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 √¶teology 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.