Friday, 20 September 2013

Just How Many Diseases are there in ADHD / A.D:D ??

It is our contention that the 'prevalence' and percieved explosive growth in ADHD/ ADD amongst teenagers is a symptom of over diagnosis. The reverse may be true amongst adults over 25, where physicians and psychologists on the front line of health care delivery and screening underdiagnose the underlying symptoms or pscyo-pathology.

Part of this is misdiagnosis, and within this we like to separate out the "social" ADHD as not being a disease, but being a discipline and motivational problem. How the prescription of stimulatory medication influences these individuals and how that will affect the long term statistics on drug efficacy and economics is a frightening proposal. Where there is a biological æteology of understimulation in neural pathways, leading to chaotic overstimulation then these amphetamine like substances have proven clinical value, but will their over all efficacy be questioned in light of over-prescribing to teenagers in particular?

The problem is that not enough is known about the causality in the spectrum of patients presenting, or being presented by their parents. We do not know how many diseases or root causes there are with ADHD and ADD.  Where as there is a biological mechanism identified, perhaps only the surface has been scratched in terms of the neural pathways, brain activity patterns and neural transmitter biology through the range patients with the diagnosis. The fundamental æteology may have a large genetic component, that perhaps being a predisposition to the environmental stresses of diet, social stress, performance angst and emotional disturbance which has lead to a proliferation in diagnosis in western societies because of the changes in family economics, divorce and single parenthood, materialism, body image etc.  An alternative proposition is that these environmental factors plus a high sugar, low vitamin and essential fatty acid diet trigger the biological response.

We return then to the complicated and touchy subject of differential diagnosis, or a null diagnosis - the disease presenting is in some cases just a social disturbance, or worse a percieved non conformity within a normal child with high activity, or attention need or low attentiveness in school. Also sleep disorders are more common among children due to poor discipline from parents and the use of "personal digital devices" for gaming and social media in bed. High sugar content in "supper" or after dinner desserts are contestable as sources for both hyperactivity and insomnia and of course obesity in children.

It would be interesting to deliver some statistics by sampling through the entire list of teenagers with the diagnososis, to consider diet and activity, and in detail  to ascertain the detailed medical, family and personal histories to see if there have been some traumatic tirggers. Within differential groups there after, that is those with a potentially high environmental causality and those with an apparently low stress life, to then consider if there are different biological disease mechanisms, or a genetic component or if the trauma related behaviour is more a neuro-psycholigical emotional disturbance (which could be addressed by markedly different regimes of treatment and counselling)

Let us also consider the new patient- prescription relationship in western societies, where the physician is often seen as a seller - a dealer - to be badgered into a prescription: This is pester-power is something the pharma' industry had been nurturing and lobbying on for many years, in many cases this means working with patient groups and charities to raise awareness of new cures and treatment regimes. There are ethical guidelines to this, and in fact it is difficult to point any blame on one company in particular, Pfizer for the patient driven demand fo Viagra. This drug was the turning point for self diagnosis en masse and patient pestering, and many physicians are sceptical to errectile disfunction within long term relationships where the fire of romance is burned out, and on the other hand younger patients seeking it as a recreational drug, to even be sold on at a profit. Prozac also marked an earlier milestone in patient brand-effect awareness. Now Ritalin too is in are area where parents openly discuss their desire to have their "ADHD" kids on the drug often before correct clinical diagnosis.

We are in a kind of parallel danger area to that of the efficacy of Antibiotics; that over prescribing becomes a self diluting prophecy and the efficacy is brought into doubt, leading to a possible arms race of new patent breakers, or eventually generic formulations which offer higher efficacy based on clinical trials of course.

Clinicians at the front line need then a clear set of diagnostic principles and as in Norway, referal to a psychiatric clinic should be part of the handling of moderate to severe ADHD, where disturbances to normal social and economic behaviour are large enough and have a clear possibility of being biological.

Saturday, 27 April 2013

The Never Ending Prescription for Pill Popping ADHD "Cure" ?

