Natural Remedies for ADHD: Are they Effective?

Stephen V. Faraone, PhD on February 25, 2015

Are Nonpharmacologic Treatments for ADHD Useful?

There are several very effective ADHD medications, and treatment guidelines from professional organizations view these drugs as the first line of treatment for people with ADHD symptoms.  (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 “natural remedies for ADHD.” 

What are these non-pharmacologic treatments and do they work?  

My upcoming 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 (CBT) 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.

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 is about 0.9, which is derived from a very strong evidence base.     The effects of dietary treatments on symptoms of adult ADHD 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.

If you are health professional, you can learn more about screening, diagnosing and treating ADHD with the latest evidence-based medicine.  Earn FREE CME on Adult ADHD.

If you are a member of the public, you can download a FREE SCREENER and take it to your healthcare professional for a discussion.  If you provider does not know about ADHD, and many don’t, them please send him or her to ADHD in Adults.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.

One Year on ADHD Medications

Anthony L. Rostain, MD MA on February 19, 2015

Fredriksen M, Dahl AA, Martinsen EW, Klungsoyr O, Haavik J, Peleikis DE “Effectiveness of one-year pharmacological treatment of adult attention-deficit/hyperactivity disorder (ADHD): An open-label prospective study of time in treatment, dose, side-effects and comorbidity.” European Neuropsychopharm 2014 24: 1873-1884.

This new study from Norway provides useful information about the long-term drug treatment of adult ADHD. Prior studies are small, of short duration (e.g. 4-10 weeks) or have problems with high dropout rates or selection biases (i.e. patients with comorbid conditions are often excluded). This naturalistic study examined 250 patients treated with ADHD drugs for one year.
The patients had a mean age of 32.6 years, virtually all of whom (98%) had never been previously diagnosed with ADHD, and none of whom had received prior treatment. Diagnoses and assessments of outcomes were conducted with state-of-the-art methods. Exclusion criteria included any major psychiatric disorder considered to be in immediate need of treatment, any medical contraindications to stimulant treatment, prior use of stimulant medication in adulthood, and the presence of autism spectrum disorder or intellectual disability (IQ < 70).

All study subjects received methylphenidate (MPH) as the first-line medication. Doses were flexibly titrated from 5 mg three times daily to 20 mg three times daily in the in the first six weeks, and to a maximum of 40 mg three times daily during the subsequent study period (one year). Extended-release MPH was offered at the 3-month visit and dosage could be decreased if subjects experienced intolerance. If MPH was not tolerated or ineffective, two alternative medications were offered: d-amphetamine (up to 50 mg daily) or atomoxetine (in doses ranging from 25 mg to 120 mg daily). Outcome measures were obtained at 3, 6 and 12 months after the initiation of treatment. In addition, all subjects received psychoeducational supportive counseling at all follow up visits.

At the end of 12 months, 92% of subjects (N=232) completed the study and 70% (N=163) remained on a medication. Of those on medication, 79% were taking MPH, 15% were taking d-amphetamine, and 6% were on atomoxetine. Mean daily dosages of medications prescribed (60 mg, 30 mg and 40 mg respectively) suggests the subjects were adequately treated. Given the small number of subjects on d- amphetamine or atomoxetine, drug-drug comparisons of treatment effects could not be carried out.

Overall, subjects still taking medication at the end of the 12 month study period were significantly more improved with respect to their ADHD symptoms and had better functional outcomes compared to those who either discontinued treatment or were never medicated. Subjects on the highest doses reported the best outcomes, and an inverse relationship was observed between side effects and effectiveness of treatment. Interestingly, the outcomes of those who discontinued were intermediate between those who never started a medication and those who stayed on one. Prominence of side effects was cited as the most likely reason for stopping medication (almost half), and discontinuation of treatment occurred most often during the first six weeks of treatment. Comorbid anxiety and bipolar disorders, non-alcohol substance use disorders and cumulative amounts of side effects were associated with less effectiveness.

This study was well designed, excellently implemented and comprised of a large enough sample to be of significance to practicing clinicians. While its open-label design makes it possible that patients on medication were over-estimating the effectiveness of treatment, the results appear consistent with prior studies of this type. Naturalistic studies of treatment effectiveness can be helpful in validating current clinical practices and in setting reasonable expectations for patients and clinicians regarding likely treatment outcomes.

Driving and ADHD

Lenard A. Adler, on February 15, 2015

Zheng Chang, PhD; Paul Lichtenstein, PhD; Brian M. D’Onofrio, PhD; Arvid Sjölander, PhD; Henrik Larsson, PhD. “Serious Transport Accidents in Adults With Attention-Deficit/Hyperactivity Disorder and the Effect of Medication: A Population-Based Study” JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.4174. Published online January 29, 2014.


