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Saturday, November 21, 2015

How Do I Know If My Child Has ADHD?

Why are children so often misdiagnosed as having ADHD? This problem is unique to the United and some European countries. There are many reasons. 

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.

To start with, drug companies market drugs to consumers and make the idea of diagnosis very simple, for example, "difficulty paying attention," "easily distracted," then you have ADHD and should talk to your doctor about drug X, Y, or Z. The American Medical Association has finally come out against drug companies targeting ads to consumers because of self-diagnosis. Doctors are often not willing to say no to patients and risk losing a patient.

Another reason is because patient advocacy groups, some of which are set-up by pharmaceutical companies, like CHADD which was started by AstraZeneca, promote the diagnosis of ADHD through promotions, like that horrible show, "ADHD and lovin' it."

The primary reasons for so much misdiagnosis is that the symptoms of ADHD are incredibly vague, in fact, they are vague enough that it's very easy to fall into the category of ADHD. Finally, the symptoms of ADHD have nothing to do with attention span or one's capacity to pay attention. The big assumption is that if someone has these behavior problems, then they must have difficulty paying attention.

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

With ADHD, there are treatments that seem to work, so, the idea that a chemical imbalance is the cause of ADHD are believed to be accurate. For example, amphetamines, such as Adderall or Ritalin seem to 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 ADHD symptoms.

The first drug used for ADHD was the amphetamine, Benzedrine. This was in the 1930's. The physicians noticed that it improved a child's mood which lead to them being more cooperative, and it also improved performance, which amphetamines will do. ADHD drugs are performance enhancing drugs, and this is why they are barred from many sports, like the NFL and more recently, MLB, where there used to be an excessive number of exemptions. It was embarrassingly easy to be diagnosed with ADHD and prescribed Adderall.

The bottom line is this: ADHD meds, in general, will not improve grades in children who have bad grades - the most important outcome. Kids may be more cooperative, they may perform tasks better, but if they don't like doing homework, studying for tests, or don't care about school, then all the ADHD meds in the world will not change that.

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

(here's a link to an article at Michigan State University's website about 1 million children misdiagnosed with ADD

I know ADHD as a motivational problem. Kids that have ADHD are kids who don't like going to school, or hate school, don't like doing homework, or avoid studying for tests. They devalue school, or never learned to value it, or they are too anxious about school. In many cases, ADHD is an extension of Oppositional Defiant Disorder - not a "co-morbidity," as psychiatrists like to point out. I believe that Psychiatrists and pharmaceutical companies willfully fail to see the connection between these two disorders. In other cases, kids with ADHD are anxious and the anxiety is causing them to have difficulty with school.

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…). 

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? Too much Dopamine may cause psychosis, while too little causes Parkinson's - but kids with ADHD do not show any signs of Parkinson's and it's clear that ADHD meds can cause psychotic reactions or manic episodes in children or adults, suggesting that they were getting too much Dopamine from the meds.

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 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, and people have all sorts of observational biases.

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

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.

For most children, 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 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, like brain injury or lead poisoning. So, in my opinion, the great majority of children diagnosed with ADHD are probably misdiagnosed and thus mistreated and suffer from ODD, Depression, or Anxiety and that is cause of their ADHD syndrome.

You can take your child to a psychiatrist who is trained to see ADHD and all other mental health problems as caused by a chemical imbalance or biological factors (lack of scientific evidence to support these ideas notwithstanding); or, you can see someone like me or another psychotherapist who is going to come up with a realistic explanation or realistic theory of what is causing your child to have these ADHD symptoms. Different ideas of cause lead to differences in treatment, and the outcomes can be extremely different from a child who is given meds compared to one who is provided the appropriate types of psychotherapy.

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 more boys are diagnosed with ADHD than girls (5 to 1)? Why do you more minority children are diagnosed with ADHD? Why do you more poor children are diagnosed with ADHD? Why do you think the younger kids in class are over-diagnosed (over 1 million in the US)? Why do you think older teachers are more likely to have younger students diagnosed with it? (they have difficulty tolerating behaviors that younger teachers find more tolerable).

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 parents should stop using corporal punishment, or over-punishing, 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.

One thing is clear, we need to find better ways to help our children function better in school settings and perform better academically. Five percent of the world's population lives in America, but Americans are prescribed 75% of the world's ADHD drugs, and these drugs are not leading to better academic outcomes or improving parent-child relationships. 
     For most kids, ADHD is simply a lack of cooperation or "defiant" behavior that is caused by poor parenting and maintained by on-going poor parenting and poor classroom management by teachers. Parents and teachers need to learn more effective techniques and interventions that could lead to improved outcomes, like better academic performance, not just sitting still in class. These techniques need to start as young as age 4, so that a child's initial experiences with school and learning are positive and so that they learn to inherently and intrinsically value education.

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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