Attention Deficit Hyperactivity Disorder (ADHD) is among our most controversial disorders. Is it really a disorder or a function of schools' inadequate response to active kids’ needs? Is the increase in prescribing stimulant drugs for ADHD mainly because it’s helpful or because drug companies are pushing it?
To help us understand current best thinking, in today's The Eminents interview, I spoke with Stephen Hinshaw. He’s Professor of Psychology at the University of California, Berkeley, Vice-Chair of Psychology, Department of Psychiatry at the University of California, San Francisco and co-author with Richard Scheffler of The ADHD Explosion: Myths, Medication, Money, and Today's Push for Performance.
Marty Nemko: Is ADHD real?
Stephen Hinshaw: It’s real, existing in every nation with mandatory education.
MN: Could that reflect that, worldwide, school is boring and active kids can’t stand it?
SH: The human brain didn't evolve to learn alphabetic codes and reading skills--Literacy was invented only a few thousand years ago and it became compulsory only in the past 150 years. At that point, those youth with the hardest time sitting still and focusing and restraining their impulses were the ones likely to receive the then-current diagnosis of minimal brain dysfunction or hyperkinesis, what today is called ADHD.
MN: Any other evidence that ADHD is real?
SH: The propensity to be unfocused, impulse, and poorly self-regulating is almost wholly genetic.
MN: What’s the evidence for that being genetic?
SH: A large number of twin and adoption studies reveal that similarities in these traits are shared far more by identical than fraternal twins, and far more by biological than adoptive relatives. ADHD's heritability is higher than that for schizophrenia and equal to that of autism and bipolar disorder, at the top of the list in all of psychiatry. Once again, though, ADHD becomes apparent when learning is rote, others control the contingencies, and the going gets rough. In other words, compulsory education unveils ADHD in the most biologically vulnerable kids. ADHD Is created by the combination of genetic risk and the modern-day push for academic performance.
MN: Some wonder if environmental toxins are causal. What’s the evidence on that?
SH: It's clear that when the developing fetus is ingesting alcohol or nicotine, or when the baby is born at low birth weight, there's increased risk for ADHD. Also, recent research shows that early exposure to pesticides or industrial chemicals might be a risk factor for ADHD and autism-spectrum disorders. Intriguingly, early attachment/bonding issues between parents and infants do not appear linked to later ADHD but are associated with later aggression.
MN: Others think ADHD is at least partly caused by poor diet, for example, too much sugar or artificial colors. What’s the evidence on that?
SH: Sugar is not the culprit, even though it may seem that kids with ADHD become hyper with sugar loading. The earlier claims that additives and dyes were the major cause of ADHD were overstated but they may add symptoms to a child already at risk.
MN: Do you believe ADHD is overdiagnosed?
SH: The U.S. rate of ADHD diagnosis is 1.5 to 2 times higher than in comparable nations--and still rising. Some contend that’s good---We’re finally recognizing a real and serious condition. But now, one in nine kids between 4 and 17 have received an ADHD diagnosis...and one in five boys over the age of 9. That's too high.
MN: What makes you say that’s too high?
SH: In part because factors having nothing to do with the disease are affecting whether kids gets diagnosed. We saw a big spike in ADHD diagnoses when the federal special education law and Medicaid started reimbursing for ADHD evaluations and treatments back in the 1990s. And there was a jump in diagnoses among poor kids when the feds started to judge school districts based on their average standardized test score. Perhaps that was just because districts wanted to help poor kids but some assert it was to get those kids, disproportionately low-scoring, excluded from the district's score average—Special ed kids used to be excluded when calculating a district’s average score.
MN: Boys are diagnosed with ADHD at three to eight times the rate of girls. Why?
SH: Well, eight times is far too high a ratio--perhaps betraying some clinicians' inaccurate belief that girls don't get ADHD. But 3:1 is accurate: boys are more likely than girls to have just about all early-appearing neurodevelopmental disorders, including autism, aggression, Tourette's, and serious aggression.
MN: You lament that many ADHD diagnoses are made in just a 10-12 minute office exam. What more should be done?
SH: First, pediatricians and general practitioners need more specialized training in ADHD. Second, professional groups such as the American Academy of Pediatrics have published excellent guidelines on how to diagnose ADHD carefully, but there's no enforcement--and worse, no reimbursement for the time and care needed.
MN: If 100 kids, based on just that 10-12-minute exam, were diagnosed yes or no, and then were thoroughly assessed as you recommend, do you have any idea what percentage of the yeses would become nos and vice-versa?
SH: It's a thought experiment but I'd guess that 30-40 of 100 diagnosed with ADHD would be false positives, that is, diagnosed with ADHD when the real issue might be maltreatment, a different disorder, or even just normal variation in behavior. Another 10-20 outside the 100 would be false negatives, that is, branded as normal because they were docile in the clinic exam room but actually poorly self-regulated at school or on the job, if only the clinician had obtained the right information.
