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January 29, 2024
Recognizing whether your ADHD is being managed appropriately requires an understanding of what constitutes effective treatment. Here are some indicators of proper ADHD treatment:
Comprehensive Evaluation: An appropriate diagnosis of ADHD involves a comprehensive evaluation, including medical history, clinical interviews, and assessment tools. It should also exclude other conditions that may mimic ADHD.
Clear Communication: Your doctor should provide a clear explanation of ADHD, its symptoms, treatment options, potential side effects, and expected outcomes. They should answer your questions patiently and help dispel any misconceptions.
Individualized Treatment Plan: ADHD treatment often involves a combination of medication, psychotherapy, and lifestyle changes. Your doctor should tailor the treatment plan to your specific needs, symptoms, and life circumstances.
Medication Management: If medication is part of your treatment plan, your doctor should monitor its effects and side effects closely, adjusting the dosage as necessary. Remember, the aim is to maximize benefits and minimize side effects. Much research shows that it is usually best to start treatment with an FDA approved medication. If your doctor decides otherwise, you should ask why.
Psychotherapy and Coaching: Pills don’t provide skills. Many adults with ADHD never acquired life skills due to untreated ADHD. Cognitive-behavioral therapy (CBT) is beneficial for managing ADHD. Your doctor might recommend this and refer you to a psychologist, or they might provide some elements of these services themselves.
Regular Follow-Ups: Regular follow-ups are critical to assess the effectiveness of the treatment plan and to make necessary adjustments. Your doctor should be tracking your progress and adapting your treatment as needed.
Empowering You: A good doctor will support you in managing your ADHD, providing education, resources, and tools that empower you to lead a healthy, fulfilling life.
Focus on Strengths: ADHD can come with strengths, such as creativity, dynamism, and the ability to think outside the box. An effective healthcare provider will help you leverage these strengths.
Involvement of Loved Ones: Depending on your circumstances, involving your loved ones in your treatment process can be beneficial. They can provide additional support and understanding.
Co-ordinating with Other Healthcare Providers: If you have other healthcare providers involved in your care, your doctor should communicate and coordinate with them to ensure consistent and comprehensive care.
Remember, you have the right to seek a second opinion if you feel your ADHD is not being appropriately managed. Trust your instincts and advocate for your health. It may also be helpful to join ADHD support groups (online or offline) to connect with others who share similar experiences. Their insights and recommendations could be beneficial. Also keep in mind that achieving an optimal outcome for one’s ADHD often requires the doctor to try a few different medications as it is not currently possible to predict which patients do best on which medications.
In our digital age, the internet serves as a powerful platform for accessing health information. Yet, with this great power comes great responsibility. Misinformation, particularly concerning ADHD (Attention-Deficit/Hyperactivity Disorder), is rife online, leading to confusion, the perpetuation of stigma, and potentially harmful consequences for those affected by the disorder and their loved ones. This blog will delve into some of these misconceptions, their impacts, and how to ensure the ADHD information you come across online is reliable, with a special emphasis on a recent study examining ADHD content on TikTok.
The Misinformation Problem
ADHD is a neurodevelopmental disorder that affects both children and adults. It's characterized by patterns of inattention, impulsivity, and hyperactivity that are persistent. Despite its recognition as a well-documented medical condition, it is often misunderstood, partly due to widespread misinformation.
Common ADHD misconceptions include:
ADHD is not a real disorder: This belief is found scattered across online forums, and even some ill-informed news articles.
ADHD is a result of bad parenting: Numerous online discussions blame parents for their child's ADHD. However, research has shown that ADHD has biological origins and is not a result of parenting styles.
ADHD only affects children: Many websites and social media posts promote this myth, but ADHD can continue into adulthood.
ADHD medication leads to substance abuse: Certain posts on social media may wrongly claim that ADHD medication leads to substance abuse.
A recent study explored the quality of ADHD content on TikTok, a popular video-sharing social media platform. Researchers investigated the top 100 most popular ADHD-related videos on the platform. Shockingly, they found that 52% of these videos were classified as misleading, while only 21% were categorized as useful. The majority of these misleading videos were uploaded by non-healthcare providers.
