Alex needed me to cut to the chase. His ADHD treatment plans was complex. He was overwhelmed by the recommendations to exercise daily, hire a coach, listen to some ADHD audio books, get more sleep and start some supplements. The idea of medications sounded promising to him, but the trials needed to find the right dose of the right one could take months.
‘How much bang-for-the-buck do these treatments give?’ is a fair question. People with ADHD have already tried hundreds of strategies to improve attention and efficiency that fizzled out—helpful at first, but downhill after that.
I paused trying to think of an answer for Alex. On the one hand, if non-medication therapies were going to successfully treat his ADHD, they already would have done that. He had worked with tutors, therapists, diet and self-help books, but he still had inattention and self-control issues. Medication response can be remarkable, but it sure isn’t the whole story. ‘Pills don’t give skills’ expresses this idea. Physicians can’t just prescribe pills and assume a patient’s ADHD will get better.
Doctors sometimes forget this basic truth, and this is not entirely due to the fact that 90% of physicians don’t have ADHD and don’t understand how much more rigorous the treatment is than the oft-heard ‘just pop a pill’. It’s also due to a quirk with the ADHD research we read. Investigators define successful treatment in scientifically accurate terms such as ‘a 40% or better reduction of investigator-rated DSM-IV symptomatology along with a CGI-I score of at least +2’.
My patients, bless them, never talk like that. They tend to have goals for successful treatment such as ‘get more organized’, ‘study or work at my potential’ and ‘be more thoughtful’ or ‘less frustrated with my children’. Those goals are hard to express in numbers. They have more of a “It’s hard to describe, but I’ll know it when I see it” endpoint.
Alex wasn’t asking me to quote studies, just to help him reach some goals. I was about to say, “50-50” to emphasize that the effects of medications and non-medication therapies are both terribly important, but what came out was, “They’re both essential. It’s 100-100. Neither of them matters much without the other.”
Researchers, of course, have worked on that question, too, and have tried to give us more accurate numbers, but they are fuzzy. It turns out that you can get some–vaguely 30% of the potential response–with medications alone and about the same from intense non-medication therapies. Either therapy on its own misses 70% of the potential improvement. There’s a magic middle 40% that requires both. The whole 100% response requires the combination of both therapies.
So here is the most accurate answer for Alex: it’s a 30-40-30 proposition. I’m glad I didn’t think of that answer, though. since Alex was already overwhelmed and didn’t need an obtuse answer with a long explanation.
I still get asked the Alex question quite often. Where’s the best bang-for-the-buck—is it medications or the non-medication therapies? The best answer is not the scientifically accurate one, but the one that spilled out intuitively that day: 100-100. The best responses come with both therapies done at full-court press levels. Either alone is probably one more disappointment.