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.

Cognitive Behavioral Therapy for ADHD: What is it? Does it work?

Cognitive Behavioral Therapy (CBT) is a one to one therapy, for adolescents or adults, where a therapist teaches an ADHD patient how thoughts, feelings, and behaviors are all interrelated and how each of these elements affects the others.   CBT emphasizes cognition, or thinking, because a major goal of this therapy is to help patients identifying thinking patterns that lead to problem behaviors.   For example, the therapist might discover that the patient frequently has negative automatic thoughts such as “I’m stupid” in challenging situations.  We call the though ‘automatic’ because it invades the patients consciousness without any effort.  Thinking “I’m stupid” can cause anxiety and depression which leads to failure.  Thus, stopping the automatic thought will modify this chain of events and, hopefully, improve the outcome from failure to success.

CBT also educates patients about their ADHD and how it affects them in important daily activities.  For example, most ADHD patients need help with activity scheduling, socializing, organizing their workspace and controlling their distractibility. By teaching specific cognitive and behavioral skills, the therapist helps the patient deal with their ADHD symptoms in a productive manner.  For example, some ADHD patients are very impulsive when conversing with others.  They don’t wait their turn during conversations and may blurt out irrelevant idea.   This can be annoying to others, especially in the context of school or business relationships.   The CBT therapist helps the patient identify these behaviors and creates strategies for avoiding them.

So, does CBT work for ADHD?  The evidence base is small, but when CBT has been used for adult ADHD, it has produced positive results in well-designed studies.   These studies typically compare patients taking ADHD medications with those taking ADHD medications and receiving CBT.   So for now, it is best to consider CBT as an adjunct to rather than a replacement for medication.  There are even fewer studies of CBT for adolescents for ADHD.  These initial studies also suggest that CBT will be useful for adolescents with ADHD who are also taking ADHD medications.  Some data suggest that CBT can be successfully applied in the classroom environment but, again, the evidence base is very small.

How can this information be used by doctors and patients for treatment planning?  Current treatment guidelines suggest starting with an ADHD medication.  After a suitable medication and dose is found, the patient and doctor should determine if any problems remain.  If so, than CBT should be considered as an adjunct to ADHD medications.

References:

Antshel, K. M. & Olszewski, A. K. (2014). Cognitive Behavioral Therapy for Adolescents with ADHD. Child Adolesc Psychiatr Clin N Am 23, 825-842.

Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M. & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: a randomized controlled trial. JAMA 304, 875-80.

Solanto, M. V., Marks, D. J., Wasserstein, J., Mitchell, K., Abikoff, H., Alvir, J. M. & Kofman, M. D. (2010). Efficacy of meta-cognitive therapy for adult ADHD. Am J Psychiatry 167, 958-68.

Myths about the Treatment of ADHD

Myth:  ADHD medications “anesthetize” ADHD children.   

The idea here is that the drug treatment of ADHD is no more than a chemical straightjacket intended to control a child’s behavior to be less bothersome to parents and teachers.  After all, everyone knows that if you shoot up a person with tranquillizers they will calm down.

Fact:  ADHD medications are neither anesthetics nor tranquillizers.

The truth of the matter is that most ADHD medications are stimulants.  They don’t anesthetize the brain; they stimulate it.  By speeding up the transmission of dopamine signals in the brain, ADHD medications improve brain functioning, which in turn leads to an increased ability to pay attention and to control behavior.   The non-stimulant medications improve signaling by norepinephrine.  They also improve the brains ability to process signals.  They are not sedatives or anesthetics.  When taking their medication, ADHD patients can focus and control their behavior to be more effective in school and work and in their relationships.   They are not “drugged” into submission.

Myth: ADHD medications cause drug and alcohol abuse

We know from many long-term studies of ADHD children that when the reach adolescence and adults they are at high risk for alcohol and drug use disorders.  Because of this fact, some media reports have implied that their drug use was caused by treatment of their ADHD with stimulant medications.

Fact: ADHD medications do not cause drug and alcohol abuse

It is true that some ADHD medications use the same chemicals that are found in street drugs such as amphetamine.   But there is a very big difference between these medications and street drugs.  When street drugs are injected or snorted, they can lead to addiction, but when they are taken in pill form as prescribed by a doctor, they do not cause addiction.  In fact, when my colleagues and I examined the world literature on this topic we found that, rather than causing drug and alcohol abuse, stimulant medicine protected ADHD children from these problems later in life.  One study from researchers at Harvard University and the Massachusetts General Hospital found that the drug treatment of ADHD reduced the risk for illicit drug use by 84 percent.  These findings make intuitive sense.  These medicines reduce the symptoms of the disorder that lead to illicit drug use.  For example, an impulsive ADHD teenager who acts without thinking is much more likely to use drugs than an ADHD teen whose symptoms are controlled by medical drug treatment.  After we published our study, other work appeared.  Some of these studies did not agree that ADHD medications protected ADHD people from drug abuse but they did not find that they caused drug abuse.

 

Myth:  Psychological or behavior therapies should be tried before medication.   

Many people are cautious about taking medications and that caution is even stronger when parents consider treatment options for their children.   Because medications can have side effects, shouldn’t people with ADHD try a talk therapy before taking medicine?

Fact:  Treatment guidelines suggest that medication is the first line treatment.

