番茄社区

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders in children. It's often first identified due to classroom disruptions from characteristic symptoms of the condition like inattention, hyperactivity, and impulsivity. There is no single test that doctors can use to diagnose ADHD. Instead, they use a combination of psychometric tests that help identify behaviors that are symptoms of ADHD.

In this exclusive 番茄社区 video, Benjamin Cheyette, MD, PhD, a psychiatrist and director of ADHD services at Mindful Health Solutions in Burlingame, California, discusses the challenges with diagnosing ADHD, and how psychiatrists aren't trained to test in the way other medical doctors have been.

Following is a transcript of his remarks:

At the end of the day, like all psychiatric diagnoses or virtually all psychiatric diagnoses, there is a subjectivity to making the diagnosis. And ADHD, like many psychiatric diagnoses, is a question of degree. You know, the symptom list for ADHD if you read through it, is not unique to people with ADHD. Everybody occasionally has problems with procrastination. Everybody has problems occasionally finishing tasks. Everybody gets distracted by their phone in meetings sometimes. In fact, you may have noticed, what I was doing a second ago was I was putting my phone on mute so it would not go off during this meeting, because I did not want to have to do that.

So we all have these challenges. That's not unique to someone with ADHD. So then the question is, well at what point do you say somebody has crossed a line where they should be treated? And I just want to reiterate that that's not unique to ADHD. That is true for just about every psychiatric diagnosis, whether you're talking about depression or anxiety. There are very few psychiatric diagnoses if any, that are truly categorical in the sense of there's a clear break between normal and abnormal, where a normal person never experiences the symptom. I mean, arguably even hallucinations, delusions, normal people under enough stress if they don't get any sleep for 3 days, will start to hallucinate.

So, that's an extreme example, but in general, psychiatric diagnoses are not characterized by a complete break from normal behavior. They're characterized by a degree of behavior that is considered beyond what is normal, and that is one reason why in the DSM [The Diagnostic and Statistical Manual of Mental Disorders], which is the diagnostic manual as many people know in the United States, but also widely used outside of the United States, or influential outside of the United States, one of the criteria for every psychiatric disease is: Do these symptoms interfere with function?

Somebody can have all kinds of symptoms, but if they're not interfering with their ability to live, then you're not supposed to make a diagnosis, and you're not supposed to treat it. It's supposed to be, we reserve this for people who need it in order to live their lives, be productive, etc.

Then we get to the question of, okay beyond just a list of symptoms, can we do better? And the holy grail in psychiatry, across psychiatry is, gee wouldn't it be great if we had tests for these disorders? And this is one area in which psychiatry lags behind the rest of medicine. Obviously, I think everyone who's been to medical school knows this. It is one thing that kind of sets psychiatry apart from just about every other medical specialty these days. We have no tests. There are no blood tests, there's no brain scans. We can't even do an EEG [electroencephalogram] test. There's nothing that you can do in spite of marketing from certain companies that are trying to do this. But if you're talking about FDA approval and really strong evidence, there are no tests for these disorders that are objective the way other medical diagnostic tests are objective.

And here's an interesting thing, ADHD is actually a bit of an outlier here because there are tests for ADHD. They're not blood tests, just like there are no blood tests for depression or anxiety or schizophrenia, and there are not yet genetic tests that people can use. Maybe one day there will be, but right now the genetics is way too complicated, and we don't know enough to really do genetic testing on a wide scale for psychiatric disorders. Be nice one day if that becomes possible, and maybe it will, but right now no.

But for ADHD, because this is something that is, and when I say this -- distractibility, hyperactivity, impulsivity -- these are actually aspects of behavior that are quantifiable, objectively for example, with a computerized test. And so there are psychometric tests that help with the diagnosis. And one of the ironies of the situation is that perhaps because it's psychiatry, they have not been more widely adopted. Like the DSM does not, for example, specify or even mention that maybe you want to do some testing if you're considering an ADHD diagnosis. It's not in there. It's all just a list of criteria, and are these symptoms bad enough that they interfere with the person's function, just like for every other psychiatric disorder.

So psychiatrists aren't trained, they're not inculcated in general, with the same attitude that other medical doctors are that, "Well, we should test." But for ADHD you can test, and it can be helpful. So I'm a fan of objective testing for ADHD, but that said, I do want to say there are some caveats to what I just said.

Is testing the answer? Can you just test somebody with some psychometric computerized tests, and then tell if they have ADHD? No, I would never advocate that. I want to be very clear. Because as I say, it's not a blood test, it's not a genetic test, it's a psychometric test. So it's an artificial construct. It's a test that's been designed on a computer to test for some defects or abnormalities in the way the person responds that are then interpreted as defects in attention or impulsivity or hyperactivity.

But this is not testing somebody in the real world. This is testing somebody in an artificial construct. So what I advocate within my own company is that we do a battery of tests, some of which are subjective survey-type questionnaires so that not just patients, but also their significant other or other people rate the patient on a variety of different behaviors. And those get then transferred into numbers. And then we get a score. And we can talk about, well, in the subjective survey-type measure, are you in the 99th percentile in terms of the way you answered the questions for inattention? Or, are you in the 60th percentile? Those are two different things. And what did your wife say? Does she place you in the 99th percentile or does she place you in the 60th percentile? That's also important.

And then finally, add into that an objective test, which is admittedly an artificial construct. It's not real life, but it does at least provide a level of objectivity to the measurement. And then of course, you still have to be a good psychiatrist or a good clinician and interview the patient, get a history, consider the DSM criteria. All of that should be going into the diagnostic process.

Comment