The Impact of Misinformation
Misinformation about ADHD can have harmful impacts on individuals with the disorder and their families:
Delayed diagnosis and treatment: Misinformation can deter individuals and parents from seeking professional help, leading to delays in diagnosis and treatment.
Increased stigma: False information can amplify societal stigma about ADHD, leading to misunderstanding and discrimination.
Harmful treatment approaches: Misinformation can lead individuals to opt for ineffective or even harmful treatments.
The proliferation of misleading ADHD content on platforms like TikTok only amplifies these problems. The TikTok study found that while the videos were generally understandable, they had low actionability — meaning they offered little practical advice for managing ADHD.
Identifying Reliable Information
Given the prevalence of misinformation, it's crucial to be able to distinguish between reliable and unreliable information about ADHD. Here are some pointers:
Use reputable sources: Trustworthy information often comes from recognized health organizations, government health departments, or reputable medical institutions. Some examples are NIH, Mayo Clinic, CDC and www.ADHDevidence.org.
Be wary of fake experts: If you see info from a self-proclaimed expert, you can check to see if they are really an expert by going to www.expertscape.com. Or go to www.pubmed.gov to see if they’ve ever written anything about ADHD that has been approved by their peers.
Look for citations: Reliable sources often cite scientific research to back their claims.
Beware of sensational headlines: Clickbait headlines often oversimplify complex topics like ADHD.
Consult a professional: If you're unsure about any information, consult a healthcare professional.
The TikTok study's findings underscore the importance of these guidelines, as healthcare providers tended to upload higher quality and more useful videos compared to non-healthcare providers.
In our era of digital information, the challenge of separating ADHD facts from fiction is significant but not insurmountable. By becoming discerning consumers of online information, we can help prevent the spread of misinformation, support those affected by ADHD, and foster a more informed and understanding society. It's also essential for clinicians to be aware of the extent of health misinformation online and its potential impact on patient care. This way, they can guide their patients toward reliable sources and away from misleading content.
Persons with ADHD have known to have high rates of psychiatric comorbidities. There is also growing evidence of somatic (non-psychiatric) comorbid disorders among youths with ADHD, such as metabolic syndrome (which can lead to type 2 diabetes) and chronic inflammation (such as asthma and allergic rhinitis). Much less is known, however, about comorbid conditions in adults with ADHD.
An international team of researchers looked for indicators of comorbid conditions in a nationwide cohort study using Swedish national registers. The target population was Swedish residents between the ages of 18 and 64 in 2013 and more specifically those who had been prescribed ADHD medication. They identified over 41,000 individuals who met these criteria, including over twenty thousand young adults aged 18-29 years, over sixteen thousand middle-aged adults aged 30-49 years, and over four thousand older adults aged 50-64. The remainder of the overall cohort were used as controls.
Young adults receiving ADHD medications were four times as likely to also be receiving somatic medications, and older adults were seven times as likely. The highest rate of co-medication -roughly five times more frequent than among controls - was for respiratory system medications. The second most common was for alimentary tract and metabolic system medications, with odds over four times higher than for controls. Cardiovascular system medications were the next most common, with odds among young adults receiving ADHD medications over four times those of controls, though reducing with age to being twice as common in older adults with ADHD. Patterns were similar among men and women.
Adults receiving ADHD medications were far more likely to also be receiving other psychotropic medications. Middle-aged adults were 21 times as likely to be dispensed such medications as controls, older adults eighteen times more likely, and younger adults fifteen times more likely.
For young adults prescribed ADHD medications, the most prevalent co-prescriptions were for addictive disorders, which were dispensed at over 26 times the rate for controls. For middle-aged and older adults, on the other hand, the most prevalent co-prescriptions were for antipsychotics, which were likewise dispensed at over 26 times the rate for controls. Results remained consistent for individuals who had an ADHD diagnosis in addition to an ADHD prescription.
In addition, individuals receiving ADHD medications were also on average taking more types of prescriptions, rising from 2.5 classes of medications at age 18 to five classes at age 64. For controls, the equivalent numbers were 0.9 types of medications at age 18, rising to 2.7 at age 64.
