Does Adhd Exist Or Not
Dissertation submitted in partial fulfillment of the requirement for the degree in Pharmaceutical Management.
1.1 Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficiency Hyperactivity Disorder (ADHD) is a medical term given to children who exhibit a persistent, developmentally inappropriate and impairing pattern of behaviour. ADHD is also the most commonly diagnosed mental disorder of children. ADHD is a neurobiological condition that becomes apparent in the preschool and early school years. ADHD is a genetically heterogeneous disease. Different genes may contribute to the group of symptoms.
ADHD has 2 clusters of behavioural symptoms which attributes to 3 subtypes of ADHD. In 1994, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which is the standard diagnostic text that mental-health professionals use, expanded the definition and listed the three specific types of ADHD.  There are namely, Inattentive subtype; Hyperactive-Impulsive subtype and lastly the Combined type which is also known as the “Classic ADHD.”
The primarily inattentive person has difficulties, listening focusing on details, organising and remembering where he put his things. In school, these children daydream at times and may not finish their work when the rest of their classmates do. Clinicians have found that when children with ADHD are highly motivated in an area, they attend quite well. For example, some parents remark that their children is very attentive playing video games or while participating in a favourite class such as art or music. However, it is difficult for them to maintain their attention throughout the day on task of varying interest to them. Though it is common that most of us have fluctuating attention to some degree during the day, the problem is more frequent and prominent for the child with ADHD.
The person with primarily hyperactive-impulsive type ADHD displays excessive extraneous movements, such as fidgeting, moving around often and talking excessively. Another characteristic is impulsive behaviour such as interrupting others and making comments without censoring inappropriate words first. These children may appear rude or uncaring. However, it is important to understand that these ADHD children often have big hearts but are so impulsive at times that they inadvertently end up offending others.
The combined ADHD shows characteristics of both inattentive and hyperactive-impulsive behaviour. People are not classified as combined if they only exhibit one characteristic of one type of ADHD.
There is some debate over these criteria. Some argue the condition is over-diagnosed. Others say it's underdiagnosed. 
The most common form of ADHD is the combined type, where the child demonstrates both inattention and hyperactivity-impulsivity symptoms. The inattentive type is the next most common, and the least common form of ADHD is the hyperactive-impulsive type. Generally speaking, ADHD is more common in boys than girls. This could because, there is a higher trend of behavioural problems like fighting, stealing observed in boys which appear more problematic and obvious, hence, a better rate of detection of ADHD as compared to girls. Rates of ADHD are fairly consistent across a broad range of geographic, racial and socioeconomic populations.
1.2 Historical Overview
ADHD has had many names over its lengthy history, including hyperkinesis, minimal brain damage or dysfunction, Hyperactive Impulse Disorder, Hyperactive Child Syndrome, Developmental Hyperactivity and attention deficit disorder (ADD) with or without hyperactivity. The current scientific name is ADHD, according to American Psychiatric Association.
1.2.1 Early Nineteenth-Century: Heinrich Hoffmann
ADHD can be traced back to early nineteenth-century observations of children and how they differed in behaviours. Peoms were written to express differences in behaviours observed among children. For example, Der Struwwelpeter (1845), a popular children’s book by the physician Heinrich Hoffmann included an illustrated story about “Fidgety Philip” (Zappelphillip) –(Refer to Appendix 1) and John-Head-in-Air (Hans-Guck-in-die-Luft). – (Refer to Appendix 2) From the two peoms by Heinrich Hoffmann, it depicted the symptoms of inattention consistent with ADHD found in Johnny’s behaviour. Johnny had difficulty paying attention to what is before him and his eyes often go astray.
1.2.1 Early Twentieth-Century: Dr. George F. Still
A more public and official beginning of ADHD study can be traced back to specifically the year 1902. A British paediatrician, Dr. George Frederic Still raised interesting issues on “Some abnormal psychical conditions in children.” In his lectures at a scientific meeting, the Royal College of Physicians of London, he described “an abnormal defect of moral control in children,” calling “urgently for scientific investigation.”
