Part 3: ADHD and Autism
MYTH: ADHD and Autism
An individual with an Autistic Spectrum Disorder should not be diagnosed with ADHD and vice versa. These are separate disorders that require different treatments.
THE FACTS: While diagnostic criteria for ADHD in DSM-IV stipulate that a diagnosis of ADHD should not be made for persons diagnosed with Autistic or Pervasive Developmental Disorders, this requirement has been challenged by multiple clinical and some epidemiological studies. Research has demonstrated that many individuals with ADHD have significant traits related to Autistic Spectrum Disorders, and that many persons diagnosed with disorders on the Autistic Spectrum also meet diagnostic criteria for ADHD. Studies have also shown that ADHD medications can be helpful in alleviating ADHD impairments in individuals on the Autistic Spectrum. Moreover, ADHD medications can also help those on the Autistic Spectrum with ADHD to improve on some of their impairments in social interactions, social perspective-taking, and other related problematic characteristics.
MYTH: Meds and Brain Changes
There is no evidence that medications for ADHD improve executive function impairments or that any improvements last.
THE FACTS: There are three different types of evidence that demonstrate the effectiveness of specific medications for ADHD improving impaired executive functions.
First, imaging studies have shown that stimulants improve, and may normalize, the ability of individuals with ADHD to get activated for assigned tasks, to minimize distractibility while doing tasks, to improve functional connections between various regions of the brain involved in executive functions, to improve working memory performance, to reduce boredom during task performance, and, in some cases, to normalize some structural abnormalities in specific brain regions of those with ADHD.
Second, experiments comparing performance of children with ADHD with matched controls or when on placebo, in comparison to prescribed medication, have shown that when on appropriate medication, children with ADHD tend to minimize inappropriate classroom behavior and control their behavior more like typical children in their class.
Experiments have also shown that medication can help those with ADHD improve their speed and accuracy in solving arithmetic problems; increases their willingness to persist in trying to solve frustrating problems; improves their working memory; and increases their motivation to perform and execute more adequately a wide variety of tasks associated with executive functions. These results do not mean that all children on such medications display these results, but group data demonstrate statistically significant improvements. However, it should be noted that these results are found only during the time the medication is actually active in the person's body.
Third, a large number of clinical trials comparing the effectiveness of ADHD medications versus placebo for alleviation of ADHD impairments in both children and adults have demonstrated that these medications, both stimulants and some non-stimulants, produce robust improvements in a large percentage of patients with ADHD. Most of these clinical trials have used DSM-IV diagnostic criteria for ADHD, but some have tested medications against the wider range of ADHD. Similar effectiveness results have been shown in symptoms from both the old and new models.
Despite the fact that the direct effects of medication do not last beyond the duration of the medication's action each day, the improved functioning made possible by the medication has been shown to result in better school classroom and test performance, reduced rates of school dropout, increased rates of graduation, and other achievements that can have lasting effects. Medication may also help support a person's adaptive performance while she awaits further brain development and enters into employment for which she is better suited, and/or improve her learning of concepts and skills she would otherwise be unlikely to master.
MYTH: Meds for Different Ages
The dose and timing of medications used to treat executive function impairment are quite similar for persons of similar age and body mass.
THE FACTS: Some medications can be appropriately prescribed in doses directly related to the patient's age, weight, or severity of symptoms, but this is not true for stimulants used to treat ADHD. Fine-tuning of dose and timing of stimulants for ADHD is important because the most effective dose depends on how sensitive the particular patient's body is to that specific medication. Usually that needs to be determined by trial and error, starting with a very low dose and gradually increasing it until an effective dose is found, significant adverse effects occur, or the maximum recommended dose is reached. Some adolescents and adults need smaller doses than what is usually prescribed for young children, and some young children need larger doses than most of their peers.
MYTH: Preschoolers and Meds
It is quite risky to administer ADHD medications to preschool-aged children.
THE FACTS: While many children with ADHD do not show significant impairments until they begin elementary school, there are some preschoolers who manifest serious, and sometimes dangerous, behavior problems between the ages of three to six years. Research with children aged three to five-and-a-half years has shown that a majority of children in this age group with moderate to severe ADHD show significant improvement in their ADHD symptoms when treated with stimulant medication. With this younger age group, side effects are slightly more common than is usually seen in older children, though such effects were still minimal. In 2012 the American Academy of Pediatrics recommended that children aged four to five years old with significant ADHD impairments should be treated first with behavior therapy and then, if that is not effective within nine months, they should be treated with stimulant medication.
MYTH: A Lifelong Condition?
If a person with ADHD is hyperactive and impulsive during childhood, he is likely to continue that way into adulthood.
THE FACTS: Many individuals with ADHD never manifest excessive levels of hyperactivity or impulsivity in childhood or beyond. Among those with ADHD who are more "hyper" and impulsive in childhood, a substantial percentage outgrow those symptoms by middle childhood or early adolescence. However, symptoms of impairments in focusing and sustaining attention, organizing and getting started on tasks, managing emotions, using working memory, and so on tend to persist, and often become more problematic, as the individual with ADHD enters adolescence and adulthood.
This article appears in the Fall issue of ADDitude.
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