College Students and Risky Behavior

Anthony L. Rostain, MD MA on April 9, 2015

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR. “ADHD Symptomatology and Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.


This study explores the relative contributions of “top-down” (i.e. effortful control) and “bottom up” (i.e. sensation seeking) mental processes to maladaptive risky behaviors in college students with ADHD. The authors review these constructs by pointing out that effortful aspects of self-regulation involve intact prefrontal circuits underlying executive functions whereas reactive behaviors not requiring conscious mental resources are influenced by emotional stimuli and are mediated by subcortical brain structures. Given that ADHD involves difficulties in both these domains of psychological functioning, it makes sense to explore which contribute to the onset of maladaptive risk-taking in college students with ADHD.


The authors studied 555 college students attending a southeastern university using an online survey for which they received class credit. Participants filled out standardized rating scales to assess outcomes. Of the total sample, 5.7% reported a history of an ADHD diagnosis and 10.8% reported elevated ADHD symptoms (> 1.5 SD above the mean) on an ADHD rating scale. There were two distinct patterns of risk behaviors: risky driving/financial behaviors and risky health behaviors. ADHD symptoms were highly correlated with these two factors as well as with sensation seeking and effortful control. More ADHD symptoms were associated with risky behaviors ONLY when effortful control was low. Sensation seeking was more highly associated with risky health behaviors but not risky driving/financial behaviors.


The authors note that the study’s reliance on self-report scales and measures limits its validity. ADHD individuals are known to underreport severity of symptoms. Moreover, it was not possible to detect the presence of antisocial behaviors (e.g. Conduct Disorder) that might have a greater impact on risky behaviors than ADHD symptoms. Finally, the fact that the study was conducted on a single campus may limit the generalizability of its findings to the entire population of US college students.


Despite these limitations, this paper reports interesting results suggesting that ADHD symptoms may not be as important as effortful control deficits and as high stimulus seeking in mediating the onset of risk behaviors in this population. These could be important targets for psychological therapies. It also points to the relevance of these two aspects of psychological functioning for preventive health efforts to reduce health, driving and financial risk behaviors, and for clinical approaches to dealing with patients presenting with maladaptive coping mechanisms.

ADHD and Risky Behavior in Adults

Anthony L. Rostain, MD MA on April 9, 2015

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR.  “ADHD Symptomatology andTony_Rostain_AIA-5Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.


This study explores the relative contributions of “top-down” (i.e. effortful control) and “bottom up” (i.e. sensation seeking) mental processes to maladaptive risky behaviors in college students with ADHD.  The authors review these constructs by pointing out that effortful aspects of self-regulation involve intact prefrontal circuits underlying executive functions whereas reactive behaviors not requiring conscious mental resources are influenced by emotional stimuli and are mediated by subcortical brain structures.  Given that ADHD involves difficulties in both these domains of psychological functioning, it makes sense to explore which contribute to the onset of maladaptive risk-taking in college students with ADHD.


The authors studied 555 college students attending a southeastern university using an online survey for which they received class credit.   Participants filled out standardized rating scales to assess outcomes.  Of the total sample, 5.7% reported a history of an ADHD diagnosis and 10.8% reported elevated ADHD symptoms (> 1.5 SD above the mean) on an ADHD rating scale. There were two distinct patterns of risk behaviors: risky driving/financial behaviors and risky health behaviors.  ADHD symptoms were highly correlated with these two factors as well as with sensation seeking and effortful control.   More ADHD symptoms were associated with risky behaviors ONLY when effortful control was low.   Sensation seeking was more highly associated with risky health behaviors but not risky driving/financial behaviors. 


The authors note that the study’s reliance on self-report scales and measures limits its validity.  ADHD individuals are known to underreport severity of symptoms.  Moreover, it was not possible to detect the presence of antisocial behaviors (e.g. Conduct Disorder) that might have a greater impact on risky behaviors than ADHD symptoms.  Finally, the fact that the study was conducted on a single campus may limit the generalizability of its findings to the entire population of US college students.  (Note: Watch our Ask the ADHD Experts Session on ADHD and College Students.)


