Where to begin?
Do I discuss the effects of recession and poverty on children’s psychological development? Do I speak of the dysfunction of the dopamine neurotransmitter system in the area of executive functioning? Do I address the ethics of using psychotropic medications in sometimes very young children? Do I entertain the topic of “the wired society” and its effects on attention? Do I turn the topic towards the child’s own perception of being diagnosed, as was done in Kaitlin Barnett’s recent book “Dosed”? What too of the achievement-oriented emphasis in some sectors, inadvertently encouraging students and adults to use stimulants outside the realm of ADHD – as performance enhancers for wakeful endurance at work or leisure, and even as part of a weight-loss regimen? Do I explore the possibility of secondary gain for ADHD diagnosis for children or adults? Do I try to decipher genetic manifestations behind some of the increases? Do I emphasize the variations in diagnosis relative to U.S. geographic region? Do I speak about pharmaceutical profit? Do I expound upon the negative changes in schools and society, which frequently are less accepting of individuality? Or do I simply grasp onto misdiagnosis in the gifted?
Perhaps beginning at the early days of our crisis may place light upon the long road left to walk.
Last year, when the CDC reported ADHD in nearly one in ten U.S. children (5.4 million), we became concerned. High-risk groups included boys, African-Americans, and foster children. Another study group this year suggested ADHD is seen in 10.4 million U.S. children (a rise of 66% in one decade).
Since the DSM-IV first was released in 1994, people began to question ADHD diagnosis and treatment. The Hoover Institute in 1999 and PBS’s Frontline in 2001 both spoke to the lack of precision in understanding ADHD. The chairman of the DSM-IV recently spoke out to the mistakes made at that time in trying too hard to serve as a safety net to prevent under-diagnosis.
Symptoms suggestive of ADHD may be a result of many other etiologies. Anxiety, depression, abuse & neglect at home or school, family stressors, side effects of allergy medications, high caffeine use, the use of legal and illegal drugs, exposure to toxins, and chronic lack of sleep or nutrition can all appear similar to ADHD. Immaturity, whether by chronological age, developmental variability, or lack of guidance, can look like ADHD. Unidentified learning disabilities, and specific neurological and medical disorders that are not controlled, can suggest ADHD. Hearing loss, seen now in 1 in 5 children, may also mimic ADHD. Family history or gender alone may influence diagnosis. Yet children with any of these other conditions can also have ADHD, and the combination of two of more conditions makes diagnostic accuracy even more difficult.
Gifted children are misdiagnosed with ADHD, yet some also have ADHD, and any of the just mentioned diagnoses. If educational (and social/emotional) needs are not met, giftedness alone may look very similar to ADHD. For gifted children who do have ADHD, the child’s intellect may over-compensate for the ADHD, thus sometimes masking ADHD for many years until a limit is reached where problems occur. This is particularly true of gifted girls. ADHD and giftedness can also entirely mask each other, making both invisible. In this situation, the child’s giftedness is not supported, nor is the child’s ADHD properly diagnosed. Minorities, the poor and boys are often least recognized as gifted, and boys in particular are most commonly misdiagnosed with ADHD.
Thus far, the recent American Academy of Pediatrics guideline on ADHD and the proposed 2013 DSM-V ADHD criteria are silent on giftedness. The DSM-IV only briefly mentioned giftedness in the text revision of 2000 (DSM-IV-TR) by saying “Inattention in the classroom may also occur when children with high intelligence are placed in academically understimulating environments.” Nothing was said of the intrinsic traits of giftedness of which parents are only too aware. Giftedness has never been a topic routinely addressed in medical training.
Today we know a little bit more about ADHD, and fMRI’s are beginning to define variations in appearance and rates of cortical development. We also see suggestions hinting at differences between the impulsiveness that leads to substance abuse, and a separate impulsiveness associated with ADHD. An article last month by Dr. Damien Fair further reports that there exists wide variability in the presentation of ADHD, a heterogeneity that strongly implores the need to individualize ADHD diagnosis and treatment. For all of our children, and in our quest to decrease misdiagnosis, this news may be the best we’ve heard thus far.
Meanwhile what can parents do to determine if their gifted child has ADHD or not? A few links and book suggestions are shown at the end of this article. If seeking an evaluation, it is important to locate an expert in both giftedness and ADHD, and barring that at least locate someone who is supportive of giftedness and thus will consider giftedness as an essential part of the whole child. Please realize that there are only 8000 child psychiatrists in the U.S., and 600 developmental behavioral pediatricians, though more child psychologists. Much responsibility ultimately falls upon the primary care practitioners, at a time of severe limitation in both time and training. Much falls too upon parents.
The more thought I put into defining the issues surrounding ADHD, the more questions I uncover, and the more I agree with Dr. Allen Francis, chairman of the DSM-IV, who so succinctly said, “This is a societal issue that transcends psychiatry”.
One thing is for certain…it is imperative that ADHD remain a diagnosis of exclusion.
Be sure to catch the previous posts in this series:
Part 2: “Autism, Giftedness – and Human Diversity“
1. Bright, Not Broken: Gifted Kids, ADHD, and Autism by Diane M. Kennedy, Rebecca S. Banks, and Temple Grandin
2. Different Minds by Deirdre V. Lovecky
3. Dosed: The Medication Generation Grows Up by Kaitlin Bell Barnett
4. Living With Intensity: Understanding the Sensitivity, Excitability, and the Emotional Development of Gifted Children, Adolescents, and Adults by Susan Daniels, Ph.D. and Michael M. Piechowski, Ph.D.
5. Misdiagnosis and Dual Diagnoses of Gifted Children and Adults ADHD, Bipolar, OCD, Asperger’s, Depression, and Other Disorders by James T. Webb, Edward R. Amend, Nadia E. Webb, Jean Goerss, Paul Beljan, and F. Richard Olenchak
6. The Mislabeled Child: Looking Beyond Behavior to Find the True Sources and Solutions for Children’s Learning Challenges by Brock & Fernette Eide
7. Uniquely Gifted: Identifying and Meeting the Needs of the Twice-Exceptional Student by Kay Kiesa