Stephen V. Faraone, PhDA Spanish team of researchers recently completed a comprehensive review of studies looking for links between compulsive video gaming (both online and offline) and a variety of psychological disorders, including anxiety, depression, social phobia, and ADHD. The focus was on behavior “of sufficient severity to result in significant impairment in personal, family, social, educational, occupational or other important areas of functioning.”

The team identified 24 studies, of which eight with a combined total of 16,786 participants looked for associations with either ADHD or its hyperactivity component. Participants included children, adolescents, and adults. One large longitudinal study, with 3,034 participants, found no association. Another study with 1,095 participants found a small effect. Two more, with a combined total of 11,868 found medium effect sizes. Four studies found large associations, but their combined total number of participants was 789, comprising less than a twentieth of the combined participants.

The authors concluded, “The relationship between Internet Gaming Disorder and ADHD and hyperactivity symptoms were analyzed in eight studies. Seven of them reported full association, with four finding large, two finding small, and one reporting moderate, effect sizes. The studies comprised two case-control, five cross-sectional and one longitudinal design; the latter found no association between the two variables.”[1] They also emphasized that 87 percent “of the studies describe significant correlations … with ADHD or hyperactivity symptoms.”[2]

Yet they did not note that all of the studies with large effect sizes were comparatively small. And while they presented funnel charts evaluating publication bias for anxiety and depression, they did not do so for ADHD, where the small studies with very large effect sizes suggest publication bias (i.e., that that evidence for association is exaggerated due to the early publication of positive findings).

Leaving out these small studies, the four high-powered studies with 15,997 participants reported effect sizes ranging from none to medium. Overall that suggests that there is an association between ADHD and videogaming, though not a particularly strong one. Moreover, due to the nature of the study designs, this work cannot conclude that the small effect observed is due to the playing video games being a risk factor for ADHD or to the possibility that ADHD youth are more attracted to video games than others.

Vega González-Bueso, Juan José Santamaría, Daniel Fernández, Laura Merino, Elena Montero and Joan Ribas, “Association between Internet Gaming Disorder or Pathological Video-Game Use and Comorbid Psychopathology: A Comprehensive Review,” International Journal of Environmental Research and Public Health, vol. 15, 668 (2018).

[1] One effect size was mischaracterized as small when in fact it was medium (OR = 2.43).

[2] In the abstract this was misleadingly worded, “The significant correlations reported comprised: 92% between IGD and anxiety, 89% with depression, 85% with symptoms of attention deficit hyperactivity disorder (ADHD),” suggesting a very strong correlation rather than an association of greatly varying effect size in seven of eight studies.


Stephen V. Faraone, PhDWe are only beginning to explore how ADHD affects sleep in adults. A team of European researchers recently published the first meta-analysis on the subject, drawing on thirteen studies with 1,439 participants. They examined both subjective evaluations from sleep questionnaires and objective measurements from actigraphy and polysomnography. However, due to differences among the studies, only two to seven could be combined for any single topic, generally with considerably fewer participants (88 to 873).

Several patterns emerged. Looking at results from sleep questionnaires, they found that adults with ADHD were far more likely to report general sleep problems (very large SMD effect size 1.55). Getting more specific, they were also more likely to report frequent night awakenings (medium effect size 0.56), taking longer to get to sleep (medium-to-large effect size 0.67), lower sleep quality (medium-to-large effect size 0.69), lower sleep efficiency (medium effect size 0.55), and feeling sleepy during the daytime (large effect size 0.75). There was little to no sign of publication bias, though considerable heterogeneity on all but night awakenings and sleep quality.

Actigraphy readings confirmed some of the subjective reports. On average, adults with ADHD took longer to get to sleep (large effect size 0.80) and had lower sleep efficiency (medium-to-large effect size 0.68). They also spent more time awake (small-to-medium effect size 0.40). There was little to no sign of publication bias and there was little heterogeneity among studies.

