A new article, published in the journal Disability and Society, questions whether the diagnosis of ADHD meets the criteria for a disorder as set out in the manual used by the medical and psychiatric fields. The researchers argue that rather than using objective criteria, the definition of ADHD relies on subjective cultural values to define “abnormal” behavior. The diagnosis thus fails to meet the criteria, as stated in the DSM, that disorders must not be reducible to behavior that violates social norms.
“We argue that the current criteria draw into question whether ADHD/HD meets the manuals’ own definitions of a disorder,” the researchers write.
The researchers – Justin Freeman at Syracuse University, NY, and Juho Honkasilta at the University of Jyväskylä in Finland – used a technique called critical discourse analysis (CDA) to investigate the language used to define the diagnosis of ADHD. For instance, the diagnosis of ADHD is listed as a “neurodevelopmental disorder” in the DSM-5, despite the research evidence suggesting that there is no neurological difference between those with the diagnosis of ADHD and those without the diagnosis.
Freeman and Honksilta argue that despite the lack of any organic or biological test for ADHD, it could still be a valid, useful construct if it “hangs together” logically. However, the criteria for the disorder appears to violate this requirement as well. They found that although the words “diagnosis” and “disorder” imply objective criteria, and the medical literature overuses the word “science” in describing ADHD, the actual language of the ADHD diagnosis is vague and subjective.
For example, each of the 18 symptoms of ADHD in the DSM-5 begins with the subjective, ambiguous specifier “often.” Thus, parents, teachers, and doctors are determining what constitutes “too much” inattention or “too much” activity for a child.
Additionally, the researchers argue that the omission of who is observing the child and judging the child’s behavior as excessive is inherently based on cultural values. They write that the criteria “Often unable to play or engage in leisure activities quietly” leaves out any context regarding why children’s leisure activities should be quiet in the first place.
Moreover, Freeman and Honkasilta suggest that normal childhood play is recontextualized, through the lens of adults who want to control and calm children, as a “disorder” and a “deficit.” Perhaps the most obvious example is that a criterion for ADHD in the DSM-5 is as simple as “feeling restless.”
Other criteria involve references to making others—people without the ADHD diagnosis—feel inadequate. For instance, included in the DSM-5 criteria are being “difficult to keep up with” and “wearing others out.”
ADHD has been the subject of controversy in the research literature of late, as studies purporting to show neurological components to the “disorder” have been discredited—in some cases, by the very researchers who popularized the diagnosis in the first place. Lancet Psychiatry, a premier research journal, recently devoted an entire issue to the debunking of one such study, which was acknowledged to be flawed in methodology.
At the same time, studies have found that more than 20% of high school boys are receiving the diagnosis, which is commonly associated with the prescription of potentially addictive stimulant medications. Concerns about overdiagnosis and overmedication are common in the popular and research literature regarding ADHD.
Indeed, this is not the first time that researchers have argued that the language of the disorder is vague, subjective, and serves the interests of parents, teachers, and the pharmaceutical industry—rather than the welfare of children. In fact, leading researchers have argued that the diagnosis does far more harm than good for children.
Freeman and Honkasilta also write that “the discourse of the manuals is intertwined with the everyday practices of schools and serve to legitimize status quo educational practices.” That is, the language used to construct the diagnosis is inseparable from the values of an education system requiring that children behave a certain way.
The researchers go on to state that the diagnosis of ADHD actually serves to reframe individual differences and cultural diversity as “mental illness.” Thus, according to the researchers, the existence of ADHD as a disorder enables the education system to continue ineffective teaching practices focused on the ideal “normal” child rather than changing to better help diverse children learn.
Freeman and Honkasilta note that the DSM-5 itself requires that a disorder not be comprised of cultural difference, or socially deviant behavior that is not harmful. The researchers therefore argue that given the cultural values implicit in the ADHD diagnosis, it fails this most basic definition. Going further, the researchers write that the “diagnosis” is actually dependent on adults in power insisting that children engage in both work and play in ways that are adult-like, which is developmentally inconsistent with common childhood behaviors.
The authors write that they are “alarmed by the DSM-5 and ICD-10 authors’ narrow view of what constitutes healthy or acceptable behaviors, such that they prescribe the manner in which individuals should play or sit.”
Finally, the researchers argue that, like homosexuality (which was considered a mental disorder by the psychiatric field until 1980), ADHD should be de-medicalized—and could be considered a normal variation on how humans, especially children, engage in the world.
Freeman, J. E. & Honkasilta, J. M. (2017). Dictating the boundaries of ab/normality: A critical discourse analysis of the diagnostic criteria for attention deficit hyperactivity disorder and hyperkinetic disorder. Disability & Society, 32 (4), 565–588. https://doi.org/10.1080/09687599.2017.1296819 (Link)