David C. Rettew, MD, is a child psychiatrist at the UVM Medical Center, where he is Director of the Pediatric Psychiatry Clinic.

David C. Rettew, MD, is a child psychiatrist at the UVM Medical Center, where he is Director of the Pediatric Psychiatry Clinic.

There has been an awful lot of public debate lately about the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD).  Some describe it as an important neuropsychiatric disease that is vastly under-recognized and under-treated, while others consider the disorder to be a completely made up entity that pathologizes typical child traits and exposes kids to toxic substances.  Listening to all the rhetoric, it is very easy for a parent to get confused in trying to understand and help their child know what to do.

To try and bring some perspective and maybe moderation to the debate, this post is devoted to summarizing what is actually known about ADHD and providing some perspective as to why things may have become so controversial.

  1. The case for a neurobiological basis underlying behaviors related to ADHD is overwhelming. From studies of twins raised in the same home to brain imaging studies to molecular genetic analyses, it is becoming quite difficult to make the argument that ADHD is not “real” from a scientific view. That said, science has yet to identify a single gene or brain problem that someone can point to on a report and say “there it is.” This brings me to my next point.
  2. ADHD exists not in yes/no form but more as a spectrum or continuum. Despite doctors still being pushed to provide an up or down diagnosis, there is increasing evidence that ADHD just doesn’t exist like that and rather is better conceptualized quantitatively like blood pressure or height. Herein lies some of the problem that stirs up controversy. When, for example, should someone be considered “tall.” Few would argue the status of people at the extremes, but there are certainly a lot of people right on the threshold. Making matters more complicated is the fact this spectrum model of ADHD likely extends beyond the observable behaviors and into the underlying neurobiology.  In other words, not only do the behaviors exist along a continuum, but brain processes, genes, and environmental causes of ADHD behavior likely do as well. Yet, while this certainly makes the situation complicated, we need not throw our hands up in defeat. Other medical problems, such as hypertension or high cholesterol, likely exist in much the same way.
  3. ADHD causes real problems. In addition to the well documented impact of ADHD on things like school performance, social relations, and achievement, there have been new studies linking ADHD, and in particular untreated ADHD, with things like higher accident rates causing emergency room visits, and criminal behavior.
  4. ADHD needs to be carefully assessed and treated. While it would be convenient, a quick office visit to the doctor and a prescription for a medication is not the way to address these problems. The diagnosis requires more in-depth assessment and the treatment of ADHD needs to be multi-modal. Yes, medication can be helpful, but so can certain types of psychotherapy and a number of wellness and health prevention measures that involve nutrition, exercise, reading, sleep, and many other areas. Many groups such as the American Academy of Pediatrics and American Academy of Child and Adolescent Psychiatry have been working to ensure that clinicians devote the time and expertise to these evaluations that ADHD deserves. While it is true that there exist many children who meet criteria for ADHD that have not received any treatment and there are children who are taking ADHD medications who don’t qualify for the diagnosis, it seems much more valuable on efforts to ensure that all kids have access to high qualify assessment and treatment rather than arguing in the media about whether under- or over- diagnosis is the bigger problem.

If you are wondering about ADHD for yourself or a family member, my advice it to ignore the media speculators who tell you that it is “just” laziness, a phase, boys being boys, etc. It is also important to resist the idea that a simple pill is going to make everything perfect. Get the facts, and take the time to address these behaviors fully, just as you would any other health concern.

David C. Rettew, MD, is a child psychiatrist at the UVM Medical Center and director of the Child & Adolescent Psychiatry Residency Program.

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