In Part One of this series on ADHD, we looked at whether ADHD is actually a real condition. Having established that it most certainly is, we move now to a quick summary of treatments. Some are effective, some not so much ... but parents of kids with ADHD may be vulnerable to misinformation because they want so badly to do the best thing for their child. And in the face of so much conflicting information, it is hard to make decisions about treatments. While I can summarise the state of the scientific literature here, my top recommendation is that you get support from a paediatrician, psychiatrist or clinical psychologist who specialises in ADHD and can help you navigate the minefield of treatment information you're likely to encounter. 

• Medication - Stimulant medication is the number one, gold standard treatment for ADHD. It significantly reduces symptoms and improves long-term functioning in approximately 80% of cases.  Long-term safety studies have found that, overall, medications such as Ritalin are very safe, with few concerning side effects. While some parents worry that the use of stimulant medication places their child at risk of later drug abuse, meta-analysis shows that ADHD medication actually reduces the long term risk of drug and alcohol abuse (possibly as children and adolescents may be less likely to self-medicate or associate with antisocial peers - see Wilens, Faraone, Biederman & Gunawardene, 2003 for more on this subject).

• Psychological Therapies - While medication is the gold standard, there are a number of psychological therapies and interventions that may be beneficial, particularly alongside medication (see Oord, Prins, Oosterlaan, & Emmelkamp, 2008 for meta-analysis). Cognitive and behavioural interventions may include parent training, behavioural therapy, and social/emotional skills training. In particular, there is strong evidence for the use of behavioural therapies and teaching parents how to manage dysregulated and oppositional behaviour. Psychologists can work with families to assist them in developing a positive parenting approach that focuses on reinforcing desired behaviours and effectively managing misconduct. 

• School-Based Interventions - The child with ADHD is likely to struggle in a school setting and their behaviour frequently draws negative attention from teachers. Parents may feel that the school doesn't understand their child's needs or manage their developmental and behavioural issues appropriately. Sometimes, the relationship between home and school completely breaks down. I try to support both parents and teachers to work together in the child's interests. Psychologists can provide teachers and learning support aides with information and support to help them understand more about a child's particular difficulties (for example, poor attention, specific learning difficulties, slow processing speed, or memory issues). We can then work together to develop an effective behaviour management plan to help school manage problem behaviours and learning difficulties.

• Dietary Interventions - You may have heard some people say that ADHD is just a symptom of too much junk food and therefore treatment should simply involve a change in diet! However, there is limited evidence for dietary interventions in ADHD. A minority of children (particularly those with food sensitivities) may benefit from restricted exposure to artificial food colourings (although more research is needed in this area due to the poor quality of some of these studies). There is also some evidence to suggest small beneficial effects for some children who are supplemented with Omega 3 and Omega 6 fatty acids. However, the current scientific evidence does not support the idea that ADHD symptoms are related to sugar or aspartame (see Rytter et al., 2014 for a recent meta-analysis of dietary interventions for ADHD). Any benefits from dietary interventions are negligible when compared to the positive effects of medication.

• Cognitive Training - An increasing number of practitioners (some psychologists included) are offering cognitive training for ADHD. This is also sometimes called 'brain-training' or 'neurotherapy'. This usually involves having the child or adolescent engage in some of kind of task (often computer/tablet-based games) with the supposed goal of improving brain functions related to attention, processing or memory. These types of therapies are often expensive and, frankly, the evidence to support them is very poor. However, those who are selling the therapies may refer to studies that they claim show benefits. Those studies tend to be of poor quality and may even have been conducted by the practitioner or agency selling the therapy! So far, the evidence suggests that cognitive training does not lead to significant or meaningful improvements in ADHD functioning (see Cortese et al, 2015, for the most recent meta-analysis on this topic)

 
So, in short, medication is where it's at for ADHD, and psychological therapies may be a useful adjunct. If you have to choose only one approach, give due consideration to medication. But if there is an option of using both approaches, they may be complementary. Psychologists can also help schools to address issues in that setting. If parents want to explore dietary interventions, many paediatricians are happy to support them to do this, although it's unlikely that limiting sugar is going to change things for your child. And if offered an expensive quick-fix, like cognitive training, it may pay to be sceptical and stick with evidence-based therapies. 

The treatment of ADHD is such a controversial topic and this makes it even more difficult for parents to deaI with the issue. I am always happy to discuss issues related to ADHD with parents at any stage in their ADHD journey; whether that is at the point of initial assessment and diagnosis, or further down the track. For more information or support for your child with ADHD, contact me here



Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
Melbourne, Australia

The Internet is a great thing; it gives us access to a whole world of information. The flipside, however, is that the quality of that information may not be fantastic. It can be very difficult for the average person to work out whether the health information that they are reading online is authoritative. Conspiracy theories, pseudoscience, and armchair expert opinions abound. It's not always easy to tell the difference between an evidence-based summary of the best scientific knowledge available, or a blog masquerading as a news article written by someone with a particular personal agenda.

