The number of children diagnosed with ADHD in the U.S. has been steadily increasing at an average of five percent a year from 2003 to 2011, according to the National Survey of Children’s Health. In 2011, more than one in ten children were diagnosed with it. Experts say the number has continued to climb since this last major data collection. The reasons behind this rise vary depending on whom you talk to, as does the definition of ADHD/ADD itself, and the best treatment approaches. We asked one of the most respected authorities on ADHD, Dr. Edward “Ned” Hallowell, a child and adult psychiatrist—and someone with ADHD himself—to break down the most important aspects of the ADHD debate, and explain the latest research on this pervasive and confusing condition, as well as speak to the experience of having ADHD as an adult. Below, he shares the perspective and methods that have made his country-wide Hallowell centers, podcast, and books like Delivered from Distraction and Super Parenting for ADD such mainstay resources. (For another, food-focused angle on ADHD/ADD, see this goop piece with nutritionist Kelly Dorfman.)
A Q&A with Dr. Edward Hallowell
What’s important to know about the distinction between ADHD and ADD? Is there a biochemical difference or a difference in potential treatment options?
In the official diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the so-called DSM-V, there is no ADD. There is only ADHD, attention deficit hyperactivity disorder.
However, within ADHD there are two subtypes: primarily inattentive and combined type. The “primarily inattentive” subtype would be what most people would call ADD, or ADHD without the “H”, without hyperactivity. This is significant because many people who have this type of ADHD often go undiagnosed because they are not disruptive, hyperactive, or calling attention to themselves through unruly behavior. Quite the opposite: They are quiet, daydreamy, and lost in their thoughts. More common in females, the primarily inattentive subtype is often overlooked, leading these girls and women to be misdiagnosed as shy, quiet, introverted, slow, or even anxious or depressed. If they get treatment at all, it is often the wrong treatment—because they never received the right diagnosis in the first place.
The “combined type” of ADHD includes symptoms of impulsivity and hyperactivity. More common in boys and men, this is the stereotypical ADHD. It is hard to overlook these people because they call attention to themselves through their behavior. While the primarily inattentive subtype is under-diagnosed, the combined type is over-diagnosed, leading to a pathologizing of normal boy behavior.
The treatment for both subtypes is the same. Start with education, learning about your ADHD, owning it, and understanding that you can achieve your dreams if you get the right help. Once you embrace the condition and dispel fear and shame, then you can get the other components of treatment: coaching; lifestyle modification (sleep, diet, exercise, meditation); regular doses of encouragement and positive human contact (which I call the other vitamin C, or vitamin Connect); and medication. Medication is effective in about eighty percent of cases. By effective I mean it improves target symptoms and causes no side effects other than appetite suppression without unwanted weight loss.
The last we heard about eleven percent of children and four percent of adults have a diagnosis—does that capture the current scope?
Most people would accept those statistics, but it is difficult to put an exact number on the prevalence of ADHD because we do not have an exact test for it. The diagnosis rests on the individual’s history, as taken from the patient, as well as additional sources like parents, teachers, spouses, friends, or significant others. Hence, there is an unavoidable element of subjectivity in making the diagnosis.
Even though we can’t say for sure where ADHD begins and non-ADHD leaves off, there still is a distinct difference between the two. Centuries ago, Edmund Burke made a brilliant analogy that applies perfectly here: There can be no clear line drawn between night and day, yet no one would deny there is a difference.
Adults remain the largest undiagnosed group, especially adult women. This diagnosis can change an adult’s life dramatically for the better, yet most of the adults who could benefit tremendously don’t know about it. Educating the public is crucial: If you are an adult reading this, and you feel you are underachieving, learn more about ADHD. It could be the answer you’ve been looking for—for years. Diagnosis and treatment could replace frustration and underachievement with success.
On the other hand, if your child is diagnosed, especially if your child is a boy, question the diagnosis until you are convinced that he actually has the condition, not just a major case of boyhood.
Is ADHD/ADD still on the rise—if so, what’s actually the cause of this trend? And how does the rate of diagnoses in the States compare to other countries?
