This article: (http://acestoohigh.com/2014/07/07/how-childhood-trauma-could-be-mistaken-for-adhd/) was sent to me by a GTRI student (Thanks Charity!). Worth the read to consider how we may mistake hyperactivity as evidence of ADHD vs. evidence of hypervigilance and PTSD. Given the high prevelance of ADHD diagnoses in areas where there is also much trauma (urban and impoverished settings), it stands to reason that there could be significant misdiagnoses. I began to understand this problem some 17 years ago during my pre and post doc experience in small town Concord, New Hampshire. We saw all sorts of boys first diagnosed with ADHD, then diagnosed (and heavily drugged) with bipolar disorder. Back then we called them emotionally-dysregulated. Nearly all had been subject to domestic violence and had witnessed their mothers abused by boyfriends. A large number had seen their mothers had guns held to their heads. Such experiences shape a child and so it stands to reason that a brain bathed in the hormones released during terror and horror would have an impact. It is also true that in this same population there was a high incidence of tobacco use, also known to be highly correlated with ADHD diagnosed children.
My suspicion is that one day we will find syndromes that encompass both diagnoses but that will not be until we have better understanding and technology to assess what is happening in the brain during an episode of “hyperactivity.”
Check out the above article and if you are a clinician, consider alternative explanations for ADHD diagnosed children. Do you see signs of emotion dysregulation? And if so, how might that be more central feature of the treatment plan?
U.S. Children Misdiagnosed with Bipolar Disorder – Newsweek
The above link is to an article I just read regarding the overdiagnosis of bipolar disorder in children. Written by a Dr. Kaplan (child psychiatrist), he notes that many children with ADHD or ODD have been diagnosed with bi-polar disorder due to temper tantrums, grandiosity, impulsivity, racing thoughts, elevated silliness, etc. These symptoms are really happening but Dr. Kaplan does not believe they are associated with bipolar disease (and thus not appropriate to be treated with medications like Lithium, Wellbutrin, or Depakote). Dr. Kaplan goes on to say that he thinks there isn’t any scientific evidence of bipolar beginning in childhood.
Not sure I would agree with him about this but I do agree that bipolar is an easy target when a child has frequent outbursts and is difficult to rein in. He and others are right to point out that irritability is not a good indicator of bipolar disease. Nor is emotional lability a good indicator. Many ADHD kids end up with a bipolar diagnosis when they should not have it.
What should the overdiagnosis tell us? It is not really about “big pharma” trying to drug our kids. It is not about psychiatrists just wanting to push pills. It is about overwhelmed parents and teachers who do not know what to do with the overwhelming emotional/behavioral rollercoaster some children exhibit. They (parents and kids) need help and our understanding of these issues (lability, irritability, grandiosity, tantrums, etc.) and how to best help these children are poor.
Rather than beat up on the system, let us figure out better methods to parent and counsel these types of children.
CNN has run a story on the issue schools/teachers encouraging parents to get their child tested for ADHD and on medications. You can read it here. The writer quotes a doctor complaining about teachers who suggest diagnoses and treatment. Then parents go to their doctor and ask for meds to treat something that has yet to be properly diagnosed. Being a psychologist I am sympathetic with the Doc–but only to a point. True, many people fancy themselves as experts because a family member or some other experience with a mental health diagnosis. And so, whenever they see something that reminds them of it they talk as if they had done a thorough assessment. The Doc goes on to point out other problems that may create similar symptoms (anxiety, abuse, learning disabilities, etc.)–thus the need for professional evaluation.
But that is where my sympathy ends. Teachers do have front row seats to child problems. We need them to speak up. Yes, they needn’t throw out diagnoses as if they are experts. But we do want them to let parents know that something might be up and the need for further evaluation.
So, who should diagnose? Yes, ADHD is considered a medical diagnosis. But, counselors and psychologists are just as capable of making the diagnosis–sometimes even better. If a Doc (psychiatrist, physician, etc.) makes the diagnosis, 9:10 times it is on the basis of 30 minutes to 1 hour of an interview with parent and child along with a physical examination. For most people with the symptoms, that is probably enough. However, most psychologists will collect data from 2-3 sources (parent, teacher, church) using interviews, checklists, psychological tests, and even computer based assessments. That kind of assessment may be more capable of ferreting out subtle learning disabilities or learning differences as well as developing a plan of action for changing the environment (school plans (IEP/504), parenting strategies, etc.
It is interesting that the article makes no mention of the use of counselors in this process.
Those who parent or counsel children with emotional troubles recognize how crude our current set of diagnostic categories are at the present time. Kids labeled ADHD, Bi-polar, and ODD all share similar symptoms. They all can be impulsive, easily angered, hyperactive, grandiose, irritable, etc. But a friend of mine sent me some literature from researchers at Johns Hopkins where they are beginning to distinguish differences between some of these children. They present information on a diagnosis they call “Severe Mood Dysregulation” where the presentation of chronic irritability differs from the episodic forms found in Bi-polar Disorder.
Check out these two links for more details if you are interested: http://www.medpagetoday.com/Pediatrics/ADHD-ADD/tb/4978