Is Attention Deficit Hyperactivity Disorder (ADHD) really a disease?

Is Attention Deficit Hyperactivity Disorder (ADHD) really a disease?

That’s the controversial question posed in a new book by British author and psychologist and lecturer Dr James Davies. Davies is convinced that the condition, which is characterised by significant difficulties of attention, hyperactivity or impulsiveness, is being over-diagnosed.

He quotes Dr Allen Frances, the chairman of the renowned ‘bible’ of the psychiatric profession, the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV), which is about to be replaced by the DSM-V.

Allen, who included the condition in the DSM-IV in 1994, has warned that ADHD has become a false epidemic. And that’s happened, declares Davies, because ADHD has become a convenient label to slap on children who are causing trouble.

In his new book Cracked: Why Psychiatry Is Doing More Harm Than Good, Davies says the inclusion of ADHD in 1994 in the DSM-IV opened the door to over-diagnosis — levels have reportedly trebled since the condition was first included in the manual.

“It can be easier to label a child and give medication than to sit down with the children over several sessions to determine what may be going on in their lives that’s leading them to behave in ways that are deemed inconvenient from a standpoint of parents, teacher or other authorities who come into contact with the child,” he told Feelgood. However, he added: “This is not to say there are not instances where the diagnosis is warranted.”

Davies points to a study of nearly one million Canadian schoolchildren which found that the younger children in a class were more at risk of being diagnosed with the condition than their older peers. The simple reason for this was that their immaturity — they started school earlier than their peers — was mistaken for symptoms of ADHD.

The prevalence of ADHD internationally is said to range between 3% and 7% of the population depending on the country — in the US it’s reportedly reached over 8%. However in Ireland the rate tends to be lower —generally between 1% and 3%. This is partly because the manual used by many psychiatrists here is not the DSM-IV but the World Health Organisation’s ICD-10, which, explains Dr Sara McDevitt, consultant child and adolescent psychiatrist within HSE South, has a narrower definition of the condition. She says, the Irish CAMHS system, is painstaking and comprehensive.

“In Ireland ADHD is generally diagnosed by the CAMHS service along with a consultant psychiatrist, so children receive a very holistic assessment of their needs by a number of mental health professionals and only after a lengthy assessment process, which would include interviews with parents and children, questionnaires, observation in clinic and may include observation in school. The team puts all of that information together and makes a decision about diagnosis. In the public CAMHS service we try to avoid the risk of over-diagnosis by offering a comprehensive assessment,” she explains adding that age and developmental stage is always taken into account.

In Ireland, she adds, medication is only a first-line treatment for ADHD in severe cases — for pre-school children or children with mild to moderate symptoms, behaviour management is the first step. Educational psychologist Mary Phelan says she can spend up to five hours assessing a child before making an diagnosis and referring the child to CAMHS for confirmation.

Principal clinical psychologist at the Child and Adolescent Mental Health Service at Dublin’s Mater Hospital, Dr Michael Drumm has been assessing and diagnosing and treating children with ADHD since 1998. There’s no strong evidence to show that ADHD is on the increase in this country says Drumm, a past president of the Psychological Society of Ireland, but he adds, he feels it’s “creeping up”.

“I believe assessment is very important. You see the child holistically, you look at his or her temperament, their development, within their family and environment and also in relation to their psychological make-up.”

Davies has a point, he says, warning that careful assessment is crucial — sometimes, he says, ADHD may be over-diagnosed because a child is just impulsive or inattentive or plain bored — as many children are, at times.

“In our clinical service, we tend to see the extreme end of it but sometimes GP surgeries or paediatric clinics can be quicker to diagnose it because they wouldn’t be seeing it as frequently.”

It’s a painstaking process he says, adding that diagnosing a child with ADHD following a 30-minute session as Davies claims, would be “highly inappropriate”.

A thorough assessment needs several hours, he says. ”

“We have quite a high bar in relation to the diagnosis of it,” says Dr Drumm, adding he believes that both Irish clinicians and Irish parents are reluctant to rush to label or medicate a child.

“Usually the response is, ‘We’ll try lots of other stuff first’. This would involve working with the parent, the school, the child — and, sometimes medication, but I have seen children with ADHD who have been put on medication and it has no effect on them whatsoever.”