Improving the Psychosocial Assessment of Young People with ADHD: Clinical and Ethical Issues from the Quebec Experience (I)
Main Article Content
Abstract
Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder that is often diagnosed in childhood and can persist into adulthood. This disorder is characterized by inattention, hyperactivity, and impulsivity that significantly interfere with daily functioning. In Quebec, there is a problem of overdiagnosis and overprescription of psychostimulants compared to the usual global statistics. In fact, the diagnosis of attention deficit hyperactivity disorder is normally based on a detailed clinical assessment, including analysis of medical, family, and environmental history, as well as the use of validated rating scales and structured clinical interviews that understand their limitations. However, the differential diagnosis is challenging due to the presence of various comorbidities, such as mood disorders, anxiety disorders, sleep disorders, and learning disabilities. In addition, some modern environmental factors, such as excessive screen exposure, have been associated with symptoms of inattention, agitation, and impulsivity in children. Since secure attachment relationships play a crucial role in a child's development, things like family instability, high parental stress, lack of emotional availability, or inconsistent parenting practices can weaken attachment and lead to “Attention-Deficit-Hyperactivity-Disorder-Like” behaviors. Beyond the clinical issues, it is also an ethical concern to ensure that the therapeutic direction is optimized for the benefit of the patient. This article examines the issues related to the diagnostic process by emphasizing the importance of a comprehensive and integrative assessment that considers environmental and relational factors. Such an approach makes it possible to better distinguish attention deficit hyperactivity disorder from other pathologies and to develop appropriate therapeutic strategies, ranging from conventional pharmacological treatments to interventions focused on managing exposure to screens and strengthening secure attachment bonds. This comprehensive diagnostic framework offers large potential to improve patient care and optimize long-term clinical outcomes.
Keywords:
children, adolescents, ADHD, psychostimulants, psychosocial assessment, clinical ethics
Article Details
How to Cite
MONZÉE, Joël; DIONNE, Anne-Isabelle.
Improving the Psychosocial Assessment of Young People with ADHD: Clinical and Ethical Issues from the Quebec Experience (I).
Medical Research Archives, [S.l.], v. 13, n. 6, june 2025.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/6536>. Date accessed: 17 july 2025.
doi: https://doi.org/10.18103/mra.v13i6.6536.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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33. Ponnou S, Thomé B. ADHD diagnosis and methylphenidate consumption in children and adolescents: A systematic analysis of health databases in France over the period 2010-2019. Frontiers in Psychiatry. 2022;13:957242.
34. Polanczyk G, de Lima ML, Horta BL et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry. 2007;164(6):942–48
35. INSPQ, Analyse des recommandations en matière de réduction des risques sur la santé associés à l’utilisation des écrans en contexte scolaire. MSSS;2023.
36. Monzée J. Impacts socioaffectifs et psychiatriques de l’usage des écrans de loisir chez les jeunes. IDEF;2024.
37. Monzée J. Les comportements dérangeants chez l’enfant. In Monzée J.(dir.). Neurosciences, psychothérapie et développement affectif de l’enfant, Liber;2014:199–236.
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40. Porges SW. The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76(Suppl 2):S86–S90.
41. Psychodynamic diagnostic manual (2nd edition), World Psychiatry, 2015.
42. Krueger M. Description of self: An exploratory study of adolescentes with ADHD. JCAPN. 2001;14(2):61–72.
43. Koutsoklenis A, Honkasilta J. ADHD in the DSM-5-TR: What has changed and what has not. Front Psychiatry. 2023;13:1064141.
44. Monzée J. Neuropsychologie et généticisation: limites scientifiques et éthiques. In Ch. Hervé et al.(dir.). Généticisation et responsabilités. Dalloz;2008:53–78.
45. Faraone S, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry. 2003;2(2):104–13.
46. Rubia K, Overmeyer S, Taylor E et al. Hypofrontality in ADHD During Higher Order Motor Control: a Study with fMRI. INABIS'98;1998.
47. Malaspina D, Corcoran C, Kleinhaus KR et al. Acute maternal stress in pregnancy and schizophrenia in offspring. BioMed Central Psychiatry. 2008;8(1):71–80
48. Laplante DP, Brunet A, Schmitz N et al. Project Ice Storm. American Academy of Child and Adolescent Psychiatry. 2008;47(9):1063–1072.