Despite these limitations, this paper reports interesting results suggesting that ADHD symptoms may not be as important as effortful control deficits and as high stimulus seeking in mediating the onset of risk behaviors in this population.    These could be important targets for psychological therapies.  It also points to the relevance of these two aspects of psychological functioning for preventive health efforts to reduce health, driving and financial risk behaviors, and for clinical approaches to dealing with patients presenting with maladaptive coping mechanisms.  

Training the ADHD Brain

Stephen V. Faraone, PhD on April 2, 2015

It sounds like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention. Two main approaches have been used: cognitive training and neurofeedback.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses. Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain. The idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process. Cognitive retraining helps people who have suffered brain damage, so was logical to think it might help the types of brain differences seen in ADHD people. Several software packages have been created to deliver cognitive training sessions to ADHD people. You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG). We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information. Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms. In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head. The patient is asked to do a task on the computer that is known to produce a specific type of brain wave. The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are. By modifying their behavior, patients learn to change their brain waves. The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied. If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine. My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals. The highest level of evidence is a meta-analysis of randomized controlled clinical trials. For my lay readers, that means that many rigorous studies have been conducted and summarized with a sophisticated mathematical method. Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms. They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective. You can learn more about non-pharmacologic treatments for ADHD from 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.

Depression and ADHD Life Events

Lenard A. Adler, on March 26, 2015

This article** examines the co-occurrence of adverse life events and depression in a cohort of older adults with ADHD. The study is important as ADHD and depression are highly co-morbid in both younger and older adults. The authors examined the co-occurrence of life events as a possible link with ADHD and depression. Patients (n=230) in the Longitudinal Aging Study Amsterdam (LASA) were examined for the presence of ADHD with the DIVA (Diagnostic Interview for ADHD in Adults).

The authors found that the older adults with ADHD had significantly more depressive symptoms and life events than the older adults without ADHD. One caveat to the interpretation of this data is that non-DSM diagnostic criteria were employed. Never the less, this association of depression and life events is of interest as it may highlight another potential consequence of the inattention or impulsivity seen with ADHD and highlights the need for future study of this association.

Logistic and linear regression analyses were used to examine the relationship between ADHD symptoms, depressive symptoms and life events. Subjects with significant cognitive decline were excluded from the sample to remove this potential confound. ADHD symptom criteria were defined as having four significant symptoms of inattention and/or hyperactivity-impulsivity in the six months prior to the interview, which is more liberal than the cut-off of five significant symptoms in DSM-5 and six significant symptoms in DSM-IV; however a stricter cut-off than DSM criteria was used of requiring six symptoms of inattention and/or hyperactivity-impulsivity in childhood. Depressive symptoms were assessed with the Center for Epidemiological Studies-Depression scale (CES-D).

 

** E.J. Semeijn, H.C. Comijs, J.J.S. Kooij, M. Michielsen, A.T.F. Beekman, D.J.H. Deeg. The role of adverse life events on depression in older adult with ADHD. Journal of Affective Disorders. DOI: http:

Natural Remedies for ADHD – Fish Oil

Stephen V. Faraone, PhD on March 19, 2015

If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine. My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals. The highest level of evidence is a meta-analysis of randomized controlled clinical trials. For my lay readers, that means that many rigorous studies have been conducted and summarized with a sophisticated mathematical method.


If you are interested in fish oil among ADHD alternative treatments, there is some good news. Many good studies have been published and these have been subjected to meta-analysis. To be more exact, we’re discussing omega-3 polyunsaturated fatty acids (PUFAs), which are found in many fish oils. Omega-3 PUFAs reduce inflammation and oxidative stress, which is why they had been tested as treatments for ADHD. When these studies were meta-analyzed, it became clear that omega-3 PUFAs high in eicosapentaenoic acid (EPA) helped to reduce ADHD symptoms. For details see: Bloch, M. H. and J. Mulqueen (2014). “Nutritional supplements for the treatment of ADHD.” Child Adolesc Psychiatr Clin N Am 23(4): 883-897.


