May 13, 2021
Myth: The ADHD diagnosis is very much "in the eye of the beholder."
This is one of many ways in which the ADHD diagnosis has been ridiculed in the popular media. The idea here is that because we cannot diagnose ADHD with an objective brain scan or a blood test, the diagnosis is "subjective" and subject to the whim and fancy of the doctor making the diagnosis.
Fact: The ADHD diagnosis is reliable and valid.
The usefulness of a diagnosis does not depend on whether it came from a blood test, a brain test, or from talking to a patient. A test is useful if it is reliable, which means that two doctors can agree on who does and does not have the disorder, and if it is valid, which means that the diagnosis predicts something important to the doctor and patient, such as whether the patient will respond to a specific treatment. Many research studies show that doctors usually agree about who does and does not have ADHD. This is because we have very strict rules that one must use to make a diagnosis. Much work over many decades has also shown ADHD to be a valid diagnosis. For details see: Faraone, S. V. (2005). The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry, 14, 1-10. The short story is that the diagnosis of ADHD is very useful for predicting what treatments will be effective and what types of problems ADHD patients are likely to experience in the future.
Myth: ADHD is not a medical disorder. It's just the extreme of normal childhood energy
Mental health professionals use the term "disorder" to describe ADHD, but others argue that what we view as a disorder named ADHD is simply the extreme of normal childhood energy. After all, most healthy children run around and don't always listen to their parents. Doesn't the ADHD child or adult simply have a higher dose of normal behavior?
Fact: Doctors have good reasons to describe ADHD as a disorder
The idea that the extreme of normal behavior cannot be a disorder is naïve. Consider hypertension(high blood pressure). Everyone has blood pressure, but when blood pressure exceeds a certain value, doctors get worried because people with high values are at risk for serious problems, such as heart attacks. Consider depression. Everyone gets sad from time to time, but people who are diagnosed with depression cannot function in normal activities and, in the extreme, are at risk of killing themselves. ADHD is not much different from hypertension or depression. Many people will show some signs of ADHD at some times, but not all have a "disorder." We call ADHD a disorder not only because the patient has many symptoms, but also because that patient is impaired, which means that they cannot carry out normal life activities. For example, the ADHD child cannot attend to homework or the ADHD adult cannot hold a job, despite adequate levels of intelligence. Like hypertension, untreated ADHD can lead to serious problems such as failing in school, accidents, or an inability to maintain friendships. These problems are so severe that the center for Disease Control described ADHD as "serious public health problem."
Myth: The ADHD diagnosis was developed to justify the use of drugs to subdue the behaviors of children.
This is one of the more bizarre myths about ADHD. The theory here is that to sell more drugs, pharmaceutical companies invented the diagnosis of ADHD to describe normal children who were causing some problems in the past.
Fact: ADHD was discovered by doctors long before ADHD medications were discovered.
People who believe this myth do not know the history of ADHD. In 1798, long before there were any drugs for ADHD, Alexander Crichton, a Scottish doctor, described a "disease of attention," which we would not call ADHD.ADHD symptoms were described by a German doctor, Heinrich Hoffman, in1845 and by a British doctor, George Still, in 1902. Each of these doctors found that inattentive and overactive behaviors could lead to a problem that should be of concern to doctors. If they had had medications to treat ADHD, they probably would have prescribed them to their patients. But a medication for ADHD was not discovered until 1937 and even then, it was discovered by accident. Dr. Charles Bradley from Providence, Rhode Island had been doing brain scanning studies of troubled children in a hospital school. The scans left the children with headaches that Dr. Bradley thought would be relieved by an amphetamine drug. When he gave this drug to the children after the scan, it did not help their headaches. However, the next day, their teachers reported that the children were attending and behaving much better in the classroom. Dr. Bradley had accidentally discovered that amphetamine was very helpful in reducing ADHD symptoms, and amphetamine drugs are commonly used to treat ADHD today. So, as you can see, the diagnosis of ADHD was not "invented" by anyone; it was discovered by doctors long before drugs for ADHD were known.
Myth: Brain scans or computerized tests of brain function can diagnose ADHD.
Someday, this myth may become fact, but for now, and shortly it is a solid myth. You may think this is strange. After all, we know that ADHD is a brain disorder and that neuroimaging studies have documented structural and functional abnormalities in the brains of patients with ADHD. If ADHD is a biological disorder, why don’t we have a biological test for the diagnosis?
Fact: No brain test has been shown to accurately diagnose ADHD.
ADHD is a biologically based disorder, but there are many biological changes and each of these is so small that they are not useful as diagnostic tests. We also think that there are several biological pathways to ADHD. That means that not all ADHD patients will show the same underlying biological problems. So for now, the only officially approved method of diagnosing ADHD is by asking patients and/or their parents about ADHD symptoms as described in the American Psychological Association's Diagnostic and Statistical Manual
Precocious puberty (PP) is defined as the onset of secondary sex characteristics before age 8 in girls or age 9 in boys.
Because it accelerates skeletal maturation by prematurely shutting down the cartilage growth plate at the tip of long bones, it tends to lead to shorter height in adulthood. It is also known to place an additional psychological burden on children, especially girls. Girls are four to 38 times more likely to develop PP than boys.
Taiwan has a single-payer national health insurance system, called National Health Insurance, that encompasses 99.6% of the island’s population. The Ministry of Health and Welfare uses it to maintain the National Health Insurance Research Database (NHIRD), enabling researchers to conduct nationwide population studies.
