ADHD Diagnosis Warrants Scrutiny

As professionals prepare for the new DSM-V, the Diagnostic and Statistical Manual of Mental Disorders, Dr. Winston Chung, a psychiatrist with Sutter Pacific Medical Foundation, appropriately labeled his concerns with the criteria for ADHD. ADHD is a disroder characterized by symptoms of inattention and hyperactivity. ADHD has been diagnosed when a person exhibits six of nine possible behaviors, but the DSM-V will reduce that to a threshhold of five. This presence of a package of behaviors may be enough to yield the diagnosis without consideration of the context of the behavior which may explain it and lead to a different approach than medication. The new standards will increase the probability of such a diagnosis and the likelihood of a prescription for stimulants where it could be avoided.

I worked with a case involving an eight-year-old boy who had been referred due to impulsive behavior in school. The referral indicated that he was never in his seat, never completed assignements, did not follow instructions and was generally disruptive in class. In order to fully understand the behavior, I requested to observe the class; I was very curious to see how the child's behavior could be as disruptive as described.

When I observed the class, I did notice that the child was out of their seat and not following directions as described, but I also saw that everyone in the class was behaving the same way. The students in this class were literally walking around the rooom, stepping over desks and generally using the classroom as a playground; it may have been a safety risk to be seated in the class. I was unsure of why they singled out this one child - perhaps they didn't.

In this case, which is admittedly an obvious one, the context of the behavior explained it more than a disorder, or at least made it difficult to diagnose under those conditions. Rather than pursue a medical intervention, the parents requested a change in classrooms and we worked to develop parenting skills to help them administer discipline at home and to coordinate with school.

As stated previously, this is an obvious example, but children's behavior is often maintained by elements of their ecology that include influences at school, parenting strategies, peer influence etc. It's important to understand the sequences of behavior and the contexts that maintain behavior in order to diagnose it well and treat is as safely and effectively as possible. This is increasingly important as the diagnostic criteria are weakened.