Advice for Parents, Loved Ones and Friends on Diagnosing and Treating ADHD
Q&A with Stephen P. Hinshaw, Ph.D
Professor of Psychiatry and Vice-Chair for Child and Adolescent Psychology University of California, San Francisco Professor of Psychology University of California, Berkeley
2019 BBRF Ruane Prize for Outstanding Achievement in Child & Adolescent Psychiatric Research
Can you describe ADHD and the emotional and behavioral problems associated with it?
ADHD is called Attention Deficit Hyperactivity Disorder but in reality, it’s not about the inability to pay attention, per se. In fact, some people with ADHD are hyper-focused—they can’t get off the video game they’re playing, or their preferred activity, for many hours. Instead, ADHD is actually a disorder involving an inability to regulate one’s attention as situational demands shift.
If you have an underlying genetic vulnerability to be either impulsive or not highly focused, the challenges of sitting still in school and learning to read (things that the human brain did not evolve to do) renders about 1 in 20 kids (about 5%) vulnerable to serious impairment. We have good evidence that ADHD predicts academic failure, difficulties in social relationships, high risk for accidental injury, elevated risk for self-harm and suicidal behavior, and neuropsychological deficits in executive functions, all of which make life difficult in a productive society.
How does ADHD present itself?
The two classic symptom dimensions of ADHD are inattention (disorganization, lack of focus) and hyperactivity-impulsivity (impulsive actions often paired with fidgeting and running around). A child who comes to clinical attention with deficits in focus and organization but not much in the way of hyperactive behavior would get diagnosed with the “inattentive presentation” of ADHD. Conversely, a kid who is impulsive and interrupts all the time but seems to be relatively well-focused would get diagnosed with the “hyperactive-impulsive” presentation. This happens most often in preschoolers.
But the most common presentation that comes to clinical attention pertains to a child presenting with both inattention and hyperactivity-impulsivity. Such youth are not able to follow the teacher’s directions, can’t get homework organized or done, and can’t sit still very well.
Do we know if ADHD is caused by purely biological factors?
Let me put it this way: Is ADHD real? Yes, decidedly so, despite the myths and the propaganda that it’s just lax parenting or lazy kids or bad classrooms. ADHD has an underlying psychobiological reality. The symptoms are highly heritable, meaning that genes play the major role in dictating your risk. However, home environments— inconsistent discipline, shouting matches, and the power struggles, as well as chaotic classrooms—can certainly maintain and intensify the symptoms.
ADHD can be tricky to diagnose. What is the right way of diagnosing this condition?
Many kids are diagnosed on the basis of 10 or 15 minutes in a pediatrician’s office without evidence-based rating scales from parents and teachers, without a thorough developmental history, and needed diagnostic testing.
In the past few months, the American Academy of Pediatrics (AAP) and the Society for Developmental and Behavioral Pediatrics (SDBP) issued new guidelines for assessment and treatment of ADHD. These involve the use of parent and teacher ratings of the child on standardized and normed scales to get a sense of what percentile of disorganization, inattentiveness, and impulsivity the child shows. There’s a recommendation, as well, that the provider, or an assistant, visit the classroom to assess the level of disorganization in the teaching environment. In short, it takes time and effort to gather and appraise the relevant information.
You’re saying that some kids might look hyperactive in instances where the teacher is not exerting proper control of the classroom and in those cases it really has less to do with the kids than the teacher.
Exactly. Even more, a child can seem to have ADHD because of maltreatment or abuse, or certain seizure disorders, or seriously deprived early home environments. Again, without a thorough developmental history (for example, were there speech delays? maltreatment? lack of structure?) and without standardized ratings from parents and teachers, ADHD can be mistaken for a host of other conditions and factors.
In some cases, there could be evidence for both trauma and ADHD, but you can’t figure that out by just “examining” the child and family for a few minutes in a pediatrician’s office. It’s going to take at least a couple of hours of detective work to uncover if the symptoms are consistent with ADHD. A doctor should always ask: Is there another condition or an unstructured classroom environment that explains the symptoms better?
