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Critical analysis of the concept of adult attention-deficit hyperactivity disorder

  • Joanna Moncrieff (a1) and Sami Timimi (a2)
Summary

We question whether adult attention-deficit hyperactivity disorder (ADHD) represents a discrete condition that is distinguishable from ordinary behaviour and other psychiatric disorders, and whether it is related to the childhood disorder, since adult and childhood ADHD are said to be characterised by a different range of symptoms. Although studies of stimulant drugs find marginal short-term effects, which can be explained by their known psychoactive properties, there is little evidence that there are any sustained long-term benefits of drug therapy. We suggest that adult ADHD represents one of the latest attempts to medicalise ordinary human difficulties, and that its popularity is partly dependent on marketing and the reinforcing effects of stimulants.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Joanna Moncrieff (j.moncrieff@ucl.ac.uk)
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Declaration of interest

Both authors are members of the Critical Psychiatry Network.

Footnotes
References
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Critical analysis of the concept of adult attention-deficit hyperactivity disorder

  • Joanna Moncrieff (a1) and Sami Timimi (a2)
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eLetters

Adult Attention Deficit Disorder

Christine M Tyrie, Independent Psychiatrist
14 November 2011

Moncrieff and Timimi (1) have challenged whether Adult Attention Deficit Hyperactivity Disorder exists as a discrete condition, suggestingit is merely a medicalising of ordinary human difficulties and that the diagnosis is being pushed by pharmaceutical companies who then make a tidyprofit. They point out the discrepancies between childhood ADHD and adultADHD and, based on this state, that adult ADHD is not the same condition presumably they ascribe to the view that childhood ADHD suddenly disappears on the child's 18th birthday.

ADHD is a developmental disorder and symptoms change over time, childhood and adulthood are characterised by different range of virtually everything, lifestyle, pressures, social and moral responsibilities of a forty year old adult are clearly very different to those of a child. A child who fails to do his homework will get a telling off or detention an adult who fails to produce a report to his employer on time may get passedover on promotion or the sack. The underlying condition is still there, the adult simply learns to cope with or hide the condition but the prescription of medication may help the individual to cope. Evidence based medicine is encouraged and the authors report studies where there isno significant difference between stimulant drug and placebo, however, individual experience has produced dramatic, positive, sustained benefit to the quality of life individual patients and their ability to function.

The suggestion that it is the medicalisation of various common difficulties is unreasonable. The persisting difficulties in ADHD are very much those of inattention and concentration rather than the overt hyperactivity seen in childhood and it is these very levels of inattentionand concentration which impact hugely on the adults ability to function inthe adult world.

Before diagnoses and prescription of medication one of us found it difficult to hold down a job ,to hold more thought in their head, to remember important facts or to control any exuberance in social settings.With the benefit of a diagnosis and stimulant medication that same individual has built a successful career as a company director, is capableof functioning in noisy offices where he previously floundered and has theability to hold more than one thought and to react in a socially appropriate manner. He has a wife who has commented, 'thank god for Ritalin!' saying now she has three children and a husband where previouslyshe had four children. This surely can not be pure coincidence.

The symptom overlaps with a number of other disorders does not negatethe existence of the condition. There are symptoms overlapping in a number of psychiatric conditions but this does not lead us to be reductionist with our diagnoses. Indeed to suggest that those with ADHD merely have personality disorders is doing them a great disservice. Adults,who after appropriate assessment, are diagnosed with Adult ADHD and treated with stimulants, have achieved stability in their lives and indeed success in their academic endeavours, their employment and relationships which otherwise would never have been possible.

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Conflict of interest: None declared

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Re:Adult ADHD problems and pitfalls

Premal J Shah, Consultant psychiatrist
11 October 2011

The controversy surrounding adult ADHD is intellectually interesting in terms of what it says about the distinction between pathology and normality and our moral response to this.

However, the role of psychiatrists is to provide impartial advice to those that we see about what intervention is likely to be more useful thanharmful. The individual decides whether the intervention is useful for them or not. This applies to any intervention, not only pharmacological.

Considering data may help to inform the debate. I have run an NHS adult ADHD clinic for the past 3.5 years, during which we have received 350 referrals, about half being for adults who believe they may have ADHD,but who have not been assessed for this before.

