Tuesday, 17 April 2012

ADHD (Attention-Deficit Hyperactivity Disorder)

ADHD: Please Pay Attention
(skip to the end for a bitesize summary)

‘ADHD is a condition that affects an individual’s ability to control attention and behaviour in an optimal and adaptive manner. It can cause individuals to become overactive and impulsive. The condition is frequently associated with educational underachievement, antisocial behaviour, and poor psychosocial adjustment.’ (Snowling and Hulme 2010). 

Attention-Deficit Hyperactivity Disorder is a story told in two parts: Hyperactivity/impulsivity (HI) and Inattention (IA). Individuals can be diagnosed with the predominantly HI or IA variety, but most are diagnosed with the combined type, hence AD+HD. More about the symptoms: NHS: symptoms of ADHD

ADHD is a hot topic. There are disagreements as to whether it is under- or over-diagnosed, and some even doubt its existence. Prevalence is in the range of 3-5% of UK school children and is more common in boys. Adults are also affected as the condition doesn’t diminish with age. 

Depending on your stance, it's caused either by: a deficit in executive functioning in the brain (control of inhibition and voluntary action thanks to dopamine and norepinephrine); an inability to defer gratification (called delay aversion), genes, or parenting styles.

Symptoms and diagnosis
  • To be diagnosed with ADHD, both symptoms of inattention and hyperactivity must be present in at least two different settings, e.g. at home and at school, for at least 6 months.
  • Clinicians are not required to observe children; rather, they rely on third-party accounts from teachers and parents, which surely plays a role in its misdiagnosis.

Adapted from Frederickson, N., Cline, T. (2009). Special Educational Needs, Inclusion and Diversity. London: OUP.

A lot of research has assessed commonly held beliefs that ADHD is under- or over-diagnosed. The latest[1] asked German psychiatrists to examine sample cases and give recommendations of diagnoses and treatment. Strikingly, the researchers found that gender played a role in likelihood of receiving a diagnosis of ADHD, with boys being more regularly misdiagnosed than girls because they fit the ‘prototypical criteria’ for the condition. These findings are pretty damning, although they are hardly comprehensive.  

Other research suggests that in fact global overdiagnosis is a myth. Sciutto and Eisenberg (2007)[2] found no justification for the claim that ADHD is overdiagnosed, pointing instead to public perceptions of the disorder.
Dr. Daniel Conner[3] offers some explanations of overdiagnosis:

·          Comorbidity (concomitant but unrelated conditions): as many as 75% of children diagnosed with ADHD also meet diagnostic criteria for other conditions like oppositional defiance disorder, depression, anxiety, and learning disorders. The trick is to tease out a set of symptoms specific to ADHD.

·          Inaccuracy: many clinicians are purported to use general rules of thumb and heuristics (trial-and-error methods) rather than relying on consistent diagnostic criteria. It seems that they rely on prototypical symptoms and characteristics, hence why boys are more likely to be diagnosed. 

·          Cognitive bias: this is an idea from social psychology whereby an individual actively seeks evidence that confirms his or her own theories and reasoning, “I’ve seen lots of kids with this condition, and you’re a lot like them, so you must also have it.”

·          Sex: as the German research shows, practitioners rely on prototypical criteria, which do not include girls. Girls are under-represented in this condition as they tend to display lower levels of disruptive behaviours, but are more likely to show inattention and social impairment.

In one study, children with late birthdays (making them younger than other classmates) were more likely to be diagnosed since their younger patterns of behaviour are misinterpreted. “We need to allow children to mature at different times and rates without pathologising these patterns”, says David Traxson[4]. He claims that DSM-5 will only exacerbate this problem.

Dr. Conner explains that before 1970 diagnosis of the condition was ~1%. Throughout the following decades the US government’s response to ADHD provided impetus for pharmaceuticals to begin feverish testing. In 2007, diagnosis rates were nearly 8%, but only 4.3% of these cases were prescribed medication. ADHD does not necessarily require medication, as there are plenty of other therapies available. Over-prescription is found in some regions, but it is certainly not a global problem. 

