The Cultural Disagreements Surrounding the Diagnosing and Medicating of ADHD

Mar 8

Attention-deficit/hyperactivity disorder is characterized by an inability to focus, hyperactivity, and a lack of impulse control. There are three types of ADHD: inattentive, hyperactive, or a combination of the two (American Psychiatric Association, 2017). While some might be quick to dismiss this behavior as children being children, research has shown that people diagnosed with ADHD are two to three times more likely to be arrested or placed in jail for crimes such as assault and theft (Mohr-Jensen & Steinhausen, 2016). In addition, those with ADHD are more likely to be involved in car accidents (Roy et al., 2020), have a substance abuse disorder (Dalsgaard et al., 2013), and exhibit risky sexual behavior (Hosain et al., 2012). However, there are also advantages to having ADHD. Those with ADHD are more likely to be able to think creatively and solve problems. Someone with ADHD has fewer mental constraints around considering what is possible when compared to their neurotypical peers (White, 2019). In order to better understand the treatment of ADHD, this blog will examine its history, causes, review the various forms of treatment both conventional and unconventional, and compare and contrast cultural views and rates of diagnosis and medication.

History

Sir George Frederic, a British pediatrician, has traditionally been credited with first describing the symptoms of ADHD in 1902. At the time Frederic observed children that were aggressive, emotional, and defiant and lacked what he called moral control. However, it has been found that the symptoms of ADHD were initially observed and written about in 1775 by Melchior Adam Weikard (Barkley, 2014; Lange et al., 2010). The theory in the early 1950s was that children suffering from what was then called hyperkinetic impulse disorder had sustained a brain injury, even when there was no history of trauma, and that was what caused the hyperactive behavior. Historically hyperactivity had been lumped in with other neurological development issues such as dyslexia, but that began to change in the early 1960s as researchers began to accept that hyperactivity and inattention were actually caused by a mechanism in the brain and could be treated with medication and therapy (Barkley). Hyperkinetic impulse disorder, which was in the second version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), was replaced by attention deficit disorder in the third version which was published in 1980 and was again revised in the fourth edition (Holland, 2018).

The first psychopharmacological treatment for hyperactive patients was accidentally discovered by Charles Bradley when he administered the stimulant Benzedrine to his patients in 1937 and noticed an improvement in their school work. In 1944 Ritalin, whose generic name is methylphenidate, became the preferred stimulant for treating symptoms related to ADHD (Barkley, 2014). Amphetamines were also used to treat ADHD. Adderall, the most popular amphetamine, was originally marketed as a weight loss drug under the name Obetrol. In 1994 it was rebranded and offered as a medication for treating ADHD despite the fact that it wasn’t yet approved for such treatment (Gaffney, 2016).

Causes, Heredity, & Environment

It is generally accepted that ADHD is highly hereditary. Some research puts the heritability at 60% and others at 90%. It is also widely accepted that environmental factors also play a role in the likelihood of developing ADHD (Fahira et al., 2019; Thapar, 2018). Neurobiologically speaking, ADHD symptoms are generally thought to be caused by an aberration in the development of the prefrontal cortex, which controls executive function. Experts speculate that this abnormal development causes hyperactive behavior, diminished impulse control, and an inability to focus (Arnsten, 2009). According to Hoogman et al. (2019) when children with ADHD were compared with their peers using brain imaging technology, they found that the former’s frontal, temporal, and cingulate regions of their cortex’s had a surface area that was smaller than their peers and there were differences in the cortical thickness. Abnormalities in ADHD patients have also been observed in the structure of the brain and the dopamine system (Preston et al., 2017). There are also genetic variants which can cause different types of ADHD. For example, recent research has shown that different gene variants affect whether symptoms continue into adulthood (Palladino et al., 2019). There is a large body of research that points to the impact that environmental factors such as diet and gut health (Cenit et al., 2017), low birth weight and maternal smoking (Langley et al., 2007), and the mental health of primary caregivers (Wüstner et al. 2019) have on the likelihood of developing ADHD.