So, if omega-3 PUFAs help reduce ADHD symptoms, why are doctors still prescribing ADHD drugs? The reason is simple. Omega-3 supplements work, but not very well. On a scale of one to 10 where 10 is the best effect, drug therapy scores 9 to 10 but omega-3 therapy scores only 2. Some patients or parents of patients might want to try omega-3 therapy first in the hopes that it will work well for them. That is a possibility, but if that is your choice, you should not delay the more effective drug treatments for too long in the likely event that omega-3 therapy is not sufficient. What about combining ADHD drugs with omega-3 supplements? We don’t know. I hope that future research will see if combined therapy might reduce the amount of drug required for each patient.


Keep in mind that the treatment guidelines from professional organizations point to ADHD medications as the first line treatment for 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.


You can learn more about non-pharmacologic treatments for ADHD from 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.

Dialetical Behavior Therapy, College Students, and ADHD

Anthony L. Rostain, MD MA on March 18, 2015

J Atten Disord. 2015 Mar;19(3):260-7. DOI: 10.1177/1087054714535951
“Pilot Randomized Controlled Trial of Dialectical Behavior Therapy Group Skills Training for ADHD Among College Students”
Fleming, A.P., McMahon, R.J., Moran, L.R., Peterson, A.P., Dreessen, A.

This article reports on the results of the first randomized controlled clinical trial of treatment program for college students with ADHD. Thirty-three college students with ADHD between the ages of 18 and 24 years were randomized to receive either group administered Dialectical Behavior Therapy (DBT) supplemented by individualized week coaching phone calls or a skills handouts (SH) intervention based on a published manual for adults with ADHD. The DBT intervention consisted of eight weekly 90 minute sessions and seven weekly 10-15 minute individual coaching phone calls designed to assist participants to address key areas of difficulty. A booster session was offered to subjects during the first week of the following academic quarter. Session topics included psycho-education about ADHD, mindfulness, daily planner use, chunking tasks, prioritization, structuring the environment, using social support, managing sleep, eating and exercise, emotion regulation, and troubleshooting about skills use. The SH material topics included psycho-education about ADHD and executive functioning, organization, planning, time management, structuring the environment and stress management. Outcome measures included the Barkley Adult ADHD Rating Scale IV (symptom measurement), the Brown ADD Rating Scales (as a proxy for executive functioning), the ADHD Qualify of Life Questionnaire, the Beck Depression and Anxiety Inventories, the Fie Facet Mindfulness Questionnaire, the subject’s GPA from the academic quarter prior to each assessment point, and performance on the Conners’ Continuous Performance Task (CPT). Both groups had similar baseline measures and treatment completion rates. At the conclusion of the study, compared to the SH participants, subjects receiving DBT and coaching phone calls showed significant improvement in treatment response rates (59-65% v 19-25%) and clinical recovery rates (53-59% v 6-13%). At follow up, DBT subjects showed greater improvements in ADHD symptoms, executive functioning and mindfulness. No differences between groups were seen in comorbid symptoms, GPA or on CPT measures, although a trend toward significance was reported. Of note, subjects in the SH group did have a treatment response rate of 25% which suggests this may be a cost effective alternative. Participants in the DBT group reported that mindfulness, planning and organization were the most helpful aspects of the program. Overall, these are promising results from a small RCT of a structured group-administered skills training program for college students with ADHD. While it is important to replicate this intervention on a broader scale, these results suggest that programs of this sort should be made more widely available to this population.

