Providing Professional Support: Experience vs Knowledge

APSARD welcomes blogs expressing the opinions of its members. The following blog is an opinion piece from APSARD member, Cindy Goldrich, Ed. M., ADHD-CCSP.

I recently wrote a blog entitled In Search Of – Mental Health Professionals Who Understand ADHD.  I wrote this blog after an experience of trying desperately to help one of my clients find therapeutic support for her 16-year-old son who has ADHD and depression and was also dealing with alcohol abuse.  My goal was to connect them with a therapist who had specific knowledge and experience with how ADHD was playing a role in his challenges.  This proved to be quite a challenging quest.

Unfortunately, I have found that many therapists who, while excellent in their craft, are not knowledgeable about the impact that ADHD (and executive function challenges) has on learning, motivation, emotions, behavior, and the whole family system.  Traditionally, ADHD has been minimally addressed in graduate training programs.  However, I believe that any professional who works with a client/patient with an ADHD diagnosis would better serve their clients if they are appropriately educated about core symptomology, traits, relevant research, and best practice treatments.

In my “In Search Of…“article, I asked Licensed Therapists who had expertise in ADHD to contact me.  I asked them to complete a form telling me about their knowledge of ADHD and how they had acquired their knowledge.  I am disappointed to see that many respondents cited their knowledge was based on their own experience as either someone with ADHD or as a parent of a child with ADHD. Quite frankly, experience is NOT knowledge. In my practice, I often say, “Parent the Child you Have.”  The main message behind this statement is that each child is different.  ADHD shows up differently in every individual.  Therefore, personal experience is not transferable, nor can it be generalized to other people or situations.

Some therapists cited that they learned about ADHD from blogs, articles, and podcasts.  Sadly, so much information is out there that is inaccurate or worse.  I am not sure that learning from unvetted sources compares to materials presented in coursework.

Although I am a trained mental health counselor, I work primarily as an ADHD Coach and Coach Trainer. As a coach, I am very clear on the lines between therapy and coaching.  In fact, I spend considerable time with the coaches that I train, making sure that they understand the importance of “staying in their lane.”

ADHD Coaching is a discipline where professionals are trained and can become certified (the International Coaching Federation is the “gold standard”) with a rigorous set of Core Competencies and a strong Code of Ethics.  Over the past decade, ADHD Coaching has become recognized as an important part of the multimodal treatment plan for individuals with ADHD by notables in the field such as Russell Barkley, Thomas Brown, Russell Ramsey, and Anthony Rostain.

In their article, Therapy and ADD Coaching: Similarities, Differences, and Collaboration, Clinical Psychologist Peter Jaska and Master Certified Coach Nancy Ratey discuss the effective collaboration between coaching and therapy.  “Coaching involves an ongoing relationship between a coach and client that is very goal-driven, structured, and focused on helping the clients actively create practical strategies to accomplish specific goals and develop general skills to be more effective in their daily lives. Many therapists are referring to coaches so that they can help the client clear the behavioral “clutter” and allow the therapist to focus more on core therapeutic issues.”  Coaches also know that there are times where their clients will be best served by therapy with a qualified practitioner.

The mission of APSARD is to “improve the quality of care for ADHD patients through research, best practices, and evidence-based education and training.” Perhaps APSARD, along with organizations such as CHADD, ADDA, and the ADHD Coaching Organization, can put out the clarion call to advocate for:

  • Better training in schools and programs that prepare future mental health professionals
  • Certification or distinction opportunities for those who meet a level of ADHD knowledge
  • Public awareness of the value and importance of seeking out qualified ADHD experts when looking at treatment options.

We have so much knowledge; it’s time we all do better in serving the public at large.

Celebrating Black History Month

Black History Month is celebrated throughout the United States, the UK, Canada, and Ireland, as a time to recognize the rich cultural heritage and achievements of the Black community (https://youtu.be/1JQ66r1KXxA). This year’s theme of Black Health and Wellness asks us to acknowledge not only Black scholars and practitioners of Western medicine, but also to recognize the cultural and non-medical aspects of wellness that are embraced throughout the African Diaspora (https://asalh.org/wp-content/uploads/2021/10/2022-Black-History-Theme-Executive-Summary.pdf).

