Attention-deficit/hyperactivity disorder: are we helping or harming?
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6172 (Published 05 November 2013) Cite this as: BMJ 2013;347:f6172
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The article is generally welcome as reinforcement of NICE guidelines on ADHD.
Some comments about its more specific claims are made:
1. Overdiagnosis is a generalised issue, even in the self-assured proponents of 'physical' medicine. Pathologists report overdiagnosis in general hospital medicine in 25.4% of cases, as high as 57.7% in MI, and 61.8% in pneumonia [1].
2. Clinical subjectivity of impairment. This is true of most medical conditions than we allow ourselves to think. How many times have we seen that severely pathological slides of plaques and tangles are often not associated with much clinical impairment in dementia, and vice versa? Ditto endometriosis. Pain, the basic beginning of much medicine, is also a psychological matter, but we readily prescribe medication for it, including very addictive opiates, when pathology could never predict its severity.
To pretend that practising medicine is some one-dimensional objectively arbitrated science, is to deny its basic humanity.
3. Increases in prescription rates is a misleading marker of overdiagnosis, and the authors must know this. Most adult ADHD clinics in the UK have only been set up over the last 5 years. In our clinic's catchment of 1 million, a conservative estimate of 2% prevalence, estimates 20,000 adults. We have seen less than one tenth of that, since we started. Would such a situation be tolerable if we were discussing a treatable cancer? Rises in prescription rates are related to rises in recognition in the first instance.
3. Effectiveness of treatment. Let's compare some data on general medicines, using the NNT as an arbiter. Amoxicillin has an NNT of 30, for treating LRTIs in primary care. Ramipril has an NNT of 67, for preventing stroke , over four and a half years of use [2] . ADHD medications have an NNT reported between 1.1, to 2.5 [3]. Yes, that's not a misprint. The treatment definitely works, in a manner that consistently surprises both clinical staff and patients. In my experience, so many adults benefit to such a night-and-day extent that their lives are transformed. Subjective? Maybe. Effective? Undoubtedly. And it isn't because the ADHD drugs are euphoriants or addictive- this is simply untrue for the dosages that we prescribe. [4]
4. More 'open-ended' definitions as a cause of oversiagnosis. DSM5 uses 'interfere with or reduce the quality of social, academic, or occupational functioning', instead of 'clinically significant' in DSM4. If anything, this is sympathetic to any disability. Consider dementia. I see nothing valid about diagnosis that is rated entirely on what we as clinicians call pragmatically defined impairment: the patients themselves experience it, and they are rightly the reference points of impairment, even given the (forced and false) dichotomy of choosing who is more right between us and them. In practice, both are involved. The DSM widens and grows, yes. But it is not a pathology instructional textbook so much as it is a glossary of definitions. Do people worry about the Oxford English dictionary getting bigger?
5. Commercial Influence. This is not unique to ADHD or even psychiatry. It is prevalent in all of medicine. Patient websites promoting 'causes' from erectile dysfunction to cancer care. Why pick on ADHD without a balanced reference to everything else? We are in the business of medicine whether we have commercial interests or not. If we were not, we would not be paid a salary or make a living based on what we do in healthcare. All medicine fields court the hand of Pharma in a perilous ballet. Picking on psychiatry is easy because it is invisible, but this does nothing to improve the stigma.
6. Adverse events of ADHD medications. Sneakily argued. No comparators are offered. Stimulants do not cause dependence, anaphylaxis, discontinuation syndromes, metabolic disorders, night-time coughs, or permanent extrapyramidal side effects. So, not like benzos, antibiotics, antidepressants, cancer drugs, diuretics, or antipsychotics. In the best study of long term stimulant use in children so far, the risk of sudden death was unquantifiable as it was not possible to separate it from other risky behaviours as a cause. It was, overall, very rare. [5]
7. Psychological harms. Again, an interesting and somewhat inverted argument is presented by the authors. Clearly, labels can be troublesome if they are taken to be used as excuses for bad behaviour. However, where a genuine impairment is concerned, the label is a massive relief. Many times in my clinic, young adults who never got the diagnosis as children describe the enormous relief they feel when they are given the diagnosis as adults, which is further vindicated when they report such massive, sustained gains from treatment.
