ADHD: a misdiagnosis, label, or a lost opportunity for the best treatment
ADHD may be a developmental visual-spatial disorder (DVSD)
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Parents conflict over the treatment of their son, diagnosed with ADHD
A close friend and colleague sent me an email asking if I could assist a psychotherapist with a troubled family that needed support from someone knowledgeable in both medication and non-medication approaches. When I spoke with the therapist, it reminded me of the significant polarization regarding the best approach, such as modern medical science versus holistic medicine, as well as the advocacy for more natural and lifestyle interventions. I realized that bridging this gap in a troubled family would be challenging.
In the news today, the same type of conflict steals the headlines, with people railing against science, research, and vaccines that have saved many from the scourges of epidemics, death, and disability. I was one of the fortunate survivors of polio as a child, before the polio vaccine. Yet I know multitudes were not so lucky and were afflicted with lifelong disabilities or died prematurely. The situation surrounding polio and vaccines has been a modern-day miracle for many.
The debate over the best approach and the need for less dependence on science and medical authority has led to a crisis in families and national politics, marked by angry polarization. When considering the psychotherapist’s difficulty in addressing family disruptions stemming from conflicting viewpoints on ADHD, what should both the father and mother understand to collaborate and potentially compromise to best help their child?
The problematic student: getting to the roots of the problem
Early in my career, I was a consultant in a day school specializing in helping children considered poor learners and problematic students in public school settings, often with poor academic performance and disruptive behavior. I remember one child who was small for his age and frequently bullied by the other children. Most of the time, he would sleep in the classroom with his head on his folded arms, falling behind in class work. Teachers and his grandmother insisted I put him on one of the stimulant medications of the day to help him, thought to be ADHD. When his grandmother he lived with and caretaker was interviewed and a team member of our staff made a home visit, it became clear he wasn’t sleeping more than a few hours a night, as he drank caffeinated soda most of the day and at night too, with him watching TV into the late-night hours. Also, he was a furious and unhappy child, as other peers in the neighborhood bullied him. In addition, he would receive punishment from his grandmother when he was late coming home, avoiding the threatening children who tormented him on his way.
As the special designed school program where I was working was well funded by the county school system, there was specialized staff that could not only do home visits but worked with him and grandmother in the home setting about simple and effective changes to allow him a quiet sleeping space without a TV, improve his diet with avoidance of caffeine especially in the afternoon and evening towards bedtime. Also, strategies to build his self-esteem and confidence were made, such as after-school programs where he was involved in activities that interested him and taught him skills. One unique program was with peers where they learned cooking and nutrition skills so they might be chefs in the future, which he loved.
Interventions were made to help him protect himself from bullies. Efforts were made to identify and intervene with the children threatening him. Also, the school curriculum was changed to have more in his areas of interest, where his learning style allowed better mastery. With these available services in a specialized school program, he did well, was a more attentive and focused learner, and his moods improved with less anxiety. Of course, in today’s world, with education funding being cut back and programs with staffing, the specialized classroom program where I worked will be eliminated. Unfortunately, more children will go without their needs being met, and there will probably be more use of medications in the hope of at least short-term benefits.
In my experience, many treated with psychostimulant medications such as Ritalin or Adderall or other ADHD-specific interventions do not benefit as expected, when other more productive and essential needs are not addressed, such as critical immediate needs, environmental factors, and adverse lifestyle. The medications can show benefits for a hyperactive, disruptive child or adult with angry or dysphoric moods. Benefits, unfortunately, are often not sustained. Medication side effects can lead to poor compliance or cessation of medications. Stimulant medications can, in some, energize a mind bored with a non-interesting or stimulating environment or exposure to unstimulating educational material for a particular person’s interests.
