An important study was recently published in April, 2015 edition of the Journal of the American Academy of Child and Adolescent Psychiatry. This study followed 11,640 kids in England from age 7 to age 16; the researchers focused on adolescent correlates of attention symptoms in childhood. These are some of their primary findings
There are three kinds of ADHD: a child has significant concentration problems but is not significantly hyperactive (ADHD, Predominantly Inattentive Type), vice versa (ADHD, Predominantly Hyperactive/Impulsive Type) and both (ADHD, Combined Type). About 75% of kids with ADHD have ADHD, Combined Type while the large majority of the rest have the inattentive type. Below are seven common myths about ADHD. Following those I list core guidelines for evaluation and treatment.
Myth: ADHD is not a real disorder. This is akin to saying that diabetes isn’t a real disorder or asthma isn’t a real disorder. To my knowledge, no reputable scientist or professional organization subscribes to this position. About four to six percent of youth suffer from this biological disorder. Studies of the brain indicate that these youth show poor functioning in the parts of the brain responsible for impulse control and sustained attention to boring tasks.
Myth: ADHD, Combined Type can be caused by poor parenting or being raised in adverse circumstances. While significant attentional problems can be caused by an assortment of problems (e.g., trauma, depression, anxiety), the degree of sustained hyperactivity required to diagnose ADHD is usually not caused by environmental stresses (I say “generally” as even a broken clock is right twice a day, but I’ve never seen a case like this or read about a case like this). ADHD is a biological disorder caused by either genetic transmission (i.e., it runs in the family) or significant insult to the brain (e.g., mom smoking cigarettes during pregnancy).
Myth: ADHD is caused by what a child ingests. Certainly what a child eats could affect just about any condition. Moreover, correcting an unbalanced diet, or eliminating allergens or toxins, would be part of a helpful treatment plan for just about any disorder. However, nothing that youth put in their mouths has been established as a primary cause of ADHD.
Myth: A positive response to medication treatment proves that a child has ADHD. Many children will experience improved concentration on low doses of stimulant medication, whether they have ADHD or not. Our culture is replete with examples of people, who do not have ADHD, using stimulants to accomplish some desired effect (e.g., pilots during the Korean war took dexedrine in order to be able to focus better during long bombing runs).
Myth: Youth suffering from ADHD, who are treated with stimulant medication, are at higher risk to develop substance abuse problems as a function of taking the medication. Actually, the exact opposite seems to be more likely: having ADHD, and not receiving effective treatment for it, seems to double to triple the odds of substance abuse in adolescence. Moreover, the number one cause of death and serious injury among teens and young adults are accidents and youth with untreated ADHD are at a much higher risk to experience those.
Myth: ADHD can be treated effectively by enhancing a child’s motivation. As I wear corrective lenses I use the following analogy with my clients: “if I told people I wasn’t willing to wear glasses but was interested in other treatments, they might try to make the light brighter for me, cheer me on, or suggest that I get closer to things I’m reading. However, nothing is going to help nearly as quickly and effectively as my just putting on my glasses. And, my not putting on my glasses could eventually make me think that my problem with reading is a problem with my effort. And, if I go there in my thinking, I’m probably going to make myself very, very upset and sick.”
Myth: People outgrow their ADHD. It is true that a small percentage of youth with ADHD reach the point that their symptoms are not significantly impairing in adulthood (these are usually the milder cases with multiple protective factors at play). So, in that case this myth has some truth to it. However, testing on those individuals will usually document the lingering presence of the disorder; it’s just not causing impairment anymore, secondary to the protective factors and brain maturation.
Keep in mind that in order to qualify for an ADHD diagnosis a child must show unusual and impairing inattention (usually to tasks that bore him or her) or hyperactivity/impulsivity at both school and home for a period of at least six months. The common standard for “unusual” is the 93rd percentile (i.e, having the symptom worse than 92% of the youth’s peer group). Moreover, the onset of the first impairing symptom should be before the age of seven and no other viable theory can explain the symptoms that are being demonstrated (i.e., ADHD is a diagnosis by exclusion).
The methodology for determining the presence of the disorder is determined by a cost/benefit analysis. As I consider the myriad of factors at play, I’d suggest the following be the default standard for ADHD evaluations: a family interview, a child/teen interview, the completion of parent, teacher and child–if the child’s reading level is sufficient–behavior rating scales, a comprehensive review of school records and a review of any other relevant records. (The behavior rating scales should include broad-band measures that endeavor to assess for a spectrum of disorders as well as narrow-band measures that try to rule out ADHD specifically.) If one of these elements is missing, I’d worry about the increased odds of an inaccurate finding. If these sources of information leave the diagnosis in doubt, I’d suggest adding a computer based continuous performance test (e.g., the Test of the Variables of Attention). (There is a reasonable argument to be made for including a continuous performance test in every evaluation for ADHD, so I wouldn’t differ with those clinicians who do.) In instances where a learning disability is suspected, additional cognitive and achievement testing would usually be in order.
The large majority of children with ADHD have at least one other co-occurring condition (e.g., Oppositional Defiant Disorder). The configuration of the co-occurring problems would normally have a substantive impact on an evidence-based treatment plan. However, for ADHD itself, medication is the primary treatment of choice (i.e., the scientific evidence supporting its efficacy is overwhelming). It is also very common to need behavioral treatments, at both school and at home, to augment the primary treatment. As a primary treatment, the following would typically not be indicated: dietary manipulations, chiropractic treatments, play therapy, art therapy, music therapy or basically any interventions that does not have a sound scientific foundation to support its usage as a first line intervention.
For more science-based information on ADHD, consider any of the following websites designed for lay people:
Also, on 12/4/12, from 1 to 2 PM EST, there will be a Twitter chat on ADHD. (I will be one of the panelists.) This will be hosted by Dr. Richard Besser, Chief Medical Editor for ABC news. Just go to #abcDrBchat at that time.