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More attention to a hyperactive diagnosis

More attention to a hyperactive diagnosis

On writing about ADHD I learned a lot about the perspective of child psychiatrists about the disorder more
On writing about ADHD, I had to discuss the criteria of its diagnosis with a few child psychiatrists. I was impressed to find that there are boiling issues behind this diagnosis. The diversity was so impressive to the extent that it warrants special attention.

The first thing that captured my attention was the child psychiatrists reactions to the Diagnostic Statistical Manual 5th edition (DSM-5). For some child psychiatrists, it is an improved level of care. Some saw other classifications too narrow with potential of missing some cases for simply not fuilfilling the criteria. They perceived that subdivision of mild, moderate and severe as a more streamlined, reality oriented diagnosis that captures the essence of the diagnosis. Others saw that it has the potential of blurring the border between a disorder and a non-disorder, they also had concerns about a false positive diagnosis by non-trained personnel. The generations' long debate about the presence of a dimensional classification as compared to a categorical, stratified categorical or quasi-dimensional apparently is viable with ADHD.  In contrast to both camps, another child psychiatrist highlighted the fact that ADHD is essentially a clinical diagnosis that has to be learned via a senior doctor and gradually the doctor would develop an 'informed clinical sense' about the disorder. To one doctor, the diagnostic criteria are guidelines and not the final word; to the other, this is a recipe for decreased uniformity of practice. The diagnostic criteria are to be followed even if they are not fully convincing and any grievances should be communicated in appropriate channels. The triad of inattention, impulsivity and hyperactivity together with other demarcations, and important negatives is apparently crystal clear for some and mysterious for others.

Voices from outside the field had concerns about the apparent lack of histrocity of the diagnosis, as the apparent earliest recording of a similar diagnosis was early 20th century, Furtermore, there are some differences in the incidence and prevalence of ADHD across different cultures. An educational psychologist voiced concerns about the educational system inquiring are our schools boring? is this the child's way to express boredom. Her concern was focused on the apparent ability of a child with ADHD to focus while playing video games. 'Did we grow intolerant to our children?' is another concern with the rising trend of diagnosis and the differences found in epidemiological studies. On the other hand, a child psychiatrist questioned the presumption that the prevalence is 'expected' to be the same world wide, saying 'Huntington's Disease is an autosomal dominant disorder and there are even more variability in its incidence and prevalence world wide, without any doubt about the validity of the disorder or the reliability of the diagnosis'. Another doctor responded saying 'perhaps, it is as simple as this: we are now better at diagnosing ADHD'. She further added 'the medical field is talking pre-diabetic, pre-hypertensive, mild cognitive disorder. A few decades ago, none of these existed'.

I thought that receiving the diagnosis of ADHD and having treatment supervised at school sometimes can be stigmatising. A child psychiatrist, informed me that there is another aspect of stigma, which is the stigma of 'not-receiving a diagnosis'. From her experience, she stated that a child with a missed diagnosis of ADHD is 'often' perceived as a disruptive, poorly achieving child. The child is subject to repetitive scholastic failures, bullying, and alienation due to unusual and occasionally erratic behaviour. The diagnosis, does not only help instigate treatment but also may help to educate teachers about the best way to identify and handle this disorder with a diagnosed child and help spot new cases early. The doctor further added the behaviour is sometimes stigmatised; the label comes secondary to a cluster of behaviours; missing this and focusing on the secondary outcome of behavioural changes, then challenging the diagnosis as labelling and stigmamay be missing the point.

DRD4 was the subject of a new MSc. thesis about the peripheral biomarkers of ADHD. A child psychiatrist did an effort to find more about the genetic role in ADHD. The field seems promising and if necessary progress appear it might be a breakthrough in the history of psychiatry and a potential termination of critical psychiatry movements in criticism of this diagnosis. Despite the potential for a biomarker, some child psychiatrists showed worries that the diagnosis should remain a clinical one. The scholastic, family, and social impairement are detrimental for the diagnosis and the need to address them immediately is a more immediate answer than waiting for lab. results. The issue seems not to be specific for ADHD. It rather encompasses the essence of an ongoing debate of the existence of diagnostic clusters in psychiatry based on descriptions.

The logical sequence of giving a diagnosis is prescribing treatment. With regards to psychosocial interventions, psychoeducation, support groups and other psychotherapeutic interventions. There seems to be some consensus about the apparent harmlessness and potential benefit. In contrast, medications prescribed for ADHD seem to receive criticism from outside the field raising concerns about psychiatry, psychiatrists, parents and the social system in general. The debate about effects and side effects is such an endless argument between the low NNT of drugs like Methylphenidate and its side effects a schism is created between supporters and critics.

After a presentation about the neuroimaging findings in ADHD, the presenter ended by saying 'What is the current clinical significance of this presenation; I dare saying nothing currently'. Equal frustration is voiced by many psychiatrists due to the seemingly slow progress in changing the clinical practice. A child psychiatrist told me once 'I cannot stop dreaming about a day where there is a biomarker, a cure rather than an effective treatment', another doctor responded 'a vaccine may be; or having no disorder at all or would that be far fetched'. The leap to the future is a hope and equally an escape.

The diversity of issues from educational reform, parenting, stigma, biomarkers, diagnosis, and treatment are occasionally too much of issues for anyone who is involved in the field of mental health.  Yet, the responsibility of mental health professionals as gate-keepers to mental health makes working through these aspects a rather needed path that is worth more attention in such a hyperactively moving field that is stretched between mental health, society, teachers and parents.

01. Badawy, H., personal communication, 2013
02. El-Islam, M.F., personal communication, 2013
03. Thomas R, Mitchell GK, B.L., Attention-deficit/hyperactivity disorder: are we helping or harming?, British Medical Journal, 2013, Vol. 5(347)
04. De Zeeuw P., Mandl R.C.W., Hulshoff-Pol H.E., et al., Decreased frontostriatal microstructural organization in ADHD. Human Brain Mapping. DOI: 10.1002/hbm.21335, 2011)
05. Diagnostic Statistical Manual 5, American Psychiatric Association, 2013
06. Diagnostic Statistical Manual-IV, American Psychiatric Association, 1994
07. International Classification of Diseases, World Health Organization, 1992
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