ScienceDaily (Sep. 28, 2011) — The prescribed use of stimulant medications to treat attention deficit hyperactivity disorder (ADHD) rose slowly but steadily from 1996 to 2008, according to a study conducted by the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ)…. They found a slow but steady increase (in stimulant use)– from 2.4 percent in 1996 to 3.5 percent in 2008…. Based on the Health Resources and Services Administration’s National Survey of Children’s Health, the percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.

I’m not surprised, but I don’t consider this good news. The percentage of children age 4-17 years diagnosed with ADHD increased from 7.8 percent in 2003 to 9.5 percent in 2007.  Will the ADHD “establishment” begin to wonder if something is wrong when it hits 15%? 20%? The only good news is that stimulant use in preschoolers actually decreased between 2002 and 2008. ADHD is real, and many children need help, but we need more careful diagnosis, and treatment that involves more than just taking a pill.

http://www.sciencedaily.com/releases/2011/09/110928105714.htm?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+sciencedaily%2Fmind_brain%2Fadd_and_adhd+%28ScienceDaily%3A+Mind+%26+Brain+News+–+ADD+and+ADHD%29

In a 2009 study, children whose parents thought they were taking their medication were tested using saliva samples, 4 times over a 14 month period. 25% of children had skipped it half of those 2 times, and about 50% had skipped it at least once. Kids who were skipping it and also had behavioral intervention had less problems than those who were only getting the medication.
This is an interesting study for a number of reasons. What exactly happened? Were parents reporting they were giving the medications daily when they were actually forgetting, or were the kids pretending to take the medications and spitting them out? If the kids were spitting it out, I wonder why. Side effects parents were not aware of? Bad taste? Just being oppositional? Unfortunately the study did not investigate these issues, so we can only speculate.
The other interesting part is that the children receiving behavioral services did better despite not taking the medicine than those only getting medication. This once more shows the importance of behavioral management in the treatment of ADHD. I do wonder, though, how many families and medical providers forget about any behavioral intervention once they begin medication. In our fast-paced and busy world, that would be easy to do.
Reference:Molina BSG et al., J Am Acad Child Adolesc Psychiatry 2009 May; 48

the definitive (or as definitive as anything gets in medical studies) word is in. Omega-3 Fatty Acids significantly improve ADHD symptoms!!!. A recent study in the Journal of the Academy of Child and Adolescent Psychiatry performed a meta-analysis, in which all of the well controlled studies on the issue were hooked together statistically. The answer was that there was a definite positive effect. the effect was described as “modest”, about 40% as strong as studies would show using psychostimulants like Ritalin. They also found that the dose of EPA was related to the strength of the effect, but not the dose of DHA. As you may know EPA and DHA are the two main Omega-3 fats found in fish oil, and different products have very different ratios of the two.
A couple of comments: First, the authors made a big point of noting how much stronger an effect medications had. This is undoubtedly true, in the short term, for children who can tolerate the medications. However, they didn’t emphasize enough, in my opinion, how much safer and better tolerated Omega 3′s are.
Second, Integrative doctors like myself do not just substitute Omega 3′s for stimulants. Omega 3′s are part of a balanced approach which includes nutrition, normalization of other vitamins and minerals, behavioral approaches, and the many other interventions I’ve discussed here and in my book. From that point of view, the news that Omega 3′s, all by themselves, are 40% as effective as psychostimulants is very good news indeed.
So go out there and get that fish oil, but make sure you get a product with more EPA than DHA. I like Carlson’s, Nordic Naturals, and Metagenics products, among others.

Here’s a link to the article, for those who are interested. O-3 Metanalysis 2011.

This new study examined whether children with ADHD could benefit from Neurofeedback Training or Computer assisted working memory training delivered in a school environment. Children were assigned to a twice/week, 4 month training using  either of the above, or put on a wait list(this served as the control group). At the end of the 4 month training parents and teachers filled out various standardized ADHD ratings forms.

Overall, parents reported significant improvements in their children’s ADHD symptoms.compared to the control group, but the teachers did not.(However,  the study mentioned that, for some reason, different teachers completed the forms in different school years.) Satisfaction with the program was high. This was a fairly small pilot study, so definite conclusions cannot be drawn, but it is a good start.

I have always been a proponent  of Neurofeedback, and more recently, computerized working memory training. The biggest obstacle is the time and cost; thousands of dollars in the case of neurofeedback., perhaps $1500 for Cogmed, the best researched omputerized memory training. If this could be brought into the schools, the time and financial costs could be significantly reduced, with a great deal of potential benefit.

This was a small pilot study, so definite conclusions cannot be drawn, but it is a good start and hopefully more and better studies will follow. Until then, I would consider Neurofeedback and Cogmed as possible tools in the Integrative treatment of ADHD.

Here is a link to the article for those who are interested

NF and computer training schools pilot study

CDC finds increase in childhood ADHD cases (Wall Street Journal)
Almost 4.7 million, or 9%, of children in the U.S. were diagnosed with attention-deficit/hyperactivity disorder in the 2007 to 2009 period — an increase from about 3.6 million, or 6.9%, in the 1998 to 2000 period, according to the CDC. The number of ADHD cases for low-income and mid-income families increased about 40% and 50%, respectively, during the period. Lead researcher Dr. Lara Akinbami said the findings may be attributed to better health care access and more awareness of the condition, adding “it’s unlikely that most of this is due to a new epidemic of ADHD.”

“The chances that results stem from overdiagnosis are low, experts say, because diagnosis takes several steps, including a medical exam, reports from parents and teachers and a functional impairment in at least two areas of life.”

My Take

The fact that the number of ADHD cases continue to rise is no surprise to me or anyone in the field. The cause of this rise is complex. Possibilities include better diagnosis of cases that we missed previously, stretching the definition, misdiagnosis, and an actual increase in the number of cases. I believe all of these play a role and perhaps I’ll discuss that more in future posts.

But for “experts” to say there is not significant over-diagnosis for the reasons above reflects a complete ignorance of how ADHD is diagnosed in the real world. Here’s a more common scenario: 1) Teacher says child needs an evaluation 2) family sees pediatrician for 10-15 minutes 3) a couple of forms are filled out by parent and teacher) 4) pediatrician looks at forms and prescribes Ritalin or something similar, all in another 10 minute visit. This situation is a complete set-up for overdiagnosis. Have learning disabilities been ruled out? depression? anxiety? A bored gifted child? A over-demanding preschool?

My opinion is that ADHD is indeed misdiagnosed on a regular and frequent basis. Its not the only reason for the 4.7 million figure, but its an important one. If you are a parent, make sure your child gets a careful and complete evaluation by a competent professional. This can be a pediatrician, developmental pediatrician, psychologist(working with a medical professional), or psychiatrist. The evaluation should take at least 2 visits and 2 hours. If that is not what is offered, I would find someone else to do it.