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Friday, December 3, 2010

Misdiagnosing ADD by not paying attention to the details

I find that the two most commonly misdiagnosed disorders are ADHD and Bipolar disorder (I'll cover Bipolar misdiagnosis in another post). Some argue that Autism is the most misdiagnosed disorder, however, I believe that ADHD wins the award for the most common misdiagnosed mental illness.  (I suggest reading this post before finishing this one: http://thementalhealthreview.blogspot.com/2014/04/what-is-adhd-add.html)

There is no known cause for ADHD.
There is no biological test or scan to determine
if a child has ADHD or will develop it.
ADHD is a set of behaviors that are caused
by lots of different factors.

Autism is an old categorical diagnostic concept based primarily on behaviors. Currently, for Autism, there is not one treatment or set of treatments that works any better than the improvement that is seen by the passage of time alone - by just letting the disorder "run its course." We just don't understand how to diagnose this disorder and how to effectively treat it. The mental health diagnostic criteria for Autism are primarily behavioral symptoms. It tells us nothing about what is going on the child's neuro-development that leads to such pervasive dysfunction. But, that is why so many interventions for Autism are comprised of "behavioral" techniques. Autism treatment is today where Schizophrenia treatment was in about 1955.

When treatments do not work,
it calls into question our theories 
about the cause of the problem

With ADHD, there are treatments that seem to work, so, the hypotheses about the cause of ADHD are believed to be somewhat accurate. For example, amphetamines, such as Adderall or Ritalin seem to help decrease hyperactivity and improve attention span in many children diagnosed with ADHD; however, this does not mean that a lack of Dopamine was the cause of the symptoms.

Just because a treatment "works" it
does not mean that it addressed the cause,
even though it alleviates symptoms.

(here's a link to an article at Michigan State University's website about 1 million children misdiagnosed with ADD http://news.msu.edu/story/8160/)

The fact that medication must be taken daily or indefinitely suggests that the medication is a band-aid, not a cure. Can it be cured? Can it be effectively treated without medication? I have only known a few parents who were aware of the long-term side effects of amphetamines (Ritalin, Adderall, Concerta, Focalin, etc…). I’m not sure if the physicians failed to inform the patient or if the patients were careless because they over-trusted their physician. In fact, the long-term side effects or outcomes of chronic amphetamine use, like Adderall can be extremely dangerous. For example, sudden death from cardiac arrest is one possible outcome. Another outcome is temporary or permanent damage to the brain’s reward system which may result in loss of motivation and the inability to experience pleasure. Lastly, children who are prescribed amphetamines may be more prone to substance use or abuse in their 20s. 

Some mental illnesses cannot be cured, only treated, like Schizophrenia, Dementia, Asperger's, and Bipolar. It is questionable whether or not ADHD falls into this category, especially when the misdiagnosis is so prevalent.

With regards to ADHD, whether or not a treatment works does not necessarily mean that the hypothesis about the cause of the disease was correct. The most popular hypothesis for the cause of ADHD is that there is a shortage of Dopamine in the brain. Many mental health practitioners take this to mean that ADHD is caused by a chemical imbalance. This is unlikely. In fact, amphetamines will improve anyone’s performance depending on the dosage.

But if there is a chemical imbalance, what causes it? Is it a lack of necessary enzymes to effectively metabolize tyrosine? Is it a head injury? Is it a shortage of or damage to the brain cells in the Substantia Nigra or Ventral Tegmental Area of the brain where Dopamine is produced? Is it poor nutrition? Is it a certain environmental chemical? Is it some other metabolic issue? Or, is it a combination of two or more of the above?

Dopamine is a "neuromodulator." Neuromodulators impact the two primary neurotransmitters, GABA and Glutamate. Dopamine is a "Catecholamine" neuromodulator. These types of neuromodulators are derived from the amino acid, Tyrosine, and they include Epinephrine and Nor epinephrine. Dopamine is released in response to stress, but it also released for other reasons, for example, to create the sensation of pleasure and desire, arouse fear, sustain attention, and also for movement. Too much Dopamine may cause psychosis, while too little causes Parkinson's. 

