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Leaving It Better Than We Found It: Moral Disengagement in Moving Goalposts of ADHD Over-diagnosis

This was written for Washington State University’s PSYCH-368.

This is a big post, again saved till later in the evening… ADHD topic is huge, and touches many… it is integrated heavily with several large issues, and it is basically at a nexus of economics, mental health, and ethics/morality. This takes into context Bandura’s (1999) concept of moral disengagement as well as there is sanitizing language detected in talk of ADHD.

Leaving It Better Than We Found It: Moral Disengagement in Moving Goalposts of ADHD Over-diagnosis

Introduction

For this week, attention-deficit hyperactivity disorder (ADHD) was chosen. It has been beneficial to operationalize keywords in questions throughout university, so it would be helpful to operationalize overdiagnosis. Curiously, while operationalizing overdiagnosis, it quickly became a greater effort in digesting various generalized perspectives of overdiagnosis. What had been helpful, however, is that this additional effort led to a generalized view of “overdiagnosis”, which bears significance in perspectives of overdiagnosis in the treatment(s) of ADHD. From here, this understanding could apply to treatments and some salient epidemiological statistics related to ethnic/racial differences and a little specificity on treatment before turning back to the topic of overdiagnosis with respect to ADHD. Because ADHD is simultaneously a clinical diagnosis and that treatments oft comprise drugs associated with stimulants and performance enhancement, it is critical to understand with respect to childhood development, because a salient sociological reality of parents wanting better futures for their children and better “control” of their children’s behaviors. When reviewing the literature, there is moral disengagement at work in ADHD overdiagnosis.

What is Overdiagnosis?

According to the German Institute for Quality and Efficiency in Health Care, overdiagnosis is “the diagnosis of a medical condition that would never have caused any symptoms or problems” whereupon it is further stated that “this kind of diagnosis can be harmful if it leads to psychological stress and unnecessary treatments” (InformedHealth.org, 2017). According to the National Cancer Institute, overdiagnosis “is finding cases of cancer with a screening test… will never cause any symptoms” (NCI, n.d.). Of particular interest are cases where the diagnosis “would never have caused any symptoms or problems” though the medical condition may be present (e.g., cancers that are benign with no symptomology or problems). Therefore, according to these definitions, this would mean that genetic or neurological predisposing factors (e.g., genetic contributions [Li et al., 2021; Kian et al., 2022; Thapar & Stergiakouli, 2008]) without symptoms or problems could be an overdiagnosis, but where is a clear operational line of symptom? The American Psychological Association itself deems symptoms as “any deviation from normal functioning that is considered indicative of physical or mental pathology”, yet seconds with “in general, any event that is indicative of another event; for example a series of strikes is a symptom of economic unrest” (APA, n.d.). It would seem, genetic deviations from “normal functioning” standard distributions of genetics could also be symptoms.

Looking at one definition alone from an authoritative source seems to exhibit face validity, yet when considering multiple definitions, one quickly realizes there is a lack of operational definition. To not reinventing the wheel, it may be worth consulting ethical perspectives. Within the Journal of Medical Ethics, Carter et al.’s (2016) review on this very subject found challenges in the definitions of overdiagnosis between various sources, arriving at a better operationalized definition via three components in search of assessing overdiagnosis with respect to populations: (a) “the condition is being identified and labeled with diagnosis A in that population (consequent interventions may also be offered)”, (b) “this identification and labelling would be accepted as correct in a relevant professional community”, and (c) “the resulting label and/or intervention carries an unfavorable balance between benefits and harms” (pp. 709-710). This is a very valuable operational framework, and lead to three kinds of overdiagnosis to consider for ADHD.

Carter et al. identify three types of overdiagnosis where harm would have been avoided, (a) predatory overdiagnosing actions, due to those diagnosing motivated by self-benefit; (b) tragic overdiagnosis, due to those diagnosing motivated by other-benefit (e.g., diagnostics or treatments that cause harm); and (c) misdirected overdiagnosis, due to diagnosing motivated by other-benefit (e.g., a new diagnostic for early detection) (pp. 710-711). There are other presentations of this issue beyond Carter et al., however it seemed salient with respect to ADHD, and therefore is presented here.

