No biomarkers just second-hand reports of children 'often' displaying unwelcome behaviours

 

Despite numerous hyped claims of imminent technological diagnostic breakthroughs, it remains the case that “no biological marker is diagnostic for ADHD”.[1] Nonetheless, many people, including some patients and parents, mistakenly believe ADHD is diagnosed using a series of 'scientific' tests.

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In reality, the 18 behavioral criteria listed below from DSM-5, produced by the American Psychiatric Association, remain the basis for a diagnosis. Every claim about ADHD should be viewed in the light of these subjective criteria. These include perfectly normal (if somewhat annoying) active behaviours like playing loudly, climbing excessively, fidgeting and inattentive behaviors like forgetting, being easily distracted and disorganised.

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How often is often? How ‘often’ a child or adolescent ‘fidgets’ or ‘interrupts’ or ‘avoids homework’ or ‘fails to remain seated’ or is ‘distracted’ so that they exhibit ‘some impairment’ is not defined in DSM5. Except for those aged 17 and over being required to display less criteria (five instead of six), the diagnostic criteria are identical for pre-schoolers and geriatrics.

 

Clinicians don't even need to observe ADHD type behaviours. They diagnose children or adolescents with ADHD by relying on third party reports of children exhibiting the above behaviours. Usually parents and teachers are asked to complete a questionnaire detailing if their child always, often, sometimes or never displays these behaviours. 

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The role of Teachers and Parents in creating ADHD type behaviours and contributing to the diagnosis

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It is an unpleasant but undeniable truth (that is rarely confronted because of the fear of giving offence) that inappropriate teaching and parenting will very often cause inappropriate behaviours in children. To put it bluntly, incompetent (however well intented) teachers and parents often create ADHD type behaviours in children and then provide the core behavioural evidence used to diagnose it.

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Parents - It is much easier for a clinician to suggest a biological problem than to ask parents to confront their own shortcomings. It is a brave clinician who will suggest to parents that they may be a part of the problem. An ADHD diagnosis helps some parents avoid that unpleasant reality and saves the clinician from having to ask difficult and confronting questions. ADHD specialists simplify the equation for ill-equipped parents by removing responsibility.

 

As early as 1998 ADHD critic American psychiatrist Dr Peter Breggin believes their message to parents is: ‘You are not the cause and you are not the cure…We are doctors; we have the knowledge and we have the treatments.’[20] Naturally some parents welcome the ADHD specialists’ absolution of responsibility and their child’s compliant behaviour on ADHD drugs. 

 

This is still the case. ADHD proponents still promote the belief that poor parenting does not create ADHD type behaviours in children. For example, the Australasian ADHD Professionals Association (AADPA) dismisses as a myth the claim that “bad parenting causes ADHD”, reinforcing the reassuring message that parents should not blame themselves for their child’s diagnosis.[21] Yet the AADPA recommends parent training as an ADHD intervention.[22] This awkward contradiction raises an obvious question: if parenting can materially change the very behaviours used to diagnose ADHD, how confidently can those behaviours be treated as evidence of an underlying neurodevelopmental disorder independent of parenting and family environment?

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Schools and Teachers - Many of the diagnostic criteria, in particular "making careless mistakes, not seeming to listen, failing to finish school work, being disorganised, disliking schoolwork or homework, blurting out answers and leaving a seat when remaining seated is expected", are all evidence of a student’s failure to thrive or comply in a school environment. Children is classes controlled by competent, engaging teachers are obviously far less likely to misbehave and are therefore less likely to qualify for a diagnosis.[2] However, a diagnosis of ADHD shifts the focus away from what might be wrong with the teacher or the school and assumes the child's biochemistry is the problem.[3]

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As well as being a primary source of the information used by clinicians to diagnose ADHD, research indicates that, in the majority of cases, teachers are the first to suggest a student be referred for diagnosis.[4][5][6]  There is a high degree of variability in teacher responses to ADHD in regards participation in the diagnostic process, teaching practice and acceptance of the validity of the diagnosis.[7][8]  A child's chances of being diagnosed with ADHD are therefore highly dependent on who there teacher is.

