Innocent Dangers: Simply Asking the Questions
“Has your child been evaluated for ADHD?”
Many variations of this seemingly innocent question often serve as the beginning of a dangerous progression. Quite often, teachers, childcare workers, and even physicians untrained in understanding and diagnosing Attention Deficit Hyperactivity Disorder (ADHD) ask this question to parents. However, frequently this question serves as more than medium to obtain information from parents, even if that is the intent of the question.
As a clinical psychologist, I have worked with children in group home settings, hospital settings, and private practice. Many children and young adults I worked with said they had been diagnosed with ADHD and placed on medication for it. Early in my career, I generally assumed that they had been evaluated by a mental health professional if they said that they had a disorder and were placed on medication. As I listened to more and more treatment histories of these individuals, I began to realize this frequently was not the case. I learned the importance of asking very specific questions about their histories:
“Who first diagnosed you or suggested the diagnosis?”
“Was the diagnosis made by a mental health professional? (If yes) What were the person’s credentials?”
“Who prescribed the medications? Was it a psychiatrist or a general practitioner?”
“Have you ever had a second opinion about the diagnosis?
Most frequently, the journey to being prescribed medication for ADHD began with a teacher or another individual with no training or qualifications to make a diagnosis of ADHD. Furthermore, it was quite common that the path from the original suggestion for an evaluation to the end result of medication never included a visit to a mental health professional. While the teacher or childcare worker may not have technically made the diagnosis, their impact on the process—even if unintentional—essentially served the role of causing the diagnosis.
While it would be easily to vilify this process, I do not want to do that. Rather, I would like to highlight the many systemic problems that make it easy for people with good intentions to contribute to a cycle of over-diagnosing and overmedicating our children.
For teachers and childcare workers, they often are working with a large number of children with fewer and fewer resources. They are under pressure from the school to meet certain standards. Parents are often rather intolerant of their children’s peers when they cause disruptions and respond by placing more pressure on teachers to keep things under control. To complicate matters, teachers remain poorly paid and under resourced while given increasing roles, responsibilities, and expectations. It is not easy to be a teacher.
The educational and mental health systems are failing teachers and children as well. Teachers are not being provided with adequate resources and training to address the issues children and teenagers are facing. Many factors such as poor diet (often resulting from poverty), overuse of technology and television, and family problems can contribute to behaviors that give the appearance of ADHD symptoms. Furthermore, these difficulties, even when assembled in a manner that fits the criteria of ADHD according to the DSM-5, are often treatable by approaches other than medication.
Yet, teachers and childcare workers are not provided with the more balanced perspective regarding ADHD. In the meantime, they are flooded with materials steeped in the bias of the medical model and advocating for medication as one of the first options for working with attention or behavior problems in children.
Let me conclude this section by returning to the “innocent” aspect of the question. I believe most teachers and childcare workers who ask, “Has your child ever been evaluated for ADHD?” are asking this question with good intentions. They want to maintain a classroom where they are able to focus on their primary responsibility: teaching children. Furthermore, they are not necessarily suggesting that the child be placed on medication. Yet, too often, parents will interpret the suggestion of an evaluation as a suggestion that their child has ADHD. Too often, teachers may not recognize the power or implications of a seemingly innocent question.
There are teachers and childcare workers who do make the suggestions of a diagnosis or encourage parents to consider medication. When this occurs, it is not so innocent, but rather acting in an unprofessional manner by making recommendations outside of one’s expertise. This requires a stronger response. However, I believe this is more the exception than the norm.
DSM-5 and the Perfect Storm
The overuse of medication in the treatment of childhood difficulties has already risen to a level that is terrifying and likely to have a significant long-term impact upon our country. Despite an increasing amount of concern being voiced about the over-diagnosis of ADHD and overmedication of children, the pattern continues.
The DSM-5 has now lowered the diagnostic threshold for diagnosing children with ADHD. The stated reason for this is that it will increase access to treatment. While this may be true in a few cases, it is much more likely to more dramatically increase the number of children taking medication when this is not the best option.
Many parents are not given and have trouble accessing and understanding resources to help them become responsible, informed consumers of mental health services and products. These resources need to be readily available, balanced, and written in an accessible language.
Furthermore, the teachers and childcare workers who are viewed by many parents as important sources of information about their children’s well-being are not adequately trained and prepared relevant to these issues. Individuals who work with children and parents, and who provide advice to parents, need to be trained regarding the limits of their competency, the potential impact and implications of their seemingly innocent questions or comments, and how to respond to parents in a way that encourages them to seek out balanced, accessible information about their child’s behavior, health, and mental health.
Children are entering into a complex, quickly changing world that is hard for children and their parents to comprehend. In this complex cultural system, many terrifying trends are emerging. Many in existential and humanistic psychology are providing strong leadership in promoting greater awareness about these complex issues. It is important that we do not create unnecessary divide in our response. While certainly there are many who are acting in an irresponsible, and at times, reprehensible manner, there are many who are contributing to the problem without an awareness of the issues or any bad intentions. Providing resources and education to these individuals, especially when they are in roles that influence people making decisions about the lives of children, is an essential component of how we need to be responding to these issues.
-- Louis Hoffman