Early intervention for ADHD: More thoughts on our definitions of psychiatric disorders

By Nestor Lopez-Duran PhD

In an article soon to be published in the Journal of Child Psychology and Psychiatry I, with a colleague at the University of Pittsburgh, discuss the need for a new approach to the development of early therapeutic interventions for child depression, as current interventions are, sadly, barely effective (see this article for a more extensive discussion on the efficacy of child depression treatments). Our basic argument is that most current interventions are not designed to address the underlying processes and pathways that lead to the emergence of depression in childhood. This is partially due to a disconnect between what we know about the development of child depression (basic science) and how clinicians are trained to diagnosed and work with these conditions.  So I was not surprised, although I was excited, when I read a new article in the same journal that discussed the need for the development of new early interventions for the treatment of ADHD. In this article, the authors use many of the same arguments we use to advocate for new child depression treatments. I was excited because this is a reflection of the ongoing changes in our entire field that advocate for 1) a reconceptualization of disorder and its onset, and 2) more translational science or the translation of basic scientific discoveries into clinical and practical applications.

How do we improve early interventions for ADHD?

The authors of this paper present a basic framework that should guide the development of new treatments:

1. That the development of treatment involves the identification of, and targeting, the underlying causes of the condition (rather than only addressing symptoms see below for more about this)

2. That causes are framed within a developmental process. That is, rather than seeing causes as fixed events (e.g., a specific physiological anomaly), causes for developmental disorders are indeed developmental processes (e.g., anomalies in the development of specific physiological process for a specific developmental period).

3. That treating these processes early can alter the developmental trajectory of this condition and thus prevent the full emergence of the disorder.

Regarding the last point the authors go on to explain how we need to reconceptualize the definition of disorder, or disorder-onset. Traditionally, most diagnostic criteria of psychiatric disorders require that the condition produce functional impairment. Thus, the symptoms must be severe enough to cause actual dysfunction in the persons personal, occupational, or educational life. Only if the symptoms produce impairment you have the disorder. Although there are many valid theoretical arguments for the need of the impairment requirement in the current diagnostic definition of most psychiatric disorders, this criteria has a political rather than empirical foundation. That is, the wide application of the impairment criteria to most conditions is not consistent with our understanding of the development of many psychiatric condition. Specifically,  in many cases, the syndrome is likely present before there are significant symptoms and consequently before there is noticeable impairment.

But what does this have to do with treatment? How can a change in our conceptualization of disorders improve the prevention of these conditions?

Imagine for a second that oncologists decided that you have to show symptoms that are so apparent that you can actually describe them (e.g., I feel a mass on my back) and that these symptoms have to cause impairment (e.g., it hurts so much I cant go to work) BEFORE they can provide a diagnosis of cancer, offer treatment, and be reimbursed by insurance companies. We would all think this would be crazy because we know that the effectiveness of cancer treatment increases if you can treat the condition at the earliest possible stage. I know this is an extreme example, but it highlights the current limitations of psychiatry. Our practice of providing diagnoses and interventions once symptoms are observable and producing functional impairment is greatly limiting the effectiveness of current therapeutic approaches. Furthermore, such conceptualization has resulted in a view of disorders that is static   you have it when it causes impairment rather than dynamic disorders have a developmental trajectory and only the end of the trajectory may cause impairment. Today we mostly diagnose and treat the end of the trajectory, when its likely too late for too many.

The reference:

Edmund J.S. Sonuga-Barke, & Jeffrey M. Halperin (2010). Developmental phenotypes and causal pathways in attention deficit/hyperactivity disorder: potential targets for early intervention? Journal of Child Psychology and Psychiatry