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Teacher attitude and practice is just one of many non-biological factors that have been shown to effect rates of ADHD diagnosis and medication use. Variations in both parent and clinician attitudes and practice have a strong impact on a child’s chances of being diagnosed and ‘medicated’ (or 'drugged' depending on your perspective). Arguably a diagnosis of ADHD says more about the adults in a child’s life (parents, teachers and doctors) than it does about the child.

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The ADHD Birthday Lottery - Possibly the clearest example of poor psychiatric and teaching practice routinely resulting in an ADHD misdiagnosis is the relative age (or late birthdate) effect. This refers to the global phenomenon where it is normal for the youngest children in a school year cohort to be diagnosed with, and medicated for, ADHD at a higher rate than their older classmates.[10] For example, research led by PsychWatch Australia Editor, Dr Martin Whitely, found that among Western Australian schoolchildren aged 6 to 10 years 'those born in June (the last month of the recommended school-year intake) were about twice as likely to have received ADHD medication than those born in the first intake month (the previous July)'.[11] This happens because teachers, and ultimately the diagnosing doctor, fail to recognise that children who are younger than their classmates typically behave less maturely than their older classmates. These dangerously over-confident doctors effectively label children as having an impaired brain when all they are is younger than their classmates.​​

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Many other factors including gender (with boys 3x more likely to be diagnosed as girls), ethnicity of students and teachers[9], divorce[12], low maternal education, lone parenthood and the receipt of social welfare[13], sexual abuse[14], sleep deprivation[15], perinatal issues[16], artificial food additives[17], mobile phone use[18], postcode and regulatory capture (drug company influence)[19], have all been associated with an increased risk of an ADHD diagnosis. Despite this, and the absence of any supporting evidence, it is widely assumed that a child with ADHD has a neurodevelopmental disorder caused by faulty brain chemistry and function.

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References

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[1]  American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, (DSM-5) pp. 59-66

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[2]  DSM-5 implicitly recognises that boring environments create bored students who misbehave.  It states: "Signs of the disorder may be minimal or absent when the person is receiving frequent rewards for appropriate behaviour, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e.g., via electronic screens) or is in a one-to-one situation (e.g., the clinician’s office)”DSM-5 p. 61

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[3]  Linda J. Graham, ‘Drugs, labels and (p)ill-fitting boxes: ADHD and children who are hard to teach’, in Discourse: Studies in the Cultural Politics of Education, Vol. 29, No. 1, March 2008, p. 94. https://www.researchgate.net/publication/249914240_Drugs_labels_and_pill-fitting_boxes_ADHD_and_children_who_are_hard_to_teach

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[4]  Linda Graham, ‘The Politics of ADHD’, in Proceedings of the Australian Association for Research in Education (AARE) Annual Conference, Adelaide, November 2006, p. 14. https://eprints.qut.edu.au/4806/1/4806.pdf

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[5]  Phillips, C. B. (2006). Medicine goes to school: Teachers as sickness brokers for ADHD. Plos Medicine, 3(4), e182–e182. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0030182

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[6]  Sax, L., & Kautz, K. J. (2003). Who first suggest the diagnosis of attention-deficit/hyperactivity disorder? Annals of Family Medicine, 1(3), 171. doi:10.1370/afm.3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466583/

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[7]  Jody Sherman, Carmen Rasmussen & Lola Baydala The impact of teacher factors on achievement and behavioural outcomes of children with Attention Deficit/Hyperactivity Disorder (ADHD): a review of the literature Pages 347-360 | Received 30 Jan 2007, Published online: 15 Nov 2008 http://www.tandfonline.com/doi/full/10.1080/00131880802499803

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[8]  Teachers' Knowledge of ADHD, Treatments for ADHD, and Treatment Acceptability: An Initial Investigation Vereb, Rebecca L; DiPerna, James C. School Psychology Review; Bethesda 33.3  (2004): 421-428 https://search.proquest.com/openview/7a943cd283c75901ee673a98b3c7ce0a/1?pq-origsite=gscholar&cbl=48217

