Stop mislabelling labels.

The last time I looked through the supermarket, I bought some baked beans. How did I know the can I took off the shelf was full of baked beans and not freshly harvested sheep’s innards? Because the label on the can said so.

Labels aren’t perfect of course. Every now and then, a can of something has the wrong label applied in the factory. Usually it’s nothing too sinister – no accidental swaps of some goat entrails instead of your tinned salmon. Instead, it’s usually something similar – tuna gets labelled as salmon and vice versa, and the worst that happens is that the tuna mornay you’ve just made had an unexpected flavour.  Even these sorts of mild mix ups are rare. Overall, we trust that the labels are guides and the information they provide us helps us make an informed decision about what do to with that particular can and its contents.

It would be pretty silly for some random person to preach out the front of the supermarket, ranting about how all labels for a particular thing are all wrong.

“Uh, just because the occasional can of tuna was accidentally filled with cat food doesn’t mean to say that all labels are wrong. And just because one person had a bad experience with the wrong label, the supermarket shouldn’t stop using them … otherwise how else is anyone supposed to manage their cans effectively without labels? Honestly, stop looking like a fool by preaching about labels and let the rest of us finish our shopping.”

Dr Caroline Leaf, communication pathologist, self-titled cognitive neuroscientist, and a self-elected champion of irrelevant mental health advocacy, has come out all guns ablazin’ over ADHD labels again. She needs to give it a rest – she’s just like the crazy person standing in front of the supermarket.

“Labels for ADHD are bad”, she says. “Look at Avery Jackson, who was labeled ADHD but did not accept the label. He went on to earn multiple degrees and become one of the top neurosurgeons in the U.S!”  The underlying message – labelling a child with ADHD will lock then into a life of pathetic excuses and they won’t ever reach their full potential until they renounce the curse of their ADHD label.

For every scary anecdote about the evils of ADHD and the mental prison that everyone with such a label is supposed to find themselves in, there are ten more where the ADHD label helped them.  There are so many more people where the ADHD label helped them to finally understand their condition and receive the correct treatment, enabling them to reach their potential and improve their life in leaps and bounds.

Take, for example, one of my patients called Little Jimmy (not his real name). When Little Jimmy was in the early primary school grades, he was a bit of a fidgeter and couldn’t concentrate well enough at school or at home to complete his homework tasks. His mother took him to a naturopath who told him he had a disorder of “pyrolles disease”. Thankfully, mum brought him to see me, and after a careful history and a long chat, Little Jimmy went to see a specialist who diagnosed him with ADHD and commenced him on stimulant medications. Before his label, Little Jimmy’s reading levels were languishing at the bottom off his class after two years of stagnation.  He was more than a year behind in reading levels and going nowhere fast.  Two weeks after getting his label and the right medication, he went to the top three reading levels in the class.  His mother told me of the massive gains he made, and the flow-on effect this had to his self-esteem and confidence in other areas of his school work and school life. She cried as she recounted his story, and then I cried too.

So perhaps Avery Jackson became an orthopaedic surgeon because he chose to ignore his label of ADHD and worked hard anyway.  Good for him.  Little Jimmy got a label of ADHD and because of it, he learnt to read. Now he’s got the chance to follow in Avery Jackson’s footsteps, BECAUSE of his label.

Labels are important. Without them, we wouldn’t know how to know who needs which treatment. Labels can help people overcome some of the strongest barriers and connect with others for support.

And let’s face it, if someone really wanted to, they don’t need a label of ADHD to find excuses in life.

So labels are not a hinderance, but rather, they are a guide to help you know what’s going on so informed choices can be made. In Dr Leaf’s mind, those kids with ADHD are just naughty children, with bad parents, who are using the label of ADHD to cover their poor parenting and their bad behaviour. Clearly all they need to do is to stop their toxic thinking and they wouldn’t need their medications, but they would be cured.

Dr Leaf is wrong … she can stand and scream blue murder about labels and ADHD all she wants.  But just like the crazy random person screaming about labels in front of the supermarket, it means very little. It’s not helping her cause, and if anything, it’s sewing distrust in an system that, despite it’s flaws, works very well, and has helped thousands of children and adults alike to achieve their potential.

That’s the power of labels, and Dr Leaf would do herself and all her followers a favour if she stopped mislabelling them.

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The truth about ADHD

ADHD is always a popular topic … and an apoplexic topic. Any mention of ADHD seems to induce everyone within ear-shot to uncontrollably expectorate their half-baked opinion on the subject, like the Tourette’s syndrome of ignorance.

I’ve heard them all over the years …

ADHD is over diagnosed.
ADHD is just a label for bad parenting.
ADHD is caused by sugar.
ADHD is caused by food colouring / preservatives / gluten / (any other fad ‘toxin’)
ADHD is cured by diet / meditation / supplements / swiss balls.
ADHD medication (Ritalin) is overused / irresponsible / lazy parenting / harmful / ungodly.
ADHD doesn’t exist in France.
ADHD doesn’t exist at all.

I could go on, but if I do, I’m just going to get myself in a tizz.

ADHD is the new AIDS. There is so much misinformation and discrimination surrounding ADHD in our modern enlightened society that the stigma is worse than the actual illness, which really says something about how badly ADHD is treated in our communities.

One of the cruellest aspects of the cultural mismanagement of ADHD is the fact that it maligns the sufferers while simultaneously isolating them from much needed support. Saying that children with ADHD should just behave themselves, or parents of children with ADHD should just have better parenting skills is victim blaming at its worst.

