ADHD: The basics and the controversies
Dodson, W.
Understanding Our Gifted
Open Space Communications
Vol. 14, No. 4
Summer 2002

This article by William Dodson answers common questions about ADHD. Each answer explains related research that has been done on ADHD and discusses treatment options and their studied outcomes. Also included is a short checklist of APA criteria used in identifying the disorder.

What does the AMA say about ADHD?
The scientific understanding of Attention Deficit Hyperactivity Disorder (ADHD) has probably made more progress in the last five years than it did in all the years since it was first described in 1937. Until recently, almost all of our information about ADHD was based on studies of hyperactive, elementary school-aged boys. We still know very little about adults with ADHD or about females at any age. It has only been the last few years, as these children have grown into adulthood and started their own families, that a more complete longitudinal picture has begun to emerge and the far ranging effects of the disorder appreciated (Weiss & Hechtman, 1993).

In response to the concerted disinformation campaign waged by the Church of Scientology, the American Medical Association (AMA) issued a Council Report (Goldman et al., 1998) in an effort to get accurate information to people with the condition, their families, their physicians, and their teachers. This article will add some of the new data that has become available since the report was issued in 1998. The AMA asked and then answered six basic questions about ADHD:

1. Does ADHD really exist or is it, as alleged by the Church of Scientology, a myth?
One of the outcomes of answering the disinformation about ADHD for more than a decade is that now ADHD is "one of the best researched disorders in medicine, and the overall data on its validity are far more compelling than for many medical conditions" (Goldman et al., 1998).

ADHD is the classic neuropsychiatric disorder--that is, a brain-based disorder with a primarily behavioral presentation. ADHD has a strong genetic clustering (80 percent), but its etiology is unknown. Like all other developmental disabilities, ADHD is a lifelong condition. Its manifestations and the patient's compensation to the disorder change throughout the lifespan (Wender, 1987). The basic features, impairments, and treatments, however, are very similar for both children and adults. People do not "outgrow" ADHD, just as no one outgrows any other genetic or developmental disorder. All people develop better abilities to pay attention and control impulses as they grow older. Most patients will benefit from lifelong medication, even if they have "learned to cope," because life stresses increase rather than diminish with age.

We once indulged in the wishful thinking that ADHD usually disappeared in adolescence. What we were actually seeing was the transformation of the most visible feature of bounce-off-the-wall hyperactivity into mere restlessness.

The disorder is manifested as a persistent pattern of inattention, easy distractibility and/or hyperactivity-impulsivity that is significantly more severe than that observed in persons of a comparable level of development. This inattention and/or impulsivity interfere significantly in all areas of function (school, work, social/family relationships, mood regulation, and self-esteem). In identified cases the gender ratio is 3:1, male to female, through adolescence but approaches almost 1:1 in adults.

Attention "Deficit," however, is a terrible name. Most people with ADHD report that their attention is not deficit, it is excessive. People with ADHD describe that they are drawn to all the stimuli around them equally and simultaneously. They are like jugglers who give fleeting attention to each ball in the air. Nothing gets sustained, undivided involvement.

TAKE HOME MESSAGE #1: For persons with ADHD, the ability to maintain attention and impulse control is determined by one factor-- if the task is interesting, desired, or challenging, the individual with ADHD has no problem with distractibility or impulsivity. If, on the other hand, the task is boring, it is a neurologic impossibility to stay on task. Interest and challenge only determine the ability to function, not importance. This "interest based performance" is coming to be the hallmark diagnostic symptom of the disorder and the key to successful management once medication treatment has been established.

The swings of attention can be profound from states of "zoned out" dissociation to a condition known as hyperfocus. As many as 40 percent of adolescents and adults with ADHD can enter what appears to be an altered state of consciousness while doing activities which they consider particularly intriguing. During a hyperfocus the person performs at almost 100 percent efficiency, does not notice the passage of time, does not become tired or hungry, and has virtually 100 percent comprehension and retention of what he reads.