Why is Overdiagnosis So Messy?

Derek Bolton (2013) of King’s College London’s Institute of Psychiatry reviewed verbiage in both the American Psychiatric Association’s various editions of Diagnostic and Statistical Manual of Mental Disorders, and the International Classification of Diseases to clarify broad level definitions of overdiagnosis and prevailing context and came away with some valuable guidance. There are some fascinating side effects of moving the goalposts on what constitutes diagnosis, arriving at a “distress and impairment” emphasis while also accounting for “antisocial aspects” (p.615). Homosexuality historically provided a reason to re-evaluate overdiagnosis (pp. 613-614). Understanding clearly where the borders of diagnoses meet diagnosis may shed some light on overdiagnosis in ADHD, especially in children, because “distress and impairment” are culturally related. Considering an economic culture of American domestic policy for individual achievement and success, couldn’t distress be ascribed to the experience of poor(er) grades used in evaluating students for academic achievement in a meritocratic society. How far ahead of distress, is distress measured? Even more so with impairment, where impairment is an impairment relative to peers in cohorts of expected outcomes where a portion of those cohorts are benefitting from drugs in advancing again, meritocratic opportunity. It’s suddenly as if overdiagnosis is wrapped up in the same arguments that doping is wrapped up in performance enhancing drugs in sports. It’s messy, however, it may be worth turning to some statistics.

Epidemiology

Sayal et al. (2018) reported varying estimations of ADHD based in meta-analysis. For the United States, a prevalence rate of 0.6% was arrived at for people younger than 18 in 1987, to about 10% in children aged between 7 and 11 between 1995-1996 (p. 176). Most ADHD studies for Americans demonstrated a peak in the 10–14-year age group (p. 176). According to Shi et al. (2021), using a cohort of 238,0111 children, 4.8% were diagnosed with ADHD (11,401 children), with an incidence of .69% (p. 4). 78% of children diagnosed are white, 3.2% are Asian, 6% are black, 9.1% are Hispanic, and 3% are other (p. 4). A striking statistic however is that 50.6% come from the southern census region (p. 4), and that 68.4% come from household incomes above $75,000, where 22.8% are below, where 8.9% is from unknown income brackets (p. 4). Notably, comorbid speech sound disorder as a pre-ADHD condition is present in 16.5% of ADHD diagnoses (p. 6). Shi et al., discuss significant racial disparities in ADHD diagnoses “in privately insured children”, in treatment, and different patterns of comorbidity (p. 7).

Treatment

With respect to ADHD, avoiding moral disengagement of euphemistic labeling (Bandura, 1999) by using drug rather than “medication” is a course correction the author is willing to assist with. ADHD treatments consist of known pharmacological drugs related to amphetamine and amphetamine-like drugs (e.g., Adderall/Adderall XR [amphetamine]; Vyvamse [converts to dextroamphetamine]; Ritalin, Concerta, Methylin, Daytrana [methlphenidates]); these are classified as stimulants and are subject to use and abuse (Mosher & Akins, 2022, pp. 108-109). While the exact impact of these drugs is unknown, ADHD drugs not only evidence attentional enhancement but physical enhancements via elevated dopamine and norepinephrine concentrations (Berezanskaya et al., 2022). For any student (or professor) of psychology today, it is noteworthy that Ritalin effectively acts like cocaine (Vastag, 2001), and produces the same effects as methamphetamine when abused (Gahlinger, 2001, p. 209).