The critical importance of the complete story and finding hidden influences and triggers
Is it more genetics, environment, lifestyle, privilege, or perhaps adverse trauma or events that affect one’s career, health, longevity, successes, or failures? A serious look at what the leading influences are and the issues that would be helpful to address is the most beneficial direction to first take when diagnoses are given as ADHD (attention deficit hyperactivity disorder), DVSD (developmental visual-spatial disorder), or my less preferred term, NVLD (nonverbal learning disorder), ASD (autism spectrum disorder), dyslexia, or neurodiversity.1
Health care providers’ and researchers’ experiences suggest that both adverse and positive influences such as environmental impacts, family, early childhood experiences, toxic exposures, trauma, the presence or absence of a healthy diet, supportive relationships, restorative sleep, deleterious stress, exercise, and the use of alcohol, tobacco, or drugs, can affect health, emotions, performance, social connectedness, and longevity. Individuals can possess specific hereditary characteristics, sometimes linked to identifiable genetic patterns in genetic testing, or display a series of observable behavioral and cognitive traits and learning patterns that influence performance or achievement.
The downside of defining an individual with a label or diagnosis is that opportunities for successful interventions and comprehensive treatment can be missed.
It has been estimated that 15% of American adolescents, or about seven million American children, according to the Centers for Disease Control and Prevention, have been diagnosed as ADHD.2
My experience treating adolescents and young adults in the hospital and outpatient or office settings was that often, someone would have a diagnosis of ADHD when coming to see me. They often would have a history of treatment with activating antidepressant medications (like Bupropion) or psychostimulant medication (like Ritalin or Adderall), or others, sometimes helpful for ADHD (as Atomoxetine). Some would have histories of treatment with multiple medications, each of which was felt to be appropriate for other mental health conditions, such as depression, anxiety, panic attacks, bipolar disorder, autism spectrum-related problems, and PTSD.
The prescribing of multiple medications suggests that many conditions or specific diagnoses overlap when using one particular diagnosis to explain everything. Diagnostic labels and treatments are added to define or relieve a new symptom or behavior. Unfortunately, as is often the case, medical science has not found a simple diagnostic test to guide therapy when different or overlapping symptoms occur. A simple blood test, sophisticated advanced medical diagnostic equipment, or artificial intelligence is not available to identify the diagnosis and conditions discussed here as ADHD. Reliance is made on information gathering, physical examination, and history from reliable sources. When symptoms overlap and closely resemble other conditions or illnesses, it isn’t easy to ascribe a simple diagnosis or intervention as a medication.
Also, over time, the symptoms ascribed to one condition can remit or disappear later in one’s life stage, suggesting perhaps other triggers or causes for what is seen or reported. Medications, if helpful, can be a transient phenomenon, and not sustained or long-lasting, with a significant rate of non-compliance or stopping medication for various reasons, such as side effects, some of which can be significant. There is research suggesting that ADHD medication doesn’t improve academic performance or learning, but that it may appear effective as it enhances the sense of well-being, energy, and mood elevation when in a boring setting with non-challenging or uninteresting tasks, or educational material.
The diagnosis of ADHD might be arbitrary, as there can be many other plausible explanations for any symptoms or presentation. Using medication or what has been felt to be routine treatments might lead people away from finding interventions more appropriate and helpful. In several situations, I had to stop medications when they were inappropriately prescribed, as when a stimulant medication was being given for ADHD, when in fact they worsened or activated another condition requiring different treatment. Some examples I’ve seen: when stimulant medication worsens, trauma related anxiety and panic as seen in PTSD; when extreme activation or mania occurs in someone with a propensity or history of bipolar disorder and severe mood swings; or when someone with an autism spectrum disorder that is extremely sensitive or reactive to psychoactive medications such as stimulants, antidepressive, sedatives, or mood/behavior affecting or regulating medications, has unexpected severe behavioral or emotional reactions.