49. Valdimarsdóttir M, Hrafnsdóttir AH, Magnússon P, Gudmundsson OO. [The frequency of some factors in pregnancy and delivery for Icelandic children with ADHD]. Laeknabladid. 2006;92(9):609–14.
50. Tian XB, Zhao YR, Ma J, Liu F. [Attentiveness in school children: effect of cesarean section birth]. Zhongguo Dang Dai Er Ke Za Zhi. 2009;11(11):913–6.
51. Amiri S, Malek A, Sadegfard M, Abdi S. Pregnancy-related maternal risk factors of attention-deficit hyperactivity disorder: a case-control study. ISRN Pediatr. 2012:458064.
52. Monzée J. Les sensations cutanées contribuent à la réassurance affective tant du poupon que de sa mère. Spirale. 2019;89:49–59.
53. Allen JG. Traumatic relationships, and serious mental disorders. Wiley & Sons Ltd;2001.
54. McGowan PO, Sasaki A, D'Alessio AC et al. Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. Nature Neuroscience. 2009;12:342–348.
55. CDC, About Adverse Childhood Experiences. Published online October 8, 2024. Accessed April 15, 2025. https://www.cdc.gov/aces/about/index.html.
56. Bellato A, Perna J, Ganapathy PS et al. Association between ADHD and vision problems. A systematic review and meta-analysis. Mol Psychiatry. 2023;28(1):410–422.
57. Seng KBH, Tan PY, Lim CC et al. High prevalence of xerophthalmia linked to socio-demographic and nutritional factors among vitamin A-deficient rural primary schoolchildren in Malaysia. Nutr Res. 2024;131:14–26.
58. Sommer A. Vitamin a deficiency and clinical disease: an historical overview. J Nutr. 2008;138(10):1835–9.
59. Généreux M. Enquête en santé psychologique chez les jeunes de 12 à 25 ans. CISSS-Estrie/R3ussir;2023.
60. Nagata JM, Ganson KT, Iyer P et al. Sociodemographic Correlates of Contemporary Screen Time Use among 9- and 10-Year-Old Children. J Pediatr. 2022;240:213–220.
61. Tamana SK, Ezeugwu V, Chikuma J et al. Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study. PLoSOne. 2019;14(4):e0213995.
62. Wallace J, Boers E, Ouellet J et al. Screen time, impulsivity, neuropsychological functions and their relationship to growth in adolescent attention-deficit/hyperactivity disorder symptoms. Sci Rep. 2023;13(1):18108.
63. Chen YY, Yim H, Lee TH. Negative impact of daily screen use on inhibitory control network in preadolescence: A two-year follow-up study. Dev Cogn Neurosci. 2023;60:101218.
64. Likhitweerawong N, Boonchooduang N, Khorana J et al. Executive dysfunction as a possible mediator for the association between excessive screen time and problematic behaviors in preschoolers. PLoSOne. 2024;19(4):e0298189.
65. Meri R, Hutton J, Farah R et al. Higher access to screens is related to decreased functional connectivity between neural networks associated with basic attention skills and cognitive control in children. Child Neuropsychol. 2023;29(4):666–685.
66. Tong L, Xiong X, Tan H. Attention-Deficit/Hyperactivity Disorder and Lifestyle-Related Behaviors in Children. PLoSOne. 2016;11(9):e0163434.
67. van Egmond-Fröhlich AW, Weghuber D, de Zwaan M. Association of symptoms of attention-deficit/hyperactivity disorder with physical activity, media time, and food intake in children and adolescents. PLoSOne. 2012;7(11):e49781.
68. Green A, Cohen-Zion M, Haim A, Dagan Y. Evening light exposure to computer screens disrupts human sleep, biological rhythms, and attention abilities. Chronobiol Int. 2017;34(7):855-865.
69. Cavalli E, Anders R, Chaussoy L et al. Screen exposure exacerbates ADHD symptoms indirectly through increased sleep disturbance. Sleep Med. 2021;83:241–247.
70. Thoma VK, Schulz-Zhecheva Y, Oser C et al. Media Use, Sleep Quality, and ADHD Symptoms in a Community Sample and a Sample of ADHD Patients Aged 8 to 18 Years. J Atten Disord. 2020;24(4):576–589.
71. Monzée J. Quelle responsabilité sociale chez les chercheurs? In Létourneau L.(ed.). Bio-ingénierie et responsabilité sociale. Thémis;2006:175–203
72. Lacroix JG, Monzée J. L’alimentation des jeunes québécois et québécoises au cours des vingt dernières années. IDEF (subpress).
