The Paradox of ADHD

“Public debate over the appropriateness of attention-deficit/hyperactivity disorder (ADHD) diagnosis has grown along with diagnosis rates.” So begins a review article published in JAMA Network Open in 2021.¹ The review authors are not the first to note that steadily increasing rates of ADHD diagnoses have been accompanied by growing public debate and skepticism. Medical professionals and social scientists have long worried that public dissension might discourage people from seeking medical help. Controversy, they reason, will scare parents away.

But has the disputed status of ADHD and medication treatment in the media and among the general public slowed the growth of diagnoses and accompanying prescriptions of stimulants drugs?

The JAMA review provides a long list of studies that document continuously increasing ADHD diagnoses, rising rates of pharmacological treatment of ADHD, and findings that these additional cases are on the “milder end of the ADHD spectrum.” A study published in 2018, for instance, found that in 2016, 10.2 percent of children and adolescents aged 4 to 17 years (14 percent of boys and 6.3 percent of girls) had received an ADHD diagnosis.² In 1997, 20 years earlier, the figure was 6.1 percent. The continuous increase across the years involved millions of young people, the majority of whom would take medication. Between 2007 and 2011 alone, according to another study, the rate of children medicated for ADHD increased by 28 percent.³

These statistics imply a widespread and eager openness to ADHD and medication treatment. Yet both diagnosis and drugs have long been a subject of controversy. In a study published in 2007, researchers, for example, found that a large majority of respondents (86 percent) agreed that doctors are overmedicating children with behavioral problems, two-thirds agreed that medications have long-term negative developmental impacts and delay solving the child’s “real” problems, and slightly over half agreed that medications blunt children’s personalities.⁴

In 2012, Carl Bowman and colleagues, including myself, conducted a nationally representative survey of 3,000 parents of school-aged children. We found similar worries about diagnosis and medication treatment. Almost two-thirds of parents (63 percent) endorsed the belief that many children “are now medicated for problems that are better treated in other ways,” with another 24 percent undecided. Nearly 4 out of 5 parents (78 percent) think “medications should generally be the last resort for solving a child’s problems.” Only 10 percent expressed some disagreement with this statement.⁵

An earlier (unpublished) focus group study I conducted to explore lay thinking about childhood problems, ADHD, and medications, as well as published studies of parents of children being treated for ADHD⁶ also find these common apprehensions. Many of the study participants believe that ADHD is over-diagnosed, favor behavioral interventions or counseling to medication, and have concerns about the effects of medication.

So despite the fears of medical professionals and social scientists, there are such high and increasing rates that the JAMA review of studies speaks of “ADHD overdiagnosis and overtreatment.” In the US, rates of diagnosis have exceeded the estimated prevalence rate published by the American Psychiatric Association (5 percent) for at least 25 years. Strong reservations about ADHD diagnosis and the use of medications does not appear to deter many parents from turning to doctors and accepting a diagnosis when children’s behavioral problems arise.

What accounts for this paradox?

The focus group discussions offer some important clues. When talking about behavioral problems and medication in the abstract, focus group participants agreed that over-prescription is a problem. They say normal children are being drugged and that many parents are acting irresponsibly. In the abstract, they linked the problem to social changes that have led to children’s lives being more pressured and managed. They describe an environment less tolerant of children’s differences and more obsessed with classroom success. Parents’ lives too are more stressful and complicated, they emphasized, promoting a desire for “quick fixes,” like drugs. At this general level, widespread medical intervention indicates a failure to address the deeper institutional roots of behavioral problems.

When talking about personal experience with kids diagnosed with ADHD, however, the conversation was quite different. Up close, the problems of properly caring for struggling children looked more complex. Over the years, the diagnostic criteria for ADHD have both broadened to include a wider range of symptoms and loosened to include far less severe clinical presentations. This expansion has helped create a “large reservoir of potentially diagnosable disease,” as the JAMA review of studies summarized. In our 2012 survey, for example, 42 percent of parents reported that at least one of their children has struggled with “excessive difficulties of focus, attention, and distractibility,” while 19 percent reported that at least one of these kids has been diagnosed with ADHD. Not every struggling child is getting diagnosed, but as the scope of ADHD expands, more and more parents are left to wonder if their child might have a medical problem.

Speaking in the abstract, focus group participants acknowledged constraints on parental time and resources and the possibility of pressure from others, including teachers and medical providers. But they made no allowances for adverse conditions. They assumed that parents have considerable latitude to resist professional advice and explore other possibilities of problem source and potential intervention, if only they have the will to do so.

