ADHD in the News: Recent Chicago Tribune Article on ADHD
Feb. 27, 2013
A recent article on ADHD in the Chicago Tribune provides some reasonably solid information about the treatment of ADHD, despite a somewhat alarmist headline, “ADHD diagnoses rising: Researchers seek causes of increase in cases*.” The article focuses on two studies by Kaiser Permanete. The first study focused on how oxygen deprivation in utero places children at greater risk for ADHD. However, the article correctly notes that ADHD is primarily a genetic disorder. The second study, found an increase in the diagnosis of ADHD at Kaiser Permanete sites. However, this increase was noted to be higher in Hispanic and African American populations, and also in girls, all groups where most experts believe ADHD is under-diagnosed. Moreover, the author correctly notes that the increase in rates of diagnosis, to 4.9% of children in the Kaiser sample, was still well within the commonly accepted rates of prevalence for ADHD. Thus, it is likely that the study simply reflects an greater awareness of ADHD.
The article also quotes Mark Stein, PhD, a professor of psychiatry, at University of Illinois at Chicago. Dr. Stein highlights several important points regarding the diagnosis of ADHD. First, that very young children exhibit behaviors that could be considered symptoms of ADHD, in older children. Second, that it is critical to have a thorough and thoughtful evaluation before making a diagnosis of ADHD. These points are critical. ADHD needs to be considered in a developmental context. Specifically, behaviors that would be considered problematic at one age, are normal at a younger age. Thus, impulsive behavior and short attention spans are normal in preschool age children, but a far more serious concern in older children. Moreover, ADHD is difficult disorder to diagnosis and careful evaluation is called for before a diagnosis is made. For example, it is important to keep in mind that many ADHD symptoms are also symptoms of other disorders, e.g., difficulties concentrating is a symptom of both ADHD and depression. In addition, children may act in disruptive ways when they are distressed or upset by problems and stresses in their lives.
Finally, in discussing treatment the article focuses on the story of one child, but also highlights the importance of parent training and parent education, i.e., of parents clearly understanding the nature of ADHD and what strategies are more effective in helping children with ADHD. However, by highlighting “tips” from a “professional ADHD coach” the article does present a slightly misleading view of the most effective approaches for treating ADHD. Research clearly shows that medication based treatment is by far the most effective treatment intervention, something the article fails to stress. Moreover, some of the coaching tips are likely to be of question utility, e.g., teaching a child “self-talk,” strategies to decrease impulsive behavior is unlikely to be helpful because by definition impulsivity precludes stopping to think before acting.
Overall, this article makes a positive contribution to the general understanding of ADHD. It might have been more helpful for the author to highlight how ADHD is primarily a genetic disorder and to provide more of a discussion of medication based treatment. However, the general tone of the article is positive. Specifically, the article stresses the importance of careful evaluation before diagnosing ADHD as well as the importance of providing education and treatment for families who have a child (or adult) with ADHD. In addition, the article notes that ADHD exits in adults, and that adults benefit from diagnosis and treatment as well as children.
*”ADHD Diagnoses Rising” by Kristen Kridel, Chicago Tribune, Health & Family, February 27 2013.
Diet: Can diet changes really help?
December 2, 2012
The issue of diet and ADHD have been controversial since the 1970s, when advocates of the Fiengold diet argued that artificial coloring and preservatives where the main culprits when it came to ADHD. Specifically, Fiengold and his followers asserted that some child were more sensitive to these ingredients and that by removing these problematic items from a child’s diet ADHD could be alleviated. However, research consistently showed that these factors accounted for very little, if any, of the symptoms and problems associated with ADHD. Subsequently, except for an occasional claim that some other dietary factor might account for ADHD symptoms there has been little focus on diet. Rather, it seems that those looking for alternatives to medication based treatment have been focusing on neurofeedback (this issue will be discussed in future posts).
Recently, new research has emerged that has been touted to document that diet does matter when it comes to ADHD. A study by Pelesser and her colleagues which appeared in the journal, the Lancet, in 2011. This study asserted that elimination diets, diets where various foods are sequentially eliminated from a child’s diet, showed significant benefit in alleviating ADHD symptoms. While this study has raised the idea that the removal of additives, such as dyes and preservatives, from a child’s diet, might be a key to the treatment of ADHD there appear to be a number of cautions that need to be considered. First, this is one study. One study is not a solid foundation for making new claims about how to best understand a disorder nor about how to best treat a disorder. Second, the findings of this study are contrary to much previous research on the benefits of diet in the treatment of ADHD. While groundbreaking research often departs from previous findings it is often more likely that one contradictory finding is an anomaly, rather than clear evidence for a new understanding of ADHD. Specifically, before one jumps on the diet is the solution bandwagon it would be prudent to wait for other studies to support this finding. Third, Pelsser is a strong advocate of diet in ADHD, which raises the possibility that investigator bias may have played (albeit inadvertently) a role. In conclusion, it would seem prudent to wait for a consistent body of evidence before advocating a new understanding of or treatment approach. There is already a strong body of evidence that supports medication and behaviorally focused interventions in the treatment of ADHD, with children.