None of the polysomnographic measurements, however, found any significant differences between adults with and without ADHD. All effect sizes were small (under 0.20), and none came close to being statistically significant.

There were four instances where measurement criteria overlapped those from actigraphy and self-reporting, with varying degrees of agreement and divergence. There was no significant difference in total sleep time, matching findings from both the questionnaires and actigraphy. On percent time spent awake, polysomnography found little to no effect size with no statistical significance, whereas actigraphy found a small-to-medium effect size that did not quite reach significance, and self-reporting came up with a medium effect size that was statistically significant. On sleep onset latency and sleep efficiency, for which questionnaires and actigraphy found medium-to-large effects, the polysomnographic measurements found little to none, with no statistical significance.

Polysomnography found no significant differences in stage 1 sleep, stage 2 sleep, slow wave sleep, and REM sleep. With the exception of slow wave sleep, there was no sign of publication bias. Heterogeneity was generally minimal.

One problem with the extant literature is that many studies did not take medication status into account. In fact, the authors concluded, “future studies should be conducted in medication naïve samples of adults with and without ADHD matched for comorbid psychiatric disorders and other relevant demographic variables.”

In summary, these findings provide robust evidence that ADHD adults report a variety of sleep problems. In contrast, objective demonstrations of sleep abnormalities have not been consistently demonstrated. More work in medication naïve samples is needed to confirm these conclusions.

Amparo Díaz-Román, Raziya Mitchell, Samuele Cortese, “Sleep in adults with ADHD: Systematic review and meta-analysis of subjective and objective studies,” Neuroscience and Biobehavioral Reviews, vol. 89, p. 61-71 (2018).

In the popular media, ADHD is sometimes portrayed as a minor condition or not a disorder at all.   In fact, it is easy to find web sites claiming that ADHD is an invention of the medical profession and that the symptoms used to diagnose the disorder are simply normal behaviors that have been “medicalized”.   These claims are wrong.  They miss the main point of any psychiatric diagnostic process which is to identify people who experience distress or disability due to a set of well-defined symptoms.  So, does ADHD cause serious distress and disability?   It is a serious psychiatric condition?  To illustrate the strong evidence base for the “Yes” answer to that question, my colleagues and I constructed this infographic for our “Primer” about ADHD,   It describes the many ways in which the symptoms of ADHD impact and impair the lives of children, adolescents and adults with the disorder.  We divided these ‘impacts’ into four categories: other disorders (both psychiatric and medical), psychological dysfunction, academic and occupational failure, social disability and risky behaviors.  Let’s start with other health problems.  We know from many studies that have followed ADHD children into adolescence and adulthood that having the disorder puts patients at risk for several psychiatric disorders, addictions, criminality, learning disabilities and speech/language disorders. ADHD even increases the risk for non-psychiatric disease such as obesity, hypertension and diabetes.  Perhaps most worrisome is that people with ADHD have a small increased risk for premature death.  This increased risk is due in part to their having other psychiatric and medical conditions and also to their risky behaviors which, as research documents, lead to accidents and traumatic brain injuries.   In the category of ‘psychological dysfunction’ we highlighted emotional dysregulation, which makes ADHD people quick to anger or to fail to tame extreme emotions.  Other serious psychological issues are low self-esteem and increased thoughts of suicide, which lead to more suicide attempts than for people without ADHD.  This increased risk for suicide is small, but it is real.    A more prevalent impact of ADHD is the broad category of social disability, which includes marital discord, poor parenting, legal problems, arrests and incarceration.   This typical starts in youth with poor social adjustment and conflict with parents, siblings and friends.  Another common impact of ADHD is on academic and vocational pursuits.  ADHD youth are at risk for underachievement in school, repeating grades and dropping out.  As adults, they are more likely to unemployed or underemployed, which leads to them having lower incomes than expected for their level of achievement in school.   So, don’t believe anyone who claims that ADHD is not a disorder or is only a mild one.   To be sure, there is a wide range of impairment among people with ADHD but, in the absence of treatment, they are at risk for adverse outcomes.  Fortunately, the medications that treat ADHD have been documented to reduce this risk, which is why they are typically the first line treatment for most people with ADHD.