73. Rodriguez del Barrio L, Corin E, Poirel ML. Le point de vue des utilisateurs sur l’emploi de la médication en psychiatrie. Revue québécoise de psychologie, 2001;22(2):1–23.
74. Pelsser LM, Frankena K, Toorman J, Rodrigues Pereira R. Diet and ADHD, Reviewing the Evidence: A Systematic Review of Meta-Analyses of Double-Blind Placebo-Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD. PLoSOne. 2017;12(1):e0169277
75. Salisbury H. The problem with outsourced diagnosis of ADHD. BMJ. 2025;389:r842
2. Sergeant J. The cognitive-energetic model: an empirical approach to ADHD. Neurosci Biobehav Rev. 2000;24(1):7–12.
3. Monzée J. La médicalisation des humeurs des enfants. Revue internationale d’éthique sociétale et gouvernementale. 2006;8(2):76–88.
4. Maumaha Noune R, Monzée J. Problématiques éthiques quant au bris de la confidentialité du dossier médical des enfants. Revue internationale d’éthique sociétale et gouvernementale. 2011;12(2):261–295.
5. Monzée J. Évolution des connaissances biotechnologiques et pratiques psychothérapeutiques. Revue québécoise de psychologie. 2012;33(2):97–122.
6. Vaillancourt JP. L'origine neurologique du trouble déficitaire de l'attention avec ou sans hyperactivité: fait ou hypothèse? Revue québécoise de psychologie. 2012;33(1):253–270.
7. Monzée J. L’usage immodéré des psychotropes chez les jeunes de 0 à 26 ans au Québec: quel avenir pour les jeunes générations? IDEF; 2024.
8. Monzée J. Evolution of psychotropic medication prescription in young people: reflection from the Quebec experience. Psychotherapy and Psychosomatics. 2025;94(1):8–14.
9. Barkley RA, Behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of ADHD. Psychol Bul. 1997;121:65–94.
10. Charney DS, Nestler EJ. Neurobiology of mental illness, Oxford PU; 2004.
11. Diagnostic and Statistical Manual of Mental Disorders-DSM-5, American Psychiatric Publishing; 2013.
12. Diagnostic and Statistical Manual of Mental Disorders-DSM-5-TR, American Psychiatric Publishing; 2022.
13. AI Dionne, J. Monzée. Improving the medical assessment of young people with ADHD: II. Genetic, psychosocial or metabolic issues? ESMED (Submitted).
14. Monzée J. Dopage sportif: de la responsabilité des chercheurs et des entreprises pharmaceutiques. Revue internationale d’éthique sociétale et gouvernementale, 2005;7(2):53–70.
15. MSSS-MEES, Protocole: trouble de déficit de l’attention avec ou sans hyperactivité, 2019.
16. Currie J, Stabile M, Jones LE. Do stimulant medications improve educational and behavorial outcomes for children with ADHD? NBER, 2013:19105.
17. J. Currie J, Stabile M, Jones LE, Do stimulant medications improve educational and behavorial outcomes for children with ADHD? J Health Econ. 2014;37:58–69.
18. Diagnostic and Statistical Manual of Mental Disorders-DSM-IV, American Psychiatric Publishing; 1996.
19. Diagnostic and Statistical Manual of Mental Disorders-DSM-IV-TR, American Psychiatric Publishing; 2000.
20. INSPQ. Surveillance du trouble du déficit de l'attention avec ou sans hyperactivité chez les enfants et jeunes adultes au Québec, 2022.
21. HCFEA. Quand les enfants vont mal, comment les aider? Conseil de l’enfance et de l’adolescence; 2023.
22. Wolraich ML, Hagan JF Jr, Allan C, et al. Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of ADHD in Children and Adolescents. Pediatrics. 2019;144(4):e20192528.
23. Psychodynamic diagnostic manual. World Psychiatry; 2006.
24. Jeannerod M. Psychothérapie et cerveau. In Monzée J.(dir). Neurosciences et psychothérapie. Liber;2009:33–49.
25. Monzée J. Développement de l’enfant et représentations symboliques. In J. Monzée, Ce que le cerveau a dans la tête. Liber;2011:107–144
26. Monzée J. Rendez-vous pour la réussite éducative. IDEF;2021.
27. Labbé V, Falardeau G, Monzée J, Poulin PC. Le TDAH et la consommation de psychostimulants et autres médicaments. Mémoire déposé à l’Assemblée nationale du Québec;2019
28. CSSS. Mandat d’initiative sur l’augmentation préoccupante de la consommation de psychostimulants chez les enfants et les jeunes en lien avec le trouble déficitaire de l’attention avec hyperactivité. Assemblée nationale du Québec;2019.
