The ADHD Diagnosis

Can anyone doubt that the spreading of the ADHD diagnosis across America—and soon the world—has more to do with marketing than with treating a genuine disease  

Seemingly reputable sources like the New England Journal of Medicine bandy about statistics such as ADHD is the most common childhood psychiatric disorder, affecting 4 to 10 percent of young people in the United States, with as many as half of them continuing to have symptoms into adulthood (Kadison, 2005). 

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Today, parents embrace the ADHD diagnosis with relief because, following the prevailing theory, they accept that the... 

RAMIFICATIONS OF THE ADHD DIAGNOSIS Destructive Behavior Disorders... 

Kean, B. (2005). The risk society and attention deficit hyperactivity disorder (ADHD) A critical social research analysis concerning the development and social impact of the ADHD diagnosis. Ethical Human Psychology and Psychiatry, 7, 131-142. 

Arriving at the ADHD diagnosis is particularly problematic when you consider that not all children diagnosed with ADHD show the same behavior, and that some toxins produce some but not all of the behavior of the ADHD disorder. For example, fetal exposure to alcohol can produce fetal alcohol spectrum disorder, but some of the symptoms of that disorder are very similar to some of the symptoms of ADHD. 

Attention Deficit-Hyperactivity Disorder (ADHD). Only recently has ADHD been added to the differential diagnosis of BPAD. ADHD was long considered a childhood illness that resolved before adulthood. Moreover, the onset of BPAD was long believed to occur exclusively during adulthood. Both of these statements are now known to be untrue. Many of the symptoms of ADHD persist into adulthood. Meanwhile, an increasing number of child psychiatrists and epidemiologists have noted that the onset of BPAD not infrequently occurs in children before they reach puberty. 

In their book Beyond Ritalin, Garber and colleagues suggest several steps in the gathering of information toward an ADHD diagnosis. A modified version of their approach is as follows ... 

The doctor hesitated. If the severity were stretched a little, Leslie s symptoms could qualify her for an ADHD diagnosis. Yet she was not really handicapped by the symptoms, since she was getting good grades and her social life was normal. 

Wc look at the diagnosis of psychological disorders in Chapter 13, but the ADHD controversy is certainly a thorny one. What seems clear is that although many of the symptoms of ADHD (inattention, fidgeting, restlessness) arc indeed common to virtually all children (and adults), Ibr some children these problems are far more severe and debilitating. 

The diagnosis of ADHD frequently occurs when other disruptive behavior disorders are diagnosed. As in many other diagnoses in pediatric psychiatry, the ambiguities involved in ADHD diagnosis mean that estimates of prevalence are loose at best. The high end of prevalence estimates is 10 percent, the low end 3 percent. 

All the children from both ID and IS areas were euthyroid at neonatal screening and afterwards (18—36 months and 8—10 years). Neuromotor evaluation revealed no signs of neurological impairment in any of the children. The diagnosis of ADHD was confirmed in 2001 and 2002 in all 9/16 ID area children in whom it had been previously suspected, and in a further 2 children in whom it had not been suspected in 1994. None of the 11 IS area children were affected with ADHD, since the tentative diagnosis made in 1994 for one of them was not confirmed in 2001-2002. 

Psychostimulants (e.g., methylphenidate and dextroamphetamine with or without amphetamine) are the most effective agents in treating ADHD. Once the diagnosis of ADHD has been made, a stimulant medication should be used first line in treating ADHD (Fig. 39-1). Stimulants are safe and effective, with a response rate of 70% to 90% in patients with ADHD.3,13,14 Generally, a trial of at least 3 months on a stimulant is appropriate, and this includes dose titration to response... 

Growth suppression or delay is a major concern for parents of children taking stimulants. However, the evidence of this side effect is not dear. At present, growth delay appears to be transient and to resolve by midadolescence, but more data are needed to firmly resolve this issue.10 Another concern is the risk of substance abuse with stimulant use. A diagnosis of ADHD alone increases the risk of substance abuse in adolescents and adults. However, stimulant use has not been shown to further increase this risk but actually may decrease this risk, provided ADHD is treated adequately.15... 

Attention Deficit Hyperactivity Disorder (ADHD) A learning and behavioural disorder characterised by reduced attention span and hyperactivity. ADHD is a diagnosis applied to young children and is typically treated with the amphetamine derivative methylphenidate (Ritalin). 

Althongh some gronps have used the controversy snrronnding ADHD as a platform to attack the nse of psychiatric medications as a whole, we should not in onr haste to dismiss snch perspectives overlook the fact that these are fair and reasonable qnestions. For that reason, we will try in this chapter to address these questions as we discnss the diagnosis, the long-term conrse, and the treatment of ADHD. The treatment options have recently expanded with the FDA approval of atomoxetine (Strattera), a selective norepinephrine renptake inhibitor that is not a psychostimn-lant, for the treatment of ADHD. 

A diagnosis of ADHD requires not only the presence of symptoms with an onset in childhood, but also a degree of distress and/or dysfunction associated with them. 

Evaluating a Child. Parents will often bring their children with the expectation that someone can test them for ADHD. It is true that certain tests can help in the initial assessment however, no single test or even battery of tests can alone make the diagnosis. Instead, this diagnosis is made only after collecting a thorough database of information from the child, his/her parents, and teachers. 

Differential Diagnosis. With a careful assessment and a dependable history, one can reliably diagnose ADHD (even in an adult who was never diagnosed as a child). However, the broad array of symptoms results in a rather wide differential diagnosis. Please consider each of the following when trying to determine if a patient has ADHD. 

Pervasive Developmental Disorders. Children with autism or one of the other pervasive developmental disorders can be impulsive and inattentive much like those with ADHD. However, the severe social disability and language problems of children with an autistic disorder usually far exceed that of ADHD. These differences are usually sufficient to clarify the diagnosis. When one is unsure, neuropsychological testing can help clarify matters. 

Starting Treatment in Children. The importance of an accurate diagnosis confirmed by obtaining information from multiple sources cannot be overstated. The mainstay of treatment for ADHD, psychostimulants, are less helpful for the other disruptive behavior disorders of childhood and may worsen the course of bipolar disorder in patients misdiagnosed with ADHD. 

When these measures have failed and impulsivity and aggression remain a problem, additional strategies are available. First, reconsider the diagnosis. Does the patient have bipolar disorder rather than ADHD Is there another disruptive behavior disorder in addition to or instead of ADHD Does (s)he have an impulse control disorder In these more severe cases, other medications such as atypical antipsychot-ics or mood stabilizers are often helpful. 

A child with attention-deficit hyperactivity disorder [ADHD] and conduct disorder is treated with 45 mg/d of methylphenidate and 2 mg/d of risperidone. A new diagnosis of complex partial seizures is made and the child is started on carbamazepine. About 10 days after the initiation of carbamazepine, the child develops withdrawal dyskinesias of mouth and tongue. After discontinuation of carbamazepine, the movements last for 1 week. 

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