Drugs are not the only treatment option, as the gold standard of psychological therapy, cognitive behavioral therapy (CBT) has been demonstrated to show efficacy (Maric et al., 2015; Pfiffner, 2014). Alternative treatments are available such as “stop and think” (Miranda & Presentacion, 2000). According to Rathus, stimulants are more efficacious (as cited in Rathus, 2022, p. 364; Green & Ablon, 2001; Waxmonskly, 2005; Whalen, 2001). [TODO: Insert stimulant comparison treatments here]. While stimulants may be considered more efficacious, one meta-analysis of psychosocial treatments reveal that behavioral parent training (Corcoran & Dattalo, 2006) and behavioral school intervention practices demonstrate greater effect sizes (Fabiano et al., 2021).

Overdiagnosis of ADHD

Turning back to overdiagnosis of ADHD, it is valuable to keep race in context. According to Rathus (2022), “there has been about a 60% rise in the prevalence of diagnoses for ADHD over the past two decades, and two of three children diagnosed with the disorder are placed on stimulants such as Ritalin and Adderall” (pp. 362-363). ADHD is considered by medical professionals as overdiagnosed (p. 363). Utilizing methods focusing on consequences of favorable/unfavorable benefits (i.e., benefit/harm), in a meta-analysis by Kazda et al. (2021) reviewing 120 studies on consequences of drug treatments, there is evidence of overdiagnosis (pp. 4-10), but noted that in certain age groups, benefits outweigh harms (p. 7).

Considering varying definitions of overdiagnosis and taking a Carter et al. and Bolton model focused on benefit and harm, contextualized with cultural ideals of “dysfunction”, one could argue that s child’s future earned income and possible potential building of wealth, especially in the United States, is contingent on the meritocratic value the same child may later provide set against known and unknown in- and out-group along with systemic stereotypes, prejudices, and discriminations. While in a phenomenological perspective, in a local frame of an individual student, a student might not report distress except in the way others are treating their relatively less focus (i.e., attention deficit) and relatively greater activity (i.e., hyperactivity). Yet, impairment takes relativity into account, determining impairment against a cultural context. Therefore, the student/child stands before a growing measuring stick of prevailing changing social diagnostics. What if this every lengthening measuring stick itself is inducing distress, just as monetary inflation induces distress? Every year demanding more with less.

Unfortunately, if a significant portion of a relative demographic is being increasingly drugged to control for attentional “deficits” and activity “excesses”, then technically, one is moving the goalpost of a cultural measuring stick these same effects, where the measuring stick itself drugged. A cultural feedback-loop is due to drugs is effectively inducing a cultural addiction to performance enhancement for the benefit of bettering one’s successes in economic competition. Strangely reflective is that this is but one argument that those against performance enhancers in competitive sports deploy when debating those for performance enhancers—if the entire sport is adopting performance enhancers, then everyone will require them to compete. Is a national policy so bent toward beating other nations that it is willing to dope its children with performance enhancers to mold human diversity into productive machinery for nationalist agendas?

Conclusion

Considering a large and growing prevalence of ADHD, is it possible that ADHD is a social disorder, contingent on DSM-5’s criteria of disorder, centering on a social perspective of impairment. As Karen Horney herself had written of neurosis, neurosis and society is interrelated. Society has come to demand so much of its people that drugs are as another layer of the “food pyramid”, accommodating demands of naturally selected beings sacrificed on an artificially selecting religion’s altars of market economics centered squarely on Merton’s (1938) strain adaptation of innovation supported by a system of conformance and ritual, with occasional offramps to retreat and rebellion. The tyranny of should is at work, and look no further than ADHD. Humanity seems to have built a society of a sleeping majority ignorant to its own drug altered measuring sticks of juiced standard deviations, built on an economy on performance enhancing drugs (e.g., stimulants, depressants, etc.), that those without them are seen as “unable to sit still” and “unwilling to work”. The drugged-up measuring stick is creating social drug addiction.

