In this article, you can read a written version of this conversation about the importance of diagnostics, the course of examination, the misconceptions of stigmas as well as about the treatment.

• (Dr András Spányik) ADHD. Everybody knows it like that, let’s start with this briefly, let’s break this letter code. What does ADHD stand for?

(Dr Gergely Mészáros) The ADHD comes from the first letters of the English name for attention deficit hyperactivity disorder. It follows from the name that people living with ADHD have problems in these areas. It includes the areas of focusing attention and activity combined with impulsivity which is a temperament characteristic: it means suddenness, impatience. These 3 symptoms: inattention, hyperactivity and impulsivity are considered the core symptoms of ADHD.

• Is it possible to break down this ADHD acronym, i.e. does everyone have the same symptoms, or might the symptoms representing each letter be more dominant?

The term ADHD is also commonly used, which is short for attention deficit disorder predominated by these symptoms. Everyone’s first impression of a child with ADHD – and usually even non-professionals’ first thought – is that he/she is a lively, restless, unstoppable, very impulsive, constantly talking little child. But ADHD is not just like that, these are also children and adults with ADHD whose activity symptoms are less present, and symptoms of attention deficit are more dominant. In the modern accessible diagnostic systems, ADHD is likewise classified as a combined subtype in which symptoms from both symptom groups are present, an attention-deficit subtype in which attention-deficit symptoms are more predominant and a hyperactive-impulsive subtype in which movement impulsivity symptoms predominate.

• A lot of information has been told. It would be difficult for a person with ADHD to follow and pay attention to this…

This would probably be difficult for a person with ADHD to follow. That’s why it is an exciting question because (…) according to current knowledge it is a predominantly biologically determined psychological difficulty and is primarily an inherited predisposition, a temperament. In many cases, when a child is diagnosed with ADHD in a family, the parents also begin to discover these symptoms in themselves.

• So, it has a genetic component, and it can be recognized in several members of the family. It is often said that it’s a fashionable diagnosis: suddenly everyone has ADHD who was formerly told to be restless or lazy or not hard-working enough, ADHD could be blamed for a lot of things. What do you think about this? How trendy is this right now? Let’s start with children first. It’s lucky that you are an adult and child psychiatrist, so we’ll be able to talk about the adult problem later. Do we impose this diagnosis on children when they don’t have it?

• I think there is a lot to read about this and it is a very complicated issue. You can’t say, he/she is ‘over-diagnosed’, or no, he/she is not ‘over-diagnosed’. Because, according to research, when tests aimed at trying to assess ADHD in a normal school population, they found that the prevalence of it in an average school class is 7-12 per cent. That is certain that 7-12 per cent of Hungarian children have never been diagnosed with ADHD and will not expected to be, in which many factors play a role. Because – as I have already mentioned – it’s all determined by a biological temperament, so it becomes a psychiatric disorder when it starts to interfere with everyday life, i.e. the child or adult falls short of the academic performance that is expected of him/her: they do not progress in school or at work as much as their IQ would otherwise suggest, for example, their peer relationships are not sufficiently stable, they fight with their peers more than necessary because of their impulsivity, their family relationships are stormy, and this interferes with their daily life and leads to suffering. That’s why early diagnosis is so important. It’s precisely because – as you said, this is a bad or lazy child, this is usually associated with pejorative adjectives – these pejorative adjectives are not good for anybody to hear. If he/she is otherwise careless and impulsive and really doesn’t perform his/her tasks as well as others, it won’t improve his/er performance if he/she gets these labels. If ADHD is not diagnosed and treated, there is a very high chance that all kinds of mood disorder will be added to it. Even personality development can shift in a direction that requires further treatment afterwards. So, the earlier ADHD is diagnosed, the better.

• You mentioned that he/she falls short of the expected academic performance, or what the environment, the given society, culture expects or assumes from the child. It’s true for almost most psychiatric disorders and diagnoses that they are social constructions, so we say, ‘to act against them like this’, and still, he/she behaves differently than the average, differs from it. Thinking about this, the question arises, how is our environment, the world changing now? Isn’t it that everything has sped up and we want everyone to adapt to it, and we think that anyone who differs is deviant? Could this have been completely normal 100 years ago?