Does the rise from ~1% to 8% indicate overdiagnosis? Definitions of the disorder have changed since it was first described in 1902, with more focus being given to inattention by the 1980s. Broadening of the criteria necessarily includes more children in its scope, but does not represent overdiagnosis.

Recent findings[5] from Canada do indicate overdiagnosis and overmedication, suggesting that ADHD medications may be prescribed to deal with related conditions like oppositional defiance disorder (ODD) and conduct disorder. After all, criteria for these conditions are very similar.

Could there be a problem with the boundaries between these different disorders? If the same drugs work for ADHD, ODD, and conduct disorders, it is not possible that they are addressing the same problem, a common deficit running through each of them? It seems natural that kids with ODD who are argumentative, prone to tantrums, and are often angry and resentful would also be inattentive and hyperactive.

The legitimacy of ADHD as a disorder
So what’s the problem? Describing and explaining this disorder seems like pulling a square through a circular hole or struggling interminably to make a line of best fit. There are problems with its legitimacy in both public and scientific spheres, but I won’t go as far as Thomas Szasz in denying its existence, or indeed all other mental health disorders for that matter.

Social Construct Theory
A Social Constructionist explanation of mental illnesses or disorders is that they are not valid medical diagnoses, but rather excuses we have constructed in order to deal with socially unacceptable behaviour. Firstly, there are no robust neural correlates of ADHD. Secondly, comorbidity is extremely high (75%) which means that it can’t be considered a distinct disorder in its own right; it’s the leftovers of another disorder. And thirdly, ADHD is frequently associated with underachievement and poor psychosocial adjustment: The symptoms derive from these facts – how else would you expect poorly adjusted, low-IQ children to behave?

Our society has degraded to a point at which we can’t hold responsibility for this disgusting behaviour. There has been a ‘breakdown in the moral authority of adults’. The doctrine of ‘mother blame’ says that we use ADHD as a way of placing ultimate responsibility with the child’s primary attachment figure and their deficient child-rearing. Schools and teachers have lost grip and are not able to control children’s behaviour: a diagnosis of ADHD is a convenient way to relieve the burden on the classroom and the teacher. The pharmaceutical industry resides in shady corners, furtively offering Ritalin and Adderall to parents and clinicians seeking a quick fix.

In my opinion, what Social Construct Theory does is explain the views of the general public about the status of ADHD. What it doesn’t do is explain the disorder itself.

A Distinct Disorder
In fact, there are neural correlates of ADHD. It isn’t correct to emphasise dysfunction in any one region; the pattern is spread out, yet still distinctive[6]. Studies have consistently found patterns of frontal hypoactivity prefrontal cortices where executive function arises. There is strong evidence for the role of genes in development of ADHD. Research has also looked at endophenotypes – ways to inherit a tendency to develop ADHD which would be triggered by environmental or social factors. And actually, severe hyperactivity is a strong predictor of later psychosocial maladjustment rather than ADHD being the effect of it.

Dr. Connor puts it best:
“Doubt and confusion as to where this disorder fits into the general spectrum of illness further feeds the general perception that ADHD is a socially constructed disorder rather than a valid neurobiological disorder. This increases the public’s concern that ADHD is overdiagnosed and stimulants are overprescribed."

It appears that misdiagnosis is merely one part of the puzzle.

Attention-Deficit Hyperactivity Disorder is a slippery fish. To say that it (supposedly) affects so many people, it is poorly understood, and this is not helped by the general public’s acerbic criticism.
  • Is ADHD overdiagnosed? In some places, yes.

  • Why? It often occurs with other disorders that share symptoms, clinicians don’t tend to stick to strict rules, and they rely on prototypical criteria (like being male)

  • Is it overmedicated? Research suggests not, but ADHD medications may be used for related disorders, distorting the picture.