29. INESSS. Portrait des services psychosociaux utilisés dans le traitement du trouble de TDAH chez les Québécois de moins de 25 ans. 2017.
30. Haeck J, Lefebvre G, Lefebvre P, Merrigan Ph. Surdiagnostic du TDAH au Québec: impact de l’âge d’entrée à l’école, différences régionales et coûts sociaux et économiques, rapport de projet, CIRANO;2023.
31. Gonon F. L’hypothèse dopaminergique du TDAH. In Le Collectif pas de 0 de conduite, Enfants turbulents. Eres. 2008:131–155.
32. Faraone S, Asherson P, Banaschewski T et al. Attention-deficit/hyperactivity disorder. Nat Rev Dis Primers. 2015;1:15020.
33. Ponnou S, Thomé B. ADHD diagnosis and methylphenidate consumption in children and adolescents: A systematic analysis of health databases in France over the period 2010-2019. Frontiers in Psychiatry. 2022;13:957242.
34. Polanczyk G, de Lima ML, Horta BL et al. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. American Journal of Psychiatry. 2007;164(6):942–48
35. INSPQ, Analyse des recommandations en matière de réduction des risques sur la santé associés à l’utilisation des écrans en contexte scolaire. MSSS;2023.
36. Monzée J. Impacts socioaffectifs et psychiatriques de l’usage des écrans de loisir chez les jeunes. IDEF;2024.
37. Monzée J. Les comportements dérangeants chez l’enfant. In Monzée J.(dir.). Neurosciences, psychothérapie et développement affectif de l’enfant, Liber;2014:199–236.
38. Mackes NK, Golm D, Sarkar S et al. Early childhood deprivation is associated with alterations in adult brain structure despite subsequent environmental enrichment. PNAS. 2020;117(1):641–649.
39. Shore AN. Affect Regulation And The Repair Of The Self. Norton Professional Books;2003.
40. Porges SW. The polyvagal theory: New insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76(Suppl 2):S86–S90.
41. Psychodynamic diagnostic manual (2nd edition), World Psychiatry, 2015.
42. Krueger M. Description of self: An exploratory study of adolescentes with ADHD. JCAPN. 2001;14(2):61–72.
43. Koutsoklenis A, Honkasilta J. ADHD in the DSM-5-TR: What has changed and what has not. Front Psychiatry. 2023;13:1064141.
44. Monzée J. Neuropsychologie et généticisation: limites scientifiques et éthiques. In Ch. Hervé et al.(dir.). Généticisation et responsabilités. Dalloz;2008:53–78.
45. Faraone S, Sergeant J, Gillberg C, Biederman J. The worldwide prevalence of ADHD: is it an American condition? World Psychiatry. 2003;2(2):104–13.
46. Rubia K, Overmeyer S, Taylor E et al. Hypofrontality in ADHD During Higher Order Motor Control: a Study with fMRI. INABIS'98;1998.
47. Malaspina D, Corcoran C, Kleinhaus KR et al. Acute maternal stress in pregnancy and schizophrenia in offspring. BioMed Central Psychiatry. 2008;8(1):71–80
48. Laplante DP, Brunet A, Schmitz N et al. Project Ice Storm. American Academy of Child and Adolescent Psychiatry. 2008;47(9):1063–1072.
49. Valdimarsdóttir M, Hrafnsdóttir AH, Magnússon P, Gudmundsson OO. [The frequency of some factors in pregnancy and delivery for Icelandic children with ADHD]. Laeknabladid. 2006;92(9):609–14.
50. Tian XB, Zhao YR, Ma J, Liu F. [Attentiveness in school children: effect of cesarean section birth]. Zhongguo Dang Dai Er Ke Za Zhi. 2009;11(11):913–6.
51. Amiri S, Malek A, Sadegfard M, Abdi S. Pregnancy-related maternal risk factors of attention-deficit hyperactivity disorder: a case-control study. ISRN Pediatr. 2012:458064.
52. Monzée J. Les sensations cutanées contribuent à la réassurance affective tant du poupon que de sa mère. Spirale. 2019;89:49–59.
