NIMH logoThe booklet Attention Deficit/Hyperactivity Disorder (ADHD) was published by the National Institute of Mental Health (NIMH) in 2009.  It is a good resource stating the current conventional wisdom (generally accepted and sometimes wrong beliefs) and treatment standards regarding ADHD.  

However, conventional wisdom about ADHD

    • doesn't tell the whole story,
    • is influenced by pharmaceutical industry marketing and involvement in research,
    • is outright wrong sometimes.

National Institute of Mental Health (NIMH) materials = Conventional Wisdom

For a more complete and accurate overview of ADHD, click these "headlines" with the red header across the top.

I have combined the NIMH booklet (conventional wisdom) with my comments (critical evaluation and study).

After extensive study of ADHD for over 20 years, and working with children for over 35, I have come to believe that the USA version of the generally accepted beliefs about ADHD has serious flaws which I point out in the boxes that appear below.  Click on each "headline" to read more.

I am sorry to say that a lot of the generally accepted beliefs about children's mental health is also wrong -- read more about that in my blog and see the award winning book Anatomy of an Epidemic by Robert Whitaker.

photo Jerry Jensen

Experts reject conventional wisdom and agree with Jerry:
"ADHD is overdiagnosed, and drugs make things worse."
 

Dr. Allen Frances was the chair of the task force that created the DSM-IV in 1994. He states the following:

Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.

Dr. L. Alan Sroufe is a professor emeritus of psychology at the University of Minnesota's Institute of Child Development.  In Ritalin Gone Wrong, an article he wrote for the New York Times, he states:

(ADHD drugs) neither improve school achievement nor reduce behavior problems. The drugs can also have serious side effects...

Sadly, few physicians and parents seem to be aware of what we have been learning about the lack of effectiveness of these drugs.

There is some disagreement among scholars and professionals about the appropriateness of these generally accepted beliefs and standards. For example, there are two different International Consensus Statements on ADHD – each saying almost the opposite of the other. Unfortunately, many who disagree with the USA version of generally accepted beliefs are dismissed offhand.

Peter Breggin and others have plenty more to say ....watch here for links.

National Institute of Mental Health (NIMH) materials = Conventional Wisdom

For conventional wisdom about ADHD, we use materials supplied by the US National Institute of Mental Health (NIMH).  The NIMH booklet on these pages is conventional wisdom -- generally accepted, sometimes incomplete, and too often wrong. 

To that, we add our critical analysis, which shows up in these highlighted areas.

Critical Analysis = Comments from Cedarbrook

Critical doesn't always mean negative -- it can mean analytical.  Comments in these areas with red along the top are critical analysis after years of study and clinical experience working with 1000's of children.

Our Categories of Information and Wisdom about ADHD

    1. Conventional Wisdomideas generally accepted as true. Though widely held, these ideas are unexamined.
    2. Critical Analysis: looking at conventional wisdom "under a magnifying glass" to discover additional insights.
    3. Cutting Edge Wisdom: the critical analysis of conventional wisdom combined with study of recent research and the latest findings.  Accurate aspects of conventional wisdom are maintained with additional insights from research and clinical practice.
    4. False, Misleading, or Erroneous: information that is just plain wrong.  Some false information may have been held to be "true" at one time, but further research and clinical practice have evolved since then.  (An example would be that the Earth was once considered to be flat.  Now most people recognize that it is round.)

Wait, wait - Healthy kids run!  So why is a picture (above) of someone running on an ADHD Booklet?

The photo of a child running may give a subtle message that running equates with ADHD.  Nothing could be further from the truth. 

All normal, healthy children run.  Actually, exercise helps reduce ADHD symptoms.

Quiz: What percent of the time is ADHD Misdiagnosed? a) 57%  b) 61% c) 72% d) all of the above

Answer: D - All of the above.  There are many studies showing that ADHD is overdiagnosed.  Here are just a few.

overdiagnosed 57% of the time (Great Smokey Mountain study, 2000)

overdiagnosed 61% of the time (South Carolina study, 2012)

overdiagnosed 72% of the time (Oklahoma study, 2012)

Sadly, there are many more studies showing the same thing. (See my blog post listing them.)