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;

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Childhood ADHD is known to persist into adolescence and adulthood in 40-70% of patients. However, its presentation changes with age; symptoms of hyperactivity become less prominent, while difficulties with attention and impulsivity may remain, and executive function problems become increasingly important[i]. Due to this evolving presentation, those with a childhood history of ADHD may not meet full ADHD diagnostic criteria, as adults. Yet, even high-functioning individuals who perform adequately on neuropsychological testing may continue to experience executive dysfunction, emotional dysregulation, and psychosocial impairment in their personal and professional lives[ii]. Over the last decade, longitudinal follow-up studies of clinic-referred adults who had childhood ADHD have begun to characterize the deleterious effects of childhood ADHD on adult functioning in various domains.

Recently, Voigt and colleagues from the Barbaresi group recently published the first prospective, population-based study documenting adult academic outcomes among patients with research-identified (including DSM-IV diagnostic criteria) childhood ADHD versus non-ADHD referents[iii]. The study sample, drawn from a 1976 to 1982 birth cohort, was unique in that 1) both ADHD and No-ADHD study subjects were members of a population-based sample, not clinic-referred individuals; 2) the subjects’ lifetime medical and school records were available to the investigators; and 3) the Barbaresi group has followed this birth cohort for over 15 years.

For this follow-up study, an academic achievement battery was administered to 232 young adults (mean age 27 years) with research-identified ADHD and 335 referents (mean age 28 years) from the birth cohort. The battery included tests of basic reading, vocabulary, passage comprehension, and arithmetic. After controlling for age, sex, comorbid learning disability status, and maternal education level, Voigt, et al. found that participants with childhood ADHD scored 3 to 5 grade equivalents lower on all academic tests, compared with their non-ADHD peers. All findings had moderate-to-large effect sizes (Cohen’s d= -.55 to -.82). 

Interestingly, only 68 of the 232 (29%) participating childhood ADHD cases met the DSM-IV diagnostic criteria for adult ADHD. Yet, there was no significant difference in test scores between childhood ADHD cases with remitted and persistent ADHD, even after controlling for the presence of a co-morbid learning disability (LD). Voigt, et al. believe that this lack of difference indicates that ADHD alone is responsible for the poorer acquisition of academic skills during childhood and adolescence. Academic underachievement in math and reading is strongly associated with lower academic motivation, shorter duration of education, and longer-term socioeconomic adversity, as Biederman and Faraone demonstrated, over a decade ago4. Consistent with their findings, Voigt’s study highlights ADHD as an independent risk factor for poor long-term academic outcomes, predicting far-reaching challenges for adult well-being.

Regarding potential interventions, Voigt, et al. suggest that their findings demonstrate that early and continuous academic interventions for ADHD should be the norm for students with ADHD, since it has a chronic course and long-term consequences, even in those whose ADHD eventually remits. Unfortunately, very few students with ADHD get more than in-class accommodations, under Section 504 of the Rehabilitation Act. While ADHD can qualify many children for specific remedial academic instruction with an Individualized Educational Plan (IEP), when ADHD is considered under the “Other Health Impairment” category of disabilities, few children with ADHD actually receive these services, unless they have a comorbid LD. Based on the positive outcomes from remedial tutoring and teaching of strategies to cope with executive dysfunction demonstrated by other studies, Voigt, et al. advocates for the more frequent inclusion of students with ADHD in formal remedial education programs. Other studies suggest that long-term treatment with stimulant medication can protect many children with ADHD from repeating a grade, and may even protect some from some of ADHD’s common psychiatric comorbidities5. Both pharmacotherapy and educational intervention are likely to produce the best outcomes.