We at APSARD would like to start by honoring the trailblazers in psychology, psychiatry, and mental health advocacy https://www.mhanational.org/black-pioneers-mental-health, who took up the fight for justice and equity in the face of structural racism https://www.psychiatrictimes.com/view/why-black-history-month-important-psychiatry.  Among those  trailblazers are:

  • Dr. Inez Beverly Prosser, PhD,  the first Black woman to receive a PhD in psychology - https://youtu.be/WURWeITVhhs
  • Dr. Francis Cecil Sumner, PhD, the Father of Black Psychology - https://youtu.be/eKJGp3Zbjmo
  • Ms. Bebe Moor Campbell, one of the most influential Mental Health Advocates raising support and awareness for the Black community, and a best-selling author - https://youtu.be/hmoUkoOJ4Pk  https://youtu.be/qztEHdkvd6A - whose books are available as audiobooks and include, “Singing in the Comeback Choir”, “Your Blues Ain’t Like Mine”, and “72 Hour Hold”.

We want to honor those who continue their work, even as we acknowledge how much more work remains to be done. Let us consider the intersection of racial diversity, ethnic diversity, and neurodiversity offered by Dr. Loucrese Rupert, MD, a neurodivergent psychiatrist who treats ADHD and shares her experiences alongside colleagues, patients, and advocates to fight stigma https://youtu.be/oh-3ULQJiEY, in support of mental health and wellness. Let us hear from scientists like Dr. Salif Mahamane, PhD who talks about his perspectives on the cognitive science of ADHD as a man with ADHD  https://www.youtube.com/watch?v=fWCocjh5aK0. And let us tune in to artists like Rene Brooks, author of “ADHD & More: How an ADHD Diagnosis Transformed Me”, https://blackgirllostkeys.com to learn how to connect with the people for whom we care.

Continue celebrating with the National Museum of African American History and Culture, and take advantage of some of their outstanding events https://nmaahc.si.edu/events.

College Students & ADHD Special Interest Group (SIG)

College students with ADHD are a unique group and, in several ways, likely differ from their same-age peers with ADHD who do not matriculate in college. For example, college students with ADHD tend to have strong cognitive abilities 1 and more effective compensatory skills than their same-age peers with ADHD who are not in college 2. College students with ADHD also assuredly experience different stressors (e.g., academic pressure) than same-age peers with ADHD who do not pursue college. In this way, college students with ADHD are likely a distinct subset of individuals with ADHD.

Academically, first semester college freshmen with ADHD (especially males) arrive on campus reporting higher levels of school disengagement, more substance use and significantly more emotional difficulties than peers without ADHD 3. Given this, it is not surprising that during their first two years of college, students with ADHD attain lower GPA’s than peers without ADHD (Cohen’s d = 0.43) and earn fewer course credits (d = 0.31) across all four semesters 4.

Emotionally, college students with ADHD (especially females) report higher levels of anxiety and depression than peers without ADHD 5-9. Depression seems especially impactful and is associated with social maladjustment 10, lower quality of life 11, explains academic impairments above and beyond ADHD symptoms 12 and mediates the relationship between past ADHD symptoms (yet not current symptoms) and cannabis use 13, possibly supporting a self-medication hypothesis / negative reinforcement model for cannabis use for some with ADHD. Finally, multiple studies have documented increased prevalence of suicidal ideation in college students with ADHD diagnoses or elevated ADHD symptoms 14-16. Unfortunately, college students with ADHD and depression use on-campus resources at especially low rates 17.

If you have an interest in college students with ADHD and discussing any topic related to college student ADHD, please consider joining the College Student with ADHD SIG. We are a group of allied mental health professionals and trainees who share an interest in improving the quality of care for 4-year and 2-year college students with ADHD through the advancement and dissemination of research, and evidence-based practices. If you’d like to join the group, please email kmantshe@syr.edu.