Unfortunately, I am neither a sociologist nor a social psychologist, so it is difficult to answer this question in some ways. I have an opinion, but I’m not sure it’s a scientific one. Of course, I think social changes are very important. But I don’t think it’s true that there used to be fewer people with ADHD before. The diagnosis has existed since the mid-eighties in the first place, although its description can be roughly dated back to the sixties of the previous century, and the medication of these symptoms had already begun at that time. That doesn’t mean that these people didn’t exist, just as people with autism spectrum disorder existed 1,000 or 10,000 years ago, presumably. But as they say that there are much more autistic people now, I say that I don’t think there are more autistic people, but that simply we know more about both ADHD and autism. Generally, this is typical of these child psychiatric developmental disorders, and that we recognise more of them than before.

• This is important. So, according to your observation, this is precisely a help, because these children – and the same is true for adults – were stigmatized, they were labelled, they couldn’t meet the expectations, and it was not their fault, they were not lazy, but simply we were dealing with a developmental problem that we didn’t know about or didn’t recognise at that time. And now we can help them to some extent.

You said that diagnostics is not an easy, trivial thing. What are its pitfalls and difficulties? What are those pitfalls? What does the diagnosis look like? And what difficulties can it have?

I could give a very long lecture on this. I will try to summarise it briefly. I would start from the point that what is wrong with psychiatric diagnoses? In contrast to, say, an internal medicine diagnosis such as the diagnosis of diabetes where there is a relatively clear laboratory parameter and we can measure people’s blood sugar and establish ranges to determine from which it is abnormal and from which it needs to be monitored, and from which it is definitely no longer abnormal. There is no such thing in psychiatry. It had an upsurge in the late eighties and early nineties, when biological psychiatry made great progress, new drugs became available, so that we were going to be able to explain everything with biological psychiatry. Then, in the last 30 years it turned out that this is not the case, and these mental phenomena are still quite complicated. that is why the classification of psychological disorders still look like the classification of most medical categories in the early twentieth century. If it has such and such symptoms and they have been going for such and such a long time, then that’s probably it is. So that – although there is a very serious science behind it – there are several editions of this diagnostic category system, it is constantly developing and they always try to measure how valid the criteria that are assigned to a specific diagnosis are, but, basically it is still about looking at whether something in life occurs, somehow, over a period of time and hinders your daily life and causes suffering. And this is the case with ADHD.

First of all, it is necessary to identify in great detail whether these are really the symptoms of ADHD – otherwise there are 9 possible attention deficit symptoms and 9 possible hyperactivity-impulsivity symptoms – whether they are present, whether they are significantly more frequent than the average, and whether they are interfering with the person’s daily life. In addition to our effort to make a long and detailed conversation with the parent and observe the child – if it is a child – and if it is an adult, observe his/her behaviour in the examination situation, there are also structured, semi-structured diagnostic algorithms. There are systems of criteria and checklists that we go through carefully to see if ADHD really exists or not. Also, differential diagnostics is a very exciting issue (when we distinguish between other illnesses), because, as I have already mentioned, very often ADHD – if left untreated – can lead to all kinds of emotional disorders like depression. At the same time, one of the very important symptoms of depression itself e.g. concentration difficulty. Here, for example, it can be a very important distinguishing factor to know when it started. So, if it roughly coincided with the onset of mood symptoms, then it is more likely to be an attention deficit disorder associated with depression. And if, it was always there, and then it was precisely because of inattention-related failures that this person started to become depressed, then it’s probably more likely to be ADHD.

• Of course, it is not possible to give an exhaustive answer to all the details, but usually, when someone searches these diagnoses on the Internet, they suddenly recognise themselves. You almost always recognise yourself, whatever you read, especially when it comes to mental illnesses. What happens when a parent might think ‘well’, should I ask for the help of a child psychiatrist now or should I contact him and take the child for a diagnosis? And what is it like when an adult needs to think that should I think of this and maybe they could help me?

