe and ankle pain, I don’t immediately diagnose you with gout; instead, I might do a focused physical exam of the area and recommend a trial of NSAIDs.  If the pain returns, or doesn’t improve, or you have other features associated with gout, I may want to check uric acid levels, do a synovial fluid analysis, or prescribe allopurinol.

That’s what medicine is all about:  we see symptoms that suggest a diagnosis, and we provide an intervention to help alleviate the symptoms while paying attention to the natural course of the illness, refining the diagnosis over time, and continually modifying the therapy to treat the underlying diagnosis and/or eliminate risk factors.  With the ultimate goal, of course, of minimizing dangerous or expensive interventions and achieving some degree of meaningful recovery.

This is precisely what we don’t do in most cases of ADHD.  Or in most of psychiatry.  While exceptions definitely exist, often the diagnosis of ADHD—and the prescription of a drug that, in many cases, works surprisingly well—is the end of the story.  Child gets a diagnosis, child takes medication, child does better with peers or in school, parents are satisfied, everyone’s happy.  But what caused the symptoms in the first place?  Can (or should) that be fixed?  When can (or should) treatment be stopped?  How can we prevent long-term harm from the medication?

If, on the other hand, we don’t make a diagnosis of ADHD, but instead document that the child has “problems in focusing” or “inattention” or “hyperactivity” (i.e., we describe the specific symptoms), then it behooves us to continue looking for the causes of those symptoms.  For some children, it may be a chaotic home environment.  For others, it may be a history of neglect, or ongoing substance abuse.  For others, it may be a parenting style or interaction which is not ideal for that child’s social or biological makeup (I hesitate to write “poor parenting” because then I’ll really get hate mail!).  For still others, there may indeed be a biological abnormality—maybe a smaller dorsolateral prefrontal cortex (hey! the DLPFC!) or delayed brain maturation.

ADHD offers a unique platform upon which to try this open-minded, non-DSM-biased approach.  Dropping the diagnosis of “ADHD” would have a number of advantages.  It would encourage us to search more deeply for root causes; it would allow us to be more eclectic in our treatment; it would prevent patients, parents, doctors, teachers, and others from using it as a label or as an “excuse” for one’s behavior; and it would require us to provide truly individualized care.  Sure, there will be those who simply ask for the psychostimulants “because they work” for their symptoms of inattentiveness or distractibility (and those who deliberately fake ADHD symptoms because they want to abuse the stimulant or because they want to get into Harvard), but hey, that’s already happening now!  My proposal would create a glut of “false negative” ADHD diagnoses, but it would also reduce the above “false positives,” which, in my opinion, are more damaging to our field’s already tenuous nosology.

A strategy like this could—and probably should—be extended to other conditions in psychiatry, too.  I believe that some of what we call “ADHD” is truly a disorder—probably multiple disorders, as noted above; the same is probably true with “major depression,” ”bipolar disorder,” and just about everything else.  But when these labels start being used indiscriminately (and unfortunately DSM-5 doesn’t look to offer any improvement), the diagnoses become fixed labels and lock us into an approach that may, at best, completely miss the point, and at worst, cause significant harm.  Maybe we should rethink this.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

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  • http://twitter.com/captivemedical Michael Allen

    An interesting article in which your message is not fully delivered until the end. I’d hypothesize that most of your “haters” did not read all the way through. What you fail to address is that often times the primary care provider must make the diagnosis and is rushed through a 15 minute office visit to remain profitable. In addition, if we eliminate the diagnosis, can you imagine the heyday insurance companies would have getting to deny off-label prescriptions? You’re absolutely right that we could eliminate the “ADHD” title and should provoke more in-depth patient analysis but at what cost?

  • http://pulse.yahoo.com/_IAGMXBAHZEVEJGLEZXI74SME2Y dave d

    Your suggested approach is being used by rheumatologists. When a patient complains of joint pain, they don’t immediately get diagnosed with RA or OA. As a matter of fact, the practice is discouraged. Rather, caregivers are encouraged to provide relief while watching for the evolution of the illness. 
    That being said, ADHD is horribly overdiagnosed in America. There is virtually no other country in the world with such a high prevalence of the condition. I will go out on a limb here and state that in many cases, the diagnosis is a manufactured one, just like the so-called “metabolic syndrome”. 
    Kids are generally full of energy and lack self discipline. This, coupled with the cultural practice of child rearing in the US, often contribute to the high prevalence of “hyperactive” and “attention-deficient” kids. I am not trying to suggest that there are no true cases of ADHD; my beef is with the prevalence. Before coming to the US, I practiced in both Africa (Nigeria) and the Caribbean (Trinidad/Tobago). ADHD in those countries were uncommon.
    I don’t think it is OK to keep drugging up our kids, and put them under chemical restraints when all they want to do is be happy, active and energetic kids.