One of the topics that is really vulnerable to this problem of Internet mythology is Attention Deficit / Hyperactivity Disorder, or ADHD. For the last 25 years, public debate about this disorder has been hot. In particular, the public seems concerned that ADHD is not 'real', and rather is just a label for 'naughty' children. There is also a lot of controversy surrounding the prescription of stimulant medication, such as Ritalin, with some arguing that it constitutes the needless drugging of kids. 

And yet, we continue to diagnose children with ADHD and, in most cases, recommend prescription medication. So why is that psychiatrists, psychologists, occupational therapists and GPs (amongst others) continue to identify ADHD as an issue amongst a small percentage of children?

DEFINING ADHD
First, we need to be clear about what we are talking about when we refer to ADHD. The current Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM V; American Psychiatric Association [APA], 2013) contains the most commonly referred to diagnostic criteria. It's quite detailed; but, to summarise, the criteria are as follows:

Six or more of the following attentional symptoms for more than six months (N.B. symptoms must be inconsistent with developmental level, have a significant negative impact on the child's functioning or on other people, and is distinct from being oppositional or not understanding directions):

• Often fails to attend to details, makes careless mistakes
• Often has difficulty sustaining attention
• Often does not listen
• Often does not follow through and finish tasks
• Often has difficulty organising tasks
• Often avoids or dislikes tasks that require sustained mental effort
• Often loses things
• Often easily distracted 
• Often forgetful

And / or six or more of the following hyperactivity / impulsivity symptoms for more than six months. Again, these must be inconsistent with a child's developmental level (so, quite different to what we might expect of a child that age) and have a significant impact:

• Often fidgets or squirms
• Often leaves seat inappropriately
• Often runs around or climbs inappropriately
• Often has difficulty playing or engaging in leisure activities quietly
• Often seems 'on the go' or 'driven by a motor'
• Often talks incessantly
• Often blurts out answers before question is completed
• Often has difficulty waiting turn
• Often interrupts or intrudes

So, there must be a significant number of these symptoms occurring on a very frequent basis and in such a manner that they significantly interfere with or reduce the quality of a child's social or academic functioning. Furthermore, symptoms must be evident across multiple settings; if they just occur at school, but not at home (or vice versa) then ADHD will not be diagnosed. This is because if a child has these types of difficulties in just one setting, then it suggests that it is not a developmental problem; rather, it may be an environmental or behavioural issue that is related to that setting or context. A child who only demonstrates poor behaviour at home because of parenting issues does not meet diagnostic criteria for ADHD. 

I'm labouring that last point for a reason; so often, I hear people say that there is no such thing as ADHD and that it is simply a label for naughty children who haven't been parented properly. Certainly there are lots of children with ADHD who have come from a family that struggles with positive, effective parenting! However, if a child's behaviour issues are simply related to parenting then, as psychologists, we can help parents to change the child's behaviour through the use of behavioural interventions. When a child has ADHD, however, such behavioural interventions may not be so effective. I have seen many excellent parents struggle with their ADHD child, in spite of the support of skilled behavioural therapists, parenting programmes, and a variety of other therapies.  I would challenge any person who claims that ADHD is simply a symptom of poor parenting to try it for themselves and see how far they get.

So, it's real then?
The scientific evidence that ADHD is real is overwhelming. Seventy five per cent of cases are linked to genetic factors and a range of neurological impairments are implicated in its development. These include disturbances in the neurotransmitter systems associated with the production and distribution of dopamine and norepinephrine, which affect the brain's ability to control behaviour and emotions. Children with ADHD are also more likely to show reductions in some parts of the brain, such as the prefrontal and parietal cortex, and reduced electrical and metabolic activity in the brain. 

If ADHD was not a problem then it, quite simply, wouldn't be a problem. However, ADHD is a serious condition that significantly affects the quality of life of young people. Individuals with ADHD are significantly more likely to experience depression, suicidality, social isolation,  learning difficulties, early educational disengagement, unemployment, antisocial/criminal behaviour, substance abuse, and a variety of calamities associated with impulsive behaviour (e.g. sexually transmitted diseases, traumatic brain injury, etc.). These problems are worse for those who are untreated. If we don't accept that ADHD is real, then we make it harder for people with ADHD to be accurately diagnosed and be treated effectively. Which means we place these young people at risk of much poorer outcomes than they might expect if they have access to the best quality, evidence-based treatments.

Which brings us to the equally hairy topic of treatment! What does the scientific evidence say about interventions for ADHD? Click here for Part Two of this series on ADHD, where we look at treatment.



Dr Rosalind Case
PhD, PGDipPsych(Clin), MSocSc, BSocSc(Hons), MAPS
Clinical Psychologist
Melbourne, Australia