In 2014, you published a much-discussed book called The ADHD Explosion in which you discussed the skyrocketing rates of ADHD in the U.S. What triggered this explosion in diagnoses? Has the surge in diagnoses peaked?
The answer is that we don’t know for sure if the explosion has peaked, but new national survey data are emerging in the years since the book came out. Apart from the U.S. and Israel, all nations around the world with compulsory education have similar rates of ADHD diagnosis— around 7% of the school-age population. The rates are much higher here and in Israel, where it’s over 11%.
Now, does that mean that there’s truly more ADHD in these two nations? It’s hard to know because we don’t yet have biomarkers—a blood test or a brain scan that definitively shows its presence. What we have is “diagnosed prevalence.” This could accurately reflect the actual prevalence, but may be subject to bias because of the way things get diagnosed.
I think of ADHD as a disorder that would probably be diagnosed more frequently in a culture with high expectations for achievement and performance. The reason? Because of its documented and real detrimental effects on school achievement and adult employment.
Not only are rates of ADHD diagnosis rising across the U.S., but major state-by-state variation exists. My colleagues at Berkeley and I set about to investigate the association between state-by-state rates of ADHD and laws in those states that link school funding to test scores. In the 21 states that passed so-called “consequential accountability legislation” in public schools after 2003, we found a 59% increase in ADHD diagnoses of kids at or near the poverty level, compared to states that had passed those laws passed previously—or compared to kids in private schools in those states, not subject to “consequential accountability.” 2003 was the year that the No Child Left Behind Act went into effect, influencing practices in the states lacking previous consequential accountability laws, creating real urgency to yield the best possible results.
In short, if a state feels pressure to improve its test scores, there’s going to be a sudden increase in ADHD diagnoses given to the poorest kids. This is because test scores tend to be lower in high-poverty public schools and an ADHD diagnosis for some of the low-achieving students can justify their removal from a school’s test-score statistics, falsely raising the district’s average scores. Especially when ADHD can be diagnosed in a brief, nonevidence-based evaluation, there’s evidence that such gaming of the system helped to fuel rising rates of ADHD diagnosis.
Let’s return to the situation that parents face: How do you find the right pediatrician and get the most out of your visit?
Often ADHD emerges in elementary school when the child begins to fall behind. Parents should talk to other parents about their own experiences, and ask for recommendations for pediatricians or other professionals who know the score. In this way they can figure out which doctor really understands the condition and which doctors may tend to diagnose every other kid who walks in the office. To find support, parents should look to self-help and advocacy groups. There’s a national self-help advocacy group called Children and Adults with ADD (CHADD). There are local groups, too, that should have a good sense of which professionals in your community can provide an evidence-based assessment.
Some HMOs have big practices where pediatricians team up with psychologists. They also have school psychologists who help with the assessment. You want to make sure to observe child behavior in the natural environments in which it occurs—at home, in school, and within the kid’s peer group.
Parents can also obtain parent and teacher ratings of the child well ahead of the pediatrician visit, so that the doctor can review these scores. It would be a great idea to get impressions from last year’s teacher as well. And I would caution parents to be very suspicious if the doctor doesn’t spend 30 to 60 minutes asking about developmental history from birth till today.
How early do the signs of ADHD start to appear?
Many toddlers look a lot like kids with ADHD because that’s their natural developmental sequence. It takes the brain a long while to start to develop and exert self-control over a child’s behavior. The AAP and SDBP suggest strongly that a valid diagnosis can be made between ages 4 and 6, with a lot of diligence. Still, one must be careful not to mistake an exuberant, normal-range preschooler for a kid who’s actually got underlying ADHD. The future will bring reliable early-detection devices. But right now, the preschool years provide an opportunity for early intervention. We know that children with ADHD in the preschool years can die of accidental injury more often than other children, and too many are already set on a course that might predict academic failure unless you start to intervene early.
What does intervention look like?
