ADHD, its diagnosis, and its treatment have been considered controversial since the 1970s. The controversies have involved clinicians, teachers, policymakers, parents, and the media. Topics include ADHD's causes and the use of stimulant medications in its treatment.
Most healthcare providers accept ADHD as a genuine diagnosis in children and adults, and the debate in the scientific community mainly centers on how it is diagnosed and treated. The condition was officially known as attention deficit disorder from 1980 to 1987, and prior to the 1980s, it was known as hyperkinetic reaction of childhood. The medical literature has described symptoms similar to those of ADHD since the 18th century. ADHD management recommendations vary by country and usually involve some combination of medications, counseling, and lifestyle changes. The British guideline emphasises environmental modifications and education for individuals and carers about ADHD as the first response.
If symptoms persist, then parent-training, medication, or psychotherapy can be recommended based on age. Canadian and American guidelines recommend medications and behavioral therapy together, except in preschool-aged children for whom the first-line treatment is behavioral therapy alone. For children and adolescents older than 5, treatment with stimulants is effective for at least 24 months; however, for some, there may be side effects. Toxins and infections during pregnancy and brain damage may be environmental risks.
It does not appear to be related to the style of parenting or discipline. It affects about 5–7% of children when diagnosed via the DSM-IV criteria and 1–2% when diagnosed via the ICD-10 criteria. Rates are similar between countries and differences in rates depend mostly on how it is diagnosed. ADHD is diagnosed approximately two times more often in boys than in girls, although the disorder is often overlooked in girls or only diagnosed in later life because their symptoms often differ from diagnostic criteria.
About 30–50% of people diagnosed in childhood continue to have symptoms into adulthood and between 2–5% of adults have the condition. Adults often develop coping skills which compensate for some or all of their impairments. The condition can be difficult to tell apart from other conditions, as well as from high levels of activity within the range of normal behavior. Brent and colleagues studied the impact of a peer suicide in 146 friends of 26 adolescent suicides compared to a demographically matched community-based control group. Friends and siblings exposed to a peer suicide were more likely than controls to have a new-onset major depression (29.5% vs. 4.8%) and PTSD (5.5% vs. 0.0%). This increased incidence of depression was found within one month of the death, but not in the time period following that.
In 2000, Cynthia Pfeffer and colleagues compared 16 children whose parents had committed suicide 1.5years prior to the interview to 64 children whose parents died from cancer. Children bereaved by parental suicide reported higher overall depression scores. However, the two groups were similar in total competence and behavior problems and both groups had levels comparable to those of a normative sample.
Died Today From Lack Of Attention Irwin Sandler and colleagues found no differences in children's mental health problems, grief, and risk and protective factors by cause of parental death. Bereavement from suicide has been of great focus in the bereavement literature in children and adolescents. Bereavement from suicide has been hypothesized to be an especially distressing form of bereavement when compared to other modes of death. In 1976, Shepherd and Barraclough were the first to assess an unselected sample of 36 children, aged 2 to 17years old, who lost a parent by suicide. About 17% of the children in this sample had psychiatric treatment since the death and 11% showed behavior problems that led to trouble with the authorities. Other studies found increased symptoms of depression, PTSD, reminiscing and reunion fantasies, and suicidal ideation.
ADHD, its diagnosis, and its treatment have been controversial since the 1970s. The controversies involve clinicians, teachers, policymakers, parents, and the media. Positions range from the view that ADHD is within the normal range of behavior to the hypothesis that ADHD is a genetic condition.
Other areas of controversy include the use of stimulant medications in children, the method of diagnosis, and the possibility of overdiagnosis. In 2009, the National Institute for Health and Care Excellence, while acknowledging the controversy, states that the current treatments and methods of diagnosis are based on the dominant view of the academic literature. In 2014, Keith Conners, one of the early advocates for recognition of the disorder, spoke out against overdiagnosis in a The New York Times article. In contrast, a 2014 peer-reviewed medical literature review indicated that ADHD is underdiagnosed in adults. As most treatment guidelines and prescribing information for stimulant medications relate to experience in school-aged children, prescribed doses for older patients are lacking. ADHD is diagnosed by an assessment of a person's behavioral and mental development, including ruling out the effects of drugs, medications, and other medical or psychiatric problems as explanations for the symptoms.
ADHD diagnosis often takes into account feedback from parents and teachers with most diagnoses begun after a teacher raises concerns. It may be viewed as the extreme end of one or more continuous human traits found in all people. Imaging studies of the brain do not give consistent results between individuals; thus, they are only used for research purposes and not a diagnosis. For infants younger than 2 who lose parents, there is a risk of attachment disorders and serious emotional, cognitive and developmental problems unless someone steps in quickly.