Let’s use a visual analogy: If a child had short sightedness, but this was never diagnosed. He couldn’t do schoolwork, was clumsy, and kept losing things for reasons that were not obvious to him or others, and people didn't believe him, or worse still, believed that short sightedness was a made-up disorder, how good would it feel for him to finally have his eyes tested aged 22? The label of short-sightedness is welcome, relieving, and treatable, provided the right diagnosis is made, and the risks of overdiagnosing are not as perilous as those of underdiagnosing. Perhaps that’s why we overdiagnose pneumonia too.
We should realise we are in the 21st century, and disbelief in anything but the purely physical and easily observed, is akin to being still amazed that planes can fly without strings.
If people think that ADHD and its treatment is of a fashion, societal value-based, and unlikely to be sustained, let them assert this with the many ex-prisoners we see in clinic who describe being completely free of their impulses to be violent, to commit repeated crimes a result of simple treatment. Moreover, they report being dramatically transformed by treatment, going back to education, and finding work. In short, they are given their 'glasses'. Where an intervention is potentially effective as being able to reduce recidivism in prisoners by up to 42% in a study reviewing 25,000 cases [6], let's not have too much cartoonish villainy about the disorder or its treatment.
The headlines and over-argued cases set out by this type of article doesn’t help move things to a more rational debate, especially where even medical professionals are prejudiced against the matter.
[1] Gibson et al. Discrepancies between Clinical and Post Mortem Diagnoses in Jamaica. International Journal of Pathology. 2006, Volume 6, Number 2.
[2] Badrinath P. Preventing stroke with Ramipril. BMJ. 2002 August 24; 325(7361): 439
[3] Wigal S. Efficacy and Safety Limitations of ADHD pharmacotherapy in Children and Adults. CNS Drugs, 2009; 23 Suppl 1:21-31
[4] Kollins S. Comparing the abuse potential of methylphenidate versus other stimulants: A review of the available evidence and relevance to the ADHD patient. J Clin Psychiatry 2003: 64(supp-14-18)
[5] Gould M et al. Sudden Deatn and use of medication in youth., Am J Psych, 2009. A1A. (1-10)
[6] Larsson et al. N Medication for ADHD and Criminality. N Engl J Med 2012; 367:2006-2014November 22, 2012DOI: 10.1056/NEJMoa1203241
Competing interests: No competing interests
Thomas’s analysis focused extensively on different issues concerning the overdiagnosis and overtreatment of ADHD, and concluded that “the overdiagnosis of ADHD resides within the clinical subjectivity of impairment” [1].
We argue that the core issue lies in the fact that there are two different steps in which clinicians are required to quantify the impairment level. The first concerns the evaluation of symptom severity as part of the diagnostic path; the second concerns a global functioning severity assessment before deciding for a pharmacological intervention. Overtreatment could therefore depend not only on the diagnosis, but also on the assessment of the ADHD impairment severity when the disorder has already been diagnosed.
According to the new Diagnostic and Statistical Manual of Mental Disorders (DSM), clinicians should distinguish the severity of symptoms and functional impairment between mild, moderate, and severe [2]. As pointed out by McClure in a recent editorial, the evidence-based recommendations from NICE were that the pharmacological treatment be considered in cases of “severe” ADHD [3]. Thus the following is questionable: is the rising trend of stimulant prescriptions related to an increase in “severe” ADHD prevalence, even though NICE reports a stable 1% [4], or is it rather related to an inadequate assessment?
In clinical practice, the clinicians’ subjectivity is often intrinsic to the psychiatric area and plays a role not only in mental health diagnosis [5], but also in the wide variation in prescription rates by country, region, and even within the same city [6]. In the ADHD context, as Thomas and coll. pointed out, practice guidelines only suggest that a medical, psychosocial, and developmental evaluation should be carried out to define ADHD severity, leaving it up to individual clinicians to rate this impairment. Unfortunately, the categorical or dimensional types of classifications (such as mild, moderate, and severe) are more academic attitudes than useful approaches in/for the practice.
As in the Wolverhampton experience,[7] different initiatives were set up in local settings to oversee the implementation of the guidelines, but only a more systematic, shared, and widespread (national) approach can prevent (or reduce the risk of) the harms of overdiagnosis and disease mongering.