  1. Weyandt LL, Oster DR, Gudmundsdottir BG, DuPaul GJ, Anastopoulos AD. Neuropsychological functioning in college students with and without ADHD. Neuropsychology. 2017;31(2):160-172.
  2. Frazier TW, Youngstrom EA, Glutting JJ, Watkins MW. ADHD and achievement: meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students. Journal of Learning Disabilities 2007;40:49-65.
  3. DuPaul GJ, Pinho T, Pollack BL, Gormley MJ, Laracy SD. First-Year College Students With ADHD and/or LD: Differences in Engagement, Positive Core Self-Evaluation, School Preparation, and College Expectations. Journal of Learning Disabilities. 2017;50:238-251.
  4. DuPaul GJ, Franklin MK, Pollack BL, et al. Predictors and Trajectories of Educational Functioning in College Students With and Without Attention-Deficit/Hyperactivity Disorder. Journal of Postsecondary Education Disability. 2018;31(2):161-178.
  5. Nelson JM, Liebel SW. Anxiety and depression among college students with attention-deficit/hyperactivity disorder (ADHD): Cross-informant, sex, and subtype differences. Journal of American College Health. 2018;66(2):123-132.
  6. Anastopoulos AD, DuPaul GJ, Weyandt LL, et al. Rates and Patterns of Comorbidity Among First-Year College Students With ADHD. Journal of Clinical Child and Adolescent Psychology. 2018;47(2):236-247.
  7. Mochrie KD, Whited MC, Cellucci T, Freeman T, Corson AT. ADHD, depression, and substance abuse risk among beginning college students. J Am Coll Health. 2018:1-5.
  8. Coduti WA, Hayes JA, Locke BD, Youn SJ. Mental health and professional help-seeking among college students with disabilities. Rehabil Psychol. 2016;61(3):288-296.
  9. Rabiner DL, Anastopoulos AD, Costello J, Hoyle RH, Swartzwelder HS. Adjustment to college in students with ADHD. J Atten Disord. 2008;11(6):689-699.
  10. Sheehan WA, Iarocci G. Executive Functioning Predicts Academic But Not Social Adjustment to University. Journal of Attention Disorders. 2019;23(14):1792-1800.
  11. Gudjonsson GH, Sigurdsson JF, Eyjolfsdottir GA, Smari J, Young S. The relationship between satisfaction with life, ADHD symptoms, and associated problems among university students. Journal of Attention Disorders. 2009;12(6):507-515.
  12. Rabiner DL, Anastopoulos AD, Costello J, Hoyle RH, Swartzwelder HS. Adjustment to college in students with ADHD. Journal of Attention Disorders. 2008;11:689-699.
  13. Morse MC, Benson K, Flory K. Disruptive Behavior Disorders and Marijuana Use: The Role of Depressive Symptoms. Substance Abuse. 2015;9(Suppl 1):69-76.
  14. Van Eck K, Ballard E, Hart S, Newcomer A, Musci R, Flory K. ADHD and Suicidal Ideation: The Roles of Emotion Regulation and Depressive Symptoms Among College Students. J Atten Disord. 2015;19(8):703-714.
  15. Eddy LD, Eadeh HM, Breaux R, Langberg JM. Prevalence and predictors of suicidal ideation, plan, and attempts, in first-year college students with ADHD. Journal of American College Health. 2019:1-7.
  16. Patros CH, Hudec KL, Alderson RM, Kasper LJ, Davidson C, Wingate LR. Symptoms of attention-deficit/hyperactivity disorder (ADHD) moderate suicidal behaviors in college students with depressed mood. Journal of Clinical Psychology. 2013;69(9):980-993.
  17. Gormley MJ, DuPaul GJ, Weyandt LL, Anastopoulos AD. First-Year GPA and Academic Service Use Among College Students With and Without ADHD. Journal of Attention Disorders. 2019;23(14):1766-1779.

 

Other Myths about ADHD

Myth: ADHD is an American disorder.

Those who claim ADHD is an American disorder believe that ADHD is due to the pressures of living in a fast paced, competitive American society.   Some argue that if we lived in a simpler world, ADHD would not exist.

Fact:  ADHD occurs throughout the world.

Wherever scientists have searched for ADHD, they have found it.  They have done this by going to different countries, speaking to people in the community to diagnose them with or without ADHD.   These studies show that ADHD occurs throughout the world and that the percent of people having ADHD does not differ between the United States and the rest of the world.   Examples of where ADHD has been found include:  Australia, Brazil, Canada, China, Colombia, Finland, Germany, Iceland, Israel, Italy, Japan, New Zealand, Spain, Sweden, Taiwan, The Netherlands, and Ukraine.   ADHD is not an American disorder.

Myth: A child who sits still to watch TV or play video games cannot have ADHD.

Many parents are puzzled that their child can sit still to watch TV or to play video games for hours but that same child cannot sit still for dinner or stay at their desk for long to do homework.  Are these children faking ADHD symptoms to get out of homework?

Fact:  ADHD does not necessarily interfere with playing video games or watching TV.

Because children cannot turn their ADHD on and off to suit their needs, it does seem odd that a child who is typically hyperactive and inattentive can sit for hours playing a video game.  But this ability of ADHD children fits in very well with scientific facts about ADHD.  First, you probably understand the effects of rewards and punishment on behavior.  If your behavior is rewarded, you are likely to do it again.  If it is punished, you will avoid that behavior in the future.  Rewards that have the strongest effect on our behavior are large and will occur soon.  For example, consider these two choices:

  1. if you listen to a boring one hour lecture, I will pay you $100 immediately after the lecture
  2. if you listen to a boring one hour lecture, I will pay you $110 one year after the lecture

Choice (a) is more appealing that choice (b).  Most people will not think it is worthwhile to wait one year for $10.  We say they have ‘discounted’ the $10 to 0$.

