Attention deficit hyperactivity disorder controversies

Controversies surrounding the topic of ADHD's nature, diagnosis, and treatment

Despite the scientifically well established nature of attention deficit hyperactivity disorder (ADHD), its diagnosis, and its treatment, although the prevalence of ADHD is consistent internationally. Most healthcare providers accept ADHD as a genuine disorder, at least in the small number of people with severe symptoms.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5), the leading authority in the US on clinical diagnosis, ADHD is a neurodevelopmental disorder with a prevalence rate in most cultures of about 5% in children and 2.5% in adults. Today, the existence of ADHD is widely accepted, However, according to sociology professor Vincent Parrillo, "Parent and consumer groups, such as CHADD (Children and Adults with Attention Deficit Hyperactivity Disorder), tend to support the medical perspective of ADHD." These guidelines reviewed studies by Ford et al. that found that 3.6 percent of boys and 0.85 percent of girls in Britain qualified for a diagnosis of ADHD using the American DSM IV criteria. The guidelines go on to state that the prevalence drops to 1.5% when using the stricter criteria for the ICD 10 diagnosis of hyperkinetic disorder, used mainly in Europe. A systematic review of the literature in 2007 found that the worldwide prevalence of ADHD was 5.29 percent, and that there were no significant differences in prevalence rates between North America and Europe. The review did find differences between prevalence rates in North America and those in Africa and the Middle East, but cautioned that this may be due to the small number of studies available from those regions.

The pathogenesis of ADHD is not wholly clear, however a large body of scientific evidence supports that it is caused by a complex mixture of genetic, pre natal and early post natal environmental factors. Jonathan Leo and David Cohen, critics who reject the characterization of ADHD as a disorder, contended in 2003 and 2004 that the controls for stimulant medication usage were inadequate in some lobar volumetric studies, which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for decreased thickness observed in certain brain regions. They believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology. There is also strong evidence to support genetic environment interactions with some fetal and early post natal environmental factors. Authors of a review of ADHD etiology in 2004 noted: "Although several genome wide searches have identified chromosomal regions that are predicted to contain genes that contribute to ADHD susceptibility, to date no single gene with a major contribution to ADHD has been identified." However, several large studies and reviews provide strong support that ADHD is polygenic in most cases, caused by a complex interaction between multiple genes – there is no single gene which would cause the majority of ADHD cases. The social construction theory of ADHD argues that attention deficit hyperactivity disorder is not necessarily an actual pathology, but that an ADHD diagnosis is a socially constructed explanation to describe behaviors that simply do not meet prescribed social norms. Psychiatrists Peter Breggin and Sami Timimi oppose pathologizing the symptoms of ADHD. Sami Timimi, who is a child and adolescent psychiatrist with the NHS, argues that ADHD is not an objective disorder but that western society creates stress on families which in turn suggests environmental causes for children expressing the symptoms of ADHD. They also believe that parents who feel they have failed in their parenting responsibilities can use the ADHD label to absolve guilt and self blame. Timimi's view has been heavily criticized by Russell Barkley, a strong proponent of ADHD as an independent pathology and of medicating children for ADHD symptoms. A common argument against the medical model of ADHD asserts that, while the traits that define ADHD exist and may be measurable, they lie within the spectrum of normal healthy human behaviour and are not dysfunctional. However, by definition, in order to diagnose with a mental disorder, symptoms must be interpreted as causing a person distress or be especially maladaptive. In this view, in societies where passivity and order are highly valued, those on the active end of the active passive spectrum may be seen as problems. Medically defining their behaviour (through medical labels such as ADHD) serves the purpose of removing blame from those causing the problem. However, strict social constructions views are controversial, due to a number of studies that cite significant psychological and social differences between those diagnosed with the disorder, and those who are not. The specific reasons for these differences are not certain, and this does not suggest anything other than a difference in behavior. Studies have also shown neurological differences, but whether this signifies an effect rather than a cause is unknown. Such differences could also be attributed the drugs commonly prescribed to people with this disorder. Studies have also been able to differentiate ADHD from other psychiatric disorders in its symptoms, associated features, life course, and comorbidity. Gerald Coles, an educational psychologist and formerly an associate professor of clinical psychiatry at Robert Wood Johnson Medical School and the University of Rochester who has written extensively on literacy and learning disabilities, asserts that there are partisan agendas behind the educational policy makers and that the scientific research that they use to support their arguments regarding the teaching of literacy are flawed. These include the idea that there are neurological explanations for learning disabilities. Gerald Coles argues that school failure must be viewed and treated in the context of both the learning environment and the child's individual abilities, behavior, family life, and social relationships. He then presents a new model of learning problems, in which family and school environments are the major determinants of academic success. In this interactive paradigm, the attitudes and methods of education are more important than inherent strengths or deficits of the individual child.

Since the early 2000s, research on the functioning of the brain has been conducted to help support the idea that Attention Deficit Hyperactivity Disorder is an executive dysfunction issue. The brains of males and females are showing differences, which could potentially help explain why ADHD presents differently in boys and girls. The current method of diagnosis made is using the DSM 5, along with a possible physical and visual examination.