In June 2011, following a previous, national drug oriented registry set up in 2007 [8-9], an official regional registry was activated in the Lombardy Region in an attempt to limit the problems outlined above, guaranteeing appropriate ADHD management to each child and adolescent from the moment the disorder is first suspected or reported. In practice, a strict diagnostic assessment of the disorder prior to treatment, as well as its systematic monitoring during treatment, must be guaranteed by each of 18 local reference centres accredited by the regional health authorities.
An “Assessment Group” was established within the register’s Working Group, consisting of a clinician from each centre and a group of researchers at the Coordinating Centre (IRCCS-Istituto di Ricerche Farmacologiche “Mario Negri”). The aim of this group was to define a complete, evidence-based, shared assessment pathway for all children and adolescents aged 5–17 years who accessed any of the 18 reference centres for a suspected ADHD diagnosis. This pathway, consisting of 6 mandatory steps, including the Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) for a complete psychopathology overview and the Clinical Global Impressions scale for Severity (CGI-S) and Children's Global Assessment Scale (C-GAS) to quantify symptoms and global functioning severity, respectively, was agreed, approved, and shared (sometimes laboriously) by all centres. Moreover, because of the great concern about both safety and overuse of drugs and overdiagnosis in ADHD, the Coordinating Centre organises training sessions and discussion meetings for the reference centres’ clinicians. Further educational events are also provided for community pediatricians, families, and other health professionals to diffuse more comprehensive knowledge on ADHD that is based on recent, evidence-based practice and European guidelines.
In such a context, the prevalence rate of ADHD was stable at around 0.5‰ in the 6-17 year old population, and, from 2011 to 2012, the rate of drug users among children and adolescents with ADHD decreased from 24 to 16%. This trend is different from other Italian regions, and from other European countries and the US, where ADHD overdiagnosis and overtreatment had already started with the previous editions of the DSM. Thus, the message to be learnt from the Lombardy Region’s registry is that “limiting overdiagnosis and disease mongering is possible!” if adequate resources are available, appropriate training initiatives are taken, and patients’ interests in care guide the decisions (even those concerning the manual classifications).
1. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172–2.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. American Psychiatric Publishing ed., Washington DC, 2013.
3. McClure I. Prescribing methylphenidate for moderate ADHD. BMJ 2013;347:f6216–6.
4. National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder.
CG72. 2008. http://guidance.nice.org.uk/CG72.
5. Jackson T. Attention, please. BMJ 2013;347:f6697
6. Arango C. To treat or not to treat? and How to treat? Two questions whose answers are far removed from evidence informed practice in child psychiatry. Eur Child Adolesc Psychiatry. 2013 Sep;22(9):521-2. doi: 10.1007/s00787-013-0457-z.
7. http://www.bmj.com/content/347/bmj.f6172/rr/671574.
8. Panei P, Arcieri R, Vella S, Bonati M, Martini N, Zuddas A. Italian attention-deficit/hyperactivity disorder registry. Pediatrics. 2004 Aug;114(2):514.
9. Didoni A, Sequi M, Panei P, Bonati M; Lombardy ADHD Registry Group. One-year prospective follow-up of pharmacological treatment in children with attention-deficit/hyperactivity disorder.
Eur J Clin Pharmacol. 2011 Oct;67(10):1061-7. doi: 10.1007/s00228-011-1050-3.
Competing interests: No competing interests
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
Thomas and colleagues1 suggest that the recent rise in prevalence of ADHD may be caused by overdiagnosis or misdiagnosis and McClure and others 2.3. have highlighted the problems of subjectivity when the diagnosis depends on observational assessment.
NICE guidance states that the diagnosis of ADHD should be made following a full clinical and psychosocial assessment and not solely on the results of rating scales or observation and recommends that Trusts should form multi-disciplinary teams to oversee the implementation of the guideline4. In practice, rating scales are often regarded as providing objective evidence whilst they are in fact subjective depending on the opinion of the rater.
In Wolverhampton we have established a multi-agency group which includes education, social care, Child and Adolescent Mental Health Services,(CAMHS) and paediatrics and have developed an ADHD diagnostic pathway.
Children are referred from a variety of sources to specialist paediatric or CAMHS clinics.
