E
Elizabeth M. Ellis, Ph.D.
Guest
No, You Don’t Have ADHD, and Here Are 5 Reasons Why.
For many months now, I have been reviewing numerous articles in the Mental Health Section of Medium that announce, “5 Hidden Signs That I Have ADHD” or something similar. (There are variations such as “5 Hidden Signs That I Have Autism” or “…That I Am Neurodiverse.”)
As an ADHD expert, I am interested in what these writers have to say. What I am finding is that these writers do not have ADHD. This is a fad, an online trend created by social media. I say this as a professional who has worked in this field since the 1970’s. Prior to the advent of social media, most Americans viewed mental illnesses as stigma, as something to be embarrassed about. With social media, people can go to a site and read about these disorders, open up about personal experiences and difficulties, share them with others, feel a sense of connection with and validation by their new online community, get sympathy and support. They belong to a “club.”
In an April post, I wrote about this phenomenon and listed some of the reasons people want to embrace diagnoses they don’t have. Right now, “neurodiverse” and “on the spectrum” are very popular, and “ADHD” to a lesser degree. These are seen as somehow desirable, or exotic, or labels that make someone feel special. After all, no one writes in with, “5 Hidden Reasons Why I Am Paranoid,” or “5 Hidden Reasons Why I Have a Shoe Fetis h.” Ugh. Those are not popular at all.
It is time that a clinical psychologist weighed in on this subject with science. This is will not get favorable reviews from those people that want to say they have ADHD. They will write disparaging comments, if they write anything. Whenever one takes away another person’s cherished assumptions, they are likely to get blowback. But someone must say, “The Emperor has no clothes.” One of my mentors, the late Dr. Scott Lillienfeld, at Emory University, my alma mater, made a career of challenging popular but wrong-headed notions in the field of psychology. These are important voices.
Here we go.
1. ADHD is a neurodevelopmental Disorder. You do not “get” ADHD past the age of 12.
There are 20 categories of mental disorders in the latest iteration of the Diagnostic and Statistical Manual-5 (5th edition, 2013) which is published by the American Psychiatric Association. The first category is called “Neurodevelopmental Disorders” because these diagnoses are caused by neurological dysfunction and are present from birth. Most children with ADHD have a family history of the same disorder in their parents or siblings, so we assume there is a genetic cause. The most recent research suggests that what is inherited is a flaw in a transporter gene that is associated with the neuro-transmitter, dopamine, and how it communicates with other connections in the frontal lobes. (In a small percentage of cases, the child has suffered some mild brain damage either in utero or in the birth process, and this appears to be the causative factor).
Because the child has inherited a gene for this disorder, the disorder must exist in childhood. One cannot not have ADHD as a child, then have ADHD as an adult. One cannot get ADHD as an adult because of an unfortunate event that happens, or because you are under stress. Let’s look at other disorders in this category.
Intellectual Disability. This is the new term for what everyone understands and what we used to call Mental Retardation (DSM-Iv-TR, 2000). Think about it for a moment. One cannot have a normal IQ as a child, make average grades in school, then suddenly at the age of 32 be diagnosed with Intellectual Disability. We all understand that that is illogical. It is usually noticed by age two or three when the child is six months to a year behind developmentally.
Specific Learning Disorder, with impairment in reading, otherwise known Reading Disability. One cannot read on grade level throughout childhood and high school, then, at 19, be diagnosed with Reading Disability. Reading Disorder is generally picked up around third grade when the child is two grade levels or more behind in reading skills and not suffering from Intellectual Disability. That seems obvious.
Autism Spectrum Disorder. As a clinician for 48 years who has worked closely with pediatricians evaluating children for ASD, I can say with authority that it is generally picked up around 18 months to two years of age when the child fails to develop normal social relatedness to others. One cannot be “normal” as a child, then “be on the spectrum” at age 27, for example. I will write more in a future article.
2. You don’t have ADHD because part of the diagnosis is the fact that the symptoms of ADHD are evident in childhood. There are no “hidden” symptoms. You may have had, at most, subclinical problems that did not rise to the level of warranting a diagnosis. Half the population does.
DSM IV-TR required the symptoms to be evident by age 7. That is because the predominant group of children with ADHD have the Hyperactive/Impulsive form of the disorder. Those children are seen to have problems around age 4 when they attend preschool and can’t function in a typical preschool class. Some manage to get through pre-school OK if they attend a program with a curriculum that focuses on play, but they are diagnosed in kindergarten when they have to sit still at a desk, listen to instructions, raise their hand before speaking, and do written work that requires concentration.
