Is it a “Lazy” Diagnosis?
In an article on WebMD, Neil Osterweil asks the question “ADHD: Real Deal or Lazy Diagnosis?”
“ADHD is a catchphrase in search of a syndrome in search of a disorder in search of a cause,” writes neurologist Jeff Victoroff, MD, in a provocative article published in a recent issue of Psychiatric Times.
Dr. Victoroff doesn’t dispute that the symptoms and problems associated with what we call ADHD are real. Rather, he suggests the art of psychiatric diagnosis has gotten itself ahead of the science of the mind — to the detriment of children who may be misdiagnosed by primary care physicians or pediatricians and overmedicated at the urging of parents or school systems looking for a quick fix to complex behavioral problems.
“To look at a kid and say if they meet six of the nine [DSM-IV] criteria — if they’re distractible or contentious or inattentive then they have this disease — is kind of a Luddite approach to the science,” Dr. Victoroff said in an interview with WebMD. He states that “we should look forward to a better psychiatry in the future where we’re looking at this very real population of kids who suffer, and whose families suffer, but identify them in a scientific way rather than a theoretical, observational way.”
His argument is supported by a recent study published in Biological Psychiatry in which researchers from Massachusetts General Hospital and Harvard Medical School in Boston reviewed a variety of outcome studies to assess the validity of an ADHD diagnosis in adults.
“Although … converging lines of evidence support the validity of ADHD in adults, follow-up studies of ADHD children have yielded ambiguous results,” write the authors.
“The question is whether, among the children who meet the current ADHD criteria, there might be a subgroup suffering from a neuropsychiatrically specific disorder with a unitary neuropsychopathology,” Dr. Victoroff writes. “There is emerging evidence that such a disorder, in fact, does exist, and that it involves frontal-subcortical circuits.”
He points to studies suggesting a clinical similarity between ADHD and other conditions such as obsessive-compulsive disorder and Tourette’s syndrome that are thought to involve the basal ganglia.
Also, MRI studies of the brain have shown that children diagnosed with ADHD have abnormalities in the basal ganglia and/or prefrontal cortex, and that low frontal and striatal volumes correlate with failure to inhibit inappropriate behaviors.
He also cites evidence of focally increased dopamine synthesis in the brains of children diagnosed with the disorder.
In the future, Victoroff told WebMD that diagnostic criteria might include functional MRI measures of response inhibition or PET scanning studies of dopamine synthesis and storage in the midbrain.
Victoroff says his intention was not to cast doubt on the existence of a hyperactivity disorder, but to raise questions about the validity of ADHD, primarily out of concern for the safety of children.
“I think it’s one thing once the brain is fully formed to expose it to a drug that alters dopamine transmission,” he tells WebMD. “I think it’s scarier when the brain is somewhat unformed and when the kid is learning those early lessons of life about reward and punishment and pleasure and pain. If you alter the chemistry of rewards during that extremely early phase, we have no way to test the safety of that in the conventional drug development format that the FDA would require. … My question is, if you have a thousand kids exposed to a drug that alters the chemistry of reward at age 3, what will those kids’ relationships be like at age 40?”
Here's the Real Article
“Calling Attention to ADHD: Is the Disorder Real?
By Neil Osterweil
WebMD Medical News Archive Reviewed By Dr. Jacqueline Brooks
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Sept. 1, 2000 — Would attention deficit hyperactivity disorder (ADHD) by any other name still be a disorder? “ADHD is a catchphrase in search of a syndrome in search of a disorder in search of a cause,” writes neurologist Jeff Victoroff, MD, in a provocative article published in a recent issue of Psychiatric Times.
Victoroff, who is an associate professor of clinical neurology at the Keck School of Medicine at the University of Southern California, doesn’t dispute that the symptoms and problems associated with what we call ADHD are real, but rather that the art of psychiatric diagnosis has gotten itself ahead of the science of the mind — to the harm of children who may be misdiagnosed by primary care physicians or pediatricians, and overmedicated at the urging of parents or school systems, who are looking for a quick fix to what may be complex behavioral problems.
Children and adults who are diagnosed with ADHD generally have trouble paying attention, are easily distracted, impulsive, and hyperactive. The disorder is frequently broken down into three subcategories according to whether the child is hyperactive and impulsive alone, inattentive alone, or a combination of all three.
Yet, as Victoroff and some other researchers have pointed out, current methods for diagnosing ADHD are based on observation alone: Johnny fidgets, talks in class, and doesn’t follow instructions, and, therefore, he must have ADHD. But that’s like saying that everyone who coughs between 50 and 75 times each day has tuberculosis, and everyone who coughs less often does not have TB; it’s a non-scientific and potentially flawed approach to diagnosing a serious condition, he contends.
Victoroff tells WebMD, “To look at a kid and say … if they’re distractible or contentious or inattentive then they have this disease,” is an approach that is resistant to change that could be brought about by ongoing advances in technology.
“It’s not to say that [the diagnosis] isn’t a valuable thing or that we should abandon it today; it’s just to say that we should look forward to a better psychiatry in the future where we’re looking at this very real population of kids who suffer and whose families suffer, but identify them in a scientific way,” he says.
There are many other possible explanations for the behaviors seen in children who are diagnosed with ADHD, Victoroff tells WebMD, including depression, physical or sexual abuse at home, or anxiety about school or some situation in the family or community. He says he is concerned that in the rush to treat ADHD, too many children may be given strong medication for treatment of a disorder they do not have.