An initial enquiry is made by the school’s educational psychologist (EP) to the class teacher. If there are concerns the EP will conduct a structured observation of the child comparing the time on task, distracted or impulsive compared with 2 reference children in the same class. This provides an efficient screening prior to more detailed assessment of those where there are concerns. Complex cases are discussed by the multi-agency group.
A recent evaluation of the pathway revealed that the school had no concerns in 65 of 137 initial enquiries (47%) Responses to the initial enquiry were usually received by the clinician within a few weeks enabling more appropriate referrals for behavioural and other support to be facilitated. Structured observation or assessment by the EP excluded ADHD in a further 7 children. Of the 45 children where concerns were raised by the EP, ADHD was confirmed in 19 (42%) and excluded in 9 in favour of alternative diagnoses: epilepsy (3), learning difficulties(3),dyspraxia (1), auditory processing disorder and dyspraxia(1) and constipation(1).
More than half the children referred for possible ADHD did not have the condition (72/137=52%). The ADHD pathway developed by our multi-agency group has provided an efficient and effective diagnostic tool which has reduced the waiting list for the specialist ADHD clinic and allowed referral to more appropriate services for those without ADHD with minimal delay.
angela.moore2@nhs.net
1. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
2. McClure I. Has NICE guidance unwittingly exposed a new challenge for assessing this condition? BMJ 2013;347:f6216
3. Timimi S. Over-prescribing methylphenidate won’t be cured by autism-style assessments BMJ 2013;347:f6622
4. Diagnosis and management of ADHD in children, young people and adults. Clinical guidelines, CG72 - Issued: September 2008 by NICE
Competing interests: No competing interests
Dr Cortese strongly supports the change in ADHD symptoms onset with age. He considers that prevalence in children should not increase significantly, “aimed at reducing false negative diagnoses in adults” (1). This sentence sounds to me euphemistic but it is quite correct, since the main reason for this change is clearly related to the growth of ADHD diagnosis in adults.
In fact, just a few days after DSM-5 criteria were adopted in the APA 2013 conference, several European countries headed by the UK authorised the new indication in adults for atomoxetine (Strattera, Lilly) (2). Conflicts of interest are playing a major role in this issue. Not only Dr Cortese has received support from Lilly, as he declares in his letter. Dr Rohde, for instance, cited by Dr Cortese in references 4 and 6, was a DSM-5 ADHD Work Group member despite the fact he declared support from Lilly (and other companies) in terms of honoraria, consultation and grants (3). Having in mind this kind of connection, in my view, it would be legitimate to wonder if potential influence of Dr Rohde (and also Dr Tannock (4)) in this work group should have been avoided. Definitely, transparency does not mean lack of bias. And this is not a new or unreasonable concern talking about ADHD. Dr Faraone and Dr Biederman, cited by Dr Cortese in reference 5 showed a really close link to Pharma interests when they accepted moving "forward the commercial goals of J&J” in their Johnson & Johnson Center Annual Report 2002 (5).
Age of seven was established when the disorder was considered typically hyperkinetic and characteristic of childhood (DSM-III, 1980) but arbitrariness is always a tempting possibility. To raise the threshold from seven to twelve seems to be based on practical reasons, making easier the adult diagnosis. So, what will be next? The times have changed a lot but, thinking about adults, has it been for the better? Regarding the validity of ADHD diagnosis in adults, we should take into account at least the following issues: a) adult ADHD criteria for diagnosis have been validated only in child population (6); b) symptoms are very different in childhood (more hyperactivity) and adulthood (more inattention) (7); c) the enormous comorbidity, even more than 90%, is also against the validity of the diagnosis (8); and d) unknown cardiovascular effects followed by ADHD medication use in adults in the long term is a matter of concern (9). In short, weak evidence. And unfortunately, atomoxetine shows weak evidence too. It has been approved for adults based mainly on three 6-months studies with high withdrawal rates, uncertain clinical significance and contradictory results (2).
The final conclusion would be that this scientific field urgently needs independent research, because it is the better road (the only one?) to raise relevant questions about ADHD without a trend to answer them in a biased way.
(1) Cortese S. Are the concerns about DSM-5 ADHD criteria supported by empirical evidence? http://www.bmj.com/content/347/bmj.f6172?tab=responses.
