"How many six year olds give close attention to details, follow through on instructions, finish school work and chores, like homework, don't run about or climb excessively, play quietly and await their turn patiently? Childhood was never meant to be that constrained, controlled, predictable and boring."
Dodgy Diagnosis
Every claim about the science of ADHD should be viewed in the light of its diagnostic criteria. The diagnostic criteria for ADHD, in all its forms, results in the ADHD labelling of children who are too active (hyperactivity), not active enough (hypoactivity), or too day-dreamy (inattentive). The diagnosis of ADHD is entirely based on observations of a child's behaviour, as "there are no laboratory tests, neurobiological assessments, or attentional assessments that have been established as diagnostic in the clinical assessment of Attention Deficit/Hyperactivity Disorder".[1] If a child "often" shows at least 6 out of 9 of the following inattentive or impulsive/hyperactive behaviours for at least six months, to an extent that is considered dysfunctional at home and school, then they meet the diagnostic criteria for ADHD.
1- fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2- has difficulty sustaining attention in tasks or play activities
3- does not seem to listen when spoken to directly
4- does not follow through on instructions and fails to finish school work or chores
5- has difficulty organising tasks and activities
6- avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort such as schoolwork or homework
7- loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools)
8- easily distracted by extraneous stimuli
9- forgetful in daily activities.
1- fidgets with hands or feet or squirms in seat
2- leaves seat in classroom or in other situations in which remaining seated is expected
3- runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness
4- has difficulty playing or engaging in leisure activities quietly
5- "on the go" or often acts as if "driven by a motor"
6- talks excessively
7- blurts out answers before questions have been completed
8- has difficulty awaiting turn
9- interrupts or intrudes on others (e.g., butts into conversations or games)
These 18 behaviours are, depending on your view, either compelling evidence of a biochemical brain imbalance or, within the normal range of childhood behaviour. However many people, children as well as adults (including this author) display them to varying degrees in homes, schools and workplaces every day. As people mature most become less impulsive and distracted, however, children are naturally impulsive/inquisitive and active/playful and often inattentive. The diagnostic criteria reflect absurd expectations of what constitutes normality in young children. They also require that "some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before age 7 years".[2] Yet how many six year olds give close attention to details, follow through on instructions and finish school work, chores, like (or even have) homework, don't run about or climb excessively, play quietly and await their turn patiently? Childhood was never meant to be that constrained, controlled, predictable and boring.
What is supposed to distinguish ADHD sufferers from the rest of the population is the level of impairment or dysfunction. Specifically, "there must be clear evidence of clinically significant impairment in social, academic or occupational functioning" and "some impairment from the symptoms is present in two or more settings (e.g. at school {or work} and at home)".[3] How "often" a child "fidgets or squirms in their seat", or " interrupts" or "avoids homework" or "fails to remain seated when remaining seated is expected" or "is distracted by external stimuli" so that they exhibit "some impairment" is not defined in DSM-IV. Like beauty, "impairment" is in the eye of the beholder.
DSM-IV states, "signs of the disorder may be minimal or absent when the person is receiving frequent rewards for approriate behaviour, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situation (e.g., the clinician's office)".[4] In other words, ADHD children will behave appropriately (not display ADHD), when they are rewarded, people pay attention to them (close supervision), are having new experiences (novel situations), and are not bored (especially interesting activities). Conversely ADHD children will be inattentive and easily distracted (have ADHD) when their good behaviour goes unrewarded, no one pays any attention to them, or they are in a boring, routine, situation. The absurdity of this proposition is self-evident.
It is of great concern that the diagnostic criteria are all behavioural, however, it should be of even greater concern that the diagnosing clinician doesn't have to observe any of the symptoms, let alone any impairment. The clinician may simply base their diagnosis on third party accounts of a child's behaviour. The child's parents and teachers usually provide these third party accounts. Parents and teachers are typically asked to fill in a questionnaire detailing if a child always, often, sometimes or never displays behaviour like avoiding homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful. Both parents and teachers are typically given no guidance as to the crucial difference between sometimes and often. Even competent parents, particularly first timers, can have unrealistic expectations of what is normal childhood behaviour. Parents and teachers are also given no guidance as to what constitutes age appropriate levels of attention or impulsivity control. The same imprecise, subjective, diagnostic criteria are applied whether the child is 2 or 17. Both parents and teachers are not routinely informed of the central role that their evidence plays in their child's diagnosis. Instead many parents are told their child has a 'biochemical brain imbalance,' despite a complete lack of supporting scientific evidence.
The ADHD industry counters this argument by stating that all psychiatric disorders, many of which are ultimately treated with psychotropic drugs, are diagnosed using similar behavioural criteria. Pointing out inadequacies in the diagnosis of other psychiatric conditions is hardly a valid defence for the inadequacies of the ADHD diagnostic criteria. Whilst the criticism is valid for a range of other psychiatric disorders, conditions such as Schizophrenia involve extreme behaviours like hallucinations and delusions, rather than normal childhood behaviours like avoiding homework and losing toys.
[1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revised (DSM-IV), (American Psychiatric Association: Washington, D.C., 2000): pp88-89