Amphetamines like Adderall and Cocaine sustain Dopamine in certain areas of the brain. Prescription amphetamines like Adderall are metabolized slowly through the body, while illicit Amphetamines like Cocaine are used up by the brain immediately. However, "snorting" 20mg of Adderall will give the user precisely the same "high" as snorting Cocaine. There are many complaints of teenagers and adults abusing Adderall and other ADHD drugs. Some even consider Adderall a performance enhancing drug. One famous US Olympic swimmer takes Adderall for ADHD; the concern with athletes is that they may simply pretend to have ADHD in order to acquire a drug that improves their performance. In the Olympics, an edge of 1/10th of a second is the difference between a Gold or Silver medal. Adderall can provide that edge.

With regards to mental health treatment, there are reasons why treatments can work even though they do not address the underlying cause of the problem, and there are reasons why treatments do not work even though they do address the underlying cause of the problem. Certain types of psychotherapy work. As a matter of fact, some techniques are almost 100% effective at curing certain mental health problems, like phobias. However, not everyone is willing to do psychotherapy - its hard work; and, not everyone who does psychotherapy is willing to do all the techniques. Often times, people shop around, looking for therapists to tell them what they want to hear, or to find someone who will just let them vent their feelings; it’s not at all likely that people will be cured by venting to an empathic listener, but they may feel better for a short period of time.

The placebo effect will make a drug appear (or a therapy) to work even though improvement was caused only by the belief and expectation of improvement, not directly by the drug. On the other hand, sometimes people resist help or treatment. For example, they take the pills, but they still have a bad attitude about school. Moreover, with ADHD, parents and teachers have been known to see improvements or declines in a child's behavior, even though nothing has really changed. This last point is most concerning since a diagnosis of ADHD relies heavily, almost entirely, on the reports by parents and teachers.

The problem of misdiagnosis with ADHD, 
begins with the process of diagnosis.

Additionally, mental health diagnosis are Syndromes. A syndrome is a set of symptoms. These symptoms are mainly behaviors, like "get's up and walks around... seems like they are driven by a motor... has difficulty waiting their turn..."  The problem with Syndromes is that they do not point to a cause. Many people think that syndromes do point to a cause, mainly a chemical imbalance that can be corrected by medications (please read my previous post, There's no such thing as a chemical imbalance).

I have seen many children diagnosed with ADHD just for having they symptoms, but without a thorough evaluation. Typically, the Connor’s rating scales are used, but these are only scratching the surface.

The process of diagnosis works like this:
If your child does enough of the behaviors under the ADHD category or syndrome, then he or she has ADHD. However, there are three qualifiers that in my experience are very often not considered by others when they are making a diagnosis: the first is that to qualify for ADHD, six of the 9 symptoms of inattention must be present in TWO or more settings (like school and home), (and six of nine for hyperactivity and impulsivity), at least “some” of the symptoms must have been present BEFORE age 7, and the symptoms must DIRECTLY cause “some” decline in the child's ability to function in two or more settings. The impairment must be “clinically significant.” Lastly, the symptoms must not be “better accounted for by another disorder” such as anxiety, depression, adjustment disorder and so on.

The diagnostic criteria are so problematic; it's hard to know where to begin. Moreover, the diagnostic process is also very problematic. You can see there’s lots of room for clinical judgment with the use of words and phrases like “some” and “clinically significant.” When I adhere to the criteria of ADHD, I have only had a few of children who truly suffered from ADHD. Most of the children suffered from Anxiety, Adjustment Disorder, Depression, poor parenting styles, and various motivational problems.

Currently in America, about 4-7% of children are diagnosed with ADHD. I suspect that a more accurate number should be 1-2% where the cause would be something unknown and probably physiological or anatomical. So, in my opinion, the great majority of children diagnosed with ADHD are probably misdiagnosed and thus mistreated. They are probably suffering from Anxiety or some other disorder which is causing them to have attention, motivation, or behavior problems.