Looking at specific somatic medications prescribed, those for respiratory conditions were ones typically prescribed for asthma and allergic reactions, reinforcing a previously known association. Insulin preparations also had high rates of co-prescription, again further confirming the known association with obesity and diabetes.
On the other hand, the most commonly dispensed alimentary tract and metabolic system medications included proton pump inhibitors, typically prescribed for gastric/duodenal ulcers and gastroesophageal reflux disease. Sodium fluoride, prescribed to prevent dental caries, was also prominent. Neither of these is an established association and warrants further exploration.
Turning to psychotropic medications, the most frequent prescriptions were with drugs used to treat addictive disorders and with antipsychotics. Rates of opioid co-prescription were also notably high, a source of concern given the higher proclivity of persons with ADHD to substance use disorders.
There is strong evidence of the effectiveness of a variety of ADHD medicines in reducing ADHD symptoms. While some are more effective than others, another factor in deciding on a course of treatment is minimizing noxious side effects.
One of those side effects is a headache.
An international team of researchers from Sweden, Germany, the Netherlands, the United Kingdom, the United States, and Australia conducted a systematic review of the peer-reviewed medical literature about ADHD and headaches on the one hand, and ADHD medications and headaches on the other.
As a baseline, they performed a meta-analysis of twelve studies with a combined total of over 2.7 million participants that compared headache rates between youths with and without ADHD. Those with ADHD were twice as likely to suffer from headaches. This held even after limiting the meta-analysis to the four studies that adjusted for confounders.
Breaking down the results by type of headache revealed a fascinating distinction. There was no significant difference in rates of tension headaches, but migraines were 2.2 times as frequent among youths with ADHD.
This strong association between ADHD and migraines suggests looking for medications that are both effective and unlikely to further contribute to the odds of migraine.
Accordingly, the team examined associations between specific ADHD medications and headaches.
Stimulant medications are generally considered the most effective medications for treating ADHD. A meta-analysis of ten studies with 2,672 participants found no association between amphetamines and headaches. On the other hand, a meta-analysis of 17 studies with 3,371 participants found that methylphenidate increased the odds of headache by one-third (33%).
The non-stimulant atomoxetine is usually considered a second-tier treatment for those among whom stimulants are contraindicated. A meta-analysis of 22 studies encompassing 3,857 participants found it increased the odds of headache by 29%.
Guanfacine fared worst of the bunch. A meta-analysis of eight studies combining 1,956 participants found it increased the odds of headache by 43%.
Finally, a meta-analysis of six studies with a combined total of 818 participants found no association with headaches.
There was no indication of publication bias in any of the meta-analyses.
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Background:
Pharmacotherapies, such as methylphenidate, are highly effective for short-term ADHD management, but issues remain with medication tolerability and adherence. Some patients experience unwanted side effects from stimulant medications, leaving them searching for alternative ADHD treatments. Alternative treatments such as cognitive training, behavioral therapies, psychological interventions, neurofeedback, and dietary changes have, so far, shown limited success. Thus, there is a critical need for non-pharmacological options that boost neurocognitive performance and address core ADHD symptoms.
First— What Are NIBS (Non-Invasive Brain Stimulation) Techniques?
Non-invasive brain stimulation (NIBS) techniques, including transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS), transcranial alternating current stimulation (tACS), and repetitive transcranial magnetic stimulation (rTMS) are generating growing attention within the scientific community.
NIBS techniques are methods that use external stimulation, such as magnets or electrical currents, to affect brain activity without any invasive procedures. In transcranial alternating current stimulation (tACS), for example, small electrodes are placed on the scalp of the patient, and a weak electrical current is administered.
The theory behind these techniques is that when a direct current is applied between two or more electrodes placed on specific areas of the head, it makes certain neurons more or less likely to fire. This technique has been successfully used to treat conditions like depression and anxiety, and to aid recovery from stroke or brain injury.
The Study:
Previous meta-analyses have produced conflicting indications of efficacy. A Chinese research team consisting of sports and rehabilitative medicine professionals has just published a network meta-analysis to explore this further, through direct comparison of five critical outcome domains: inhibitory control, working memory, cognitive flexibility, inattention, hyperactivity and impulsivity.
