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ADHD diagnosis and controversy often seem to go hand in hand. Who is qualified to make a diagnosis? What are the best diagnostic tools? Daniel Amen, MD, has filled numerous books with sage advice on the subject; he joined us to share his expertise.
The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
Moderator: Welcome to WebMD Live, Dr. Amen. Who should be involved diagnosing ADHD?
Amen: Usually I think the best people to diagnose ADHD are child psychiatrists and psychologists. Many other people can if they have the proper training, but the reason I like child psychiatrists is because they spend half their days with people who have ADHD.
Member question: We have a severe shortage of child psychiatrists in our area. The few that are on our health plan aren't taking any more patients.
Amen: That's correct, there is a shortage of child psychiatrists, although usually it's better if it's possible to wait and get another opinion from a specialist, but if you can't wait then make sure as a parent, or a person who has ADHD, you learn as much information as you can, because there are many mental health professionals who really don't have very good training and can steer you in the wrong direction.
Member question: How involved should school personnel be? Can school psychologists help with the diagnosis? What about pediatricians?
Amen: Schools are often very helpful in making the diagnosis of ADHD. School psychologists often are wonderful resources of information and evaluation.
Pediatricians are variable. Some have good training in it and do a good job; others do not. So one question to ask your pediatrician is about their level of training, which is very hard for patients to do, but it is important to ask about their level of training and experience.
Member question: What kinds of things do doctors and psychologists look at when deciding if someone has ADHD?
Amen: The most important way to diagnose ADHD is by understanding the story of a person's life. We look at symptom clusters. The hallmark symptoms of ADHD, as I see it, are:
Now, having said that, psychiatry in general, I think, has a big problem, in that we make medical diagnoses based on symptom clusters without ever looking at the brain. What we do in our clinic is we take histories on a patient's problem and then if the issue is complicated, we also do brain scans, which we believe gives us more information.
Member question: I am fascinated by your use of brain scans to diagnose ADHD. But my insurance won't pay for scans. When do you think the rest of the world will catch up with you in the use of scans? It seems that they would provide a much more reliable tool to diagnose ADHD.
Amen: It's a hard question. I think the kind of work we are doing will be standard in about 20 years. It's unthinkable to me that we will continue to make diagnoses based on symptom clusters without ever looking at the organ we treat, which is the brain. Cardiologists don't act that way; they look. Orthopaedic doctors don't act that way; they look. It's time we in psychiatry look as well.
I am painfully aware, as I travel around the world and talk about my work, that many people do not have access to the brain imaging technology. This is the primary reason that I write about what we do and include helpful checklists so that people might be able to predict what the scans would look like. In my book, Healing ADD, where I break ADHD into six different types, there's a checklist that people can take to help them figure out what we might see on the scan. That's important because knowing what type you have helps, in our experience, to predict treatment response.
If you look at any psychiatric journal today almost half of their articles are related to brain imaging. So brain imaging in psychiatry research is happening at a furious pace. It's just there are very few people applying it to clinical practice.
Member question: Do these same images work for diagnosing adults with ADHD?
Amen: Let me try to be really clear on this point: When we look at a brain scan we don't make a diagnosis. When we look at a brain scan what we're looking at is the underlying physiology of our patient's problem, but you always need to put the brain scan in the context of the person. So scans don't give you the answer; they give you part of the answer. They give you the biology of the answer. You still have to put it into the context of a good history and understanding of the patient.
So scans are not a doctor in a box, but are a very helpful tool in helping us understand what's going on in a person's brain.
Member question: My 6-year-old stepdaughter has been having trouble since preschool completing tasks, remembering to do things asked of her, and especially has trouble following directions and paying attention in school and at home. I have talked to her teacher and we are both going back and forth between ADHD and immaturity. I don't feel that the tasks given to her are beyond her developmental capability. What is my next step, or what else do I look for?
Amen: In 3-year-old children, 30% of them look hyperactive and meet many of the criteria for ADHD. For 4-year-old children, only about 10% of them look like they have ADHD, and at about 7 years old, it's even less than that.
Sometimes what looks like ADHD is a maturation lag. If I had a 5 year old who looked like they had ADHD, the very first thing I would do is change their diet, make sure they get enough exercise, and put them in a structured environment. Giving them those advantages, if they still had the hallmark features of ADHD, at that point I would consider making the diagnosis and consider a medicine.
Moderator: What kind of dietary changes do you suggest?
Amen: After doing this for 20 years I'm a huge believer that our diet matters. Part of it depends on the kind of ADHD people have, because ADHD is not one thing. By and large, higher-protein, lower simple-carbohydrate diets are the best natural treatment for ADHD. Keith Connors did a study with ADHD children and found that if you give them protein in the morning their medications last longer.
I think how we feed children in this country is a scandal. They get way too many refined foods, simple carbohydrates, and non-nutritional foods; in a sense we're poisoning them. How you feed kids really does matter.
There are simple things you can do to make a difference: First, give them protein in the morning; some form of meat, eggs, or cheese. Second, when they come home from school, do not give them a sugar snack; replace it with deviled eggs, with string cheese, or with a handful of nuts. Now, I'm not saying that you should never give a child a cookie or a bowl of ice cream, but don't do it before they need to concentrate.
Moderator: You mentioned that there are "types" of ADHD? Can you explain?
Amen: Here is a quick list:
Member question: I suspect that my husband has ADHD. What are some classic signs of it in adults?
Amen: Adults really have very similar symptoms. Now, they show up a little differently, but the good news is adults get better, like children get better, with the right treatment.
Adults with ADHD:
Member question: Do you have any tips for living with an adult with ADHD?
