Some things I learned at the 2018 Annual Conference on ADHD

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I recently attended the 2018 Annual International Conference on ADHD, co-hosted by CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), ADDA (Attention Deficit Disorder Association), and the ACO (ADHD Coaches Organization). The experience was amazing - the content, the people, everything. Four days of material, broken into six simultaneous tracks for Mental Health Clinicians, Physicians/Psychiatrists, Coaches/Organizers, Educators, Parents/Caregivers, and adults with ADHD. Gloriously overwhelming!

Of course, I was only able to attend the presentations that were most relevant for my ADHD Coaching and Professional Counseling practice(s). And some that were simply interesting for myself as a lifetime ADHD’er. I took copious notes, and have distilled what I think are some of the most important points to share.

Some overarching points:

For adults, ADHD is a productivity disorder. Clinically speaking, it is a chronic disorder of inhibition and self-regulation. It is NOT about simply “sitting still and paying attention”. Rather it is about regulating critical psychological functions such as motivation, focus, attention, emotions, and behaviors.

Put another way, ADHD is a disorder of life management. (see below for examples)

Two unfortunate paradoxes were presented:

  • ADHD is a stress producing disorder, and excessive stress makes managing ADHD harder

  • People with ADHD have a harder time succeeding with self-improvement; with the development of the exact skills they need in order to survive with ADHD.

Two basics that everyone should know:

  • The causes of ADHD are no longer unknown. ADHD is a neurodevelopmental disorder, with clearly established neurobiological underpinnings, neurochemical imbalances (dopamine, norepinephrine, etc), specific impaired neural networks, and genetic etiologies (70% heritability).

    • Things that do NOT cause ADHD: Bad parenting, anything related to breastfeeding, too much screen-time, learning to walk too late, dishonest marketing by drug companies.

  • Most children do NOT “grow out of it”. Research now indicates that 60% - 80% of people carry their ADHD into adulthood (throughout their entire lifespan). Sadly, less than 20% of adults with ADHD who were not diagnosed as children, will ever be diagnosed or treated. Actually, this is tragic, and you’ll understand why after you read the next section.

ADHD bites its own tail because its harder to do the things we need to do to manage ADHD.
— Mark Bertin, MD

Keynote Speaker: Russell Barkley, PhD

Dr. Barkley is the worlds leading researcher on ADHD. He has published literally hundreds of academic/scientifc articles, almost 100 textbook chapters, and dozens of books. Dr. Barkley is not in the camp of ADHD as a “gift”, and was a particularly heavy-hitter on the topic of the painful realities of adult ADHD:

  • “Across all of our results, one thing seems abundantly clear – ADHD in adults is a significantly impairing disorder, associated with numerous difficulties in virtually every domain of major life activity.”

  • “Whether one studies functioning in education, occupation, social relationships, sexual activities, dating and marriage, parenting and offspring, psychological morbidity, crime and drug abuse, health and related lifestyles, financial management, or driving, ADHD can be found to produce diverse and serious impairments.”

  • “As such, ADHD impairments are more substantial than are those seen in other disorders most likely to present to outpatient mental health clinics, such as anxiety disorders, dysthymia, and major depression.”

If those points weren’t heavy enough, these should be:
ADHD is a public health disorder, not just a mental health problem.
• ADHD rivals autism in the stress burden on parents.
• ADHD as a quality-of-life threatening illness!

His keynote was largely focused on presenting the findings of his recently completed long-term study of people with ADHD. His bottom line finding was shocking and profound: Undiagnosed people with ADHD have a lifespan 10+ years shorter than average!

ADHD is not a disorder of not knowing what to do…its a disorder of not being able to do what you know.
— Russell Barkley, PhD

ADHD & the DSM-5

It’s pretty well agreed that, despite the fact that there are 50,000+ scientific articles published on the subject, the APA missed the proverbial boat in regards to getting ADHD correct in the DSM-5. In fact, the APA has proven to be pretty good at pooch-screwing in general (for example, see my article on their handing the topic of Behavioral Addiction, wherein I illustrate how they actually formally posited in the DSM-5 that asian males with “internet connected computers” are the most likely people in the world to develop a gaming disorder!!) Accordingly, many conference presenters had very little positive to say about the APA’s handling of the disorder.

Here are some fun facts they pointed out:
• In 1994, the APA added “Hyperactivity” to the name, but removed it as a required criteria (huh?).
• The word “Impulsivity” isn’t even mentioned in the list of criteria for “Hyperactivity and Impulsivity”.
• Problems with Emotional Regulation aren’t addressed at all, despite their being a key impairment.

