ADHD: Diagnosis Dilemma

You're distracted at work, behind the wheel, at dinner with your spouse. You can't remember what someone said just minutes after speaking to them. When you see one of those drug ads on TV, you think, "Hey, that's me! I lose my keys all the time."

It seems like half of the working world is wondering whether they have attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD). Word is out that it doesn't affect just kids: Experts say attention deficit also strikes an estimated 4 to 8 percent of adults, many of whom had it as children but were never diagnosed.

Now overstimulated, overscheduled grown-ups are flocking to doctors in hopes that a pill can cure a scattered brain. But unlike the fairly clear-cut symptoms of depression and schizophrenia, symptoms of ADHD are considerably fuzzier. A diagnosis is in large part a doctor's subjective interpretation. (Characteristic patterns have been detected in brain scans of ADHD patients, but few doctors use them in diagnosis.)

ADHD may manifest in a variety of ways: restlessness and distraction, short-term memory impairment, blurting out inappropriate thoughts, difficulty organizing activities, failing to follow through on a project or finish one's work. In short, all behaviors that are part of being human in the modern world. Perhaps that's why a recent Kaiser Family Foundation poll found 20 percent of Americans believe ADHD is a bogus disease.

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So when does normal behavior cross the line? For clinicians, the buzzword is impairment: The symptoms are so severe that a person is failing in some part of life. Among experts, however, there is strong disagreement over what the standard of comparison for impairment should be. Should a distracted lawyer be compared with others who have similar cognitive abilities? Or should a lawyer be compared to a grocery store clerk or a bus driver—whose job doesn't require the same intellectual focus?

Some researchers say there is a danger of creating different standards for various strata of society.

Already, there's evidence that a diagnosis of attention deficit depends largely on socioeconomic status and access to mental health care. Of adults who are diagnosed with ADHD, 73 percent are white, while only 15 percent are Hispanic and 6 percent are black. "ADHD is now a boutique diagnosis for middle-class people," says Ronald Kessler, a professor of health care policy at Harvard Medical School. Among professionals, "the attitude is, 'if I have a concentration problem and it affects my job, and this is an illness I can fix, then I want to fix it,'" he says.

Russell Barkley, a professor of psychiatry at the Medical University of South Carolina in Charleston, advocates more restraint in diagnosing and medicating ADHD. He argues that too many people believe intelligence should equal success, when it is merely a benchmark of one's cognitive ability. "It's not an indicator of how well your job or your family relationships should be going," he says.

The point of comparison, Barkley says, should be what is normal for an average, healthy adult. People who truly have ADHD often have segments of their life, such as work, finances or parenting responsibilities, that are a complete disaster. "Unless you can show me that you're functioning below normal—not simply below your level of intellect—you don't have a disorder," he says.

Thomas Brown, associate director of the Yale Clinic for Attention and Related Disorders in Connecticut and professor of psychiatry, says it would be wrong to withhold medication from a person who is high functioning, but still struggling. One of Brown's patients is a young man who scored a 1.37 grade point average in his first semester at Duke University, despite scoring near 1400 on the SATs. "He wasn't partying," says Brown. "He just couldn't get organized. He couldn't remember what he'd read." Brown diagnosed ADHD around Christmas time, prescribed a stimulant and in the spring semester the student's GPA shot up to 3.74.

One could make the argument that if a student can't keep up at a top college, he shouldn't be there in the first place, says Brown. "But why not treat them?" he asks. "Are we only going to provide glasses to people who are practically blind?"

In the meantime, more Americans are visiting their doctors for a screening, which is a good thing, says Kessler. His studies show that only a small fraction of ADHD sufferers are being treated. Moreover, an increase in ADHD screenings is almost certain to turn up other serious disorders: About a third of people with ADHD abuse drugs, and another third will suffer depression. Anxiety disorders are common with ADHD, while over half of people with ADHD of all ages have a major learning disability. Says Kessler: "I've had people come in thinking that they have ADHD, but actually they had a whopping huge depression."

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