Amen: Yes:
Member question: I have heard that adults that have ADHD are more prone to addictions such as alcohol or nicotine. Is this true?
Amen: Untreated ADHD adults have a much higher incidence of alcohol and drug abuse. In one study it was up to 52%. When we treat people effectively we decrease their risk for substance abuse, but there is a huge connection between ADHD and substance abuse.
Member question: For a child diagnosed with classic ADHD, is there a drug on the market that does not have to be taken orally? My child cannot and will NOT swallow a pill.
Amen: Most of the standard drugs for ADHD need to be taken orally. There are some other drugs, such as Clonidine, that sometimes works, that you can wear as a patch. There are also companies that are looking into making patches for the stimulant medications.
Member question: What is the relationship between ADHD and depression? ADHD and bipolar disorder?
Amen: They go hand in hand. In one study 50% of teenagers with bipolar disorder also had ADHD, and depression also runs commonly with ADHD. We really don't know about the connection between ADHD and bipolar, as to why that is.
With depression, the theory is people who have ADHD struggle quite a bit and they get chronically demoralized. If you try and it doesn't work and you try and it doesn't work, pretty soon you feel helpless and you give up, which sets the seeds for depression.
Member question: I am 33-year-old woman who has been having increased trouble concentrating on my work. I am a freelance graphic designer and work at home. I recently took your online ADHD screener at your web site, which said I might have ADHD. I then completed the type checklist, which said that it's highly probable that I am ADHD Inattentive Type. What should I do next? I am kind of embarrassed to bring this up to my family physician because part of me wonders if it's not just a fact of life, and my tendency to space off is a product of work-related stress or living in today's world. My friends have often kidded me that I have ADHD, but because I am not hyperactive or impulsive I have always laughed it off. How do I know when I need to take the next step? And how can I bring it up to my physician without appearing like I was just brainwashed by TV adds touting ADHD meds? Or should I just read a book about it and try to chill out?
Amen: I think the first thing you should do is investigate it. Reading my book, Healing ADD, or another good book, Driven to Distraction, by Dr. Hallowell, would be a great next step.
ADD is very common in adults, and it's something that if you have it you should pursue it. When the treatment works, it's usually very helpful.
We have two web sites: www.amenclinic.com and www.brainplace.com. They're linked. You can see 300 color 3-D spectral images related to ADHD and a host of other problems.
Member question: I have recently been diagnosed with ADHD at the age of 42 after an episode of losing my temper at work. I have been prescribed Concerta and Trilepital and want to know what else I should be doing to get a handle on myself, as this has been a real eye opening into my past.
Amen: I hear this story every day. From the combination of medication it sounds like our temporal lobe ADHD type, so for sure you want to read about it and learn about it. In addition, watch what you eat, incorporate physical exercise into your day, and I would also consider learning some relaxation techniques that will help you if you're getting upset and you've forgotten your medicine. Look for ways to be in better control.
Member question: You said when it works it's usually very helpful; what if the treatment doesn't work?
Amen: That's a great question. When the treatment doesn't work you have to think if you have the right diagnosis, or you might have a type of ADGD that does not respond to traditional treatment. There might also be interfering factors, such as another medical problem or other medications or taking medicine with orange juice, which tends to deactivate its effectiveness.
Member question: Is it just orange juice that decreases effectiveness or any citrus beverage, and how soon after taking your dose can you drink OJ?
Amen: It's any citrus beverage, so I recommend you don't have it an hour before or an hour after you take your medication.
Member question: My son is on a stimulant for ADHD. It helps with his ADHD but I am wondering if it is affecting his growth. He seems so much shorter than everyone else in the family.
Amen: There are a number of studies on growth and Ritalin. They contradict each other. It seems that when people take Ritalin, for the first year or two they are on it, it slows their growth, but over time kids end up to where they should be. So at this point it does not appear that there are any long-term effects on growth.
You have to think of it from another angle, and that is what are the long-term effects of having untreated ADHD? And we know there are many negative effects.
Member question: I have recently been diagnosed with ADHD/depression. My question is about parenting. I believe my daughter may also have ADHD. Whether or not she does she would definitely benefit from a more structured environment. How can I structure someone else's environment when I can't even balance my own (I've set up charts, tried writing out rules/schedules, etc. I have been inconsistent with these attempts as I keep forgetting to go back and check in)? Do you know of any resources specifically for parents of kids with ADD who have ADHD?
Amen: The first thing is to get yourself fully treated. That is critical. I have another book I wrote, called New Skills for Frazzled Parents, and that also might be helpful for you.
Member question: So ADHD runs in the family?
Amen: No question. Yes, it does.
Member question: How much of an effect does cigarette smoking have on medications given for bipolar with ADHD?
Amen: Cigarette smoking decreases blood flow to the brain and will decrease the effectiveness of the medication. So work to get off of it. Some people use nicotine as a way to self-medicate, but it's not very good medicine.
Moderator: Do you have any final words for us, Dr. Amen?
Amen: ADD is a family disorder. Odds are if you have a child that has it, the mom or dad or both of them have it, and it's important to get everyone treated.
We now have three clinics and a fourth one on the way. We have a clinic in Tacoma, Wash., Newport Beach, Calif., Fairfield, Calif., and a new one in Reston, Va., to open early next year. We think more people should be able to benefit from imaging, not for simple things to diagnose, but more complicated things, for example if you have ADHD and stimulants make you worse, or if you have ADHD and bipolar, or significant problems with your temper. Obviously imaging will be part of our future in psychiatry.
Moderator: Thanks to Daniel Amen, MD, for answering our questions.
WebMD does not provide medical advice, diagnosis or treatment. See additional information.
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