Stephen Faraone, PhD, ADHD in AdultsMyth: The ADHD diagnosis is very much “in the eye of the beholder.”
This is one of many ways in which the ADHD diagnosis has been ridiculed in the popular media. The idea here is that because we cannot diagnose ADHD with an objective brain scan or a blood test, the diagnosis is “subjective” and subject to the whim and fancy of the doctor making the diagnosis.
Fact: The ADHD diagnosis is reliable and valid.
The usefulness of a diagnosis does not depend on whether it came from a blood test, a brain test or from talking to a patient. A test is useful if it is reliable, which means that two doctors can agree who does and does not have the disorder, and if it is valid, which means that the diagnosis predicts something that is important to the doctor and patient such as whether or not the patient will respond to a specific treatment. Many research studies show that doctors usually agree about who does and does not have ADHD. The reason for this is that we have very strict rules that one must use to make a diagnosis. Much work over many decades has also shown ADHD to be a valid diagnosis. For details see: Faraone, S. V. (2005). The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder. Eur Child Adolesc Psychiatry 14, 1-10. The short story is that the diagnosis of ADHD is very useful for predicting what treatments will be effective and what types of problems ADHD patients are likely to experience in the future.

Myth: ADHD is not a medical disorder. It’s just the extreme of normal childhood energy
The mental health professions use the term “disorder” to describe ADHD, but others argue that what we view as a disorder named ADHD is simply the extreme of normal childhood energy. After all, most healthy children run around and don’t always listen to their parents. Doesn’t the ADHD child or adult simply have a higher dose of normal behavior?
Fact: Doctors have good reasons to describe ADHD as a disorder
The idea that the extreme of a normal behavior cannot be a disorder is naïve. Consider hypertension (high blood pressure). Everyone has a blood pressure, but when blood pressure exceeds a certain value, doctors get worried because people with high values are at risk for serious problems, such as heart attacks. Consider depression. Everyone gets sad from time to time, but people who are diagnosed with depression cannot function in normal activities and, in the extreme, are at risk for killing themselves. ADHD is not much different from hypertension or depression. Many people will show some signs of ADHD at some times but not all have a “disorder.” We call ADHD a disorder not only because the patient has many symptoms but also because that patient is impaired, which means that they cannot carry out normal life activities. For example, the ADHD child cannot attend to homework or the ADHD adult cannot hold a job, despite adequate levels of intelligence. Like hypertension, untreated ADHD can lead to serious problems such as failing in school, accidents or an inability to maintain friendships. These problems are so severe that the US Center for Disease Control described ADHD as “a serious public health problem.”

Myth: The ADHD diagnosis was developed to justify the use of drugs to subdue the behaviors of children.
This is one of the more bizarre myths about ADHD. The theory here is that, in order to sell more drugs, pharmaceutical companies invented the diagnosis of ADHD to describe normal children who were causing some problems in the past.
Fact: ADHD was discovered by doctors long before ADHD medications were discovered.
People who believe this myth do not know the history of ADHD. In 1798, long before there were any drugs for ADHD, Alexander Crichton, a Scottish doctor described a “disease of attention,” which we would not call ADHD. ADHD symptoms were described by a German doctor, Heinrich Hoffman, in 1845 and by a British doctor, George Still, in 1902. Each of these doctors found that inattentive and overactive behaviors could lead to a problem that should be of concern to doctors. If they had had medications to treat ADHD they probably would have prescribed them to their patients. But a medication for ADHD was not discovered until 1937 and even then, it was discovered by accident. Dr. Charles Bradley from Providence Rhode Island had been doing brain scanning studies of troubled children in a hospital school. The scans left the children with headaches that Dr. Bradley thought would be relieved by an amphetamine drug. When he gave this drug to the children after the scan, it did not help their headaches. However, the next day, their teachers reported that the children were attending and behaving much better in the classroom. Dr. Bradley had accidentally discovered that amphetamine was very helpful in reducing ADHD symptoms and, in fact, amphetamine drugs are commonly used to treat ADHD today. So, as you can see, the diagnosis of ADHD was not “invented” by anyone; it was discovered by doctors long before drugs for ADHD were known.

Myth: Brain scans or computerized tests of brain function can diagnose ADHD.
Someday, this myth may become fact, but for now and the near future it is a solid myth. You may think this is strange. After all, we know that ADHD is a brain disorder and that neuroimaging studies have documented structural and functional abnormalities in the brains of patients with ADHD. If ADHD is a biological disorder, why don’t we have a biological test for the diagnosis?
Fact: No brain test has been shown to accurately diagnose ADHD.
ADHD is a biologically based disorder, but there are many biological changes and each of these is so small that they are not useful as diagnostic tests. We also think that there are several biological pathways to ADHD. That means that not all ADHD patients will show the same underlying biological problems. So for now, the only officially approved method of diagnosing ADHD is by asking patients and/or their parents about ADHD symptoms as described in the American Psychological Associations Diagnostic and Statistical Manual.

http://medicalwritingtraining.com/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.