    • http://warmsocks.wordpress.com/ WarmSocks

      Dave D, I hope you aren’t a rheumatologist. x-rays show whether there’s visible joint damage; it’s not supposed to be that difficult to diagnose OA and then recommend appropriate treatment. Who discourages diagnosing RA promptly? You’re not supposed to watch the evolution of the illness – waiting so that the joints become permanently damaged and the patient must endure a lifetime of painful deformity. The standard of care for RA and the other autoimmune arthritic diseases is “early, aggressive treatment.” Prompt diagnosis is critical.

      -Dr Balt, sorry for getting off topic.  Great article.

  • David Lawrance

    Couldn’t one say similar things about migraine or tension headache where diagnosis is based solely upon symptoms.Or depression. Or anxiety.  Medical treatment can be helpful. Environment matters a lot. 

    I don’t know whether ADHD is simply a cluster at one end of the distribution of normal attention or whether it is way outside of the normal range. But, I do know that the encouragement of good behavioral practices and ADHD medication taken by someone with ADHD can turn school failure into school success. Maybe it is the design of school itself  that is at faul, at the root of the matter. If so, then let the social engineers change the schools. Because parents can’t. And, children can’t. Treatment, management, often contributes toward school success where there had been marginal or failing academic performance. Am I treating a disorder or am I opening a door out of a disordered relationship of child and school? We’re not talking about short kids vs tall kids. Success in school means everything. If you can’t sit, and if you can’t pay attention,  you can’t succeed unless you happen to also be really bright. This has tremendous significance.Diagnosis doesn’t really tell me much about the person or what they are capable of. That’s not the point of making a medical diagnosis. ADHD isn’t an excuse.  Despite all of the politics surrounding DSM-IV and 5, and ICD-9 and -10, they aren’t about politics. They are about the broad physical and mental spectrum of the human experience and ultimately they are about therapy. Just as the tree of life is a contrivance, so are systems of medical nosology. Thesemere  contrivances are major accomplishments, major advances that encapsulate how we think about the order of things within the convention of our own time.We carefully screen our patients who have ADHD symptoms. 75% of these don’t meet criteria for ADHD. If some providers elsewhere complete an evaluation in 15 minutes, okay, I understand their time and financial constraints. But, that doesn’t make it right, nor doesit make more careful evaluations are wrong.

  • http://parentingmythsandfacts.com/ Dr Sarah

    I think abolishing a diagnosis as a requirement for medication could end up backfiring badly.  At least now people have the concept that those drugs should only be used in cases where children have A Disease Label, and, as loosely as that label is dished out in the US from what you’re saying, I would be very surprised if there were not also a lot of people getting put off the idea of using the medication for their children’s hyperactive symptoms by their reluctance to label their child.  If we open the doors to the idea that it can be beneficial for something as vague as ‘hyperactive symptoms’, and remove the idea that it is only supposed to be beneficial in a particular subcategory of children… well, floodgates, anyone?

  • Michal Haran

    People are different from the day they are born. Some have blue eyes and some brown. Some are short and some are tall. They also differ in their personality traits and the way they will respond to various environmental stimuli. The diversity of human emotions and traits is enormous. Many traits are of advantage under some circumstances and a disturbance under other circumstances. Being a giraffe is great if most of the available food is on the trees, but not so when it is mostly on the ground. 
    Hyperactivity is not helpful when having to sit down with many other kids and study boring material. It is excellent when developing your creativity. People and even more so growing children do very well in an environment that helps them harness and improve their abilities without constantly being faced with their disabilities. Neither modern society nor modern medicine is ready to deal with those that don’t “fit the box”. A teacher that has constant disturbances from an unhappy child will be glad to give him medications that will make him more easy to deal with, or isolate him from the rest of the class to his “benefit”. This is much easier (even though much less rewarding) than thinking of innovative ways to utilize his abilities and skills. Those rare teachers that do find the way to work with such children and their parents are a proof that it is possible and very rewarding. Did Albert Einstein have ADHD and should he have been given Ritalin? No doubt that his innovative way of thinking caused him to clash with the authoritative school he was in.  
    In the modern world the spectrum of normal has become so narrow, that it should not come as a surprise that there is so much pathology and abnormal. This in my opinion is a social issue not a medical one.  

