Tag Archives: Attention Deficit Hyperactivity Disorder

ADHD


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With the increased prevalence of ADHD in the Western world, there is an immediate and pressing need to justify and explain the underlying cause of explosive growth in the ADHD population.  This justification comes with high stakes, since critics of the pharmaceutical industry and psychiatry in general have implicated greed on the part of North American mental health providers.

At stake is ADHD’s identity as a bona fide mental disorder (as opposed to a social construction).  When initial reports of ADHD prevalence emerged, higher prevalence in North American than European samples was remarked upon. This observation spawned a 10-year debate, exemplified by articles with titles such as “Is Childhood Hyperactivity the Product of Western Culture?” and, more recently, “ADHD Is Best Understood as a Cultural Construct?”  Having an explanation for inconsistencies in the cross-national prevalence of ADHD is important because such inconsistencies fuel assertions that ADHD is a fraud propagated by the “profit-dependent pharmaceutical industry and a high-status profession [psychiatry] looking for new roles.”  (Moffitt & Melchior, 2007)

Later, in the same article, it is suggested that prevalence in North America is elevated primarily because of differences in the definition of ADHD.  Specifically, the DSM-IV-TR is more lenient in its definition of ADHD when compared to the ICD-10.

The ICD-10 strictly requires that a child must show symptoms in all three dimensions (inattention, hyperactivity, and impulsivity) and must meet all criteria at home and at school. The ICD-10 also excludes children with co-occurring disorders. DSM-IV is more lenient. It is possible to diagnose a child who shows symptoms in only one dimension (inattention). Some impairing symptoms – but not all- must be shown at home and at school. DSM-IV allows diagnosing ADHD alongside co-occurring disorders.  (Moffitt & Melchior, 2007)

Although differences in clinical definition can have an impact over space (geography), can they also have an impact over time?  Leon Eisenberg, M.D. would assert that the continued refinement of the definition has contributed to a broader interpretation of what constitutes ADHD.  Hyperkinetic reaction of childhood appeared as a category in DSM II in 1968.  It was not, however, until DSM III (1980) that attention-deficit/hyperactivity disorder (ADHD) entered the official lexicon.  (Eisenberg, 2007)  The end result is a shift from diagnosing the presenting features of ADHD as symptoms of other classified disorders, to a new and entirely separate diagnosis.  And so, ADHD was “staking a claim” to the prominent clinical features it encompassed, thus differentiating itself as a clinically valid diagnosis and not a sub-type of an underlying behavior disorder.  ADHD has morphed from a relatively un-common condition 40 years ago to one whose current prevalence is estimated to be just under 8% of U.S. children 4–17 years of age.  (Eisenberg, 2007, p. 283)

Societal expectations and parental influences continue to play a significant role in the search for the etiological roots of all pathologies, including ADHD.  We as a culture have a long history of implicating parental inadequacies in child psychopathology.  The continued search for biological causes serves to reinforce our convictions that we are indeed good parents.

In many public school jurisdictions, the diagnosis led to additional services for such children because of the implication that their problems were organic or endogenous, as opposed to psychological or psychogenic. For this very reason, parents welcomed it. Furthermore, the term proved they were not responsible for their child’s problems (no small victory at a time when parent blaming was widespread in child psychiatry and education).   (Eisenberg, 2007)

Parental pressures, when taken in conjunction with recent advances in brain imaging and the relative effectiveness of pharmacological interventions, have contributed to a “consensus that neurochemical imbalances play a central role in the etiology of ADHD.”    (Netherton, Holmes, & Walker, 1999, p. 103)  This biological model is further supported by evidence that, in a limited number of cases, “it can be acquired after birth, via head injury, neurological illness, elevated lead levels, and other biological complications.”  (Netherton et al., 1999, p. 103)

Recent technological advances in brain imaging have served as catalysts to futher underscore attempts to localize the etiology of ADHD in the brain.  In a recent morphological study of ADHD, researchers incorporated the novel measures of local shape, complexity, volume, and thickness and align structural MRI with other imaging modalities, such as the delineation of white matter tracts by diffusion tensor imaging and maps of brain activation generated by functional MRI.  The study’s most striking finding was marked volume loss in the region of the pulvinar nuclei bilaterally in the ADHD group.  (Shaw, 2010, p. 363)

Despite mounting evidence that ADHD can be attributed to biological factors, there remains a contingent of dedicated psychological practitioners who would assert that familial deficiencies do serve to exacerbate the biological predispositions of ADHD.  (Netherton et al., 1999, p. 104)  If we aim to address the etiological causes of ADHD, we have to do so with a conscious widening of our world view.  We need to take the entirety of geographic, historical, societal, technological, and pharmacological information into consideration before passing judgment on the etiology of Attention-Deficit/Hyperactivity Disorder (ADHD).  Although it is not within the scope of this article to drill down on any one specific aspect, it should serve as a baseline by which we can all being to explore the complexities of the etiology of ADHD.

