ADHD: A Modest Proposal

February 1, 2012

I’m reluctant to write a post about ADHD.  It just seems like treacherous ground.  Judging by comments I’ve read online and in magazines, and my own personal experience, expressing an opinion about this diagnosis—or just about anything in child psychiatry—will be met with criticism from one side or another.  But after reading L. Alan Sroufe’s article (“Ritalin Gone Wild”) in this weekend’s New York Times, I feel compelled to write.

If you have not read the article, I encourage you to do so.  Personally, I agree with every word (well, except for the comment about “children born into poverty therefore [being] more vulnerable to behavior problems”—I would remind Dr Sroufe that correlation does not equal causation).  In fact, I wish I had written it.  Unfortunately, it seems that only outsiders or retired psychiatrists can write such stuff about this profession. The rest of us might need to look for jobs someday.

Predictably, the article has attracted numerous online detractors.  For starters, check out this response from the NYT “Motherlode” blog, condemning Dr Sroufe for “blaming parents” for ADHD.  In my reading of the original article, Dr Sroufe did nothing of the sort.  Rather, he pointed out that ADHD symptoms may not entirely (or at all) arise from an inborn neurological defect (or “chemical imbalance”), but rather that environmental influences may be more important.  He also remarked that, yes, ADHD drugs do work; children (and adults, for that matter) do perform better on them, but those successes decline over time, possibly because a drug solution “does nothing to change [environmental] conditions … in the first place.”

I couldn’t agree more.  To be honest, I think this statement holds true for much of what we treat in psychiatry, but it’s particularly relevant in children and adolescents.  Children are exposed to an enormous number of influences as they try to navigate their way in the world, not to mention the fact that their brains—and bodies—continue to develop rapidly and are highly vulnerable.  “Environmental influences” are almost limitless.

I have a radical proposal which will probably never, ever, be implemented, but which might help resolve the problems raised by the NYT article.  Read on.

First of all, you’ll note that I referred to “ADHD symptoms” above, not “ADHD.”  This isn’t a typo.  In fact, this is a crucial distinction.  As with anything else in psychiatry, diagnosing ADHD relies on documentation of symptoms.  ADHD-like symptoms are extremely common, particularly in child-age populations.  (To review the official ADHD diagnostic criteria from the DSM-IV, click here.)  To be sure, a diagnosis of ADHD requires that these symptoms be “maladaptive and inconsistent with developmental level.”  Even so, I’ve often joked with my colleagues that I can diagnose just about any child with ADHD just by asking the right questions in the right way.  That’s not entirely a joke.  Try it yourself.  Look at the criteria, and then imagine you have a child in your office whose parent complains that he’s doing poorly in school, or gets in fights, or refuses to do homework, or daydreams a lot, etc.  When the ADHD criteria are on your mind—remember, you have to think like a psychiatrist here!—you’re likely to ask leading questions, and I guarantee you’ll get positive responses.

That’s a lousy way of making a diagnosis, of course, but it’s what happens in psychiatrists’ and pediatricians’ offices every day.  There are more “valid” ways to diagnose ADHD:  rating scales like the Connors or Vanderbilt surveys, extensive neuropsychiatric assessment, or (possibly) expensive imaging tests.  However, in practice, we often let subthreshold scores on those surveys “slide” and prescribe ADHD medications anyway (I’ve seen it plenty); neuropsychiatric assessments are often wishy-washy (“auditory processing score in the 60th percentile,” etc); and, as Dr Sroufe correctly points out, children with poor motivation or “an underdeveloped capacity to regulate their behavior” will most likely have “anomalous” brain scans.  That doesn’t necessarily mean they have a disorder.

So what’s my proposal?  My proposal is to get rid of the diagnosis of ADHD altogether.  Now, before you crucify me or accuse me of being unfit to practice medicine (as one reader—who’s also the author of a book on ADHD—did when I floated this idea on David Allen’s blog last week), allow me to elaborate.

First, if we eliminate the diagnosis of ADHD, we can still do what we’ve been doing.  We can still evaluate children with attention or concentration problems, or hyperactivity, and we can still use stimulant medications (of course, they’d be off-label now) to provide relief—as long as we’ve obtained the same informed consent that we’ve done all along.  We do this all the time in medicine.  If you complain of constant toe and ankle pain, I don’t immediately diagnose you with gout; instead, I might do a focused physical exam of the area and recommend a trial of NSAIDs.  If the pain returns, or doesn’t improve, or you have other features associated with gout, I may want to check uric acid levels, do a synovial fluid analysis, or prescribe allopurinol.

That’s what medicine is all about:  we see symptoms that suggest a diagnosis, and we provide an intervention to help alleviate the symptoms while paying attention to the natural course of the illness, refining the diagnosis over time, and continually modifying the therapy to treat the underlying diagnosis and/or eliminate risk factors.  With the ultimate goal, of course, of minimizing dangerous or expensive interventions and achieving some degree of meaningful recovery.

This is precisely what we don’t do in most cases of ADHD.  Or in most of psychiatry.  While exceptions definitely exist, often the diagnosis of ADHD—and the prescription of a drug that, in many cases, works surprisingly well—is the end of the story.  Child gets a diagnosis, child takes medication, child does better with peers or in school, parents are satisfied, everyone’s happy.  But what caused the symptoms in the first place?  Can (or should) that be fixed?  When can (or should) treatment be stopped?  How can we prevent long-term harm from the medication?

If, on the other hand, we don’t make a diagnosis of ADHD, but instead document that the child has “problems in focusing” or “inattention” or “hyperactivity” (i.e., we describe the specific symptoms), then it behooves us to continue looking for the causes of those symptoms.  For some children, it may be a chaotic home environment.  For others, it may be a history of neglect, or ongoing substance abuse.  For others, it may be a parenting style or interaction which is not ideal for that child’s social or biological makeup (I hesitate to write “poor parenting” because then I’ll really get hate mail!).  For still others, there may indeed be a biological abnormality—maybe a smaller dorsolateral prefrontal cortex (hey! the DLPFC!) or delayed brain maturation.

ADHD offers a unique platform upon which to try this open-minded, non-DSM-biased approach.  Dropping the diagnosis of “ADHD” would have a number of advantages.  It would encourage us to search more deeply for root causes; it would allow us to be more eclectic in our treatment; it would prevent patients, parents, doctors, teachers, and others from using it as a label or as an “excuse” for one’s behavior; and it would require us to provide truly individualized care.  Sure, there will be those who simply ask for the psychostimulants “because they work” for their symptoms of inattentiveness or distractibility (and those who deliberately fake ADHD symptoms because they want to abuse the stimulant or because they want to get into Harvard), but hey, that’s already happening now!  My proposal would create a glut of “false negative” ADHD diagnoses, but it would also reduce the above “false positives,” which, in my opinion, are more damaging to our field’s already tenuous nosology.

A strategy like this could—and probably should—be extended to other conditions in psychiatry, too.  I believe that some of what we call “ADHD” is truly a disorder—probably multiple disorders, as noted above; the same is probably true with “major depression,” ”bipolar disorder,” and just about everything else.  But when these labels start being used indiscriminately (and unfortunately DSM-5 doesn’t look to offer any improvement), the diagnoses become fixed labels and lock us into an approach that may, at best, completely miss the point, and at worst, cause significant harm.  Maybe we should rethink this.

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