  • Anonymous

    Hi, as an occupational therapist working with children (UK trained but Swiss based) I have to say I am staggered at the amount of children diagnosed with ADHD in the USA, compared to Europe. This would seem to be directly related to the power of the drug companies and the desire to have a quick fix, as well as your healthcare system, which sees health as a business. As OT’s we are not allowed to diagnose, but often use the sensory profile and other detailed assessments to work out the child’s abilities, then prescribe environmental adaptations and adjust expectations, and maybe start therapy. Sometimes the extra attention alone calms a child down. My colleagues in the UK don’t have that kind of time to give a child, so a pill would be much easier. Even amongst wealthy and caring parents a lot of children are not getting sufficient opportunities to move/exercise or a decent diet. Rarely is a child here on medication, and many cases it seems to be of minimal use or have unwanted side effects, consequently the children who continue with it are generally only those for whom it works. As the mother of a “daydreamy” child, I sometimes think it would be great to use a stimulant, but would never dream of giving her cocaine so why would I give her Ritalin, so little is known of teh long term side effects? With every diagnosis comes an opportunity to make money, the useful part of the diagnosis is that it helps us see patterns of behaviour and understand why our children behave the way they do.

  • Craig Koniver, MD

    I like your article here because what you are proposing makes sense in terms of trying to think more holisticly and figure out what other “things” contribute to a diagnosis. We need to do this with all diagnoses, actually. Just like every other “disorder” ADHD arises via the combination of the interplay of genetic predisposition and interaction to one’s environment. The more we take a step back and view illness in this sense, the better we, as doctors, will be able to better care for our patients.

    The more time we take to better understand each patient in their immediate environments, the better we will be able to offer them more options than just stimulant medication. I have plenty of children and adults in my practice who are able to manage that attention issues with dietary choices. Others manage by taking nutritional supplements. And others manage with cognitive behavior choices.

    My concern with the diagnosis is not the diagnosis itself, that is just a label, but how we go about advising our patients which ends up most of the time putting them on stimulant medication. That then reinforces the notion to then that instead of taking the time to evaluate their life as a whole, it is easier to just pop a pill.

  • http://www.facebook.com/profile.php?id=1311249696 Tanya Woldbeck Gesek

    This is what psychology has already been doing – assessing and intervening with environmental variables! The side effect of seeing a psychologist?  A better life.  Great arguments and I would offer that we extend this suggestion to many other DSM diagnoses!

  • Anonymous

    I could not agree more and have been frustrated for years that more people have not thought to do the same. I grew up watching my aunt coddle my cousin, 10 years younger than I, and develop almost a self fulfilling prophecy. In my personal opinion, by her making excuses for his behavior and bailing him out of every prediciment by continually using ADHD as the cause, rather than looking more deeply into what might be causing him to act out, he has been the only one of the rest of us (his 3 siblings and I, all 1 year apart) to be arrested by the police on numerous occasions for stealing the neighbors car, drug possession, etc and now “recreationally” uses drugs…pot and acid being his favorites. Still, his mother continues to spoil him with anything that he wants (BMW, rent paid, etc) because the poor child had to grow up with ADHD, which she sees as the disadvantage he has faced in life. The more that we look to find the fix for hyperactive children without taking the time to understand the cause of each individual case first, the more that we continue to overmedicate children rather than involving them in activities to help manage their hyperactivity, the more (in my opinion) we are enabling them to continue acting that way throughout their life without being able to hold them accountable.

  • http://profile.yahoo.com/WIWDMS6SKC5AQPZ2WPIFUOZTZQ rainman

    My Cure: Go outside and play, and don’t come in until dinner time.