Of those who were ultimately identified as having significant ADHD traits and offered pharmacological intervention:

A. 70% were unemployed or had dropped out of educationB. 15% had been in trouble with the police previouslyC. 72% had had previous contact with mental health services (and no consideration given to the possibility of ADHD)D. 30% had 2 other mental health problems apart from ADHDE. 70% of those prescribed medication (stimulant on non-stimulant) returned to work or education.

It is the latter finding that is most telling. These are individuals who are, and have always been struggling significantly. Medication can help the individual to successfully complete ordinary but important tasks like hold down a job, stick to a course or maintain personal relationships. It is not a cure, but a powerful tool that can empower the individual.

The psychiatrist has a critical role in diagnosing and prescribing a substance that can have such profound effects (both positive and negative). Perhaps we should focus more on trying to identify who would benefit from intervention, and less on the intellectual exercise involved in 'pathologicising normality'.

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Conflict of interest: None declared

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Are we missing the point in the debate on Adult ADHD?

Rahul Bhattacharya, Consultant Psychiatrist and Honorary Clinical Senior Lecturer
11 October 2011



There is no doubt ADHD in adults is a relatively new concept and as the evidence base emerges it is a good idea to critically appraise it. It has its problems being a 'trait' condition where the traits are distributed across the spectrum in the population. This poses a challenge to clinicians on where to set the bar for illness. One can argue on to what extent this process is influenced by societal values and expectations.

However, this dilemma of categorizing a symptom present in continuum in the population, into an illness and wellness dichotomy, is not unique to ADHD or even to mental health. It resonates with dilemmas faced in setting the bar for hypertension or hyperglycaemia.

Rather than getting into a critical analysis Moncrieff and Timimi (1) seem to have approached the subject in a one sided-way that tends towards not accepting the condition exits rather than objectively weighing up-to-date evidence.

For example they state: 'The evidence from randomised trials in adults and children therefore provides little basis for the sort of long-term drug treatment that is now being implemented for adults presenting with ADHD de novo, of for those with a continuation of a childhood presentation'. With regard to this statement, it is unclear who is recommending this.

The paper repeatedly quotes secondary research and uses qualitative remarks without systematically analysing data. Rather than looking into evidence base for current pharmacological treatment the authors mention the NICE guidance and focus on three randomised control trials quoted in that document. The recent Cochrane review on the matter found seven studies (2, 3).

The authors raise the issue of lack of genetic overlap between ADHD in children and adults referring to the European consensus statement on diagnosis and treatment of adult ADHD (4). The study does mention 'to date several publications highlight potential associations with ADHD in adults, some but not all of which are shared with genetic association findings in children', which is again a conclusion they draw from five other pieces of research. This information gets subtly presented as: there are 'some' similar genes between adult and child ADHD but 'many are different' (genes) in the paper.

Further, the authors themselves state that 'there have been many challenges to the validity of the childhood disorder’. They support this statement with three references two of which were written by Timimi and Moncrieff.

The debate to be had in the clinical world of adult ADHD in UK is the issue of false positives! Due to the relative lack of stigma of the condition (which is not necessarily a bad thing!), and the issue of diagnostic overlap (particularly with emotionally unstable personality disorders) we as front-line adult clinicians face a major challenge. Emotional instability is increasingly recognised in adults with ADHD (5).

With these commonalities in impulsivity and emotional dysregulation the difference between ADHD and emotionally unstable or borderline personality disorder gets blurred in adults (particularly with inclusion of attenuated varieties in DSM IV) and hinge almost exclusively on 'inattentiveness'.

In my opinion, the authors let us down in not exploring these and other real diagnostic and prescribing challenges surrounding adult ADHD in depth. References: 1.Moncrieff, J. & Timimi, S. Critical analysis of the concept of adult attention-deficit hyperactivity disorderThe Psychiatrist 2011; 35: 334-338 2.Castells X, Ramos-Quiroga JAntoni, Bosch R, Nogueira M, Casas M. (2011) Amphetamines for Attention Deficit Hyperactivity Disorder (ADHD) in adults. 3.Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD007813. DOI: 10.1002/14651858.CD007813.pub24.Kooij SJ, Bejerot S, Blackwell A, Caci H, Casas-Brugue M, Carpentier PJ, et al (2010) European consensus statement on diagnosis and treatment of adult ADHD: The European Network. Adult ADHD. BMC Psychiatry; 10: 67.5.Asherson P, Chew W, Craddock B, Taylor E (2007)Adult attention-deficit hyperactivity disorder: recognition and treatment in general adult psychiatry, British Journal of Psychiatry 190:4-5
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Conflict of interest: None declared