The DSM 5 raised that criteria to “before age 12” because many clinicians noted that children with the Inattentive form of ADHD are not disruptive in class and seldom pose a behavior problem. They are quiet, spacy, disorganized, highly distractible and frequently off-task. They may function OK through elementary school with a lot of assistance from the parent and teacher, but then tend to fall apart around age 12 with the entry to middle school. They cannot make the adjustment to keeping up with homework in six classes, multi-part assignments, note taking and expectations to work independently for 30 to 45 minutes.
That said, ADHD might exist in a child but not be diagnosed, but that is because many parents, when confronted by the teacher with complaints about the child’s conduct in the classroom, dismiss it as “just being a boy” or “just something he’ll outgrow.” Fathers, especially, will say, “Maybe the class is too boring,” or “I was the same way as a child,” or “I don’t believe in psychiatry.”
ADHD is not “missed” in childhood any more than Intellectual Disability, Reading Disorder, or Autism are “missed” in childhood. If no one noticed you having symptoms of ADHD as a child, then you didn’t have them.
3. Functional Impairment. You do not have ADHD because you were/are not functionally impaired.
This is a term used throughout the DSM-5. It means that the ADHD symptoms you had as a child were so severe that you could not function within the normal range, or within the parameters of what would be expected based on your age, social class, parents level of education, peer group, etc. In fact, the requirement for the diagnosis is that the child/adolescent must have functional impairment in two areas i.e., school/home, or school/daycare center, or school/soccer field.
Think of the Bell Curve. Virtually all human traits, all human abilities, even abnormal behaviors fall along a range from “Very Low score” on the left tail of the curve to “Very High Score” on the far right tail of the curve. Most IQ scores, for example, cluster between 85 on the low end to 115 on the high end, making that mid-range, around 100, the peak of the Bell Curve. Scores below 70 are at the lowest 5 percentile on the Bell Curve and are in the category of Mild Intellectual Disability (Mild Mental Retardation).
In diagnosing ADHD, as in diagnosing other mental disorders, we generally are looking at a cutoff score on ADHD symptom checklists and questionnaires, that is above the 95th percentile (in the UK, the cutoff is around the 98th percentile). At that level, the child (and his classroom and his family) are clearly impacted. He is not completing work in class, is making failing grades. He is often being punished by the teacher for his impulsive, disruptive behavior. Other children don’t like to play with him because he is loud, rude, won’t follow the rules of the game, “doesn’t listen,” etc. The daycare center has warned the parents that he is on probation and is about to be asked to leave. Grandma won’t babysit him because he is “too much to handle.” The parents don’t like to take him out in public because he often has tantrums. That is functional impairment at or above the 95th percentile in two areas.
The fact that you were a B student in school, even though you thought you could have made A’s if you tried harder, is not functional impairment. It means you were a B student. The fact that you talked a lot in class means that you were very social. It does not qualify as functional impairment.
4. ADHD has a chronic course with most cases persisting into adulthood, negatively affecting a person’s ability to use their strengths and abilities to live successfully. You have had a successful life. You do not have ADHD.
There are children who were noted and diagnosed with ADHD in childhood who had mild symptoms — more likely the Inattentive subtype — who got good treatment with medication, had understanding and devoted parents, and an academic team who put together appropriate classroom accommodations, who, by the age of 16, not longer qualified for a diagnosis of ADHD. That’s a wonderful success story. Longitudinal research studies have found that around 2/3 of children with ADHD continue to have significant behavior problems into adolescence and adulthood.
Teens with ADHD are more likely to get involved in abusing drugs and illegal substances, to have unplanned pregnancies, to be arrested and face juvenile court charges. They are much more likely to drop out of high school. If they make it to college, they have a much higher rate of not finishing with a degree. They are more likely to work low-wage jobs. They show poor judgment in early adulthood — mismanaging money, getting into debt, quitting jobs impulsively. They are highly likely to have a pattern of driving infractions — speeding, not wearing a seatbelt, drinking and driving. They start projects and degree programs but seldom finish them. Others will say, “She just doesn’t think about the consequences,” or “He doesn’t seem to learn from experience what not to do.”