Stephen_Faraone_PhD_AIA_2016_XM7MQd.png.jpgMyth: ADHD is caused by poor parenting or teaching.
Parents and teachers are popular targets for those who misunderstand ADHD. This myth posits that ADHD would not exist if parents and teachers were more effective at disciplining and teaching children. From this perspective, ADHD is a failure of society, not a brain disease.
Fact: ADHD occurs when genes and toxic environments harm the brain.
Blaming parents and teachers for ADHD is wrong. We know from research studies that many parents of ADHD children have normal parenting skills and even when we train parents to be better parents, ADHD does not disappear. In fact, many parents of ADHD children have a non-ADHD child that they raised with the same discipline methods. If bad parenting causes ADHD, all of the children in the family should have ADHD. Equally important, decades of research studies have shown that genes and toxic environments cause ADHD by harming the brain. I’m not saying that all parents and teachers are perfect. In fact, by teaching parents and teachers special methods for dealing with ADHD can help children with ADHD.

Myth: Watching Television causes ADHD.
This myth hit the media in 2004 when a research group published a paper suggesting that toddlers who watched too much TV were at risk for attentional problems later in life.
Fact: The study was wrong.
Sometimes researchers get it wrong. But fortunately science is self-correcting; if an incorrect result is published, subsequent studies will show that it is wrong. That’s what happened with the ADHD television study. After the first study made such a media splash, several other researchers did similar studies. They found out that the original study had errors and that watching too much TV does not cause ADHD. But, because the popular media did not pick up the later studies, the myth persists. I’m not recommending that toddlers watch a lot of television, but rest assured that, if they do, it will not cause ADHD.

Myth: Too much sugar causes ADHD.
This idea is based on common sense. Many parents know that when their children and their friends have too much sugary food, they can get very active and out of control.
Fact: Sometimes, common sense is wrong.
As a parent, I thought there was some truth to the sugar myth. But when a colleague, Dr. Wolraich, reviewed the world literature on the topic, he found that there have been many studies of the effect of sugar on children. These studies show that sugar does not affect either the behavior or the thinking patterns of children. Having too much sugar is bad for other reasons, but it does not cause ADHD.
 

REFERENCES
Wolraich, M. L., Wilson, D. B. & White, J. W. (1995). The effect of sugar on behavior or cognition in children. A meta-analysis. JAMA 274, 1617-21.

Stevens, T. & Mulsow, M. (2006). There is no meaningful relationship between television exposure and symptoms of attention-deficit/hyperactivity disorder. Pediatrics 117, 665-72.
Evans, S. W., Langberg, J. M., Egan, T. & Molitor, S. J. (2014). Middle School-based and High School-based Interventions for Adolescents with ADHD. Child Adolesc Psychiatr Clin N Am 23, 699-715.

Pfiffner, L. J. & Haack, L. M. (2014). Behavior Management for School-Aged Children with ADHD. Child Adolesc Psychiatr Clin N Am 23, 731-746.

http://medicalwritingtraining.com/In contrast to a large literature demonstrating the effects of medications for adult ADHD, a small but growing literature is beginning to document the value of naturopathic treatments. A good example was recently published by Rucklidge et al. (2014, British Journal of Psychiatry, Epub). These investigators evaluated the efficacy and safety of a micronutrient formula comprised of vitamins and minerals, without omega fatty acids. It is the first double-blind randomized controlled trial to assess the effects of micronutrients (N = 42) compared with placebo (N = 38) on ADHD symptoms. It found that, compared with placebo, the micronutrient formula led to greater improvements in ADHD symptoms for self-ratings and observer-ratings but not for clinician ratings. The effect size of the clinical response ranged from 0.46 to 0.67, which is less than what is typically seen for ADHD medications (Faraone & S. J. Glatt (2010) J Clin Psychiatry 71 754-763). Only 48% of patients in the micronutrient group were rated as improved or very much improved. Although this was greater than the 21% rate in the placebo group, it is about half the response rate seen with stimulant medications. Importantly, the micronutrient and placebo groups did not differ in rates of adverse events. They authors wisely concluded that their results, albeit intriguing, provide only preliminary evidence for the value of micronutrients in treating adult ADHD. This work, and related studies of children and adolescents, will likely motivate more research into micronutrient treatments. Such treatments are especially appealing to patients due to their low side effect burden but given the small evidence based, they should be used with caution if their use will delay the use of treatments whose efficacy has been established. Of note, Rucklidge et al. reported treatment effects after eight weeks. Thus, if patients insist on monotherapy with micronutrients, they should not delay other treatments for longer than eight weeks without evidence that the micronutrients are working.