Early this month I ran a post about attention deficit/hyperactivity disorder, known as ADHD, which many parents and teachers don’t fully understand — to the detriment of kids who have it. (You can read that post here.) This is a follow-up, with new information from Ned Hallowell, one of the country’s foremost experts on ADHD, based on questions from readers who were interested in learning about treatment options and other related issues.
Hallowell is a child and adult psychiatrist and the founder of the Hallowell Center for Cognitive and Emotional Health in Sudbury, Mass., New York City, San Francisco and Seattle, and was a member of the faculty of the Harvard Medical School from 1983 to 2004 until he began working full-time on his clinical practice, lectures and writing. He is the author of a number of books, including, with co-author John Ratey, “Driven to Distraction,” “Answers to Distraction,”and “Delivered from Distraction.” He also co-authored, with Peter S. Jensen, “Superparenting for ADD.”
I asked Hallowell the following questions, and below them is his response.
*How are kids diagnosed with ADHD and is it different for boys and girls? How accurate are the diagnostic tools? Is it easy to confuse ADHD with anxiety or something else?
* There are a lot of different kinds of drugs now given to kids with ADHD. Is one better than another? How do they work? Are there serious side effects to some of the most popular drugs, such as Ritalin and Concerta and Adderall?
* Are there non-medical treatments that actually work?
Here’s Hallowell’s response in which he incorporates answers to all of the above questions:
Contrary to popular belief there is no foolproof test for ADHD.
Often people come to my office and tell me, “My son was tested in fifth grade, and the test showed he doesn’t have ADHD, but now we are in seventh grade and the same symptoms of inattention and disorganization keep getting in his way.” Another common statement is, “The psychologist tested my daughter and said the results were inconclusive. She has some of the symptoms of ADHD, but the psychologist did not want to make a definitive diagnosis.” A third common mistake is, “My pediatrician says my son couldn’t have ADHD because he pays perfect attention when he’s in the pediatrician’s office.” All these people have ADHD, undiagnosed.
The closest measure we have to a definitive test is the individual’s history, be it an adult or a child, a male or a female. The history needs to be taken from multiple sources: in the case of children, from the child, the parent(s), and the school teachers; in the case of adults, from the individual as well as spouse or some other person who knows him/her well. This is because people with ADHD are poor self-observers, and teachers often see a different child than parents do.
If the person in question has ADHD, it will emerge from the history. Common attributes will include, on the positive side, a natural sparkle or charisma; an ability to hyper-focus when interested; boundless curiosity; natural creativity and ingenuity; an original cast of mind; acute intuition; fertile, active imagination; a mind that is always on the go; tendency to come up with new ideas seemingly out of nowhere; tenacity, to the point of stubbornness; and grit.
On the problematic side, a pattern of inconsistent achievement, summing to underachievement; inconsistent mental focus, mind wandering when not interested; trouble with time management and a tendency toward procrastination; problems with organizing books, homework, papers, as well as problems with tidying up room, getting dressed, brushing teeth, and following sequential directions in general; forgetful; impulsive (but remember, the flip side of impulsivity is creativity); restless, disruptive, or hyperactive; reckless risk-taking; in adolescents and adults tendency toward substance abuse or compulsive activities such as gambling, sex, spending, or excessive use of electronic devices.
If the history, as taken from multiple sources, points up ADHD, then you usually get neuropsychological testing. I say “usually” because it is expensive and is not absolutely essential for the diagnosis. It is very helpful and provides a ton of useful quantitative data, which is why I get if if I can on all my patients. In addition, keep in mind that if the testing concludes the individual does not have ADHD, but the history shows that he/she does, go with the history. The history trumps testing. Some people, especially those with a high IQ or highly motivated people ace the tests and look as if they do not have ADHD, but when they are observed on the open prairie, so to speak, they clearly do.
ADHD rarely appears alone. A reading problem may accompany it (as it does in my case, having dyslexia…but I majored in English in college), or anxiety, or depression, or substance abuse or a history of trauma. Often the anxiety and depression occur in the wake of the untreated ADHD. It is depressing not to be doing as well as you know you could, and it is anxiety-provoking not to know what you’re going to forget next!
There is no difference in how males get diagnosed vs. females. However, girls and women are often not diagnosed because they are not disruptive and are not hyperactive. If anything, they are quiet and serene, so they get passed over as shy, slow, or even depressed. The largest undiagnosed group in the country today are adult females. This is a shame, because treatment can change their lives dramatically for the better.
One of the tools we have in our treatment toolbox is medication. Unfortunately, it is the most misunderstood and controversial of all the interventions we offer. People sometimes ask me, “Do you believe in Ritalin?” My answer is that it is not a religious principle. It is a medication, and like all medications, can be helpful or harmful, depending on how it is used.