ADHD is one of the most commonly diagnosed neurobehavioral disorders of childhood. ADHD is also misdiagnosed. Many children labeled with ADHD do not have ADHD and are getting the wrong treatment to help with their attention difficulties.

Society has come to believe two misconceptions:

  1. There is one cause of attention difficulties – ADHD.
  2. There is one treatment – stimulant medication.

Nothing could be further from the truth.

Attention difficulties are common in children because their brains are still developing, they are still growing, and still learning.  Sure they may have attention difficulties, but some are caused by one of the other 59 causes of attention difficulties.

Why is paragraph 2 (below) is the most important paragraph in the whole NIMH booklet?

Everyone grows at different rates.  Everyone!

Kid's with ADHD are the same as any other kid -- except their brain is growing at a different rate.  See it here.  Kid's grow -- be patient.

too big shoesWe need to give their brains the right environment, nutrition, learning opportunities, and experiences.  At Cedarbrook, we take the time to determine the exact nature of your child's (or your own) attention difficulty, determine his/her developmental stage, and correct any difficulties or deficiencies.

See my book One Size Fits None.  

Jerry Jensen

Yes -- “It is normal for all children to be inattentive, hyperactive, or impulsive sometimes.”


As a developmental psychologist, I suggest that ADHD “symptoms” are normal behavior for 2- and 3- year-olds. Since we all grow at different rates the "symptoms" may be "normal" for some 5- and 6-year-olds.

Just because a kid has energy or is creative does not mean they have ADHD.

There are many causes for attention difficulties -- see the list of "ADHD Imitators."

What about ADD?

What was once called ADD (before 1994) is now "ADHD - inattentive presentation."

The three subtypes of ADHD.

A person can be diagnosed with one of the three subtypes of ADHD:

  • ADHD - predominantly hyperactive/impulsive presentation,
  • ADHD - predominantly inattentive presentation (called ADD before 1994), or
  • ADHD - combined presentation.

The NIMH booklet WRONGLY broadens the criteria and blurs the boundaries between normal behavior and ADHD

NIMH attempts to both describe the symptoms of ADHD and give examples. This is common, but none of these are DSM-5 criteria for ADHD:

  • Dash around, touching or playing with anything and everything in sight
  • Become bored with a task after only a few minutes, unless they are doing something enjoyable
  • Daydream, become easily confused and move slowly
  • Have difficulty processing information as quickly and accurately as others

A blurring example, "does not seem to listen when spoken to” is pretty close to the actual criteria of “often does not seem to listen when spoken to directly.” But they are not the same and the, one word directly makes a big difference. This language blurs the boundaries between what's normal and the disorder. J. Jensen

More often than not, Other Problems Can Be Mistaken for ADHD rather than the other way around!

ADHD can be mistaken for other problems - like an undisciplined child or shyness. However, in my experience it happens the other way around more often -- children are diagnosed with ADHD when they actually have something else going on.

Research supports my experiences. One study showed that children are misdiagnosed with ADHD 57% of the time. Some estimates have been as high as 75%. And a 2012 German study confirmed the misdiagnosis "pattern."

What causes Attention Difficulties or ADHD?

No one is sure what causes ADHD. We do know that individuals identified as having ADHD have less blood flow to the frontal lobes. The frontal lobes are where decision making and “executive functioning” occur. We also know that the frontal lobes are not completely developed until age 25 or so.

There are over 59 causes of attention difficulties – ADHD is only one. (See the list of “ADHD Imitators” here.) Society's homework needs correction.

  • There is only one cause of attention difficulties (ADHD) There are over 59 causes of attention difficulties.
  • There is one treatment (stimulant medication). There are many interventions -- see the American Academy of Pediatrics suggestions for starters.