If you are and have been highly successful, you do not have ADHD, and probably never have had ADHD. People who write for this online magazine and say things like, “I had ADHD in high school, but despite that, I made straight A’s, went to college, and finished two degrees in five years. I now own my own successful business despite having ADHD…” are deluding themselves. Even among my peers, I have heard a fellow psychologist say, “My daughter is in graduate school at Yale, getting her Ph.D. in clinical psychology. She has ADHD.” That’s nuts. Where is the functional impairment?? A person getting a Ph.D. at Yale is at the upper 99th percentile in academic success.
These people do not have the life course of those people who really do have ADHD and struggle every day to manage their very problematic behavior. A majority of adults with ADHD experience depression, regret, and anger at themselves because they have failed so many times, because they have made dumb decisions, because they have pushed away people who tried to help them. We, as clinicians, treat them very seriously and offer expert help.
5. Response to stimulant medication. Responding positively to stimulants does not mean that you have ADHD.
Most ADHD medications are in the category called stimulants. Nicotine and caffeine are mild stimulants. Stimulants accelerate the brain’s speed and efficient processing of incoming information. Probably a majority of adult Americans drink coffee in the morning in order to be fully alert and ready for the workday. We don’t say that they are treating “CDD, caffeine deficit disorder.” Most experts have argued that all people perform better when on stimulants, not just those with ADHD. So, the fact that you performed better when taking these drugs is not diagnostic of ADHD.
Perfectly normal people who do not have ADHD want to take these stimulants as a performance enhancing drug, a quick solution to get more work done. Most medical and mental health providers see this use as inappropriate because the healthier course would be to improve focus and attention by getting 8 hours of sleep a night, eating three healthy meals a day, and engaging in regular exercise. They can improve their output by working in a quiet room with few distractions, turning off the cellphone and putting it in another room where it cannot be seen and thus checked every few minutes for notifications.
The fact that you pulled an all night-er and finished a 10 page term paper when you took your roommate’s ADHD medication, or read a book for an hour, or cleaned the entire apartment, does not mean that you have ADHD.
Elizabeth M. Ellis, Ph.D. private practice, since 1977. www.dr-elizabethellis.net. Author of: Raising A Responsible Child (Birchlane Press), Divorce Wars (Amer. Psych. Assn.), and Raising Your ADHD Child With Love, Laughter, and Neuroscience (forthcoming).
Continue reading...
For many months now, I have been reviewing numerous articles in the Mental Health Section of Medium that announce, “5 Hidden Signs That I Have ADHD” or something similar. (There are variations such as “5 Hidden Signs That I Have Autism” or “…That I Am Neurodiverse.”)
As an ADHD expert, I am interested in what these writers have to say. What I am finding is that these writers do not have ADHD. This is a fad, an online trend created by social media. I say this as a professional who has worked in this field since the 1970’s. Prior to the advent of social media, most Americans viewed mental illnesses as stigma, as something to be embarrassed about. With social media, people can go to a site and read about these disorders, open up about personal experiences and difficulties, share them with others, feel a sense of connection with and validation by their new online community, get sympathy and support. They belong to a “club.”
In an April post, I wrote about this phenomenon and listed some of the reasons people want to embrace diagnoses they don’t have. Right now, “neurodiverse” and “on the spectrum” are very popular, and “ADHD” to a lesser degree. These are seen as somehow desirable, or exotic, or labels that make someone feel special. After all, no one writes in with, “5 Hidden Reasons Why I Am Paranoid,” or “5 Hidden Reasons Why I Have a Shoe Fetis h.” Ugh. Those are not popular at all.
It is time that a clinical psychologist weighed in on this subject with science. This is will not get favorable reviews from those people that want to say they have ADHD. They will write disparaging comments, if they write anything. Whenever one takes away another person’s cherished assumptions, they are likely to get blowback. But someone must say, “The Emperor has no clothes.” One of my mentors, the late Dr. Scott Lillienfeld, at Emory University, my alma mater, made a career of challenging popular but wrong-headed notions in the field of psychology. These are important voices.
Here we go.
1. ADHD is a neurodevelopmental Disorder. You do not “get” ADHD past the age of 12.
There are 20 categories of mental disorders in the latest iteration of the Diagnostic and Statistical Manual-5 (5th edition, 2013) which is published by the American Psychiatric Association. The first category is called “Neurodevelopmental Disorders” because these diagnoses are caused by neurological dysfunction and are present from birth. Most children with ADHD have a family history of the same disorder in their parents or siblings, so we assume there is a genetic cause. The most recent research suggests that what is inherited is a flaw in a transporter gene that is associated with the neuro-transmitter, dopamine, and how it communicates with other connections in the frontal lobes. (In a small percentage of cases, the child has suffered some mild brain damage either in utero or in the birth process, and this appears to be the causative factor).