(2) www.mhra.gov.uk/home/groups/pl-a/documents/websiteresources/con020684.pdf
(3) www.dsm5.org/MeetUs/Documents/ADHD%202012/Rohde%20Disclosure-2012.pdf
(4) www.dsm5.org/MeetUs/Documents/ADHD%202012/Tannock%20Disclosure-2012.pdf
(5) http://psychrights.org/states/alaska/PsychRightsvAlaska/090324Opp2StayEx...
(6) Lahey BB et al. DSM-IV field trials for attention deficit hyperactivity disorder in children and adolescents. Am J Psychiatry 1994;151:1673-85.
(7) Serrano-Troncoso E, et al. Is psychological treatment efficacious for attention déficit hyperactivity disorder (ADHD)? Review of non pharmacological treatments in children and adolescents with ADHD. Actas Esp Psiquiatr 2013;41(1):44-51.
(8) Jensen PS, Martin D, Cantwell DP. Comorbidity in ADHD: Implications for Research, Practice, and DSM-V. J Am Acad Child Adolesc Psychiatry 1997;36(8):1065-1079.
(9) Mick E, McManus DD, Goldberg RJ. Meta-analysis of increased heart rate and blood pressure associated with CNS stimulant treatment of ADHD in adults. Eur Neuropsychopharmacol 2013;23(6):534-41.
Competing interests: No competing interests
According to Samuele Cortese [1], our concern [2] that changing the DSM-5 age of onset criterion from 7 to 12 is likely to increase the risk of misdiagnosing pubertal restlessness and distractibility as ADHD, is currently not supported by empirical evidence. Cortese refers to a prospective study by Polanczyk et al. [3] which showed that extending the age-of-onset criterion from 7 to 12 years resulted in an increase of ADHD prevalence of only 0.1%.
The ideal diagnostic criteria should minimise the risk of overdiagnosis, and at the same time minimise the risk of underdiagnosis – a false negative diagnosis. The problem is that increases can greatly exceed predictions when changed criteria are published and drug companies get involved [4]. In the words of Allen Frances, chair of DSM-IV: “The thing I learned with DSM-IV is that if anything can be misused, it will be” [5].
The required age of onset of 7 years was not set arbitrarily. DSM-III and DSM-III-R introduced this criterion to avoid misdiagnosing children who react with inattention, hyperactivity, and impulsivity to school stress [3]. Extending the age of onset criterion to 12 years increases the risk of society mistaking bad schools for ADHD in our children.
We acknowledge the Kessler reference [6] that points out that most people diagnosed as adults could not recall an onset before 7, but do recall an onset below 12. On the other hand, a prospective study by Mannuzza and colleagues [7] concluded that retrospective diagnoses of childhood ADHD made on the basis of self-reports will in most cases be invalid in settings such as epidemiological surveys and primary care facilities.
Getting this right is critical. In the United States population of 300,000,000 a seemingly negligible 0.1% increase in prevalence will result in 300,000 new cases [4]. In the United Kingdom (population 60,000,000), the number of new cases will be 60,000. The DSM 5 criteria have to be handled with care.
References
1. Cortese S. Are the concerns about DSM-5 ADHD criteria supported by empirical evidence? Response to Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172. BMJ 2013 published online http://www.bmj.com/content/347/bmj.f6172/rr/671232
2. Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
3. Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE. Implications of extending the ADHD age-of-onset criterion to age 12: results from a prospectively studied birth cohort. J Am Acad Child Adolesc Psychiatry 2010;49(3):210-216.
4. Batstra L, Frances A. DSM-5 further inflates ADHD. Journal of Nervous and Mental Disease 2012; 200(6):486-8.
5. Lopatto E. Psychiatrists Redefine Disorders Including Autism. Bloomberg 2012; Dec 3: http://www.bloomberg.com/news/2012-12-02/psychiatrists-redefine-disorder... retrieved at Nov 10 2013.
6. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):593-602.
