ADHD … is complicated, but manageable
Two weeks ago I found some information about the whereabouts of a high school friend. When I met him, he was funny, handsome, brilliant, social, had a great personality, a wonderful sense of humor and a beautiful singing voice. His future looked promising. It was very disconcerting that, despite all its advantages, he did not seem capable of getting decent grades. After we both went on missions and moved to another city, we lost contact. When I met him recently, I learned that I had undiagnosed ADHD. He told me that he was undiscovered and untreated until he turned 50. That did not serve him well. He did not finish college, he has gone through three marriages and countless jobs, he has struggled with depression.
People with ADHD are more likely to be expelled from school, are twice as likely to drop out of high school and are 11 times more likely not to set foot in college. They are also 11 times more likely to be unemployed than young adults. When they are adults, they are 4 times more likely to have unskilled jobs, are more likely to have difficulty getting along with co-workers, and are more likely to be laid off, laid off or quitting. Not surprisingly, they are often depressed.
In this final segment in ADHD, we take into question whether the medications are effective in treating ADHD and whether the condition is over-diagnosed or underdiagnosed.
Are ADHD medications effective in controlling ADHD symptoms? Initially, yes. Stimulant drugs such as Vyvanse, Ritalin, Concerta and Adderall have repeatedly shown that they improve attention, reduce impulsivity and decrease hyperactivity. A fourteen-month study of 579 children convincingly demonstrated that stimulant medications alone or in combination with behavioral treatment had a significant impact on ADHD symptoms compared with behavioral treatment alone or with no treatment. The addition of behavioral therapy to stimulants produced better social skills and better parent-child relationships.
However, at the two-year follow-up, approximately half the benefit of stimulant medications had dissipated, compared to untreated controls. At age eight, there were no differences between treatment groups and controls. In addition, whether treated or not, these now teenagers and young adults still had more academic struggles, social challenges, legal problems, and psychiatric disorders than their non-ADHD peers. James Swanson, co-author of the original study, said, “If you take long-term medications beyond three years, I do not think there is evidence that medication is better than no medication.” But not all researchers interpret these results similarly. Some note that at the eight-year follow-up, 61.5% of subjects had already stopped taking ADHD medications, which could confound the results.
Dr. Rachael Klein, while acknowledging that the long-term efficacy of ADHD medications is nebulous, says it is clear that ADHD medications have positive short-term effects and no long-term negative results. Stimulant medications allow parents and children a window of time to control behaviors while establishing positive routines. She suggests that parents weigh the risk of not treating a child’s ADHD.
Thirty years ago it was estimated that attention deficit disorder affects 3% -5% of children. In 1997, that estimate was increased to seven percent, according to the Centers for Disease Control. In 2014 it was 10.2%. So is it an overdiagnosis? The prevalence of ADHD varies widely by country (11% of the US, Brazil 5%) and by state (Kentucky 14.8%, Nevada 4.2%). Researchers scratch their heads when trying to explain such discrepancies.
There is a legitimate argument for over-diagnosis, and it is based on when a child is born. A study of kindergarteners found that 10% of those born in August (the youngest in the class) were diagnosed with ADHD compared to 4.5% of those born in September (the oldest in the class). In a nine-year longitudinal study, children born in August were 122% more likely to be diagnosed and 137% more likely to be medicated than those born in September. This suggests that we can do a poor job of separating ADHD from immaturity. We do not know if the younger children were over-diagnosed or the older children were underdiagnosed, but clearly our observations and judgments may be flawed.
“Who is medicating kindergarten children, anyway?” You ask. It is clear that they have not paid attention to the changing academic landscape. When most of us were in kindergarten, all we had to be able to do was eat, sleep, play, and from time to time listen. Kindergarten students are now expected to read and write basic phrases and most face the challenge, although studies show that there is no overall cognitive benefit for that early training. But for a few in each class, it’s going to be just one step too far. In his book The ADHD Explosion, Dr. Stephen Hinshaw says that since “No Child Left Behind” (NCLB) was adopted, schools have been encouraged to increase test scores that, according to Hinshaw, have resulted in increases in The diagnoses of ADHD. If a school can not afford to increase special education, perhaps stimulants can help raise a child’s grades, or ensure a diagnosis of ADHD may allow a school to exclude that child’s grades from the general average of the students. Hinshaw says that in low socioeconomic neighborhoods, the increase in ADHD diagnoses after NCLB was as high as 59% compared to an increase of less than 10% in the better-off districts.
The problem with the opinion of “ADHD is epidemic” is that it tends to invalidate the legitimacy of ADHD. Skepticism about ADHD has become widespread, despite massive clinical research in support of ADHD and its treatment. Unfortunately, this leads parents of children with ADHD and / or the youth themselves to deny a condition that is harmful and refuse treatment.
So, do we make too much diagnosis or an insufficient diagnosis of ADHD? Yes! As a society and as professionals we are capable and guilty of making mistakes in both directions. But there are ways to reduce the frequency of diagnostic errors. First, we need to understand that distinguishing ADHD is not as simple as checking for symptoms. Many conditions share symptoms of inattention, impulsivity and / or hyperactivity with ADHD including depression, some forms of anxiety, substance abuse, head injuries, thyroid dysfunction, petit mal seizures and more. ADHD, however, is developmental. There is no sudden onset and can be traced back to infancy. Therefore, a detailed medical history including the onset, persistence and severity of symptoms is required. Learning disabilities, depression, anxiety, and PTSD should be assessed. The environment and the child’s experiences at school and at home should be considered. Direct observation of the child should be combined with the comments and observations of parents and teachers.
Unfortunately, most ADHD diagnoses are performed by those who have less time for such family physician evaluations. That often leaves well-intentioned documents with parents filling out a questionnaire, doing a quick review of the symptoms and making a diagnosis. Only 15% of physicians used information from multiple sources in their assessments.
ADHD is … complicated. It is not easy to diagnose, it can be overdiagnosed, it can be lost as a diagnosis, and the long-term efficacy of the treatment of stimulant drugs is uncertain. There are options for non-stimulant medications for ADHD such as Strattera, but the effect is often less robust. However, in those cases where stimulants are not tolerated or stopped working, non-stimulant medications for ADHD may be a lifeline, and Strattera may be used in combination with stimulant medications for ADHD. Without treatment, ADHD can be devastating. When it comes, results can vary greatly. The prevalence of ADHD appears to be increasing, intensifying questions about whether we are dealing with a genetic disorder or whether we are becoming more demanding than we expect from children. There are still many questions that need to be addressed and the need for answers is growing.
Dr. Bruce Johns is a clinical psychologist at Mt. Logan Clinic.