When used properly, stimulant medications, like Ritalin, Concerta, Focalin, Metadate, Provigil, Adderall, and Vyvanse, to name a few, can be remarkably helpful. The work like eyeglasses, sharpening focus but not changing a person in any other way. They do not make you smarter, but they do help you use your smarts more effectively. Should they have any negative effect, you simply stop the medication. One side effect that usually does occur is appetite suppression. As long as you keep eating and do not lose weight, that side effect is tolerable. All other possible side effects, some mild, some severe, are cause to reduce dosage, change medication, or discontinue the medication altogether. These include elevated heart rate or blood pressure, anxiety, depression, paranoid psychosis, suicidal thoughts or behaviors, insomnia, loss of personality or pizzazz, tics, sedation or “zombiefication,” feelings of depersonalization, or agitated, disruptive behavior.
It is unfortunate that people fear medication because, when used properly, these medications can make life significantly better, turning failure into success at any age. They work about 80 percent of the time. I have ADHD, and the medications do not work for me, so I am in the 20 percent for whom they do not work. To be safe and get the best results, be sure you are working with a doctor who has extensive experience in prescribing stimulant medication.
There are non-stimulant medications used to treat ADHD, like Strattera, Wellbutrin, Kapvay, and Intuniv. These can be effective, but their track record is not as strong as the stimulants. However, for the person who can’t tolerate stimulants or who, for whatever reason, prefers not to take stimulants, the non-stimulants provide an excellent alternative.
Keep in mind that medication is only one tool in the toolbox. It should never be the only treatment, and in many cases, like my own, medication is not used at all. Actually, I do use one “medication,” and that is caffeine! Works well for me. But be careful, caffeine can have side effects, too. It is a diuretic and a laxative (i.e., makes you need to go to the bathroom), can elevate heart rate and cause arrhythmias, cause anxiety, and lead to a severe headache if stopped abruptly. But it remains the world’s favorite performance-enhancing drug.
There is also a spectacular website called Understood.org. Understood has culled all the most recent information and brought it together in one totally user-friendly site for parents. Over a hundred experts (including me) contributed to the site. Non-profits put up nearly $50 million to build it, so it is state-of-the-art and then some. It is tailored to the user, so, ofr example, if you have a 12-year-old son with ADHD and dyslexia, you can go to the site, type in “12 yo boy with ADHD and a reading problem” and get all the info on the site that relates to you, with no extraneous stuff to sort through. Understood.org is truly a mammoth achievement. It’s totally free and impeccably orchestrated.
Included in education, be sure to explain the condition to your child (and yourself) in strength-based terms. “You have a Ferrari engine for a brain, but you have bicycle brakes,” is the best way to sum it up. You are a dynamo, but we gotta work on those brakes. Good news, there are brake specialists out there (like me) can can guarantee your brakes will get stronger, with the proper work. You can become a winner, if you put in the effort, over time.
Coaching and/or tutoring have also proven to be helpful in developing organizational skills and habits usually subsumed under the heading “self-discipline.” The right coach or tutor can make a world of difference. Parents are de facto coaches and tutors, but they often lose their effectiveness due to what I call “the nag factor.”
Physical exercise makes a tremendously positive impact on the brain in general and ADHD in particular. My friend and colleague, John Ratey, wrote the definitive book on this called, “Spark: The Revolutionary New Science of Exercise and the Brain.”
Meditation and mindfulness training have also proven to be hugely beneficial. And yes, kids and adults with ADHD can meditate!
Based on her research at UCLA, Lidia Zylowska wrote an excellent book about this for adults called “The Mindfulness Prescription for Adult ADHD.” I routinely recommend the app called CALM. You can download it and be meditating in minutes!
Nutrition also makes a big difference. The closer you can get to vegan (I know, I can’t do it either), the healthier you’ll be. And many people with ADHD have found that a gluten-free and/or lactose-free diet helps a lot.
For sure, the future lies in non-medication treatments. In addition to the ones mentioned above, there is a computer game in development called the Atentiv system. For the past five years I’ve been part of the research and development of Atenitv. It is producing results on a par with medication not only in improving academic scores but also behavioral rating scales. One must be careful, though, as not all games or brain exercises deliver what they promise. They do no harm (beyond costing you some money) but so far they don’t cure or prevent Alzheimer’s or improve mental acuity as much as their advertising seems to promise.
Nonetheless, I am convinced that in the coming years medication will take a definite backseat to the development of a wide array of non-medication interventions. We are living in tremendously exciting times when it comes to the care and feeding of the human brain!
(Correction: Fixing amount of money spent to build Understood.org)