Now consider the choices:

  1. if you listen to a boring one hour lecture, I will pay you $100 immediately after the lecture
  2. if you listen to a boring one hour lecture, I will pay you $2,000 one year after the lecture

Choice (d) is more appealing that choice (c).  Most people will wait one year for $2,000.   It is obvious here is that if I want the best chance of having you watch a lecture, I should offer you a large sum of money immediately after the lecture.  What is not so obvious is that people vary a great deal in the degree to which they are affected by rewards that are either small or distant in the future.   For some people, getting $2,000 in one year is almost like getting nothing at all.  We say that such people are not sensitive to distant rewards.

What does this have to do with ADHD and video games?  Well people with ADHD are usually not very sensitive to weak or distant rewards.  To affect the behavior on a person with ADHD, the reward needs to be immediate and fairly large.  When a child with ADHD sits down to do homework, the potential reward is getting a good grade on their report card, but they won’t receive that grade for weeks or months, so it is very distant.  Thus, it is not surprising that the possibility of that reward cannot control the child’s behavior.  In contrast, video games are created so that players are rewarded very frequently by winning points or completing one of the many levels one must pass to finally complete the game.  Because playing well is also rewarded by friends, the video game rewards are strong and immediate, which makes it easy for people with ADHD to sit still and play for long periods of time.

Myth: ADHD disappears in adulthood.

Until the 1990s, it was commonly believed that children grew out of ADHD.  The reason for this is not clear.  Some theories about ADHD suggested that ADHD children had a lag in brain development and that they would make up that lag during adolescence.  So ADHD was seen as a delay in brain development that could be overcome.   In fact, the idea that children routinely recovered from ADHD was so strong that many insurance companies would not pay for the ADHD treatment of adults.

Fact: In the majority of cases, ADHD persists into adulthood.

This myth about ADHD has been proven wrong by studies that diagnosed ADHD in children and then examined them many years later as adults.  These studies showed that, although there was some recovery from ADHD, about two-thirds of cases persisted into adulthood.  The studies also taught us that ADHD symptoms tend to change with age.  The extreme and disruptive hyperactivity of many ADHD children gets somewhat better by adulthood as do some symptoms of impulsivity.   In contrast, inattentive symptoms do not decrease much with age.

 Myth: People with ADHD cannot do well in school or succeed in life.

This myth is based on several facts: 1) ADHD affects many aspects of life; 2) ADHD impairs thinking and behavior and 3) for most people, ADHD is a lifelong disorder.   Altogether, doesn’t this mean that people with ADHD won’t succeed in life?

Fact: People with ADHD can succeed and live productive lives.

There are two reasons why people with ADHD can succeed in life.  The first is obvious.  Although treatments for ADHD are not perfect, they can eliminate many of the obstacles that would otherwise make it difficult for ADHD patients to do well in school or on the job.  But, more importantly, having ADHD is only one of many facts about a person’s life.   Some ADHD people have other skills or traits that help them compensate for their ADHD.   For example, if you have a high level of intelligence, an engaging personality or excellent athletic skills, you can do well despite having ADHD.   Consider Michael Phelps, who broke so many Olympic swimming records.  He was diagnosed with ADHD at age 9 and took Ritalin to help his hyperactivity.   James Carville has ADHD, but he completed law school and helped Bill Clinton become president of the United States.  Cammi Granato’s ADHD did not stop her from becoming captain of the United States Olympic ice hockey team and Ty Pennington’s ADHD did not stop him from becoming a  star on TV.

Myth: ADHD does not affect highly intelligent people

The mistake behind this myth is that it assumes that being very intelligent protects people from having ADHD.  It’s true that if you are highly intelligent, you can use that intelligence to compensate for some of ADHD’s effects, but does high intelligence completely protect a person from ADHD?

Fact: People with ADHD can succeed and live productive lives.

When my colleagues and I studied this question, we found clear evidence that high intelligence does not completely protect people from ADHD.  Like people who don’t have ADHD, having high intelligence will help ADHD people do better than ADHD people who are not a smart.  But when we compared highly intelligent ADHD people with highly intelligent non-ADHD people we found that the highly intelligent ADHD people had many of the impairing problems that are know to be associate with ADHD.  For details about these problems, see Complications of ADHD.  In another study, we compared ADHD adults who had received straight A grades in high school, with non-ADHD people who had achieved the same grades.  Despite their good grades, these ADHD adults were not doing as well in their jobs and not earning as much income as the non-ADHD adults.  And ADHD also has an impact at every level of education.  As you can see from the figure, even for people with college degrees, having ADHD lowers your chances for being employed.