I could go on and on, however, I’ll just say that while the APA purported to update the diagnosis to better include adults, they didn’t do a very good job of it. Here are specific thoughts from some of the masters in the field:

Some thoughts from Russell Barkley, PhD:

The DSM-5 requires that impairments are present in two or more settings, and they list school/work, and home as the only examples. Unfortunately, this ignores many important domains of major life activities that comprise adult adaptive functioning. Example domains of major adult life activities that current criteria fail to reflect include:

•   General functioning within the community (eg. legal, social, driving, chemical use/abuse)
•   Financial management
•   Parenting and child-rearing
•   Marital functioning
•   Routine health maintenance activities (eg. self-care)

Some thoughts from Dr. William Dodson, MD:

The DSM criteria are only behavioral and observational, and they neglect critical aspects of ADHD such as:
•   Cognition and Thinking Styles
•   Emotional Regulation
•   Psychosocial Maturation
•   Interpersonal Relationships
• Sleep

Plus, the name ADHD downright stinks. The AD is incidental - the problem isn’t a deficit of attention, it is a problem with attentional engagement on demand.
— William Dodson, MD

On the topic of Dual Diagnosis

It is well known that there is a high rate of comorbidities with ADHD. It was very interesting to learn, however, that all the co-morbidities aren’t necessarily alway correct. Specifically, the following was discussed at the conference:

  • There is a 50% comorbidity reported between ADHD and anxiety. Oftentimes, however, the stress of living with ADHD often creates its own anxiety, and is not a distinct diagnosis. Although many practitioners treat the anxiety first, it should be the other way around. (source: William Dodson, MD)

  • What is mistakenly diagnosed as co-morbid Depression is often actually frustration and demoralization at repeated failure and falling short of potential. This is frequently triggered by negative life events, is shorter than 2 wks duration, and is relieved by finding new interests. 50% of co-occurring depressions resolve with stimulant medications alone (ie. no added antidepressants). (source: William Dodson, MD)

People with ADHD have genetic markers that make them more susceptible to PTSD after experiencing a trauma.
— Mark Bertin, MD

Regarding ADHD medications

ADHD medications are not a “crutch”, and there are numerous misunderstandings, bordering on memes and myths about ADHD medications (stimulant medications in particular). Here are some important take-aways from the conference:

  • “Drug Holidays” hurt, not help. ADHD is a 24-hr disorder, and should be treated accordingly.

    • See above DSM-5 section for other domains impaired beyond simply work and school. Just because someone doesn’t have to study/do homework/goto the office/work on a project/etc doesn’t mean they don’t need optimal access to their ability to organize, not procrastinate, not be overwhelmed, better manage their impulses and emotions, etc. It was the consensus option (among the medical doctors) that prescribing practitioners who still advise “only take your ADHD meds when you need to study or concentrate” should get updated training on ADHD.

  • The European Consensus Statement on the Treatment of Adult ADHD recommends the daily use of stimulant medications, as does the white paper/consensus statement by the NIH (link pending).

  • Stimulant medications do not increase anxiety (when properly dosed).

    • 23 studies actually found that stimulant medications are almost always associated with significantly lower levels of anxiety.

  • There are only 4 true side effects from stimulant medications (when properly dosed): appetite suppression, insomnia, stomach ache, & headache.

  • Life is harder without meds, or if they aren’t right.

    • The “or if they aren’t right” refers to the rampant mis-prescribing of Adderall (especially non extended release) by prescribers. Methylphenidate, not amphetamine, is the first-line drug for adult ADHD. Further, standard release formulations should only be used when “absolutely necessary”. That comes from authorities such as the NIH, WHO, AMA, APA, and the European Consensus Statement on the Diagnosis and Treatment of Adult ADHD. Nonetheless, probably 80% of the clients that come to me for ADHD Coaching and/or Counseling are being prescribed Adderall. And probably 50% of them are on standard release…

  • ADHD is the most treatable disorder in psychiatry.

    • This claim, made by multiple psychiatrists specializing in ADHD, is based on the high efficacy of ADHD stimulant medications.

  • ADHD stimulant medications are safer than aspirin. This statement was made in the ADD & Loving It? documentary by Dr. Ned Hallowell, expert ADHD psychiatrist and co-author of one of the seminal books in the field (Driven to Distraction). He backed up this seemingly bold statement by comparing the fatality rates of the two medications.

Medication levels the neurobiological playing field, and allows adults with ADHD to learn and develop the skills they ned to succeed.
— Beiderman & Spencer, 2002

ADHD and Addiction

This was my talk, and I am super-honored that they accepted my proposal. The topic is critical, as research indicates that up to 50% of people seeking treatment for addiction also have ADHD. Most haven’t yet been diagnosed or treated, and have instead been attempting to compensate by self-medicating with chemicals and/or behaviors (gambling, porn, internet gaming, etc). I go in great detail about the neurobiological overlap between the two disorders, and focus on both chemical and behavioral addictions. I presented for 75-mins, so I won’t try cover it all here, and will instead distill it down to two sets of myths.

