August 13, 2021

How to Improve Driving Safety for Teens and Adults With ADHD

Drivers with ADHD are far more likely to be involved in crashes, to be at fault in crashes, to be in severe crashes, and to be killed in crashes. The more severe the ADHD symptoms, the higher the risk. Moreover, ADHD is often accompanied by comorbid conditions such as oppositional-defiant disorder, depression, and anxiety that further increase the risk.

What can be done to reduce this risk? A group of experts has offered the following consensus recommendations:

·        Use stimulant medications. While there is no reliable evidence on whether-stimulant medications are of any benefit for driving, there is solid evidence that stimulant medications are effective in reducing risk. But there is also a “rebound effect” in many individuals after the medication wears off, in which performance becomes worse than it had been before medication. It is therefore important to time the taking of medication so that its period of effectiveness corresponds with driving times. If one has to drive right after waking up, it makes sense to take a rapid-acting form. The same holds for late-night driving that may require a quick boost.
·        Use a stick shift vehicle wherever possible. Stick shifts make drivers pay closer attention than automatic transmissions. The benefits of alertness are most notable in city traffic. But using a stick shift is far less beneficial in highway driving, where shifting is less frequent.
·        Avoid cruise control. Highways can be monotonous, making drivers more prone to boredom and distraction. That is even more true for those with ADHD, so it is best to keep cruise control turned off.
·        Avoid alcohol. Drinking and driving is a bad idea for everyone, but, once again, it’s even worse for those with ADHD. Parents should consider the no-questions-asked policy of either picking up their teenager anytime and anywhere or setting up an account with a ride-sharing service.
·        Place the smartphone out of reach and hearing. Cell phone use is as about as likely to impair as alcohol. Hands-free devices only reduce this risk moderately, because they continue to distract. Texting can be deadly. Sending a short text or emoticon can be the equivalent of driving 100 yards with one’s eyes closed. Either turn on Do Not Disturb mode or, for even greater effectiveness, place the smartphone in the trunk.
·        Make use of automotive performance monitors. These can keep track of maximum speeds and sudden acceleration and braking, to verify that a teenager is not engaging in risky behaviors.
·        Take advantage of “graduated driver’s licensing laws” wherever available. These laws forbid the presence of peers in the vehicle for the first several (for example, six) months of driving. Parents can extend that period for teenagers with ADHD, or set it as a condition in states that lack such laws.
·        Encourage practicing after obtaining a learner’s permit. Teenagers with ADHD generally require more practice than those without. A “pre-drive checklist” can be a good place to start. For example: check the gas, check the mirrors, make sure the view through the windows is unobstructed, put your cell phone in Do not disturb mode and place it out of reach, put on a seatbelt, and scan for obstacles.
·        Consider outsourcing. Look for a driving school with a professional to teach good driving skills and habits.

Experts do not agree on whether to delay licensing for those with ADHD. On the one hand, teenagers with ADHD are 3-4 years behind in the development of brain areas responsible for executive functions that help control impulses and better guide behavior. Delaying licensing can reduce risk by about 20 percent. On the other hand, teens with ADHD are more likely to drive without a license, and no one wants to encourage that, however inadvertently. Moreover, graduated driver’s licensing laws only have a legal effect on teens who get their licenses at the customary age.

Paula A. Aduen, Daniel J. Cox, Gregory A. Fabiano, Annie A.Garner, Michael J. Kofler, “Expert Recommendations for Improving Driving Safetyfor Teens and Adult Drivers with ADHD,”ADHD Rep. (2019) 27(4): 8–14. doi:10.1521/adhd.2019.27.4.8.

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Swedish Population Study Confirms Association Between ADHD and Height

Nationwide population study in Sweden confirms association between ADHD and shorter height in children and adolescents, suggests stimulant medications are not a factor

A commonly reported risk associated with ADHD medication is reduced growth in height. But studies to date have generally not adequately described or measured possible confounders, such as genetic factors, prenatal factors, or socioeconomic factors. What if ADHD were associated with reduced height even in the absence of medications? 