This inconsistency of performance based on interest leaves the impression that the ability to function is under the control of the ADHD patient who is just being lazy or uncooperative. We used to use a trick question with the parents of children brought in for assessment of ADHD. We asked them what their child's favorite TV program was in the smug belief that a truly ADHD child would not sit long enough to have a favorite program. Now we understand that more than half of children and adults have the ability to become deeply and productively involved in tasks that interest and challenge them, only to fall apart when they become bored.

Many people would also like to drop the term "disorder" because ADHD seems to convey a large number of positive traits along with the distractibility and impulsivity. People with ADHD usually have much higher than average intelligence, although they commonly express frustration at not being able to demonstrate it consistently. They tend to be very creative and inventive. Sometimes this presents as being artistic, musical, or inventive, but almost always it manifests itself in intuitive problem solving. People with ADHD can often pull together the threads in complex problems to develop ingenious solutions that no one else would ever see. People with ADHD are also described as having "relentless determination" whenever they do hook into a challenge. Finally, people with ADHD tend to be affable, likable people who often have a quick and zany sense of humor. They tend to have a close, tight group of friends and family who describe them as being "high maintenance but high reward" individuals.

2. How common is ADHD and what accounts for its being diagnosed more often in the United States?
There is a misperception that ADHD is a diagnosis of white, middle class, American boys. In fact, every time that prevalence studies have been done around the world, ADHD has been found in much the same rates. It has not mattered whether it was New Zealand, Puerto Rico, China, England, or Germany. Rather than being an American disorder, ADHD seems to be something that is fundamentally human and present if one bothers to look for it.

TAKE HOME MESSAGE #2: The historic estimates for prevalence are almost certainly low at 3 to 5 percent of the population because only the hyperactive or "noisy" child was detected, and the "silent," purely inattentive child was missed. Two recent, nearly identical prospective studies give clearer estimates indicating that ADHD may be more common than major depression, bipolar mood disorder, schizophrenia, panic disorder, and obsessive-compulsive disorder combined. If these estimates are correct, ADHD is not "over-diagnosed" or a fad diagnosis. Three out of four people with the disorder still go undetected.

3. What are the adverse consequences of having ADHD that would justify its treatment?
By definition, in order to make the diagnosis of ADHD, the person has to have significant impairment in at least two areas of functioning. In real life this is usually easy to do since ADHD impairs every area of life. For example:

  1. Accidents are the leading cause of death until the age of 44. Without treatment, adolescents with ADHD have 400 percent more serious injuries and 300 percent more motor vehicle violations than do adolescents without ADHD or adolescents with ADHD who consistently take medication (Barkley, 1993).
  2. Perhaps the primary historical focus of outcome research has been on academic functioning. Despite more than adequate intellectual ability, adolescents with ADHD are three times more likely to have failed one or more grades, been suspended, or expelled. Eighty percent of persons who drop out of school before attaining a high school diploma have ADHD, an impairing learning disability, or both.
  3. Many people with ADHD try to self-medicate their illness. Until the age of 15, drug and alcohol experimentation is little different from non-ADHD adolescents. After age 15, however, the risk of a substance use diagnosis triples as compared to the general population. Luckily, treatment with stimulant class medication seems to protect against this increased risk (Biederman & Wilens, 1999).
  4. In the longest longitudinal outcome study thus far done, Barkley (1996) has followed a cohort of ADHD children into their mid-20s. Their sexual lives give a grim look at the impact of untreated ADHD. At the most recent follow-up more than half of the ADHD group had been tested for HIV disease. No one in the matched control group had been tested. Of the 43 children born to participants in the study, 42 had been born to the ADHD group. Perhaps the most disturbing finding was that 54 percent of these parents had already lost custody of their children.