This study examines the association of adult ADHD with transport accidents and potential effects of ADHD treatment. The authors note that transport accidents exert a substantial burden on the world economy, such that they account for 2% of the global GNP. Untreated adult ADHD has been previously associated with increased rates of transport accidents or poor driving (increased accidents, false brakes and speeding) when adults with ADHD are examined on a driving stimulator. ADHD pharmacotherapy has also been shown to ameliorate performance on the driving simulator in these adults (Barkley RA, Cox D. J Safety Res. 2007;38(1):113-28. Epub 2007 Feb 15.) However, these studies are of relatively small sample sizes and concerns have been raised regarding potential referral bias influencing the study results.


Chang and co-authors examined over 17,000 individuals with ADHD over a four year period in the Swedish national registries. Cox proportional hazards regressions were used to examine the association between ADHD and serious traffic accidents (resulting in death or emergency room visit). Stratified Cox regressions were used within patients to examine the rates of accidents on and off medication. ADHD treatment was defined as filling a prescription for an ADHD medication within a six month period.


The study found significantly higher rates of transport accidents in men (adjusted hazard ratio, 1.47; 95%CI, 1.32-1.63) and women (1.45; 1.24-1.71) with ADHD, compared to the control group. Medication treatment was associated with a 58% risk reduction in men, but no significant risk reduction in women. The potential reasons for this gender difference is not fully known, but the 40% lower base rate of accidents in women versus men may have created a floor effect, where the base rates were lower in women to an extent which minimized potential ameliorative effects of medication. It was estimated that continuous medication treatment would have cut accident rates almost in half, presumably from positive effects on ADHD related symptoms and impairment and resulting improvement in driving (the ameliorative effects of medication on accidents is associative not causative in this trial).


This is a very important trial as it extends observations of increased motor vehicle accidents in untreated adults with ADHD to a large community based sample. It further highlights the ameliorative effects of ADHD pharmacotherapy observed in driving simulator studies to a large population based sample, which further emphasizes the importance of adults with ADHD receiving treatment. Of note, the definition of being on medication in the study, of filling a prescription in the last six months, is a fairly liberal definition of adherence to treatment; therefore, the potential beneficial effects of medication may if anything be under-estimated by this study given the long period of time individuals presumed to be treated with medication might have been off medication. Furthermore, the authors did examine whether defining medication treatment as filling a prescription within three months, would influence the findings; this tighter definition of treatment yielded similar results.


Overall adherence rates to treatment in ADHD are fairly poor, whereby most adults and young adults do not fill beyond their second prescription of psychostmulants. (Adler LD, Nierenberg AA. Review of medication adherence in children and adults with ADHD. Postgrad Med. 2010 Jan;122(1):184-91. doi: 10.3810/pgm.2010.01.2112.) It is important, given the earlier findings and results of the current study, for ADHD adults and young adults to be treated pharmacologically in periods when they are driving motor vehicles. Overall treatment principles for adults and young adults with ADHD suggest treatment throughout the day, to ensure symptomatic relief for longer periods of time during the day and especially during periods when driving (Adler LA, Barkley RA, Newcorn JH. Performance improvement CME: adult ADHD. J Clin Psychiatry. 2011 Apr;72(4):e15. doi: 10.4088/JCP.9066pi4c.). Clinicians may use the increased risk of motor vehicle accidents in untreated adults with ADHD as means of reinforcing the importance of medication adherence, when discussing adherence to pharmacotherapy with patients.

Myths About the Diagnosis of ADHD

Stephen V. Faraone, PhD on February 12, 2015

Myth: 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.

Non Pharma Overview

Stephen V. Faraone, PhD on February 5, 2015

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.

“Does Pharmacological Treatment of ADHD in Adults Enhance Parenting Performance?”

Anthony L. Rostain, MD MA on January 29, 2015

Treatment of ADHD in Adults Enhance Parenting Performance? Results of a Double-Blind Randomized Trial.” CNS Drugs (2014) 28:665-677.

This study examines the impact of pharmacologic treatment of parents with ADHD on their parenting performance.  It has long been observed that parental ADHD reduces the efficacy of parenting behaviors and is often associated with higher rates of comorbid problems in their ADHD children (Hinshaw et al, 2000) and with lower response rates to intervention (Sonuga-Barke, et al 2002, Jensen et al, 2007).  One prior study (Chronis-Tuscano et al 2010) examined the effects of OROS methylphenidate treatment of mothers with ADHD on parent-child interactions.   The results showed some reduction in self-reports of inconsistent discipline and use of corporal punishment.  It also found however no significant treatment effects on observed dyadic interactions.