Dr Still used descriptive cases of children to elaborate his points. He explained that the term “attention deficit” seems to imply that children with ADHD are unable to pay attention at all. However, this is not the true. Children with ADHD can pay attention, but they do demonstrate inconsistency, over time and in a variety of settings. One of Dr Still’s points was, these children require constant and close supervision. To this very present day, parents with hyperactive children are often quite concerned about basic safety and day-to-day activities of their children.
1.2.2 Mid- Twentieth Century: Dr Charles Bradley’s Arithemetic Pills
In 1930s, the first treatment for ADHD was introduced. George Lathrop Bradley’s only child, Emma was suffering from encephalitis. After the illness, Emma started to exhibit severe behavioural problems and seizures. Emma’s parents opened a children’s home in Rhode Island. Dr Charles Bradley, M.D, a cousin of George Bradley studied neurology. Charles was actively in research with his team of doctors, where they stumbled upon a common treatment for allergies and asthma, Benzedrine. Benzedrineis a “stimulant”, the current most effective treatment in ADHD was termed at “Arithemetic Pill.”
Ritalin is a drug with two faces. It is the drug doctors prescribe for children who cannot sit still at school. It is a mild drug, safe enough for five-year-olds to take. It varies in individuals as it either works miracles or causes unpleasant, though rarely serious side effects. The other face of Ritalin is the face of abuse. Ritalin is chemically similar to methamphetamine and is as addictive as cocaine. Ritalin abuse began in the early 1990s. Ritalin controls the disorder, and do not cure attention disorders.
By the 1960s, ADHD was best characteristed as “minimal brain dysfunction.” However, this name was very soon discarded. By the late 1960s, the American Psychiatric Association introduced the term “hyperkinetic reaction of childhood.” In the early 1970s, scientistis deduced that ADHD may be caused by abnormal brain processing, and there might be differences in the normal shape and size of the brain. It was also emphasized that ADHD could be found in multiple members of the same family, genetic factors were highly possible to contribution of the presence of ADHD.
In the early 1980s, a new name, ADD emerged. Depending on symptoms, the child was either diagnosed as ADD with hyperactivity or ADD without hyperactivity. A focus on attention became crucial in diagnosis. Although there are differences at the symptom level in children with and without hyperactivity, both class of children respond similarly to treatment and are considered to have more similarities than differences.
The most updated and current terminology for this disorder came at the end of twentieth century.
1.2.3 Twenty-First Century
Beginning early in the twenty-first century, World Health Organisation (WHO) recognised ADHD as a worldwide concern, thereby there was a need for spread of knowledge and understanding. Although ADHD is known to occur across the world, there are differences in reported rates between countries. It is believed that this could be studies using different classification methods. In studies using International Classification of Disease criteria, rates may be lower as they have narrow criteria standards.
As compared to the earlier DSM diagnostic criteria, the current criteria include hyperactive-impulsive and inattentive symptoms, results in higher rates of diagnosis.
2. Causes of ADHD
Scientists are not sure what causes ADHD, although many studies suggest that genes play a large role. Like many other illnesses, ADHD probably results from a combination of factors. In addition to genetics, researchers are looking at possible environmental factors, and are studying how brain injuries, nutrition and the social environment might contribute to ADHD.
2.1 Increased risk for ADHD based on family history
ADHD is a disease that runs in families passed down through generations. In families of children with ADHD, it is very common to have a “first degree” relative with ADHD. ADHD is found to be one of the most heritable among the other psychiatric disorders.
2.2 Increased risk for ADHD based on genetic studies
The gene(s) responsible for ADHD is unknown. It is still under clinical research on blood samples from children and adults for genetic testing. However, the likelihood that the genes involved in controlling how chemical messages are passed between specific areas of the brain is high. If a gene responsible for forming a receptor on a nerve cell is abnormal, then the receptor may malfunction. In result, the brain is unable to function normally. It is likely that ADHD results from a combination of genes with slight variation in different individuals. One-third of all children with ADHD have family members who also have the disorder.