First, I talked about 3 Myths about ADHD & Addiction:

  1. Myth: Stimulant medication treatment of ADHD in childhood can lead to addiction later in life.

    • False. In fact, most research has found the opposite -that ADHD stimulant medication has a protective effect for children, drastically reducing the risk of developing a SUD later in life.

  2. Myth: Long-term use of stimulant medication will lead to addiction.

    • Incorrect. There have been no valid studies showing that stimulant medications (properly prescribed) lead to addiction in people with ADHD (properly diagnosed).

  3. Myth: People with ADHD will eventually abuse their stimulant medication.

    • Not true. Neurotypical Brain ≠ ADHD Brain. Ask anyone with ADHD if they enjoy being a given too large of a dose of their meds. Overwhelmingly, the answer is NO. Our brains are wired differently, and we don’t get “high” from the meds. Instead we go into either “Zombie Mode” or “Starbucks Syndrome”.

I also talked about 3 Myths about Addiction Treatment for people with ADHD:

  1. Myth: We don’t need to screen for that.

    • Wrong. Based on the huge co-morbidity between ADHD & SUD, there should ALWAYS be a screening.

  2. Myth: People with ADHD must discontinue their stimulant medication while in treatment for addiction in order to get sober.

    • Wrong again! According to the NIH, subject matter experts at Harvard, and other formal published position papers (such as the International consensus statement on screening, diagnosis and treatment of substance use disorder patients with comorbid attention deficit/hyperactivity disorder), concurrent treatment is the recommended practice. Don’t let addiction treatment centers tell you otherwise, as they are flat wrong (and oftentimes causing multiple forms of iatrogenic harm).

  3. Myth: People with ADHD and history of substance abuse will be unable to safely use their medication to manage their ADHD symptoms after they become sober.

    • Wrong yet again. Multiple studies show that the risk for relapse is actually reduced.

Consistent with findings in untreated ADHD in adults, untreated ADHD was a significant risk factor for SUD in adolescence. In contrast, pharmacotherapy was associated with an 85% reduction in risk for SUD in ADHD youth.
— Biederman, J., et al. (1999). "Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder." Pediatrics, 104(2): e20-e20.
ADHD medication was not associated with increased rate of substance abuse. Actually, the rate during 2009 was 31% lower among those prescribed ADHD medication... Also, the longer the duration of medication, the lower the rate of substance abuse.
— Chang, Z., et al. (2014). "Stimulant ADHD medication and risk for substance abuse."

Keynote Speaker - Jessica McCabe.

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Her closing keynote speech on Sunday was MINDBLOWING. Equally mindblowing was sitting in a room full of a thousand people (or so) all becoming simultaneously teary-eyed.

Her talk was titled “Getting fish out of trees, one brain at a time”. I had no idea what this meant, until I saw the following slide (I pirated this picture; I assume she’d be ok with it). To fully appreciate the point, read the first half, pause and let it sink in before reading the second.

Her point is profound, on multiple levels. For those who don’t have ADHD, never underestimate the depth of shame that results from living a life of continuously making small mistakes, and being repeatedly told (explicitly or subtly) that you wrong, stupid, weird, lazy, or whatever.

Her TedX talk below isn’t her talk from the conference (obviously), but it covers much of what she had to say. She even talks about fish in trees (although she presented it better at the conference, IMHO). For readers who aren’t familiar with Jessica, she is an amazing layperson contributer to the field via her highly watched YouTube channel How To ADHD. The video linked to the right is her most popular talk, viewed over 1,000,000 times.


In conclusion…

Ok, I actually don’t have a fancy conclusion. In true ADHD style, I’ve become tired of writing (it took me an entire weekend to put this together). I do want to acknowledge that there there were TONS of other speakers at the conference, covering TONS of other related topics (such as parenting children with ADHD, teaching students with ADHD, or the many techniques for and benefits of ADHD Coaching). My apologies to anyone from the conference whose work I didn’t reference, (or whose work I may have accidentally misstated).

For those who are interested in learning more about the conference, you can follow these two links (one and two) to download many (but unfortunately not all) of their handouts and/or presentations. There was so much awesome stuff there that I haven’t even mentioned (lots on mindfulness, updates on CAM (complementary alternative medicine), and more).

So, I’ll end here now, with the following quote from the conference:

In the history of calming down, no-one has ever calmed down, by being told to calm down.
— (I forgot who said this, but it resonates deeply)

Source: some things learned at the 2018 ADHD ...