Diagnostic Criteria

ADHD is a neurodevelopmental disorder that is characterized by symptoms of inattention and/or hyperactivity that are present across multiple settings (school, home, work, etc.). By definition, a neurodevelopmental disorder must become apparent during development, and for ADHD symptoms must emerge before age 12. Most children at this age are in their elementary or primary school years. In the large majority of cases, children with ADHD have both inattention and hyperactivity which is typically diagnosed as ADHD, combined type, though children may also present with only inattention or only hyperactivity. Determining whether a child's (or adult's) symptoms meet the criteria for ADHD requires a careful and nuanced process conducted by a qualified professional that has extensive training in psychological and developmental assessment. Typically, this is a clinical psychologist, a clinical neuropsychologist, or a psychiatrist who has specialized training in assessment, psychometrics, and testing (this latter scenario is quite rare). While many inattentive or hyperactive symptoms reported by the general population may superficially resemble the diagnostic criteria for ADHD, determining whether these symptoms represent ADHD, normal variability in attention, or overlap of cognitive symptoms with other psychosocial processes requires an assessment conducted by a professional who is truly qualified to assess, test, and diagnose the patient.

Why does overdiagnosis occur?

In the Diagnostic and Statistical Manual of Mental Disorders - 5th Edition (DSM-5), symptoms of inattention and/or hyperactivity are fairly subjective. Accordingly, there is varying interpretation of the criteria by healthcare professionals. Additionally, healthcare professionals have difficulty discriminating symptoms of ADHD from other psychological or developmental conditions that can produce similar symptoms. Examples of other psychological or developmental conditions that can mimic ADHD include:

• Depression
• Anxiety
• Stress
• PTSD/Trauma history
• Fatigue/Poor sleep
• Dyslexia
• Autism
• Intellectual disability or borderline intellectual functioning
• Medications with cognitive side effects

Because ADHD symptoms frequently superficially resemble normal variability in attention and behavior, and that there is considerable overlap between ADHD symptoms and other factors like fatigue, stress, or psychiatric symptoms, many clinicians are tempted to label these symptoms as ADHD when in reality the cause is far more benign.

Why do people seek diagnoses of ADHD?

Even among people without any form of developmental evidence of ADHD or any other developmental condition that causes significant barriers or functional impairment in achievement or functioning, many will aggressively seek ADHD diagnoses, and recruit parents, friends, therapists, and physicians on their path. Why to these individuals seek an ADHD diagnosis so tenaciously? Some reasons may include:

• Redefining life experiences following trauma​
• Explanation for behavioral health treatment non-response​
• Relief of personal responsibility for change​
• Avoidance of punishment or culpability​
• Access to benefits, accommodations, or compensation​
• Access to controlled substances
• Permission to be different​
• Social contagion and recent impact of social media

Societal and Cultural Factors

In the United States of America, there is a strong cultural expectation in many communities for high achievement in school, social or work settings. Such high expectations can pull for a desire for a "quick fix" among parents, therapists, workers or students to address perceived shortcomings in achievement, performance, or progress in therapy. Additionally, an aversion to being labeled as "normal" or "average" may pose as a strong motivator in some communities to pursue a diagnosis that identifies them as unusual, special, different, exceptional, or even "neurodivergent," as a way to explain perceived underperformance in school, social, or work settings. While the term "neurodivergent" has traditionally been used to refer to individuals along the autism spectrum, people seeking diagnoses of various developmental disorder like ADHD have come to appropriate this label and use it to refer to anyone who subjectively feels different or like an outsider in their community.

ADHD is not viewed as a completely cultural or societal construct, but rather as a real and significant neurodevelopmental disorder. While ADHD may certainly present with different phenotypes and appearances in different communities in this country, there is little debate in the field of developmental psychology that ADHD presents significant functional challenges regardless of cultural origin.

In this age of social media, there is an abundance of information on the Internet about a wide range of health topics, including neurodevelopmental disorders and psychiatric disorders. While this insertion of social media into the behavioral healthcare space has served as an important vehicle for destigmatization, normalization, and community among people confronted with behavioral health symptoms, it has also introduced a high degree of misinformation, predatory online marketing, clickbait, and snake oil salesman eager to cash in on the fears, hopes, or desires of people researching their content. Unscrupulous online marketers, influencers, or content creators often exploit a phenomenon called the Barnum Effect which they use to establish credibility, recruit followers, and generate likes and comments.

The Barnum Effect

The Barnum Effect (AKA the Forer Effect) is a social psychology phenomenon in which people perceive that vague and general information about their life, personality, or circumstances applies uniquely to them even though the information readily applies to many people in the general population. For example, let's say you watch a TikTok video where someone says "I have ADHD and I often start too many projects and then I can't finish them." While you might strongly identify with this statement, in reality, everyone in the world has had experiences of being too busy to get everything done that they need to, whether they have ADHD or not. The person's use of the label "ADHD" in this statement links ADHD with this incredibly common tendency experienced by millions of developmentally healthy people every day. However, the Barnum effect leads us to believe that the statement is true and applies specifically to us. The Barnum Effect happens because we often want to feel special and understood, so when we hear something that sounds like it describes us, we tend to believe it, even if it's not actually that unique or specific. It is so important to keep the Barnum Effect in mind as we peruse social media, consume news media, work with salespeople, or decide whether to pursue costly treatments marketed as an easy fix for everyday problems and inconveniences, such as those purported to be caused by ADHD.

Why is ADHD Overdiagnosis Bad?

