Vancouver Sun doesn't get the point about ADHD Diagnosis and Treatment

This story has been around for some time, and has been misused by many in the anti-medicine, anti-science and anti-medical crowd. Most papers have done as poor a job as the Vancouver sun in reporting this story. But on the front page? It's sad that here in Vancouver we don't seem to have a decent science reporter, and very sad that such a simplistic interpretation science appears as front page news. You would expect something a little deeper and thought-out for a front page story. Instead we get a hysterical headline, "One in five hyperactive kids possibly misdiagnosed. Youngest in kindergarten are most at risk, study says." Gosh! you think you had better warn all your friends who have kids on medication!

The writer, Tracy Sherlock, goes on to tug at your heart strings with a story of a child who has taken Ritalin, and as his mom says,"I saw that he was a zombie and it took his joy away..." Those evil drugs and doctors! Making kids into zombies!

But the Vancouver Sun writer doesn't seem to know how to deal with a science based story. If it's about science, you really need to get the facts right. And maybe shouldn't mess the story up trying to turn it into a human interest story. Here's an example: "Although a psychologist said X's son was gifted, she decided to try Ritalin to see if it helped." Research becomes human interest ....1,2,3!

Two issues: One, being "gifted" has no relationship with having ADHD (Attention Deficit Hyperactivity Disorder). As a matter of fact, many gifted (and I assume we mean "intelligent" or academically gifted here, not art or dance kind of gifted) students have ADHD. One does not preclude the other. And understand that because of poor impulse control, an inability to focus, concentrate, pick out what's salient or important, or initiate and follow through on tasks, these "gifted" children fail at school all the time. (How many children with ADHD drop out of school? How many stay in? How many students with ADHD taking medication graduate, as compared to students with ADHD not taking medication? Russell Barkley has all that information, and there is a link to his web site below.

These "gifted" children often become frustrated, angry, depressed and learn to hate and avoid school. The research is clear that stimulant medication makes a positive difference for these children, adolescents and even adults. They are far more likely to do well at school, to graduate, to stay out of legal trouble and stay off illegal drugs.

But all the research crumbles under the weight of one human interest story of a boy who becomes a "Zombie." Not giving the full story is a disservice to all of our families and individuals struggling with the problems of ADHD (Attention Deficit Hyperactivity Disorder).

A side note or two: The writer seems to not understand how the health system works here in BC. Registered Psychologists do not, and can not, prescribe medication. Period. Medical doctors do not prescribe medication because a psychologist told them to. Sherlock's understanding of how the process works is minimal and not up to the most basic standards we would expect, at least what one would hope would be the standards for a front page story.

Next we read that Mrs. X (the mother, not the doctor, not a doctor, not a researcher, not an expert in the field) "believes many kids with vision or hearing problems are misdiagnosed with ADD and ADHD." How can that be? ANY school psychologist, registered psychologist, family doctor or psychiatrist would seek out the results of your child's vision and hearing assessment prior to making a diagnosis. At least anyone who follows the rules. And why are we writing about the opinion of someone's mother? How much effort would it take to find out if hearing problems and vision problems are often misdiagnosed as ADHD? (They aren't.)

Then the story takes the big leap, and this is common: "I was not going to have my son labelled..." We often hear this. It's part of the anti-medical meme out there. It's not a "label," it's a diagnosis, like a broken leg, a viral or bacterial infection. The diagnosis helps providers focus their interventions. The child's problems are not caused by the diagnosis or "label."

If there are significant problems with behaviour at school or home, how do we approach the problem if we cannot name it? I understand that in schools once a child is diagnosed with ADHD, a learning disability or any other number of learning deficits staff behave differently. And not every child on ADHD needs medication. Staff often focus on the medication issues rather than the many other positive and supportive interventions that are possible and necessary even if medication is used. But this is a systemic problem, a staff problem. And ignoring the diagnosable disorder and refusing to name it doesn't help. We don't know what to treat if we can't even say what it is.

Later in the article "Vancouver's expert on boys" says, "There is no blood test for ADHD- it's very subjective and this study makes that very clear...." He goes on to point out that it is a developmental disorder, and that boys develop more slowly than girls, and therefore that explains why more boys are diagnosed with ADHD than girls. Except that we see the same numbers with teens and with adults. I don't think this is proof of any problem with the validity of the diagnosis. It IS a problem of poor staff training, expectations on young children that are unreasonable, and societal pressures that are far greater than anyone might suspect on young children.