MN: Medication is prescribed to 70% of those diagnosed. What do you think of that?
SH: Medications for ADHD--usually stimulants—yield one of the best response rates in all of psychiatry. If they're used only after a complete diagnostic workup, if care is taken to establish the right dose, and if ongoing monitoring is careful, ADHD meds can help boost self-control, reduce impulsivity, and enhance academic performance. The evidence, across hundreds of studies, is convincing. But remember: Medications don't teach skills. The evidence is clear that, even when meds help, behavioral, academic, and social skills treatments are also needed.
MN: What's the response rate for medication treatment?
SH: Around 80 percent of accurately diagnosed individuals show a positive response, ranging from mild to night-and-day. But again, to promote real competence and not just behavior control, parents, teachers, and the child need active engagement in behavioral treatments.
MN: What typically gets covered in parent training?
SH: A major focus is on tightening family routines and discipline and engaging the kid's teachers. Parents didn't cause ADHD by ineffective parenting but they can exacerbate it by yelling and setting poor limits. So parent management focuses on engendering a calm approach to limit setting and on active use of praise and rewards. Also, we try to get parents and teachers to agree on target behaviors and skills and modify the classroom setting to promote better learning. Ultimately, the goal is to foster self-control.
MN: What typically gets covered in direct work with the child?
SH: Unfortunately, kids with ADHD don't respond well to 1:1 therapy, although adults do well with cognitive-behavioral coaching. What they need is work on gaining social skills, often through structured group treatments.
MN: Does effectiveness depend on factors within the individual child, for example, high-IQ versus average-IQ kids?
SH: We know that evidence-based treatments for ADHD, both medications and behavioral skill-building, can and do work for all kids with the condition, but lower IQ, more family disharmony, and the presence of additional disorders makes the work harder.
MN: You write that teens and adults are the fastest growing segment of people diagnosed with ADHD. Is the treatment or advice for them different than for kids?
SH: Teens with ADHD invariably hate taking medication, which makes them feel different and stigmatized. Behavioral work with families needs to emphasize contracts--parent and teen give-and-take. Organizational skills are also super-important for teens--Just think of negotiating middle-school and high-school if you're not pretty organized. Job skills and relationship skills for adults are also incredibly important.
MN: What’s the evidence on the side-effects of long-term use of ADHD stimulant medication like Ritalin? For example, does long-term use of stimulants puts stress on the heart that increases the chances of premature cardiac problems?
SH: This has been controversial and is now well-studied. Stimulants, if monitored well by a medical professional, do raise pulse and BP slightly but this does not appear to be a significant long-term health risk. Others have wondered whether medicating kids with impulse-control problems might actually increase their likelihood of abusing drug later on, but there's no evidence that’s the case--again, if the meds are carefully prescribed and monitored.
MN: Drug companies have placed ever more ads for ADHD medication. What do you think of that?
SH: Only two nations on earth--the U.S. and New Zealand--allow direct-to-consumer ads. On one hand, perhaps they promote active discussion and reduce stigma. On the other, too many of the ads are misleading and may promote disease-mongering or doctor shopping until meds are prescribed.
MN: Some data is showing biofeedback helpful. What’s your take on that?
SH: It's promising, and studies are getting better, but (a) it's expensive, (b) it's not clear whether it works better than 'fake' biofeedback (i.e., it could be a 'placebo effect), and (c) if it does work, will its effects spread to the classroom, homework sessions, soccer field, or workplace? ADHD treatments are notorious for working only during the session.
MN: What’s a primary focus today of clinical research on ADHD?
SH: There’s serious effort to develop a holistic, integrated, nuanced approach: ADHD isn’t all or none. It’s a continuum. It’s not all biology nor all environment. Meds are only sometimes required. Parents of kids with ADHD are likely to have the symptoms themselves, so they may need treatment, as well.
MN: Is there another major research focus?
SH: There are efforts to convert the reward-based programs used for kids into self-management approaches for teens and adults.
MN: Some people make light of ADHD as just a bunch of active boys. But you assert that ADHD imposes major societal costs. What are they?
SH: Kids with ADHD experience not just academic failure and peer rejection but also high rates of accidental injury (impulsivity has serious consequences) and later substance use...and, for girls, self-injury. Adults have a really hard time on the job. Economic costs are a staggering $100-200 billion per year caused by impairments linked to ADHD.
MN: Is there anything else you’d like the readers of PsychologyToday.com to know about ADHD?
SH: ADHD is a serious issue but if skills are taught and the shame and stigma are reduced, some of ADHD traits can predict creativity, energy, and thinking outside the box. Many levels of society need to work together to understand and treat ADHD.
Marty Nemko's bio is in Wikipedia.