Day after day in practice, concerned parents ask me why ADHD has suddenly become so prevalent. ‘Better recognition’ has been my standard response. But I am no longer satisfied with this reply, and nor are these parents. Let’s examine this question in more detail.
Attention Deficit Hyperactivity Disorder refers to a condition in which a child (or adult) displays excessive inattentiveness, hyperactivity and impulsivity. These symptoms can occur in varying combinations, giving us three subtypes of the condition, namely the inattentive, the combined, and the hyperactive-impulsive subtypes. It seems to affect boys more than girls. According to well-designed epidemiological studies, the prevalence of ADHD in school aged children is around 6%. This figure is constant across countries, ethnic groups and cultures, and has not increased over the years. Contrast these findings with the numbers of children actually receiving the ADHD diagnosis and/or treatment, and a very different picture emerges. In the United States, according to 2013 data from the Centre for Disease Control, 11% of children between the ages of 4 and 17 had received the diagnosis of ADHD compared to 5% in the early 1990’s. In Britain, the estimated prevalence of ADHD in school children has risen from around 2% in 2003, to 5% in 2013. Inaccuracies in diagnosis have been highlighted in several studies, such as the Great Smoky Mountain study in the USA. In this study, some 1422 children, their parents and their teachers were given structured interviews to ascertain the prevalence of various conditions in the community. The results were quite startling. A mere 57% of the children who had been prescribed stimulant medications actually met criteria for ADHD! Of the entire group who did not meet diagnostic criteria for ADHD, as many as 4.5% had received stimulants. What’s going on?
Part of the problem lies in the very nature of ADHD itself. Unlike other disorders in medicine, ADHD is a dimensional condition. The symptoms of inattentiveness, impulsivity and hyperactivity exist on a spectrum, without clear boundaries between normal and abnormal. We speak of a ‘zone of ambiguity’ between clear-cut cases and those who are obviously unaffected. This means that diagnostic rigour is required in the assessment of the condition, and one has to carefully appraise the frequency and impact of each symptom before it can ‘count’ as part of the diagnosis. Rushed assessments, and those based on quick checklists, will invariably lead to over-diagnosis. It is fairly commonplace these days for a doctor to casually write a script for a stimulant medication ‘to see if it helps,’ as if this was some sort of diagnostic test. There is now a large body of evidence attesting to the cognitive benefits of stimulant medications in those without the ADHD diagnosis. Indeed, there is growing international concern about the phenomenon of cognitive enhancement, defined as the amplification of core capacities of the mind through improvement of information processing systems through medical means without therapeutic intentions. And this phenomenon is now becoming more socially acceptable, fuelled no doubt by the greater importance given by contemporary society to tertiary education, and the increased competition for admission to degree courses. This cavalier approach to cognitive enhancement is a worrying trend on South African campuses. I have been approached by more than one concerned lecturer to provide some guidance on the matter, and a South African policy framework is urgently required to address this issue. Other sociological reasons have been put forward to explain the burgeoning number of stimulant scripts. As a society, we have become increasingly prone to find medical explanations for aberrant behavior. Whereas in the past we may have tended to moralize or criminalize such behavior, we now medicalise it, finding a suitable diagnostic home for the symptoms we see. Related to this is the phenomenon of ‘medical reductionism,’ whereby inherently complex issues are overly simplified to a one-dimensional diagnosis. Here is an excerpt from What’s the fuss about ADHD:
‘ Both doctors and parents can fall into this trap, for different reasons. The doctor, because it is easier and he has a treatment to offer for this diagnosis, and the parents, because they actually prefer a label which lets them off the proverbial hook, rather than implicating their parenting, family lifestyle or worse… ‘
The symptoms of ADHD are non-specific and can occur in a number of other neuropsychiatric conditions. All too often, these conditions are ignored in favour of the ADHD diagnosis. Learning disorders, sensory modulation disorders, anxiety disorders, childhood depression and bipolar disorder can all masquerade as ADHD. Unidentified hearing or visual impairments may present with what appears to be inattentiveness and disruptiveness. Sleep disorders such as obstructive sleep apnoea may not manifest with yawning or somnolence in the classroom, but rather with increased hyperactivity and inattentiveness, thus incorrectly invoking a diagnosis of ADHD. Special mention should also be made of the oft-neglected Adjustment Disorder, which refers to the presence of emotional or behavioural symptoms (including hyperactivity and inattentiveness) occurring within three months of an identifiable stressor in a child’s life. If a child’s parents have recently separated, and she becomes distractible in class, the correct diagnosis is an Adjustment Disorder, not ADHD. A script for Ritalin or Concerta is inappropriate in this situation, and treatment should rather be targeted at the environment, in this case the parenting system, surrounding the child.
Another overlooked area in psychiatry is that of attachment, which refers to the close emotional bonds of affection that develop between babies and their primary caregivers. Depending on what happens between the mother and child in these crucial early months, children may become either securely or insecurely attached. Healthy attachment requires a primary caregiver who is consistently present, and attuned enough to the child to respond appropriately to her needs for focused attention, physical affection and stimulation. This is why it is so important to recognise and treat postnatal depression, a condition in which the mother cannot provide the emotional availability which her child requires. Secure attachment leaves the child with an ‘internal working model,’ or template, which allows her to see herself as valued, and others as ‘basically good.’ This facilitates healthy relationships in childhood and later life. In addition, studies have shown that securely attached children have longer attention spans and show more persistence in tasks. Interesting findings, considering that children with ADHD show impairments in these very areas. There is actually very little in the scientific literature on this, but the few studies which have been published, support an association between insecure attachment and ADHD. This overlap has prompted some to refer to the condition, somewhat cynically, as Attachment Deficit Hyperactivity Disorder.
An ADHD epidemic? Better recognition? Neither. At least in certain communities, we are over-recognizing ADHD, which has emerged as a more palatable alternative to a deeper, thornier complex of societal and environmental issues. This has contributed to what Russell Barclay refers to as the ‘trivialisation’ of the ADHD diagnosis.
We urgently need to find a balance between proper recognition and treatment of this often debilitating condition, and accurate appraisal of the more subtle forces at play in our society.
Dr Brendan Belsham is a child psychiatrist and author. His book, What’s the Fuss about ADHD? is available from amazon(click here)