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When discussing their personal experience, however, group participants said little about non-medical options and opportunities. Parents they knew who had a struggling child or adolescent did in fact seek medical help and put their son or daughter on medication. In speaking of the parents’ role in these “genuine” cases, participants emphasized that the decisions were not entered into lightly. The child’s struggles with activity level, impulsiveness, or attentiveness to tasks, at school and perhaps also at home, just didn’t yield to reasonable discussion or discipline and seemed beyond their rational control. Medical intervention was the proper, indeed, responsible thing to do.

This apparent inconsistency between abstract critique and personal experience is revealing. That the focus group participants seemed to know of only “genuine” cases suggests the limits of their reservations. Few actually expressed any doubts about ADHD, its criteria, or the potential benefits of medication. It is a “great drug,” said one. Rather, the question, they stressed, is how to determine the child’s “real problem,” whether ADHD or something else. Making this assessment does not preclude “appropriate”—i.e., informed, cautious—use of medical professionals, but presupposes it. For these skeptical citizens, if there is any possibility that a child might have ADHD, then parents have an obligation to their child to seek expert advice.

Given the “large reservoir” of childhood struggles, such an obligation makes seeking expert consultation for an affected child nearly mandatory. And this obligation, more than any other, may be the most important reason why leery parents find themselves compelled toward medicalized solutions, even when they prefer to explore non-medical or non-pharmacologic options.

Consider this definition of parental responsibility from the well-known psychologist Russell Barkley in his best-selling book Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. For those with a struggling child, “taking charge” means becoming a “scientific parent,” able to “question everything” and to preside over your child’s “professional and educational care.” It means being “proactive” and a “voracious” seeker of health information. It means serving as the “case manager of your child’s life” and treating professionals as “your advisors.” And it means becoming “immensely free” and “awesomely accountable.”

Focus group participants placed a similarly heavy emphasis on parental responsibility. Like Barkley, and medicine more generally, they stressed the need for parents to become knowledgeable, adopt a critical attitude, and, in their role as decision-maker, consult with and coordinate professional help toward solving problems and maximizing their child’s likelihood of success.

How does this responsibility play out? At first glance, Barkley appears to be affirming the parents’ independent judgment and discretion. They are in charge, making the final decisions. And yet “empowering” parents in this paraprofessional way is not affirming their reasoning and evaluations; it is transforming them. It is inviting parents to abandon their own nonscientific point of view, their “folk psychology” as the professionals derisively call it, and adopt a new orientation toward their own children. Barkley translates this “scientific parenthood” into step-by-step guidance for the management of diagnosis and treatment, while warning against other practices that he regards as without scientific merit. So “empowered,” parents are part of the team, educated in the medical perspective, and “awesomely accountable” to expert standards for their child’s “professional and educational care.”

Once flattered and coaxed into this paraprofessional role, the freedom that parents have to resist medical advice and medication shrinks dramatically. That’s the point. It’s the reason Barkley opens his book defining parental responsibility. Specifying its terms does not directly impose expert recommendations, which will almost always favor the benefits of medical treatment, but it shapes the very context to subtly direct people to follow those recommendations. At issue is not whether the parents have a say, but what can be said at all—what values, practices, and understandings of care are not already foreclosed but open and available for actual consideration.

At a minimum, defining responsibility in this way places a heavy burden of proof on parents should they resist seeking or following expert advice. The possibility that they are harming their struggling child by withholding diagnosis and medication can be hard to bear. Studies of parents find that they report feelings of moral blame around children’s struggles. A diagnosis—a biomedical explanation—is felt to ease this blame, enhance a sense of legitimacy, and bring understanding and sympathy.

Parents in our survey believed medication should be a last resort but were most inclined to see it as a “good thing” if boosting a child’s school performance was thrown into the balance. One of the survey respondents we subsequently interviewed explained her decision: “So medication seemed—wasn’t my first ideal, but you know, I wanted to do what was best for her so that she could be focused and stuff in school.”

Parents want to do the best for their struggling children. Judging from the very high and increasing rates of diagnoses and prescriptions, doctor visits tend to equate the best with a medicalized solution. In fact, some professionals are worried that not nearly enough kids are being diagnosed and insist that even more “psychoeducation” is needed.⁷

Meanwhile, as the JAMA review notes, many studies identify harms from the biomedical view of struggling kids. These harms are quite like the concerns that many parents themselves raise about overdiagnosis, concerns that the widespread challenges of young people are a sign that something is profoundly awry in our society. More medicine is not the answer and they (and many consciousness medical practitioners) know this. But when viable alternatives are not in the mix, addressing the struggles of a particular child is likely to lead to a place that many parents say they don’t want to go.