  • Some say that it isn’t a real disorder – explain. It’s seen as an excuse for slipping societal moral standards and bad parenting, which the pharmaceutical industry is cashing in on.

  • But some say it is a real disorder explain. Neurological studies have found distinctive patterns of brain function in people with the disorder, genes play a strong role, drugs have a significant effect in treating it, and it can predict later psychosocial maladjustment.

DSM: The Bible of Mental Illness

The Beleaguered DSM: a love story with consistency and classification
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been hailed as the ‘mental health bible’ for psychiatrists and other clinicians. It is used to diagnose mental health disorders such as depression, anxiety, ADHD, schizophrenia, bipolar disorder, autism, among many lesser-known maladies of the mind. The DSM is updated periodically, inevitably along with an increase in the number of diagnosable disorders
(see table). It has been dogged by criticism since its conception but has also served as a reflection of changing times; in 1980 DSM-III listed homosexuality as a mental disorder.

Good Intentions
Although collated and published by the American Psychological Association, the DSM is also used, or at least referred to, in the UK. Conceptually, it is wonderful; an all-encompassing one-stop-shop for clinicians to consistently diagnose mental health disorders...right? As Michael Conner [1] puts it, ‘the mere fact that any diagnostic system is reliable does not mean the process is valid, useful and not harmful.’ One particular sample of mental health patients found that diagnoses of schizophrenia ranged from 163 to 19 cases, depending on the interpretation of the diagnostic criteria used.

Conner sees mental health diagnostic processes as no less sophisticated than those used to diagnose headaches or inner ear problems. He distances subjective psychological problems from hard-nosed, matter-of-fact medical diagnoses of, say, cancer, wherein objective variations in biochemistry become arbiters of diagnosis instead. The premise is that subjective diagnosis, by definition, cannot be scientific and as a result the concept of consistency in psychiatry is flawed.

Publication Date
Major diagnostic categories
Possible Diagnoses

One need only look at the table above to recognise that they didn’t get it right first time. In fact, the biggest increase of possible diagnoses was between DSM-I and II. Post-WWII America was discovering its sensitive side by spending more time on the psychiatrist's couch. I think there is no doubt that history and culture played a part in fleshing out the DSM - what were doctors supposed to do with all those shellshock sufferers?

An Example
Before we move on, it may be useful to look at an example of how the DSM defines disorders. I have chosen diagnostic criteria for a Major Depressive Episode (depression). You needn’t read it all, but it’s just to give an idea of the layout and kind of information provided:

Diagnostic criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either:

  • (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 
  • (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) 
  • (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.  
  • (4) Insomnia or Hypersomnia nearly every day 
  • (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) 
  • (6) fatigue or loss of energy nearly every day 
  • (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 
  • (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 
  • (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide 

Taken from DSM-IV.

The Latest Addition to the Family
According to an FAQ on the specially set-up DSM-5 website [2], new technologies (primarily fMRI) and intensive research mean that the Bible must be updated. Surely no one would argue with this; it would be preposterous to ignore the tasty fruits of contemporary research. However, some have highlighted links between DSM-contributors and the pharmaceutical industry [3],[4] . Is the number of diagnoses being tampered with in order to deepen pockets? More possible disorders equates to a wider range of drugs to treat them, right? I am sceptical of this claim – they are clinicians after all, and wouldn't you be worried if they didn't have any links to the industry that bases its products on their research?

Further enquiry reveals that DSM-5 (which is getting rid of Roman numerals to be down with the kids), has been in pre-planning talks since the beginning of the 21st century. Even previous revisions were taken into deep consideration, being published 7 and 6 years respectively after their progenitors (I refer to DSM-III, DSM-III-R, etc). According to the website, “work groups (made up of global experts in various areas of diagnosis) have looked at what elements of the current edition (DSM-IV) are working well, what elements do not meet the needs of clinicians and how best to correct those concerns.” So at least they're trying.

