Attention Deficit/Hyperactivity Disorder: Over-Active or Over-Diagnosed?

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Centuries of scientists have recorded observations of patients presenting with symptoms consistent with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD), however the conditions were not actually recognized in psychology until the twentieth century (Lange et al.). In 1968, the American Psychiatric Association (APA) acknowledged a mental condition, with the same symptoms noted throughout history, called hyperkinetic impulse disorder.

The APA replaced hyperkinetic impulse disorder in 1980, introducing ADD to the list of recognized mental disorders (Lange et al.). This sample essay will look at how the evolution of the disorder has continued in recent years as scientists and practicing medical professionals debate the definition, diagnosis criteria, relevant treatments and even the existence of the disorder.

DSM-III: The introduction of ADD

The first academic study of what is now known as ADHD was undertaken quite by accident, as the intended topic of research was the newly approved medication, Benzedrine. During his experience with the drug, Dr. Charles Bradley noted several peculiar side effects when he administered it to children for its intended purpose as a headache reliever. In his initial study of the phenomenon, Bradley remarked:

It appears paradoxical that a drug known to be a stimulant should produce subdued behavior in half of the children. It should be borne in mind, however, that portions of the higher levels of the central nervous system have inhibition as their function, and that stimulation of these portions might indeed produce the clinical picture of reduced activity through increased voluntary control. (p. 582) Bradley completed a second study in 1940, again linking the drug to a marked improvement in the schoolwork, attention span and impulse control of his patients, however, his studies were largely ignored by main stream medicine (Strohl).

The ASA is responsible for publishing the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a compilation of classifications, diagnostic criteria and detailed information for all mental disorders in the United States. Currently, only the conditions listed within the publication are acknowledged by the healthcare system at large (Diagnostic and Statistical Manual of Mental Disorders - V). The addition of ADD to the DSM-III in 1980 acknowledged the separation of ADD into two subtypes.

Scientists agreed that the presentation of ADD could be accompanied by hyperactivity, but was not defined by it and instead the underlying symptom was inattention, leading to the ADD/H, with hyperactivity, and ADD/WO, without hyperactivity labels (Holland and Higuera). Diagnosing the condition involved an analysis of three symptoms (inattention, hyperactivity and impulsivity) for the exhibition of co-existing and persistent occurrences (Public Broadcasting Service). 

The 1987 revision of the of the DSM-III once again changed the name of the disorder, now recognizing only ADHD and combining all three symptoms into a single diagnosis with criteria to present with all three noted symptoms in order to be diagnosed as having ADHD (Holland and Higuera). This would mark the end of the medical validity of the term ADD in terms of learning disabilities.

The evolution of ADHD

By the early 1990’s additional research began to emerge validating the potential of the original ADD diagnostic criteria, arguing the patients could in fact present with impulsiveness and inattention without the presence of hyperactivity (Frick). This information prompted the revision of the definition and characteristics of the illness and it was officially updated with the release of the DSM-IV in 1994 (American Psychiatric Association). Three subtypes were established in the 1994 publication: inattentive, hyperactive-impulsive and a combination of the two. These subtypes have remained unchanged and are consistent through the most recently published DSM-5, which was released in 2013. 

Diagnosis and treatment of ADHD

The current diagnostic procedure for ADHD is complex, with no fool-proof test for identifying patients suffering from the disorder (Center for Disease Control and Prevention). Like many mental disorders, the difficulty of diagnosis lies in the similarities between the symptoms in a large number of conditions. In order for a valid diagnosis to be made, clinicians must verify the presence of six or more symptoms in either or both of the main categories: inattention or hyperactivity/impulsivity (Center for Disease Control and Prevention). The recognized symptoms must have been persistent for at least six months and must be identified as misaligned with age or developmental level of the patient (Center for Disease Control). If symptoms are validated in both of the following categories, the patient is diagnosed with combined ADHD. 

Inattention symptom

Identifying the presence of six or more symptoms from the following list is consistent with an inattentive ADHD diagnosis, as according to the Center for Disease Control and Prevention:

(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities; (b) often has trouble holding attention on tasks or play activities; (c) often has trouble holding attention on tasks or play activities; (d) often has trouble holding attention on tasks or play activities; (e) often has trouble organizing tasks and activities; (f) often has trouble organizing tasks and activities; (g) often has trouble organizing tasks and activities; (h) often has trouble organizing tasks and activities; (i) often has trouble organizing tasks and activities. (par. 4)

In the DSM-5, the requirement of six characteristics was reduced to five for the diagnosis of adults, which had not previously been recognized directly (American Psychiatric Association, 2013).

Hyperactivity and impulsivity in ADHD

Identifying the presence of six or more symptoms from the following list is consistent with a hyperactive/impulsive ADHD diagnosis, as according to the Center for Disease Control and Prevention:

(a) Often fidgets with or taps hands or feet, or squirms in seat;

(b) often leaves seat in situations when remaining seated is expected;

(c) often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless);

(d) often unable to pay or take part in leisure activities quietly;

(e) is often “on the go” acting as if “driven by a motor”;

(f) often talks excessively;

(g) often blurts out an answer before a question has been completed;

(h) often has trouble waiting his/her turn;

(i) often interrupts or intrudes on others (e.g., butts into conversations or games). (par. 5)

Similarly the DSM-5, reduced the requirement of symptoms to five for the diagnosis of adults, which had not previously been recognized directly (American Psychiatric Association, 2013). 