7. Mannuzza S, Klein RG, Klein DF, Bessler A, Shrout P. Accuracy of Adult Recall of Childhood
8. Attention Deficit Hyperactivity Disorder. Am J Psychiatry 2002; 159:1882–1888.
Competing interests: No competing interests
ADHD is an increasing problem in working age group adults in the UK. This article focuses its attention on worldwide view particularly in children . The name of the diagnosis itself points to its DSM roots. In ICD 10 It is Hyperkinetic disorder. How many psychiatrists in the UK use the ICD10 name?
The children who had been diagnosed and treated with ADHD medications continue to be treated as adults. The current trend by some specialists is to prescribe ADHD medications than not to. The long-term impact of these medications on this population is to yet to be answered. Science is yet to prove how this treatment could be effective?
NICE guidance on these ADHD prescriptions requires that the special psychiatrist who should be prescribing should wait at least for 10 weeks before they start pharmacological treatment.(1) This should be provided along with CBT and general social skills training. Adults prescribed should have the choice of self-help group and other agencies information.
The Health and Social Care Information Centre's Adult Psychiatric Morbidity in England – 2007 survey estimated that 8% of adults in England have ADHD.(2) Despite this both in children and adults to prescribe the medications without further input from the treating services happens or name sake agencies are delegated .The psycho social approaches are not generally available . This has led to increase in prescriptions of psychostimulants by 11% in England and wales.
This over diagnosis has led one to disbelief in the diagnosis itself. The concept of ADHD has been challenged by Moncrieff J et al in her articles in BMJ and The psychiatrist. Until we have fool proof data for effectiveness of these medications we need to continue the process of questioning the validity of the diagnosis. Best wishes for such thought provoking and timely article (3)
Ref:
1. Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Clinical guidelines, CG72 - Issued: September 2008 by NICE
2. A survey carried out for The NHS Information Centre for health and social care
Edited by Sally McManus, Howard Meltzer, Traolach Brugha, Paul Bebbington, Rachel Jenkins
National Centre for Social Research and the Department of Health Sciences, University of Leicester
3. Is ADHD a valid diagnosis in adults? BMJ 340:547 Moncrieff J, Timimi S (2010)
Competing interests: No competing interests
Thomas et al.[1] are concerned that the recent change in the maximum age of symptoms onset in the ADHD diagnostic criteria (from 7 years in the DSM-IV [2] to 12 years in the DSM-5 [3]) may increase “the risk of confusing ADHD with normal developmental processes, such as pubertal restlessness and distractibility”. Whilst it is legitimate to be concerned about medicalising normal processes, I am not aware of any empirical evidence supporting such concern.
Indeed, a prospective study by Polanczyk et al. [4] conducted in a cohort of 2,232 British children showed that extending the age-of-onset criterion from 7 to 12 years resulted in an increase of ADHD prevalence of only 0.1%. If raising the maximum age of onset led to diagnose non-pathological behaviors as ADHD, one would expect a significant increase in the prevalence of this disorder. Additional results of this study are consistent with other research reports showing that individuals with retrospectively reported ADHD symptoms onset before or after 7 years do not significantly differ in terms of ADHD severity, comorbid disorders [5, 6], and outcome [7].
Such evidence supported the DSM-5 change in the age of onset criterion, aimed at reducing false negative diagnoses in adults. It has been shown that only 50% of adults referred for ADHD assessment retrospectively recall an onset of symptoms before age 7; on the other hand, 95% report ADHD an onset be¬fore age 12 [8]. However, the study by Polanczyk et al. [4] showed that adults who retrospectively report onset of ADHD between 7 and 12 years very likely had symptoms before 7 years. Therefore, keeping the maximum age of onset at 7 years would contribute to underdiagnose ADHD in a substantial number of adults.
The practitioner should also keep in mind that, to avoid labelling transitory processes as “ADHD”, DSM-5 criteria include a note specifying that “…symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level…”. Thus, DSM-5 criteria are unlikely to increase the risk of misdiagnosing pubertal restlessness and distractibility as ADHD.
In sum, the concern that the DSM-5 age of onset criterion contributes to confuse ADHD with normal developmental processes, leading to an inappropriate increase in the diagnosis of this disorder, is currently not supported by empirical evidence. However, as Thomas et al. [1] thoughtfully remind us, transitory restlessness and distractibility during puberty should be considered in the differential diagnosis of ADHD.
