vrijdag 26 februari 2010

ADHD - A Social construct? A look at some criticisms of ADHD as a disorder.

This is a difficult and emotive subject. We are used to the very status of ADHD as a disorder being challenged in the media in such a lazy way that we develop a knee jerk reaction to these questions. Often reporting does not distinguish fact from opinion and confuses a balanced debate with giving equal space on the one hand to mainstream scientific or clinical personnel and patients groups representatives and on the other side an individual with some kind of agenda-
As Russell Barkley said of the critics:
‘Many of them approach it with political agendas such as the Church of Scientology and its Citizens Commission on Human Rights. They don’t care whether this is a real disorder or not, because they deny that there are any psychiatric disorders, period. That’s their political agenda.

So let’s look at the current criteria for a mental disorder to decide if ADHD meets those criteria:
Currently, the working definition for a disorder in clinical medicine is based on Wakefield’s definition of ‘harmful dysfunction’. Or as the DSM-V puts it - a disorder should be such that:
The consequences of which is clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning)

This is a link to the criteria for a mental disorder as proposed for the DSM-V in 2013. (The DSM is the American manual of mental disorders, it is very influential, being more through then the only near equivalent the ICD-7 published by the world health organisation.).Thus to meet medical criteria for a disorder, ADHD must be shown to be harmful to the individual with ADHD, it must cause impairment in some major life activities e.g. relationships, work, education
1. i. Evidence for Impairment caused by ADHD
Extremely convincing evidence of impairment exists and is overwhelmingly accepted by scientists. This includes statistically increased chance of accidents, school failure, career underachievement, relationship problems, delinquency, addictions, depression, and anxiety and so on. See for example this recent paper on quality of life outcomes for children with ADHD (Dankearts & Sonuga-Barke, 2010),36 studies were reviewed and determined that ADHD had significant effects on the quality of life of children with ADHD and that quality of life outcomes were significantly improved by treatment.
1. ii other criteria that should also be met (in addition to impairment):
Diagnostic validity on the basis of various diagnostic validators (e.g., prognostic significance, psychobiological disruption, response to treatment) (DSM-V)
Good evidence that diagnostic procedures consistently identifies people in need of help (if diagnostic procedures are followed properly) that the syndrome is cohesive ,that is symptoms co-occur regularly and are distinct from other disorders. Evidence shows that treatment is effective, for example Biederman (2009) followed a group of children with ADHD for ten years, some treated with medication and some not. He found that the treated children were significantly less likely to develop comorbid disorders such as depression and conduct disorders.
iii Presence of other meaningful external associations
(Such a occurring in families well above chance levels consistent biological finding about ADHD that argue good clinical validity)
Conclusion: ADHD easily meets the clinical criteria for a disorder.
Etiological refers to causes, this traditional criteria refers to the extent to which the causes of the disorder and the nature of the impaired function is known. This criterion is difficult for ADHD to meet, for most other mental disorders including schizophrenia and even for disorders in other branches of medicine. Causes can often not be precisely known e.g. lung cancer in a smoker cannot be wholly attributed to smoking, but other factors such as genetic susceptibility, diet and occupation may play a part.
We do know that the etiology of ADHD is biologically based and Multifactorial (- complex with many causes).
Multifactorial mental disorders are defined behaviourally and behavioural criteria are used as part of the diagnostic process Link to Criteria for adult ADHD based on the DSM-IV and developed by WHO
Such criteria are frequently criticized:’ doesn’t everyone have this symptoms sometimes’? This misunderstands how ADHD is diagnosed. Picking out one or two symptoms irrespective of frequency is misleading. For example to diagnosis an adult 4 criteria from the first section should be met very frequently (depending on the criteria). Almost all normal adults will meet one or two; diagnosis depends on a bunch of symptoms co occurring frequently. But that is not sufficient for a physician to give a diagnosis of ADHD, they must occur in different settings, have started in childhood, be causing impairment in major life activities and other disorders must be ruled out.

Traits are predictors of personality and can also predict mental disorders. The pathways of a child's development build on early temperamental precursors.
Research into Big 3 personality traits and ADHD.
Has found that Symptoms of inattention and disorganization are weakly related to low conscientiousness. Extraversion related weakly to hyperactivity and impulsivity (this relationship clearer for men than women).No strong correlations for ADHD as such.
Big five personality traits
Less clear correlations between personality traits and ADHD Neuroticism is related to all mental disorders.
Conclusion: there is a weak correlation with some personality traits and markers for different subtypes of ADHD

See ‘Causes of ADHD’ for an evaluation of factors such as television or parenting often cited by critics as significant causes of ADHD

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