But let me stop here. I'm afraid this front page article is very problematic not only in what it says, but in what it doesn't say. So let me say a few things:

ADHD is a real disorder. It leads to school, work, and social dysfunction. Unaddressed it leads many to a failed school experience. To avoid the topic, to refuse to even say it or name it (no labels please!) hurts children more than it helps. Ask your school district what the percentage of students with an ADHD diagnosis graduate, as compared to a diagnosis of autism, Asperger's or even mental retardation. You will be very surprised by the numbers.

Medications help in many cases. The research on this is clear. Student's with significant ADHD who do not take medication are less likely to graduate from high school, less likely to attend college, more likely to become involved with the law (impulsive behaviour), when involved in accidents they have more serious accidents that lead to longer hospitalizations and higher costs. All of this research is well documented over many years and many studies. I suggest going to Russell Barkley's web page for more information on the research. Russell Barkley has a number of video's you can watch, some on YouTube, that go over these numbers.

There are non-medical interventions for ADHD. These include some visual supports, use of schedules, reinforcement programs and other simple behavioural interventions. Many medical doctors and psychologists may not be familiar with these interventions, so you should see someone who is an expert in the field.

Changes in diets have little effect, except on those few kids who had a food allergy. There are no toxin treatments that work, and very little or contrary evidence for the effectiveness of supplements, vitamins and "alternative treatments" like "sound therapy" or bio-feedback.

The diagnosis is not as subjective as some would want you to believe. For medical doctors, there is ample information through The Centre for ADHD/ADD Advocacy, Canada (CADDAC). CADDAC is a national, not-for-profit organization providing leadership in education and advocacy for ADHD organizations and individuals with ADHD across Canada. CADDAC's mandate is to take a national leadership role in networking all organizations, professionals, patients, caregivers and other stakeholders involved in ADHD related issues, and to then support those people through education and advocacy. They have standards for assessment which are excellent and comprehensive. There are other standards for diagnosis which, if followed, also prevent much of the misdiagnosis we read about. Most of the children misdiagnosed underwent the most minimal of assessment. Russell Barkley, again, has an excellent program for completing a child, adolescent and adult diagnosis.

The problem we often see is that a teacher or other person who knows the child thinks "Tommy has ADHD." Then someone simply goes through the most basic diagnostic criteria the find on the web, gives the teacher and parents a simple self-report consisting of 20 or so obvious questions and makes a diagnosis because Tommy meets the minimal criteria.

This is NOT how a diagnosis is made. To complete a true diagnosis we need to rule out other possible causes for the behaviours at issue. Yes, this means ruling out a vision problem, ruling out a hearing problem, ruling out possible medical issues, ruling out mood disorders and other more serious problems. This process is called a "differential diagnosis." It means following a procedure of gathering information, history, tests and assessments that guide us to the best possible diagnosis. Using a simple 20 question form is NOT best practice in making this diagnosis.

Often I see ADHD medications given to children, adolescents or adults and they do not see the doctor for several months afterwards. This seems rather odd. There are numerous means of tracking behavioural changes and the effectiveness of medications. These include parent observation reports, self reports and even computerized neuropsychological tests that we repeat over time to see the real effects of the medication and not just what people hope or wish. This follow up is done too infrequently. But this doesn't mean ADHD isn't real. It doesn't mean the diagnosis isn't right. And it doesn't mean the medication doesn't help.

Finally, ADHD is a form of what is often called an "executive disfunction." There may not be one simple test for ADHD, but as I pointed out above there are a series of tests, assessment tools and history taking methods that can help us in not just making the diagnosis, but in understanding the exact nature of this person's ADHD. This can mean we are able to provide specific behavioural interventions, specific environmental changes and specific medications that don't just address generic ADHD but address the child's individual problems. Parents who don't want an assessment because they fear labelling their child need to think about what they will miss.

This research article (actually what the original article does is compares the rate of ADHD diagnosis and prescribing of medication for the youngest and oldest students in schools and we shouldn't mistake this kind of look at data with real "experimental research") is regretfully being used all over the country to bash doctors, psychologists, teachers and life changing medication. ADHD is a real disorder. It can be very destructive to a child's life, but most importantly, it can be addressed and dealt with safely and with a fairly good rate of success.

I hope the Vancouver Sun can do a better job next time when making the decision to address a complex issue in a headline.

For more information about my practice in Vancouver and Burnaby you can click here. Information on adult and child diagnosis for ADHD can be found by clicking here.
Information on CADDAC can be found by clicking here.
To find Russell Barkley's web page on ADHD click here.
My Psychology Today web site can be found by clicking here.
My AAMFT web page can be found by clicking here.

Dr. Jim Roche
Child and Adolescent Treatment for ADHD
Adult Treatment for ADHD