ADHD: 2012 In A Snapshot

Sunday, December 30th, 2012

Two themes stand out for me this year with respect to research on ADHD: 

Diagnosis: We continued to observe a potential paradox – ADHD may be overdiagnosed, yet many kids do not receive proper diagnosis and care. Here’s why. The overdiagnosis aspect comes about because kids are given a label of ADHD without going through a rigorous interdisciplinary evaluation. And that’s where some kids slip through the cracks – some kids with severe symptoms do not get evaluated properly and struggle for years without appropriate intervention. So even though studies suggest that the rate of ADHD is very high (like some of the data reported by the Centers for Disease Control and Prevention), that does not translate into saying that all kids who may suffer from high levels of severity and impairment are getting the clinical services they need.

Treatment: The debate about using medications to treat ADHD got more extreme this year. A controversial opinion piece by a leading developmental researcher essentially negated the role of biology as a root cause of ADHD. On the other side of the issue, there were suggestions that kids as young as 4 years of age should start receiving medications to control their symptoms – and there were reports that in some (economically disadvantaged) areas of the country doctors are giving kids ADHD medication (without assessment and diagnosis) to try to improve their behavior and performance in school. Lost in the debate is the very real need for behavioral treatments that focus on parental strategies to help kids with ADHD function better both at home and in school. My viewpoint on all this continues to be that behavioral approaches should be tried first and should always be in place – and that once those effects are established clinicians and parents can have a more meaningful dialogue about the possible additional advantages of medication.

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A (Very Brief) Primer On Genetics And Behavioral/Emotional/Developmental Disorders

Wednesday, November 28th, 2012

This will be brief.

There continues to be loads of information on the role of genetics on behavioral/emotional/developmental disorders. This pace will continue. But the big picture for parents can be elusive. So here is a primer.

Some disorders  are “genetic” in the classic sense—meaning they primarily have a genetic foundation. They tend to be very rare and distinctive. Examples are Fragile-X syndrome, and Down syndrome.

That said, most disorders these days are assumed to be “complex”—meaning that they arise from a combination of risk factors, both genetic and non-genetic in origin. In many cases, there may not be “one” definitive etiology but rather a range of causes that can vary from kid to kid. For example, it is believed that some cases of autism are due to rare genetic mutations (some of which may be associated with paternal age). But this type of causation may only account for a small fraction of the cases in the population. There may be a number of genes (some suggest it could be in the hundreds) that convey some level of risk for autism. And for these cases, the environment can also be a potent influence, as evidenced by recent twin studies. That said, the actual environmental factors remain elusive.

This idea of “complex” causation probably applies to the vast majority of behavioral/emotional/developmental disorders. ADHD is believed to be highly heritable—but there are no genetic markers that distinguish normative levels of inattention and hyperactivity from problematic ones. And just because ADHD is heritable, that doesn’t mean that the environment doesn’t matter. Biological environments (such as prenatal exposures) may play a role. The psychosocial environment is also very important in terms of shaping how ADHD gets expressed. In the case of “complex” disorders, genetics is often described as influencing “what is,” but not “what can be”—which is another way of saying that psychosocial interventions can be powerful approaches for altering behaviors that are “genetic” in origin.

We’ve learned a lot about genetics over the past few decades. We will continue to learn even more. But the reality right now is that, with the exception of rare “genetic” disorders, there is still more unknown than known about the role that genes play in the evolution of behavioral/emotional/developmental disorders. What we do know, though, is that environment matters. So whether we are talking about autism or ADHD or conduct problems or other issues, a parent’s best line of action is to get reputable psychosocial interventions that have been shown to work. Remember, genetics is, more times than not, more about “what is” rather than “what can be.”

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Prenatal Exposure To Mercury And Childhood Risk For ADHD

Tuesday, November 27th, 2012

The role of prenatal influences on development can be profound. But it is still a very murky science, as was beautifully illustrated in Annie Murphy Paul’s “Origins: How The Nine Months Before Birth Shape The Rest Of Our Lives”. Case in point: a new study that looks at the role of prenatal exposure to mercury and risk for ADHD.

Forget about the study details – let’s cut to the two bottom lines of the study. First, documented mercury exposure during pregnancy (validated using gold standard methods) was indeed predictive of risk for ADHD in the offspring. Second, eating fish during pregnancy, which is sometimes thought to be a risk factor for mercury exposure, was protective with respect to ADHD.

So…what does a pregnant woman do with these findings?

Well, right now, not too much. This study did not identify the sources of mercury exposure, so it’s hard to say how to prevent it. And it’s not entirely clear which type of fish to eat, and what type to avoid.

Now, this is kind of where the science is at these days. It’s very important research, and not easy to conduct. But it’s worth keeping in mind, if you are following it, that it will be a long and winding road before the studies sort through all the complexities and possible contradictions and yield empirically validated guidelines.

Pregnant Woman via Shutterstock.com

Do The Youngest Kids In Class Get Labeled ADHD More Frequently?

Tuesday, November 20th, 2012

A new study suggests that they do. 