Stimulants, Non-Stimulants, & Alternative Treatment

There are currently 29 approved stimulants broken out by amphetamines and methylphenidate approved by the Food and Drug Administration (FDA) to treat ADHD. Eight-five percent of those treated with stimulants experience an improvement in alleviating their inattention and hyperactivity and tolerate side effects well (Williams, 2020). Both of these stimulants increase dopamine and norepinephrine in the brain which affects the part of the brain that manages executive function. While it is unknown as to why some people with ADHD respond to one stimulant better than the other, they are considered the most effective treatment for ADHD. The research has concluded that there is no substantial difference between amphetamines and methylphenidate (Connolly et al., 2015; Faraone, 2018). The common side effects for both types of stimulants include a loss of appetite, interrupted sleeping patterns, headaches or stomach pains, involuntary tics, emotional dysregulation, especially if doses are too high, and depression (Silver, 2019).

In 2003 non-stimulant medications became available for treating ADHD (Centers for Disease Control and Prevention, n.d.). Since stimulants are viewed as extremely effective, most people turn to non-stimulants when the former do not work, or the side effects are too great. Unlike stimulants, which start working almost immediately, non-stimulants take time to show results and this can delay feedback on which medication or dose is best. Non-stimulants range from blood pressure medication to antidepressants and work in a variety of ways with different side effects. For example, Kapvay is an alpha-agonist that is used to treat high blood pressure. It also causes the brain to release norepinephrine, which can help with ADHD symptoms. Its side effects include fatigue, sore throat, bad dreams, earaches, and more (Rodden, 2019).

The list of medication options could leave a person or the parent of a child with ADHD wondering which medication is right for them, or if medication is necessary at all. According to the Nation Institute of Mental Health (n.d.), 75% of the children in the U.S with ADHD are receiving either medication, behavioral therapy, or both. Those diagnosed with ADHD generally benefit when their medication is combined with psychotherapy. According to Chandler (2013), adults with ADHD who were on a stimulant benefited from cognitive behavioral therapy (CBT) and it was found to be more effective at relieving symptoms when compared to group therapy, relaxation therapy, or just medication. Philipsen (2012) also found that CBT was the most effective form of psychotherapy for treating ADHD and added that CBT group focused therapy was more effective than regular group therapy. While medication is still considered to be the front-line treatment for children with ADHD, Coles et al., (2020) found that when students between the age of 5 and 13 were given low-intensity behavioral interventions it resulted in some students not needing medication and others were able to put off taking medication or decreasing their dose. According to Coles et al., there is a growing body of research that supports not medicating children with ADHD in favor of behavioral therapy.

In addition to psychotherapy, there are complementary and alternative medicine (CAM) options that can positively influence those with ADHD. According to Bernstein & Voll (2015) these can include meditation, herbal supplements, and more. In their article Bernstein & Voll look at alternative treatments such as using melatonin to help with sleep and acupuncture to improve mood. Unfortunately there doesn’t appear to be enough research on CAMs to say with certainty that they can be used without medication, but the authors collected a compelling amount of research that should encourage practitioners to include things like diet and exercise as part of a holistic ADHD treatment plan. In addition, Mehren et al. (2019) found that adults with ADHD benefited from regular aerobic exercise which improved behavior and neurophysiology.

Cultural Disagreements: Diagnosis & Overmedicating

Globally the rate of ADHD diagnoses has increased from 6.8% to 14.4% between 2005 and 2014. This jump is associated with shifting attitudes from parents who now see the diagnosis as helpful for their children to achieve academic success and a substantial increase in the number of females being diagnosed (Davidovitch et al., 2017). According to Xu et al. (2018), the rate of ADHD diagnoses in children in the U.S. rose from 6.1% in 1997-1998 to 10.2% in 2015-2016. Is this a case of misdiagnosing? Or are doctors and therapists getting better at diagnosing? There are a few differing opinions as to why this is. According to Bluth (2018), there is a hypothesis that children of color are getting more access to healthcare through the Affordable Care Act (ACA), which increases their chances of seeing a medical professional and getting an ADHD diagnosis. While the U.S. has higher rates of ADHD when compared to other developed countries, the research does not indicate that there is an overdiagnosis. Bluth hypothesizes that there are technological and social factors at play. As mental health becomes less stigmatized people are seeking care and receiving diagnoses. Also, a decrease in low birth-weight infant mortality, which has been tied to an increased chance of having ADHD, has also contributed to the prevalence of ADHD. Of course, no system is perfect. According to Bruchmüller et al. (2012), children in the U.S. are being overdiagnosed with ADHD due to a variety of social factors. For example, Bruchmüller et al. found that male therapists were more likely to make a diagnosis of ADHD than their female counterparts.