Using this database, a Taiwanese study team investigated the relationship between ADHD and precocious puberty among children and adolescents (under 18). And because methylphenidate (MPH) is the only psychostimulant approved for the treatment of ADHD in Taiwan, the team also explored the effect of MPH on this relationship.
Most diagnoses of ADHD in the NHIRD are made by board-certified psychiatrists, enhancing diagnostic validity.
Of the more than 3.3 million persons born in Taiwan between 1997 and 2001, 186,681 were diagnosed with ADHD. Of these, 122,302 were prescribed MPH.
After adjusting for sex, low-income households, and neuropsychiatric comorbidities, children diagnosed with ADHD were twice as likely to be diagnosed with PP. This held equally true for boys and girls.
However, children diagnosed with ADHD and prescribed MPH were more than a third less likely to subsequently be diagnosed with PP than those diagnosed with ADHD but not prescribed MPH.
For girls with ADHD, who without an MPH prescription were nine times more likely than boys with ADHD to be diagnosed with PP, an MPH prescription reduced that ratio to five times more likely than boys with ADHD and prescribed MPH.
That suggests a strong protective effect of MPH.
The team concluded, “Our study found that children with ADHD were at a greater risk of PP, and girls with ADHD were a particularly vulnerable group. … MPH appeared to be protective against PP in patients with ADHD, especially in girls. However, these preliminary results need further validation.”
Maternal infections and inflammatory responses during pregnancy have been proposed as risk factors for neurodevelopmental disorders such as ADHD.
Taiwan has a single-payer health insurance system that covers virtually the entirety of its population. Its Ministry of Health and Welfare maintains the National Health Insurance Research Database (NHIRD), with detailed information on outpatient services, hospitalizations, and medical treatment for nearly 99% of all residents.
A Taiwanese study team used NHIRD to examine to examine the relationship between maternal hospitalization for infection, and early childhood infection, and subsequent ADHD in offspring. The study cohort originated with all 3,260,879 individuals born between 2001 and 2018.
The team excluded births from foreign mothers, still births, births with congenital defects, low birth weights, abnormally late births, twins, triplets, and other multiple births, culminating in a final population cohort of 2,885,662 live-born single infants across 1,893,171 families, and 1,864,660 individuals with full siblings from 872,169 families comprising the full sibling cohort.
Study participants were followed until diagnosis of a neurodevelopmental disorder, their death, or the end of 2021.
After adjusting for sex, birth year, paternal and maternal ages, birthweight, birth season, parity, delivery method, 1 minute APGAR score (evaluating baby’s appearance, pulse, grimace, activity and respiration at birth), gestational age, pregnancy and delivery complications, parental history of neurodevelopmental disorders, maternal asthma and diabetes, urbanization level of the residential area, and family’s insurance amount, offspring of mothers hospitalized for infections had 14% greater odds of being subsequently diagnosed with ADHD.
However, in the full sibling cohort of over 1.8 million, this association vanished. That held true for each of the three trimesters of pregnancy. It also held true for bacterial infections. Surprisingly, offspring of mothers hospitalized for viral infections were 24% less likely to be diagnosed with ADHD than their siblings not exposed to maternal viral infection. Because of that, they also had a 6% lower risk overall.
After the same adjustments, early childhood infection was associated with 16% greater odds of being diagnosed with ADHD.
Nevertheless, in the full sibling cohort of over 1.8 million, this association again vanished. That held true overall, as well as separately for childhood infections in months 1-6 and months 7-12. The association vanished altogether both for bacterial infections as well as for viral infections.
The authors concluded, “the results of this nationwide birth cohort study with population and sibling analyses suggest that the association between maternal infection during pregnancy and offspring neurodevelopmental risk is largely due to familial confounding factors.”
Most previous studies of suicide and self-harm risk among persons with ADHD have focused on adolescents and adults. They’ve also tended to be cross-sectional, analyzing data from a population at a specific point in time.
An Australian study team took a different approach, conducting a before-and-after study through the birth cohort of the Longitudinal Study of Australian Children (LSAC), comprising 5,107 children who have been followed up every two years since birth.
The diagnosis of ADHD was based on parents reporting that their child had received a diagnosis of ADHD at or before age ten.
Suicide and self-harm were defined as children’s self-report at age 14 of any thought or attempt of suicide and self-harm respectively over the past year.
The team adjusted for the following confounders: socioeconomic status, birth weight, ADHD medication history, maternal education level, maternal age at birth, experience in bullying victimization at age 12, and depression score based on Short Mood and Feelings Questionnaire (SMFQ).
Of the 5,107 participants, 3,696 had all the valid data required for analysis and were included in the final cohort. Of these, 3.6% were diagnosed with ADHD by age 10.
With diagnosis of ADHD at age 10 and all other factors held constant:
Both depression and exposure to bullying were statistically significant mediators for the relationship. Nevertheless, depression and exposure to bullying each accounted for well under 10% of the overall effect.
Neither socioeconomic status nor maternal factors had any significant mediating effect on outcomes.
Conclusion:
The authors concluded, “This study provides compelling evidence that children diagnosed with ADHD at the age of 10 years face significantly elevated risks of experiencing suicidal thoughts, planning, or attempts, as well as self-harm, by the age of 14 years, which underscores the critical importance of recognizing and addressing these heightened risks in children with ADHD.”
While factors like depression and bullying contribute, ADHD itself remains a key risk factor. Early intervention and strong mental health support are crucial to protecting these children’s well-being.
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