It is with some real concern that once again we enter a phase where a therapeutic class shows all the promise of being well tolerated, non addictive, non carcinogenic bla-de-blah, while in fact we are going forward with yet another on-going drug trial for the antagonist medications now the first line approach to treating ADHD.

There are a good number of biochemical and population-genetic arguments and of course presidents from Thalidomide to Valium but what about the ethics of long term prescribing in ADHD ?

My point of view is that psychiatrists now have a new, powerful tool.... to go and conduct a 20 year drug trial with. Ritalin and the other preparations are now established as very successful treatments for many with classical symptoms of ADHD or ADD. However the treatment is not like an anitbiotic: you do not get better from a course of it, you are on it indefinetly.

With any drug on "chronic management of xx disease",  physicians are conducting a wider scale trial: it probably kills less people than those who would continue with ADHD/ADD would, including suicides. That we know from the ADEMTOX and full phase clinical trials. What we dont know is the very long term effects from management over many years or decades.

Another issue is that the medication over stimulates a central neural pathway, and we may miss the needle in the haystack by burning the whole barn down.  The accurate ætiology of ADHD/ADD is not fully established by any means, nor is that for non-reactive depression for a very good parallel example to take.

It could be like this analogy;: the car over heats because it leaks water, but instead of finding the leak in the radiator, we come upon using a bigger water pump and have a header tank to feed the system. In fact we then treat the whole system and get the desired "cure" while actually walking over the root-cause of the disease.

Currently from what clinicians say, Ritalin and the other preparations are in fact in an area of prescribing where it is UNETHICAL not to utilise them when clear signs and symptoms of ADHD/ADD present.

The problem is that the alternatives are a bit lame: dietry alterations work, but not as comprehensively as the drugs; exercise and comprehensive regimes work, but take time and investment which can be disproportionate to benefit and affect the economic activity of the subjects enough to make them inpractial; psychological and cognitive approaches, once again more vairable results and also there is far lower compliance in self  "medicating" to these regimes over longer time.

So pill-popping it is then  for the time being, being the best treatment based on the best biological information drug comapnies 10-15 years ago.

I think we are still missing the point;: Why ADHD ?

Tuesday, 16 April 2013

One Account of Mid Life Adult Diagnosis of ADHD

From a near friend of ours who agreed to contribute their recollections and experiences of having lived with ADHD as a "mild to moderate" affliction without knowing that was the cause of many problems through life:

"Several friends who were medical students, had said to me in the late 80s that I had hypo-mania  I took it as a bit of teasing me for being talkative, distractable and being a bit variable in what I achieved. 
As a small child and adolescent I had been a little tempestuousness. To my friends above, I did admit to having issues which seemed to be "reactive depressions": my father dying when before I became a teenager; the usual teenage crises of identity, friendship and the opposite sex; feeling depressed and under-stimulated in my crucial fifth year at "high school". 

In this year I had a lot of what I recently described in two ways: " Glue Brain" where I experience drowsiness and a lack of thought, and socially related to this "rabbit in the headlights" during confrontation or some ordinary conversations for example. 

I sought help a few times, and the first serious advice I got was the best for me: 'go out and do exercise- an hour a day at least on average! Get your aggression out. ' from my exercise mad GP. I got on my bike so to speak and took it literally, often 14 hours a week in the summer. In many ways a good exercise but not ideal for my "quarter back" underlying physique! Cycling was then a pretty antisocial, individualistic sport with a cliquey coaching structure. Mountain biking was originally far more sociable, with a lot of "innovators / early adopters" taking part.

Physical exercise then can abate negative feelings and give a focus which seems to be kind of meditative for ADHD then, although I just presumed I was suffering from a reactive-depression with some emotional disturbance underlying that from my father's death.

I finished high school on a very high point, retrieving character in a couple of borderline passes and a fail from the year before to A grade, and doing the preparation exams at 1st year uni' sort of level.

