Define ‘Better’

“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. Young Girl Reading by Mary Cassatt. 1908‘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.”

“Less distracted?”

“No. That’s about the same.”

“Less impulsive?” 

“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.

 

Core Symptoms

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

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

Posted in ADD, ADHD, medications, treatment
8 comments on “Define ‘Better’
  1. Kathy says:

    Thank you for writing this! It is essential that we as parents understand the core symptoms and remember that is the treatment goal.

    Liked by 1 person

  2. excellent point, we need clarity and precision, when we can get them. but i do wonder why chloe is “better”?

    Like

  3. Thanks for starting this series, looking forward to it. I’ve often wondered for myself and others exactly what “successful” treatment looks like. I have my own personal criteria, but by definition of “better” I may be way off.

    Like

  4. Reblogged this on Faithfully ADHD and commented:
    This is a great blog post to get you thinking about how we define “Better” when treating ADHD.

    Like

  5. chaddgr says:

    Excellent points! I had no idea how much better things could be until we’d experienced it. People often don’t know what they are missing. I’m so glad we could start our son on meds when he was four, before his behavior could be assumed to be a “learned behavior,” he became discouraged or viewed himself as “naughty.” He could have also gotten himself injured, if we’d waited.

    It was a relief, after he was on meds, to be able to get out of the car to pull down the garage door, and leave the car keys in the ignition, without having to worry he might wiggle out through the top of his car seat and try to drive it! I am not kidding! He was great at parallel parking his fire engine, but didn’t want to take any chances! They don’t have to be that impulsive, though, to have AD/HD.

    It’s great that Dr. Mason is educating people, so they can make informed decisions and not blame themselves for treating their child for AD/HD.

    Like

  6. chaddgr says:

    I was glad our son’s symptoms were so overt, so we could see, first hand, how much more thoughtful, mature, and reasonable he would suddenly become, 40 minutes after taking short acting Ritalin. That’s how we knew, without a doubt, his unmedicated self was not how he was choosing to be.

    This would be so much harder to understand, however, if he’d had the inattentive subtype, who suffer just as much, if not more, due to internalizing their feelings and being ashamed of having fallen short of their potential, and “making excuses,” when they try to explain why they read the wrong chapter or forgot to turn in their homework, and then feeling ashamed for “resorting” to drugs, which someone in their life may view as taking the easy way out, as if they are for performance enhancement, to do better than normal. Shame, in itself, can be crippling. As I heard Laurie Assadi, in Kalamazoo, once say, “No one is going to write on your tombstone, SHE DID IT WITHOUT MEDICINE!”

    Perhaps, someday, if a police officer pulls over a driver who has AD/HD, for speeding or running a red light, the person could be fined for NOT being on their medication! Perhaps there will be some way to screen for AD/HD at the Secretary of State’s office, the way they screen for vision problems, now. Perhaps that would help us compete in a global economy, more than anything else, once people can get credit for what they are truly capable of and students don’t get kicked out of school instead of helped!

    I read that in one study, 80% of kids who are expelled, have AD/HD. Another study estimated that treating AD/HD, in the department of corrections, alone, would save $4 billion/year, due to a 37% decrease in the rate of recidivism in adults, and higher in youth and women. THAT would be “better!”

    Like

  7. This is great stuff. I have only started to even look at ADHD in the past month. Previous to that I believed it was just a “disorder” of undisciplined little boys.
    In that time, I have read 6-7 books, innumerable articles, websites and blogs.
    Oh, and I’ve been diagnosed with ADHD at the tender age of 56.
    I am a medical professional with 25 years in the field and a Master’s degree.
    After the first dozen or so websites (by actual doctors, therapist, researchers, etc.) everything sounds pretty much the same. I got it. And I have it. Yup. Now what to do about it.
    You are explaining some of the nuances and controversies that I missed as a newcomer.
    Thanks for your posts.

    Like

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Oren Mason MD
Oren Mason MD

Oren Mason MD

Physician specializing in diagnosis and management of attention deficit disorders and related conditions.

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