Hyperactive Prescribing? Ctd

A clinical psychologist writes:

I work primarily with children and families and I am routinely asked to do ADHD evaluations. Typically big crowds show up in October, after those first parent-teacher conferences, and again in April, as the year winds down and parents panic about their kids’ grades. I have three major points to make:

I. ADHD is absolutely over-diagnosed. There are two populations where this happens:

(1) Non-upper-class boys (and a few girls) who display disruptive or aggressive behavior, whose schools go diagnosis-shopping so the kid can be chemically restrained with stimulant drugs. In most cases, the behavior is totally operant: The kid has learned that if he curses, threatens, hits, dances on the furniture, etc., he will be sent out of the classroom and/or out of the school. Mission accomplished! And then people have the balls to tell me that “discipline doesn’t work.” Well, no shit. If you consistently reward a behavior, you get more of it.

2) Upper-class children whose parents go diagnosis-shopping so their kids can get extra services, supports, and stimulant medication to help them study.

II. ADHD is absolutely under-diagnosed. There are two populations where this happens:

1) Girls (and a few boys) who are merely distractible, not hyperactive or impulsive, so they’re not behavior problems. Your daydreamers. Your space cadets. Your absent-minded professors. These kids get called lazy. Unmotivated. Disorganized. Won’t do her homework. Makes simple mistakes; she should know better! She knows what to do, she just doesn’t do it! These kids develop a very negative self-image because they get a lot of negative feedback from their environment. They wind up depressed. I have seen one kid become suicidal because he truly believed he was stupid and would never achieve anything meaningful in life. (The under-diagnosis is more likely when the kid is intelligent and does well on standardized tests. Jimmy is so intelligent, but…)

2) Adults who are older than about 30 and were missed as kids. They (we) grew up before the great over-diagnosis wave, or grew up outside of the urban areas where it was more common. These people tend not to have achieved everything they could have. They tend to have problems in their working life because they forget things, miss details, make simple errors that most people just wouldn’t make. Quite a few develop hobbies or great big life projects that never quite coalesce. Most develop some neat tricks to compensate for their problems with attention, memory, and task completion. Some really believe, after a lifetime of negative feedback from their environment, they are stupid and underachieving. Depression and low self-esteem is fairly common in this group. A few develop anxiety problems because they’re terrified of the constant mistakes they make at work.

III. Your reader who’s a counseling psychology student is full of shit. ADHD and other learning disabilities show up when they show up, when the kid’s compensatory abilities intersect with an environment that’s too demanding for them. That can happen in childhood or it can happen later. The big points where it shows up, in my experience, are in about fourth grade, in the transition to middle or high school, or once in a while in college or beyond.

Another adds, “The fact that a third-year graduate student in psychology can say this is terrifying”:

While I agree that medicating kids who don’t have ADD is a problem, under-diagnosis is as well. I’m a 34-year-old man with ADD (the inattentive form). I was only diagnosed with it 18 months ago, and the first day I took medication was a revelation. I felt more alert and less foggy than I ever had before; the continual slush and confusion that sapped my brain on a daily basis was gone.

Why did it take until 32 for me to be diagnosed? Three of the big warning signs for ADD – bad grades in school, trouble holding down a job, and more car accidents – never showed up. The inattentive variety wasn’t well known – Driven to Distraction didn’t even come out until my freshman year in high school. ADD people thrive on structure, so if you’re someone who enjoys school and works hard, it’s possible for you to do well despite ADD. I was a creative person, too (still am) so the ADD behaviors I did have just got written off as spaciness.

Unfortunately, as my struggles with my creative work increased, my combined ADD and depression drove me to suicidal thinking, which so alarmed my therapist that she sent me to a talented and sympathetic psychiatrist who, after digging into my life, diagnosed me. (A key “tell” for him: while I like to read, I can’t get through two pages of a book without my brain veering off into some related fantasy.) I am not exaggerating when I say that without this diagnosis and treatment for the disorder, I could be dead.

Another identifies himself as “one of those ‘privileged’ students your psychological doctoral student scoffed at”:

I was diagnosed with ADHD after failing to get my master’s degree for six years. My entire life has been hampered by this problem that no one thought I had because I didn’t fit the typical hyperactive behavior profile. I think back to the times when I was playing outfield, trying desperately to pay attention through an inning and failing. About how I couldn’t excel at a simple manual labor job because I’d “zone out” and slow down. And how I got good (but not great) grades, but it took me about twice as long to finish my assignments as other people.

After my diagnosis and a prescription of amphetamine, my life fell into place. I started taking and excelling in advanced mathematics courses I’d been dreaming about for half a decade. Jesus, it even helped my fucking social issues. It was probably the most content I had ever been in my life.

But then my doctor left, and a new one took over. He decided I was not ADHD, but was in fact one of those people “gaming the system,” as your psychology student described it. Thus my diagnosis was rescinded. I have never been more furious in my life than when I was sitting in his office, realizing that he didn’t give a shit what I said; he’d already decided I was a fraud, and the appointment amounted to Kabuki theatre.

The fallout was pretty epic. I could barely keep up with my next semester’s workload, and to this day (over a year later) I’m not functioning at the level I was before stimulants. I lost my research position due to inability to work. Now I have no funding, even without taking courses or working I cannot make inroads with my thesis, and I’m realizing that without stimulants I will never excel in my chosen career of engineering. Since this is the United States, I can’t afford to see doctors independent of the university system, so I live in a state of perpetual impasse: my choice is to either be effectively owned by the psychiatric system for the rest of my life, or walk away from the career I’ve been building for most of my life. I have no money, no job, no future, and no hope.

Previous Dish on ADHD herehere, and here.