ADHD impairs every aspect of life, and the consequences of not treating ADHD get worse as the individual gets older. Car accidents are worse than scrapes on the playground; losing a job that supports your family is worse than having to repeat the 2nd grade; alcoholism is worse than eating candy to slow down. Strong consideration should be given to treatment in every case and earlier rather than later before:

  • the individual falls behind academically and loses hope of ever catching up.
  • the aggressive/disruptive behavior interferes with the parent-child bond.
  • the behavior gets the person labeled as a "bad kid."
  • the children label themselves as lazy, stupid, and "bad."

4. What, then, is the best treatment for ADHD?
Here the AMA came down very strongly on the fact that there are more than 170 double blind, controlled studies which demonstrate that the mild stimulant medications were the best studied, most effective, best tolerated, and safest treatment of ADHD.

Since the Council Report was issued, another important study of the treatment of ADHD has been published. The Multimodal Treatment Study of ADHD, or "MTA," is the largest and longest study of a mental disorder in children ever done. It was designed to answer once and for all what is the optimal treatment for ADHD.

The 579 children in the study were selected because they had "screaming ADHD" that was unmistakable. These children were randomly divided into four treatment groups:

  1. Just stimulant class medication that was fine-tuned to the needs of each unique child
  2. Just intensive behavior management
  3. Both medication and intensive behavior management
  4. A community treatment group to see what was happening in the real world

At the end of 24 months the results were striking. The two groups that received medication did exceptionally well. The group that got both medication and intensive behavioral therapy did no better than the children who received only medication. The group that got behavioral treatment alone did improve but much less than those who received medication. Surprisingly, when the follow-up assessments were done three months after the intensive behavioral therapy had ended, no evidence could be found that the therapy had ever occurred. Just as with medication treatment, when the behavioral treatment ended, so did the benefits. This also was consistent with what was so commonly seen in the real world…families would become hyper-structured in order to help an ADHD child succeed, but the child would flounder as soon as she left the family to try to make it out in the real world that was not structured for her. The group that did by far the worst was the community treatment group. Out in their communities one third of these children with "screaming ADHD" received no treatment of any kind, and those that did were significantly under-dosed when given medication. As with the other studies that came before, the MTA demonstrated that the assertion that ADHD is over-diagnosed and over-treated has no basis whatsoever in fact.

It is important to be very specific about what the MTA means and doesn't mean.

It DOES NOT mean that adjunctive treatments such as behavioral management are not effective or not needed. These treatments are often absolutely necessary to teach the self control and social consciousness that were not learned at age appropriate times due to the interference of ADHD. Behavior management and "trying harder" do not treat the major criteria of inattention, impulsivity, and motor restlessness.

It DOES mean that:

  1. ADHD is not the result of bad parenting skills. These were good, involved parents who got even better. It just didn't make any difference.
  2. ADHD is not the result of a defect in character or laziness. Trying harder even with the intensive support of specialists in the field was ineffective.
  3. Stimulant medications are where everyone should start, not the treatment of last resort when everything else has failed. Therefore, start medication as early as possible before maladaptive coping mechanisms and self-image issues become ingrained.
  4. "Pills don't give skills." Medication levels the neurologic playing fields so that the many needed remedial interventions have a hope of being effective. Once the ADHD is under consistent control, many other interventions are often necessary and beneficial. Children and adults need remedial education to make up for the classroom work to which they could not pay attention. They need to learn organization and time management skills. They need to learn how to interpret non-verbal social cues and how to understand the emotions of others. They must learn how to understand their own emotional states and intimate relationships. The medication "gets them into the game" with a realistic hope of success.

5. What are the adverse consequences of using the stimulant class of medications to treat ADHD?
Once again the AMA emphasized that the minor stimulants were both safe and well tolerated if properly taken, stating that, "Adverse effects from stimulants are generally mild, short lived, and responsive to dosing or timing adjustments." They acknowledged that in the early years of medication treatment of ADHD, many patients had been prescribed higher dosages than necessary in the mistaken belief that "more medication is better." We now know that the dose of medication that provides optimal performance and benefits has no side effects except a mild, transient loss of appetite. Unfortunately, no one can predict the dose of medication that produces optimal performance based on any known parameter....