Voigt, et al.’s findings also suggest another mechanism for the association between ADHD and poorer adult outcomes. If childhood ADHD interferes with the acquisition of foundational academic skills, perhaps it also hinders the development of other life skills important to navigating adulthood successfully. With so much at stake, it becomes crucial for patients diagnosed with ADHD as children to receive adequate and ongoing multimodal treatments, with adjustments over time as new challenges appear. Multiple interventions and careful follow-up throughout the lifespan must become the norm in the treatment of those with ADHD, as it is for all other chronic medical disorders.



  1. Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, Ramos-Quiroga JA, Rohde LA, Sonuga-Barke EJS, Tannock R, Franke B. Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers 2015; Aug 6: 15020.
  1. Torralva T, Gleichgerrcht E, Lischinsky A, Roca M, Manes F. “Ecological” and Highly Demanding Executive Tasks Detect Real-Life Deficits in High-Functioning Adult ADHD Patients. Journal of Attention Disorders 2012; 17(1): 11–19.
  1. Voigt RG, Katusic SK, Colligan RC, Killian JM, Weaver AL, Barbaresi WJ. Academic Achievement in Adults with a History of Childhood Attention-Deficit/Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics 2017; 38(1): 1–11.
  1. Biederman J, Faraone SV. The effects of attention-deficit/hyperactivity disorder on employment and household income. MedGenMed 2006; 8(3): 12.
  1. Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV. Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics 2009; 124(1): 71-78.




I have too often seen on the Internet or media the statement that ADHD is a recent invention of psychiatrists and/or pharmaceutical companies.  Such statements ignore the long history of ADHD that my colleague and I reviewed in our “Primer” about ADHD,   As you can see from The Figure, ADHD has a long history.  The first ADHD syndrome was described in a German medical textbook by Weikard in 1775.  That’s not a typo.  The ADHD syndrome had been identified before the birth of the USA.   Dr. Weikard did not use the term ADD or ADHD, yet he described a syndrome of hyperactivity and inattention that corresponds to what we call ADHD today.  As you can see from the Figure, ADHD-like syndromes were described in Scotland in 1798 and in France in the late 19th century.  The first description of an ADHD-like syndrome in a medical journal was by Dr. George Still in 1901 who described what he called a ‘defect of moral control” in The Lancet.  The discovery that stimulant drugs are effective in treating ADHD occurred in 1937 when Dr. Charles Bradley discovered that Benzedrine (an amphetamine compound) improved the behavior of children diagnosed with behavioral disorders.  In subsequent years, several terms were used to describe children with ADHD symptoms.  Examples are Kramer-Pollnow syndrome, minimal brain damage, minimal brain dysfunction and hyperkinetic reaction.  It was not until the 1980s that the term Attention Deficit Disorder (ADD) came into widespread use with the publication of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM).   During the ensuing decades, several changes were made to the diagnostic criteria and the term ADD was replaced with ADHD so as not to overemphasize either inattention of hyperactivity when diagnosing the disorder.  And, as the graphic below describes, these new and better diagnostic criteria led to many breakthroughs in our understanding of the nature of the disorder and the efficacy of treatments.   So, if you think that ADHD is an invention of contemporary society, think again.  It has been with us for quite some time.


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;