The aim of this investigation was to test the impact of lisdexamfetamine (LDX) on observable parenting behaviors in adults with ADHD using a double-blind randomized design.   The study participants consisted of parents of ADHD children (aged 5 – 12 years old) who met criteria for ADHD themselves as measured by the ADHD Rating Scale with adult prompts (>28) and with at least moderate severity on the Clinical Global Impressions Severity Scale.  Parents with medical or psychiatric conditions that could be worsened by stimulant medication were excluded from the study.   Children were eligible if they met DSM-IV criteria for ADHD along with Oppositional Defiant Disorder or Conduct Disorder, and were excluded if they met criteria for any other mental disorders.

A total of 30 parents (27% male) were enrolled in the study. In the initial open-label three-week LDX trial, subjects were given medication at increasing doses until an optimal dose was determined (either 30, 50 or 70 mg daily).  In Phase I, parents were given either placebo or medication during each of the two weeks and were observed in a structured interaction with their children.  In Phase II, parents were randomly assigned to receive placebo or medication (at optimal dose) for a 30-day period at the end of which they were assessed during another interaction with their children.  

The results of the study revealed that during the parent-child interaction task, parents on LDX versus placebo gave fewer commands, praised their children more, and had children who exhibited lower rates of inappropriate behavior.  There was also a trend seen in fewer verbalizations and more responsiveness to their children in parents taking LDX.  In addition, lower parental ADHD symptoms at the end of the study period were significantly correlated with greater amounts of giving praise, improved children’s behavior, and reduction in commands given by parents.  Side effects reported by subjects in the study were generally mild and well tolerated.

The authors of this paper conclude that LDX helps ADHD parents of children with ADHD to perform better in a structured parent-child interaction task as compared to parents who did not receive LDX.  While this is a small N study, the results imply that LDX, an approved long acting stimulant treatment for ADHD in adults, can be helpful for parents of ADHD children who have ADHD themselves by improving their parent-child interactions.  It suggests that clinicians should encourage these parents to seek adequate treatment for their ADHD symptoms, and that in so doing, there is a greater likelihood they will be better able to manage their children, and that psychosocial interventions like parent behavior training will be more effective helping ADHD children reduce their negative behaviors.

 

References

Chronis-Tuscano AM, Rooney M, Seymour KE, et al (2010).  Effects of maternal stimulant medication on observed parenting in mother-child dyads with attention-deficit/hyperactivity disorder.  J Clin Child Adolesc Psychol 39:581-587.

Hinshaw SP, Owens, EB, Wells KC, et al (2000).  Family process and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment.  J Abnorm Child Psychol 28:555-568.  

Jensen PS, Arnold LE, Swanson JM, et al (2007).  Three-year follow up of the NIMH MTA study.  JAACAP 46:989-1002.

Sonuga-Barke EJS, Daley D, Thompson M (2002).  Does maternal ADHD reduce the effectiveness of parent training for preschool children’s ADHD?  JAACAP 41:696-702.

Myths About the Causes of ADHD

Stephen V. Faraone, PhD on January 26, 2015

Myth: 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.

Atomoxetine and the Treatment of Executive Dysfunction

Lenard A. Adler, on January 23, 2015

DHD Patients with Executive Dysfunction: Atomoxetine vs Placebo Studies


Although they are not included in the formal DSM-5 criteria for adult ADHD, studies have shown that clinically significant executive dysfunction can occur in one-third to one-half of all adults with ADHD. Executive functions are a set of neuropsychological parameters including: 1) working memory, 2) awareness of one’s self in the environment, 3) higher level cognitive functions of prioritization, planning and time estimation/planning and 4) emotional control. Symptoms of ADHD are separate from executive dysfunction and both should be considered in possible treatment design for the particular patient.


There have been two recent reports on the response of executive functions to the non-stimulant atomoxetine used to control ADHD symptoms. (Adler LA, Clemow DB, Williams DW, Durell TM.. Atomoxetine Effects on Executive Function as Measured by the BRIEF-A in Young Adults with ADHD: A Randomized, Double-Blind, Placebo-Controlled Study. PLoS One. 2014 Aug 22;9(8):e104175. doi: 10.1371/journal.pone.0104175. eCollection 2014. and Adler L, Tanaka Y, Williams D, Trzepacz PT, Goto T, Allen AJ, Escobar R, Upadhyaya HP, Executive function in adults with attention-deficit/hyperactivity disorder during treatment with atomoxetine in a randomized, placebo-controlled, withdrawal study. J Clin Psychopharmacol. 2014 Aug;34(4):461-6. doi: 10.1097/JCP.0000000000000138.) Both studies present data on changes in the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A, which is a 75 item, self-report clinical measure of executive function).