Qualifying criteria

In addition to meeting the diagnostic criteria, the Center for Disease Control and Prevention states that patients must meet all of the following criteria in order to be given a medical ADHD diagnosis:

(a) Several inattentive or hyperactive-impulsive symptoms were present before age 12 years;

(b) several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities);

(c) there is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning;

(d) the symptoms do not happen only during the course of schizophrenia or another psychotic disorder;

(e) the symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (par. 6)

Once all qualifying criteria are met, the patient may be diagnosed with one of the three designated sub-types of ADHD. 

ADHD treatment

Since Bradley’s discovery of ADHD symptoms responding positively to stimulants, the majority of treatment methods identified have been within the drug class (The Feingold Association). This has given pause to many professionals and parents alike, hesitant about treating a child as small as six with otherwise illicit and addictive stimulants (Berchelmann). In recent years, the introduction of non-stimulant ADHD medications have been introduced as an alternative for children who cannot tolerate the use of stimulant medication and for parents who are leery of stimulant therapy (Watkins). 

Controversy over ADHD diagnosis

The stigma surrounding the presence of mental illness has been around for centuries and can be attributed to a lack of applicable knowledge about identified conditions (Byrne). The invisibility of most disorders, as well as the lack of finite testing make it easy for people to dismiss individuals with valid diagnoses as weak or crazy (Corrigan and Miller).

This, combined with a standard treatment that is derived from an otherwise illicit substance, is the perfect storm for the controversy surrounding ADHD. Fueling the fire of doubt, current research aimed at calculating just how many people are faking the symptoms of ADHD, primarily college students (Sollman, Ranseen and Berry).

Acknowledging that readily accessible symptomology profiles and the use of self-completed diagnostic tools, Sollman, Ranseen and Berry found that without the use of additional cognitive diagnostic tools, the ability to detect a student who was feigning symptoms was reduced to a nominal amount. In fact, in a 2008 study by Fishers and Watkins, over 77% of participants were able to fake the symptoms of ADHD, successfully acquiring a diagnosis, after studying the diagnostic criteria online for only 5 minutes.

Although faking illness is nothing new, there are perceived benefits to acquiring an ADHD diagnosis, such as academic accommodations or advantage and access to stimulants for personal or financial interests (Harrison, Edwards and Parker). 

Although the motivation for feigning illness is fairly high in the case of ADHD, as a diagnosable disorder in the DSM it is difficult to write off as a complete fraud. Between the stigma of mental illness and the lack of motivation or intelligence for a young child to feign ADHD, one could reasonable determine that ADHD exists on some level. However, until the treatment becomes less appealing than the disorder, it’s hard to tell just how many people are actually afflicted by the disorder. 

Works Cited

American Psychiatric Association. 'DSM | Psychiatry.Org'. N.p., 2015. Web. 12 Nov. 2015.

American Psychiatric Association. DSM-5 | Attention Deficit / Hyperactivity Disorder. 2013. Print.

Berchelmann, K. 'Why Do Stimulants Work For Treatment of ADHD?. ChildrensMD. N.p., 2010. Web. 12 Nov. 2015.

Bradley, Charles. 'The Behavior of Children Receiving Benzedrine'. American Journal of Psychiatry 94.3 (1937): 577-585. Web.

Byrne, P. 'Stigma of Mental Illness and Ways of Diminishing It'. Advances in Psychiatric Treatment 6.1 (2000): 65-72. Web. 12 Nov. 2015.

Center for Disease Control and Prevention. 'Symptoms and Diagnosis | ADHD | NCBDDD | CDC'. N.p., 2015. Web. 12 Nov. 2015.

Corrigan, Patrick W., and Frederick E. Miller. "Shame, blame, and contamination: A review of the impact of mental illness stigma on family members." Journal of Mental Health 13.6 (2004): 537-548.

 Diagnostic and Statistical Manual of Mental Disorders - V. 'Frequently Asked Questions | APA DSM-5'. N.p., 2015. Web. 12 Nov. 2015.

Fisher, April, and Marley Watkins. 'ADHD Rating Scales' Susceptibility to Faking In a College Student Sample'. Journal of Postsecondary Education and Disability 20.2 (2008): 81-92. Print.

Frick, Paul J., et al. "Academic underachievement and the disruptive behavior disorders." Journal of consulting and clinical psychology 59.2 (1991): 289.

Harrison, Allison, M. Edwards, and K. Parker. 'Identifying Students Faking ADHD: Preliminary Findings and Strategies for Detection'. Archives of Clinical Neuropsychology 22.5 (2007): 577-588. Web.

Holland, K, and V Higuera. 'The History of ADHD: A Timeline'. Healthline. N.p., 2015. Web. 13 Nov. 2015.

Lange, Klaus W. et al. 'The History of Attention Deficit Hyperactivity Disorder'. ADHD Attention Deficit and Hyperactivity Disorders 2.4 (2010): 241-255. Web. 12 Nov. 2015.

Public Broadcasting Service. 'Adhd - The Diagnostic Criteria | PBS - Medicating Kids | FRONTLINE | PBS'. N.p., 2015. Web. 12 Nov. 2015.

Sollman, Myriam J., John D. Ranseen, and David T. R. Berry. 'Detection of Feigned ADHD in College Students.'. Psychological Assessment 22.2 (2010): 325-335. Web.

Strohl, Madeleine P. “Bradley’s Benzedrine Studies on Children with Behavioral Disorders.” The Yale Journal of Biology and Medicine 84.1 (2011): 27–33. Print.

The Feingold Association. 'History of Development and Use of Drugs for ADHD'. N.p., 2015. Web. 12 Nov. 2015.

Watkins, C. 'Non-Stimulant Medication for Children, Adolescents and Adults with ADHD - Northern County Psychiatric Associates'. Northern County Psychiatric Associates. N.p., 2015. Web. 12 Nov. 2015.