Because the child has inherited a gene for this disorder, the disorder must exist in childhood. One cannot not have ADHD as a child, then have ADHD as an adult. One cannot get ADHD as an adult because of an unfortunate event that happens, or because you are under stress. Let’s look at other disorders in this category.
Intellectual Disability. This is the new term for what everyone understands and what we used to call Mental Retardation (DSM-Iv-TR, 2000). Think about it for a moment. One cannot have a normal IQ as a child, make average grades in school, then suddenly at the age of 32 be diagnosed with Intellectual Disability. We all understand that that is illogical. It is usually noticed by age two or three when the child is six months to a year behind developmentally.
Specific Learning Disorder, with impairment in reading, otherwise known Reading Disability. One cannot read on grade level throughout childhood and high school, then, at 19, be diagnosed with Reading Disability. Reading Disorder is generally picked up around third grade when the child is two grade levels or more behind in reading skills and not suffering from Intellectual Disability. That seems obvious.
Autism Spectrum Disorder. As a clinician for 48 years who has worked closely with pediatricians evaluating children for ASD, I can say with authority that it is generally picked up around 18 months to two years of age when the child fails to develop normal social relatedness to others. One cannot be “normal” as a child, then “be on the spectrum” at age 27, for example. I will write more in a future article.
2. You don’t have ADHD because part of the diagnosis is the fact that the symptoms of ADHD are evident in childhood. There are no “hidden” symptoms. You may have had, at most, subclinical problems that did not rise to the level of warranting a diagnosis. Half the population does.
DSM IV-TR required the symptoms to be evident by age 7. That is because the predominant group of children with ADHD have the Hyperactive/Impulsive form of the disorder. Those children are seen to have problems around age 4 when they attend preschool and can’t function in a typical preschool class. Some manage to get through pre-school OK if they attend a program with a curriculum that focuses on play, but they are diagnosed in kindergarten when they have to sit still at a desk, listen to instructions, raise their hand before speaking, and do written work that requires concentration.
The DSM 5 raised that criteria to “before age 12” because many clinicians noted that children with the Inattentive form of ADHD are not disruptive in class and seldom pose a behavior problem. They are quiet, spacy, disorganized, highly distractible and frequently off-task. They may function OK through elementary school with a lot of assistance from the parent and teacher, but then tend to fall apart around age 12 with the entry to middle school. They cannot make the adjustment to keeping up with homework in six classes, multi-part assignments, note taking and expectations to work independently for 30 to 45 minutes.
That said, ADHD might exist in a child but not be diagnosed, but that is because many parents, when confronted by the teacher with complaints about the child’s conduct in the classroom, dismiss it as “just being a boy” or “just something he’ll outgrow.” Fathers, especially, will say, “Maybe the class is too boring,” or “I was the same way as a child,” or “I don’t believe in psychiatry.”
ADHD is not “missed” in childhood any more than Intellectual Disability, Reading Disorder, or Autism are “missed” in childhood. If no one noticed you having symptoms of ADHD as a child, then you didn’t have them.
3. Functional Impairment. You do not have ADHD because you were/are not functionally impaired.
This is a term used throughout the DSM-5. It means that the ADHD symptoms you had as a child were so severe that you could not function within the normal range, or within the parameters of what would be expected based on your age, social class, parents level of education, peer group, etc. In fact, the requirement for the diagnosis is that the child/adolescent must have functional impairment in two areas i.e., school/home, or school/daycare center, or school/soccer field.
Think of the Bell Curve. Virtually all human traits, all human abilities, even abnormal behaviors fall along a range from “Very Low score” on the left tail of the curve to “Very High Score” on the far right tail of the curve. Most IQ scores, for example, cluster between 85 on the low end to 115 on the high end, making that mid-range, around 100, the peak of the Bell Curve. Scores below 70 are at the lowest 5 percentile on the Bell Curve and are in the category of Mild Intellectual Disability (Mild Mental Retardation).
