No, it is not ADHD! Why and How?
“10 Hidden Signs That I Have ADHD” or something similar.
(There are variations such as “7 Hidden Signs That I Have Autism” or “…That I Am Neurodiverse.”)
These writers do not have ADHD. This is a fad, an online trend created by social media. As a professional who has worked in this field for a long time. Prior to the advent of social media, most people viewed mental illnesses as a stigma, as something to be embarrassed about. With social media, people can visit a site and read about these disorders, open up about personal experiences and difficulties, share them with others, feel a sense of connection and validation from their new online community, and receive sympathy and support. They belong to a “club.”
It is time that a clinical psychologist weighed in on this subject with science. This will not get favorable reviews from those people who want to say they have ADHD. They will write disparaging comments if they write anything.
Whenever you take away another person’s cherished assumptions, you are likely to get blowback. But someone must say, “The Emperor has no clothes.” One of my mentors, the late Dr. Scott Lillienfeld at Emory University, my alma mater, made a career of challenging popular but misguided notions in psychology. These are important voices.
Here we go.
1. ADHD is a neurodevelopmental Disorder.
You do not “get” ADHD past the age of 12.
There are 20 categories of mental disorders in the latest iteration of the Diagnostic and Statistical Manual-5 (5th edition, 2013), which is published by the American Psychiatric Association. The first category is called “Neurodevelopmental Disorders” because these diagnoses are caused by neurological dysfunction and are present from birth.
Most children with ADHD have a family history of the same disorder in their parents or siblings, so we assume there is a genetic cause.
The most recent research suggests that what is inherited is a flaw in a transporter gene that is associated with the neurotransmitter dopamine and how it communicates with other connections in the frontal lobes.
(In a small percentage of cases, the child has suffered some mild brain damage either in utero or in the birth process, and this appears to be the causative factor).
Because the child has inherited a gene for this disorder, the disorder must exist in childhood. One cannot have ADHD as a child, then have ADHD as an adult. One cannot get ADHD as an adult because of an unfortunate event that happens, or because you are under stress. Let’s look at other disorders in this category.
Intellectual Disability. This is the new term for what everyone understands and what we used to call Mental Retardation (DSM-IV-TR, 2000). Think about it for a moment. One cannot have a normal IQ as a child, make average grades in school, then suddenly at the age of 32 be diagnosed with Intellectual Disability. We all understand that that is illogical. It is usually noticed by age two or three when the child is six months to a year behind developmentally.
Specific Learning Disorder, with impairment in reading, otherwise known as Reading Disability. One cannot read on grade level throughout childhood and high school, then be diagnosed with Reading Disability at 19. Reading Disorder is generally identified around third grade, when the child is two grade levels or more behind in reading skills and does not have Intellectual Disability. That seems obvious.
Autism Spectrum Disorder. As a clinician for 48 years who has worked closely with pediatricians evaluating children for ASD, I can say with authority that it is generally picked up around 18 months to two years of age when the child fails to develop normal social relatedness to others. One cannot be “normal” as a child and then “be on the spectrum” at age 27, for example.
2. You don’t have ADHD because part of the diagnosis is the fact that the symptoms of ADHD are evident in childhood.
There are no “hidden” symptoms. You may have had, at most, subclinical problems that did not rise to the level of warranting a diagnosis. Half the population does.
DSM IV-TR required the symptoms to be evident by age 7. That is because the predominant group of children with ADHD has the Hyperactive/Impulsive form of the disorder. Those children often show problems around age 4 when they attend preschool and can’t function in a typical preschool class. Some manage to get through preschool OK if they attend a program with a play-based curriculum, but they are diagnosed in kindergarten when they have to sit still at a desk, listen to instructions, raise their hand before speaking, and do written work that requires concentration.
The DSM 5 raised that criterion to “before age 12” because many clinicians noted that children with the Inattentive form of ADHD are not disruptive in class and seldom pose a behavior problem. They are quiet, spacey, disorganized, highly distractible, and frequently off-task.
They may function OK through elementary school with a lot of assistance from the parent and teacher, but then tend to fall apart around age 12 with the entry to middle school. They cannot adjust to keeping up with homework in six classes, multi-part assignments, note-taking, and expectations to work independently for 30 to 45 minutes.
That said, ADHD might exist in a child but not be diagnosed, but that is because many parents, when confronted by the teacher with complaints about the child’s conduct in the classroom, dismiss it as “just being a boy” or “just something he’ll outgrow.”
Fathers, especially, will say, “Maybe the class is too boring,” or “I was the same way as a child,” or “I don’t believe in psychiatry.”
ADHD is not “missed” in childhood any more than Intellectual Disability, Reading Disorder, or Autism are “missed” in childhood. If no one noticed you having symptoms of ADHD as a child, then you didn’t have them.
3. Functional Impairment.
You do not have ADHD because you were/are not functionally impaired.