I think that with children, one of the leading problems is definitely that the parent gets feedback about behavioural problems or perceives them themselves. The child simply cannot sit through the forty-five minutes, he/she clowns around, everything distracts him/her, loses and forgets things, doesn’t perform in school as expected. And it is very important that as we move into adulthood, the symptoms of hyperactivity-impulsivity tend to decrease, but the attention deficit symptoms remain. At the same time, it is also an interesting question that adult ADHD is an exciting thing because, according to research, about half of the children diagnosed with ADHD have their symptoms reduced so much by young adulthood or late adolescence that they no longer need any treatment, and in large numbers they do not differ from the average population, or in other words from those who develop normatively. However, about half of them still have roughly the same symptoms: e.g. that they are inattentive, delay things, can’t meet deadlines, can’t organize their work, notice that they lose the thread in a conversational situation, need to be asked back, and this also impairs their everyday functioning. There are disorganized people who still somehow get along, and still somehow their various areas of life function. However, there are some people who can’t do it that way…

• We also used to say that ‘they can’t outrun themselves’. They feel that their intellect and knowledge might predestine them, enable them to perform better, but let’s say that they just can’t. And in such cases, an adult may think that a specialist should be consulted.

Even before we move on to the treatment and therapy of this disorder, I would like to ask whether can this sometimes be a desired, convenient diagnosis? I mean that there is some kind of problem in a family, there is something that causes tension, and then comes the diagnosis solving everything at once, oh, it’s not that I should be spending more time with my child, and them my guilt is relieved because he/she has this developmental disorder, and the doctor gives him/her medication and we’re done. What do you think about that?

This is a provocative question. It is complex because if a problem develops in a family where a parent pays less attention to the child, and the child doesn’t have ADHD, but something else, for example anxiety because of the parents are less able to pay attention to him/her – or regardless of this – it is still a simplistic explanation that the parent should pay a little more attention to the child, since in such cases there are usually complex problems, and the parent also has his/her own reasons for being able to pay less attention to the child. So, this leads us to look at the family as a system. In child psychiatry, it is a very important thing to examine who is in balance and how in all this.

So, I don’t want to avoid the question: but this can really be a quasi-desired goal on the part of the parent, that ‘someone relieve me now, the problem is not with me’. But it’s not that simple either!

You must explore the symptoms in the diagnostics very carefully and rule out that it is not this or not that, but something else… Not to mention the fact that in adulthood, when a person’s personality functioning can be very different due to all kinds of relationship traumas, which can occasionally reach the level of personality disorder, there can often be a desire to ‘relieve me, because it’s much easier if I get medication than if I happen to have to go to psychotherapy for years and also have to hear unpleasant things about myself, or have to face these unpleasant things too’.

• I would like to emphasise that we don’t want to create a sense of guilt here, we just want to draw attention to the complexity. Maybe the two are not mutually exclusive, so that someone may go to family therapy or self-knowledge therapy, but they may also have a problem with attention deficit disorder.

Absolutely, and for this very reason it is important that the therapeutic approach, both the international and domestic protocols emphasize the complex approach in childhood as well as in adulthood. And what these protocols also say is that in mild or moderate to mild cases, medication is not the first choice of treatment for ADHD at all, but rather that people should know a lot about what ADHD is, so there should be an informative – so-called psychoeducational – part of the treatment, which is about helping the patients to understand as much as possible what they’re dealing with. And there’s another part that we call behaviour therapy which in the case of children is much more about expectations for the environment, so that the school and the parents coordinate the system along which they try to motivate the children. Moving towards adulthood – adolescence-adulthood – it is more and more a self-awareness task to realize if I ‘just’ have ADHD. That I should learn to live with the fact that I am more impulsive, more inattentive – this has a lot of emotional and self-awareness implications. So: psychoeducation, psychotherapy and then the third leg is medicine. Which is also not from the devil, as medication treatment can be very effective in improving attention performance. It is therefore important that not everyone with ADHD needs medication, but at the same time, some people do.

• There is usually an interesting question about the medicine, that it is a stimulant drug, and why would the doctor give a stimulant drug to a child who is hyperactive and has attention deficit disorder? How will that calm him down?