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References

Eisenberg, L. (2007, Jun). Commentary with a historical perspective by a child psychiatrist: When “ADHD” was the “brain-damaged dhild”. Journal of Child and Adolescent Psychopharmacology, 17(3), 279–283. doi: 10.1089/cap.2006.0139

Moffitt, T. E., & Melchior, M. (2007, Jun). Why does the worldwide prevalence of childhood attention deficit hyperactivity disorder matter?. The American Journal of Psychiatry, 164(6), 856-859. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1288245351&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

Shaw, P. (2010, April). The shape of things to come in attention deficit hyperactivity disorder. The American Journal of Psychiatry, 167(4), 363-366. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1996846691&sid=2&Fmt=3&clientId=4683&RQT=309&VName=PQD

Attention Deficit Hyperactivity Disorder (ADHD)


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Attention-deficit/hyperactivity disorder (ADHD) is characterized by chronic, pervasive, and developmentally inappropriate patters of inattention, impulsivity, and/or hyperactivity.  (Netherton, Holmes, & Walker, 1999, p. 98)

I wasn’t surprised at all that ADHD was mockingly referred to as “the latest fad in psychiatry” or “the disorder of the 90s.”  I graduated from high school in 1995, and I remember hearing about it as early as 8th grade.  It was probably the first “formal” pathology I was ever exposed to, and the first disorder I was able to have a conversation about with my school peers.  Obviously this was driven by the media to some degree, but at some point it became part of our collective conscious as high school students.  Even as kids, we could drop ADHD in a conversation and everyone would have some general idea what you were talking about.  I was barely 14 the first time I saw someone trade Ritalin for enough cash to get a soda and a candy bar.

We all grew up with people that “didn’t listen to instructions” or “became bored easily.”  We’ve all ran into the kid who “makes indiscreet remarks without regard for social consequences,” I like to call them the class-clowns.  What confuses me, is that the ambiguous nature of the criteria for diagnosis could probably apply to most kids in one way, shape, or another.

This is the first DSM-IV-TR I have experienced that requires sub-typing.  I was previously unaware of ADHD Combined Type, ADHD Predominantly Inattentive Type, ADHD Predominantly Hyperactive-Impulsive Type, ADHD in Partial Remission, or ADHD NOS.  (Netherton et al., 1999, p. 101)  The separation of the diagnostic criteria in the DSM-IV-TR and the ICD-10 seems to make logical sense to me.

I, too, was under the impression that most people outgrow their ADHD problems as they reach adolescence.  (Netherton et al., 1999, p. 103)  I still know a few adults that would describe themselves as ADHD, despite the fact that research suggests that the vast majority of people learn to compensate for these problems and therefore make a satisfactory adult adjustment.  Perhaps the few self-described adults I know are more the exception than the rule.  It leaves me to wonder about prevalence, and how many “normal” adults I know that were previously diagnosed with ADHD.

ADHD is best diagnosed outside the clinical environment since symptoms are much more likely to occur in situations that are highly repetitive, boring, or familiar.  (Netherton et al., 1999, p. 104)  Because of the nature of the pathology, we are increasingly dependent on the accounts that are reproduced by parents, teachers, and other engaged caretakers.  I totally agree with Netherton and associates that it can provide “a basis for determining how likely it is that parents and other caretakers will implement recommended treatment strategies on behalf of their child or adolescent,” (Netherton et al., 1999, p. 106) but I question the consistency of the reporting as a measure of diagnosis.  While I can’t totally discount second hand accounts, I would be inclined to go observe personally so that I can draw my own conclusions.  Is it considered acceptable for a clinician to go observe a kid in the classroom?

I have never heard of “drug-free holidays,” nor have I know my associates who were diagnosed with ADHD to discontinue the use of pharmacotherapy on the weekends… but I would be inclined to recommend it just we can get a measure of exactly what effects the medication is having.  I think the concept is especially useful where combined interventions have been implemented.

Reference

Netherton, S. D., Holmes, D., & Walker, C. E. (1999). Child and adolescent psychological disorders: A comprehensive textbook. Oxford, NY: Oxford University Press.

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