Ethical Aspects of ADHD
Screening och Diagnostics
Ingemar Engström,
Professor of Child and Adolescent
Psychiatry
Örebro University, Sweden
AD(H)D
Attention Deficit (Hyperactivity) Disorder
Prevalence about 5 %
Geographical variations
Wide variations in symtoms and levels
of dysfunctioning
Why is ADHD so controversial?
Not easily distinguishable from normal variation
Vague and ambigous criteria
No clear-cut objective findings
Subjective (evaluative) assessment
The general criteria of suffering difficult to apply
Levels of controversies
Ontology
Epistemology
ADHD?
does ADHD exist?
how can one get knowledge about
Language
what does ADHD connotate?
Causality
what is the reason for ADHD?
Power
who decides what ADHD is?
Business
is/should ADHD be profitable?
Some central ethical issues
The term ”neuropsychiatric”
Explanatory models
Diagnostic validity
Diagnostic shifts in psychiatry
Pharmacological treatment
Screening
The term neuropsychiatry
Mind-body distinction
What does this tell us about other
disorders?
Gives primacy to neuroscience
Explanatory models
Neuroscientific model
Stress-vulnerability model
Environmental model
Sceptical model
CAP diagnoses
60’s
Psychoanalytic diagnoses
70’s
Symtom diagnoses
80’s
Family diagnoses
90’s
(DSM)
Phenomenological diagnoses
00’s
Neuropsychiatric diagnoses
Diagnostic shifts
ADHD and other behavioural disorder
diagnoses in Swedish CAP
fourfold increase
10 – 63 %
Medication
doubled over five years
CAP diagnostics
Diagnostic shifts
History has not ended
Naïve realism
Earlier we believed, now we know
Key questions
What is the ”true” prevalence?
What is the optimal number of children
treated with pharmacological agents?
A valid diagnosis
Well defined
Criteria easy to assess
High inter-rater reliability
International acceptance
Prognostic value
Diagnostic validity
As long as there is no clear and
indisputable scientific rationale for the
growing rates of ADHD diagnosis and
treatment in children, the validity of
ADHD diagnosis will continue to come
under social and ethical scrutiny.
Singh 2008
The purpose of a diagnosis
Who needs the diagnosis?
The use of the diagnosis
Can it be used for other purposes?
Screening
Valid tests that can be performed on primary
levels
Should work without complex interpretations
Outcome should lead to an a priori-determined
measure
High sensitivity
High specificity
Support in community
Screening
No studies have shown the value of primary
prevention
Preventive programs – general effects on
behavioral symtoms
Today not possible to screen for ADHD if
the WHO criteria are applied
Pharmacological treatment
What is the optimal prevalence?
Safety vs benefit
long-term effects
Psychological effects
The child’s view
Empirical knowledge
Surprisingly limited knowledge
Children are generally positive to
medication
Questions about self-image, identity and
authenticity have not been studied
Complex issues
The child’s understanding of informed
competence
Age related competence in judging treatment
options
When should the question pass from the parents
to the child?
What to do if parents and child disagree?
How does this relate to children’s rights?
Conclusion
Neuropsychiatry is a difficult term conceptually
Multiple controversies
Sensational diagnostic shift
Many ethical problems with regard to diagnostics,
screening and treatment