First year uni went well two: In fact I loved it and found it easy to make new friends, although some prove to be problematic (arrogant, egocentric types who I mistook for being interesting and stimulating!) I liked the structured lectures but the tell tale signs of ADHD overload were there, of all things Ironically enough with the 1630 - 1730 lectures which I rarely attended. I read the texts and missed out on a lot of stimulation and learnign, because I just was too fatigued and lacked motivation to turn up. I failed the course twice and had to spend a final summer studying, before entrance to the honours programme in molecular biology with genetics.

Second year too had a good deal of structure and was well taught and the text books were excellent.

Here I did not pick up on a few tell tale signs of being a little "sandwich too many for the picnic" I was hyper-sociable, and quite superficial in being interested in politics and philosophy. Also I had no girl friend, just casual sex or dates with kind of inappropriate types upon reflection. I found also that shy people irritated and bored me instantly.  

The key here was that University 1 & 2nd year had enough structure to train me in, while enough freedom to allow me to study in my own time. However I did notice that i would sometimes struggle to take in as much detail as my compatriots.

3rd year was poorly structured with a set of more research oriented scientists lecturing us, generally in badly structured lectures, with badly structure, long lab sessions often using only "placebo" reagents and biologicals. I had a difficult time socially in some ways again, poaching my best friends ex who I was in love with, on the opportunity over the summer they split up.  As a first love she was pretty much Ideal, but she dumped me for unknown reasons because we were still clearly very close when we had a parting drink and later when we met again. I took it very hard and as a lecturer asshole I had said "it does not surprise me you when you say you are having personal problems" Clearly there was many things in my demeanor which other people didn't like my behaviour. 

So that year I really showed ADHD : I made bad decisions socially, I was inattentive and responded badly to the expectation of a high level of self  discipline and open learning with lectures as a stimulus rather than a structure. Also the converse was that lab work became much longer and more tedious. I suffered a good deal of "glue brain" but socially I was active and more mature.

I worked a summer as a research assistant and lacked a good deal of motivation, going off between experiments or on quiet days to cycle or work in the bike shop I had normally just a Saturday job in.

Somehow in final year I found a huge burst of enthusiasm and positiveness. I found my own structure: i started reading what I was interested in and finding in particular review papers and then following back the key papers in the references. My mind could run a little "ADHD" free with hindsight. Often reading became skim reading with then a focus on rather short take out, or I used a lot of time to understand the concepts and language. 

I found then the lecture programme to be super stimulating and ran with the best of them, and got a great character as a dedicated student, eventually gaining my goal of a higher second honours BSc. 

Lab work though suffered: I was really just a lower second on this but I was let off because my write up of the work was okay, my supervisor was recognised as being a bit duff,  and book based thesis was really conceptually difficult. 

So Uni showed the positive and negative sides of ADHD. On the up side, often overlooked, ADHD can contribute to a wide and quite detailed intake of information seemingly, and spurn creative thought as is well known in performers and some great minds allegedly "suffering". On the down side the "glue brain" periods.

So in fact ADHD was perhaps neutral on my education: or put another way my intelligence and drive as a late adolescent /early adult, compensated very much for the disease. This is a theme i will speak of later.

However later in life the same cannot be said :

I struggled to redefine my direction in a way which was appropriate and I did not follow a path which was most productive : to continue as a paid scientist somewhere. I wanted to teach english abroad in Prague. I was a typical young adult dreamer with wander lust but from a poor family. I wanted also to work on the commercial side of Biotech but really just expected that to happen without any interactivity and information seeking or network building from my side. I wandered into  sales which I sort of thrived in relatively speaking, and then back to education at business school.

Around this time I was quite rebellious and socially crass. I had a wide range of new and old acquaintances. I had a steady, if a little immature, girl friend and we moved in together. I had been a little distractable and used the sales job to my own ends to travel and take my bike with me and often hiking or cycling trips were combined with far flung and basically uneconomic sales visits. I found it hard to study sometimes and take in economics, consumer behaviour, business strategy and so on. My grades were down on my bachelors through laziness and not being able to absorb and reformulate information in essays.

In more creative essays where I was able to draw on experience from business myself and group work got top character oddly enough, but on absorbing often rather dry or long winded texts i floundered and in writing good English I also floundered around more than before.

