During the 3rd South Africa Multidisciplinary Congress for ADHD, Prof Stephen Faraone presented various aspects relating to stigma and addressed various paradoxes occurring in the clinical care setting.
The presentation was opened with the powerful phrase ‘Stigma – the most painful word in mental illness’. The effects of stigma are far reaching and have real consequences, including a decrease in self-esteem, social isolation, and less acceptance by peers. Various communication strategies should be employed in order to decrease stigma:
- Humanize struggles and experiences
- Highlight policy barriers to the treatment of mental illness
- Emphasize that treatment for mental illness is effective
- Don’t place blame on the individuals or their families
- People with mental illness should not be described as violent, particularly by the media
- Do not describe the disorder as an adjective e.g. ‘An ADHD patient’ when it is preferable to say ‘A patient with ADHD’
The effects of stigma are far reaching and have real consequences, including a decrease in self-esteem, social isolation, and less acceptance by peers.
Paradox 1: Medications for ADHD are highly effective, yet are demonized by the media
The stigma associated with taking these medications, largely perpetuated by the media, may lead to increased rates of non-adherence despite this being one of the most effective classes of medicine. It is prudent to consider if stigma creates a nocebo effect - treatment which is associated with side effects or worsening of symptoms due to negative expectations of the psychological condition of the patient.
It is prudent to consider if stigma creates a nocebo effect - treatment which is associated with side effects or worsening of symptoms due to negative expectations of the psychological condition of the patient.
Paradox 2: Parents and patients crave nondrug treatments, with homeopathic remedies four times more likely to be recommended. Parents in particular, expressed a desire to avoid stimulant medication, partially due to their beliefs regarding the causes of the illness, their knowledge of available treatments, treatment goals and previous experiences with treatment.
Paradox 3: An ADHD diagnosis is criticized as subjective and over diagnosed. Youngest children in the grade are potentially more likely to be diagnosed with ADHD as they struggle with the academic and social demands placed on them, which could contribute to ADHD related functional impairment. By this token, the inverse interpretation is then also possible and older children may be underdiagnosed. This has led to the development of neuropsychological tests to try and confirm an objective, concrete diagnosis. However, it has been clinically proven that these tests cannot confirm or rule out a diagnosis, and high stake decisions cannot be made based on the results of these tests. A good diagnosis is reproducible and gives meaningful predictions regardless of whether it is objective or subjective.
It is also important to be cognizant that some patients may show subthreshold symptoms, which do not warrant a full-blown ADHD diagnosis
Paradox 4: ADHD symptoms are traits which occurs on a continuum in the population, and it is also a disorder. In psychiatry, symptoms or traits along a continuum are not treated – a disorder is treated. Based on DNA assays, it was shown that there are multiple genes at play which increase one’s risk for ADHD, and the impairment associated with the disorder indicates it does not ‘fall somewhere’ along a continuum. Thresholds, such as those which are common in other branches of medication (hypertension, BMI, cholesterol) need to be defined. It is also important to be cognizant that some patients may show subthreshold symptoms, which do not warrant a full-blown ADHD diagnosis, however there is still psychopathology, scholastic failure, substance use and psychosocial impairment. These patients may have a high cognitive reserve, cope well and hence the diagnosis is missed in childhood and may only present later only when demands are increased. Scaffolding, or routine and structure may protect against the emergence of ADHD symptoms.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.