Possible genes involved in ADHD includes genes that code for chemical transportaters (DAT – Dopamine Transporter gene)
2.3 Environmental Causes
Although genetics is probably the main cause of ADHD, the disorder can sometimes be caused by environmental factors. Two types of chemical toxins have also been linked to ADHD; lead and polychlorinated biphenyls (PCBs). In 1960s, it was discovered that high level of lead might cause learning disabilities in children and make them hyperactive. PCBs were banned in the United States in 1976. Yet, they remain in the environment for decades. They can be found in bodies of fishes, when a pregnant mother eats this contaminated fish PCBs can pass through her bloodstream to her fetus. They can cause problems with the brain development of children, reducing their ability to learn and causing hyperactivity. Convincing evidence for dietary influences on ADHD is lacking.
2.4 Problems in Pregnancy
Environmental risk factors during pregnancy, except for smoking, often seem to related to hypoxia to the fetus. Older age of the mother is also a risk factor during pregnancy, though may also indirectly be related to hypoxia. Hypoxia can occur when there are complications during the pregnancy or during birth. Pregnancy sometimes increases the mother’s blood pressure sharply, which can be related to problems with placenta and can result in poor blood supply to the baby. Pre-mature birth is associated with ADHD as well. Smoking and drinking during pregnancy are additional risk factors for ADHD.
The ultimate aim of this dissertation is to conclude that ADHD does exist and these children are not just naughty children. They ought to seek proper treatment as early as possible so as to attain better prognosis.
3. Diagnosis of ADHD
There is currently no single, simple laboratory or imaging tests to diagnose ADHD. A diagnosis relies only on behavioral symptoms, verbal history from parents/guardians, from child itself and clinical history of the child. There are short-term problems that result from illness, lack of sleep, intake of stimulants (such as caffeine) or stress, In these cases, the symptoms usually occur in only one setting.
Many experts believe that the disorder is both over- and underdiagnosed. Diagnosis of attention-deficit hyperactivity disorder is difficult for some of the following reasons:
Arguments that ADHD is Overdiagnosed in Some Children
The popularity methylphenidate (Ritalin) has encouraged some parents and teachers to pressure doctors into prescribing this standard ADHD drug for children who are aggressive or who have poor grades, where they were simply poorer learners or had no problems at all.
Some children are more likely to receive medication were young for their grade, indicating they may have been socially and intellectually immature, rather than behaviourally impaired.
Being in poverty or single parent household contribute to emotional and behavioral problems. The significant increase in these problems has also paralleled an increase in the diagnosis of ADHD children, who may simply be responding to social and economic problems.
Arguments that ADHD is Underdiagnosed in Some Children
Some evidence suggests that many girls with ADHD may go underdiagnosed. Research indicates that girls with ADHD are often inattentive but not hyperactive or impulsive. In fact, older girls with ADHD tend to have social problems due to withdrawal and internalized emotions, showing symptoms of anxiety and depression. The inattentive subtype, in any case, may first show up in older children and adolescents.
Doctors may fail to diagnose children with ADHD because they often behave normally in the quiet doctor's office where there are no distractions to trigger symptoms.
In spite of the fact that there seems to be no differences in response to treatment among population groups, African American, Hispanic, and Asian children with ADHD are half as likely to be diagnosed and treated as Caucasian children. This could be due to cultural differences where Asian families react strongly against visiting a psychiatrist.
Lastly, ADHD may also be underdiagnosed in adults as it is commonly known that ADHD exist in children thus, neglecting the fact that ADHD do present in adulthood too
3.1 Symptoms of ADHD
According to Americian Psychiatric Association’s Diagnostic and Statistical Manual, a child who shows six or more symptoms of inattention or hyperactivity-impulsivity or both classification of symptoms (Refer to below table 1) for a duration for six months with onset before age seven meets the criteria for ADHD, inattentive type, ADHD hyperactive-impulsive type or ADHD combined type respectively. Symptoms must be present in a persistent pattern for at least six months and must occur to a degree that is more frequent and severe as compared in other healthy children of similar level of development.
often fails to give close attention to details or makes careless mistakes in schoolwork, or other activities.