    • Sapphire Storm

       brilliant…

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    Oh Rainman – I was always so shocked when my kids were in elementary school and the teachers took away recess as punishment. Just who were they punishing? Themselves? With a class of 20-25 RESTLESS kiddos to deal with all day and no way to burn off all that energy? And silent lunches? Good grief!!! I totally agree! A private boys school in our city has 2 recesses. They get it. I can’t believe PE is often the first thing to go in public schools when funding is cut. 

    I joke that my mom sent us out and locked the doors until the street lights came on. She denies it but then again, she can’t remember how much we fought  either.To bad there aren’t any street lights in my neighborhood…..

  • http://twitter.com/DocJohnG Dr. John Grohol

    Let me go Dr. Balt one further and suggest something even more radical — let’s eliminate all psychiatric diagnoses! The arguments he makes for ADHD apply equally to every psychiatric diagnosis.

    Because if we don’t assign labels to things, that’ll make everything better. Much like if we bury our heads in the sand and forget that meanwhile, researchers still need to research these things (and use the same language so as to understand one another), clinicians still need to talk to other clinicians about these things (and use the same language so as to understand one another), and insurance companies still want to bill for specific treatment of specific conditions.

    There is not a single diagnosis in the DSM-IV that describes how that diagnosis is caused. A diagnostic system should be causation-neutral at this stage of our very early understanding of the brain.

    It is up to individual clinicians and doctors to look for causes of a disorder — and assigning a diagnostic label does not rob a professional of this ability. In fact, if a professional feels a label is all they need to prescribe a broad array of psychiatric and psychological treatment to a given individual, they are probably in the wrong profession.

    • Michal Haran

      A diagnosis is a tool that enables stratification of  patients, so that we as physicians, can give them better treatment. The goal of that treatment (be it medications or other interventions) is to prolong life and improve the quality of life of the patient. 
      A diagnosis, as you say is also a communication tool that enables physicians discuss their patients and also assess various treatments in a large group of similar patients, to be able to eventually make better management evidence-based decisions. 
      Some diagnoses in medicine have been abandoned or changed, because they provided neither. 
      Or (specifically in psychiatry) because it was realized that they are not a disease, even if they are “skewed” from what is considered normal. A good example is homosexuality. 
      The criteria to diagnose “depression” have also been seriously questioned in an excellent book- reviewed here-http://www.nejm.org/doi/full/10.1056/NEJMbkrev58551
      Further more, our normal emotions are many times the driving force for our actions and not something that has to be treated like diabetes or cancer, even if they are not pleasant. 
      In my field of practice (hematology) I can easily tell if a patient’s anemia is due to a primary hematological disorder or secondary to blood loss for instance. I would cause more harm than good if I treated all patients with anemia in the same way, regardless of the cause. 
      But, this is many times what happens in psychiatry. 
      Further more, some psychiatric diagnoses are “waste basket diagnoses” that rely mainly on the lack of knowledge/ ignorance of the medical profession. And once the cause of the condition (in a specific patient or in general ) is found, it ceases to be a psychiatric problem. 

      I think it is good that psychiatrists are questioning certain diagnostic categories and trying to find better and more accurate criteria to diagnose those who are truly ill, so that they can better stratify their treatment, and also be able to safely tell people that they are mentally healthy and just have a transient response to a life event or a certain less common trait. 
      The diagnosis of lymphoma has undergone major changes since its first classification. With better stratification we can now give much better and more tailored treatment.the term histiocytic lymphoma is no longer used. We learned that the morphology of the cells may be misleading etc.. 

      So, why should there not be similar revisions and a better understanding in the field of psychiatry? 
      Psychiatric diagnoses, like any other medical diagnoses are not meant to make the life of lazy teachers and ignorant physicians easier. Nor, are they meant to facilitate the work of insurance companies. They are definitely not meant to make people lose their trust in themselves and their abilities. If this is what they achieve they clearly defeat their purpose. 

      • http://twitter.com/DocJohnG Dr. John Grohol

        Psychiatric diagnoses undergo such revisions as often as there is a new DSM edition. Nobody disagrees with the need for editing and revisions of diagnostic criteria from time to time.

        A psychiatrist suggesting we should just do away with an entire category of diagnosis because it doesn’t sit well with his belief system or treatment approach is beyond ridiculous.

        A diagnostic system doesn’t say anything about how you treat the person in front of you presenting with the problem (the DSM is completely silent on treatment). A doctor who lets a diagnosis dictate treatment choices — without regard for the patient’s unique needs, personal situation and circumstances, psychological makeup, personality, stressors, social support system, and environment — is a doctor I would never, ever want to see.

