Monday, 15 April 2013

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  

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