And where would this ultimately lead? Consider the ecological sciences. The more humanity’s natural state devoid of performance enhancement is bifurcated from a “juiced” state of performance enhancement (i.e., the have nots vs. the haves), the greater the probability of allopatric speciation between two humanities selecting for attributes that intelligence may falsely attribute to societal dispositions. Reality is that nature favors efficiency of energy, not markets—ecology wins, even at the extinction of a dimension of what is seen today as humanity. So in departing, should children with ADHD be mainstreamed into classrooms? The answer may surprise you—it’s too late, they already were, it’s the diagnosis that’s lagging. It’s another moral disengagement, “mainstream” is a sanitized version of desegregation, and as Allport already provided evidence of, the best way to eliminate stereotype, prejudice, and discrimination is inter-group contact. The question is made more saliently human as illuminated with moral re-engagement: should children diagnoseable with ADHD be segregated from peers (i.e., humans). I don’t recommend Niccol’s (1997) Gattaca. Work together, not separate. Maybe the structure of society needs rethinking, because it’s not looking good ecologically to continue down this road that seems to look more and more, like… rebellion, but maybe that’s what’s intended. There is a growing deficit in attention to salient themes of policies past, that produced economic hyperactivity present, resulting in threatening all life on this planet. The story of ADHD and its treatment, is profound, and you can see it in the lives of your sons and daughters, please leave it better than you found it.

References

Allport, G. W. (1954). The nature of prejudice. Addison-Wesley Publishing Company.

American Psychological Association [APA]. (n.d.). Symptom. APA Dictionary of Psychology. Retrieved from https://dictionary.apa.org/symptom (Links to an external site.).

InformedHealth.org. (2017). What is overdiagnosis? National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK430655/ (Links to an external site.).

Bandura, A. (1999). Moral disengagement in the perpetration of inhumanities. Personality and Social Psychology Review, 3(3), 193-209. https://doi.org/10.1207%2Fs15327957pspr0303_3 (Links to an external site.)

Bolton, D. (2013). Overdiagnosis problems in the DSM-IV and the new DSM-5: Can they be resolved by the distress-impairment criterion? The Canadian Journal of Psychiatry, 58(11), 612-617. https://doi.org/10.1177/070674371305801106 (Links to an external site.)

Kazda, L., Bell, K., Thomas, R., McGeechan, K., Sims, R., & Barratt, A. (2021). Overdiagnosis of attention-deficit/hyperactivity disorder in children and adolescents: A systematic scoping review. JAMA Network Open4(4), e215335–e215335. https://doi.org/10.1001/jamanetworkopen.2021.5335 (Links to an external site.)

Kian, N., Samieefar, N., & Rezaei, N. (2022). Prenatal risk factors and genetic causes of ADHD in children. World Journal of Pediatrics: WJP, 18(5), 308–319. https://doi.org/10.1007/s12519-022-00524-6 (Links to an external site.)

Li, T., Franke, B., Arias Vasquez, A., & Roth Mota, N. (2021). Mapping relationships between ADHD genetic liability, stressful life events, and ADHD symptoms in healthy adults. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics, 186(4), 242–250. https://doi.org/10.1002/ajmg.b.32828 (Links to an external site.)

Mosher, C. J., & Akins, S. M. (2022). Drugs and drug policy, 3rd ed. Sage.

National Cancer Institute [NCI]. (n.d.). Overdiagnosis. National Cancer Institute. Retrieved from https://www.cancer.gov/publications/dictionaries/cancer-terms/def/overdiagnosis (Links to an external site.).

Niccol, A. [Director]. (1997). Gattaca. Columbia Pictures, Jersey Films.

Rathus, S. A. (2022). Childhood and adolescence: Voyages in development, 7th Ed. Cengage.

Sayal, K., Prasad, V., Daley, D., Ford, T., & Coghill, D. (2018). ADHD in children and young people: prevalence, care pathways, and service provision. The lancet. Psychiatry, 5(2), 175–186. https://doi.org/10.1016/S2215-0366(17)30167-0 (Links to an external site.)

Thapar, A., & Stergiakouli, E. (2008). An overview on the genetics of ADHD. Xin li xue bao. Acta psychologica Sinica, 40(10), 1088–1098. https://doi.org/10.3724/SP.J.1041.2008.01088