ADHD Diagnosis in the Internet Age
I was probably around 7 years old when my best friend told me something I didn't quite believe; he claimed that there was a wall in China that goes across the entire country. At the time I doubted this claim; surely I would have heard about this 'wall' before from someone more authoritative than my friend if it truly existed, and my friend was know to me to have a somewhat tenuous relationship the truth. But as I stood there listening I decided that perhaps there was truth in what he was saying.
Of course, growing up in the 70's, there was really only one definitive source for reliable information; the Encyclopedia Britannica set on our bookshelf. I ran into the den where the well-worn set of books sat wedged between countless old National Geographic magazines, John LeCarre paperbacks, and various textbooks my parents acquired during their long love affairs with higher education. I deftly thumbed the "C" book out of its slot and lowered myself to the floor and onto my stomach; book in-hand. I curled page after page until I found the entry for China, mumbling phrases as I searched for any evidence of this supposed wall, "... second largest state in the world... communist... Qin Dynasty... " and there it was; The Great Wall of China. It even had pictures of the wall and detailed information about when it was constructed.
And so, at that moment, I learned about the Great Wall of China. What's important to note about that moment, and the context of that moment, is that I never had to doubt whether that content was true. It was Encyclopedia Britannica!
I still have my father's Encyclopedia Britannica set, and they sit proudly on a bookshelf in my living room... gathering dust. I don't believe I've turned a page in those books in 20 years. That's because I hold on my hip a smartphone which can easily access (and this is not an exaggeration) the entirety of all information about everything in the known universe... plus some ideas about what lays beyond our universe. If I want to know about any detail about Great Wall of China a simple Google search will result in countless pages. Encyclopedia Britannica never provided me with this saturation of information on any subject I pondered quite like the internet has. If I wanted to know how many bricks were used in the Wall I never could have learned that from my father's encyclopedia set, but Google instantaneously provides me with the answer! (it's 3,873,000,000 individual bricks, just in case you're now curious)
The information age was touted to be the great equalizer and, for the most part, it has removed
most of the fog that has encapsulated many subjects. It has connected people and cultures and ideas as never before in history. It's allowed people in different areas to share a community of ideas. This has led to many momentous occasions. It's no surprise that in Egypt during the Arab Spring demonstrations in 2011 that toppled the Mubarak regime that the first thing the regime did in an attempt to quash the democracy demonstrations was to cut off the internet in the country so the protesters couldn't organize or stream to the world what was happening. In the internet age any subject you're interested in you have instantaneous access to a wealth of information.
But this democratization of information has had an unexpected consequence; the level playing field has also brought reputable and disreputable sources onto the same footing. The algorithms of Google and Bing and Yahoo were all the great emancipators of information; treating all sources as equal. But the problem is that all sources are not equal. Navigating the internet for information requires a critical eye and a requirement for questioning the sources. Before the internet there was no need to delve into the sources and biases of the purveyors of information because we trusted the sources: CBS News with Walter Cronkite, Encyclopedia Britannica, Webster's Dictionary, the New York Times. Simply by default we knew that the information provided by these sources was trust worthy, was vetted, and reliable. By the same token, we knew that being handed a pamphlet by a stranger on a street corner was probably not a reliable source of information; we might glance at the words on the page, then quickly crumple the paper and discard it (but more likely-than-not we'd simply discard it without even looking at it). Why? We could immediately determine if the source of the information was trustworthy.
Today, the internet presents the information of the Journalist and the Jester, the scientist and the simpleton, and the conscientious and the crank... equally. Now no longer are credentials and peer-reviewed symbols of reliability; only page-rank holds value. Furthering the descent is most search engines have algorithms that will tailor your results based upon what you've searched previously. So once you start down the rabbit hole of selecting questionable sites for information the search engines will dutifully begin serving up more 'fringe' sources of information for you to consume. The user will quickly believe that these repeated and numerous sites being provided are proof of their beliefs; a confirming bias.
Adding to the complexity, even reputable sources can get it wrong. Several years ago (unfortunately I can't recall the exact study or site) I found an article on a reputable news site with an article stating that a new study found a link between alzheimer's and certain risk factors. In the article it included a link to the actual study. Of course, most people never read the actual study because, to be honest, they're very dry and clinical. Dr. Larery decided to actually read the study itself and found that the assertions made in the news article were not made in the study. The author of the article completely misinterpreted the study and, even worse, had a very grandiose headline.