Having finished things went well, but i remember feeling naive and mis-used in my first consultancy internship more or less, and then naive in the labour market. 

I had a tour on Lustral and another antidepressant and a week of up time on few snorts of pharma grade coke . 

The thing about my "reactive depressions" were really that I tackled events badly or did not act very proactively and could not find pragmatic and expansive ways of approaching problems and finding solutions in life and love. I would be down a while, worry a lot, go the the GP or psychologist in the worst times, but then suddenly forget it all and have an upswing and get quite hyper.

So it went until 1996 when I had a tough time controlling my temperament with a girl friend who was a bit of a bad choice yet again! Flirty and cuddly with other boy friends I felt shunned and got really aggressive. I seemed not to be able to control my aggression. I knew I had a bit of a screw loose when the failure of the relationship completely set my mind into an obsessional spin of driving past her house a couple of times each day with no purpose in mind, just a magnetic need, and not sleeping.

I had then an autumn of "glue brain" trying to get into the internet business by re-training on a practical course at a non academic uni computer services dept. This went ok, but I had little self-structuring.

Finally I got my real break through in career: but to cut a long story short:

a) I had difficulty with authority and seemed a bit spoiled or reticent for many years with the more domineering type of boss.
b) I failed to really make the mark in action oriented decision making
c) I did some tasks well, but others where low motivation or high stress were involved I floundered in
d) I showed a lot of social angst and lack of self confidence in sales pitches and conflict situations
e) basically overall I would say I lacked personality and thought pattern tools aka ASSERTIVENESS

In personal life I found it difficult to either hold on to a girl I really liked, or alternatively to stop a dead-end relationship in it's tracks so I did not hurt someone I did not really love. Friendships began to annoy me: I still had a tendency to gang around with quite arrogant types who I looked for some leadership from or involvement but I just ended up getting frustrated with both friends and women!

So this went on, and it went on again, only amplified by emigrating and starting a family.

Eventually I was back in the internet business and a job as an analyst I just could not handle the summarisation required, and could not be assertive with the  very arrogant employees I had to work with. I lost the job and it started the whole thinking "THIS CANNOT GO ON; THERE IS SOMETHING WRONG WITH ME AND IT AFFECTS MY CONCENTRATION AND GIVES ME SOCIAL ANGST "

I made some changes myself, deciding on a new more structured career and taking a low risk way into it through a government sponsored trainee-ship. I moved out of the family house in a new job and visited weekends, holidays and some weeknights. In the midst of these practical actions to kind of reduce stress I was then diagnosed as having strong symptoms / problems associated to ADHD.  "

Monday, 15 April 2013

Quick Tips for Families and Friends : Identifying Potential ADHD in adults

It is generally proposed that ADHD is a life-long ailment: It can however be debated as to how much environment effects, especially crises in life or dramatic personal and family dramas and deaths influences the behaviour. Also how much ADHD is suppressed by either the individual, by the discipline in the family, or by the regiment in schooling.

Latency of ADHD,  is however in fact a result of the condition "lying sub-clinical" or as in our last discursive essay, being misdiagnosed.

In then a patient presenting clinically so to speak, getting in touch with the health services, then in fact a   clear history can be established that is as diagnostic of the disease as the most modern brain activity scans: there will be a catalogue of social, sexual and economic blunders and abnormal behaviour, usually never before being interpreted as such by the patient.

The reasons adults go undiagnosed through childhood and adolescence are as diverse as you may like to imagine most likely any number of explanations on family, school and friends where the behaviour was either interpreted differently, seen as fairly normal to that individual, or over shadowed by general bad social behaviour in the class room and outside school.

In adulthood, ADHD often shows a slow, mild yet insidious progress or pattern. Very often it "presents" to the health profession as stress or reactive-depression, after a particular life crisis is confronted or experienced. It can even be misdiagnosed as post-traumatic-stress-disorder.

The symptoms are however pretty clear for the layman who has a relationship over a long period of time with the subject: Here are some key pointers which will help family, friends and concerned-colleagues to suggest that the person seek help which would help in solving their problems:

1) classic inattentiveness during films, lectures, business meetings or family gatherings.

