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Josep Antoni Ramos Quiroga, psychiatrist: "There is a brutal underdiagnosis of attention deficit hyperactivity disorder in adults"

2023-02-20T10:44:53.507Z


The head of Psychiatry at the Vall d'Hebron Hospital rejects the excessive detection of ADHD in children and warns of a predisposition to the consumption of some drugs


More than a century ago, Professor Augusto Vidal Perera described the child with attention deficit disorder as a butterfly that goes from flower to flower: "Everything is new for him and he wants to cover everything", but so many times "he sees his weak attention demanded" , who "does not come to form a clear concept of things," he explained.

“The reckless child is restless;

he needs to talk, he gestures, he expounds his thoughts in a rush;

the slightest motive interrupts his ideation;

he contradicts himself at times, and is carried away by the vividness of his imagination;

he does not wait to answer ”, he drew in his work

Compendium of Child Psychiatry

(1907).

Today, the diagnosis of that "reckless child" would probably be attention deficit hyperactivity disorder (ADHD), an ailment that, according to the head of Psychiatry at the Vall d'Hebron Hospital in Barcelona, ​​Josep Antoni Ramos Quiroga (Barcelona, 52 years), has a prevalence that dances between 6% and 8% of the child population.

50% of those affected drag the disorder into adulthood.

Despite the controversy that sometimes surrounds ADHD, with angry criticism of excessive pathologization of children, Ramos Quiroga, a specialist in this type of ailment, denies that minors are being overdiagnosed.

The psychiatrist attended EL PAÍS after a presentation on ADHD at the National Congress of Child and Adolescent Mental Health, held last week in Salamanca:

More information

What happens to children with ADHD when they become adults?

Ask.

ADHD has always been controversial, with bitter positions: there are those who say that it is an invention, that it does not exist;

others claim that normal behaviors in children are pathologized.

But what is ADHD?

Answer.

It is a neurodevelopmental disorder: there is a dysfunction in how our brain is developing from childhood.

What probably confuses people is that the defining symptoms of ADHD, in isolation, are very non-specific:

per se

, being more distractible, or not maintaining attention well, does not define ADHD.

ADHD is defined by having at least six symptoms of this type of inattention and [others] of hyperactivity and impulsivity, that these symptoms occur in different environments (at home, school...) and most importantly: that these symptoms give a disorder and have a negative functional impact.

It's not about labeling anyone.

There are people who are suffering and we have to see what this suffering is due to.

Q.

How do you tell ADHD from just being a rambunctious kid?

R.

This is like with depression: sadness is a concept that would fall within normality, but when that sadness is deep, intense and persistent over time, we talk about it being probably related to depression.

A child may find it difficult to sit, but that, on its own, without any other symptoms, is a variant of normality.

The child with ADHD will find it difficult to sit down, they will be a child who rushes when they are asking questions, who does not know how to wait, who cuts off others when they are talking;

he is a child who does things without thinking about what he is doing, with impulsiveness;

a child who climbs on chairs, tables and can impulsively cross the street... There is no ADHD if there is no negative impact, if that does not alter the child's daily life.

Those who say that ADHD does not exist probably have models of understanding mental health that are somewhat outdated and outdated today”

Q.

Why is there so much controversy?

A.

Because,

per se

, the symptoms that define the disorder are part of normality.

But here we are talking about these symptoms occurring in a greater intensity and in a more persistent way over time and in different spaces of social activity.

Those who say that the disorder does not exist probably have models of understanding mental health that are somewhat outdated and outdated today.

Q.

What is happening right now with ADHD?

Is there underdiagnosis?

Overdiagnosis?

What's up?

R.

Today we can clearly say that in the adult population there is a brutal underdiagnosis.

In the years that we have analyzed from 2013 to 2018, with 1.17 million people, we see that the prevalence of ADHD in adults is 0.1% and is far from the 3% indicated by all international studies.

In children, in Spain it was 4.9%, which is closer to 6% or 8% [of global prevalence].

But when you look at the children who are receiving drug treatment, they are only 80% and this is not a bad figure: there is a percentage of ADHD, the mild one, that will not require drug treatment.

Q.

Why is there so much underdiagnosis in adults?

R.

Probably, one of the explanations is that they are adults who are 40 years old.

If now there is a scarcity of resources, then, 40 years ago, when they were children, the resources for community mental health care for children and adolescents were really very scarce at the public level and that meant that correct diagnoses were not made at that time.

Q.

How does ADHD manifest itself in adults?

R.

Exactly the same as in children.

Perhaps the only big difference is that hyperactivity, instead of being a person who constantly gets up from a seat or running around in a room, is an adult who has an internal sensation of a motor that is always doing things in a restless, accelerated way, that he cannot relax, that he always has to be active.