Some recent recommended amendments include the collapsing of Autism, Asperger’s, Pervasive Developmental Disorder, and Childhood Disintegrative Disorder into one ‘overarching category of ASD [Autism Spectrum Disorder][5], as well as the reduction of personality types to six, including: antisocial, avoidant, borderline, narcissistic, obsessive/compulsive and schizotypal. “In the past, we viewed personality disorders as binary”, says Dr. Andrew Skodol[6]. “You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.” The Personality Disorders Work Group advocates a more dimensional approach, as opposed to a categorical one: as Dr. Skodol says, this kind of thing simply isn’t black or white as patients may exhibit characteristics that straddle boundaries.

Medicalising Normality
Chair of the DSM-IV task force and staunch opponent of the latest edition, Dr. Allen Frances has voiced his concerns that DSM-5 will “medicalise normality”[7]. He alludes to the over-diagnosis of ADHD (something I will blog about separately at a later date), ‘false epidemics’ of binge-eating and hypersexuality, and over-prescription of antipsychotic medication. In Psychology Today [8], he blames fads for apparent surges in overdiagnosis, but who is guilty of giving into the fad? Surely he must mean the psychiatrists themselves, since they are the ones who are doing the diagnosing. And is it never acceptable that certain conditions may be more prevalent today than previously?

Perhaps Frances' reaction is bitter and antagonistic since losing his former level of authority and control with the previous edition. Dyslexia was once scorned and laughed at as a pseudo-disorder. Today it is (pretty much) widely accepted by the psychological community of clinicians and researchers as a legitimate disorder, for which support is available. Dyscalculia, a congenital condition in which leaves the individual without a ‘basic feel for number’, is "rather where dyslexia was thirty years ago"[9]. In other words, its existence is disputed, although it is listed in DSM-IV as 'mathematics disorder'.

A disorder is simply a label for a specific set of symptoms or characteristics. Unfortunately we’re all too aware of what can happen to labels, namely negative associations and inappropriate use. I have heard people complaining – yes, complaining – that the label ‘dyslexia’ used to be commonly known as ‘stupidity’. People bemoan the fact that they have one less way to offend others who would formally have been openly subject to another label: stupid. While we’re at it, dyslexia bears no correlation with intelligence.

My stance is that advances in diagnostic tools and research have allowed us to investigate the previously arcane and clandestine workings of the mind. A lot of time and resources have been poured into researching cognitive faculties of people who struggle with numeracy. The result has been the classification of a new disorder.

What is a disorder? It's a pattern (of behaviour) that is not considered part of normal development. In 1980 it was argued that homosexuality was indeed within normal development and variation, much to the chagrin of DSM-III authors. But here's the thing - homosexuality is not a disability. It doesn't represent a deficit in functioning or some kind of problem to be overcome. The point I'm trying to make is that a set of behaviours can and should be termed a 'disorder' if it negatively affects the individual's life.

So what's wrong with those 'false epidemics' of binge-eating and hypersexuality? Why is Frances so resistant? If we, as psychologists and fellow compassionate humans, can do anything to help these individuals, why would we deny them this?

Sunday, 15 April 2012


My name's Chris and I've set up this blog for the purpose of thinking aloud*. A broad title entertains a broad remit, giving me scope to write about everything and anything that interests me. My interests include: psychology, cognition, learning, neurology, dyslexia, ADHD, autism, psycholinguistics, mental health, anxiety and depression, schizophrenia, education, special educational needs, inclusion, the human condition, and everything in between! Of course this is just to start out with; I'm continually adding to the list.

My aim is to post news stories and research related to any of the above, or indeed that interest me. I'd appreciate any input, so please don't hesitate!

*As 'thinking aloud' wasn't available as a URL, I chose 'edupsych1', giving away my aspirations to become an Educational Psychologist or researcher in the future.