Some red flags for misdiagnosis of ADHD include:
(1)    failure of the provider to rule out other disorders like anxiety and depression which can cause ADHD (including OCD, GAD, Social Anxiety, Phobias, and Separation Anxiety),
(2)    failure to ask specific questions about the child’s developmental history which may indicate learning disabilities or other developmental problems that underlie the ADHD,
(3)    failure to ask specific questions about the frequency, onset, duration, and severity of the symptoms in order to develop a complete understanding of the problems,
(4)    failure to critically evaluate the comments of parents and teachers in order to challenge self-diagnosis by parents and teachers, or to challenge parental mis-characterizations of the child’s behavior as ADHD when it is not,
(5)    a late diagnosis of ADHD, for example, being diagnosed when the child is 8 years old or older, where other issues may be the cause of the ADHD,
(6)    the symptoms are not present in two or more settings,
(7)    the symptoms are not “clinically significant,”
(8)    there are no academic performance problems,
(9)    Did the provider explore the child’s subjective reports about their motivation and interests (because ADHD is often a problem of motivation, not inattention and boredom),
(10)    Are the parents permissive in general, or are the parents split in their parenting styles (because ADHD can often be a sign of poor parenting),
(11)    Are the parents authoritarian in general? Do the parent and child’s temperaments clash (because these problems often cause ADHD-like behavior problems)?
(12)     Do parents permit the child to watch TV and play video games while at the same time make no demands for the child to read challenging books from a young age (because children need to learn how to sustain their attention, and by nature an 8 year old will have a 5 minute attention-span at best)?
(13)     Do parents take an active role in the child’s school performance and homework (because parent attitudes and interest in school will be reflected in their child's school behaviors)?
(14)     Have behavior modification methods been taught and wholeheartedly attempted by the parents (because most parents do not try the right techniques or do them consistently)?
(15)     Does the child have too many demands in their life (because too much anxiety about demands can lead to loss of motivation or disorganization and poor decision-making for children)?
(16)     Has the child been a victim of trauma, corporal punishment, abuse or neglect, bullying, or other life stressors, like divorce or moving neighborhoods (because these problems will lead to ADHD-like behaviors and school behavior problems)?
(17)      Did the assessor explore whether or not the problematic behaviors are being reinforced by other children or adults or by other factors not apparent to the parents or teachers (because many parent reactions will just reinforce ADHD behaviors)?
(18) Does either parent suffer from depression, anxiety, or have substance abuse problems or another type of mental health problem?
(19) Does the child get enough sleep for their age (e.g., a 5 year old should sleep about 10-12 hours a night, because sleep problems underlie ADHD problems)? 

The professional who is doing the diagnosing might not consider these important factors. This is why so many children are diagnosed with ADHD, or misdiagnosed. Why do you think more boys are diagnosed with ADHD than girls? Why do you more minority children are diagnosed with ADHD? Why do you more poor children are diagnosed with ADHD?

When children do have problems with attention, it does not mean that they need medication. Some children need to have less stress in their life, or they need more attention from their parents, or they need to be challenged more, or they need to reinforcements to learn to sustain their attention at activities which they naturally find boring. I find that many children with attention problems are simply bored.

Boredom can be caused by a physiological or anatomical dysfunction, however, boredom is also an emotional reaction. Boredom is mostly caused by the thought that “what I’m doing right now is not worthwhile,” or “is stupid.” If a child believes that certain activities are stupid or worthless, they will avoid those activities. For children, boredom is a painful emotion. Children need help solving the problem of boredom. If your child finds school boring, then they would probably benefit by receiving incentives for putting forth effort at doing homework or other academic activities. There are many other benefits to incentives that help improve a child’s motivation. If you choose to try incentives to motivate your child, they have to be implemented thoughtfully and strategically.


Mental Health Advice Disclaimer
The information included in this post and blog are for educational purposes only. It is not intended nor implied to be a substitute for professional mental health treatment or medical advice. The reader should always consult his or her mental health provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a mental health or medical condition or treatment plan. Reading the information on this website does not create a therapist-patient relationship.
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