Expert says symptoms of ADHD is a "false epidemic"

Dr. Allen Frances was the chair of the task force that created the current DSM-IV in 1994. He states the following:


I learned from painful experience how small changes in the definition of mental disorders can create huge, unintended consequences. Our panel tried hard to be conservative and careful but inadvertently contributed to three false "epidemics" -- attention deficit disorder, autism and childhood bipolar disorder. Clearly, our net was cast too wide and captured many "patients" who might have been far better off never entering the mental health system.

Which facts on the next page are TOTALLY WRONG? 

Well, all of the facts here are incomplete -- so more info is needed.  I'll just state the most common information from research.

Environmental factors.  

  • Kids don't get out in nature enough -- you know outside playing, running, climbing trees, walking in nature. Taylor and Kuo (2008) findings indicate that environments can enhance attention not only in the general population but also in ADHD populations.
  • KId's get too much "screen time" (TV, computers, phones, video games).  Time spent with screens is associated with:
    • sleep disturbances
    • childhood obesity
    • attention span issues

Sugar.

Oh my gosh -- I can't believe they can print this and sleep at night.  There are tons of research articles linking sugar to attention difficulties (and tons of other chronic diseases). When I say tons -- I mean tons.  I'm writing a whole section on this elsewhere on these pages and will link to it here when finished.

Food Additives.

Proper diet and nutrition fuel the brain.  Poison damages the brain.  More later.

Jerry

Special note to teachers!

Please don't tell parents "your child has ADHD" or "he needs meds." Instead, describe for them what you observe and have them see a specialist to sort out which of the 59 causes of attention difficulties may be impacting their child.

The diagnosis takes time -- even NIMH says "months."

In a different NIMH publication, they state "it can take months for a doctor or specialist to know if your child has ADHD."

If you get an ADHD diagnosis in 10 minutes (which is too common) -- ask for a second opinion from someone who will spend adequate time with you and your child.

How is ADHD diagnosed?

No single test can diagnose a child as having ADHD. NIMH suggests the steps for diagnosis take time:

  1. rule out other possibilities for the symptoms (i.e. see if one of the other 59 causes of attention difficulties applies)
  2. check school and medical records
  3. gather information from the child's parents, teachers, and others
  4. pay close attention to the child's behavior during different situations
  5. diagnose ADHD if the child meets the criteria.

In the USA, we use the criteria in Diagnostic and Statistical Manual of Mental Disorders (DSM-5) which are listed here for your information. Did you know that there is another set of diagnostic criteria for ADHD? The World Health Organization has adopted the ICD-10 criteria which you can see here. The DSM and ICD criteria are compared on this chart. (Well, as soon as I get the links to work)

More info coming soon

See the the American Academy of Pediatrics suggestions 

There are many interventions, including psychotherapy, which help children with attention difficulties including ADHD. The the American Academy of Pediatrics recommends the following:

  • Behavior Therapy with medication
  • Biofeedback (Neurofeedback, EEG Biofeedback)
  • Contingency Management
  • Education
  • Self-Verbalization
  • Parent Management Training (alone, with Problem Solving, or with Teacher Psycho-education)
  • Physical Exercise (with or without Relaxation)
  • Social Skills
  • Working Memory Training

We do all of these at Cedarbrook (well, except the medication, that's why I crossed it out)

There is good research supporting the use of Omega-3 and other nutritional interventions.

If the attention difficulty is caused by one of the other 59 causes of attention difficulties, an intervention is selected that addresses the particular cause

How is ADHD treated?

ADHD is only one cause of attention difficulties for which there are many interventions. The appropriate intervention depends on which of the 59 causes of attention difficulties are impacting your child.

If the attention difficulty is caused by ADHD, the treatments listed in the NIMH booklet are the current standard practice. These are "supported" by the results of the 1999 NIMH-funded Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study. 