For preschoolers, a variety of somatic complaints, anxiety symptoms, clinginess and aggressive behavior would be typical. They may be overly responsible to take care of the surviving parent or blame themselves for the parent's death. This may take time to resolve or may linger as anxiety, depression or separation phobias. They improve symptoms in 80% of people, although improvement is not sustained if medication is ceased. Methylphenidate appears to improve symptoms as reported by teachers and parents. Stimulants may also reduce the risk of unintentional injuries in children with ADHD.
Magnetic resonance imaging studies suggest that long-term treatment with amphetamine or methylphenidate decreases abnormalities in brain structure and function found in subjects with ADHD. A 2018 review found the greatest short-term benefit with methylphenidate in children, and amphetamines in adults. ADHD is often comorbid with disruptive, impulse control, and conduct disorders. Oppositional defiant disorder occurs in about 25% of children with an inattentive presentation and 50% of those with a combined presentation.
It is characterized by angry or irritable mood, argumentative or defiant behaviour and vindictiveness which are age-inappropriate. It is characterized by aggression, destruction of property, deceitfulness, theft and violations of rules. Adolescents with ADHD who also have CD are more likely to develop antisocial personality disorder in adulthood. Conduct disorder involves more impairment in motivation control than ADHD. Intermittent explosive disorder is characterized by sudden and disproportionate outbursts of anger, and commonly co-occurs with ADHD.
The United Kingdom's National Institute for Health and Care Excellence recommends use for children only in severe cases, though for adults medication is a first-line treatment. Conversely, most United States guidelines recommend medications in most age groups. Underdosing of stimulants can occur, and can result in a lack of response or later loss of effectiveness.
This is particularly common in adolescents and adults as approved dosing is based on school-aged children, causing some practitioners to use weight-based or benefit-based off-label dosing instead. They can also occur as a side effect of medications used to treat ADHD. In children with ADHD, insomnia is the most common sleep disorder with behavioral therapy the preferred treatment. Problems with sleep initiation are common among individuals with ADHD but often they will be deep sleepers and have significant difficulty getting up in the morning. Specifically, the sleep disorder restless legs syndrome has been found to be more common in those with ADHD and is often due to iron deficiency anemia. However, restless legs can simply be a part of ADHD and requires careful assessment to differentiate between the two disorders.
Delayed sleep phase disorder is also quite a common comorbidity of those with ADHD. Treatment-emergent psychotic or manic symptoms, e.g., hallucinations, delusional thinking, or mania in children and adolescents without prior history of psychotic illness or mania can be caused by stimulants at usual doses. In a pooled analysis of multiple short-term, placebo controlled studies, such symptoms occurred in about 0.1% of stimulant-treated patients compared to 0 in placebo-treated patients. Rates of diagnosis and treatment have increased in both the United Kingdom and the United States since the 1970s. Prior to 1970, it was rare for children to be diagnosed with ADHD while in the 1970s rates were about 1%.
This is believed to be primarily due to changes in how the condition is diagnosed and how readily people are willing to treat it with medications rather than a true change in how common the condition is. It is believed that changes to the diagnostic criteria in 2013 with the release of the DSM-5 will increase the percentage of people diagnosed with ADHD, especially among adults. There are a number of non-stimulant medications, such as Viloxazine, atomoxetine, bupropion, guanfacine, and clonidine, that may be used as alternatives, or added to stimulant therapy. There are no good studies comparing the various medications; however, they appear more or less equal with respect to side effects. For children, stimulants appear to improve academic performance while atomoxetine does not.
Atomoxetine, due to its lack of addiction liability, may be preferred in those who are at risk of recreational or compulsive stimulant use. Evidence supports its ability to improve symptoms when compared to placebo. There is little evidence on the effects of medication on social behaviors.
There are other psychiatric conditions which are often co-morbid with ADHD, such as substance use disorders. The reason for this may be an altered reward pathway in the brains of ADHD individuals. This makes the evaluation and treatment of ADHD more difficult, with serious substance misuse problems usually treated first due to their greater risks. Eminent creators do not necessarily emerge from happy, stable, conventional home environments. On the contrary, they tend to suffer more than their fair share of trials and tribulations during childhood and adolescence. Their families may experience big fluctuations in financial well-being, and many grow up in minority or immigrant homes that must overcome prejudice and discrimination.
Often future creators have had to surmount some intellectual, emotional, or physical disability, as well as endure extreme loneliness and isolation. But probably the traumatic event that has received the most attention in published research is the experience of parental loss or orphanhood. Eminent people in general, and famous creators in particular, seem to have suffered this type of trauma at incidence rates noticeably higher than what is seen in the overall population. At present we do not know how traumatic events contribute to creative development. First, these experiences may disrupt the standard socialization process, and this disruption leaves enough freedom for the emergence of an independent, even iconoclastic intellect. Second, such encounters help the young talent to develop the robustness necessary to overcome the many obstacles and setbacks faced by adult creators.