The DSM-5 uses this term throughout. It means that the ADHD symptoms you had as a child were so severe that you could not function within the normal range, or within the parameters of what would be expected based on your age, social class, parents’ level of education, peer group, etc.
In fact, the requirement for the diagnosis is that the child/adolescent must have functional impairment in two areas, i.e., school/home, or school/daycare center, or school/soccer field.
Think of the Bell Curve. Virtually all human traits and abilities, even abnormal behaviors, fall along a range from “Very Low score” on the left tail of the curve to “Very High Score” on the far right tail of the curve. Most IQ scores, for example, cluster between 85 on the low end and 115 on the high end, making the mid-range around 100 the peak of the Bell Curve. Scores below 70 are at the lowest 5th percentile on the Bell Curve and are in the category of Mild Intellectual Disability (Mild Mental Retardation).
In diagnosing ADHD, as with other mental disorders, we generally look at a cutoff score on ADHD symptom checklists and questionnaires above the 95th percentile (in the UK, the cutoff is around the 98th percentile). At that level, the child (and his classroom and his family) are clearly impacted. He is not completing classwork and is earning failing grades. The teacher often punishes him for his impulsive, disruptive behavior. Other children don’t like to play with him because he is loud, rude, won’t follow the rules of the game, “doesn’t listen,” etc. The daycare center has warned the parents that he is on probation and may be asked to leave. Grandma won’t babysit him because he is “too much to handle.” The parents don’t like to take him out in public because he often has tantrums. That is functional impairment at or above the 95th percentile in two areas.
Being a B student in school, even though you thought you could have made A’s if you tried harder, is not functional impairment. It means you were a B student. Talking a lot in class means you were very social. It does not qualify as functional impairment.
4. ADHD has a chronic course with most cases persisting into adulthood, negatively affecting a person’s ability to use their strengths and abilities to live successfully.
You have had a successful life. You do not have ADHD.
There are children who were noted and diagnosed with ADHD in childhood who had mild symptoms — more likely the Inattentive subtype — who got good treatment with medication, had understanding and devoted parents, and an academic team who put together appropriate classroom accommodations, who, by the age of 16, no longer qualified for a diagnosis of ADHD.
That’s a wonderful success story. Longitudinal research studies have found that around 2/3 of children with ADHD continue to have significant behavior problems into adolescence and adulthood.
Teens with ADHD are more likely to get involved in abusing drugs and illegal substances, to have unplanned pregnancies, to be arrested and face juvenile court charges. They are much more likely to drop out of high school. If they make it to college, they are much less likely to finish with a degree. They are more likely to work low-wage jobs. They show poor judgment in early adulthood — mismanaging money, getting into debt, quitting jobs impulsively. They are highly likely to have a pattern of driving infractions — speeding, not wearing a seatbelt, drinking and driving. They start projects and degree programs but seldom finish them. Others will say, “She just doesn’t think about the consequences,” or “He doesn’t seem to learn from experience what not to do.”
If you are and have been highly successful, you do not have ADHD, and probably never have had ADHD. People who write for this online magazine and say things like, “I had ADHD in high school, but despite that, I made straight A’s, went to college, and finished two degrees in five years. I now own my own successful business despite having ADHD…” are deluding themselves. Even among my peers, I have heard a fellow psychologist say, “My daughter is in graduate school at Yale, getting her Ph.D. in clinical psychology. She has ADHD.” That’s nuts. Where is the functional impairment?? A person earning a Ph.D. at Yale is in the upper 99th percentile for academic success.
These people do not have the life course of those people who really do have ADHD and struggle every day to manage their very problematic behavior. A majority of adults with ADHD experience depression, regret, and anger at themselves because they have failed so many times, because they have made dumb decisions, because they have pushed away people who tried to help them. As clinicians, we take them seriously and offer expert help.
5. Response to stimulant medication.
Responding positively to stimulants does not mean that you have ADHD.
Most ADHD medications are in the category called stimulants.
Nicotine and caffeine are mild stimulants. Stimulants speed up the brain’s processing of incoming information.
Most adults probably drink coffee in the morning to be fully alert and ready for the workday. We don’t say that they are treating “CDD, caffeine deficit disorder.” Most experts have argued that all people perform better when on stimulants, not just those with ADHD. So, the fact that you performed better when taking these drugs is not diagnostic of ADHD.
Perfectly normal people who do not have ADHD want to take these stimulants as a performance-enhancing drug, a quick solution to get more work done.
Most medical and mental health providers see this use as inappropriate because a healthier approach is to improve focus and attention by getting 8 hours of sleep a night, eating three healthy meals a day, and exercising regularly.
They can improve their output by working in a quiet room with few distractions, turning off their cellphone, and putting it in another room where it cannot be seen or checked every few minutes for notifications.
The fact that you pulled an all-nighter and finished a 10-page term paper when you took your roommate’s ADHD medication, or read a book for an hour, or cleaned the entire apartment, does not mean that you have ADHD.
Dr. Adel Serag