For ADHD, until you’re in your late teen or adult years, the main consumers of behavioral therapy are parents and teachers. Through parent management training and classroom interventions that include behavioral supports, parents and teachers can break down skills into small steps. For instance, parents can use a reward system with their children because so many youth with ADHD don’t develop intrinsic motivation as fast as other kids. So instead of yelling, “I told you a thousand times you’re going to sit still for dinner for 20 minutes,” parents can start the clock at 5 minutes and use extra dessert as positive reinforcement. And then gradually increase the time. If done well, and if coordinated with schools, such behaviorally based interventions can promote real gains. As kids get older, organizational skills become quite important, and evidencebased interventions for these skills are also available.
By late adolescence and adulthood, cognitive-behavior therapy (CBT) is effective, including time management, anger control, organizational skills, and relationship management.
And what about medications?
ADHD-related medications include (a) stimulants such as Adderall and Ritalin and (b) other kinds of medicine that focus on what we call the noradrenergic pathways of the brain. These are effective in managing symptoms for most individuals with ADHD. However, it takes clinical skill and close observation to decide which medications (and at which dosages) are optimal for a given patient.
For preschoolers, behavioral interventions are considered first-line treatments; for grade-schoolers, both medications and behavioral interventions are treatments of choice. A number of studies reveal that the most effective treatment regime for most individuals with ADHD is “multimodal,” involving a combination of behavioral and medication interventions, carefully monitored.
You are renowned for your multi-year ADHD studies of girls. What have you learned?
When I was in graduate school a long time ago, the field used to believe that girls don’t get ADHD. So, 25 years ago, my team began the Berkeley Girls with ADHD Longitudinal Study (BGALS). We designed therapeutic summer camps to observe how girls with and without ADHD interact with one another in the playground and the classroom. We have followed our sample regularly.
We have found that girls with ADHD are just as academically impaired as boys. They have the same kinds of executive function deficits. And they actually encounter more peer rejection because other girls are very sensitive to intrusive, impulsive behaviors.
During our 5-, 10-, and 16-year followups, we have found that girls with ADHD, in addition to maintaining these core problems, also have different sets of longterm outcomes. More than boys, they’re more likely in their late teens and twenties to engage in self-harm, including both non-suicidal self-injury and actual suicide attempts.
We also found that girls with ADHD who had also been physically or sexually abused or neglected had 50% higher rates of suicide attempts than those girls with ADHD who had not experienced maltreatment. It’s a classic example of genetic risk being compounded by early adverse experiences.
Is the treatment course in girls any different?
There’s no data to suggest that girls respond any differently than boys to medications or behavioral interventions. There’s still a lack of recognition of ADHD in girls because the doctor may say, “Well, she wasn’t running around the waiting room.” Or the teacher might report that she’s not climbing up on desks like her male peers with ADHD. Girls are more likely than boys to have the purely “inattentive” form of ADHD and they’re more likely to be hyper-verbal rather than hyperactive physically. So, clinicians must recognize some of the gender-specific manifestations of ADHD.
You said in one of your papers that few girls with ADHD show “positive adjustment” later in life. What does this mean?
With our Berkeley sample we didn’t find much evidence for the kind of magical thinking that if you just wait long enough. kids with ADHD somehow grow out of it. Yes, when you’re 18 compared to 8, you may not be running around a classroom but academic problems may well magnify, as do organizational problems, relationship problems, and problems on the job.
We found one out of five of our girls with ADHD were doing well in most domains of life by their adolescent years, and we’re trying to explore what predicts such resilience or “positive adjustment,” on into adulthood. But sadly, we find that most are struggling academically and socially. Sixteen years after the summer camps, girls (now women in their 20s) with ADHD show a 45% risk of unplanned pregnancy compared to a 10% risk for the comparison group Both inattention and impulsivity contribute to that high risk for unplanned pregnancy, which demonstrates that there are consequences beyond immediate symptoms of the disorder.
You make clear that ADHD continues to have consequences as you go forward in life. So would you agree that a key takeaway is for parents to intervene as early as possible?
Yes, please be concerned as a parent, so long as you’re not over-concerned with fidgeting or temporary lack of focus. Every child is inattentive sometimes, right? But if you’re getting feedback in preschool and grade school, from teachers, coaches, and peers, please look into it. On average, if these behaviors are above the developmental norm and they’re causing real problems in life, they’re not likely to go away on their own without some serious intervention. I think that’s the core message here.
— Written By Peter Tarr