Third, such trauma may produce a 'bereavement syndrome' to which creative achievement serves as a form of compensation or adjustment. It is hoped that once researchers discover exactly how trauma contributes to the development of creative genius, they will also learn why some distinguished creators do indeed manage to grow up in totally normal and pleasant home environments. Psychoanalytic approaches to depression emphasize its relationship to loss experience, particularly in childhood. As a result there has been much investigation of childhood loss of a parent and vulnerability to adult disorders such as depression. Detailed investigation of childhood deaths of parents has shown that these have marked long-term impact only when neglectful or abusive parenting follows, or when the loss is considered aberrant in terms of abandonment.
When death of a parent in childhood occurs in otherwise caring and supported circumstances, no long-term dysfunction occurs. The symptoms of ADHD arise from a deficiency in certain executive functions (e.g., attentional control, inhibitory control, and working memory). Executive functions are a set of cognitive processes that are required to successfully select and monitor behaviors that facilitate the attainment of one's chosen goals. People with ADHD appear to have unimpaired long-term memory, and deficits in long-term recall appear to be attributed to impairments in working memory.
Due to the rates of brain maturation and the increasing demands for executive control as a person gets older, ADHD impairments may not fully manifest themselves until adolescence or even early adulthood. This includes epilepsy, a neurological condition characterized by recurrent seizures. Loss trauma including loss of parents, loss of partners, and loss of close friends may be expected to occur at any life stage. However, when such losses occur off-time (i.e., nonnormatively), this may be a contribution to their traumatic nature and impact.
Thus, losses of parents in childhood, losses of children, and widowhood in early- or mid-adulthood are all candidates for traumatic loss. Middle childhood parental loss may deal a blow to self-esteem and set up a child for short- and long-term emotional problems. Academic achievement and friendships are at risk, and they may even have a fear of being stigmatized by peers. An overly adult demeanor may mean the child feels too much responsibility. The long-term effects of ADHD medication have yet to be fully determined, although stimulants are generally beneficial and safe for up to two years for children and adolescents.
Stimulant psychosis and mania are very rare at therapeutic doses, appearing to occur in approximately 0.1% of individuals, within the first several weeks after starting amphetamine therapy. Chronic heavy abuse of stimulants over months or years can trigger these symptoms, although administration of an antipsychotic medication has been found to effectively resolve the symptoms of acute amphetamine psychosis. The DSM provides potential differential diagnoses - potential alternate explanations for specific symptoms. Assessment and investigation of clinical history determines which is the most appropriate diagnosis.
For diagnosis in an adult, having symptoms since childhood is required. Nevertheless, a proportion of adults who meet the criteria for ADHD in adulthood would not have been diagnosed with ADHD as children. Most cases of late-onset ADHD develop the disorder between the ages of and may therefore be considered early adult or adolescent-onset ADHD. Twin studies indicate that the disorder is often inherited from the person's parents, with genetics determining about 75% of cases in children and 35% to potentially 75% of cases in adults. Siblings of children with ADHD are three to four times more likely to develop the disorder than siblings of children without the disorder. Autism spectrum disorder co-occurring at a rate of 21%, affects social skills, ability to communicate, behaviour, and interests.
As of 2013, the DSM-5 allows for an individual to be diagnosed with both ASD and ADHD. Learning disabilities have been found to occur in about 20–30% of children with ADHD. Learning disabilities can include developmental speech and language disorders, and academic skills disorders. ADHD, however, is not considered a learning disability, but it very frequently causes academic difficulties.
While children with ADHD may climb and run about excessively, adults may experience an inability to relax, or may talk excessively in social situations. Adults with ADHD may start relationships impulsively, display sensation-seeking behavior, and be short-tempered. The DSM-5 criteria do specifically deal with adults—unlike those in DSM-IV, which were criticized for not being appropriate for adults. This might lead to those who presented differently as they aged to having outgrown the DSM-IV criteria.
Given that these symptoms have such overlap, there is an attempt in the existing literature to distinguish if there is a relationship between the two, and if so, what the nature of that relationship is. Additionally, it is simply possible that the lack of an appropriate understanding of the particular individual's history can lead to an incorrect diagnosis of one as opposed to the other. The first-generation measures of stress in childhood were based on the questionnaire format to provide overall scores of degree of life change. The assumption was that change per se, not necessarily the unpleasant nature of the experience, was stressful for children. In parallel with these overall approaches, numerous studies of specific life events such as family breakup, bereavement, and disasters such as floods, earthquakes, or hijacking were carried out. Childhood trauma has been extensively studied by Leonie Terr, who identified different symptoms following from single-blow or multiple-blow trauma.
Type I trauma, that following a sudden single shock, was found to evince symptoms such as full repeated memories, strangely visualized or repeated, repetitive behaviors, trauma-specific fears, omens, and misperceptions. In contrast, type II trauma, following multiple or chronic shock, evinced denial and numbing, dissociation, and rage. In both instances childhood trauma led to changed attitudes about people, aspects of life, and the future.