Screen Shot 2017-03-12 at 8 Ralh0G




Eight Pictures Describe Brain Mechanisms in ADHD

When my colleagues and I wrote our “Primer” about ADHD,, the topic of brain mechanisms was a top priority.   Because so much has been written about the ADHD brain, it is difficult to summarize.   Yet we did it with the eight pictures reproduce here in one Figure.   A quick overview of this Figure shows you the complexity of ADHD’s pathophysiology.  There is no single brain region or neural circuit that is affected.   Figures (a) and (b) show you the main regions implicated by structural and functional neuroimaging studies.  As (c) shows, these regions are united by neural networks rich in noradrenalin (aka, norepinephrine) and dopamine, two neurotransmitters whose activity is regulated by medications that treat ADHD.  Figure (d) describes two functional networks.   The Executive Control network is, perhaps, the best described network in ADHD.  This network regulates behavior by linking dorsal striatum with the dorsolateral prefrontal cortex.  This network is essential for inhibitory control, self-regulation, working memory and attention.  The Corticocerebellar network is a well-known regulator of complex motor skills.  Data also suggest it play a role in the regulation of cognitive functions.   Figure (d) describes the Reward Networks of the brain that link ventral striatum with prefrontal cortex.   This network regulates how we experience and value rewards and punishments.   In addition to its involvement in ADHD, this network has also been implicated in substance use disorders, for which ADHD persons are at high risk. Figures (f) (g) and (h) complete the puzzle with additional regions implicated in ADHD whose role is less well understood.  One role for these regions is in the regulation of the Default Mode Network, which controls what the brain does when it is not focused on any specific task (e.g., daydreaming, mind wandering).  People differ in the degree to which they shift between the default mode network and networks like Reward or Executive Control, which are active when we engage the world.  Recent data suggest that the brains of ADHD people may be in ‘default mode’ when they ought to be engaged in the world.    


Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;

Faraone 8 Brain Images

Kevin Antshel, PhD, ADHD in AdultsOccupational impairments are one of the most common outcomes for adults with ADHD. As a function of ADHD symptoms and associated problems such as psychiatric comorbidities and executive function impairments, adults with ADHD often experience difficulties finding and maintaining jobs and are at increased risk for being unemployed or underemployed. Given the variety of outcomes that are associated with occupational functioning (e.g., quality of life, socioeconomic status and subsequent healthcare access, etc.), efforts to understand ADHD in the occupational setting represent a clinically significant topic. Despite being an environment in which adults with ADHD spend considerable time, very few existing studies have considered how the occupational environment impacts ADHD.

A very recently published paper1 fills this void and examines how young adults with ADHD perceive their occupational environment and the extent to which this environment influences their ADHD symptoms. Using a qualitative research design, one of the primary research questions that the authors investigated was the extent to which certain occupational settings are a better fit for young adults with ADHD. The participants in this study all were young adults with well defined ADHD that was diagnosed in childhood. All participants were ascertained from the Multimodal Treatment Study of ADHD (MTA)2 and were approximately 24 years of age at the time of their qualitative interview.

The majority of young adults with ADHD reported a connection between occupational environments and ADHD symptoms. While certain work environments intensified ADHD symptoms, other work environments ameliorated symptoms. The importance of the “goodness of fit” between occupational environment and person was a consistent theme that emerged from the qualitative interviews. A view that problems were environmental, not personal, helped to reduce feelings of inadequacy. The young adults with ADHD commonly reported that a highly stimulating environment provided the best person-environment fit. A highly stimulating environment was further operationalized as consisting of some of these elements: stressful work that is novel and requires multitasking, working in a busy and fast-paced environment, completing work that is physically demanding or hands-on in nature, and/or working on tasks that are intrinsically interesting.

The authors concluded that ADHD symptoms are occupationally context-dependent; work environments may either increase or decrease ADHD symptoms dependent upon the “goodness of fit”1. The authors further assert that future research should consider the effectiveness of occupational “fit” as a potential intervention. In my own clinical experiences, I can relate that person-environment fit indeed has a salient impact upon symptom and functioning levels. As I commonly tell parents of children with ADHD, “there is no better intervention than a great teacher who understands your child”. These recently published data suggest that the same principles may hold for young adults, albeit with a different environmental context. This paper is important and reinforces the notion that context “matters”. Rather than ADHD being static, it is more accurate to view ADHD as dynamic and an interaction between the person and the environment.