Overdiagnosis typically refers to the phenomenon of children without ADHD being systematically erroneously diagnosed with ADHD. These instances are termed as false positives. However, the "presence of false positives alone does not indicate overdiagnosis". There may be evidence of overdiagnosis if inaccuracies are shown consistently in the accepted prevalence rates or in the diagnostic process itself. "For ADHD to be overdiagnosed, the rate of false positives (i. e., children inappropriately diagnosed with ADHD) must substantially exceed the number of false negatives (children with ADHD who are not identified or diagnosed)." Children aged 8 to 15 years living in the community indicated an ADHD prevalence rate of 7.8%. However, only 48% of the ADHD sample had received any mental health care over the past 12 months. Evidence also exists of possible differences of race and ethnicity in the prevalence of ADHD. Some believe this may be due to different perceptions of what qualifies as disruptive behavior, inattention and hyperactivity. It is argued that over diagnosis occurs more in well off or more homogeneous communities, whereas under diagnosis occurs more frequently in poorer and minority communities due to lack of resources and lack of financial access. Those without health insurance are less likely to be diagnosed with ADHD. It is further believed that the "distribution of ADHD diagnosis falls along socioeconomic lines", according to the amount of wealth within a neighborhood. Therefore, the difficulty of applying national, general guidelines to localized and specific contexts, such as where referral is unavailable, resources are lacking or the patient is uninsured, may assist in the establishment of a misdiagnosis of ADHD. Development can also influence perception of relevant ADHD symptoms. ADHD is viewed as a chronic disorder that develops in childhood and continues into adulthood. However, some research shows a decline in the symptoms of ADHD as children grow up and mature into adulthood. As children move into the stage of adolescence, the most common reporters of ADHD symptoms, parents and teachers, tend to focus on behaviors affecting academic performance. Some research has shown that the primary symptoms of ADHD were strong discriminators in parent ratings, but differed for specific age groups. Hyperactivity was a stronger discriminator of ADHD in children, while inattentiveness was a stronger discriminator in adolescents. Issues with comorbidity are another possible explanation in favor of the argument of overdiagnosis. As many as 75% of diagnosed children with ADHD meet criteria for some other psychiatric diagnosis. The debate of underdiagnosis, or giving a "false negative", has also been discussed, specifically in literature concerning ADHD among adults, girls and underprivileged communities. It is estimated that in the adult population, rates of ADHD are somewhere between 4% and 6%. However, as little as 11% of these adults with ADHD actually receive assessment, much less any form of treatment. Between 30% and 70% of children with ADHD report at least one impairing symptom of ADHD in adulthood, and 30% to 50% still meet the diagnostic criteria for ADHD. Research on gender differences also reveals an argument for underdiagnosis of ADHD among girls. The ratio for male to female is 4:1 with 92% of girls with ADHD receiving a primarily inattentive subtype diagnosis. Typically, females with ADHD exhibit less disruptive behaviors and more internalizing behaviors. Girls tend to show fewer behavioral problems, show fewer aggressive behaviors, are less impulsive, and are less hyperactive than boys diagnosed with ADHD. These patterns of behavior are less likely to disrupt the classroom or home setting, therefore allowing parents and teachers to easily overlook or neglect the presence of a potential problem. As stated previously, underdiagnosis is also believed to be seen in more underprivileged communities. These communities tend to be poorer and inhabit more minorities. More than 50% of children with mental health needs do not receive assessment or treatment. Access to mental health services and resources differs on a wide range of factors, such as "gender, age, race or ethnicity and health insurance". Therefore, children deserving of an ADHD diagnosis may never receive this confirmation and are not identified or represented in prevalence rates. The British Psychological Society said in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention related disorders: "The idea that children who don't attend or who don't sit still in school have a mental disorder is not entertained by most British clinicians." The NICE, in collaboration with others, release guidelines for the diagnosis and treatment of ADHD. An update was last published in 2019. There have been notable differences in the diagnosis patterns of birthdays in school age children. Those born relatively younger to the school starting age than others in a classroom environment are shown to be more likely diagnosed with ADHD. Boys who were born in December in which the school age cut off was December 31 were shown to be 30% more likely to be diagnosed and 41% to be treated than others born in January. Girls born in December had a diagnosis percentage of 70% and 77% treatment more than ones born the following month. Children who were born at the last 3 days of a calendar year were reported to have significantly higher levels of diagnosis and treatment for ADHD than children born at the first 3 days of a calendar year. The studies suggest that ADHD diagnosis is prone to subjective analysis.

ADHD management recommendations vary by country and usually involves some combination of counseling, lifestyle changes, and medications. The British guideline only recommends medications as a first line treatment in children who have severe symptoms and for them to be considered in those with moderate symptoms who either refuse or fail to improve with counseling. Canadian and American guidelines recommend that medications and behavioral therapy be used together as a first line therapy, except in preschool aged children.