In order to counter the prevalent ignorance of ADHD, even just a little, I want to give a crash course on the science so that at least somewhere on the searchable web, there is a counterbalance to the thousands of misinformed arm-chair ‘experts’ whose only experience with ADHD is reading the misguided perspectives of other so-called ‘experts’.

ADHD stands for Attention Deficit Hyperactivity Disorder.

The current formal definition that must be matched to have a diagnosis of ADHD is:

  1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
    * Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
    * Often has trouble holding attention on tasks or play activities.
    * Often does not seem to listen when spoken to directly.
    * Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
    * Often has trouble organizing tasks and activities.
    * Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
    * Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
    * Is often easily distracted
    * Is often forgetful in daily activities.
  1. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
    * Often fidgets with or taps hands or feet, or squirms in seat.
    * Often leaves seat in situations when remaining seated is expected.
    * Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
    * Often unable to play or take part in leisure activities quietly.
    * Is often “on the go” acting as if “driven by a motor”.
    * Often talks excessively.
    * Often blurts out an answer before a question has been completed.
    * Often has trouble waiting his/her turn.
    * Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:
– Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
– Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).
– There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
– The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.
– The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder.

(http://www.cdc.gov/ncbddd/adhd/diagnosis.html)

In Australia, ADHD cannot be formally diagnosed by anyone other than a paediatrician or a psychiatrist. So even as an experienced GP, I can’t officially diagnose it. The school counsellor or local naturopath can’t diagnose it. You can’t just pluck it out of the air. The diagnosis can only come from a medical specialist with at least a decade of university level training.

The official prevalence rate of ADHD (the number of people with a current diagnosis) is only 5%. According to some US based community surveys, nearly a half of those children are not on medication for it (http://www.cdc.gov/ncbddd/adhd/data.html). So much for Ritalin being overprescribed.

Stimulants vs nothing

ADHD is a predominantly genetic disorder which leads to specific structural deficiencies in the brain. Children with ADHD have a significant global reduction in the volume of grey matter, most prominently in a part of the brain called the right lentiform nucleus. These changes usually improve with age and improve with stimulant medication. There is also evidence of changes to the shape and size of other brain structures such as the amygdala and the thalamus (areas of the brain integral to sensory and emotional processing). Early evidence also exists which suggests changes in the white matter pathways connecting a number of critical brain regions. Studies investigating brain development have estimated that the frontal lobe development of ADHD children lags that of normal children by an average of about three years.

These changes in the brain are not caused by the child’s behaviour, since other studies have shown the same changes in the brains of unaffected first degree relatives (brothers or sisters), just to a milder degree.

Modern functional imaging techniques show that the brains of children with ADHD have abnormally low functioning in most of the brain structures related to attention and planning (numerous areas of the frontal cortex as well as the basal ganglia, thalamus and parietal cortices). At the same time, there is extra activity in portions of the brain related to the Default Mode Network (the day-dreaming part of your brain). So children with ADHD have brains in which the ‘day-dreaming’ network activity persists into, or emerges during, periods of task-related activity. This takes processing power away from the competing task-specific processing causing a deficit in performance. Studies show that Ritalin normalises this dysfunction.

The best evidence suggests that dopamine is the main neurotransmitter involved in ADHD. Other neurotransmitters are likely to be involved but the evidence is still being confirmed. Medications like Ritalin improve ADHD symptoms by increasing the amount of dopamine that the nerve cells have access to, improving the clarity of the signal between them.

Underlying all of these neural changes are genetics. While there have been no specific genes discovered in research thus far, twin studies have demonstrated a heritability of ADHD of up to 76%. The most significant environmental factors that are responsible for the remainder of the influence on ADHD are not nutritional factors such as sugar or food additives, but are low birth weight/prematurity and exposure to smoking during pregnancy.

Are there any better treatments for ADHD other than stimulants like Ritalin? Other non-stimulant medications are available although at this stage, Ritalin and Dexamphetamine still out-perform them. Cognitive therapies may mimic some of the brain changes of Ritalin but it is not clear whether the effectiveness of cognitive therapies are equal to or better than the stimulant medications. What is clear is that Ritalin doesn’t lead to a euphoric state (a “drug high”) when given orally. So children can not get addicted to Ritalin when used responsibly.

In summary, ADHD exists. It’s caused by the interaction of a number of genes and some environmental factors such as those related to prematurity, low birth weight and maternal smoking, which alter the growth and development of the brain, specifically the grey matter of the frontal cortex, the basal ganglia and thalamus, and the pathways which connect them. These structural changes cause the day-dreaming part of the brain to be more active and the attention and planning parts of the brain to be less active.

ADHD is not caused by food additives or sugar. There is no evidence that autoimmunity plays a significant part. Forcing your child to consume bone broth or stop eating gluten will not cure them.

ADHD is not caused by bad parenting. Ritalin is not evil. Medications like Ritalin and Dexamphetamine have been shown to improve the functioning of children with ADHD and improve their underlying neurological deficits.

It’s time to cut the crap. Our culture needs to stop victimising the child with ADHD and their parents, who already suffer enough from the ADHD without ignorant busy-bodies and self-titled experts chiming in and making their suffering even more pronounced. It’s time to stop judging those who choose the best for their child by medicating them, who do so in spite of the unfair and ill-informed criticism of everyone from their mother-in-law to the milkman when they do. It’s time to remove the stigma from one of the most common psychiatric disorders of childhood so that every child has an equal chance of growing into an adult that can realise their full potential.

That’s the truth about ADHD.

Bibliography:

Cortese, S. (2012). The neurobiology and genetics of Attention Deficit/Hyperactivity Disorder (ADHD): what every clinician should know. Eur J Paediatr Neurol, 16(5), 422-433. doi: 10.1016/j.ejpn.2012.01.009