Oros Methylphenidate, ADHD and Executive Function Deficits

Anthony L. Rostain, MD MA on March 12, 2015

Proven ADHD Medications for Adults – OROS-methylphenidate

Many studies have documented that ADHD patients have difficulties with the type of complex brain processes neurologists call “Executive Functions” (EF). A 2011 study of ADHD in Adults for example found roughly 40% have executive function deficits (EFDs) (Biederman, et al. 2011). EFs help us organize our lives, manage time, remember complex material and complete complex sequences of behavior. A deficit in executive function is therefore one of the common symptoms of Adult ADHD.
A recent study on medication for ADHD in adults examines the effects of OROS-methylphenidate on executive function deficits (EFDs) (Tannetje I. et al.. “OROS-methylphenidate efficacy on specific executive functioning deficits in adults with ADHD: A randomized, placebo-controlled cross-over study.” European Neuropsychopharma-cology. Available online 17 January 2014, ISSN 0924-977X. http://dx.doi.org/10.1016/j.euroneuro.2014.01.007). The authors used a randomized, placebo-controlled cross-over design to examine the effects of a 72 mg dose of OROS-MPH on 22 subjects’ performance on two versions of the Continuous Performance Test (CPT), a measure of sustained attention and working memory.

Study subjects were stimulant medication-naive. 25% had no Continuous Performance Test (CPT) deficits, 50% had a few CPT deficits, and 25% had multiple deficits, which is consistent with the Biederman study previously noted. Compared with placebo, OROS-MPH improved performance only on reaction time variability (RTV), a measure of sustained attention. High RTV indicates a deficit in information processing and functional integration. Patients with higher EFDs and more severe ADHD symptoms had a better response to medication. Differences in commission errors and discriminative ability between placebo vs OROS-MPH individuals were not noted. In addition, there was a poor relationship between objective and subjective efficacy of the medication.

The findings of this well designed experimental study are interesting in several ways. First, even with a small sample, robust effects of OROS-MPH vs. placebo were seen on Response Time Variability (RTV). In individuals with ADHD, RTV has been shown to be highly responsive to stimulant medication (Kofler, et al, 2012). This study confirms this finding.
Second, this study validates the use of an objective neurocognitive test to measure the responsiveness of adults with ADHD to pharmacologic treatment. An objective test of medication response could help to allay public health concerns about ADHD treatment options and the safety and efficacy of stimulant medications for ADHD symptoms in adults.

Thirdly, the RTV finding is compelling. While there remains a great deal of controversy about the role of EFDs in the etiology of ADHD, it is reasonable to assert that RTV has a great deal of salience to the phenomenology of the disorder, especially in adults. Indeed, trouble maintaining sustained attention is the most common subjective complaint reported by adults with ADHD, and is arguably the most constant neurocognitive impairment seen in this population. Clearly it is not unique to ADHD, but it certainly comprises a core feature of the disorder, and has become a central construct in neuropsychological and neuroimaging research.

The authors are honest in their appraisal of the limitations of the study (most notably the small sample size and the heterogeneity of sample subjects’ performance on the CPT at baseline), and they are very reasonable in recommending that more research be undertaken to document the clinical relevance of using the CPT in patient care, as well as to extend our understanding of the underlying neuropsychology of ADHD.

 

References
Biederman J, Mick E, Fried R, Wilner N, Spencer TJ, Faraone SV (2011). “Are stimulants effective in the treatment of executive function deficits? Results from a randomized double blind study of OROS-methylphenidate in adults with ADHD.” Eur. Neuropsychopharmacol., 21: 508–515.
Kofler MJ, Rapport MD, Sarver DE, Raiker JS, Orban SA, Friedman LM, E.G. Kolomeyer EG (2013). “Reaction time variability in ADHD: a meta-analytic review of 319 studies.” Clin. Psychol. Rev., 33 795–811.
Tamm, L, Narad ME, Antonini TN, O’Brien KM, Hawk Jr. LW, J.N. Epstein JN (2012). “Reaction time variability in ADHD: a review.” Neurotherapeutics: J. Am. Soc. Exp. NeuroTherapeutics, 9: 500–508.

ADHD and PTSD

Lenard A. Adler, on March 6, 2015

J Atten Disord. 2014 Feb 24.  The Neuropsychological Profile of Comorbid Post-Traumatic Stress Disorder in Adult ADHD. Antshel KM, Biederman J, Spencer TJ, Faraone SV.