The MTA was a multi-site study designed to evaluate the leading treatments for ADHD. The MTA covered only two treatments for ADHD (medication and behavioral therapy). Today we know there are many more treatments that have shown effective by research.

A critical analysis of the MTA shows many flaws but let's just look at some findings from the MTA and two NIMH-funded follow-up studies. Cursor down to see more.

Summary of research by NIMH: (cursor over to see yellow boxes with details

The MTA study showed there was no difference between medication and behavioral therapy 80% of the time (12 out of 15 areas).

The 3-year follow-up reported that medication made things worse.

The 8-year follow-up reported that medication made things worse.

Conclusion: ADHD Medication makes things worse. And it has many serious side effects.

The NIMH brochure correctly states the standard practice for treatment of ADHD. Their research shows that the standards need to be changed. 

NIMH MTA studies (continued from above)

From the original MTA 14-month study, there were 15 outcome domains measured. Medication performed better than behavioral therapy on 3. "Medication management and behavioral treatment did not differ significantly on any other outcomes." So on 12 out of 15 areas, there was no difference.

The 3-year follow-up research states: "participants using the medication in the 24- to 36-month period actually showed increased symptomatology during that interval relative to those not taking medication." From 2 to 3 years, the medication made things worse.

The 8-year follow-up research states that medication use was "associated with worse hyperactivity-impulsivity and ODD symptoms and CIS impairment." (CIS is a tool for rating impairment). After eight years, those using medication were worse.

The MTA study showed there was no difference between medication and behavioral therapy 80% of the time (12 out of 15 areas).

The 3-year follow-up reported that medication made things worse.

The 8-year follow-up reported that medication made things worse.

Conclusion: ADHD Medication makes things worse. And it has many serious side effects.

The NIMH brochure correctly states the standard practice for treatment of ADHD. Their own research shows that the standards need to be changed.

Summary of research by NIMH

The NIMH brochure correctly states the standard practice for treatment of ADHD. Their own research shows that the standards need to be changed.


For a more in-depth account, look at the award-winning book Anatomy of an Epidemic by Robert Whitaker.

Conventional Wisdom - No cure for ADHD

In the last paragraph, the NIMH booklet correctly states the current view that there is no cure for ADHD. Medication manages the disorder while one is taking medicine. Once you stop the medication, the behavior returns. See also: Long-Term Use of Medication for ADHD Makes Things Worse.

Research Contradicts Conventional Wisdom - There are Many Cures 

At Cedarbrook we provide interventions proven by research to work.  In 2010, Neurofeedback (EEG Biofeedback) was recognized by the American Academy of Pediatrics as an effective evidence-based intervention for attentional difficulties.  We've been offering it since 2008.

We also have other non-medication interventions that are supported by research.

Cure implies a “restoration to health.” In that sense, there are cures for many of the other 59 causes of attention difficulties. 

And there is a significant amount of research indicating “cures” for ADHD, too. Many cure attention difficulties mislabeled as ADHD. Either way, the attention problems are solved – forever.

There are many treatments for ADHD.  And many more for all the other causes of attention difficulties

We'll start with the American Academy of Pediatrics suggestions.  I have many more too -- all backed by research and clinical experience.

Medications DO NOT cure ADHD!  They make things worse!

Medications do not cure ADHD; they only control the symptoms for a short time. Here NIMH is wrong when they say “it is not clear, however, whether medications can help children learn or improve their academic skills." It is very clear that medication makes things worse.  The MTA research study funded by NIMH was terribly flawed, but let's pretend we believe the results anyway (like most practitioners who only read the conclusion and not the whole study).  NIMH's own MTA research and two follow-up studies indicate that medication makes things worse. (See comment boxes above.)  More recent studies show that children's academic performance is not improved over the long-term.photo of Jerry Jensen

FDA Warnings

Besides the lengthy list of side effects, I think the NIMH booklet downplays the FDA warnings. Here are excerpts from the black box warnings required by the FDA:

"ADHD Drug" is a federally controlled substance (CII) because it can be abused or lead to dependence.