The first study presents the changes in BRIEF-A ratings in a study of atomoxetine (40-100 mg/day) versus placebo in young adults with ADHD. Significant effects of atomoxetine vs. placebo were seen on the major indices in the BRIEF, Global Executive Composite (GEC), Behavioral Regulation Index (BRI), and Metacognitive Index (MI), and a number of brief subscales. In other words, the non-stimulant atomoxetine had measureable effects on both ADHD symptoms and executive dysfunction when compared with the administration of a placebo.


The second trial was a randomized, withdrawal study of atomoxetine vs. placebo in patients who previously responded to an open label trial of atomoxetine. Atomoxetine significantly improved the executive function major indices and some subsets compared with placebo, which was maintained for 25 weeks or more. The executive function of patients in the placebo group worsened but did not return to baseline levels after randomization.

In both of these studies the overall effect size on measures of executive dysfunction was less than core ADHD symptoms observed for atomoxetine. Also, the effect on symptoms of emotional control subsets was somewhat less than seen on other subsets. Clinicians should be aware of co-travelling symptoms of executive dysfunction in their adult patients with ADHD and should consider whether to target these symptoms as part of the treatment plan.

Micronutrient Treatment

Stephen V. Faraone, PhD on January 15, 2015

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.

ADHD in Older Adults

Lenard A. Adler, on January 9, 2015

Just as there have been concerns about the treatment and potential increased societal burden as we improve disease recognition with adolescents recently diagnosed with ADHD aging into adulthood, there are similar concerns as middle aged adults recently diagnosed with ADHD become older adults with ADHD. In fact, the largest percentage growth in stimulant prescriptions in the last year is in adults over the age of 50 years of age (Adler LA. ADHD in Older Adults. Paper Presentation at the Annual Meeting of the American Psychiatric Association, New York , New York, May 2014). However, there are special concerns re: the diagnosis and treatment of older adults which merit heightened attention.

The evidence basis for ADHD in older adults is quite small, when compared to the literature for childhood and adult ADHD. In fact a recent Pubmed search found 100 times fewer peer-reviewed publications on geriatric and older adults with ADHD, than for adult ADHD in general (Adler LA 2014).

The epidemiology of ADHD in older adults indicates:

Similar prevalence to overall adult ADHD
Some diminution in symptom severity with age – this is true through the lifespan, not just true with geriatric ADHD.
Impairment: Notable deficits in social interactions, which is larger than younger adults with ADHD
The diagnosis of ADHD in older adults is complicated by potential overlap with disorders of cognitive decline, such as Mild Cognitive Impairment (MCI).
Inattentive (IA) symptoms (relative to hyperactive-impulsive (HI) ones) increase with the transition from childhood to adulthood (Kessler RC. Arch Gen Psychiatry 2010). It is not clear that this pattern continues with the transition to older adulthood. It is also not clear if the number and burden of IA symptoms might be limited with retirement as individuals perform less cognitively challenging tasks.
The co-morbidities seen in adults with ADHD are similar to those seen in adult ADHD in general.
Symptoms also seem similar. However, there is some support in the literature for increasing rates of depression as adults with ADHD become geriatric adults.

A specific co-morbidity which must be addressed in the evaluation of adults for ADHD is Mild Cognitive Impairment (MCI). It is critical that physicians examine whether there are formal memory deficits. Deficits in MCI are more memory-related as compared with attentional issues seen in ADHD. Other potential issues in establishing this differential include that executive function deficits are somewhat less common in MCI as compared with ADHD in general (except for amnestic MCI).

The time courses of the illnesses differ with an older onset in life for MCI, while ADHD is more or less present throughout the lifespan. A MMSE may be quite helpful in establishing whether memory deficits are present, or formal neuro-psychological testing can be obtained to further delineate the presence of memory vs. attentional issues.

There are special treatment considerations for older adults with ADHD. ADHD medications should be used carefully, with regular cardiovascular monitoring and consultation with primary care physicians as all FDA approved medications for adult ADHD (sustained release stimulants and atomoxetine) have a small risk for increasing the heart rate (on the average 5 beats/minute) and blood pressure (on the average 3 mm Hg); this is especially important as geriatric adults have higher rates of cardiovascular illness and hypertension. Geriatric adults with ADHD should also be monitored for potential agitation or activating effects of the medication.

In conclusion, just as ADHD persists from the transition from adolescence into young adulthood, it also persists in the transition to older adulthood. As always, clinicians should perform careful clinical evaluations and establish appropriate treatment programs, taking into account the special issues involved with the older adults.