        • http://twitter.com/balts Dr Steve Balt

          “A doctor who lets a diagnosis dictate treatment choices — without
          regard for the patient’s unique needs, personal situation and
          circumstances, psychological makeup, personality, stressors, social
          support system, and environment — is a doctor I would never, ever want
          to see.”

          Again, I agree entirely.  That was the whole point of my article.

          My suggestion to “do away with an entire category of diagnosis” will never come to pass.  It was a thought experiment, something to provoke criticism and fruitful discussion, like this one.  I don’t have a “treatment approach” that I espouse to all ADHD patients, and as for a “belief system,” my belief is that we should be thorough, honest, and provide care that is patient-centered and relevant to each patient’s unique situation.

    • http://twitter.com/balts Dr Steve Balt

      “It is up to individual clinicians and doctors to look for causes of a
      disorder — and assigning a diagnostic label does not rob a professional
      of this ability. In fact, if a professional feels a label is all they
      need to prescribe a broad array of psychiatric and psychological
      treatment to a given individual, they are probably in the wrong
      profession.”

      Agree entirely. The whole reason I wrote this article (with a somewhat less provocative title, I might add) is because I’ve noticed that, for many docs, “assigning a diagnostic label” does indeed END the search for causes, the efforts to help the patient develop skills/strengths/resilience, or the development of creative treatments that might be more empowering (and safer) to the patient.

  • Anonymous

    THANK YOU!!! Thank you for so many things in this article!  I (as a non-physician) have been saying this exact same thing for YEARS!

    Children are treated more as burdens in the household these days and the parents have too many ‘outs’.  Back in my day (I’m 37 now), I didn’t have the internet or massive video game SYSTEMS.  I had two arms, two legs, 10 fingers & toes, and an IMAGINATION that I was forced to used when I was BORED.  I got in trouble for not coming in on time because I was out riding my bike with friends, or not putting my dad’s tools away because I was building something, or coming into the house dirty because I was playing football or something.  My parents had very clear expectations of me: grades, chores, level of respect when interacting with adults, getting a job when I was 16, paying for my own ‘extras’.  And when the expectations were not met, there were CONSEQUENCES.  And the consequences were not threats, they followed through! Taking TV away, taking telephone PRIVILEGES (any privileges for that matter), grounding, extra chores, writing apologies, spanking, etc.

    Children now days are GIVEN their imaginations. Massive gaming systems for hand eye coordination, TV in lieu of a babysitter, and internet instead of actual human interaction, have taken over a child’s ability to think for themselves.  I remember writing poetry and short stories as my outlet when I was a teenager.  Lincoln logs were the coolest thing EVER when I was about 6 and then it was Legos around age 8.  And sports! Nine years of playing softball did a lot for that energy of mine!  Kids don’t do that anymore. I haven’t seen a dad in the front yard playing catch with their child, since I was a child myself.  This is sad.  Parents need to go back to parenting 101, being involved in their kids’ lives. I am not blaming technology for any of this…I am blaming the parents for abusing technology. 

    It’s not that I don’t think that ADHD doesn’t exist.  I truly believe that it does. Attention deficit (who is paying attention to them) hyperactivity (who is engaging and teaching children how to use their energy constructively) disorder [a morbid physical or mental state].  I just believe that it is not always a MEDICAL condition. It is an environmental condition that can be treated with out medication.  I do believe that very few of the medical Dxs being made are accurate. The author was very right in saying, “you’re likely to ask leading questions, and I guarantee you’ll get positive responses.”  I saw the criteria, I read it, I understood it. In reading a lot of it, all I kept saying was “I would have been punished for that. For that. For that.”  I believe that it is environmental behaviors that can be changed with proper parenting.  It’s just easier for a parent to “fix it” with a pill, instead of sitting down at the dining room table and helping with homework, or coloring, or something that requires the parent to interact and pay attention to their kid. 

    With regards to the family practice doctor making a Dx in a 15 min OV, that is just poor medical decision making.
    Insurance companies will have a heyday in denying off label drugs, but there are ways to deal with that and have the medications covered. There hoops that will have to been jumped through and people will need to patient.