In diagnosing ADHD, as in diagnosing other mental disorders, we generally are looking at a cutoff score on ADHD symptom checklists and questionnaires, that is above the 95th percentile (in the UK, the cutoff is around the 98th percentile). At that level, the child (and his classroom and his family) are clearly impacted. He is not completing work in class, is making failing grades. He is often being punished by the teacher for his impulsive, disruptive behavior. Other children don’t like to play with him because he is loud, rude, won’t follow the rules of the game, “doesn’t listen,” etc. The daycare center has warned the parents that he is on probation and is about to be asked to leave. Grandma won’t babysit him because he is “too much to handle.” The parents don’t like to take him out in public because he often has tantrums. That is functional impairment at or above the 95th percentile in two areas.
The fact that you were a B student in school, even though you thought you could have made A’s if you tried harder, is not functional impairment. It means you were a B student. The fact that you talked a lot in class means that you were very social. It does not qualify as functional impairment.
4. ADHD has a chronic course with most cases persisting into adulthood, negatively affecting a person’s ability to use their strengths and abilities to live successfully. You have had a successful life. You do not have ADHD.
There are children who were noted and diagnosed with ADHD in childhood who had mild symptoms — more likely the Inattentive subtype — who got good treatment with medication, had understanding and devoted parents, and an academic team who put together appropriate classroom accommodations, who, by the age of 16, not longer qualified for a diagnosis of ADHD. That’s a wonderful success story. Longitudinal research studies have found that around 2/3 of children with ADHD continue to have significant behavior problems into adolescence and adulthood.
Teens with ADHD are more likely to get involved in abusing drugs and illegal substances, to have unplanned pregnancies, to be arrested and face juvenile court charges. They are much more likely to drop out of high school. If they make it to college, they have a much higher rate of not finishing with a degree. They are more likely to work low-wage jobs. They show poor judgment in early adulthood — mismanaging money, getting into debt, quitting jobs impulsively. They are highly likely to have a pattern of driving infractions — speeding, not wearing a seatbelt, drinking and driving. They start projects and degree programs but seldom finish them. Others will say, “She just doesn’t think about the consequences,” or “He doesn’t seem to learn from experience what not to do.”
If you are and have been highly successful, you do not have ADHD, and probably never have had ADHD. People who write for this online magazine and say things like, “I had ADHD in high school, but despite that, I made straight A’s, went to college, and finished two degrees in five years. I now own my own successful business despite having ADHD…” are deluding themselves. Even among my peers, I have heard a fellow psychologist say, “My daughter is in graduate school at Yale, getting her Ph.D. in clinical psychology. She has ADHD.” That’s nuts. Where is the functional impairment?? A person getting a Ph.D. at Yale is at the upper 99th percentile in academic success.
These people do not have the life course of those people who really do have ADHD and struggle every day to manage their very problematic behavior. A majority of adults with ADHD experience depression, regret, and anger at themselves because they have failed so many times, because they have made dumb decisions, because they have pushed away people who tried to help them. We, as clinicians, treat them very seriously and offer expert help.
5. Response to stimulant medication. Responding positively to stimulants does not mean that you have ADHD.
Most ADHD medications are in the category called stimulants. Nicotine and caffeine are mild stimulants. Stimulants accelerate the brain’s speed and efficient processing of incoming information. Probably a majority of adult Americans drink coffee in the morning in order to be fully alert and ready for the workday. We don’t say that they are treating “CDD, caffeine deficit disorder.” Most experts have argued that all people perform better when on stimulants, not just those with ADHD. So, the fact that you performed better when taking these drugs is not diagnostic of ADHD.
Perfectly normal people who do not have ADHD want to take these stimulants as a performance enhancing drug, a quick solution to get more work done. Most medical and mental health providers see this use as inappropriate because the healthier course would be to improve focus and attention by getting 8 hours of sleep a night, eating three healthy meals a day, and engaging in regular exercise. They can improve their output by working in a quiet room with few distractions, turning off the cellphone and putting it in another room where it cannot be seen and thus checked every few minutes for notifications.
The fact that you pulled an all night-er and finished a 10 page term paper when you took your roommate’s ADHD medication, or read a book for an hour, or cleaned the entire apartment, does not mean that you have ADHD.
Elizabeth M. Ellis, Ph.D. private practice, since 1977. www.dr-elizabethellis.net. Author of: Raising A Responsible Child (Birchlane Press), Divorce Wars (Amer. Psych. Assn.), and Raising Your ADHD Child With Love, Laughter, and Neuroscience (forthcoming).
Continue reading...