To be included, randomized controlled trials needed to have participants diagnosed with ADHD, use sham control groups, and assess ADHD symptoms and executive functions – such as inhibitory control, working memory, cognitive flexibility, inattention, hyperactivity, and impulsivity – using standardized tests.
A total of thirty-seven studies encompassing 1,615 participants satisfied the inclusion criteria. It is worth noting, however, that the authors did not specify the number of randomized controlled trials nor the number of participants included in each arm of the network meta-analysis.
Furthermore, the team stated, “We checked for potential small study effects and publication bias by conducting comparison-adjusted funnel plots,” but did not share their findings. They also did not provide information on outcome variation (heterogeneity) among the RCTs.
Results:
Ultimately, none of the interventions produced significant improvements in ADHD symptoms, whether in inattention symptoms or hyperactivity/impulsivity symptoms. Likewise, none of the interventions produced significant improvements in inhibitory control. Some tDCS interventions enhanced working memory and cognitive flexibility, but details about trial numbers and participants were missing. The team concluded, “none of the NIBS interventions significantly improved inhibitory control compared to sham controls. … In terms of working memory, anodal tDCS over the left DLPFC plus cathodal tDCS over the right DLPFC … and anodal tDCS over the right inferior frontal cortex (rIFC) plus cathodal tDCS over the right supraorbital area ... were associated with significant improvements compared to sham stimulation. For cognitive flexibility, only anodal tDCS over the left DLPFC plus cathodal tDCS over the right supraorbital area demonstrated a statistically significant benefit relative to sham. ... Compared to the sham controls, none of the NIBS interventions significantly improved inattention. ... Compared to the sham controls, none of the NIBS interventions significantly improved hyperactivity and impulsivity.”
How Should We Interpret These Results?
In a word, skeptically.
If one were to read just the study’s abstract, which states, “The dual-tDCS and a-tDCS may be considered among the preferred NIBS interventions for improving cognitive function in ADHD”, it might seem that the takeaway from this study is that this combination of brain stimulation techniques might be a viable treatment option for those with ADHD. Upon closer inspection, however, the results do not suggest that any of these methods significantly improve ADHD symptoms. Additionally, this study suffers from quite a few methodological flaws, so any results should be viewed critically.
Background:
Despite recommendations for combined pharmacological and behavioral treatment in childhood ADHD, caregivers may avoid these options due to concerns about side effects or the stigma that still surrounds stimulant medications. Alternatives like psychosocial interventions and environmental changes are limited by questionable effectiveness for many patients. Increasingly, patients and caregivers are seeking other therapies, such as neuromodulation – particularly transcranial direct current stimulation (tDCS).
tDCS seeks to enhance neurocognitive function by modulating cognitive control circuits with low-intensity scalp currents. There is also evidence that tDCS can induce neuroplasticity. However, results for ADHD symptom improvement in children and adolescents are inconsistent.
The Method:
To examine the evidence more rigorously, a Taiwanese research team conducted a systematic search focusing exclusively on randomized controlled trials (RCTs) that tested tDCS in children and adolescents diagnosed with ADHD. They included only studies that used sham-tDCS as a control condition – an essential design feature that prevents participants from knowing whether they received the active treatment, thereby controlling for placebo effects.
The Results:
Meta-analysis of five studies combining 141 participants found no improvement in ADHD symptoms for tDCS over sham-TDCS. That held true for both the right and left prefrontal cortex. There was no sign of publication bias, nor of variation (heterogeneity) in outcomes among the RCTs.
Meta-analysis of six studies totaling 171 participants likewise found no improvement in inattention symptoms, hyperactivity symptoms, or impulsivity symptoms for tDCS over sham-TDCS. Again, this held true for both the right and left prefrontal cortex, and there was no sign of either publication bias or heterogeneity.
Most of the RCTs also performed follow-ups roughly a month after treatment, on the theory that induced neuroplasticity could lead to later improvements.
Meta-analysis of four RCTs combining 118 participants found no significant improvement in ADHD symptoms for tDCS over sham-TDCS at follow-up. This held true for both the right and left prefrontal cortex, with no sign of either publication bias or heterogeneity.