Pelsser et al’s article can be found at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)62227-1/abstract.
For a detailed critique of Pelsser’s work the reader is referred a detailed discussion of this study by Russell Barkley, PhD., in the ADHD Report, October 2012, Guilford Press.
Stimulant Abuse: A Growing Concern and an argument for thorough assessment and family involvement in treatment
Sunday, June 17th, 2012
A recent New York Times article (June 9,2012 )* details a growing pattern of stimulant abuse by high school students seeking to boost test scores and grades. While clearly not a scientific piece this article details a concern that many who work with adolescents are already aware of: students are under tremendous pressure to succeed and achieve, and often seek an additional boost to help them. The Times article provides a series of anecdotes about students who are using stimulant medication to help them focus on their work and achieve better grades.
The article highlights how students “fool” their doctors by feigning ADHD symptoms, and how parents can be unaware that their children are abusing their medication, or providing it to friends. The article does note that the diagnosis of ADHD requires that ADHD symptoms be present before age 7, and that there is significant impairment, caused by ADHD symptoms. Moreover, for a diagnosis of ADHD to be made, there must clearly be no better explanation for current symptoms/problems. The desire to obtain better grades, can sadly be a better explanation in the case of some students.
While not stated, the implication is clear: many of those prescribing medication and diagnosing ADHD are not conducting a complete and thorough assessment. Such an assessment would most likely derail many of those seeking medication solely to enhance performance, as they would not meet criteria for diagnosis. One needs to remember that ADHD does not equal a failure to accomplish one’s goals. Specifically, Bs or scores below 30 on the ACT are not meaningful impairments. The criteria for diagnosing ADHD are well established (see our website for detailed discussion of diagnosing ADHD). However, when professionals cut corners the risk of inaccurately diagnosing ADHD increases markedly. Those who truly have ADHD are likely to be struggling in multiple areas: behaviorally and academically, and are not likely to be those whose only concern is that they are not achieving at high levels.
Additionally, when assessing ADHD, professionals need to be particularly cautious when a teenager seeks a diagnosis, with no history of previous treatment or assessment. This is particularly true for teenagers who are highly motivated to achieve and who are attending schools where there is much focus on achievement and obtaining admission to top colleges.
Finally, when ADHD is diagnosed and medication prescribed, it is even more critical than ever that parents be involved in the treatment process. This includes the management of medication. The New York Times articles notes the dangers of stimulant abuse, but fails to high light that the sale of stimulant medication could also result in a felony charge. The solution is to help parents better understand the risks of medication and be more active in monitoring their teens access to medication. This is true for those teenagers who truly have ADHD, as the temptation (particularly for impulsive teens) to sell their medication, may be high.
Monday, January 30th, 2012
In an Op-Ed piece in this Saturday’s (January 28, 2012) N.Y. Times, professor L. Alan Sroufe, Ph.D, professor emeritus, of psychology at the University of Minnesota’s Institute of Child Development, asserted that stimulant medications are over prescribed, and more importantly fail to help children, in the long run. Dr. Sroufe offers a strongly worded critique of the use of stimulant medication. He argues that there is no evidence that stimulant medications result in long term gains in school achievement or reductions in behavior problems. He argues that while research clearly supports the short term benefits of stimulant medication, that this improvement is not lasting. He suggests that children acclimate to ADHD medications over time. Dr. Sroufe dismisses any studies suggesting that ADHD medications result in long term benefits, arguing that these studies are flawed methodologically. He then goes on to note that in 2009 the results of a long term study (still ongoing) conducted by himself and his colleagues found that while medication and medication plus therapy (two different treatment conditions they evaluated) showed benefits at 3 years, that at an 8 year follow up found that the positive benefits had “faded” and there was “no evidence” that medication produced any benefits in academic achievement or behavior.
Before we jump to the conclusion that ADHD medications are not working it is important to:
(1) more thoroughly and carefully examine both Dr. Stroufe’s findings and claims, as well as other research that does not support his work.
(2) remember that one study is not sufficient grounds for rejecting an established body of research supporting medication treatment.
In future articles I will offer a more in-depth discussion of Sroufe’s arguments, his research, and other research which challenge and reject his conclusions that stimulant medications are ineffective and greatly over prescribed.