The problem with trying talk or behavior therapy before medication is that medication works much better.   For ADHD adults, one type of talk therapy (cognitive behavioral therapy) is recommended, but only when the patient is also taking medication.   The Multimodal Treatment of ADHD (MTA) study examined this issue in ADHD children from several academic medical centers in the United States.  That study found that treating ADHD with medication was better than treating it with behavior therapy.  Importantly, behavior therapy plus medication was no more effective than medication alone.  That is why treatment guidelines from the American Academy of Pediatrics and the American Academy of Child and Adolescent recommend medicine as a first line treatment for ADHD, except for preschool children.  It is true that ADHD medications have side effects, but these are usually mild and typically do not interfere with treatment.   And don’t forget about the risks that a patient faces when they do not use medications for ADHD.   These untreated patients are at risk for a worsening of ADHD symptoms and complications.

 

Myth: Brain abnormalities of ADHD patients are caused by psychiatric medications

A large scientific literature shows that ADHD people have subtle problems with the structure and function of their brains.   Scientists believe that these problems are the cause of ADHD symptoms.  Critics of ADHD claim that these brain problems are caused by the medications used to treat ADHD.   Who is right?

Fact: Brain abnormalities are found in never medicated ADHD patients.

Alan Zametkin, a scientist at the US National Institute of Mental Health was the first to show brain abnormalities in ADHD patients who had never been treated for their ADHD.   He found that some parts of the brains of ADHD patients were underactive.  His findings could not be due to medication because the patients had never been medicated.   Since his study, many other researchers have used neuroimaging to examine the brains of ADHD patients.  This work confirmed Dr. Zametkin’s observation of abnormal brain findings in unmedicated patients.  In fact, reviews of the brain imaging literature have concluded that the brain abnormalities seen in ADHD cannot be attributed to ADHD medications.

 

 

REFERENCES

 

Wilens, T., Faraone, S. V., Biederman, J. & Gunawardene, S. (2003). Does Stimulant Therapy of Attention Deficit Hyperactivity Disorder Beget Later Substance Abuse?  A Meta-Analytic Review of the Literature. Pediatrics 111, 179-185.

 

Humphreys, K. L., Eng, T. & Lee, S. S. (2013). Stimulant Medication and Substance Use Outcomes: A Meta-analysis. JAMA Psychiatry, 1-9.

 

Chang, Z., Lichtenstein, P., Halldner, L., D'Onofrio, B., Serlachius, E., Fazel, S., Langstrom, N. & Larsson, H. (2014). Stimulant ADHD medication and risk for substance abuse. J Child Psychol Psychiatry 55, 878-85.

 

Nakao, T., Radua, J., Rubia, K. & Mataix-Cols, D. (2011 ). Gray matter volume abnormalities in ADHD: voxel-based meta-analysis exploring the effects of age and stimulant medication. Am J Psychiatry 168, 1154-63.

 

Rubia, K., Alegria, A. A., Cubillo, A. I., Smith, A. B., Brammer, M. J. & Radua, J. (2014). Effects of stimulants on brain function in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Biol Psychiatry 76, 616-28.

 

Spencer, T. J., Brown, A., Seidman, L. J., Valera, E. M., Makris, N., Lomedico, A., Faraone, S. V. & Biederman, J. (2013). Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of magnetic resonance imaging-based neuroimaging studies. J Clin Psychiatry 74, 902-17.

Psychotherapy for ADHD

Psychotherapy and ADHD: How a Harvard Professor Help his Patients

Professor Larry Seidman is world renowned for his neuropsychology and neuroimaging research.   In addition to all of his creative science, he has found the time to create what he calls “Neuropsychologically Informed Strategic Psychotherapy (NISP) in Teenagers and Adults with ADHD.”   Let’s start with what NISP is not.  NISP is not cognitive behavior therapy (CBT).  CBT emphasizes teaching patients to identify thinking patterns that lead to problem behaviors.  NISP describes how the interpersonal interaction we call psychotherapy can help patients increase self-regulation and self-control.  NISP treatments vary in duration from brief psycho-educational interventions of one to five sessions to much longer term therapies of indefinite duration.  The duration of therapy is tailored to the needs and goals of the individual.  The methods of NISP can be adaptively applied into well-known therapy modalities such as CBT and family therapy.  By creating a solid therapeutic alliance, NISP improves adherence to medications and addresses ADHD’s psychiatric comorbidities and functional disabilities.  NISP is “neuropsychologically informed” because it follows a comprehensive neuropsychological assessment of strengths and weaknesses.  This leaves the therapist with an understanding of the patient's personal experience of ADHD, the meaning of the disorder, how it affects self-esteem, and how cognitive deficits limit the ability to self-regulate and adapt to changing circumstances.   Attending to the patient’s strengths is a key feature of Prof. Seidman’s method.  ADHD is a disorder and it usually has serious consequences.  But ADHD people also have strong points in their character and their neuropsychological skills.  These sometimes get lost in assessments of ADHD but, as Dr. Seidman indicates, by addressing strengths, patient outcomes can be improved.   A NISP assessment also seeks to learn about the psychological themes that underlie each patient’s story.  He gives the all too common example of the patients who view themselves as failed children who have not tried hard enough to succeed.  A frank discussion of neuropsychological test results can be the first step to helping patients reconceptualize their past and move on to an adaptive path of self-understanding and self-regulation.

Prof. Seidman’s approach seems sensible and promising.  As he recognizes, it has not yet, however, been subject to the rigorous tests of evidenced-based medicine (my blog on EBM: http://tinyurl.com/ne4t7op).  So I would not recommend using it as a replacement for an evidenced-based treatment.  That said, if you are a psychotherapist who treats ADHD people, read Prof. Seidman’s paper.   It will give you useful insights that will help your patients.

REFERENCES

Seidman, L. J. (2014). Neuropsychologically Informed Strategic Psychotherapy in Teenagers and Adults with ADHD. Child Adolesc Psychiatr Clin N Am 23, 843-852.  (In: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.)