Growing up with, and out of, ADHD

MELISSA HEALY, "Growing up with, and out of, ADHD", Bradenton Herald,
February 23, 2008,
Link: http://www.bradenton.com/health/story/417808.html

Doctors and parents have long been left to guess at which children
with a diagnosis of attention-deficit hyperactivity disorder, or ADHD,
will go on to become adults with significant attention problems, how
well they will navigate the challenges of adulthood and whether early
recognition of - and medication for - their condition will make a
difference in the trajectory of their lives.

Now a series of studies following 457 Finnish children from birth to
ages 16 to 18 offers a glimpse of how the primary symptoms of ADHD
typically evolve. At the same time, the studies raise provocative
questions about the long-term effect of treating those symptoms with
medication.

The studies focus on a subset of 188 Finnish teens considered to have
"probable or definite ADHD" that will follow them into adulthood and
103 kids with conduct disorder - behavior issues that fall short of an
ADHD diagnosis but put kids at higher risk for similar problems. Those
teens were compared with a group of Finnish teens with no ADHD
diagnosis.

Researchers found it is the can't-sit-still kids - the stereotype of
the "ADHD generation" - who are most likely to mature out of the
disease. Among those with persistent ADHD, they also found, half have
problems with cognitive skills that are key to success in adulthood,
but half have no such deficits.

And when researchers compare the findings from Finland with studies of
Americans with ADHD, an even more intriguing discovery emerges: By the
time they're in their late teens, those who receive drugs for
attention problems seem to fare about the same as those who do not.

That is sure to fuel a simmering debate over the extent to which
American kids with ADHD receive medication, often with little other
support. In Finland, medication for ADHD is extremely rare.

"This begs the question: Are current treatments really leading to
improved outcome over time?' " wrote neuropsychologist Susan L.
Smalley and co-author Dr. Marjo-Riitta Jarvelin in a special section
of December's Journal of the American Academy of Child & Adolescent
Psychiatry. Smalley co-directs the Center for Neurobehavioral Genetics
at the University of California, Los Angeles. Jarvelin is a professor
of public health and of medicine at Imperial College School of
Medicine in London and University of Oulu, Finland, respectively.

UCLA neuroscientist Robert Bilder, who was not involved in the Finnish
research, said the studies suggest that ADHD might best be treated, in
some kids, by shoring up weaknesses in underlying cognitive skills
rather than by focusing exclusively on behavioral symptoms that can
change with age.

"We all hope in the future we'll find the optimal combination of
treatments - whether behavioral or pharmacological - that'll provide
young people with these problems the best chance to succeed in school
and social environments," Bilder said. "It's clear so far that no
treatment's been identified that's a panacea."

Two decades ago, as the diagnosis and medication of American children
with ADHD began to soar, researchers and psychiatrists scarcely
entertained the possibility of adults with ADHD. Today, experts
estimate that 4.4 percent of American adults - more than 10 million
people - suffer from attention problems serious enough to warrant a
diagnosis of ADHD.

But like the generation of children first diagnosed in large numbers
with ADHD, research on what the disorder looks like across the life
span has just begun to mature.

The new research suggests that, as children with ADHD grow into
adolescence, it is the dreamy, forgetful, inattentive types who are
most likely to continue to struggle with the disorder - especially if
they also suffered from depression, anxiety or serious behavior
problems in their preteen years. When their childhood symptoms
included hyperactivity and impulsiveness as well as inattentiveness,
their chances of having adult ADHD grew higher still.

Underscoring the strong role of genes in the development of attention
deficit disorders, the studies found that a child's likelihood of
having ADHD that persists into adulthood is significantly greater if
either parent - but especially his or her father - suffers from
serious attention problems too.

By contrast, those whose childhood symptoms were confined to
hyperactivity are the most likely to mature out of the disease in
adolescence, the Finnish studies found. By age 18, most with
persistent ADHD will struggle with mental rather than physical
restlessness.

In all, roughly 2 in 3 of the Finnish children who were diagnosed with
ADHD as children continued to exhibit severe attention problems
between ages 16 and 18.

Although about 60 percent of American children diagnosed with ADHD are
medicated - at least at some point - for its symptoms, virtually no
Finnish children are given medication. And yet, by the time they reach
16 to 18 years old, these two populations look very much the same.

In an interview, Smalley stressed that the studies do not cast doubt
on the short-term benefits a child with ADHD might get from a
stimulant or other medication that treats the symptoms of the
disorder. She cited recent studies showing that at the end of one
year, children medicated for ADHD symptoms function better at home and
school than those who get behavioral and cognitive therapy. But after
three years, the difference between the two groups begins to wane.

"We really need to look at how effective, really, is medication alone
in long-term prevention" of the intellectual deficits and psychiatric
problems that plague those with ADHD at higher rates than those
without, Smalley said.

She also emphasized that the studies show that ADHD is "an extreme on
a continuum" of normal for humans. Just as kids range across a
spectrum in glucose tolerance or reading ability - putting some at
higher risk of diabetes or dyslexia - they are also distributed across
a spectrum in terms of their ability to focus, the strength of their
working memory and their propensity for developing social and
emotional problems. As children age, some will "age out" of the
disorder, no longer meeting diagnostic standards for ADHD.

If better medication or specialized therapy, or both, can drive down
the risks that these children will be hobbled by academic failure, ill-
chosen impulses and other psychiatric problems, their other talents
could shine through, Smalley said. And the world would be a better
place for it, she added.

"We need to step back and embrace neurodiversity, diversity in human
behavior and try to work on ways to embrace and enhance being at the
extreme, instead of only focusing on the deficits and disorder aspects
of ADHD," Smalley said.