Professor Stephen Faraone – professor in Psychiatry at SUNY Upstate University and expert on ADHD – was interviewed by dr. Therese Markow for the podcast series ‘Critically Speaking’. In this podcast they discuss myths about ADHD and the scientific evidence that debunks these myths. Stephen Faraone explains why it is so important to diagnose and treat ADHD early. He also explains why ADHD is often undiagnosed in girls, and why sometimes adults are diagnosed with ADHD who have not sought treatment earlier in their life.
Critically Speaking is a podcasts series hosted by dr. Therese Markow who interviews experts to discuss in plain language complex issues that concern our health, society and planet.
One often hears that the first written description of ADHD stems from the book of the German physician Melchior Adam Weikard “Der Philosophische Arzt” (translated: “The philosophical doctor”) published in 1775. Other well-known old descriptions include for example George F. Still’s description from 1902 published in the Lancet, and Alexander Crichton’s description from 1798. However, this year a Brazilian research group published a report where they claim that the first know description of ADHD, or at least ADHD-like behavior, might be more than 2000 years old!*
The philosopher Theophrastus was a former pupil of Plato and Aristotle who lived in ancient Greece. In approximately 319 years BC he wrote “The Characters”, which essentially is a collection of texts that describes the behavior of 30 stereotypical characters where each character is devoted 10-15 phrases. One of these characters, “the obtuse man”, is an adult man who is described to have both inattention symptoms (forgets important appointments) and hyperactivity symptoms (tires out his children while playing). In addition, “the obtuse man” also has sleep problems and has problems with planning, which both are more common among individuals with ADHD than among those without.
Despite that it can be argued that the behavior of the “the obtuse man” is not a perfect description of typical ADHD, it is still interesting that the oldest known description of ADHD-like behavior describes these symptoms in an adult, in contrast to the later descriptions of ADHD-like behavior that are about children with these symptoms. Moreover, Theophrastus’ more than 2000-year-old text further supports that ADHD (and other psychiatric disorders) has been a part of human life as long as we have been humans.
*Victor MM, Bruna SdS, Kappel DB, Bau CH, Grevet EH. Attention-deficit hyperactivity disorder in ancient Greece: The Obtuse Man of Theophrastus. Aust N Z J Psychiatry. Jun 2018;52(6):509-513.
Tor-Arne Hegvik is medical doctor who is doing research on ADHD and its co-morbidities as a part of the CoCA project: https://coca-project.eu/
Despite the high prevalence of ADHD in adults, until recently, only the Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID) was the validated semi-structured interview available for the accurate diagnostic assessment of ADHD based on the DSM-IV criteria in the adult population. However, an important limitation of the CAADID that needs to be highlighted are the costs that come with its administration.
On the other hand, the DIVA 2.0 interview (Diagnostic Interview for ADHD in adults, DIVA 2.0, for its acronym in Dutch) is a semi-structured instrument which is freely available as a PDF on the website of the DIVA Foundation (www.divacenter.eu) and via a small one-off charge as a downloadable app. This semi-structured interview allows a thorough evaluation of the diagnostic criteria of DSM-IV-TR for ADHD in adulthood, as well as in childhood. It is divided into two domains, each applicable for childhood (before age 12) and for adulthood: the DSM-IV criteria for inattention, and for hyperactivity/impulsivity. The third part deals with the impairment caused by the ADHD symptoms in five areas of functioning (including work and education; relationships and family life; social contacts; free time and hobbies; self-confidence and self-image). For each criterion and age period, the DIVA 2.0 provides a list of specific and realistic examples of current or retrospective behaviors throughout life, that simplify the assessment of each of the 18 DSM-IV criteria required for the diagnosis of ADHD. The examples are based on common descriptions provided by the patients themselves. DIVA 2.0 also provides examples of the types of impairment commonly associated with the symptoms in five areas of daily life mentioned above. Whenever possible, the adult is interviewed in the presence of the partner or close relative who is familiar with the patient’s childhood, in order to evaluate simultaneously collateral and retrospective information (hetero-anamnesis).
This study investigates criterion and concurrent validity of the DIVA 2.0, a diagnostic semi-structured interview for ADHD in adults, based on the DSM-IV-TR criteria. Given that only one other study has investigated the validity of this interview, this is one of the first studies to carry forward the appropriate statistical analysis to explore the psychometric properties of the diagnostic tool in Spanish (Pettersson et al., 2015). Nevertheless, the study of Pettersson et al. compared DIVA 2.0 with an open clinical interview and in this study DIVA 2.0 was correlated with a semi-structured interview (CAADID).