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[9]  Schneider H, Eisenberg D. Who receives a diagnosis of attention-deficit/ hyperactivity disorder in the United States elementary school population? Pediatrics. 2006;117(4):e601-9. https://pediatrics.aappublications.org/content/117/4/e601

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[10]  Whitely M, Raven M, Timimi S, Jureidini J, Phillimore J, Leo J, Moncrieff J, Landman P,  Attention deficit hyperactivity disorder late birthdate effect common in both high and low prescribing international jurisdictions: systematic review, Journal of Child Psychology and Psychiatry, October 2018. https://onlinelibrary.wiley.com/doi/abs/10.1111/jcpp.12991

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[11]  Whitely M, Lester L, Phillimore J, Robinson S,  Influence of birth month of Western Australian children on the probability of being treated for ADHD, Medical Journal of Australia, 2017.

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[12]  Hjern A, Weitoft GR, Lindblad F. Social adversity predicts ADHD-medication in school children--a national cohort study. Acta Paediatr. 2010;99(6):920-4. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1651-2227.2009.01638.x

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[13]  Russell G, Ford T, Rosenberg R, Kelly S. The association of attention deficit hyperactivity disorder with socioeconomic disadvantage: alternative explanations and evidence. J Child Psychol Psychiatry. 2014;55(5):436-45. https://www.ncbi.nlm.nih.gov/pubmed/20002622

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[14]  Weinstein D, Staffelbach D, Biaggio M. Attention-deficit hyperactivity disorder and posttraumatic stress disorder: differential diagnosis in childhood sexual abuse. Clin Psychol Rev. 2000;20(3):359-78. https://www.sciencedirect.com/science/article/pii/S027273589800107X

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[15]  Thakkar VG. Diagnosing the Wrong Deficit. New York Times. 2013 27 April. https://www.nytimes.com/2013/04/28/opinion/sunday/diagnosing-the-wrong-deficit.html

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[16]  Schmitt J, Romanos M. Prenatal and perinatal risk factors for attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 2012;166(11):1074-5. https://jamanetwork.com/journals/jamapediatrics/fullarticle/1357759

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[17]  McCann D, Barrett A, Cooper A, Crumpler D, Dalen L, Grimshaw K, et al. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet. 2007;370(9598):1560-7. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61306-3/fulltext

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[18]  Byun YH, Ha M, Kwon HJ, Hong YC, Leem JH, Sakong J, et al. Mobile phone use, blood lead levels, and attention deficit hyperactivity symptoms in children: a longitudinal study. PLoS One. 2013;8(3):e59742. https://www.ncbi.nlm.nih.gov/pubmed/23555766

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[19]  Whitely MP. Attention Deficit Hyperactivity Disorder Policy, Practice and Regulatory Capture in Australia 1992–2012 [PhD]. Perth, WA: Curtin University; 2014. https://espace.curtin.edu.au/bitstream/handle/20.500.11937/1776/225953_Whitely%202014.pdf?sequence=2

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[20]  P. Breggin, Talking Back to Ritalin, p. 188.

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[21]  Australasian ADHD Professionals Association (AADPA), ADHD Myths & Misinformation, Australian Evidence-Based Clinical Practice Guideline for ADHD, 2023. AADPA states that “Bad parenting causes ADHD” is a “common myth about ADHD”.  https://adhdguideline.aadpa.com.au/adhd-myths-and-misinformation-factsheet/

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[22]  Australasian ADHD Professionals Association (AADPA), ADHD Parent/Family Training, Australian Evidence-Based Clinical Practice Guideline for ADHD. AADPA recommends parent/family training for parents and carers of children and adolescents with ADHD and reports that the evidence suggests small-to-moderate improvements in ADHD symptoms and functioning based on parent reports, although most studies had high levels of bias. Available here