ADHD and Boys

The American Psychiatric Association states in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) that 3%-7% of school-aged children have ADHD. However, studies have estimated higher rates in community samples. In fact according to surveys of parents 13.2% of boys have been diagnosed with ADD or ADHD. In the same survey, 5.6% of girls have ever been diagnosed with ADD or ADHD. This survey's statistics states that 9.5% of school aged children (4-17) have been - at one time - diagnosed with ADD or ADHD. This is 2.5% higher than the high end of the American Psychiatric Association's estimate.

The real question that arises from these statistics is, are school aged children being "misdiagnosed" as having a "disorder"? If this is true, then it is certainly likely that boys are being misdiagnosed at a much higher rate. According to the CDC, children that are diagnosed with ADD or ADHD report three times more problems with peers than those who are not diagnosed and they are almost ten times as likely to have problems with relationships.

I suppose this makes me wonder if some of the problems associated with ADHD come from the label of such a diagnosis. Anyone who works with children understands that peer to peer and teacher to student relationships are extremely important in the development of that child. In addition these relationships are fragile and can change rather quickly. Would a student who has been "diagnosed" as having a disorder, be more likely to have difficulties with relationships simply because of his or her diagnosis as opposed to the actual "Disorder"? I believe that such a diagnosis may affect a student's sense of self and therefore affect the way that student relates with others.

According the CDC, "Using a prevalence rate of 5%, the annual societal ‘‘cost of illness’’ for ADHD is estimated to be between $36 and $52 billion, in 2005 dollars. It is estimated to be between $12,005 and $17,458 annually per individual". So even with a low estimate, there is quite a bit of money to be made with each diagnosis of ADHD, therefore it is benificial to doctors and corporations to liberally diagnosis this disorder. So why are boys more than twice as likely to recieve such a diagnosis? Is it because 13.2% are born with a "Disorder"? Or does it come from school's and society's expectations of what is "normal"?

To understand this we must first look at the criteria set our by the DSM-IV for diagnosis of ADHD:

DSM-IV Criteria for ADHD
I. Either A or B:

A.Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1.Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2.Often has trouble keeping attention on tasks or play activities.

3.Often does not seem to listen when spoken to directly.

4.Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5.Often has trouble organizing activities.

6.Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7.Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8.Is often easily distracted.

9.Is often forgetful in daily activities.

B.Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1.Often fidgets with hands or feet or squirms in seat.

2.Often gets up from seat when remaining in seat is expected.

3.Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4.Often has trouble playing or enjoying leisure activities quietly.

5.Is often "on the go" or often acts as if "driven by a motor".

6.Often talks excessively.

Impulsivity

1.Often blurts out answers before questions have been finished.

2.Often has trouble waiting one's turn.

3.Often interrupts or intrudes on others (e.g., butts into conversations or games).

II.Some symptoms that cause impairment were present before age 7 years.

III.Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV.There must be clear evidence of significant impairment in social, school, or work functioning.

V.The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1.ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

2.ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months

3.ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.


It is easy for me to look at this list of criteria and see the ambiguous nature of it. It seems to me that many of these "criteria" could be exhibited by any student from time to time and how each criteria may be noticed more or less depending on the personality and tolerance level of the teacher observing the behavior. As a teacher of boys, I often find a sheet with the statements made above and student's name on it in my mailbox. I am asked to check the following {never}, {almost never}, {sometimes), {often}, or {almost always}. It is usually associated with a student who has run into problems at school, often times associated with classroom behavior or "acting out". This student would more than likely have been recently asked to leave a class because of disruptive behavior, and now the teacher who he has disturbed is asked for input to help discern if this student has a disorder. This does not seem to be a very scientific manner in which to diagnose a student.

I believe that when my students start to fidget and act out, that the first person to look at is not the student but me and how prepared I am. I believe that often students begin to fidget and act out as a way to "stay awake" or maintian focus during the tedious hum drum of school. I believe that boys tend to be more agressive in the manner in which they express themselves and when they feel a teacher is not prepared or that someone is wasting their time, they will get antsy and "act out" in an act of defiance. This may be rooted more in a student's sense of anger or helplessness than in some sort of disorder that requires drugs. Maybe the DSMIV should have as one of the criteria "Student attends a class with an underprepared teacher" or "Student is enrolled in an inadequate and unjust education system"