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Psychiatry in Europe
Delay of Attention-deficit–Hyperactivity Disorder Diagnosis in France –
Reasons and Resolutions
a report by
Diane Purper-Ouakil and Samuele Cortese
Child and Adolescent Psychopathology Unit, Robert Debré Hospital, Paris
Attention-deficit–hyperactivity disorder (ADHD) is a frequent, chronic and the first appointment for impairing symptoms and ADHD diagnosis was
impairing condition that persists into adulthood in a significant number of 2.8 years.
6
Another investigation in nine other countries showed that
patients. ADHD is characterised by age-inappropriate levels of impulsivity, mean time to diagnosis was generally below two years, except in Italy,
inattention and motor hyperactivity, and is frequently associated with where there was a diagnostic delay of 3.1 years.
7
This makes the
other disruptive behaviours, learning disorders, anxiety or substance use. diagnostic delay in France among the longest reported worldwide.
ADHD is a multifactorial and heterogeneous disorder determined by
complex interactions between genes and environment.
1
In addition to the Several factors were related to time to ADHD diagnosis in the French
impairments associated with the behavioural and cognitive symptoms of sample, including co-morbidity profiles and patterns of healthcare access.
ADHD, patients and their families also may suffer from social stigma In the majority of cases, the professionals suspecting ADHD were general
and general misconceptions about the disorder. Adequate diagnosis and practitioners. Paradoxically, previous contact with mental care
treatment of ADHD are needed to improve not only ADHD core professionals was associated with a longer time to diagnosis. Clinical
symptoms, but also social, academic and familial functioning. Current presentation of symptoms, specifically ADHD with co-morbid
guidelines recommend the use of evidence-based criteria to improve the anxiety/depressive disorders, was also linked to a significantly larger
reliability and validity of diagnosis.
2,3
Multimodal treatments combining diagnostic delay related to overlapping symptoms (e.g. impaired
behavioural interventions and well-monitored medications tailored to sustained attention) between the conditions. These results also indicate
individual needs have shown significant benefits in short- and medium- that there may be differences between mental health professionals and
term outcomes (Multimodal Treatment Study of ADHD [MTA] trial).
4
primary care practitioners with regard to ADHD diagnosis or suspicion,
Factors associated with under- (and over-) diagnosis and diagnostic delay the latter being more familiar with evidence-based medicine.
should be assessed and addressed in order to optimise the patient’s access Psychodynamic and sociological approaches to behavioural disorders,
to appropriate care. Despite similar rates of ADHD in North America and popular among many child psychiatrists in France, sometimes promote
Europe, with an aggregated prevalence of 5.9% in epidemiological critical attitudes towards diagnostic criteria, biological underpinnings of
studies with standardised assessments,
5
local medical culture, public behaviour and medications. In this context, ADHD symptoms may be
health policies and beliefs carried by media and general opinion may preferentially attributed to other diagnostic categories (e.g. behavioural
influence the diagnosis of ADHD and available treatment options. expression of internalised disorders, protection from depressive
breakdown) or considered a reaction to environmental factors (e.g.
Attention-deficit–Hyperactivity Disorder – Delays in stressful parent–child interactions, early trauma).
Time to Appointment and Diagnosis and Related Factors
A recent study investigating predictors of diagnostic delay in a French In some cases, ADHD may have been suspected but not discussed with
sample of referred ADHD patients showed that the mean delay between parents. Fear of overdiagnosis of ADHD and overprescription of
stimulants may also affect diagnostic delay. The widespread public
perception of ADHD as ‘overdiagnosed’ is possibly shared by a number of
Diane Purper-Ouakil is a Child Psychiatrist at the Robert
Debré Hospital in Paris. She is responsible for an outpatient
healthcare professionals. In a recent analysis, Sciutto et al.
8
showed no
facility with a multidisciplinary team dedicated to primary evidence that the rate of false-positives was greater than the rate of false-
mental healthcare. She is also involved in a second-line
negatives in ADHD. Similarly, the public perception of ADHD not being a
outpatient clinic. For the next three years she will be
collaborating with the National Institute of Medical Research
‘real’ disorder contrasts with general scientific agreement on its validity,
(INSERM) on attention-deficit–hyperactivity disorder (ADHD)
even in the absence of relevant biological markers.
9
In addition to a long
and substance use research. Her main fields of interest are
ADHD, mood disorders and psychopharmacology.
time to diagnosis in ADHD, there was also a significant delay between the
first impairing symptoms appearing and the first healthcare appointment
E:
diane.ouskil@orange.gr
(mean three years) in the French ADHD sample. This may be due to the
reluctance of parents to seek help, or limited access to mental healthcare.
Samuele Cortese is Chief Resident in the Child and
Adolescent Psychopathology Unit of the Robert Debré
Hospital. He is the author or co-author of 23 peer-reviewed
Regulatory and Healthcare Specificities of
publications and 30 conference presentations at national
Attention-deficit–Hyperactivity Disorder in France
and international meetings. His areas of research are
attention-deficit–hyperactivity disorder (ADHD) and the Factors related to a delay in ADHD diagnosis in France should be examined
psychopathology of obesity. He received his doctorate cum
in the context of the organisation of healthcare facilities and regulatory
laude from Verona University.
aspects. Methylphenidate is currently the only compound marketed in
France for ADHD in children above six years of age. It has been on the
12 © TOUCH BRIEFINGS 2008
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