Re: Attention-deficit/hyperactivity disorder: are we helping or harming?
In their helpful overview, Thomas et al explain that ADHD is probably being overdiagnosed because ascertainment of degree of impairment (as mild, moderate, or severe) is subjective and therefore unreliable1.
However, the ADHD concept itself is inherently subjective. ADHD is diagnosed according to the recorded presence (or abscence) of attention deficit, hyperactivity and impulsivity. These are all behavioural signs observed by informants (parents, teachers) or the clinician and then rated (as being present or absent) subjectively. They are rarely spontaneously complained about by the child or adolescent patient and are not therefore symptoms.
In other child or adolescent psychiatric conditions, the pitfall of observer subjectivity is tempered by the possibility of patient self report. In depression, anxiety, eating disorders or psychosis, the patient both experiences and complains of symptoms. They are aware of their differences of thinking or feeling (which, in turn may affect their behaviour). Additionally, in some neurodevelopmental psychiatric conditions, the thinking differences which cause behavioural difference are directly assessable, such as the reduced empathy found in autism or the cognitive impairments of intellectual disability. In many cases, such thinking differences are also self-reported.
In its current construct, ADHD cannot consistently deliver this extra layer of clinical information. Decades of ADHD research have not even attempted to deliver valid and reliable measurement of the patient’s subjective experience2. Despite this, DSM-5 has continued the expansion of the ADHD paradigm1 3.
Why have child psychiatrists allowed purely behavioural constructs, such as ADHD, to become labelled as ‘psychiatric’?
It is time for psychiatry to get back to thinking about thinking.
1 Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172–2.
2 McClure I. Prescribing methylphenidate for moderate ADHD. BMJ 2013;347:f6216–6.
3 Association AP. DSM-5 Development. www.dsm5.org. http://www.dsm5.org/Pages/Default.aspx (accessed 6 Jan2013).
Competing interests:
No competing interests
21 November 2013
Iain McClure
Child & Adolescent Psychiatrist
NHS Lothian
The Esk Centre, Ladywell Way, Musselburgh, EH21 6AB.
Rapid Response:
Re: Attention-deficit/hyperactivity disorder: are we helping or harming?
In their helpful overview, Thomas et al explain that ADHD is probably being overdiagnosed because ascertainment of degree of impairment (as mild, moderate, or severe) is subjective and therefore unreliable1.
However, the ADHD concept itself is inherently subjective. ADHD is diagnosed according to the recorded presence (or abscence) of attention deficit, hyperactivity and impulsivity. These are all behavioural signs observed by informants (parents, teachers) or the clinician and then rated (as being present or absent) subjectively. They are rarely spontaneously complained about by the child or adolescent patient and are not therefore symptoms.
In other child or adolescent psychiatric conditions, the pitfall of observer subjectivity is tempered by the possibility of patient self report. In depression, anxiety, eating disorders or psychosis, the patient both experiences and complains of symptoms. They are aware of their differences of thinking or feeling (which, in turn may affect their behaviour). Additionally, in some neurodevelopmental psychiatric conditions, the thinking differences which cause behavioural difference are directly assessable, such as the reduced empathy found in autism or the cognitive impairments of intellectual disability. In many cases, such thinking differences are also self-reported.
In its current construct, ADHD cannot consistently deliver this extra layer of clinical information. Decades of ADHD research have not even attempted to deliver valid and reliable measurement of the patient’s subjective experience2. Despite this, DSM-5 has continued the expansion of the ADHD paradigm1 3.
Why have child psychiatrists allowed purely behavioural constructs, such as ADHD, to become labelled as ‘psychiatric’?
It is time for psychiatry to get back to thinking about thinking.
1 Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172–2.
2 McClure I. Prescribing methylphenidate for moderate ADHD. BMJ 2013;347:f6216–6.
3 Association AP. DSM-5 Development. www.dsm5.org. http://www.dsm5.org/Pages/Default.aspx (accessed 6 Jan2013).
Competing interests: No competing interests