“The widespread drugging of preschoolers ups the ante,” he writes. “We need to discover scientifically rigorous, replicable specific and scientific markers that could rescue parents, child psychiatrists, pediatric neurologists, and especially family doctors from being forced to make this critical diagnosis based on the current [criteria] — and rescue a mixed group of children from being swept like dolphins into a tuna net to [mood-altering] intervention with potentially lifelong consequences.”
But as another psychiatrist points out to WebMD, the lack of a specific or sensitive diagnosis for a specific condition doesn’t mean that ADHD is not a very real problem.
“We have no objective test, we all know that, that’s why it’s called a disorder. … It’s a clinical diagnosis, just as rheumatic heart disease was a clinical diagnosis until we had a specific test, but that doesn’t mean that rheumatic heart disease did not exist. We’ve done field trials in thousands and thousands of kids. This has been a stable diagnosis since the 1930s. We have treatments for it, and we have ways of following improvement, but we don’t have a test for it,” says Charles H. Enzer, MD, associate clinical professor of psychiatry at the University of Cincinnati Medical Center.
Victoroff says that his intention was not to cast doubt on the existence of a hyperactivity disorder, but to raise questions about the validity of ADHD primarily out of concern for the safety of children. “I think it’s one thing once the brain is fully formed to expose it to a drug that alters [chemicals involved in transmission of nerve impulses],” he tells WebMD, explaining though that we cannot be sure of the consequences for the brain of a child, which is not fully developed.
He says that in the near future, it may be possible to accurately diagnose ADHD based on brain-imaging studies or laboratory tests using spinal fluid to show specific chemical indications of ADHD.”
http://my.webmd.com/content/article/27/1728_60960.htm?lastselectedguid={5FE84E90-BC77-4056-A91C-9531713CA348}
The Real Article is Quite Different
Thanks for posting this Julie. It is a good reminder that as parents we should ALWAYS do our own checking and maintain a healthy skepticism about what we read on the Internet. When we are looking for reliable information about the risks and benefits of particular treatments, we should turn to properly conducted research (double blind, adequate sample size, consideration of confounding factors) and to reliable professionals who are up to date with research and current trends. Our personal stories about what does or doesn’t work are helpful, but mostly as arrows pointing us in the direction of things that we need to explore rather than things that we can view as proven.
Andrea
Re: A lazy diagnosis and more
Well said, Julie and Andrea. Hopefully, people realise that and do their own thorough research.
There are still some parent-bashers around who believe the century-old anachronism that child misbehavior is always a moral problem of the “bad child.” Under this model, the treatment has been to “beat the Devil out of the child.” Fortunately, most of us are more enlightened today. A body of family interaction research conducted by Dr. Russell Barkley and others has unequivocally demonstrated that simply providing more discipline without any other interventions worsens rather than improves the behavior of children with ADHD. One can’t make a paraplegic walk by applying discipline. Similarly, one can’t make a child with a biologically-based lack of self-control act better by simply applying discipline alone.
Contrary to the tripe posted by the Anti-eveything club, research has repeatedly shown that children, adolescents, and adults with ADHD benefit from treatment with Ritalin (also known as methylphenidate), which has been safely used for approximately 50 years. There are NO published cases of deaths from overdoses of Ritalin; if you take too much Ritalin, you will feel terrible and act strange for a few hours, but you will not die. This cannot be said about many other medications. The unexplained deaths cited in some articles are from a combination of Ritalin and other drugs, not from Ritalin alone. Further investigation of those cases has revealed that most of the children had unusual medical problems which contributed to their deaths. It is true that many children experience appetite loss, and some moodiness or “rebound effect” when Ritalin wears off. A very small number of children may show some temporary tics, but these do not become permanent. Ritalin does not permanently alter growth, and usually does not result in weight loss. Ritalin does not cause Tourette’s syndrome, rather many youngsters with Tourette’s also have ADHD. In some cases, Ritalin even leads to an improvement of the of tics in children who have ADHD and Tourette’s.
[color=red]I also need to dispell the bolony the anti-everything club has posted about the increase in Ritalin in the USA. [/color]The production quotas for methylphenidate increased 6-fold; however that DEA production quota is a gross estimate based on a number of factors, including FDA estimates of need, drug inventories at hand, [color=red]EXPORTS[/color], and industry sales expectations. One cannot conclude that a 6-fold increase in production quotas translates to a 6-fold increase in the use of methylphenidate among U.S. children any more than one should conclude that Americans eat 6 times more bread because U.S. wheat production increased 6-fold even though much of the grain is stored for future use and export to countries that have no wheat production. Further, of the approximately 3.5 million children who meet the criteria for ADHD, only about 50% of them are diagnosed and have stimulant medication included in their treatment plan. [color=red]The estimated number of children taking methylphenidate for ADD suggested in some media stories fails to note that methylphenidate is also prescribed for adults who have ADHD, people with narcolepsy, and geriatric patients who receive considerable benefit from it for certain conditions associated with old age such as memory functioning.[/color]
[color=red]So you see, yet more twisted bunk folks. I realize these guys sound like they know what they are saying. But trust me, they are trying to victimize you and use your newness to the situation against you. There isn’t a post they can write that I cannot prove false. I’m no doctor or scientist, just a mom (with attitude) living on Long Island trying to help parents realize that this isn’t their fault and they CAN do something about it. I go to the library and I know how to use the internet to research. My advice is READ READ READ all you can, so you don’t have to rely on the misinformation some people will victimize you with. Yea, maybe I sound like a B***H but I know you people know I would never do this to any of you. This is a special situation…and hey, if you think I’m bad, you should meet the husband![/color]
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