There’s a big gap between how ADHD should be diagnosed and treated and what too often happens in the real world. Far better outcomes would occur if we avoided these pitfalls and did it right. Here’s what I see as the five mistakes that are often made:
1. Cursory evaluation. While it’s tempting to just examine whether the child has ADHD, often there are complicating factors arguing in favor of a comprehensive evaluation. The child might be inattentive because he or she is gifted, has dyslexia, is depressed, has a growth disorder, or a multitude of other factors. If these alternatives remain unexamined we may never know if the child actually does have ADHD, or whether another problem is the real cause of their symptoms. Even if the child does have ADHD a failure to identify commonly accompanying conditions leaves those challenges unaddressed. Comorbidity is the coexistence of physical or psychological challenges. ADHD and dyslexia are comorbid in 25 to 40% of cases, ADHD and depression in 20% to 30%, and ADHD and anxiety in more than 25% of cases. For autism, comorbidity rates with ADHD range from 37% to 85%. So I’m a big advocate of comprehensive evaluation.
Even when an evaluation focuses solely on whether the child has ADHD, it is often too limited in scope. I see this most often when a general pediatrician who has not received much training in ADHD bases a diagnosis entirely on two 10-minute forms: one filled out by a parent and one by a teacher. A lot of children are put on ADHD medications based on just this sort of brief evaluation. A proper ADHD evaluation should include at least: a thorough developmental history; parallel behavior rating scales filled out by multiple reporters at home, school, and self-report; neuropsychological tests of attention performed in an office; observations of parent-child interaction and child behavior; and – optimally – classroom observations.
2. Willing the results to go one way or another. Since a good chunk of the information contributing to an ADHD diagnosis comes from parent and teacher reports of behaviors they feel they observe, bias and perspective can come into play. Often I see teacher reports weighing strongly in favor of a diagnosis and parent reports suggesting there is no problem whatsoever. Or the opposite. Or a father who sees no symptoms and a mother who sees many. As beauty is in the eyes of the beholder, so is ADHD. A highly structured teacher who values control and compliance may be more likely to see a child’s behaviors as indicative of ADHD than a permissive, creative teacher who values spontaneity. Sometimes parents or teachers are eager for a “quick fix” in the form of a “magic pill.” Sometimes teens or young adults want an ADHD diagnosis to get their hands on a pill they feel may give them a leg up in the competition for good grades and college admissions. Sometimes parents are reluctant to have their child given a potentially stigmatizing diagnosis. A good evaluator needs to see beyond these motivations.
3. Pursuing treatments that have no (or very little) scientific evidence to support their effectiveness. I can’t begin to tell you how often well-meaning parents are drawn to alternative, untested therapies that have little or no scientific evidence of effectiveness. These include neurofeedback, CogMed, acupuncture, special diets, fish oil, and the like. I understand why parents do this. They are hoping for a solution that avoids medication. But the majority of these approaches are not evidence-based (there is no scientific evidence to suggest that they actually do any good). Most will do no harm, but a lot of time and money can be wasted. The “evidence” that does exist supporting many of these approaches is purely anecdotal and there may be a placebo effect at play. I don’t work for the pharmacology industry and I have no vested interest in reporting that the scientific evidence, over 75 years of research, indicates that stimulant medication is effective at improving concentration and reducing impulsivity and lack of control in 80% of individuals with ADHD.
4. Not taking the time to carefully trial type and dosage of medication. When a family decides to try medication, too often the prescribing doctor doesn’t take the time to carefully trial the different types of medication available and find the best dosage for that particular child. It’s not a “one size fits all” science, and there is no way to predict in advance which medication and what dosage will work best. Sometimes a 160 pound teenager needs less than a 6-year old. Sometimes an amphetamine like Adderall is better than a methylphenidate like Ritalin. Sometimes short-acting formulations are better than long-lasting. What should happen is a careful trial of several different dosage levels and different medications with feedback from parents, teachers, and the child on effectiveness. Far too many clinicians fail to take the time to do this. Even when an optimal medication is found, it’s important to continue with regular, ongoing evaluations of its effects and monitor changes over time.
5. Failing to also implement behavioral interventions. While medication certainly can help it can’t solve everything. A child with ADHD usually doesn’t have the same kinds of intrinsic motivation for task completion and performance as others. Regular, consistently delivered rewards (and punishments) may be needed in the classroom and at home to optimize performance. Clinically-administered behavioral therapy and/or social skills training may be needed. For older children cognitive behavioral therapy can have real benefits. Parent training can be very helpful for learning how best to manage the child’s behavior.
I urge my clients to take the time to do it right. Get a good evaluation, try to be impartial about the results, be scientific about the treatments you pursue, and realize that a pill can’t fix everything.
And in the midst of all this please don’t forget to focus on your child’s strengths (see my blog titled Top 10 ADHD Superpowers).