2) disrupted sleep patterns : typically drowsiness during the daytime at inappropriate times, difficulty in waking and conversely, hyper active  late at night with rushing thoughts often beginning after they have actually gone to bed and turned over to sleep.

3) undue amounts of either anxiety or optimism. This is the spiral-up / spiral-down of hyperactive, uncontrolled and "unnormalised" thought patterns. An ADHD sufferer will most likely experience both the euphoric positive thought streams and the overly anxious, exploring many negative outcomes rather than producing a balanced picture around the situation.

4) Uninhibited sexual activity : a lack of judgement making in choosing partners, and an orientation around gratifying sex or frequent casual sex. " Sexoholism " or "nymphomania" can in some cases most probably be associated to ADHD. Unprotected sex, and failing to see emotional consequences of sex with friends and new partners, and failing to take precautions.

5) overly talkative:; lacking in normal conversation skills, and prone to talking very much and not listening to others around, Offering one sided monologue theories and solutions without there being the usual dialogue.

6) variable sociability and variable performance at work and in education or sports: this is somewhat symptomatic of the up and down phases: a real talent for creative thought or actually heightened reasoning can then be contradicted by the subject's failure to be consistent, or to actually tackle mundane daily tasks.

7) A difficulty in being assertive and poor judgement in making life changing decisions

8) Tending to over-react and react with strong emotions to some situations when there is an element of confrontation, or that the load of normal stimuli in a demanding situation which would be tackled by an ordinary person, who may choose to take flight from the situation due to the overload, leads to an emotional status. This is more obvious in Children, and seems to be un-learned if you like in many adults who have had some degree of social modification to their underlying, undiagnosed affliction.

9) Seemingly becoming easily bored and frustrated with jobs, hobbies and personal relationships: the subject may enter into any of the above with a great deal of enthusiasm, which belies the lack of reasoning and reflection which is lacking the ADHD sufferer. However they have difficulty in holding onto a job, becoming bored and frustrating others with their social foibles and variable performances. They may struggle to form lasting relationships, often because they make a poor choice of partner on outset, one who is not compatible enough for the longer term, or do not assert their own needs in a relationship, or the other partner, as with the employer, tires of their behaviour and loses respect and trust for them.

10) failing to consider the consequences of their actions: a failure to weight up alternatives. Impulsiveness.

On their own, any one of these types  type of behaviour would not of value in a fuller diagnosis, but in the picture with other traits, the layman should probably discuss with their friend that the types of poor judgement and lack in inhibitions, coupled to "down time" is the bipolar nature of ADHD or other diseases and they should seek medical attention.

It may be that the person afflicted by such symptoms above actually will fall into a different diagnosis, such as hypo-mania, but it is worth encouraging the person to seek help: for family members, partners, close friends or personnel managers, it would be worth getting the person to write down the some of the issues they have had:

" 10 girl friends in 5 years.....change job on average every year....makes sexual-gratification oriented decisions ...does not see consequences of their actions.....does not have a good "take out" from lectures or presentations.....goes off on irrelevant tangents in study, presentation or conversation....tackles creative tasks well, often showing insight, but fails to undertake mundane tasks well.....has a distinct threshold for some types of social situation where they become agitated or behave unusually...have also a threshold for tasks in work, or education, often reaching a low threshold in assimilating information. Failed to cope with an emotionally challenging event in life"

ADHD: The Teenage Over Diagnosis and Adult Under-Diagnosis ?

As I have blogged before we have personal experience with ADD/ADHD in both adults and children, and have reviewed much of the leading current literature and reviews of papers. In this qualitative review, we discuss a practical and critical approach to the disease, from a perspective of the over diagnosis amongst "youth"- the plague-and-the-pills, and from the point of view of adults who actually have life ling ADHD, but whose symptoms only are apparent during life crises or general under-achievement for example.