How does this relate to the diagnosis ADHD? Simply put, the internet places the majority of the responsibility on the individual to perform the vetting of information. In our practice we often have to overcome misinformation that has been gleened from the internet by our patients. A 1975 study kicked off the correlation between food dyes and ADHD. BF Fiengold stated that if you remove the offending ingredients from your child's diet that the unsettling behavioral problems will decline. The difficulty was that the study didn't define ADHD as it is defined for diagnostic purposes (our practice uses the criteria defined in the DSM-IV). Subsequent studies focusing on additives and other substances that Feingold linked to hyperactivity had varying results: Some confirmed while others contradicted Fiengold's conclusions. Most concerning was that there were numerous cases of publication bias (publication bias is when the publisher of the study has a vested interest in the results of the study falling a certain way. In the 1970's the petroleum industry funded studies to refute the link between lead in gasoline to the high levels of lead in people's blood. Those studies were rife with publication bias because the petroleum industry had a vested interest in there not being a link).
Finally, in 2012, the Journal of the American Academy of Child Adolescent Psychiatry (yes, that' s quite a mouth-full) published their meta-analysis about the link between ADHD and synthetic food additives. A meta-analysis is, essentially, a study of studies. Since each of the previous studies were all very small sample sizes and had some errors that might have swayed the results, a meta-study allows you to look at a much larger sample size and correct for previous errors. Basically, it took every study on the subject of food dyes and their effect on hyperactivity and grouped them all into one big mega-study. The result was very interesting in that there was no absolute, conclusive link between food dyes and hyperactivity. Once bias and study errors were corrected for, there was actually very limited cases where food dyes caused hyperactivity in children. While there was some evidence that some children did show sensitivity to food dyes, there certainly was not a universal finding indicating that food dyes are the cause of ADHD in all cases. However, a cursory search on Google for "Food dyes and ADHD" will result in pages and pages of articles declaring there is absolutely a link and you might come away thinking "yes food dyes cause ADHD and I am a horrible parent if I feed my children anything with an artificial food dye!"
So, back to the question: Do food dyes cause ADHD - hyperactive type? The answer is, in a small minority of cases, yes. There is some evidence that some children show sensitivity to certain food ingredients, including food dyes. This sensitivity is manifested as, among other things, hyperactivity. But the research is far from conclusive and it can't be universally applied. Not every case of ADHD can be traced to the ingestion of food dyes.
So, as a parent of a child who is exhibiting, or has been diagnosed, with ADHD - Hyperactive type, what are you to do? Who are you to believe? There are so many sources of information and they seem to conflict with each other. We suggest that every family first start with a qualified clinician who is experienced in performing the evaluations. Neuropsychologists, like Dr. Angela Larery focus on keeping up with the latest research on disorders that affect personality, behavior and cognition. Very few lay-people could possibly read, let alone understand, many of the scientific studies most neuropsychologists are constantly reviewing. They also review the latest research in professional journals as well studying the changes in the diagnostic criteria for various disorders.
Next we ask our families to come in with an open mind and be willing to look at all of treatment recommendations and that each option build on the previous. There rarely is a 'silver bullet' which will quickly resolve all of the issues, but there are several things that usually help:
• We recommend that the family begin to address their child's ADHD by providing them a very structured and reliable daily agenda and that the agenda be consistently applied (for example if the child brushes their teeth and then makes their bed, then every day the parent must reinforce that that is the order of things because structure builds habits... and habits don't need to be remembered, they just happen).
• We recommend simple reminders; timer watches are fantastic, and giving the child only one task at a time and praising them for sticking to their task. These strategies will help the child learn how to cope with their ADHD.
In cases where it warrants, we will also recommend that medications might benefit a patient. Some parents are hesitant to begin giving their children medication for ADHD because, again, of something they've read on the internet about stimulant medications. However, we remind people that ADHD is a biochemical imbalance. There are other biochemical imbalances that most people have no trouble medicating; Diabetes is a biochemical imbalance as well. In mild cases of diabetes medication may not be necessary to manage the symptoms; by changing your behaviors you can manage the symptoms quite well. But in more severe cases, diabetes and their symptoms are very difficult to manage without medication. ADHD is the same; in mild cases, providing a very structured environment, setting smaller goals, providing lists and reminders, and providing a reward structure can manage the symptoms just fine. But in severe cases the neurochemical imbalance cannot not be easily overcome with just behavior strategies and environmental changes.
But, again, just because we recommend a certain strategy or action doesn't mean that the parent must oblige. In the end, the parent must do what they feel is best for their child; including deciding whether to treat their child's ADHD with medication or not.
The internet age has now placed upon all of us the responsibility of verifying the sources of our information... even this post! I hope you went through and checked my links to the sources of the information! And that is what we all must do in every article, every web-search, every blog and forum we read. That will ensure that all of us only use reliable and unbiased information for our decision making.