    Thank Doctor for writing this article.  As a mother, I greatly appreciate it and agree with you 100%

  • Sapphire Storm

    Oh my god! I just can’t believe the paternalistic backwards thinking of your article. To say that you would get a glut of false negatives but get less false positives means that all those ‘false negatives’ would continue to suffer with the terrible symptoms ADD causes. You cannot take anecdotal cases (as the one comment below) and apply it to the very real consequences of being born with this condition. I have a child who suffers from this as do I. Let’s see; he was not neglected, our household was not chaotic; his nutrition was great…..and he suffered every day in school and is now failing in 11th grade. Because of extreme ignorance of teachers and the psychologists at the school he could never get the real help he needed. Your article proposes something akin to ‘throwing the baby out with the bathwater’. I’d like to know what is so bad about a diagnostic category of ADHD/ADD? People with fibromyalgia and CFIDS have faced this same prejudice. I am pretty sickened by this backlash especially coming from people in the psychological profession, remote from the suffering this condition causes. Thanks for nothing.

  • http://expatdoctormom.com/ Expat Doctor Mom

    Great article. No I will not crucify you!  I have thought that the pendulum with ADHD swings form under diagnosing perhaps in the 90′s then we say it become over diagnosed in the late 90′s til now,

    I agree that the symptoms cause can be/are multi-factorial and that some of the correctable causes (like mild sleep deprivation etc) don’t get addressed. 

    Interesting that students are now falsifying symptoms to get into Harvard.  I had parents falsify symptoms to sell it on the street!  How things have changed.

    Best,
    Rajka

    • Sapphire Storm

      Of course the media exaggerates sensational practices such as students faking symptoms or others selling medications and then connect it to a (for some reason) controversial diagnosis of ADHD. It’s not very clinical to just read a story or go by anecdotal incidents to then judge the validity of a diagnosis! That’s pretty absurd.

      • http://expatdoctormom.com/ Expat Doctor Mom

        I don’t doubt ADHD as a diagnosis nor would I not treat it.  I am sorry if you misunderstood my response.  It is just sad that along with ensuring an accurate diagnosis we as clinicians have to weed out those who falsify symptoms. 

  • Anonymous

    This is a rather myopic piece that seems to illustrate the author’s disdain for diagnoses and psychiatric issues more than it pertains to ADHD.  It is disingenuous to imagine competent psychiatrists diagnosing ADHD because it gives them jollies.  

    It is true that psychiatry is symptomology-based, but the naiveté in eliminating diagnoses is striking.  Do you suggest internists diagnose you with ‘fever’ and give acetaminophen and see what happens?

    Though I don’t know anything about you, I’d venture to suggest that you come to terms with whatever it is you feel, or have been told, your diagnosis before advocating what would surely amount to lesser care for people with mental illnesses.

  • http://www.facebook.com/drjoe.kosterich DrJoe Kosterich

    Great article. Putting labels on children does not help them and it is completely arbitrary where we draw the line between “normal” and disease. If we better catered to the differing learning and emotional needs of children we would solve the problems of ADHD

  • Anonymous

    Good article–any critique of diagnostic labels gets volumes of negative
    comments. It took alot of guts to write this. Living does not need a
    diagnosis. I have worked for many years without ever needing to go
    there..and you know what, people change and heal even without diagnosis
    and often faster and more fully.
    If you take time to listen, think and pay attention to a person’s experience etc..  you find a whole host of things to work with.   Go ahead and send the negative comments.   I am sorry for those professionals who do not get it.  Such a shame for the profession. 
      From a Child Psychiatrist.

  • http://makethislookawesome.blogspot.com/ PamC

    I know this article is written with children in mind, but my father was diagnosed in his 40s and I was diagnosed after college… 

  • Anonymous

    What a refreshing article on ADHD! 

  • http://www.facebook.com/profile.php?id=100003340977690 Safia Mohiuddin

    Wonderful article and very realistic. I completely agree, and was hoping that some psychiatrist wrote about eliminating ADHD diagnosis, since I am a Technical Writer and not a doctor.

    From my parenting experience, I completely agree about environmental influences on children and also about parents’ role in shaping attitudes and behaviors of children.

    The whole article seems so true, and in fact, the proposal about extending this strategy  to other realms of psychiatry sounds very sensible, especially in case of major depression.