We (the U.S.) diagnose it far more than any other country. Most countries still don’t “believe in it,” as if it were a religious principle. Not believing that ADHD is real is like believing the world is flat. Science has proven the condition to be real.
Diagnosis is on the rise, for good and bad reasons. The good reason is that we have learned a lot in the past twenty-five years, and we have progressed from an era when no one had heard of ADHD to an era in which most people have (even though most people still don’t understand what it truly is).
The bad reason is that sometimes clinicians can’t take the time to make a careful assessment and so diagnose too quickly, mistaking what isn’t ADHD for ADHD. We need better training for clinicians and better funding from insurance carriers so clinicians can take the time required to make an accurate diagnosis.
What’s new and/or promising in ADHD/ADD research?
The strength-based approach to ADHD is the critical new development. Instead of languishing under a label saturated in pathology, the strength-based model says: You’ve got a ton of talent, but you have work to do to develop it.
I sum this up by telling kids: “You have a Ferrari engine for a brain, but you have bicycle brakes. But don’t worry, I am a brake specialist. If we work together and strengthen your brakes, you can win races and become a champion.”
We need to replace the deficit-based model with the strength-based model to dispel stigma and instill hope and pride.
A new finding from research concerns diagnosis in adults. It is currently a requirement in the DSM-V that for an adult to get diagnosed with ADHD, a childhood history of the symptoms must be documented. However, recent studies have shown what I and most seasoned clinicians have known for decades: that ADHD can emerge in adulthood with no childhood history of the condition. Therefore, if you are an adult and you identity with the symptoms—unexplained underachievement; inconsistent focus; hyperfocus alternating with wandering focus; trouble with planning, organizing, managing time, money, and other details; a tendency toward procrastination; an impulsive style of making decisions; a feeling of inner restlessness; a mind that just never shuts down—but have no childhood history of the condition, you still ought to seek help as you may very well have adult-onset ADHD. Treatment could change your life significantly for the better.
You’re careful to frame ADHD/ADD as a trait, and not a disability. What’s the potentially positive side of having ADHD/ADD, and how do you tap into it?
So many positive attributes can appear with ADHD. Before I name those, though, let me be clear on one point. ADHD can cripple a person, ADHD can be a severe disability or disorder, if it is not identified and managed properly. The prisons, the halls of the unemployed, addicted, depressed, and marginalized are all full of people with undiagnosed, untreated ADHD. It can ruin your life.
But people with ADHD often possess tremendously positive qualities: creativity, originality, an ability to think outside the box, to go “where no man [or woman] has gone before,” entrepreneurialism (most entrepreneurs have ADHD), inventiveness (Edison was classic ADHD), fertile imagination, and the capacity to dream big, poetic qualities, an unusual ability to make metaphors and analogies, uncanny intuition, stick-to-it-iveness to the point of being stubborn, big-heartedness and generosity, high energy, sparkle and charisma, as well as an unusual warmth of spirit.
You avoid the negative and tap into the positive by first of all recognizing that you have ADHD, understanding what it is in its full dimension—both positive and negative—and then working with a coach or other professional to maximize the upside and minimize the downside.
What’s the first thing parents should do when their child is diagnosed with ADHD/ADD?
First of all, learn what ADHD is and what it isn’t. Embrace a strength-based approach that says, If I get the right help, I am a champion in the making. Rid your mind of the many misconceptions and flat-out wrong information that abounds in the general public. There is a TON of misinformation out there, so you really should not rely on the internet uncritically.
Instead, there is a reliable, authoritative, free site online called Understood that has ALL the information a parent could ever want or need, so that can be one-stop shopping for you. Understood offers daily access to the top experts in the field, as well as frequent chats and webinars. It also offers a unique feature that will totally blow your mind, if I may say so. It is called Through Your Child’s Eyes. This tool allows you to experience firsthand what it’s like to have ADHD, dyslexia, or some other learning difference. It is amazing, and I do not use that term lightly.