Solutions might very well be for things other than medications, such as setting up or having a more conducive environment, a more engaging or stimulating classroom for students, a better working environment for job holders, or a calm, supportive, and non-chaotic environment in one’s home situation. 3
The confusion between DVSD (developmental visual–spatial disorder), ADHD (attention deficit hyperactivity disorder), and ASD (autism spectrum disorder)
When observed characteristics, symptoms, or patterns of dysfunction or illness are researched, systematized, and codified, they may be included in diagnostic compendia such as the DSM-5 (The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), which is used by mental health professionals to label or diagnose neurodevelopmental and mental health conditions to aid in research, treatment, and public health efforts. The critical question when discussing ADHD, DVSD, ASD, or any learning or cognitive performance or difficulties becomes: what are the significant influences that bring about better outcomes, including adaptability, health, happiness, survival, illness prevention, and treatment?4
DVSD presents similar difficulties and behaviors as seen in ADHD or ASD. Although nonverbal learning disability (NVLD), the commonly accepted name, has been shown by research to be a distinct type of learning disorder, it has not been defined sufficiently to be included as an official diagnosis in the DSM-5 manual. The current group of academics and scientists working to include DVSD in a future edition of the DSM believes that the best diagnostic term would be DVSD, effectively reflecting the primary deficit of visual-spatial problems. They believe that this term and the future research surrounding it would enhance the identification of individuals with significant visual-spatial deficits and related functional impairments, aiding future research, diagnosis, and treatment.5
Developmental visual-spatial disorder (DVSD) is characterized by impairments in the connectivity, communication, and development of visual and spatial information processing areas, primarily in the brain’s right hemisphere. The reduced connectivity or availability to the intellectual thought processing region, mainly in the left hemisphere, makes visuospatial skills and associated memory less accessible and contributory. When significant dysfunction and difficulties arise, including social and spatial disabilities, DVSD is classified as a neurodevelopmental disorder.
Individuals who predominantly learn and process information verbally, with a reduced reliance on visual-spatial processing and memory-related brain regions, generally recognize the disadvantages or challenges. Similarities or traits of DVSD are often observed in other family members. When greater genetic penetration (more extensive genetic influence and impact) occurs, it may manifest as significant dysfunction that requires support and intervention. It is estimated that developmental visual-spatial disorder affects 4% of children in our population.
In both children and adults, signs of DVSD may include awkward responses in sports activities, as well as a lack of fine motor skills and physical coordination. Difficulties with depth perception and hand-eye coordination indicate deficits in visuospatial skills. Those affected may struggle with math tasks, using maps, interpreting body language, socializing and relationship challenges, playing sports, or understanding physical objects in a spatial context. They may find it difficult to visualize concepts in their minds or solve problems requiring visual imagery. Challenges with organization, attention, executive functioning, nonverbal communication, mathematical reasoning, and visual-spatial memory may also arise.
Other difficulties may include problem-solving, pattern recognition, understanding information, and organizing thoughts and concepts for application in planning or adapting to new situations. Social skills and communication difficulties can arise from an inability to interpret emotions through facial cues and body language. Unique speech patterns may also occur. Signals in social interactions are frequently overlooked, resulting in behavior or speech that is out of context or inappropriate for the setting.
Challenges with executive functioning appear when the skills necessary for problem-solving, organizing thoughts, planning, and executing actions are insufficient. Weaknesses in organization and planning may stem from an inability to break down a large project into smaller tasks or identify the necessary steps to start or complete a project. Occupational therapy and social skills groups provide valuable resources for intervention.
Being hyper or hyperactive, worried, or anxious, as often ascribed to ADHD, can be a prominent characteristic of DVSD. When relying more on verbal intelligence and intellect, there can be excessive activation (hyper-ness) because of diminished influence from the right brain area, which may offer a better perspective, presence, and calming effect. A good “workaround” for this imbalance or excessive activation is to take planned time-outs, exercise, walk in nature, meditate, or vacation to regain perspective.
Children and adults with NVLD can be marginalized, bullied, and isolated, facing social challenges and barriers throughout their lives. However, they may also have the advantage of superior verbal intelligence, cognitive processing abilities, and exceptional problem-solving, and speaking and writing skills, as seen in many scientists, professionals, analysts, artists, and individuals who excel in creative vocations and information workers (professionals who use data and information to drive success in their positions).
The brain’s neuro-structures can change through growth and aging, nurtured by the environment. This facilitates adaptation through learned workarounds and skill development. Where possible, other brain areas can compensate for those under-contributory or not readily available. DVSD symptoms or characteristics can become less apparent with aging. When people recognize these features that cause fewer or minimal problems, they can be referred to as traits or as verbally dominant learners rather than as having a disorder or disability.6
Tips and Points to Ponder
1. Be open-minded and flexible in your thinking and attitudes. Always look beyond our often restrictive or narrow reasoning, beliefs, or definitions to embrace broader perspectives and deepen understanding, making the unknowable more knowable. Be kinder and more receptive to new relationships, and embrace evolving wisdom, science, and paradigms to better care for ourselves and the planet.