The enigma at the core of ADHD (over ADD alone) is that it is contradictory in nature: it goes between phases of AC and DC if  you like. The name given to the disorder was of course coined from the  description of the presenting-symptoms which are socially interpreted. The symptoms were defined externally, classically from how the school child could not concentrate and was then also overly active, when compared to the average child. "They can't listen and they just can't sit still".

The actual bipolar nature however was discovered somewhat later, when the attention deficiency  was uncovered as actually being the reverse of hyper-activity: the brain was chronically under stimulated in those afflicted with ADD and ADHD in its' 'true sense', when experiencing those phases of lack of focus, distractability and drowsiness.

Later on research in neurology and new psychological assessments confirmed this, and further demonstrated the link between the under stimulated higher thought processes, and the super-stimulation pathways present in ADHD, which then try to "kick start" the brain and actually lead to classically uncontrolled streaming thoughts, and in many cases a reduction in natural inhibition  leading to dangerous or socially crass behaviour.

So the circle was closed: the ADD was related to the ADHD and often children in particular were experiencing a bipolar disease, and living with the frustrations of a lack of concentration at both poles.

Differential Diagnosis as a Counter to the Over-Diagnosis of ADHD

There above then, you have the ætiology and diagnosis in a nutshell: however ADHD is amongst the most over diagnosed and correspondingly over-medicated area in teenage mental health. In some school classes it has been seen as the predominant chronic medical affliction.

On the other hand, in adults not previously diagnosed with ADHD as children, and  presenting potentially with symptoms for the first time, it is likely that ADHD is very often misdiagnosed as depression and bipolar-depressive disorder. The extent of this in adults, has not been established while over diagnosis in teenagers is a "hot potato" in health authorities.

 Resulting medication and psychological exercises or therapy then can lead to patients continuing with difficulties and also developing a focus-complex : in the teenager the incorrect (or patient lead ) diagnosis of disease can be offered as an excuse for attitudinal and behavioural problems which should be tackled with motivation and schooling methods; For adults, there can be a focus on reactive depression, or other longer term  negative events in life which in fact are not the source of the bipolar behaviour, rather it is an internal disease.

Economic and Societal Importance

Differential diagnosis for both ADHD and then the mono-polar Attention Deficiency Disorder is therefore important for public health authorities to assert within their structures so as to reduce the burden on mental health services and pharmacy budgeting in child health which is heavily subsidised with tax payers money. Also for private practitioners alike,  they should consider the potential for litigation stemming from aberrant and potentially damaging medication with "Ritalin" and related substances for patients who are actually not relevant or even should have a contra-indication for such stimulants.

The key questions for the medical delivery system are then :

a) does this teenager actually have a social-problem, which can and should be tackled with social, educational and parental means or is this an ætiology of ADHD likely to respond to drugs, diet and concentration regimes?

b) Does this adult presenting with situation reactive symptoms actually have an underlying ADHD which has a negative influence on their life and has contributed to the current malaise and indeed is a major factor in creating or exacerbating the negative situation or crises.

In the cases of a disease being misdiagnosed,  the a path for treating ADHD or treating a different condition is counter productive and even can be contra-indicated from the medical point of view and is a misuse of funds. A reactive depression may be a meta-symptom in adults for example, relating to a life event, but if sufficient patient history points to ADHD then a longer term investigation and treatment of the disease will be cost effective.

In the case where a "null" diagnosis- this patient has no sickness, just a social problem: then this is important to establish that the prevalence, especially amongst teenagers, is a system problem: that schools and social services have then a responsibility to modify methods and take remediation of those pupils with the worst attitude problems.

This is then a case for systems management outside the health profession. However as a gate keeper,  practitioners being there a sceptical police who alert the educational authorities that there is a social problem being presented as ADHD on a basis frequent enough to merit immediate intervention and longer term system re-evaluation. Schools then must find new ways of teaching which manage unruly students, including them and borderline students in general classes and excluding them from ordinary academic classes when their attitudes lead to disruptive behaviour and contaminate other pupils.

What Are the Alternative Diagnoses and to What Extent Are We Discussing a Societal Perceived Disease?