This question was also in my mind when I was a medical student, that it doesn’t make any sense the way it is, until I started to learn how it really is, and I started to experience myself in working with clients. It’s terribly simple: hyperactivity symptoms are very often on top of attention deficit symptoms. When a child with ADHD is sitting in class, you can imagine that all kinds of things are going through his mind: the fact that spring has just started outside, it might be that Mrs Rózsika who teaches maths is also interesting – but let’s be honest, that’s usually less of a winner among the competing stimuli – while Katika has a new skirt, Peti has a new, cool toy, and it’s all at the same time. It’s somehow difficult for a child with ADHD to grasp that, okay, this is all interesting, but I should still pay attention to Mrs Rózsika who is currently trying to teach maths. You can imagine this state a little bit like when we are very tired and have some tasks to do, e.g. we must write an end-of-month report for work, some kind of deadly boring administrative work. We find it very difficult to bring ourselves to start this end-of-month report, and even as adults – even as non-ADHD adults – we often drink a cup of coffee which increases our alertness level a little bit, and by being alert, we can focus more easily on what we are less concerned about. One of the medications used for ADHD works in a similar way. By moving our attention capacities in the direction of what we really need to be concerned with, it will also make our behaviour more organised, so we will be less distracted.

• At what age does it make sense to start the medical examination? Also, how many sessions are usually required for diagnosis?

Precisely because it’s a complex thing, we at Panoráma have a complex examination package which includes psychological assessment, special education examination and neuropsychological tests in addition to child psychiatric examination. Just because we want to explore and approach this issue from all sides.

It is not easy to answer at what age, because I think that’s when it starts to cause problems. When a parent notices that his/her child doesn’t make friends because of this, he/she is somehow left behind in kindergarten, he/she is often scolded for this even in kindergarten. At the same time, however, it is important to note that drug treatment in Hungary is currently only available for children over the age of 6.

• Many people may have aversion to the medicine. Is the medicine dangerous, does it have side effects, can it be addictive? What could be the reasons why someone might refuse to use the medicine? What can be done if this is the case?

I wouldn’t encourage anyone to refuse the medication, because of all the psychiatric drugs, the stimulants for ADHD are the most effective – compared to all psychiatric drugs, including antidepressants, antipsychotics for schizophrenia, and even sedatives and anti-anxiety drugs. However, I can understand the fears. Not because they are objectively very harmful drugs, but because it is understandable that people are afraid to think about giving medicine to their child for something that is so subtle. It’s an understandable fear. In my opinion, it is worth consulting with a specialist first and asking for detailed information. Of course, I can’t tell you everything right now, but in general it can be said that one of the drugs works only during the time the drug is in the body (shorter duration of action). Like other stimulants, it is very typical that it doesn’t undergo any transformation in the body. This, anyway, typical of very few drugs in the human body, that in the same form as they enter the body, they are excreted from it in the urine through the kidneys, and thus have a relatively short duration of action. It can be said that even if there is a side effect, it only occurs during the time window for which the effect of medicine lasts.

• Are these serious side effects?

It is difficult to judge whether the side effects are serious or not serious. One of the main side effects can be the loss of appetite, but it is also very important that this also only occurs during the period of use. Whether this is a side effect or not is difficult to say, because these types of drugs were developed as weight-loss products in the 1950s. Otherwise, they are not good weight-loss drugs, precisely because their appetite-reducing effect wears off, and therefore a compensatory, greater hunger develops. So, this usually does not cause problems, because if the child eats less during the day, he/she will make up for it in the evening. Also, it is very important that precisely because this drug is effective in the mentioned time window, therefore – from a professional point of view, we used to say that it has an on-off effect – there is no point in taking it on weekends or during school holidays in most cases, because these intervals don’t require so much concentration.

• What side effects appear when the drug excretes?

When excreting, side effects do not appear, but a so-called rebound effect can appear, which means that as the medicine excretes – which is mainly a problem with the fast-absorbing and quick-draining tablet forms – the symptoms of ADHD return more powerfully. Even more seriously than usual. Therefore, most of the time – in general – if we replace this medicine with a long-acting product that has a little extended absorption and then excretion time – this is achieved with carrier substances by the manufacturer – then this rebound effect is usually significantly reduced.

Panoráma Polyclinic

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