Similar research has been published in outlets that are likely not familiar to mental health professionals. In the entrepreneur literature, several recent papers have been published on the association between entrepreneurship and having an ADHD diagnosis3 or elevated ADHD symptoms4,5. These research groups have demonstrated positive relationships between ADHD and entrepreneurial intentions (commitment to performing a behavior that is necessary to start a business venture) and the link between ADHD and entrepreneurial orientation (generally considered to be the level of innovation, creativity, proactiveness and risk-taking that an individual possesses). These three studies as well as a case study6 suggest that it is hyperactivity-impulsivity symptoms, not inattention symptoms, that are positively linked to entrepreneurship. Similar to the MTA ADHD researchers described above, these entrepreneurship investigators also concluded that the functional outcomes associated with ADHD are dynamic and context-dependent.

While these entrepreneur data are interesting, much research remains to be done regarding the association between ADHD and entrepreneurship. For example, the existing studies have methodological constraints (e.g., the variance of entrepreneurial orientation explained by ADHD symptoms is low, common method bias [relying exclusively on self-report], etc.). Likewise, these entrepreneurship papers have considered entrepreneurial orientation and intention, not entrepreneurial success. Thus, future work should consider the extent to which individuals with ADHD experience successful outcomes as entrepreneurs. For example, in which industry and contexts/situations (e.g., managing finances, developing a new product, marketing, etc.) might individuals with ADHD experience entrepreneurial success? My suspicion is that there will be no, “one size fits all” conclusions. In other words, the entrepreneurship success is context-dependent and varies widely among adults with ADHD. The exciting part of this line of investigation, however, is the seismic shift in focus: conventional workplace liabilities associated with ADHD may emerge as abilities in an entrepreneurship context.

1. Lasky AK, Weisner TS, Jensen PS, et al. ADHD in context: Young adults’ reports of the impact of occupational environment on the manifestation of ADHD. Social science & medicine. 2016;161:160-168.
2. MTA Collaborative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of general psychiatry. 1999;56(12):1073-1086.
3. Dimic N, Orlov V. Entrepreneurial Tendencies Among People with ADHD. International Review of Entrepreneurship. 2014;13:187-204.
4. Thurik R, Khedhaouria A, Torrès O, Verheul I. ADHD symptoms and entrepreneurial orientation of small firm owners. Applied Psychology: An International Review. 2016;65:568-586.
5. Verheul I, Block J, Burmeister-Lamp K, Thurik R, Tiemeier H, Turturea R. ADHD-like behavior and entrepreneurial intentions. Small Business Economics. 2015;45:85-101.
6. Wiklund J, Patzelt H, Dimov D. Entrepreneurship and psychological disorders. Frontiers of Entrepreneurship Research. 2014;34:50-59. the growth of the Internet, we are flooded with information about attention deficit hyperactivity disorder from many sources, most of which aim to provide useful and compelling “facts” about the disorder. But, for the cautious reader, separating fact from opinion can be difficult when writers have not spelled out how they have come to decide that the information they present is factual.

My blogs several guidelines to reassure readers that the information they read about ADHD is up-to-date and dependable. They are as follows:
Nearly all the information presented is based on peer-reviewed publications in the scientific literature about ADHD. “Peer-reviewed” means that other scientists read the article and made suggestions for changes and approved that it was of sufficient quality for publication. I say “nearly all” because in some cases I’ve used books or other information published by colleagues who have a reputation for high quality science.

When expressing certainty about putative facts, I am guided by the principles of evidenced based medicine, which recognizes that the degree to which we can be certain about the truth of scientific statements depends on several features of the scientific papers used to justify the statements such as the number of studies available and the quality of the individual studies. For example, compare these two types of studies. One study gives drug X to 10 ADHD patients and reports that 7 improved. Another gave drug Y to 100 patients and a placebo to 100 other patients and used statistics to show that the rate of improvement was significantly greater in the drug treated group. The second study is much better and much larger, so we should be more confident in its conclusions. The rules of evidence are fairly complex and can be viewed at the Oxford Center for Evidenced Based Medicine (OCEBM;