The crux of the matter in over-diagnosing teenagers as having ADHD is that there is on the one hand, a perceived nuisance and non conformity issue: in highly structured schooling or in societies (for example small towns) where people have often "modest " behaviour patterns, a higher level of activity, of physical and mental energy can be misinterpreted and indeed the individual can be  labelled as having the disease. In more normal classrooms, poor discipline and weak leadership can also result in an unruly class, with ring leaders using "ADHD" as a scapegoat.

The more intelligent child ;  the more communicative child ; the more physically active child ;  the poorer socialised child, the child who seeks social leadership by disruption : ADHD as a sickness has a social element but it is a disease, while the cultural interpretation of misbehaviour and hyperactivity is realistically the first step to differential diagnosis: IS THIS A SOCIAL PERCEPTION ISSUE and not a disease in this child ?

The very reverse can be true in adults: The adult is diagnosed as being socially inept, prone to moods, rebellious, "slow on the take up", and a poor learner: an "odd-ball" in many cases. So it is perhaps symptoms of depression actually are those which the patient presents with, or alternatively they are referred to psychological services by a family member or doctor. In the worst cases of course, they are referred by the courts or the prison authorities. It is these criminal cases perhaps which are taken most seriously as having a root in a disease, ADHD.

To summarise this little dilemma ; in the child a diagnosis of disease has more prevalence, where as in the adult, the social circumstances and personality issues are often the misdiagnosis or "sub clinical" . This is kind of a para-thesis : the "fundamental attribution error" in a new context, where unruly or ADD behaviour in children is over diagnosed as being an inherent neurological disease, where as in adults the social history and personality defect become the focus.

Differential Diagnoses Proposed:

1) Is this a social-judgemental problem or actually a disease in the child? Is the social referral of an adult the reverse, actually possibly ADHD?

2) If this is a hyperactivity disorder, is there a bipolar nature with "down" times somewhat cyclical?

a) Does the "down time" come after prolonged periods of hyperactivity and reduced sleep?
- seek also information on hypo-mania and other super-stimulated disorders. Including brain damage and neurological hyperactivity as a post traumatic event chronic reaction. - Test also for substances of abuse in the amphetamine like area.

b) Does the "down time" come at particular times of day or on a fairly predictable cyclical pattern ?
- this can be seen in many ADHD cases, but also it could be related to diet- for example lactose intolerance/lactose to opiate metabolism, diabetes or early stage blood sugar homeostatic problems, poor diet, irregular eating times;  Also insomnia/parasomnia and narcolepsia are also areas to uncover.

c) Misdiagnosis: Stress, PTSS, Depression in adults:  is the adult in particular, seemingly themselves the cause of the stress or depression? Has their behaviour actually created the situation which is the source ? Should a similarly qualified or experienced person cope with the sources of stress or depression better ? Has the patient actually a longer history of ADHD like symptoms ?

d) is the ADD person being misdiagnosed with depression ? In fact is the bipolar nature of a patient suppressed by social circumstances and personality and infact they have both the AD and the HD sides ?

e) Is the patient self diagnosing? A whole topic in itself:

Initial Diagnosis as Ammunition for Googling, and the Internet for Self-Fulfilling-Illness ?

The actual diagnosis of ADHD is of course for the vast majority, outside neurological research institutes. Diagnosis at the GP, psychologist or psychiatrist is based on a consultation by in large, with in some cases a bank of traditional concentration, attention, short-term memory and "boredom" fatigue tests.

The Danger in using pateint-provided-history alone is that of course, a teenager may be inventing their ADHD to gain attention (Munchhausen?), to find an excuse for lack of discipline and effort in class when they could change-their-ways consciously, or in the worst cases, effecting the procurement of Ritalin for resale as a substance of abuse? Furthermore an initial discussion can plant keywords literally for later Googling in the patient's own time, and they can return with a construct matching their issues to ADHD ( or the reverse, following a lead word from the first consultation into a misdiagnosis).