2. Childhood and adult behavioral, mental, brain, and physical abilities, along with performance characteristics, observed from the early years of life, are often referred to as “neurodevelopmental” in nature. As individuals age, especially toward the end of life, similar declines and deficits are frequently classified as “neurodegeneration or neurodegenerative diseases.” Our reflection on diagnostic labels emphasizes the need to be open-minded to well-executed studies by credible academic researchers, advising therapeutic interventions proven effective by research and studies.
In Alzheimer’s, medications may be necessary for agitation, but only when environmental management is insufficient. Non-medication approaches include minimizing or eliminating potential triggers by modifying the environment and creating a schedule of enjoyable activities for the person.7
3. With the establishment of a diagnostic label such as Alcohol Use Disorder and the definition of the characteristics of the illness, there was a positive change in the recognition and acceptance of alcoholism, now referred to as Alcohol Use Disorder, as a condition with which more people could identify. Self-help groups emerged due to the limited and mostly ineffective treatment options available. They flourished because they successfully guided individuals into recovery and a substance abuse-free life.
Alcoholics Anonymous showed how healing and recovery are possible through fellowship, lifestyle changes, the power of support and positive intention, a sense of community, spirituality, and connectedness that goes beyond isolative personal ideas and limiting beliefs. An integrative medicine/psychiatry perspective looks beyond labels, symptoms, or characteristics to find understanding and positive treatment options for substance use problems.8
4. It is human nature to latch onto outdated ideas or beliefs about any issues involving disturbing traits, difficulties, dysfunctions, illnesses, and medical or psychiatric diagnoses. Science and knowledge can evolve, while ingrained ideas and beliefs can remain stagnant. Therefore, do your best to stay updated with reliable and trusted resources. Keep an open mind and stay as informed as possible through your research, study, and support from a trusted friend, adviser, or healthcare practitioner. Identify current changes you can implement or programs that meet your improvement nee
ds, and direct your attention and energy toward these areas where you can foster some benefit or necessary change.
Practice kindness and love towards yourself, accepting those aspects beyond your capacity to change, at least in the present moment. As expressed in the simple words of the Serenity Prayer, recited by Alcoholics Anonymous members, “God (Higher Power) grant me the Serenity to accept the things I cannot change, Courage to change the things I can, and Wisdom to know the difference.”
I appreciate your interest. Please share with others.
Thanks to Shan Parks, writer and editor, for his final edits and suggestions.
*To watch as a video podcast click below:
Content is created and published for educational purposes only and should not be a substitute for professional or medical services or guidance. Please always look for your healthcare provider's advice and care regarding medical or mental health concerns.
What Matters More for Longevity: Genes or Lifestyle? By Dana G. Smith 01/08/2025, https://www.nytimes.com/2025/01/08/well/longevity-influences-genetics-lifestyle.html)
Centers for Disease Control and Prevention, Diagnosis of ADHD. https://www.nytimes.com/2025/04/13/magazine/adhd-children-research-takeaways.html
Have We Been Thinking About ADHD All Wrong? With diagnoses at a record high, some experts have begun to question our assumptions about the condition and how to treat it. By Paul Tough, Apr 16, 2025, https://www.nytimes.com/2025/04/13/magazine/adhd-medication-treatment-research.html
Cognitive Styles Vs. Learning Styles: https://classroom.synonym.com/cognitive-styles-vs-learning-styles-8109736.html
Report of a Work Group on Nonverbal Learning Disability: Consensus Criteria for Developmental Visual-Spatial Disorder: Re-conceptualizing Nonverbal Learning Disability for DSM Consideration - Journal of the American Academy of Child & Adolescent Psychiatry, https://www.jaacap.org/article/S0890-8567(25)00014-0/fulltext
Medscape CME Part of Clinical Advances in Diagnosis and Management of Agitation in Alzheimer’s Disease: https://www.medscape.org/sites/advances/alzheimer-agitation?sso=true&uac=372718HX&src=mkmcmr_reeng_recap_mscpedu_activity#ca-section-4
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