 

REFERENCES

Faraone, S. V., Sergeant, J., Gillberg, C. & Biederman, J. (2003). The Worldwide Prevalence of ADHD: Is it an American Condition? World Psychiatry 2, 104-113.

Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J. & Rohde, L. A. (2007). The Worldwide Prevalence of ADHD: A Systematic Review and Metaregression Analysis. Am J Psychiatry 164, 942-8.

Scheres, A., Lee, A. & Sumiya, M. (2008). Temporal reward discounting and ADHD: task and symptom specific effects. J Neural Transm 115, 221-6.

Faraone, S., Biederman, J. & Mick, E. (2006). The Age Dependent Decline Of Attention-Deficit/Hyperactivity Disorder:  A Meta-Analysis Of Follow-Up Studies. Psychological Medicine 36, 159-165.

Are Nonpharmacologic Treatments for ADHD Useful?

There are several very effective drugs for ADHD and that treatment guidelines from professional organization view this drugs as the first line of treatment for people with ADHD.  The only exception is for preschool children where medication is only the first line treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available.

Despite these guidelines, some parents and patients have been persuaded by the media or the Internet that ADHD drugs are dangerous and that non-drug alternatives are as good or even better. Parents and patients may also be influenced by media reports that doctors overprescribe ADHD drugs or that these drugs have serious side effects. Such reports typically simplify and/or exaggerate results from the scientific literature.  Thus, many patients and parents of ADHD children are seeking non-drug treatments for ADHD.

What are these non-pharmacologic treatments and do they work?  My next series of blogs will discuss each of these treatments in detail.  Here I’ll give an overview of my evidenced-based taxonomy of nonpharmacologic treatments for ADHD described in more detail in a book I recently edited (Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.).  I use the term “evidenced-based” in the strict sense applied by the Oxford Center for Evidenced Based Medicine (OCEBM; http://www.cebm.net/).

Most of the non-drug treatments for ADHD fall into three categories: behavioral, dietary and neurocognitive.  Behavioral interventions include training parents to optimize methods of reward and punishment for their ADHD child, teaching ADHD children social skills and helping teachers apply principles of behavior management in their classrooms.  Cognitive behavior therapy is a method that teaches behavioral and cognitive skills to adolescent and adult ADHD patients. Dietary interventions include special diets that exclude food colorings or eliminate foods believed to cause ADHD symptoms.  Other dietary interventions provide supplements such as iron, zinc or omega-3 fatty acids.   The neurocognitive interventions typically use a computer based learning setup to teach ADHD patients cognitive skills that will help reduce ADHD symptoms.

There are two metrics to consider when thinking about the evidence-base for these methods.  The first is the quality of the evidence.   For example, a study of 10 patients with no control group would be a low quality study but a study of 100 patients randomized to either a treatment or control group would be of high quality and the quality would be even higher if the people rating patient outcomes did not know who was in each group.  The second metric is the magnitude of the treatment effect.  Does the treatment dramatically reduce ADHD symptoms or does it have only a small effect?  This metric is only available for high quality studies that compare people treated with the method and people treated with a ‘control’ method that is not expected to affect ADHD.

I used a statistical metric to quantify the magnitude of effect. Zero means no effect and larger numbers indicate better effects on treating ADHD symptoms.  For comparison, the effect of stimulant drugs for ADHD is about 0.9, which is derived from a very strong evidence base.     The effects of dietary treatments are smaller, about 0.4 to 0.5, but because the quality of the evidence is not strong, these results are not certain and the studies of food color exclusions apply primarily to children who have high intakes of such colorants.

In contrast to the dietary studies, the evidence base for behavioral treatments is excellent but the effects of these treatments of ADHD symptoms is very small, less than 0.1.    Supplementation with omega-3 fatty acids also has a strong evidence base but the magnitude of effect is also small (0.1 to 0.2).    The neurocognitive treatments have modest effects on ADHD symptoms (0.2 to 0.4) but their evidence base is weak.

This review of non-drug treatments explains why ADHD drug treatments are usually used first.  Their evidence base is stronger and they are more effective in reducing ADHD symptoms.  There is, however, a role for some non-drug treatments. I’ll be discussing that in subsequent blog posts.

See more evidenced based information about ADHD at www.adhdinadults.com

 

References :

Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.

Faraone, S. V. & Antshel, K. M. (2014). Towards an evidence-based taxonomy of nonpharmacologic treatments for ADHD. Child Adolesc Psychiatr Clin N Am 23, 965-72.