Using a Bank of Neuro-Psychological Tests and Questionnaires to Assist in Differential Diagnosis of ADHD:

The bank of simple and well proven, normalised tests for attention deficiency is actually a route to which some adults are delivered as presenting with life long ADHD. Often administered by specialist neuro-psychologists, the patient may have had a referral for a provisional diagnosis of post-traumatic-stress, or potentially brain damage or several other routes to this little circus of elementary and well established motor-cognitive, memory and motivation  tests.

These tests then are sometimes concluding that ADHD is a probable ætiology from a different route to the neuro- psychologist's desk.  However it is our contention that such a bank of tests be conducted on all teenagers who present with socially-diagnosed ADHD. 

One of the key's to their applicability in teenagers is that some of the tests use a subterfuge, and also they set goals which a teenager may either like to meet  (or fully reject, demonstrating a larger social problem). The subterfuge is in the test appearing to be a trial or puzzle, an aptitude test, when actually measuring things like attention span, short term memory or motivation for tasks.

Some studies with control non ADHD subjects in single blind studies where the ADHD is clearly established in the patient group, have not shown effectiveness, while on the other hand other studies have shown that the reverse is the case, and adult specific studies suggest that tests can establish a differential diagnosis where symptoms are non specific, resulting from social crises or other "bi-products" of the ADHD afflicted person.

The bank of tests is then usually administered by a neuro-psychologist and this is important because they may be able to identify other motor-cognitive diseases by the demeanour and physical approach the patient takes to the tests, and in considering the results.

Sometimes a more directed ADHD questionnaire is 'administered' to help explore the patient's social behaviour and perceptions around attentiveness, concentration, thought and day-dreaming etc. Alternatively a wider questionnaire which may be used as a means to open discussion or to exclude other illnesses is administered by the psychiatrist. These stages could be partly moved to the GP surgery or even school nursing station for administration such that a degree of triage is conducted at lower cost to establishment and at lower risk of contaminating the patient with the self-gratification that escalation to consultant psychiatry service entails.

Also adults who present with situational reactive depressions and stress related disorders, should be questioned on their earlier life and patterns of problematic interactions, lack of assertiveness, social ineptness etc to establish if there is cause to follow a route of finding ADHD as the "carrier signal" to which other disruptions are amplified: such as depression and stress at work, and a lack of assertiveness and sound- judgement in situations which leads to negative consequences or even chaotic, downwards spiral in risk taking, revenge, and other over-reaction or inability to handle circumstances.

Neurological tests then should be chosen from a bank of tests which are all culturally normalised for the nation or region. Physicians and psychologists may like to actually normalise these tests to a local area or indeed to a school authority such that average responses are mapped and a mean deviation threshold for diagnostically valuable results is established in the special context. This can be done on a relatively small sample size, chosen from a definable and finite sub-population eg 15 year old school pupils in a county.  Also a further blind trial can be conducted where those with clear ADHD diagnosis are fed into 'healthy' candidate studies. 

Failures in these tests may be attributed to a lack of normalisation perhaps, but also to using them only selectively: the "consultation" and overall assessment is taken in a context of a fairly intense series of
tests, where the net result is also indicative of ADHD by virtue of attention span flagging, and the same measure being analysed by disparate techniques.

Conclusion: ADHD - Cut to the Quick , Sift out the Fakers.

To repeat what we conclude above, our contention is that ADHD is over-diagnosed in children (esp. adolescents)  and under-diagnosed in adults by patient provided histories or subjective reports from from private or public social bodies around the afflicted.

 Many medical authorities require by statute that patients be referred to a psychiatrist prior to medication, and this should be standard practice once the first steps to establish that a "rigorously skeptical" differential diagnosis is under way. This is to prevent that on the one hand, the teenage patient has not been given a bias in language towards ADHD, and on the other, that an adult is not being misdiagnosed when ADHD is actually the "vector of their misfortunes" .

In the case of the teenager we want to avoid the case where after initial consultation,  they self diagnose by Googling the topic and misrepresent their symptoms or misreport the wider symptoms which may point to another disease or actually have just a "social problem". In the adult presenting with stress, or a strong reactive depression, or series of life crises for example then