often has difficulty sustaining attention in tasks
often does not seem to listen when spoken to directly
often does not follow through on instructions and fails to finish schoolwork, chores, duties in workplace (not due to oppositional behaviour or failure to understand instructions
often loses things necessary for tasks
often avoids, dislikes, or is reluctant to engage in tasks that requires sustained mental effort (homework)
often have difficulty organising tasks and activities
is often easily distracted by extraneous stimuli
is often forgetful in daily activtites
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 has difficulty playing or engaging in leisure activities quietly
often runs about or climbs excessively in situations in which it is inappropriate
often talks excessively
is often “on the go” or often acts as if “driven by a motor”
often blurts out answers before questions have been completed
often has difficulty waiting turn
often interrupts or intrudes others (eg. Butts into conversations or games)
There are a few key points to note for the symptoms of ADHD in use for diagnosis. Each symptom must occur to a degree that is unusual for a child of his/her age. For behaviours to be symptoms of ADHD, they must happen very often, which is unusual for a child of his/her age. The second key point is that ADHD symptom must happen in more than one setting. Any child can be restless in one activity, but an ADHD child will typically have problems wherever they are. The third key point to note is ADHD symptoms must present before the age of seven. Hyperactivity will be more obvious when the child is faced with greater expectations. The final key point is the symptoms for ADHD should not be explained by another condition. This means the child should not be diagnosed with ADHD when the child’s clinical history of a condition that explains the symptoms presented similar to an ADHD individual. To summarise, for a child to be diagnosed with ADHD, it requires detailed examination of multiple factors.
ADHD symptoms can persist throughout a person’s lifetime. It can happen at any time in one’s life. In terms of appearance, ADHD individuals present without much difference but they behave differently. These children have a disorder that makes they find it difficult to follow instructions or participate in activities. Even though the child often want to concentrate, the erratic behaviour can be very troublesome – so much so that it interfere their ability to live normal lives. Thus resulting in adults classifying them as “naughty”
3.2 Screening or Rating Scales
In addition to clinical history, some doctors and schools uses rating scales. These are usually pencil-paper forms accompanied with symptoms of ADHD. The ratings can be tallied among the people who have associations with the child and used to gauge if the symptoms of ADHD in a child is significant and the severity of the disorder. These scales are useful as a complementary assessment for the diagnosis and will not replace the clinical review of the patient’s history by a physician.
4. Materials and Methods
5.1 Diagnosis versus Assessment
Diagnosis is a process of identifying an illness or disorder, in contrast to assessment are designed to evaluate all possible causes of a problem and determine specific approaches to improve the symptoms. The point of view in a diagnosis and assessment differs as well. In diagnosis, the negative aspect of the disorder is being focused on while assessment looks for evidence of a child’s skills and strengths to offset the symptoms. Most importantly, assessments serve to determine if there is more than one cause for the symptoms.
5.2 The Medical Establishment Answer
“There is no controversy among practicing scientists,” says Dr Russel Barkley, professor of psychiatry at State University of New York Upstate Medical University at Syracuse. “No scientific meetings mention any controversies about the disorder, about its validity as a disorder, about the usefulness of using stimulant medications like Ritalin for it. There is simply is no controversy. The science speaks for itself.”
Some people “say that ADHD can’t be real – that it can’t be a valid disorder – because there’s no measure for it,” Barkley continues. “But that’s tremendously naive. A disorder doesn’t have to have a blood test to be valid. If, that were the case, all mental disorders would be invalid. Schizophrenia, manic depression would all be fake. There is no blood test or x-ray for any mental disorder right now in our science. That does not make them invalid. Doctors approach these diseases in the same way they do ADHD. They listen to patients’ history and their complaints, compare the symptoms with the disease and rule out other possible explainations.
5.3 The Critics Answer
Dr. Peter Breggin, one of the most outspoken critics of Ritalin, calls ADHD a fake disease. “This diagnosis (ADHD) was created for the specific purpose of suppressing children,” he says. “Every single item in the list of symptoms has to do with controlling large groups of children in classroom settings. Could it be a defect in the brain that makes you do everything a teacher can’t stand? We’ve got a disease that goes away if you act in an interesting, warm, caring way with kids.”
Critics continue to point out that there is no blood test, x-ray or brain scan that can definitively diagnose ADHD. However, researchers using magnetic resonance imaging (MRI) may be close to finding evidence in brain scans that could reliably confirm or rule out whether someone has ADHD. Even if ADHD does exist, many critics claim, doctors do not spend the time to find out what is really wrong with the kids.
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Refer to health and safety management system, risk assessments 1 and 2
Justified, complete and practical
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