Diagnosis of ADHD

Making a diagnosis ADHD is what gives ADHD increasing controversy. The process is so unclear, that some clinicians and researches begun to question validity of ADHD as a clinical entity.

One problem is that ADD / ADHD can be confused with wide range of conditions, either mimicking them, or being a part of this condition.

Mental health conditions that can be diagnosed as ADHD include: anxiety disorders, affective (mood) disorders, substance abuse disorder (stimulants, cocaine, phencyclidine, others), conduct disorder, oppositional defiant disorder, impulse-control disorder, mental retardation, autism spectrum disorder (including Asperger’s disorder), schizophrenia and other psychotic disorders,

Personality disorders (as antisocial personality disorder), developmental coordination disorder, adjustment disorder.

Medical Conditions that can look like ADHD include: hyperthyroidism, early stages of progressive neurodegenerative disorders, subclinical epilepsy (epilepsy without convulsions), frontal lobe tumor or abscess, fetal alcohol syndrome, Klinefelter syndrome, Angelman syndrome, Williams syndrome, velocardiofacial syndrome, Sotos syndrome, effects of therapeutic medication (phenobarbital, antihistamines).

Environmental problems, related to chaotic environment that can mimic ADD include: child abuse and neglect, severely dysfunctional family dynamics, excessive TV watching, cognitively challenged student placed in a regular classroom, highly gifted student placed in unchallenging regular classroom. The last one is probably one of the most common misdiagnoses of ADD / ADHD, resulting from exposure to bad and unimaginative teachers.

Much larger problem is a disagreement among the clinicians on selection and use of clinical criteria for diagnosing ADHD.
The American Academy of Pediatrics guidelines have the following recommendations for diagnosis of ADHD:
1) When a child 6 to 12 years old presents with inattention, hyperactivity, impulsivity, academic underachievement, or behavior problems, primary care clinicians should initiate an evaluation for ADHD;
2) The assessment of ADHD requires evidence directly obtained from parents or caregivers regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment;
3) Evaluation of the child with ADHD should include assessment for coexisting conditions;
4) Other diagnostic tests are not routinely indicated to establish the diagnosis of ADHD but may be used for the assessment of other coexisting conditions
5) The assessment of ADHD requires evidence directly obtained from the classroom teacher (or other school professional) regarding the core symptoms of ADHD, duration of symptoms, degree of functional impairment, and associated conditions;
6) The diagnosis of ADHD requires that a child meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria;

The first three recommendations are reasonable, whereas the last three are inconsistent with our current understanding of medical science and ethics.
Other diagnostic tests are not routinely indicated… mainly for one reason: there are none. There is not a single laboratory test for diagnosing ADD / ADHD. Unlike most of the medical conditions, ADHD does not have a biological marker. Biological marker is any kind of medical test that alone or in combination with other tests can unequivocally prove or disprove presence of the disease. For example: low insulin level in diabetes, “shadow” on a chest X-ray in pneumonia, positive urine culture in urinary tract infection, ESR / CRP in rheumatic fever are biological markers. In addition to making a diagnosis, biological markers allow to monitor disease progress. Absence of biological markers for diagnosing ADD / ADHD leaves a lot of room for interpretation of DSM-4 criteria.

ADHD evidence directly obtained from the classroom teachers… is the most outrageous AAP recommendation. It is unimaginable that a physician received evidence of the disease from a lawyer, plumber, janitor, or anyone else who does not have medical training. In fact, relying on such evidence would be unprofessional and unethical. If the child has a fever, vomiting, or some other commonly recognized sign of not being well it is not only appropriate, but advisable to refer the child to a health care professional for evaluation. On the other hand it is totally wrong for non-medical professionals to refer children for evaluation of a specific “health issue”, such as ADHD to medical professionals. By making this  recommendation AAP placed ADHD in a unique and exclusive category, potentially making every teacher a clinician. Doctor, facing uncertain diagnosis would refer their patients to a specialist, selecting the most appropriate specialist out of many dozens. The process of making this selection requires years of acquiring of what is called “clinical judgment” in order to avoid sending their patients on expensive, unfruitful and time wasting wild goose chase. The situation when teaches are encouraged to make medical decisions does not make bad teachers better. It makes bad teachers bad clinicians. As a result, teachers become unqualified participants of dispensing health care and subsequently unpaid sales representative of pharmaceutical companies and pharmaceutical companies quietly encourage teachers to be even more involved by disseminating “educational” material among them.

Diagnostic and Statistical Manual of Mental Disorders, IV Edition (DSM IV) ADHD diagnostic criteria… lists 18 parameters under 3 categories:

I. Inattentiveness
1.     Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2.     Often has trouble keeping attention on tasks or play activities.
3.     Often does not seem to listen when spoken to directly.
4.     Often does not follow instructions and fails to finish schoolwork, chores, or duties
in the workplace (not due to oppositional behavior or failure to understand
5.     Often has trouble organizing activities.
6.     Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort
for a long period of time (such as schoolwork or homework).
7.     Often loses things needed for tasks and activities
8.     Is often easily distracted.
9.     Is often forgetful in daily activities.
II. Hyperactivity
1.     Often fidgets with hands or feet or squirms in seat.
2.     Often gets up from seat when remaining in seat is expected.
3.     Often runs about or climbs when and where it is not appropriate.
4.     Often has trouble playing or enjoying leisure activities quietly.
5.     Is often “on the go” or often acts as if “driven by a motor”.
6.     Often talks excessively.
III. Impulsivity
1.     Often blurts out answers before questions have been finished.
2.     Often has trouble waiting one’s turn.
3.     Often interrupts or intrudes on others (e.g., butts into conversations or games).

Many diseases are diagnosed by using certain set of criteria, rather than a single test. Rheumatic fever is one example. Whenever a disease is diagnosed by a set of criteria, each criteria is given a numerical value. For example, one of the criteria for rheumatic fever is the numerical value one of the blood tests either ESR, or CRP. It is the numerical value that makes it possible to apply scientific approach to medicine. One problem with DSM-4 ADHD diagnosis is lack of a single numerical value attached to any of the criteria. In fact, the most commonly used word in DSM-4 list of ADHD criteria is “often”. Everyone defines “often” as they feel. Inept, unimaginative, poorly trained teacher, who is unable to control classroom and does teaching for the sake of income and fringe benefits only may define it differently than a well trained, talented and patient teacher who loves teaching and knows how to engage children into learning process. The previous psychiatric manual DSM-3

Another big problem is the arbitrary selection of the diagnostic criteria.  This is one of the reasons why a lower percentage of American children were diagnosed with ADHD using the previous diagnostic manual, DSM-3. European physicians apply a different diagnostic manual, called ICD-10 and use the term “Hyperkinetic Disorder” instead of ADHD. The difference between DSM-4 and ICD-10 results in only 1% of European children being diagnosed with Hyperkinetic Disorder compared with over 5% of the American children being diagnosed with ADHD.

Due to all of the inconsistencies and problems surrounding ADHD diagnostic process, it is understandable why some medical doctors and psychologists question the validity of an ADHD diagnosis in the current form.

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