In 2012 Wedge published an article entitled Why French kids don't have ADHD. While the title was misleading and later updated to Do French kids have ADHD?, the author claimed that French children were treated with a more holistic strategy including behavioral psychotherapy rather than medication. This was due to the divergent beliefs of psychiatrists in the U.S. versus France. The former believes that ADHD is a biological illness and should be treated with medication. The latter believes that ADHD is a condition caused by psychosocial factors. As a result, children in France are typically treated with psychotherapy and the underlying causes of the behavior are considered. French psychiatrists look at factors like diet and how they influence a child’s behavior and do not immediately reach for their prescription pad. Wedge also points out that French psychiatrists use different criteria than American psychiatrists for diagnosing ADHD. While it is appealing to think that ADHD can be treated with a better diet and psychotherapy, more current research does not support this stance. According to Ellison (2015), France's High Health Authority has started urging doctors to acknowledge ADHD as a diagnosis. In fact, the underdiagnosis of ADHD is an issue across Europe. It isn’t that Europeans don’t have ADHD, it is that psychiatrists are resistant to the diagnosis. Ellison does acknowledge that there are parts of the U.S. where ADHD is overdiagnosed, but that fact should not preclude psychiatrists globally from recognizing ADHD as a legitimate neurobiological disorder. According to Heal et al. (2013) European physicians have long viewed ADHD as an American problem and efforts were made in the UK to reject or minimize its existence. This resulted in pediatricians recommending psychotherapy despite evidence that showed that stimulants with psychotherapy were the most effective course of treatment. Heal et al. goes on to argue that ADHD is in fact the most-underdiagnosed mental disorder. Since Wedge’s 2012 article, things in Europe continue to change. As noted France has made moves to encourage psychiatrists to be more open to ADHD. In 2018 the Section Neurodevelopmental Disorders Across the Lifespan of the European Psychiatric Association created new guidelines for the treatment of ADHD. The guidelines covered the common symptoms of ADHD as well as genetic and biological causes. In addition, they acknowledge the emotional toll that ADHD can take on an individual and recommend treating patients with psychoeducation, medication, CBT, and coaching (Kooij et al., 2018).

Conclusion

Based on my review of the literature it appears that the largest challenge for those suffering from ADHD in both the U.S. and Europe is the stigma associated with a diagnosis. On both sides of the Atlantic, there appears to be resistance to a more holistic treatment plan that includes both medication and lifestyle adjustments. For every argument that points to the flaws in the diagnosis, there appears to be a response. For example, early on I read that boys are more commonly diagnosed with ADHD. However, Wüstner et al. (2019) can solve that misnomer by explaining that girls develop different symptoms later in childhood and thus are less likely to be diagnosed with ADHD. Ultimately it comes down to what is best for the client and to help them navigate the challenging and at times hostile waters of an ADHD diagnosis.

If you would like to work with me I am accepting clients based in the state of California for telehealth. I’m an associate marriage and family therapist (AMFT #131631) practicing under the supervision of Pam Shaffer (LMFT #91321).