The evidenced-based approach incorporates two types of information: a) the quality of the evidence and b) the magnitude of the treatment effect. The OCEBM levels of evidence quality are defined as follows (higher numbers are better:

  1. Mechanism based reasoning.   For example, some data suggest that oxidative stress leads to ADHD and we know that omega-3 fatty acids reduce oxidative stress.  So there is a reasonable mechanism whereby omega-3 therapy might help ADHD people.
  2. Studies of one or a few people without a control group or studies that compare treated patients to those that were not treated in the past.
  3. Non-randomized, controlled studies.    In these studies the treatment group is compared to a group that receives a placebo treatment, which is a fake treatment not expected to work.   Non-randomized means that the comparison might be confounded by having placed different types of patients in the treatment and control groups.
  4. Single randomized trial.   This type of study is not confounded.
  5. Systematic review and meta-analysis of randomized trials.  This means that many randomized trials have been completed and someone has combined them to reach a more accurate conclusion.

It is possible to have high quality evidence proving that a treatment ‘works’ but the treatment might not work very well.  So it is important to consider the magnitude of the treatment effect, also called the “effect size” by statisticians.  For ADHD, it is easiest to think about ranking treatments on a ten point scale.   The stimulant medications have a quality rating of 5 and also have the strongest magnitude of effect, about 9 or 10.  Omega-3 fatty acid supplementation ‘works’ with a quality rating of 5, but the score for magnitude of effect is only 2 so it doesn’t work very well.  We have to take into account patient or parent preferences, comorbid conditions, prior response to treatment and other issues when choosing a treatment for a specific patient, but we can only use an evidenced-based approach when deciding which treatments are well supported as helpful for a disorder. 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:
-if you listen to a boring one hour lecture, I will pay you $100 immediately after the lecture
-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:
-if you listen to a boring one hour lecture, I will pay you $100 immediately after the lecture
-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.

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. myths have been manufactured about attention deficit hyperactivity disorder (ADHD).  Facts that are clear and compelling to most scientists and doctors have been distorted or discarded from popular media discussions of the disorder.   Sometimes, the popular media seems motivated by the maxim “Never let the facts get in the way of a good story.”  That’s fine for storytellers, but it is not acceptable for serious and useful discussions about ADHD.

Myths about ADHD are easy to find.  These myths have confused patients and parents and undermined the ability for professionals to appropriately treat the disorder.   When patients or parents get the idea that the diagnosis of ADHD is a subjective invention of doctors, or that ADHD medications cause drug abuse, that makes it less likely they will seek treatment and will increase their chances of having adverse outcomes.

Fortunately, as John Adams famously said of the Boston Massacre, “Facts are stubborn things.”  And science is a stubborn enterprise; it does not tolerate shoddy research or opinions not supported by fact.   ADHD scientists have addressed many of the myths about the disorder in the International Consensus Statement on ADHD, a published summary of scientific facts about ADHD endorsed by a of 75 international ADHD scientists in 2002.  The statement describes evidence for the validity of ADHD, the existence of genetic and neurobiologic causes for the disorder and the range and severity of impairments caused by the disorder.The

Statement makes several key points:

  • The U.S. Surgeon General, the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, and the American Academy of Pediatrics recognize ADHD as a valid disorder.
  • ADHD involves a serious deficiency in a set of psychological abilities and that these deficiencies pose serious harm to most individuals possessing the disorder.
  • Many studies show that the psychological deficits in people with ADHD are associated with abnormalities in several specific brain regions.
  • The genetic contribution to ADHD is routinely found to be among the highest for any psychiatric disorders.
  • ADHD is not a benign disorder. For those it afflicts, it can cause devastating problems.

The facts about ADHD will prevail if you take the time to learn about them.   This can be difficult when faced with a media blitz of information and misinformation about the disorder.  In future blogs, I’ll separate the fact from the fiction by addressing several popular myths about ADHD.