This article describes an examination of potential differences in neuropsychological functioning between a cohort of adults with ADHD (n=186), ADHD and PTSD (n=20) and a non-ADHD control group (n=123) who received psychiatric evaluations and neuropsychological tests (including WAIS intelligence, tests of frontal executive function (Wisconsin Card Sorting Test, Stroop Color and Word Test) the California Verbal Learning Test (CVLT) the Rey-Osterrieth Complex Figure Test (ROCF) and an auditory working memory continuous performance task (CPT). 


CME LEARN HERE  Improving Executive Function   in Adult ADHD


Overall the group with ADHD (whether they had PTSD or not) had significantly lower scores on the battery of neuro-psychological tests than the non-ADHD controls. However, the group with ADHD and PTSD had lower neuropsychological test scores on a number of measures versus the group with ADHD alone (WAIS full scale IQ and block design, ROCF copy accuracy and copy time and Stroop Color T-score). 


Measures of quality of life were not shown to be predictors of PTSD status. Additionally, in this study, the group with ADHD had lower socio-economic status and were more likely to be of non-Caucausian ethnicity.


Interpretation of the findings of this trial is somewhat limited by the small cohort of ADHD and PTSD patients.  Never the less, this study is important as it is the first investigation to examine neuropsychological deficits in individuals with ADHD and PTSD; it also adds to our increasing understanding of the increased burden of having ADHD and PTSD. Prior studies have shown that PTSD may be a vulnerability factor for developing future ADHD. 


These studies indicate that clinicians should be careful in screening individuals with ADHD for co-morbid PTSD and that the combination of disorders may carry a higher neuropsychological burden that should be accounted for in making the adult ADHD diagnosis.

Myths About the Treatment of ADHD

Stephen V. Faraone, PhD on March 2, 2015

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.

ADHD and Diet

Stephen V. Faraone, PhD on February 26, 2015

If we are to believe what we read on the Internet, dieting can cure many of the ills faced by humans. Much of what is written is true. Changes in dieting can be good for heart disease, diabetes, high blood pressure and kidney stones to name just a few examples. But what about ADHD? Food elimination diets have been extensively studied for their ability to treat ADHD. They are based on the very reasonable idea that allergies or toxic reactions to foods can have effects on the brain and could lead to ADHD symptoms.

Although the idea is reasonable, it is not such an easy task to figure out what foods might cause allergic reactions that could lead to ADHD symptoms. Some proponents of elimination diets have proposed eliminating a single food, others include multiple foods and some go as far to allow only a few foods to be eaten so as to avoid all potential allergies. Most readers will wonder if such restrictive diets, even if they did work, are feasible. That is certainly a concern for very restrictive diets.

Perhaps the most well-known ADHD diet is the Feingold diet (named after its creator). This diet eliminates artificial food colorings and preservatives that have become so common in the western diet. Some have claimed that the increasing use of colorings and preservatives explains why the prevalence of ADHD is greater in Western countries and has been increasing over time. But those people have it wrong. The prevalence of ADHD is similar around the world and has not been increasing over time. That has been well documented but details must wait for another blog.

The Feingold and other elimination diets have been studied by meta-analysis. This means that someone analyzed several well controlled trials published by other people. Passing the test of meta-analysis is the strongest test of any treatment effect. When this test is applied to the best studies available, there is evidence that exclusion of food colorings helps reduce ADHD symptoms. But more restrictive diets are not effective. So removing artificial food colors seems like a good idea that will help reduce ADHD symptoms. But although such diets ‘work’, they don’t work very well. On a scale of one to 10 where 10 is the best effect, drug therapy scores 9 to 10 but eliminating food colorings scores only 3 or 4. Some patients or parents of patients might want to try this diet change first in the hopes that it will work well for them. That is a possibility, but if that is your choice, you should not delay the more effective drug treatments for too long in the likely event that eliminating food colorings is not sufficient. You can learn more about elimination diets from: Nigg, J. T. and K. Holton (2014). “Restriction and elimination diets in ADHD treatment.” Child Adolesc Psychiatr Clin N Am 23(4): 937-953.

Keep in mind that the treatment guidelines from professional organizations point to ADHD drugs as the first line treatment for 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. You can learn more about non-pharmacologic treatments for ADHD from 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.
ADHD Foods ADHD diet
Feingold diet