A population-based study in Iceland looked at the association between relative age in a classroom and likelihood of being prescribed a stimulant medication for ADHD. What they found was startling: the youngest third of a class was 50% more likely to be prescribed stimulant medication for ADHD. This finding held up for girls as well as boys (although much fewer girls get diagnosed), and was observed between the ages of 7 and 14. These younger kids were also more likely to experience academic problems.

This study did not report on the mechanism underlying this association. But the speculation is pretty straightforward. It may be that the youngest kids in a class are a bit more immature in their behaviors. In order to get a diagnosis of ADHD, a child must be showing symptoms at both school and at home. Since the youngest kids reference point isn’t their chronological age – it’s their classroom – they may be more likely to be rated as having elevated symptoms at school.

That said, these findings are a bit more complex than that. The kids who get diagnosed have to be showing problems at home as well. But, again, there may be expectations about how they should be behaving if their peer group is typically older than them.

The overall implication from this study is that schools – and parents – need to take into account a kid’s relative age in the classroom if behavioral (and academic) issues come up. If a kid is one of the youngest, then perhaps the bar should be raised higher in terms of level of symptoms before proceeding with a diagnosis – and stimulant medication.

This study also brings up the issue of “redshirting.” I’m not a big fan of the idea of parents trying to hold back their kids in order to make sure they will be the oldest in a class so that they can excel academically and athletically. Rather, I think studies like this one suggest that parents should consider carefully the implications of their child being the youngest in a class – particularly in terms of academic and social readiness. Another way to look at the data, and this issue, is to recognize that a number of the younger children in a class were doing fine. Thoughtful evaluations of readiness and age need to be made in order to make appropriate placement decisions.

Once these decisions are made, it does seem reasonable to suggest that relative age in a classroom should always be a variable when interpreting behavioral and academic performance. ADHD is a complicated disorder to diagnose. It’s clear that a very small percentage of kids fully meet diagnostic criteria. But it’s also becoming clear that it is important to not rush into medication strategies without careful consideration of a wide range of factors – including if a kid is one of the youngest in a class.

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“Meducation”: Giving ADHD Medication To Kids Who Are Struggling In School (But Not Diagnosed)

Friday, October 12th, 2012

There is much ongoing conversation about an article in the New York Times which featured a pediatrician who reports giving kids who are struggling in school Adderall – which is prescribed for kids with ADHD –  without first diagnosing them with ADHD. His rationale is that he does this for kids who are in low-income families who do not get sufficient support for their academic development or for services to help them if they have problems. He notes that this is a short-cut he takes because he knows that society, overall, does not invest nearly enough resources into giving kids the proper social and academic resources they should get. This practice was aptly captured by Stephen Colbert who coined the term “meducation” to refer to this practice of giving pills to kids to improve their school performance. 

A lot can be said about this (and much has been already written). I’ll make three points.

First, it’s dangerous practice to give kids medication for anything unless a clinician goes through the proper steps to make a meaningful clinical diagnosis. For ADHD, there is a series of steps which include:

• gathering information from a number of sources, including parents, teachers, and sometimes the kids themselves (because kids with ADHD don’t just show problems in school or in home – the problems should appear across a number of contexts)
• using that information to consider a diagnosis in relation to the standard criteria (it’s not just a subjective impression)
• assessing symptoms of a number of other conditions such as anxiety, sleep problems, and learning problems like dyslexia (because symptoms of ADHD can be seen in kids with a number of other clinical conditions)

Without taking these steps, it’s just not acceptable practice to make a diagnosis. It would be like seeing that a kid is sneezing and has a runny rose and assuming they have the flu. Now it’s acknowledged that we don’t have biological markers that allow us to diagnose ADHD – it’s a behavioral syndrome. But ensuring that a kid meets the criteria that have been established is the best available way of identifying kids who could greatly profit from intervention – and it’s also a way to make sure a kid isn’t just slapped with a label without going through a rigorous diagnostic process.

Second, even when a child is diagnosed with ADHD, it is not a given that they will go on medication. A number of behavioral methods are available and should always be considered (and in my opinion used). And when a decision is made to go on a medication, the dosage, potential side effects, and impact on symptoms needs to be tracked carefully and consistently. Drugs like Adderall can be used safely but only with sufficient monitoring.

Third, giving kids medications to try to solve social problems is just not right. We shouldn’t be messing around with kids’ biology to circumvent the lack of adequate resources, overcrowding of classrooms, and the multitude of other factors that can undermine a kid’s academic progress. These are, without question, very hard problems to solve. But rather than giving kids pills, it’s interesting to note that Paul Tough’s new book begins to explore the utility of giving kids psychological boosts via social initiatives that may turn out to have real educational advantages.

There are kids in the world who have the severe level of symptoms that are consistent with a diagnosis of ADHD. I would guess that it’s about 2% of school-aged kids (prevalence estimates land somewhere around 9%, but estimates of kids with severe levels of symptoms are typically less than 2%). Routinely treating kids who suffer from social disadvantage with a medication that should be reserved for kids with the most severe symptoms is just not the solution anyone is looking for.

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