“We started a new ADHD treatment for our daughter Chloe, and she’s doing much better.”
If this is your friend talking, or if you’re an ADHD nerd like me, this is a wonderful thing to hear. Oddly, though, no one knows precisely what you mean by ‘better’. Behavior is complex and varied. ‘Better’ could mean a thousand things including more focused, less fidgety, less oppositional or longer attention span. So let’s dig a little:
“So she’s less hyperactive now?”
“No, she was never hyperactive.”
“No. That’s about the same.”
“No, she was never impulsive. She has inattentive ADHD, not the rowdy, troublemaker kind”
“So what does ‘doing much better’ mean?”
“She’s sleeping better and less negative around us.”
The parents among us all recognize the positive changes. But I’m not sure the treatment is working. For an ADHD treatment to work–please excuse this ridiculously obvious point–Chloe’s ADHD should be getting better. So far, it’s not.
This point seems picky, so bear with me here. Much confusion regarding established and alternative treatments for ADHD arises here.
Core symptoms and other ADHD symptoms.
There are hundreds of symptoms that we see commonly in ADHD, but only 18 core symptoms. The following table illustrates core symptoms on the left, common, but not ‘core’ symptoms on the right.
The goal of treatment for ADHD is to decrease core ADHD symptoms. The ideal treatment will decrease non-core symptoms too. But a treatment that improves non-core symptoms without reducing core symptoms, isn’t actually successful. That would be like a pneumonia treatment that decreased the fever and cough, but didn’t kill the germs.
Chloe has less insomnia and negativity, so non-core symptoms are better. If she was treated with a sleep aid and an anti-depressant, we would say the treatment was successful. Since she’s being treated for ADHD, we can’t say that the treatment is successful until her attention improves and her distractibility declines.
Chloe is better, but her ADHD isn’t
Chloe’s ADHD is not appropriately treated, even though she is better. She still has the same ADHD symptoms that led her parents to seek treatment. We need to continue with medication trials until her core ADHD symptoms are better.
For the record, I’m not such a literalist, that I would tell Chloe’s parents that she has to stop the treatment. They might decide that the sleep and attitude issues are so important that the first treatment should be continued while another is sought for her inattention.
Furthermore, it’s not right to ignore non-core ADHD symptoms in a treatment plan. A medication that helps Chloe’s attention but leaves her sleepless and oppositional is treating her ADHD alright, but is certainly not a complete plan.
A definition of ‘better’
ADHD affects every behavior. A team of careful observers can document its impacts on a person thousands of times in a day. ADHD is ‘better’ when most of those begin improving. When we talk about treatments for ADHD, I’m going to limit the word ‘treatment’ to mean a substance or practice that improves most or all ADHD symptoms. Medications and behavioral reward systems are examples of this.
Any treatment that helps single symptom or a very narrow range of behaviors is not an ‘ADHD treatment’ per se. Melatonin to improve sleep onset and phone- or watch-based reminder systems are two examples of the hundreds of treatments that can help, but not broadly enough to be an ADHD treatment.
The bottom line is that the whole notion of “treating ADHD successfully” needs some specificity. This is the first of a series of posts on “Getting Better”, so a definition of terms is a useful, if not sexy, place to begin.
Next up: “Getting Better: Measuring Improvement“