LET'S CHAT

References

American Psychiatric Association. (2017, July). What Is ADHD? Retrieved December 4, 2020, https://www.psychiatry.org/patients-families/adhd/what-is-adhd
Arnsten A. F. (2009). The emerging neurobiology of attention deficit hyperactivity disorder: The key role of the prefrontal association cortex. The Journal of Pediatrics, 154(5), I–S43. https://doi.org/10.1016/j.jpeds.2009.01.018
Barkley, R. A. (2014). History of ADHD. In Attention–deficit hyperactivity disorder: A handbook for diagnosis and treatment (pp. 3–50). The Guilford Press.
Bernstein, B., & Voll, A. (2015). Supplements, diets and other complementary and alternative interventions in adolescent mental health. Adolescent Psychiatry, 5,73–83. https://10.2174/221067660502150430154627
Bluth, R. (2018, September 10). ADHD numbers are rising, and scientists are trying to understand why. The Washington Post. https://www.washingtonpost.com/national/health-science/adhd-numbers-are-rising-and-scientists-are-trying-to-understand-why/2018/09/07/a918d0f4-b07e-11e8-a20b-5f4f84429666_story.html
Bruchmüller K., Margraf, J., & Schneider, S. (2012). Is ADHD diagnosed in accord with diagnostic criteria? overdiagnosis and influence of client gender on diagnosis. Journal of Consulting and Clinical Psychology, 80(1), 128–38. https://doi.org/10.1037/a0026582
Cenit, M. C., Nuevo, I. C., Codoñer-Franch, P., Dinan, T. G., & Sanz, Y. (2017). Gut microbiota and attention deficit hyperactivity disorder: new perspectives for a challenging condition. European Child & Adolescent Psychiatry, 26(9), 1081–1092. https://doi.org/10.1007/s00787-017-0969-z
Centers for Disease Control and Prevention. (n.d.). Treatment of ADHD. Retrieved November 22, 2020, from https://www.cdc.gov/ncbddd/adhd/treatment.html
Chandler M. L. (2013). Psychotherapy for adult attention deficit/hyperactivity disorder: A comparison with cognitive behaviour therapy. Journal of Psychiatric and Mental Health Nursing, 20(9), 814–820. https://doi.org/10.1111/jpm.12023
Coles, E. K., Pelham, W. E., Fabiano, G. A., Gnagy, E. M., Burrows-Maclean, L., Wymbs, B. T., … Pelham, W. E. (2020). Randomized trial of first-line behavioral intervention to reduce need for medication in children with ADHD. Journal of Clinical Child & Adolescent Psychology, 49(5), 673–687. https://doi.org/10.1080/15374416.2019.1630835
Connolly, J. J., Glessner, J. T., Elia, J., & Hakonarson, H. (2015). ADHD & pharmacotherapy: Past, present and future: A review of the changing landscape of drug therapy for attention deficit hyperactivity disorder. Therapeutic Innovation & Regulatory Science, 49(5), 632–642. https://doi.org/10.1177/2168479015599811
Davidovitch, M., Koren, G., Fund, N., Shrem, M., & Porath, A. (2017). Challenges in defining the rates of ADHD diagnosis and treatment: trends over the last decade. BMC pediatrics, 17(1), 218. https://doi.org/10.1186/s12887-017-0971-0
Dalsgaard, S., Madsen, A. G., & Bikic, A. (2013). Attention-deficit hyperactivity disorder and substance abuse. Minerva Psichiatrica, 54, 281–95.
Ellison, K. (2015, November 4). French kids do have ADHD. Psychology Today. https://www.psychologytoday.com/us/blog/pay-attention/201511/french-kids-do-have-adhd
Fahira, A., Li, Z., Liu, N., & Shi, Y. (2019). Prediction of causal genes and gene expression analysis of attention-deficit hyperactivity disorder in the different brain region, a comprehensive integrative analysis of ADHD. Behavioural Brain Research, 364, 183–192. https://doi.org/10.1016/j.bbr.2019.02.010
Faraone, S. V. (2018). The pharmacology of amphetamine and methylphenidate: Relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities. Neuroscience & Biobehavioral Reviews, 87, 255–270. https://doi.org/10.1016/j.neubiorev.2018.02.001
Gaffney, A. (2016, September 23). How ADHD was sold. The New Republic. https://newrepublic.com/article/137066/adhd-sold
Heal, D. J., Smith, S. L., Gosden, J., & Nutt, D. J. (2013). Amphetamine, past and present--a pharmacological and clinical perspective. Journal of psychopharmacology (Oxford, England), 27(6), 479–496. https://doi.org/10.1177/0269881113482532
Holland, K. (2018, September 29). The History of ADHD: A timeline. Healthline. https://www.healthline.com/health/adhd/history
Hoogman, M., Muetzel, R., Guimaraes, J. P., Shumskaya, E., Mennes, M., Zwiers, M. P., Jahanshad, N., Sudre, G., Wolfers, T., Earl, E. A., Soliva Vila, J. C., Vives-Gilabert, Y., Khadka, S., Novotny, S. E., Hartman, C. A., Heslenfeld, D. J., Schweren, L. J. S., Ambrosino, S., Oranje, B., … Weiss, E. O. (2019). Brain imaging of the cortex in ADHD: A coordinated analysis of large-scale clinical and population-based samples. The American Journal of Psychiatry, 176(7), 531–542. https://doi-org.antioch.idm.oclc.org/10.1176/appi.ajp.2019.18091033
