ADHD the Facts

How is ADHD diagnosed?

There are no objective, scientific, diagnostic tests for ADHD. Clinicians can diagnose children with ADHD by relying entirely on third party (usually parent and teacher) reports of children exhibiting childish behaviours including; failing to pay close attention, not finishing school work and chores, disliking homework, running about or climbing excessively, playing loudly and being impatient. In layman’s terms, the diagnostic criteria are so broad as to enable the labeling as ADHD of children who are too active (hyperactive) or inattentive and not active enough (hypoactive).

The diagnostic criteria defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the American Psychiatric Association’s catalogue of mental illness. The diagnosis of ADHD is based on reports of a child’s behaviour, as ‘no biological marker is diagnostic for ADHD’.[1]  

Extract from DSM-5:[2]

ADHD Diagnostic Criteria

To be diagnosed with ADHD a child should meet six of the criteria below at 1 (Inattentive type/passive ADD) or six at 2 (Hyperactive type ADHD) or six at both 1 and 2 (Combined type ADHD) to an extent that is inconsistent with the child’s developmental level, and has a negative effect on their social and academic activities. For adolescents 17+ and adults five are sufficient.

1. Inattention

  • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities
  • often has difficulty sustaining attention in tasks or play activities
  • often does not seem to listen when spoken to directly
  • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
  • often has difficulty organizing tasks and activities
  • often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
  • is often easily distracted by extraneous stimuli
  • is often forgetful in daily activities

2. Hyperactivity and Impulsivity 

  • often fidgets with hands or feet or squirms in seat
  • often leaves seat in classroom or in other situations in which remaining seated is expected
  • often runs about or climbs excessively in situations in which it is inappropriate
  • often unable to play or engage in leisure activities quietly
  • is often “on the go” or often acts as if “driven by a motor”
  • often talks excessively
  • often blurts out answers before questions have been completed
  • often has difficulty awaiting turn
  • often interrupts or intrudes on others (e.g., butts into conversations or games)

The 18 behaviours are, according to ADHD proponents, evidence of a ‘biochemical brain imbalance’ or defective ‘brain circuitry’, though most children, and many adults, display them to varying degrees in homes, schools and workplaces every day.  What is supposed to distinguish ADHD sufferers from the rest of the population is their level of behavioural impairment or dysfunction. However, how ‘often’ a child ‘fidgets or squirms in their seat’, or ‘interrupts’ or ‘avoids homework’ or ‘fails to remain seated when remaining seated is expected’ or ‘is distracted by external stimuli’ so that they exhibit ‘some impairment’ is not defined. Like beauty, ‘impairment’ is in the eye of the beholder.

The predecessor of DSM5 first published in 1993 DSM-IV states: Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behaviour, is under close supervision, is in a novel setting, is engaged in especially interesting activities, or is in a one-to-one situation (e.g., the clinician’s office)’.[3]  In other words, ADHD children will behave appropriately and not display ADHD symptoms when they are rewarded, when people pay attention to them (close supervision) and when they are having new experiences. Conversely, ADHD children will be inattentive, easily distracted and display ADHD symptoms when their good behaviour goes unrewarded, no one pays any attention to them, or they are bored.

The diagnosing clinician doesn’t have to observe any of the symptoms, let alone any impairment. He or she may simply base their diagnosis on third party accounts of a child’s behaviour. The child’s parents and teachers usually provide these and are typically asked to fill in a questionnaire detailing if their child always, often, sometimes or never displays behaviour like avoiding homework and chores, losing toys, not listening, fidgeting, butting in, talking excessively or being easily distracted or forgetful.

Parents are not routinely informed of the central role that their evidence plays in their child’s diagnosis. Many are simply fed the line that their child has a ‘biochemical brain imbalance’ – without any supporting evidence other than the observed behaviour of their child – and that this ‘imbalance’ is best treated with what is euphemistically called stimulant medication (but in reality is amphetamine).

One counter argument to this is that all psychiatric disorders, many of which are also treated with medication, are diagnosed using similar behavioural criteria. Pointing out inadequacies in the diagnosis of other psychiatric conditions is a poor defence for the inadequacies of the ADHD diagnostic criteria. However, at least conditions like schizophrenia involve extreme behaviours such as delusions or catatonia.

The Drugs used to treat ADHD

There is no doubt biochemical interventions are the most immediate method of altering behaviour. However, using ‘medication’ masks symptoms, does nothing to address the causes of real problems, risks a host of adverse side effects and creates withdrawal effects that worsen baseline behaviours.