Meta-analysis of five studies totaling 148 participants likewise found no improvement in inattention symptoms or hyperactivity symptoms for tDCS over sham-TDCS at follow-up. AS before, this was true for both the right and left prefrontal cortex, with no sign of either publication bias or heterogeneity.
The only positive results came from meta-analysis of the same five studies, which reported a medium effect size improvement in impulsivity symptoms at follow-up. Closer examination showed no improvement from stimulation of the right prefrontal cortex, but a large effect size improvement from stimulation of the left prefrontal cortex.
Interpretation:
It is important to note that the one positive result was from three RCTs combining only 90 children and adolescents, a small sample size. Moreover, when only one of sixteen combinations yields a positive outcome, that begins to look like p-hacking for a positive result.
In research, scientists use something called a “p-value” to determine if their findings are real or just due to chance. A p-value below 0.05 (or 5%) is considered “statistically significant,” meaning there's less than a 5% chance the result happened by pure luck.
When testing twenty outcomes by this standard, one would expect one to test positive by chance even if there is no underlying association. In this case, one in 16 comes awfully close to that.
To be sure, the research team straightforwardly reported all sixteen outcomes, but offered an arguably over-positive spin in their conclusion: “Our study only showed tDCS-associated impulsivity improvement in children/adolescents with ADHD during follow-ups and anode placement on the left PFC. ... our findings based on a limited number of available trials warrant further verification from large-scale clinical investigations.”
Children and adolescents with ADHD tend to be less active and more sedentary than their typically developing peers. This is concerning, since physical activity benefits mental, physical, and social development. For youth with ADHD, being active can improve symptoms like inattention, working memory, and inhibitory control.
A major barrier to physical activity for children and adolescents with ADHD is limited motor competence. This stems from challenges in developing basic motor skills and more complex abilities needed for sports and advanced movements.
Difficulties in developing fundamental movement skills – such as locomotor (running, jumping), object-control (throwing, catching), and stability skills (balancing, turning) – can reduce motor competence and limit physical activity. These basic movements are learned and refined with practice and age, not innate abilities.
To date, research on the link between ADHD and motor competence has remained inconclusive. This systematic review and meta-analysis by a Spanish research team therefore aimed to determine whether children and adolescents with ADHD differ in motor competence from those with typical development (TD).
Studies had to include children and adolescents diagnosed with ADHD. They had to involve a full motor assessment battery, not just one test, and present motor competence data for both ADHD and TD groups.
The team excluded studies involving participants with other neurodevelopmental disorders or cognitive impairments, unless separate data for the ADHD subgroup were reported.
Meta-analysis of six studies combining 323 children and adolescents found that typically developing individuals were twelve times more likely to score in the 5th percentile of the Movement Assessment Battery for Children as their peers diagnosed with ADHD. They were also three times more likely to score in the 15th percentile (five studies, 289 participants). Results were consistent across the studies (low heterogeneity). All included studies were randomized.
Meta-analysis of five studies totaling 198 participants using the Test of Gross Motor Development reported significant deficits in both locomotor skills and object control skills among children and adolescents diagnosed with ADHD relative to their typically developing peers. In this case, however, results were inconsistent across studies (very high heterogeneity), and one of the studies was unrandomized. Because the team published only unstandardized mean differences, there was no indication of effect sizes.
Meta-analysis of two studies encompassing 164 participants using the Bruininks-Oseretsky Test of Motor Proficiency similarly yielded significant deficits among children and adolescents diagnosed with ADHD relative to their typically developing peers, but in this case with low heterogeneity. Notably, one of the two studies was not randomized.
Moreover, the team made no assessment of publication bias.
The team concluded, “The findings of this review indicate that children and adolescents with ADHD show significantly lower levels of motor competence compared to their TD peers. This trend was evident across a range of validated assessment tools, including the MABC, BOT, TGMD, and other standardized test batteries. Future research should aim to reduce methodological heterogeneity and further investigate the influence of factors such as ADHD subtypes and comorbid conditions on motor development trajectories.”
However, without a publication bias assessment, reliance on unrandomized studies in two of the tests, no indication of effect size in the same two tests, and small sample sizes, these results are at best suggestive, and will require further research to confirm.
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