References
1.Thomas R, Mitchell GK, Batstra L. Attention-deficit/hyperactivity disorder: are we helping or harming? BMJ 2013;347:f6172.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text revision. American Psychiatric Publishing ed., Washington DC, 2000.
3.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. American Psychiatric Publishing ed., Washington DC, 2013.
4.Polanczyk G, Caspi A, Houts R, Kollins SH, Rohde LA, Moffitt TE. Implications of extending the ADHD age-of-onset criterion to age 12: results from a prospectively studied birth cohort. J Am Acad Child Adolesc Psychiatry 2010;49(3):210-216.
5.Faraone SV, Biederman J, Spencer T, Mick E, Murray K, Petty C et al. Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry 2006;163(10):1720-1729.
6.Rohde LA, Biederman J, Zimmermann H, Schmitz M, Martins S, Tramontina S. Exploring ADHD age-of-onset criterion in Brazilian adolescents. Eur Child Adolesc Psychiatry 2000;9(3):212-218.
7.American Psychiatric Association, 2013. http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf. Accessed: 09/11/13
8.Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62(6):593-602.
Competing interests: Dr Cortese has served as scientific consultant for Shire Pharmaceuticals from June 2009 to December 2010. He has received support to attend meetings from Eli Lilly and co in 2008 and from Shire in 2009-2010. There are no further conflicts of interest.
I think this publication is a well-balanced overview of the current state of affairs. As mentioned, overdiagnosis is becoming an disorder in itself. However I feel that too much emphasis is put on the impairments of ADHD. The reality is that ADHD can be a strength - if managed properly. This should be the focus in treatment, in contrast to current methods that inhibit personality development (and focus on the negatives).
I agree with prior responders in that the psychiatric status-quo is walking a dangerous path and are themselves becoming the epitome of 'conflict of interest'. As a result, they are undermining their own credibility. Big Pharma is playing a dangerous game with public mental health. This not just affects a selected few, but will affect a substantial part of the population (1 out of 10 is not insignificant).
I find the mass drugging of our children a frightening premise. Since the community has little longitudinal data on long-term effects, how dare they assume that such effects won't be detrimental? We don't know yet how current pathology affects brains, not to think of patients' mental dispair or even suicide. We don't know yet if sustained medications impacts our genes and offspring. And how does our ecosystem process drugged wastewater in the long run?
Why has natural selection allowed ADHD to occur for such a long time and why has it just recently become such a big problem?
Competing interests: I am editor at Selfdestination, a website that promotes sensible development based on innner strenght. I have recently written an article instigated by this publication.
Re: Attention-deficit/hyperactivity disorder: are we helping or harming?
Hyperactive syndrome and attention-deficit hyperactivity disorder (ADHD) treatment, from the perspective of the holistic method of Maria Summer, Rankweil/Austria.
ADHD children are constantly changing their mental mood. Sometimes, they exhibit behavioral disorders, even aggression.
Child hyperactivity leads it to chaos, because it moves in space without purpose.
"In nature, chaos would reign if every movement stopped, but the same would happen if the movement of beings lacked purpose." Maria Montessori
It's a mental mess, and this leads to lack of concentration-attention, as observed in children and adults with increased impulsivity and irritability.
This child is not receptive; it is not able to accept the commands of a parent, a teacher, or a speech therapist.
Since it is not paying attention, the child can neither be positively affected, nor proceed to knowledge.
Toddlers, at 6-10 years of age, still do not know how to play.
Playing is very important for spiritual growth and personality formation for a child.
"Without movement with purpose, there is no perception, learning or knowledge." Maria Summer (1984)
In hyperactivity, we should bring the child to movement with purpose. For this to happen, and for the child to learn to observe, they must first come into harmony with their breathing, experience tranquility and relaxation.
A hyperactive child is not growing spiritually, only physically.
It is wrong to be severe or punish hyperactive children, as this may exacerbate the problem and their disorders.
This method, developed and perfected by Maria Summer in Rankweil Austria, is for quick and effective treatment of disorders of speech, voice, breathing and learning, in approximately 60 sessions, without medication.
A child with hyperactivity is constantly anxious and presents respiratory tension, with characteristic high respiration (hochatmung).
The first steps in treatment are to bring peace, relaxation, harmonious breathing for the child.
In the beginning, we only try to make the child relax and pay attention, even for a second.