The validation of this diagnostic interview provides us with an accurate and free diagnostic tool for assessing ADHD in the adult population, which can be useful in daily clinical practice and research settings. Findings from this piece of research provide support for the good reliability of this interview for the diagnosis of ADHD within the adult population. The findings demonstrate that DIVA 2.0 has a diagnostic accuracy for ADHD in adults of 100% when compared with the diagnosis obtained using the current gold standard diagnostic interview, the CAADID. Moreover, DIVA 2.0 appears to have similar psychometric properties as the CAADID as a diagnostic tool for adult ADHD. Regarding the validity of the interview, the results show a good correlation with the WURS scale when assessing ADHD symptoms for inattention, hyperactivity/impulsivity, and total symptoms during childhood. Along the same lines, fair results for concurrent validity were obtained for the assessment of symptoms during adulthood using the ADHD-Rating Scale and DIVA 2.0. Finally, a new updated DSM-5 version of DIVA is coming soon.
Complete abstract with link to pubmed and reference:
ADHD Europe – the European patient organisation for people with ADHD – has launched a declaration on behalf of teenagers with ADHD. The declaration states that adult services in all European countries should offer suitable care for teenagers with ADHD who transition into adulthood, and to adults who are newly diagnosed. Andrea Bilbow is the president of the ADHD Europe organisation. I asked her about the importance of this declaration, and what she thinks that the consequences of the declaration will be.
Why was this declaration to urgently needed?
“Well it’s a bit of a long story that goes back 20 years. We started as organisations to raise awareness for ADHD in children, and to organise good services for these children. In most European countries there now are good services for children with ADHD.”
“However, these children are all becoming adults. For many young people across Europe as soon as they reach 18 years of age, they find that transition to adult services is very poor. In many cases treatment is withdrawn altogether leaving them vulnerable and at risk. And for those fortunate enough to receive the medication that they need for ADHD in adulthood, the medication is no longer reimbursed. This puts a huge burden on families who often have two or more children with ADHD and who do not have the resources to pay for the medication. Only in one or two countries in Europe are there official adult licences for the medication needed by adults with ADHD. Besides medication, young adults with ADHD do not have access to the services for ADHD in adult clinics, while they were receiving help in children’s services.”
Why is it so important that adults with ADHD receive suitable care?
“18 is a very vulnerable age. It’s the age when adolescents move up to Higher Education or start with their first jobs. Having ADHD, these young people are vulnerable to substance abuse, academic failure, job loss, becoming homeless or even crime. Furthermore, many of them will be starting to drive. Studies have shown that a significant number of young people with untreated ADHD will be involved in car accidents.”
“For years the EU has been trying to address the problem of school dropout in Europe, without success. Having medication for ADHD continue to be reimbursable and proper services for young adults with ADHD available would go a long way to reduce the number of young people who abandon education. So it is very, very important that they receive proper treatment and support. It’s probably one of the most important things you can do for this age group.”
People can now sign the declaration to show their support. What do you think will happen next?
“Well first of all, it’s amazing to see how much support we are receiving. The Declaration has been launched for only a week and already we have more than 500 signatures. More importantly, these signatures come from all over the world. But it also shows that what this declaration states is very much needed. Clearly, 18+ people across Europe are really struggling.”
“First, we will let this run for a couple of months to see how many signatures we can receive. We encourage professionals to also show their support: professors, doctors, medics, researchers, teachers, police. Anybody who has any stake in improving the lives of people with mental health problems. Once we have gathered this support, we will encourage the member countries to take it to their MEPs and try to get the required number of MEPs to sign the declaration in order for it to be discussed in the European Parliament. That is our mission. We will try to find out why in some countries they don’t want psychiatrists to diagnose and treat adults with ADHD. This is a human right that’s being breached.”
The Declaration also shows the importance of research on ADHD. The CoCA project for example will investigate the societal costs of ADHD and comorbid disorders. Such data can assist in persuading governments about the importance of providing suitable care for those – children and adults- with ADHD.
This post was written by Jeanette Mostert. Jeanett is Dissemination Manager of the CoCA project.