  • http://www.attentiondifferencedisorder.com/ Dr. Kenny Handelman

    Steve, let me take a bird’s eye view of your argument:
    Let’s take a condition called ADHD – which is multifactorial, may be different disorders under one label, and may have psycho-social causes which aren’t being addressed in a medical system which prescribes medications too quickly and then stops looking for any other strategies which may help. (how am I doing so far, am I on track?).

    In this current medical environment, where stimulants are in short supply in the USA because of some situation between the pharma companies, and the DEA (and I don’t know who actually knows why this is happening – but Obama wants a hearing to review it, so we may get ‘answers’). And although no one knows why there is a problem with medication shortage, the media is repeatedly discussing the fact that stimulants are being misused and abused, and that is why the DEA is trying to keep an extra tight control on these medicines.

    Ok – part 1 (your argument): ADHD is complicated, and doctors are prescribing too quickly and not looking for other psychosocial causes or treatments to help.
    And part 2 (the current situation): the stimulant medicines for this condition are being misused and abused (to some degree), and this issue is coming to a head right now in the USA. 

    And your suggestion is to throw out the diagnosis of ADHD, and just give stimulants to people who may have some inattention, or hyperactivity or impulsivity?
    All under the guise that it will somehow make the doctors search for other causes?

    So the limited supply of stimulants in the USA will flow more freely to anyone who seems like they have trouble focusing… (I may be overstating your argument here, but I am following your logic)

    Now let’s pause for a second. I’m a Canadian psychiatrist, and I didn’t train in the USA, and I don’t work in the USA. (I have met many very intelligent, thorough and caring doctors from the USA though… but that’s not the point). If I follow your logic – it seems your concern is that the DOCTORS aren’t taking the time to look beyond a diagnosis to find other possible causes, and more importantly, other solutions/strategies/therapies to help. And while I don’t work in the US medical system, I imagine that there are also significant limitations to the accessibility for funding and coverage for the psychological treatments even if they are recommended and needed. 

    So if we actually eliminated the diagnosis of ADHD, what would that really achieve?

    The same doctors, the same insurance companies, the same societal pressures (i.e. your child only gets help in school if they have a diagnosis) – will they really change their behaviour significantly because there is no diagnosis of ADHD anymore?

    I think that the same pressures of the ‘system’ would continue, and the doctors who took too little time with patients would still take too little time with patients, and if they were excessively biologically focused, they would continue to be.

    Research in ADHD has been clear that it is important to use multi-modal treatments. Combination of medication AND behavioural treatment, parenting strategies, and academic strategies. 

    It seems your real concern is the lack of implementation of the ‘best practices’ of using the known research.
    In other words, your perception is that doctors make the diagnosis of ADHD, give an Rx and then stop doing anything else. And I don’t know if that is really the case, on the ground, day in and day out. Of course the press wants us to think so, and I guess you support that point of view… (but where is the data?)

    The solution is NOT to eliminate a diagnosis, expecting that it will make doctors look for more causes, and treat people like the individuals they are. (And of course, when you suggest eliminating a diagnosis, it upsets and invalidates people who have been fighting for the needed support and accommodations for decades, and their work is critically important to decrease stigma and improve people’s quality of life).

    The solution is to work on the system which drives doctors to this approach (if it is as rampant as you say). Training which emphasizes psychotherapy, and bio-psycho-social formulation of patient’s problems, and also focuses on their strengths, rather than just on their disorders and weaknesses.

    I suspect that looking at physician training, insurance payment models, funding of children’s mental health programs and other strategies would yield a much better result than just suggesting the elimination of a disorder.

    While you repeatedly talk about how you are concerned that others may criticize you, yet you put forward an immature argument, with little data to support you. Your proposed solution is a farce, which even in your own make believe world wouldn’t work. 

    I started writing this comment because of the frustration that I felt (for all of the great clinicians I have worked with who address all sides of someone with ADHD’s life, and for all of the kids and adults with ADHD who have worked their butts off to improve themselves and to function well – with or without medication).

    At this point, now that I’ve written a comment which is approaching the length of your blog post – my only frustration is that I’ve given your post so much time.

    • http://twitter.com/balts Dr Steve Balt

      Dr Handelman,

      Thanks for your thoughtful response.  I feel that I should clarify something for you and for other commenters.  I do not believe that we will (or should) ever “eliminate” the diagnosis of ADHD, for many of the reasons you describe in your comment.  My proposal was simply a thought experiment, meant to stimulate discussion and debate.  I should also emphasize that my original post didn’t have the provocative title that Kevin gave when he re-posted it here.