If a person struggles with concentration problems, brain fog, or disorganization, why not just diagnose them with ADHD? After all, people with ADHD commonly report these symptoms so perhaps physicians should just provide stimulant medications, accommodations, or interventions for anybody with these complaints. Unfortunately, doing so causes immense harm not just to the person with the inaccurate diagnosis, but to the broader ADHD community. Apart from simple diagnostic inaccuracy, when a person receives a "false positive" ADHD diagnosis (meaning they are diagnosed with the condition, but do not actually have it), several adverse outcomes occur. These negative outcomes include:

• Entrenching pathological beliefs and behavior​
• Encouraging accommodating behaviors in loved ones and society​ (unnecessary accommodations or interventions)
• Promoting an external locus of control​ (believing ADHD prevents them from making positive changes in their life)
• Diverting resources away from the ADHD community​
• Delaying treatment of psychopathology​
• Incurring unnecessary medical and behavioral health costs
• Developmentally healthy individuals appropriating the very real and significant experiences of people with a true developmental disorder

How do I Ensure an Accurate ADHD Assessment?

Raising awareness among healthcare professionals, educators, parents, and the general public about the complexities of ADHD diagnosis is crucial. This can help prevent hasty decisions and encourage a more informed and thoughtful approach. While ADHD is a genuine and serious condition, the tendency to diagnose it too readily can lead to significant negative consequences for individuals and society at large. ADHD assessments are typically covered by major health insurance companies with a physician referral to a qualified provider such as a clinical psychologist, neuropsychologist, or psychiatrist. It is crucial that an ADHD assessment is completed by a qualified professional such as a clinical psychologist, neuropsychologist, or psychiatrist so that an accurate diagnosis can be provided that is accepted by prescribers, accepted by health insurance payers, and meets requirements for diagnostic rigor.

There are several Red Flags to watch for that can signal an ADHD assessment will not provide the necessary expertise or requirements for adequate clinical care, and are likely to be harmful to patients:

• ADHD assessments completed by masters-level clinicians without any oversight or supervision from doctoral level providers such as clinical psychologists, neuropsychologists, or psychiatrists. This guideline may vary by jurisdiction, though in the state of Missouri and others, clinicians with masters-only levels of training are unable to provide diagnoses that meet qualifications for accurate diagnosis, prescription of medications, or coverage from health insurance companies. This leaves patients and families often having to pay exorbitant out of pocket costs to unqualified providers for assessments that are not even capable of addressing their diagnostic questions or getting them help that they may need. Before engaging services of any clinician for an ADHD assessment, it is important to ask if a doctoral-level provider is conducting or supervising the assessment, or if the provider's credentials meet requirements for insurance billing or recommending prescription of medications.
• ADHD assessments that use any form of neuroimaging such as SPECT, QEEG, DTI, PET/CT, neurofeedback, MRI, CT scans, FNIRSs, etc. While the field of neuroradiology has exploded in its complexity and utility in recent years, as of the writing of this article in 2023, there are currently no reputable studies that are able to incorporate neuroimaging as a diagnostic tool to improve accuracy of ADHD diagnosis. Providers that claim to give ADHD or other developmental diagnoses on the basis of these kinds of scans should be treated with skepticism.
• ADHD assessments that are administered using solely self-report questionnaires. There are a large number of questionnaires that purport to provide examinees with information on whether they meet criteria for ADHD. Self-report questionnaires are those that ask a person about how they are feeling about a certain topic or symptom, and rely on the person to rate how much, how frequently, or how severely they experience that symptom. Unfortunately, many self-report questionnaires that are free and readily available online lack any kind of research that ties their scores to true ADHD diagnoses. Indeed, many of these free online questionnaires exploit the Barnum Effect described above and simply inquire about vague and nonspecific symptoms that are readily experienced by the general population (like disorganization, brain fog, or poor time management). Even reputable self-report measures such as the Connors Adult ADHD Rating Scale (CAARS) are prone to symptom exaggeration, and influence from non-ADHD conditions like depression, anxiety, or traumatic brain injury. When used in isolation by underqualified providers, the CAARS can produce results that are misleading, resulting in false positive diagnostic conclusions.
• ADHD diagnoses given on the basis of an office visit or therapy appointment. ADHD is a complex, nuanced, serious, and frequently debilitating condition. When a provider gives a diagnosis of ADHD following either a brief office visit or therapy session, the diagnosis is frequently inaccurate because these encounters frequently fail to account for things like developmental history, objectivity of deficits reported by patients, or other conditions are are capable of producing the patient's subjective symptoms. In these circumstances, oftentimes the provider or therapist themselves are falling victim to the Barnum Effect by attributing their patient's vague and nonspecific symptoms like brain fog or procrastination uniquely to ADHD when these symptoms are experienced at high rates in the general population.

Conclusion

Ultimately, YOU are the only one with control or responsibility over the healthcare information you consume from the healthcare community. If your healthcare team includes behavioral healthcare providers, it is important that you work with providers who have the training, education, and tools necessary to address your specific concerns. Your behavioral healthcare providers including clinical psychologists, neuropsychologists, and psychiatrists are tasked with providing you with accurate and specific information about your psychiatric or cognitive functioning, even if that information is not what you want or expect to hear. By educating yourself on how to spot sketchy or misleading information about ADHD or other developmental conditions purveyed on social media and other Internet sources, you are well on your way to being an educated healthcare consumer. It is critical that you get your healthcare information from sources that are designed to provide clinical care - not designed to generate likes, followers, or comments.