Hosain, G. M. M., Berenson, A. B., Tennen, H., Bauer, L. O., & Wu, Z. H. (2012). Attention deficit hyperactivity symptoms and risky sexual behavior in young adult women. Journal of Women’s Health, 21(4), 463–468. https://doi.org/10.1089/jwh.2011.2825
Kooij, J., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balázs, J., … Asherson, P. (2018). Updated European consensus statement on diagnosis and treatment of adult ADHD. European Psychiatry, 56(1), 14–34. https://doi.org/10.1016/j.eurpsy.2018.11.001
Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010). The history of attention deficit hyperactivity disorder. Attention Deficit and Hyperactivity Disorders, 2(4), 241–255. https://doi.org/10.1007/s12402-010-0045-8
Langley, K., Holmans, P. A., van den Bree, M. B., & Thapar, A. (2007). Effects of low birth weight, maternal smoking in pregnancy and social class on the phenotypic manifestation of Attention Deficit Hyperactivity Disorder and associated antisocial behaviour: investigation in a clinical sample. BMC Psychiatry, 7(26). https://doi.org/10.1186/1471-244X-7-26
Mehren, A., Özyurt, J., Lam, A. P., Brandes, M., Müller, H. H. O., Thiel, C. M., & Philipsen, A. (2019). Acute effects of aerobic exercise on executive function and attention in adult patients with ADHD. Frontiers in Psychiatry, 10, 1–15. https://doi.org/10.3389/fpsyt.2019.00132
Mohr-Jensen, C., & Steinhausen, H. C. (2016). A meta-analysis and systematic review of the risks associated with childhood attention-deficit hyperactivity disorder on long-term outcome of arrests, convictions, and incarcerations. Clinical Psychology Review, 48, 32–42. https://doi.org/10.1016/j.cpr.2016.05.002
Nation Institute of Mental Health. (n.d.). Attention-deficit/hyperactivity disorder (ADHD). Retrieved November 19, 2020, from https://www.nimh.nih.gov/health/statistics/attention-deficit-hyperactivity-disorder-adhd.shtml
Palladino, V. S., McNeill, R., Reif, A., & Kittel-Schneider, S. (2019). Genetic risk factors and gene-environment interactions in adult and childhood attention-deficit/hyperactivity disorder. Psychiatric Genetics, 29(3), 63–78. https://doi.org/10.1097/YPG.0000000000000220
Philipsen A. (2012). Psychotherapy in adult attention deficit hyperactivity disorder: implications for treatment and research. Expert Review of Neurotherapeutics, 12(10), 1217–1225. https://doi.org/10.1586/ern.12.91
Preston, J. D., O'Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). New Harbinger Publications.
Rodden, J. (2019, August 31). Non-stimulant ADHD medication overview. ADDitude. https://www.additudemag.com/non-stimulant-adhd-medication
Roy, A., Garner, A. A., Epstein, J. N., Hoza, B., Nichols, J. Q., Molina, B. S., … Hechtman, L. (2020). Effects of childhood and adult persistent attention-deficit/hyperactivity disorder on risk of motor vehicle crashes: Results from the multimodal treatment study of children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 59(8), 952–963. https://doi.org/10.1016/j.jaac.2019.08.007
Silver, L. (2019, September 16). ADHD medication side effects no one should tolerate. ADDitude. https://www.additudemag.com/adhd-medication-side-effects-that-no-one-should-tolerate
Thapar A. (2018). Discoveries on the genetics of ADHD in the 21st century: New findings and their implications. The American Journal of Psychiatry, 175(10), 943–950. https://doi.org/10.1176/appi.ajp.2018.18040383
Wedge, M. (2012, March 8). Do French kids have ADHD?. Psychology Today. https://www.psychologytoday.com/us/blog/suffer-the-children/201203/do-french-kids-have-adhd
Williams, P. (2020, June 23). A patient's primer on the stimulant medications used to treat ADHD. ADDitude. https://www.additudemag.com/stimulant-medications-for-adhd
White, H. (2019, March 5). The creativity of ADHD. Scientific American. https://www.scientificamerican.com/article/the-creativity-of-adhd
Wüstner, A., Otto, C., Schlack, R., Hölling, H., Klasen, F., & Ravens-Sieberer, U. (2019). Risk and protective factors for the development of ADHD symptoms in children and adolescents: Results of the longitudinal BELLA study. PloS one, 14(3). https://doi.org/10.1371/journal.pone.0214412
Xu, G., Strathearn, L., Liu, B., Yang, B., & Bao, W. (2018). Twenty-year trends in diagnosed attention-deficit/hyperactivity disorder among US children and adolescents, 1997-2016. JAMA Network Open, 1(4). https://doi.org/10.1001/jamanetworkopen.2018.1471