Does current research support the use of medication for treating ADHD/ADD? And in your own experience, have you found medication to be an effective tool?
I personally do not take medication, because it does not work for me. However, for about eighty percent of people, of all ages, medication can be hugely helpful, truly transformative.
I prescribe stimulant medication every day, and see its beneficial effects all the time. Used properly, stimulant medication is like eyeglasses; it improves focus. Used and monitored properly it causes no side effects other than appetite suppression without unwanted weight loss.
What is your position on the controversies surrounding addiction and ADHD drugs like Adderall?
When used properly, Adderall and drugs like Adderall actually reduce the likelihood of addiction. By taking the correct medication a person is far less tempted to abuse the wrong “medication,” in other words a drug of abuse. If used improperly, of course, Adderall and pretty much any drug can be dangerous. We have to be particularly careful with Adderall because it is a controlled substance. And there is a black market for it.
What’s the best combination of treatments in the long run?
The best combination of treatments include: education; coaching with an eye toward finding talents and developing them, as well as learning skills of executive functioning; lifestyle modification with emphasis on physical exercise, adequate sleep, proper nutrition, daily meditation, and massive doses of positive human contact (again, what I call the other vitamin C, vitamin Connect). In that context, medication is often dramatically helpful, about eighty percent of the time. Medication should never be the only treatment, but it can be a powerful component of treatment.
Have you seen good results with any alternative treatments?
The best alternative treatments really are not alternative. They include what’s listed above, and should be considered mainstream.
Beyond that, there are some new and promising treatments. One of my favorites, because I’ve been closely involved in the research developing it, is a system called Atentiv. It is a computer game that uses a forward-loop feedback system to train the brain, to rewire the brain so to speak, so as to develop what I call the muscle of attention. The Atentiv system isolates that muscle, then works it day after day until it grows strong enough to be called upon at will. Results of the research so far show that the Atentiv system produces results, both in cognitive functioning as well as behavioral ratings, on a par with medication. To learn more go to Atentiv.com. (I should disclose that I have a financial interest in the company.)
Why do you say that connection is particularly important for kids with ADHD/ADD? And as parents, how can we ensure that our kids feel connected?
Connection is the most powerful force in the world for growth, success, longevity, and happiness. By connection I mean a feeling of being a part of something larger than yourself that is positive. You create this feeling in a person by fostering connections of all kinds: to family; to friends; to neighborhood; to favorite activities; to nature and the outdoors; to favorite places; to traditions, rituals, and the past; to heroes and people you admire; to teams, clubs, groups, institutions, schools, and other organizations; to pets (everyone ought to have a pet if they possibly can; I especially recommend a dog); to the world of the arts and beauty; to special projects and interests; to a mission or a dream; to some spiritual reality or to God; to the world beyond knowledge; to the world of information and ideas; and finally, to yourself.
Connection is free and infinite in supply. And yet, most people do not get nearly enough of it. Make it a point, starting now, to pig out on connection. Make sure your friends and family do as well. Nothing but good will come of it.
How many kids “outgrow” ADHD/ADD, and what does ADHD/ADD typically look like in adults?
In my opinion, no one outgrows ADHD. I believe what happens to people who look as though they do is what happened to me: I learned to compensate so well that it appears as if I do not have ADHD. However, ask my wife, and she will tell you that indeed I do!
Adult ADHD is the same as childhood ADHD, only more socialized, with less antsy-ness and hyperactivity.
Are more adults being diagnosed with ADHD/ADD later in life, and are there tools that have proven to be helpful post-diagnosis?
More adults are being diagnosed, but adults remain the largest undiagnosed group, especially adult women.
The same treatments as outlined above work for adults, just as for children. Medication is just as effective in adults as it is in children. The strength-based approach is especially helpful for adults as it allows them to reframe what they may have seen as a character flaw. Now they can see it as a neurological difference, which, if they manage it properly, can lead to a whole new life.
The diagnosis of ADHD and the treatment that follows, if done properly, truly can change a life, at any age, from one of frustration and underachievement (if not worse), to one of triumph, fulfillment, and joy.
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