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Adult ADHD as a Dimensional Disorder

Peter Lepping, Consultant Psychiatrist, Visiting Professor, Associate Medical Director
10 October 2011

Moncrieff and Timimi recently argued that there is no specific evidence to link adult ADHD with childhood ADHD (1). They also question the increase in the use of stimulants for the condition and the role of the pharmaceutical industry in this. Whilst we can all lament the way in which the pharmaceutical industry has tried to increase the use of their products, the mere fact that they have done so does not invalidate their use.

The authors seem to ignore that most clinicians and academics see ADHD as a dimensional disorder. Just as with depression, the cut off pointfor treatment is essentially arbitrary. This is the case in many psychiatric and other medical illnesses and conditions. We all recognise apatient when the illness is severe but it is less clear whether treatment is the appropriate course of action in less severe cases.

Majority opinion clearly suggests that the reason for the symptoms ofADHD is an increased density of dopamine transporter (DAT) complexes. Withincreasing age, there is a natural decline of these complexes, which causes a reduction of core symptoms. This leads to a change of prioritisation of core difficulties in adults, which does not represent a completely different set of symptoms as they authors suggest. The other argument the authors pursue is the high rate of co-morbidity which they argue invalidate the diagnosis. However, untreated A.D.H.D. is likely to cause secondary difficulties such as conduct problems, personality disorder and substance misuse. Of course these difficulties cause some symptoms that are similar to the core symptoms of ADHD, but this does hardly invalidate the primary diagnosis. More research is needed to find out whether adult treatment of ADHD mitigates the impact of acquired secondary problems. The current evidence would suggest that this is probably not the case. Therefore, the authors are certainly correct when they urge caution in the use of stimulants in adults if the main reason for the treatment would be to treat secondary diagnoses.

The authors argue that the wide variation of prevalence rates in difference studies is an argument against the validity of the concept of ADHD. However, such varieties are found in many dimensional syndromes. Depression and personality disorder are only two examples where this is the case. The American studies usually show higher prevalence rates because of their lower cut-off point for caseness of ADHD. However becausethe cut-off point is arbitrary and European researches usually have a higher cut-off point, the prevalence figures in Europe appear different.

The authors mention a follow-up study which, they claim, shows that any beneficial effects from stimulant use are not sustained at long-term follow up. Careful analysis of this study would have shown that the reported lack of sustained benefit had to do with the relatively high drop-out rate in the intention to treat analysis. This is not surprising as most psychiatric studies over 3 years have high drop-outrates. However, the sub-group of children that stayed in this study and continued with their medication actually maintained the benefits throughout the 3 year period. I fully agree with the authors that the evidence in adults is rather less clear, although on current evidence the effect sizes of stimulant drugs are certainly amongst the highest in medicine.

At the end of the day, the decision to treat adult ADHD with stimulants is a clinical one that should take into account the severity ofsymptoms, potential side-effects as well as the likelihood of reasonable improvement.

(1) Joanna Moncrieff and Sami Timimi Critical analysis of the concept of adult attention-deficit hyperactivity disorderThe Psychiatrist 2011; 35: 334-338

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Conflict of interest: None declared

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Adult ADHD problems and pitfalls

Prabhat Mahapatra, Consultant Psychiatrist
14 September 2011

Moncrieff and Timimi must be congratulated for their courage in challenging the concept of Adult attention-deficity hyperactivity disorder (ADHD).

The authors have reported that National Institute for Health and Clinical Excellence (NICE) guidelines note a substantial overlap between the condition and various mental disorders including personality disorders.

They also highlight the fact that managed care in America has possibly led to persons with personality disorders being labeled as having Adult ADHD.

As the authors pointed out, clinicians need to weigh up the potential benefits carefully against the potential risks, before making decisions about these prescriptions.
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Conflict of interest: None declared

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