When we achieve this, we start reinforcing training exercises.
Later on, when we acquire attention for a longer duration, we assign some simple tasks to perform.
With relaxation and achievement of diaphragmatic breathing (i.e. low breathing), the child acquires a new boldness-presence.
Then, we can switch over to different exercises, targeting the acoustic and visual perception.
A couple of seconds or longer breaks are necessary for the positive outcome of any treatment.
Without the break, there can be no perception, attention-concentration, or learning.
Myokinetic exercises invented and perfected by Maria Summer are not gymnastics, rhythmic exercise, yoga, or meditation.
The therapist-educator or psychologist should remain calm, without any stress, with proper diaphragmatic breathing, in order to have a positive impact on the child.
Importantly, he/she should always remain lower in height, or below the height of the child.
We describe herein some exercises for hyperactive children with ADHD. Proper execution of these exercises is more important than quantity. Proper implementation is difficult to describe and must be experienced by each therapist in practical training sessions.
Position hedgehog (der IGEL) leads the child to complete relaxation, fetal position, cutting off most external stimuli, allowing it to concentrate on himself.
With chin to chest, head between legs, body curled forward, arms at sides, the child is kneeling in front of the therapist.
The therapist, at posture IGEL, is kneeling in front of the child's head on the floor.
With his/her fingers perpendicular, remaining perfectly calm, the therapist makes vibrations along the spine of the child, just aside of the vertebrae, from the bottom up to the head, whispering a hum (summen), in various tones.
mmmmmmmmmmmmmmmmmm…
mmmmmmmmoooooooooooooooo…
etc
The child, after a break of some seconds, repeats the hum, mimicking his therapist.
At IGEL posture, the child must slowly be rolled forward.
A big break, of 2-3 minutes, follows, on the floor, on a hard surface, no cushion, chin to chest, cheek leaning down, arms close to the trunk aside of the body, palms facing upward, feet very open, relaxed.
At this posture of complete relaxation-peace, we observe the child's breathing. We can spot the characteristic high respiration (hochatmung), by the vibrations of the back and shoulders of the child.
In this case, the expert therapist intervenes with various exercises and techniques in order to restore diaphragmatic breathing.
All this is done on the ground, on a hard orthopedic mattress, in a well-ventilated room, with the child wearing overalls and not clothes that restrict his/her movements.
All exercises for proper breathing function should not be conscious for the child, at whom we never mention the word "breathing".
At cobra posture, the child, from the ground face down slowly lifts his head, keeping the chin attached to the chest, and focuses his gaze, for a few seconds, at a distant point.
When tired, the child returns to the posture of complete relaxation-peace on the ground.
After a few sessions, when we observe improvement, we pass to attention-concentration exercises, on a wooden table.
Therapist and child are sitting side by side on a wooden table, with legs at right angles, hands one over the other at the edge of the table, their foreheads resting on their hands.
The wooden table is a good conductor of pulsations (resonanz) to be transferred from the therapist to the child.
With hums (summen) in different tones and styles, vibrations are transferred to the child from the therapist.
mmmmmmmmmmmmmmmmmm…
mmmmmmmmoooooooooooooooo…
etc
In turn, the child, having learned to wait a bit and listen, begins to repeat the hum mimicking his/her therapist.
Later on, we proceed in short-term tasks, like learning words, concepts, etc.
In some cases of hyperactivity the swing posture is appropriate. The child is hugged in our arms, in the fetal position, and slight oscillation is performed.
The therapist must remain completely calm, without breathing wrong.
In this hug, while gently shaking, the therapist murmurs hums, mainly with the letter mmmmmmmmm.
Maria Summer would return in the early stages of development when she understood that a child did not have the right experience.
Competing interests: Chasapis Athanasios studied, for many years, at the speech therapist Center and Institute of breathing run by Mrs. Maria Summer, and participated in many seminars for Advanced Speech Therapy abroad. He then transferred and extensively used these practices of the holistic method (speech-voice-breathing-attention-learning disorders-etc.) in his speech therapy Practice in Greece, from 1982 until now. He is the author of a forthcoming book in German, which describes extensively the pioneering holistic method of Mrs. Maria Summer, who died in 2007, without leaving a textbook behind.