Daydreaming Is Not a Disorder

With ADHD diagnoses up 42 percent in a decade, we’ve got a new diagnosis to worry about: SLT, or ‘sluggish cognitive tempo.’

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Daydreams? Check. Absent-minded? Check. (Two checks on that one, probably.) Attention fluctuates? Check.

It seems there is no escaping the truth. I have sluggish cognitive tempo (SCT).

This really isn’t a surprise to me. I lost track of time the other day because I found the various U.S. State Department warnings about travel to dangerous countries endlessly fascinating, and couldn’t seem to stop clicking on them. (Not that I was planning to visit North Korea, but learning exactly how the government tries to talk people out of it was captivating.) As a kid, I was constantly turning assignments in late. If I don’t force myself to attend to paperwork immediately when I receive it, it languishes in various nooks for indefinite periods of time.

Up until now, I’ve simply considered myself scatter-brained. But no longer! No, now I can safely give myself the diagnosis of SCT, which seems much tidier.

As reported by Peter Aldhous in Slate, SCT and the controversy surrounding its legitimacy has moved from the realm of academia into the media mainstream. Typified by complaints such as a tendency to daydream, be easily bored, and lose one’s train of thought, the question of whether SCT is a subtle form of ADHD or its own discrete diagnosis was the focus of several articles in a recent issue of the Journal of Abnormal Child Psychology.

Color me a deep shade of skeptical.

When parents bring their children in to see me, quite frequently they have concerns about some aspect of their child’s behavior. Sometimes the problems are severe enough that there isn’t any real doubt that there is some kind of disorder at play. But oftentimes the issues are subtle, and the parents are turning to me to ascertain if they are diagnosable or merely related to the kid’s temperament.

As a rule, I am chary about doling out diagnoses unless there is a clear indication to do so. Human beings are endlessly complex creatures, and there is a wide range in normal behavior across a number of domains. Some traits are considered more socially valuable, such as gregariousness, but that doesn’t mean there’s anything wrong with the child who is a little bit shy and takes a while to warm up to new people and experiences. Most of the time I am able to reassure the parents, and offer suggestions for helping their children adapt and function while still retaining a sense that it’s okay to be true to themselves.

Whenever this kind of question arises, the most salient criterion I consider when weighing temperament vs. disorder is whether or not there is any impairment present. The more solitary child who is content to spend most of his free time alone but is capable of making and keeping friends is different from the one who is unable to form interpersonal relationships. While certain temperamental traits may present challenges in different settings, that’s not the same thing as a disorder that significantly interferes with a patient’s quality of life or ability to function.

One of the prominent proponents of SCT as a diagnosis gestures toward impairment, but seems to have a very loose idea of what should count. Russell Barkley, a psychologist at the Medical University of South Carolina is quoted by Slate saying “Is SCT posing enough of a harm to an individual in order to be called a disorder? That is the question.” But then he goes on to tell Aldhous “I champion the treatment of those who are impaired, even if they are on the margins of the diagnostic criteria.”

The fewer diagnostic criteria required to call a person impaired, the more “any difficulty whatsoever” can be deemed impairment.

There are two major problems with this approach. By labeling as disordered any deviation from a restrictive, palatable definition of normal, we communicate to children who thus deviate that there is something wrong with them. The more children we pin with diagnoses, the narrower our understanding of normal behavior will become, and the less tolerant we will grow of any behavior that does not conform to it.

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Which leads to the converse problem of treating children for disorders they do not have. As this horrifying article in the New York Times reports, some doctors are doling out stimulants for their poorer patients merely to boost their academic performance, whether or not they truly believe these children have ADHD. (I wonder what Barkley, who disputes the notion that ADHD is over-diagnosed, would have to say about it.) On the opposite end of the socioeconomic scale, periodically I will see adolescent patients of affluent parents who would like me to consider a prescription for a stimulant to help boost their academic performance. These kids are typically already getting good grades, but their attention sometimes wanders in class, a phenomenon that is apparently no longer a tolerable state of affairs. SCT seems veritably tailor-made for these situations. It’s already hard enough to dissuade these parents from a prescription, and I may as well fork over the pad if the bar is merely going to drop lower anyway.

Do some kids struggle more than others to attend to tasks, both academic and household? Of course. Some of these children have legitimate disorders that warrant diagnosis and treatment. But with ADHD diagnoses up 42 percent in the past decade, comprising 11 percent of American children last year, the very last thing we need is to be diluting the criteria for making the diagnosis, or adding new diagnoses to describe normal behavior. As one article critical of skeptical discussion of SCT makes clear, it is a long way from becoming a widely accepted diagnosis. Frankly, I hope it never arrives.

Some kids are prone to letting their minds wander and daydreaming. Sometimes that gets them into trouble. That doesn’t mean we should be calling it a disorder, or trying to medicate it away.