Calling Attention to ADHD: Is the Disorder Real?

From the WebMD Archives

Sept. 1, 2000 -- Would attention deficit hyperactivity disorder (ADHD) by any other name still be a disorder? "ADHD is a catchphrase in search of a syndrome in search of a disorder in search of a cause," writes neurologist Jeff Victoroff, MD, in a provocative article published in a recent issue of Psychiatric Times.

Victoroff, who is an associate professor of clinical neurology at the Keck School of Medicine at the University of Southern California, doesn't dispute that the symptoms and problems associated with what we call ADHD are real, but rather that the art of psychiatric diagnosis has gotten itself ahead of the science of the mind -- to the harm of children who may be misdiagnosed by primary care physicians or pediatricians, and overmedicated at the urging of parents or school systems, who are looking for a quick fix to what may be complex behavioral problems.

Children and adults who are diagnosed with ADHD generally have trouble paying attention, are easily distracted, impulsive, and hyperactive. The disorder is frequently broken down into three subcategories according to whether the child is hyperactive and impulsive alone, inattentive alone, or a combination of all three.

Yet, as Victoroff and some other researchers have pointed out, current methods for diagnosing ADHD are based on observation alone: Johnny fidgets, talks in class, and doesn't follow instructions, and, therefore, he must have ADHD. But that's like saying that everyone who coughs between 50 and 75 times each day has tuberculosis, and everyone who coughs less often does not have TB; it's a non-scientific and potentially flawed approach to diagnosing a serious condition, he contends.

Victoroff tells WebMD, "To look at a kid and say ... if they're distractible or contentious or inattentive then they have this disease," is an approach that is resistant to change that could be brought about by ongoing advances in technology.

"It's not to say that [the diagnosis] isn't a valuable thing or that we should abandon it today; it's just to say that we should look forward to a better psychiatry in the future where we're looking at this very real population of kids who suffer and whose families suffer, but identify them in a scientific way," he says.

There are many other possible explanations for the behaviors seen in children who are diagnosed with ADHD, Victoroff tells WebMD, including depression, physical or sexual abuse at home, or anxiety about school or some situation in the family or community. He says he is concerned that in the rush to treat ADHD, too many children may be given strong medication for treatment of a disorder they do not have.

"The widespread drugging of preschoolers ups the ante," he writes. "We need to discover scientifically rigorous, replicable specific and scientific markers that could rescue parents, child psychiatrists, pediatric neurologists, and especially family doctors from being forced to make this critical diagnosis based on the current [criteria] -- and rescue a mixed group of children from being swept like dolphins into a tuna net to [mood-altering] intervention with potentially lifelong consequences."

But as another psychiatrist points out to WebMD, the lack of a specific or sensitive diagnosis for a specific condition doesn't mean that ADHD is not a very real problem.

"We have no objective test, we all know that, that's why it's called a disorder. ... It's a clinical diagnosis, just as rheumatic heart disease was a clinical diagnosis until we had a specific test, but that doesn't mean that rheumatic heart disease did not exist. We've done field trials in thousands and thousands of kids. This has been a stable diagnosis since the 1930s. We have treatments for it, and we have ways of following improvement, but we don't have a test for it," says Charles H. Enzer, MD, associate clinical professor of psychiatry at the University of Cincinnati Medical Center.

Victoroff says that his intention was not to cast doubt on the existence of a hyperactivity disorder, but to raise questions about the validity of ADHD primarily out of concern for the safety of children. "I think it's one thing once the brain is fully formed to expose it to a drug that alters [chemicals involved in transmission of nerve impulses]," he tells WebMD, explaining though that we cannot be sure of the consequences for the brain of a child, which is not fully developed.

He says that in the near future, it may be possible to accurately diagnose ADHD based on brain-imaging studies or laboratory tests using spinal fluid to show specific chemical indications of ADHD.