When the American Academy of Pediatrics changed the guidelines for ADHD to expand age of diagnosis to include children from age 4-18 (from 6-12), that the number of cases would rise was, by definition, inevitable. The recent survey by the CDC, published in the current issue of the Journal of the American Academy of Child and Adolescent Psychiatry, indicating that one in 10 children in the US carry a diagnosis of ADHD, confirms just that.
I felt re-energized and hopeful in ongoing efforts to, in my colleague's words "move the mountain of ADHD," when I received a request to speak at an international child psychiatry conference as part of a panel with a working title: "The ADHD Diagnosis: a Deconstruction from Developmental, Psychoanalytic, Infant Mental Health and Neuropsychiatric Perspectives."
"Deconstruction" is a brilliant word, and captures well what I do in my clinical practice. Consider 4-year-old Max, whose parents brought him to my behavioral pediatrics practice to "see if he has ADHD." His preschool teacher had recommended the visit, suggesting that he might benefit from medication. I asked his parents, Ann and Peter, if we might, acknowledging that Max did have symptoms of inattention, hyperactivity and impulsivity, take the time (we had an hour) to ask why he had these symptoms: to make sense of his behavior. While they had been hopeful that they would leave the visit with a prescription, reflecting Max's teacher's concern that he might "fall behind" without treatment, they were overjoyed to consider another approach.
Max had been adopted at age 3 months. Prior to this he had lived with his biological parents who were actively using drugs. They reportedly had a history of ADHD as did some biological siblings. Ann and Peter had been struggling in their marriage in the face of caring for this challenging child, and had recently separated. While Max had been a good sleeper, for the past several months he had been getting up multiple times a night and the whole family was chronically sleep deprived. Max had multiple sensory sensitivities. He cried with the sound of the vacuum cleaner; getting dressed was an ordeal because he could not find a pair of socks that was comfortable. He had difficulties with "personal space."
We had, in a sense, "deconstructed" the "symptom" to examine its various parts. We identified a genetic vulnerability for problems of attention, early neglect, ongoing family stress, sleep deprivation, and sensory processing challenges.
At age 4, there are multiple avenues of intervention. I usually start with sleep, as chronic sleep deprivation is inextricably linked with emotional and attentional dysregulation. Child-parent psychotherapy, where a clinician works with parents and child together, has been shown to be effective in helping children develop capacities for emotional regulation, even in the face of early developmental trauma. A good occupational therapist, who addresses sensory processing challenges in the context of relationships, can help Max to use his body to manage his symptoms. Ann and Peter could examine the effects of their marital conflict on Max, and perhaps consider couples therapy.
The preliminary write up for the panel I refer to above speaks of what is now called "ADHD" as a valid symptom complex. But it proposes that
this terminology should not ever be used in our clinical thinking. "ADHD," used as a primary diagnosis, has no etiologic significance, is conceptually and diagnostically distracting, leads to a paucity of thinking about a patient's early developmental history and trauma, and is therapeutically misleading.I hope that there will be a large scale movement to "deconstruct" the ADHD diagnosis. In essence deconstructing the diagnosis means eliminating the diagnosis. Instead we would understand and treat the multiple parts that make up what is now called "ADHD." Such a process would result in effective early intervention and prevention.
If I were to diagnose Max with ADHD and start him on stimulant medication, it would be in keeping with the current standard of care. Stimulants are powerful medications that have been shown in the short term to eliminate symptoms. But such an approach is simply a silencing of children. It would be a great disservice to Max and his family.
Just as expanding the age range for diagnosis inevitably led to a rise in cases, "deconstructing" the diagnosis would lead to a significant drop in cases. The difference is that this change would reflect, not silencing of children, but rather improving access to meaningful help.
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