The most commonly used drugs to treat ADHD are the amphetamine-based psycho-stimulants dexamphetamine (brand names include Adderall, Dexedrine, Dexostrat) and the near amphetamine methylphenidate (Ritalin, Concerta, Attenta).[4]  The effects of medicinal amphetamines are virtually indistinguishable from illicit ones. In the USA methamphetamine (brand name Desoxyn) is used as an ADHD treatment.[5]

When taken orally in low doses all these drugs will temporarily sharpen focus in most people regardless of their ADHD status. As a result parents and teachers often see increased concentration and more compliant behaviour as immediate effects.

However, the stimulant effects are very short, lasting a matter of hours with ‘no evidence that the medications promote or cause psychological, social, or emotional growth’ in the long term.[6] When the short-term stimulant effects of the drugs wear off there are often “bounce” or withdrawal effects that worsen ADHD type behaviours.[7] Ironically, witnessing the rebound effect reinforces parents’ and teachers’ belief that the child is chemically imbalanced without the drug and that he or she needs to keep taking medication.

ADHD medications carry a range of short and long term risks including Suicide, Strokes and Psychosis and Addiction, Anorexia, Blurred Vision, Dizziness, Growth Retardation, Headache, Heart Attack, Hypertension, Insomnia, Liver Damage, Palpitations and Seizures.

The above is not a full set of potential adverse side effects. For complete information see the Product Information Leaflets for:

Ritalin (active ingredient methylphenidate)

Dexedrine (active ingredient dexamphetamine or dextroamphetamine)

Concerta (active ingredient methylphenidate)

Adderall (active ingredients dexamphetamine and other forms of amphetamine)

Strattera (active ingredient atomoxetine)

Vyvanese (active ingredient lysine-dexamphetamine)

ADHD Amphetamines and addiction and misuse

All ADHD stimulants are addictive and carry warnings for abuse similar to that below which appears on the prescribing information Dexedrine, a brand of dexamphetamine.[8]

AMPHETAMINES HAVE A HIGH POTENTIAL FOR ABUSE. ADMINISTRATION OF AMPHETAMINES FOR PROLONGED PERIODS OF TIME MAY LEAD TO DRUG DEPENDENCE AND MUST BE AVOIDED. PARTICULAR ATTENTION SHOULD BE PAID TO THE POSSIBILITY OF SUBJECTS OBTAINING AMPHETAMINES FOR NON-THERAPEUTIC USE OR DISTRIBUTION TO OTHERS, AND THE DRUGS SHOULD BE PRESCRIBED OR DISPENSED SPARINGLY. MISUSE OF AMPHETAMINES MAY CAUSE SUDDEN DEATH AND SERIOUS CARDIOVASCULAR ADVERSE EVENTS.

Even the inventors of ADHD, the American Psychiatric Association recognise that amphetamines (including dexamphetamine and methamphetamine), methylphenidate (Ritalin) and cocaine are ‘neuropharmacologically alike’.[9]  The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders categorises the abuse and addiction of these drugs in a common class of ‘Amphetamine or Amphetamine-Like – Related Disorders’. It states: ‘Prescribed stimulants have sometimes been diverted into the illegal market…Most of the effects of amphetamines and amphetamine-like drugs are similar to those of cocaine.’[10]

Furthermore, the diagnostic criteria for ‘Amphetamine Intoxication’ include ‘recent use of amphetamine or a related substance (e.g. methylphenidate)’ and many of their potential side effects such as ‘impaired social or occupational functioning, tachycardia, elevated blood pressure, nausea or vomiting, weight loss dyskinesia and dystonia’.[11]

References

[1]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, (DSM-5), (American Psychiatric Association: Washington, D.C., 2013)

[2]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, (DSM-5), (American Psychiatric Association: Washington, D.C., 2013)

[3]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revised (DSM-IV), (American Psychiatric Association: Washington, D.C., 2000): pp86-87

[4]  Other less commonly used brand names for methylphenidate include Methylin, Daytrana, Rubifen, Equasym and Metadate.

[5]  See the FDA approved Prescribing Information Leaflet for Desoxyn (dextroamphetamine sulfate).

[6]  Lydia Furman, ‘What is Attention-Deficit Hyperactivity Disorder (ADHD)?’, Journal of Child Neurology, Vol. 20 No. 12, 2005, p 998. Victoria BC, Trafford Publishing (2006): p6.

[7]  Peter R. Breggin, M.D., Talking Back to Ritalin: What Doctors Aren’t Telling You about Stimulants for Children, Common Courage Press, Monroe, 1998, p.22.

[8]  GlaxoSmithKline, Prescribing Information – Dexedrine (dextroamphetamine sulphate).

[9]  American Psychiatric Association, Treatments of Psychiatric Disorders: a task force report of the American Psychiatric Association 1st ed., 1989, quoted in ibid., p. 71.

[10]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC, 2000, p. 223.

[11]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC, 2000, p. 225