      That said, your comments reflect precisely why this proposal needs to be, if not executed, then at least considered by professionals working with ADHD.  My concern is *precisely* the “lack of implementation of the ‘best practices’” and I entirely agree that “the solution is to work on the system that drives doctors to this approach.”

      I’m as frustrated as you are because I have seen cases of “ADHD” who have truly benefited from good professional care, cognitive training, psychostimulant medication, and, yes, having a “label.”  But I’ve also seen this label thrown around unnecessarily and irresponsibly, by people who should know better.

  • http://profile.yahoo.com/NOFQLMDA5XHYLROOXOHWG246HE Ron C

    Dr. Balt,
    I also agree with your excellent article.  I would also add that some psychiatric “diagnoses”, such as ADHD, have another potentially adverse effect:  they remove all sense of responsibility from the patient for his/her ability to get better.  A case in point is this relatively recent “diagnosis” of “addictive personality”.  I am not saying that this is an actual psychiatric diagnosis, but there are people who believe in it.  The problem is, one of the most effective treatment modalities for alcoholism (alcoholics anonymous) requires that the patient assumes some level of responsibility for his addiction.  Now, people are beginning to blame their addiction on their “psychatric disorder”.   In the same way, a diagnosis such as ADHD removes all responsibility from the parents in terms of how they raise their child (“there is nothing wrong with how I raise my child….he has ADHD”).  Labels are dangerous not only in how it affects society’s perception of the patient.  It also affects how the patient’s view themselves. 

  • Anonymous

    If you can get managed care to cover treatment without a DSM code, go for it.

    As a mental health professional and person with a psychiatric diagnosis or two, I think people put too much weight on diagnoses in some ways. Human nature to want to categorize things, of course, and there isn’t anything inherently wrong with putting names to the faces that are symptoms.

    Diagnosis is a complicated issue. And even if we nixed it, there’s human nature. Just because people aren’t given a name for it, doesn’t mean they will take responsibility for it. There will always be people who make excuses, people who will stigmatize themselves or others, and people who will take responsibility for their care. All we can do is provide empathy and tools so people can better themselves.

    Though if we eliminate the AD/HD diagnosis, it could result in some amusing conversations with school administrators. “I think your son has a problem.” “What kind of problem?” “Well, he’s aggressive, he doesn’t pay attention in class, and he has a lot of energy.” “Sir, I think you just described atleast two-thirds of six year-olds.” “His behavior is really distracting to the other students.” “Can you actually tell me what the issue is here, because so far I’m seeing more of a discipline problem than whatever it is you’re talking about.” “We can have the school psychologist evaluate him.” “For what?” “Behavioral difficulties.” “Why would you need formal evaluation for that, you just said he’s distracting and aggressive?” “I don’t know how to describe it and I don’t know what to call it, but your son is clearly struggling with something.” “Uh huh.”

  • Anonymous

    Dr. Balt,

    I love this article! I could not agree with you more about getting rid of the diagnosis of ADHD. This is not because I do not think there are some people who do have it, but as a person who was diagnosed with it at age 5, it is something that I hold dear. My parents were always holding it over my head if I forgot to “take” my medication as a teenager, forcing me to take it. I would sneak into the bathroom early in the mornings and flush it down the toilet so they thought I was taking it. It took me months to bounce back and learn how to handle myself without my medication. When my parents found out, we were at my counciling session with my Psychiatrist and he basically told them that they needed to give me time to prove to them that I could function with out the medication. It was the first time we had been to their to see him, but he was more suprised that NOT once was I ever reevaluated, taken off, or even trialed with out it since age 5 (I was 17 at the time). My youngest daughter was diagnosed with ADHD about 2 years ago and was placed on medication about 1 1/2 ago. The differece between my parents and I are that I ONLY use it for school and every weekend or any type of school breaks she will not be medicated. I want her to learn how to control herself and one day hope that she won’t have to take it. I work with her consistently when she is unmedicated, this allows me to help and teach her different techinques that can help her improve. She has come a long way in school since she started taking her medication and I am so proud of her gains, but my hope for her is that one day she will be able to function without her medication at school.

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