Page 26 - IDF Journal 2023

26
IDF – Study Weekend IDF News – Spring 2023
So is ADHD Overdiagnosed?
Dr Helen Read
Attention deficit hyperactivity disorder (ADHD) is one
of the most common and challenging childhood neurobehavioural disorders.1 It negatively impacts children, their families, and their community. Worse
still, between 1/3 and 1/2 of patients with ADHD will have persistent symptoms into adulthood.2
There is a wide variability in the prevalence of ADHD worldwide and within countries. This is thought to be due to many factors and obstacles that affect accurate assessment.3 Ongoing controversies mean that diagnosis and treatment of ADHD has continued to be a source of debate when it really shouldn’t be.
Some have suggested that ADHD is
an overdiagnosed and overtreated condition.4 However, the evidence does not support this. The reality is that ADHD is still underdiagnosed, misdiagnosed, and undertreated.5
This article aims to show that a failure
to diagnose ADHD prevents children and their families from getting the assistance they need to achieve their full potential across academic, health, and psychosocial settings.6 And of course, ADHD children often live in ADHD families, and often grow up to be ADHD adults.7
I want to stress that the consequences of untreated ADHD develop across the lifespan and can be harder to recognise in motivated intelligent patients who
are often “made of strategies” as I say
in my clinic. This excellent illustration comes from ‘ADHD across the lifespan’, published in 2020 by the fabulous professor Phil Asherson.8
Why does this matter? Well, let’s start with the most obvious, and arguably the most costly, consequence of untreated ADHD to society, as well as to individuals.
A conservative estimate would be that one in four prisoners in Britain is thought to have ADHD, described as ‘critically underdiagnosed’. The academic literature points to ‘a five to tenfold’ increase
in prevalence in jails compared to the general population rate. If ADHD is recognised in prisons and ‘managed appropriately’, research indicates there could be a reduction in criminality of 32% for men and 41% for women.9
And don’t forget that around 96% of prisoners with ADHD have comorbidity, including substance use, conduct and personality disorders. There is an 8-fold increase in aggressive incidents involving prisoners with untreated ADHD. Across the ADHD population, comorbidity of all kinds is the norm, not the exception.9
We all know about the appalling lack of recognition and treatment in prisons but let us also remember the many adverse physical health outcomes from untreated ADHD.
Fascinatingly, people with ADHD have well over twice the prevalence of ankylosing spondylitis, ulcerative colitis, and autoimmune thyroid disease, and over 50 % greater likelihood of asthma, allergic rhinitis, and atopic dermatitis.10 I routinely screen for these when assessing new ADHD patients in my clinic.
I find that one third to half of the women
I assess for ADHD are fully or partially
hypermobile. Almost all my patients have
a degree of orthostatic hypotension, if
not full postural tachycardia syndrome
(PoTS).11 Many experience migraine,
functional gut disorders, and eye issues.12,13,14
Now I would like to share a growing hypothesis in the ADHD community that we may actually be talking about
a subpopulation of humans here, with different genetic, medical and other vulnerabilities.15 Lack of understanding and appropriate treatment means life stresses and associated mental health issues get worse. Perhaps in the future, medical historians will lament the inadvertent harm done by our profession failing to recognise and treat ADHD.
And let’s not forget mental health!!!
It is really shocking how often ADHD
lurks beneath common mental health presentations.16 Before I left the NHS,
I had one session for the 3 borough ADHD service and the other 10 for the general psychiatry front line GP intake clinic. During that 4 years, I diagnosed large numbers of ADHD cases presenting with these comorbidities in the general clinic, and in fact, there were some weeks where almost all the new clients had ADHD.
Treatment is very effective, largely comprising medication, and referral
into secondary services is generally not required. The figures were unequivocal. NHS management were impressed but what I failed to make them see, and I take full responsibility for my lack of ability to find better ways to communicate this vital information, was that the good figures were because I was correctly diagnosing the underlying ADHD in so many of our mental health referrals.
And the really shocking thing? If someone has ADHD underlying another psychiatric or substance misuse comorbidity, research shows that treatment for the comorbidity is often largely ineffective until the ADHD is treated, after which treatment works far better.17
We all know that the NHS is overwhelmed and failing, with long waiting lists and exhausted colleagues leaving in droves. Nowhere is this more true than in mental health services. I really do think that screening for, and treating, ADHD in NHS mental health referrals would change the landscape here - saving millions currently wasted on far less effective treatment which could be directed where it can actually make a difference. It’s not just for