The following have been reported with use of stimulant medicines.

1. Heart-related problems:

  • sudden death in patients who have heart problems or heart defects
  • stroke and heart attack in adults
  • increased blood pressure and heart rate

2. Mental (Psychiatric) problems:

  • new or worse behavior and thought problems
  • new or worse bipolar illness
  • new or worse aggressive behavior or hostility
  • new psychotic symptoms (such as hearing voices, believing things that are not true, are suspicious) or new manic symptoms

FDA Medication Guides

Click here for the current list of ADHD Medications Approved by U.S. Food and Drug Administration (FDA).

http://www.fda.gov/drugs/drugsafety/ucm085729.htm

But even better...here's a link to an FDA archived file with much more information.

http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm107918.htm

Each drug has a link to a Medication Guide which lists side effects. The link to Label actually takes you to the Prescriber's Guide (which is longer but includes important information including the fact that the long-term effectiveness and risks of ADHD medication have not been studied. It is shocking that "long-term" is described as only 3 to 4 weeks.  Kids are on these meds for years!

Are Stimulant Medications Safe? Side effects. The NIMH booklet is accurate, but not complete.

Accurate but not complete can be deceiving. Each of the medication guides list all side effects. See the FDA links mentioned above for complete documentation. A side effects list can also be found in our ad Pick Your Poison The list of side effects is taken directly from the Medication Guide for a stimulant medication.

What does co-exist really mean? Comments by Jerry

Most of the conditions that “coexist” with ADHD are also one of the 59 causes of attention difficulties. If we step back, we can see that these are most often the only cause of the attention difficulty – not something “in addition” to ADHD.

Using a silly example: If I have my mouth full of marbles, I have difficulty speaking. People with speech impediments also have difficulty speaking. However, we wouldn't say that Jerry has "a dual diagnosis" of both marbles in his mouth AND a speech impediment. We realize that these are not two things that coexist -- taking the marbles out of my mouth clears up the speech impediment.

The same can be true for ADHD "coexisting conditions." Address the main issue and the attention difficulty goes away. J. Jensen

What conditions can coexist with ADHD?

Children with attention difficulties are commonly diagnosed with ADHD and another condition. NIMH lists conditions that are commonly diagnosed in children with ADHD.

The computer guy left space for me to fill these in later.

I'm sure to have something to say.

Teens can have attention difficulties.

Like children, the intervention depends upon which of the 59 causes are impacting them. By definition, ADHD symptoms need to be "present before age 12 years". If your teen develops these symptoms during the teen years, there is a good chance that they are caused by some of the other 59 causes of attention difficulties – not ADHD.

Teens diagnosed when young

If your teen was diagnosed with ADHD when younger, he or she might continue to have the symptoms as a teenager. (Kids used to "outgrow" ADHD, but not so much anymore.) Although there is no research to prove this, here's what I think happens.

The most common intervention for ADHD has been medication. Medication does not cure ADHD or attention difficulties, only manages the symptoms.

It's like a crutch that helps you walk. If we use the crutch long enough, we are not able to walk without it. I believe that is what happens for those who use medication for ADHD. Medication manages the symptoms but doesn't let us learn to focus and concentrate on our own. Then we continue to need the crutch of the ADHD drugs.

Should Kids with ADHD be allowed to drive?

If not allowed to drive -- I know that many cases would clear up around age 15.  It's not your teens' fault -- we overindulged them and turned them into victims.

Anyone can have attention difficulties. BUT...

Children and teens are more likely to have attention difficulties because their brains are still developing. Children use attention skills for things that interest them. Some children have difficulty sustaining attention for longer periods (especially for things that do not interest them). Technically, this is called a lack of vigilance or lack of concentration. At Cedarbrook, we have the same philosophy about adult attention difficulties as we do with childhood attention difficulties. Find out which of the 59 causes are causing your attention problems and then use an appropriate intervention to overcome those causes. 

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