  • Not severity of the disorder
  • Not body weight or height
  • Not age
  • Not gender
  • Not baseline scores from any rating scale or continuous performance test

Everyone must fine-tune the dose of medication to his or her unique needs and biochemistry.

Thus far, ALL of the adverse consequences are associated with NOT treating the disorder. There was initially some concern that treatment with mild stimulants in childhood might predispose some children to drug abuse in later life. Recent research (Biederman & Wilens, 1999) has demonstrated that exactly the opposite is true.

6. Are children being appropriately assessed or is ADHD being overdiagnosed?
Every time that Congress has asked the National Institutes of Health (NIMH) to investigate these concerns, we have found that the majority of people with ADHD are never detected and offered treatment. The MTA study demonstrated that one-third of the children referred into their communities with documented "screaming ADHD" got no services whatsoever. Those who did receive some form of intervention usually got medication, but at doses that were on average half of what the study had determined to be optimal doses. An NIMH study by Jensen (1999) of the patterns of treatment in all mental disorders in children found that only one in eight children with ADHD had received services of any kind (school intervention/medication, behavioral treatment, social skills training, etc.) in the previous 12 months. Increased recognition (especially in girls) and increased willingness to treat ADHD has made it seem that there has been an explosion of the disorder in recent years. The irony is that despite a tremendous increase in our awareness of ADHD, all of the evidence points to the fact that it is still grossly under-diagnosed and under-treated.

ADHD is here to stay. It is neither a myth nor an over-reaction. It is a genetically based condition that usually presents in childhood but continues to impair life functioning throughout the life cycle. It has a good, safe, and effective treatment with a combination of stimulant class medications and skill building. When aggressively treated early, the disorder does not continue to invisibly hold back the people who have the condition, and they can go on to have happy and productive lives.

Criteria for Attention Deficit-Hyperactivity Disorder

Inattention
6 or more of the following, manifested often:
___Inattention to details/makes careless mistakes
___Difficulty sustaining attention
___Seems not to listen
___Fails to finish tasks
___Difficulty organizing
___Avoids tasks requiring sustained attention
___Loses things
___Easily distracted
___Forgetful

Impulsivity/Hyperactivity
6 or more of the following, manifested often:
Impulsivity
___Blurts out answer before question is finished
___Difficulty waiting turn

Hyper activity
___Fidgets
___Unable to stay seated
___Inappropriate running/climbing
___Difficulty in engaging in leisure activities quietly
___"Always on the go"
___Restlessness
___Talks excessively
___Interrupts or intrudes on others

William W. Dodson is a psychiatrist, in private practice in Denver, Colorado, specializing in adult attention deficit/hyperactivity disorder.

References

American Psychiatric Association. (1994). The Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C.

Barkley, R.A. (1993), Driving-related Risks and Outcomes of ADHD in Adolescents and Young Adults. Pediatrics, 92(2), 212-218.

Barkley R.A. (1996). ADD Research: A Look at Today and Tomorrow. ATTENTION! , 8-11.

Biederman, J. & Wilens, T.E. (1999). Pharmacotherapy of Attention Deficit/Hyperactivity Disorder Reduces Risk for Substance Use Disorder. Pediatrics, 104(2), 20-24.

Goldman, L.S.; Genel, M.; Bezman, R.J.; & Slanetz, RJ. (1998). Diagnosis and Treatment of Attention Deficit/ Hyperactivity Disorder in Children and Adolescents. Journal of American Medical Association, 279(14), 1100-1107.

Jensen, RS. (1999). Are Stimulants Overprescribed? Treatment of ADHD in Four U.S. Communities, Journal of American Academy of Child and Adolescent Psychiatry, 38(7), 797-804.

Weiss G. & Hechtman, L.T. (1993). Hyperactive Children Grown Up. Guilford: New York.

Wender, RH. (1987). The Hyperactive Child, Adolescent and Adult-Attention Deficit Disorder Through the Life Span. Oxford University Press: New York.

(American Psychiatric Association, 1994).


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