When Labels Don’t Fit - Psychiatricanswers

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Letter to the Editor of Clinical Psychiatry New.

When Labels Don’t Fit.

April 2010
www.clinicalpsychiatrynews.com
E-mail: cpnews@elsevier.com

I respect the contributions of Dr. F. Xavier Castellanos to the field of child and adolescent psychiatry but disagree with some of his statements in an article on attention-deficit/hyperactivity disorder (“ADHD Work Group Weighing Options,” December 2009, p. 1).

One of his statements about the diagnostic criteria of ADHD: “It turns out that the 18 criteria that we have as a whole work rather well,” really took me by surprise. But the worst was yet to come.

Later in the article, Dr. Castellanos says another likely change will be to diagnose ADHD in a child who also has a pervasive developmental disorder (PDD). He goes on to say that 40% to 70% of patients with PDD also have substantial problems with attention and concentration.

On this matter, suffice it to say that children with autism spectrum disorders pay normal attention to nothing—not even to their mothers. This is why the DSM-IV wisely states that ADHD cannot be diagnosed in the presence of a PDD. Ironically, the same issue of Clinical Psychiatry News reported that aripiprazole has been approved for autism-related irritability. Now the question becomes: Do we want to give stimulants to children with obsessive behavior and irritability?

With regard to the alleged accuracy of the ADHD diagnostic criteria, are we forgetting the papers published by Dr. Joseph Biederman and several others prominent researchers showing that children with ADHD diagnosis also met criteria for mania?  Furthermore, I have published papers with abundant data of children with posttraumatic stress disorder who had been labeled ADHD because they were distracted and inattentive, not secondary to an innate deficit but for a sad reason: flashback of past abuse and anxiety. Similar situations can be said of children with obsessive-compulsive disorder and social anxiety disorder who have a different source of “distraction.” The OCD child is “running behind” because of his or her effort for “getting it perfect,” while the socially shy youths cannot pay attention because of the stress of being around people.

I saved the worst scenario for last:  One of my patients, with treatment-resistant schizophrenia, was on methylphenidate for 6 years until 2003, when I evaluated him and asked about hallucinations. Then he explained in detail the multiple conversations running in his mind. After 6 years of antipsychotic medications, he has a bright affect and ventures out of his room to interact with his family. But this patient is still delusional about his marriage with a famous Hollywood star and the children they have together.

Manuel Mota-Castillo, M.D.

____________________________________________________________________________

Dr. Castellanos and Dr. David Shafer reply:

We thank Dr. Mota-Castillo for highlighting several of the complex challenges that confront the field as we care for children and adolescents with psychiatric disorders. As was noted at the symposium on the revision of DSM-IV with regard to ADHD and disruptive behavior disorders held at the American Academy of Child and Adolescent Psychiatry meeting, no definitive decisions have been made by the work group or by the DSM-5 task force.

With regard to the specific points brought up by Dr. Mota-Castillo, the statement that the current 18 DSM-IVTR criteria for ADHD “as a whole work rather well” was based on newly presented data obtained from longitudinal studies of individuals diagnosed as having ADHD in childhood and followed prospectively into adulthood. We agree that there is always theoretical room for improvement, but the intent was to communicate that it is unlikely that the DSM-5 will incorporate dramatically different ADHD criteria from those we now use.

The question of the hierarchical exclusion of ADHD in the presence of pervasive developmental disorders is a contentious one. On the one hand, no one doubts that many, and probably most children with autism spectrum disorders exhibit impairing levels of inattention with or without hyperactivity. Advocates for such children make a strong case that the exclusion of ADHD has impeded the provision of potentially effective treatments in too many cases. On the other hand, for many of such children the phenomenological quality, and probably the underlying neurobiological substrates, are distinctly different from those associated with “garden-variety” ADHD.

Dr. Mota-Castillo also notes the challenges of differentiating ADHD from bipolar disorder, PTSD, social anxiety disorder, or obsessive-compulsive disorder. We would add that the list does not stop there. We anticipate that refining our diagnostic system will gradually make such distinctions more straight forward, but we also realize that DSM-5will not provide the final word.

Finally, we also agree that, despite all the gaps in our knowledge, good patient care begins with careful comprehensive assessment and continuous monitoring for common and rare adverse effects.

______________________________________________________________________________

Footnote:

Children with Autism Spectrum Disorders or Mental Retardation do not benefit from the increase in brain dopamine induced by medications such as Concerta, Adderall, Vyvanse and alike. In fact, their obsessive, ritualistic behavior becomes much worse.  On the other hand, if we already know that they can not pay attention because of Autism or a low IQ there is not need for a diagnosis such as ADHD, which is expected to be applied when other causes for lack of attention or hyperactivity have been eliminated.

I appreciate the professional response given by Dr. Castellanos and Dr. Shafer but I wish if the APA and the AACAP will stop for a second and think of the damage inflicted upon a child born to a mother and a father with bipolar disorder, who is "more hyper than the Energizer Bunny."  Can you imagine what happens to the brain of a little child that is racing out of control when assaulted with substances such as methylphenidate (Concerta, Focalin, Ritalin, Metadate) which will make his body to turn even more "hyper."?

Like a mother of a patient said: "What is wrong with these doctors?....I told them that I am bipolar and that my ex is too but they kept saying that my son can't be bipolar".

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