53. Allen JG. Traumatic relationships, and serious mental disorders. Wiley & Sons Ltd;2001.
54. McGowan PO, Sasaki A, D'Alessio AC et al. Epigenetic regulation of the glucocorticoid receptor in human brain associates with childhood abuse. Nature Neuroscience. 2009;12:342–348.
55. CDC, About Adverse Childhood Experiences. Published online October 8, 2024. Accessed April 15, 2025. https://www.cdc.gov/aces/about/index.html.
56. Bellato A, Perna J, Ganapathy PS et al. Association between ADHD and vision problems. A systematic review and meta-analysis. Mol Psychiatry. 2023;28(1):410–422.
57. Seng KBH, Tan PY, Lim CC et al. High prevalence of xerophthalmia linked to socio-demographic and nutritional factors among vitamin A-deficient rural primary schoolchildren in Malaysia. Nutr Res. 2024;131:14–26.
58. Sommer A. Vitamin a deficiency and clinical disease: an historical overview. J Nutr. 2008;138(10):1835–9.
59. Généreux M. Enquête en santé psychologique chez les jeunes de 12 à 25 ans. CISSS-Estrie/R3ussir;2023.
60. Nagata JM, Ganson KT, Iyer P et al. Sociodemographic Correlates of Contemporary Screen Time Use among 9- and 10-Year-Old Children. J Pediatr. 2022;240:213–220.
61. Tamana SK, Ezeugwu V, Chikuma J et al. Screen-time is associated with inattention problems in preschoolers: Results from the CHILD birth cohort study. PLoSOne. 2019;14(4):e0213995.
62. Wallace J, Boers E, Ouellet J et al. Screen time, impulsivity, neuropsychological functions and their relationship to growth in adolescent attention-deficit/hyperactivity disorder symptoms. Sci Rep. 2023;13(1):18108.
63. Chen YY, Yim H, Lee TH. Negative impact of daily screen use on inhibitory control network in preadolescence: A two-year follow-up study. Dev Cogn Neurosci. 2023;60:101218.
64. Likhitweerawong N, Boonchooduang N, Khorana J et al. Executive dysfunction as a possible mediator for the association between excessive screen time and problematic behaviors in preschoolers. PLoSOne. 2024;19(4):e0298189.
65. Meri R, Hutton J, Farah R et al. Higher access to screens is related to decreased functional connectivity between neural networks associated with basic attention skills and cognitive control in children. Child Neuropsychol. 2023;29(4):666–685.
66. Tong L, Xiong X, Tan H. Attention-Deficit/Hyperactivity Disorder and Lifestyle-Related Behaviors in Children. PLoSOne. 2016;11(9):e0163434.
67. van Egmond-Fröhlich AW, Weghuber D, de Zwaan M. Association of symptoms of attention-deficit/hyperactivity disorder with physical activity, media time, and food intake in children and adolescents. PLoSOne. 2012;7(11):e49781.
68. Green A, Cohen-Zion M, Haim A, Dagan Y. Evening light exposure to computer screens disrupts human sleep, biological rhythms, and attention abilities. Chronobiol Int. 2017;34(7):855-865.
69. Cavalli E, Anders R, Chaussoy L et al. Screen exposure exacerbates ADHD symptoms indirectly through increased sleep disturbance. Sleep Med. 2021;83:241–247.
70. Thoma VK, Schulz-Zhecheva Y, Oser C et al. Media Use, Sleep Quality, and ADHD Symptoms in a Community Sample and a Sample of ADHD Patients Aged 8 to 18 Years. J Atten Disord. 2020;24(4):576–589.
71. Monzée J. Quelle responsabilité sociale chez les chercheurs? In Létourneau L.(ed.). Bio-ingénierie et responsabilité sociale. Thémis;2006:175–203
72. Lacroix JG, Monzée J. L’alimentation des jeunes québécois et québécoises au cours des vingt dernières années. IDEF (subpress).
73. Rodriguez del Barrio L, Corin E, Poirel ML. Le point de vue des utilisateurs sur l’emploi de la médication en psychiatrie. Revue québécoise de psychologie, 2001;22(2):1–23.
74. Pelsser LM, Frankena K, Toorman J, Rodrigues Pereira R. Diet and ADHD, Reviewing the Evidence: A Systematic Review of Meta-Analyses of Double-Blind Placebo-Controlled Trials Evaluating the Efficacy of Diet Interventions on the Behavior of Children with ADHD. PLoSOne. 2017;12(1):e0169277
75. Salisbury H. The problem with outsourced diagnosis of ADHD. BMJ. 2025;389:r842