Diagnosis of ADHD

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The American Psychiatric Association (APA) establishes the criteria for determining an psychiatric diagnosis within their Diagnostic and Statistical Manual (DSM). The APA initially created the diagnosis Attention Deficit Disorder in the year 1980 after it released its third edition of the DSM. Then, in subsequent editions, this diagnosis changed its name to Attention Deficit Hyperactivity Disorder (ADHD.)

There isn’t a biological test for ADHD. According to DSM guidelines, an assessment of ADHD is possible in the event that a child is believed as being “inattentive,” “hyperactive” or “impulsive,” and such actions “interfere” with “functioning and development.” The child who is fidgets at school or fails to pay attention to his teacher, may be displaying “symptoms” of ADHD. Because there isn’t any biological indicator for the disorder and there is no biological marker, there is a factor that affects the diagnosis. What might be viewed as an issue in one situation–by teachers, parents or a pediatrician — could be considered normal in another setting.

Age, gender and cultural differences impact the diagnostic criteria. Boys are between two and three higher likely than females to suffer from ADHD and the children with the lowest grades in the classroom are 50 percent more likely than older children to be diagnosed and treated; and when 13% of elementary-school students in the United States are said to suffer from ADHD but only around 2 percent among children from the UK are believed to be suffering from issues with attention deficit (with the disorder referred to as hyperkinetic syndrome, not ADHD.) Because the majority of children who experience difficulty attending to “attention” also have behavioral issues and/or problems with their behavior, the diagnosis of ADHD frequently occurs in conjunction with other diagnoses such as oppositional defiant disorder (ODD), disruptive mood dysregulation disorder conduct disorder and various other issues with behavior. Treatments for these various diagnoses are also similar, as do the stimulants commonly prescribed to children who have these behavioral issues.

How ADHD Drugs Act on the Brain

When parents are trying to determine the benefits of psychiatric medication to their kids, as well as their potential benefits and risks it is beneficial to know how these medications “act” on the brain.

How brain neurons communicate

The brain is home to an estimated 100 billion neurons inside the brain. The transmission of messages through neuronal pathways in the brain by neurotransmitters, or molecules and serve like “chemical messengers.” The first neuron releases a neurotransmitter to the small space between neurons, known as the synaptic-cleft and then the neurotransmitter bonds to receptors in the neuron that are located on the other. The neurotransmitter can be able to fit inside the receptor as it is a “key into a lock.” The binding action causes the second nerve to activate, or impedes the firing. The excitatory response transmits the message through the neuronal pathway, while the inhibitory response stifles this neuronal activity. To stop the message, the chemical messenger then “transported” back into the primary neuron to be saved for future use.

The hypothesis of chemical imbalance

in the 60s scientists discovered that antidepressants and antipsychotics believe that mental illnesses are caused by chemical imbalances in the brain. These imbalances can then be “fixed,” or put back to normal with psychotropic drugs. For instance, antidepressants were discovered to raise levels of serotonin within the brain. Thus, researchers speculated that depression could be caused by a lack of serotonin. Antipsychotics were discovered to block dopamine pathways within the brain. Thus, researchers suggested that schizophrenia might be due to a high concentration of dopamine levels in the brain.

To test these hypotheses researchers conducted research studies to find out if people suffering from depression had too much serotonin levels in their brains or if people suffering from schizophrenia frequently had too much dopamine activity. The decades of research did not give the evidence that would confirm these theories. The year 2005 was the first time Kenneth Kendler, coeditor in chief of Psychological Medicine summed up these findings in this succinct manner: “We have hunted for big simple neurochemical explanations for psychiatric disorders and have not found them.”

A new paradigm to understand psychotropic drugs

In a paper from 1996 that was published in 1996, NIMH Director Stephen Hyman provided a good description of how psychiatric medicines in fact “work.” The drugs are more accurately described as agents that cause disruptions in brain functioning. Psychotropic medications, Hyman noted, all interfere with normal neurotransmitter activity within the brain. The brain however has a variety of feedback mechanisms to regulate its neurotransmitter activity as well as in reaction to the drug’s disruption of normal function it will go through various “compensatory adaptations.” The brain is trying to preserve its normal function.

For example, if the drug increases levels of serotonin the brain reduces the activity of its own serotonergic system. If the drug blocks dopamine receptors then the brain is able to increase the activity of dopamine. And so on. After this compensatory process Hyman stated that the brain is operating in a way that is “qualitatively as well as quantitatively different from the normal state.”

ADHD medications alter dopamine function

Ritalin, as well as other stimulants prescribed to treat ADHD boost the levels of dopamine within the brain. They accomplish this by increasing the release dopamine by neurons, or by preventing the normal reuptake and release of dopamine from in the synaptic gap. Cocaine boosts dopamine levels in this way also.

The Right to Informed Consent

The majority of guidelines for clinical ADHD treatment recommend that the decision-making process includes the health professional, parents/carers as well as the child who suffers from ADHD. Health professionals are reminded to provide complete “informed consent” to the parents and the child. This is a requirement for discussing evidence about the benefits and risks of different strategies, including their long-term impacts. More information on shared decision-making

“A Bill of Rights for Children and Adolescents Considering Psychiatric Medications”

Canadian Paediatrics Society guidelines for ADHD.

NICE recommendations for ADHD.

Risks and benefits of ADHD medications

Effects of short-term duration

The initial studies of the methylphenidate (Ritalin) in the treatment of ADHD in children showed that the drug systematically decreased their motor activity as well as their social interaction with others. The study found that children who were taking the drug were less “passive” and “submissive.” Stimulants, as described in in the Oxford Textbook of Clinical Psychopharmacology and Drug Therapy can reduce hyperactivity through “reducing the number of behavioral responses.” This shift is seen as a positive change in the ADHD scales used to assess the effectiveness of ADHD medication.

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