Then they have a symptom which is that their mind does not stop: they are thinking about one thing, they jump to another... It is difficult for them to pay attention, they are not organized, the tasks are always at the last minute, out of time and they are very forgetful.

Q.

With ADHD there are always suspicions that there are commercial interests behind it, that they try to pathologize everyday situations... What do you think?

R.

In the end, it is common sense and professional sense.

There is no doctor, no psychologist, who makes a diagnosis of a disorder if there is no disorder: if it is functional and its development is optimal, there is nothing to do.

Q.

But that assessment can be very subjective.

R.

But that's what the experience of a well-trained professional is for.

The same happens when someone evaluated an analysis and did not give importance to a parameter and then it turns out that that parameter was important.

That is, diagnostic errors exist in all specialties.

Now, from that to thinking that there are diagnostic errors in ADHD and that it is poorly managed in Spain... What the statistics show us is that, really, we manage it little.

Sometimes there are positions that are a priori, more ideological than others.

Nobody wants to diagnose something that is part of everyday life.

Q.

What happens to the brain of a child with ADHD?

A.

The brain is smaller than that of children who do not have ADHD.

And when we look at brain structures below the cerebral cortex, we see that there are differences: there are dysfunctions in the amygdala, which controls emotional regulation;

in the nucleus accumbens, which is very important for the control of drug use;

and in the hippocampus, in the caudate nucleus and in the putamen, which are nuclei that regulate our control of motor activity.

Q.

What are the risk factors?

Is it a genetic issue or influences the environment?

R.

What explains the variance of ADHD has to do, in 74%, with genetic variants and the other 26% has to do with more environmental issues, such as prematurity, the consumption of toxins during pregnancy.... And we also observe more non-specific variables that not only confer more risk for ADHD, but also for other mental disorders: childhood sexual abuse and situations of extreme poverty.

It is the interaction of genetics with the environment.

Q.

In a Vall d'Hebron study, they detected an association between ADHD and a greater predisposition to cannabis use.

Does it happen only with this drug or with the others as well?

A.

What we have observed is that there is a greater predisposition with alcohol, cocaine and cannabis.

It is intuitive to think that this is the case because the nucleus accumbens is where drug use ends up having an impact, where it has that final effect at the neurobiochemical level, and this has differences with respect to people who do not have ADHD.

Q.

In another study they found genetic links, common bases between ADHD and other disorders.

What does that mean?

R.

With major depression, for example, they share 30%.

What does it mean?

That of those genetic factors that predispose to ADHD, 30% are common for depression.

And, to a lesser extent, also in bipolar disorder and schizophrenia.

And it makes sense because, deep down, these genetic differences must be correlated with symptoms: schizophrenia has many attention deficit symptoms, very similar to those of ADHD;

In bipolar disorder, there is a very high emotional dysregulation, very common in patients with ADHD.

Q.

Does the fact that some disorders share a genetic basis make the patients of one more vulnerable to the other disorder?

A.

It certainly is.

That is why we see that there are 10% of people who have ADHD who have bipolar disorder and vice versa.

It is easier for there to be that comorbidity.

Q.

What do you need to know about ADHD?

R.

The great challenge of psychiatry is to find those proteins in the blood, those markers, that only by looking at a level you can tell if this is depression, schizophrenia, bipolar disorder or ADHD.

I don't like to tell anyone that ADHD is for life because we don't know what's going to happen years later."

Q.

During the congress, the psychologist Ángel Terrón explained in his presentation that what the kids with ADHD conveyed to him was that feeling of low self-esteem, of thinking that they are “dumb”.

R.

That hurts.

And that is what should hurt those people who say that this diagnosis is artificial, that it does not exist.

You just have to see a patient and listen to a boy or a girl when they tell you: "I feel like a fool."

Because there are children who have that interest, they try to make things come out for them and they can't study because they have a problem maintaining their attention, to control their hyperactivity.

And they realize, they are aware.

And they see that they make a brutal effort while the rest of the teammates are taking it out normally.

Q.

Can ADHD be permanently cured?

R.

There are about three longitudinal evolutions: one that, before reaching adolescence, you see that the symptoms go away and that this person has a normal evolution and does not persist into adulthood;

then there are other people that we see that the symptoms persist into adulthood, but many times they do not reach the degree of dysfunction, it does not just cause disorder;

then there is that 60% that you observe that requires follow-up and attention and, depending on the intensity of the symptoms, it can be only pharmacological, only psychological or both at the same time.

I don't like to tell anyone that this is for life because we don't know what will happen years later.

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Source: elparis

All news articles on 2023-02-20

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