An international study team explored this question by performing a nationwide population study comparing data from before (1968-1991) and after (1992-2020) the adoption of stimulant therapy for ADHD in Sweden. 

The country’s single-payer health insurance system that connects patient records with all other national registers through unique personal identification numbers makes such analysis possible. Sweden also has military service conscription, which records the heights of 18-year-old males.

The participants were all 14,268 Swedish males with a diagnosis of ADHD who were drafted into military service at any time from 1968 through 2020. 

Up to five non-ADHD controls were identified for each ADHD case, matched by sex (they had to be male), birth year, and county. The total number of controls was 71,339.

Among 34,586 participants in the period before adoption of stimulant medications (1968-1991), those diagnosed with ADHD had roughly 30% greater odds of being shorter than normal (166-172 vs. 173-185 cm) than typically developing controls. That dropped to 20% greater odds among the 34,714 participants in the cohort following adoption of stimulant medications.

The odds of those diagnosed with ADHD being much shorter than normal (150-165 vs. 173-185 cm) remained identical (about 55% greater) among the almost 30,000 participants in both cohorts.

In other words, there was no increase in the odds of ADHD individuals being shorter than normal after adoption of stimulant therapy in Sweden compared with before such adoption.

Furthermore, after adjusting for known confounders, including birth weight, inflammatory bowel disease, celiac disease, hypothyroidism, anxiety disorders, depression, substance use disorder, and highest parental education, the odds of those diagnosed with ADHD being shorter than normal or much shorter than normal in the 1992-2020 cohort dropped to roughly 10% and 30% greater, respectively.

Could it be the disorder itself rather than stimulant treatment that is associated with reduced height in individuals diagnosed with ADHD?

To address effects of environmental and familial/genetic confounding, the team then compared the entire cohort of males diagnosed with ADHD from 1968 through 2020 with typically developing male relatives, ranging from first cousins to full siblings.

Among full siblings, the odds of those with ADHD diagnoses being shorter (over 90,000 participants) or much shorter (over 77,000 participants) were a statistically significant 14% and 18%, respectively.

The authors concluded, “Our findings suggest that ADHD is associated with shorter height. On a population level, this association was present both before and after ADHD-medications were available in Sweden. The association between ADHD and height was partly explained by prenatal factors, psychiatric comorbidity, low SES [socioeconomic status] and a shared familial liability for ADHD.”

January 9, 2024

Swedish nationwide population study finds mothers with ADHD have elevated risk of depression and anxiety disorders after childbirth

Swedish nationwide population study finds mothers with ADHD have elevated risk of depression and anxiety disorders after childbirth

In the general population, most mothers experience mood disturbances right after childbirth, commonly known as postpartum blues, baby blues, or maternity blues. Yet only about one in six develop symptoms with a duration and magnitude that require treatment for depressive disorder, and one in ten for anxiety disorder.

To what extent does ADHD contribute to the risk of such disorders following childbirth? A Swedish study team used the country’s single-payer health insurance database and other national registers to conduct the first nationwide population study to explore this question.

They used the medical birth register to identify all 420,513 women above 15 years of age who gave birth to their first child, and all 352,534 who gave birth to their second child, between 2005 and 2013. They excluded miscarriages. They then looked for diagnoses of depression and/or anxiety disorders up to a year following childbirth.

In the study population, 3,515 mothers had been diagnosed with ADHD, and the other 769,532 had no such diagnosis. 

Following childbirth, depression disorders were five times more prevalent among mothers with ADHD than among their non-ADHD peers. Excluding individuals with a prior history of depression made little difference, lowering the prevalence ratio to just under 5. Among women under 25, the prevalence ratio was still above 3, while for those 25 and older it was above 6.

Similarly, anxiety disorders were over five times more prevalent among mothers with ADHD than among their non-ADHD peers. Once again, excluding individuals with a prior history of depression made little difference, lowering the prevalence ratio to just under 5. Among women under 25, the prevalence ratio was still above 3, while for those 25 and older it was above 6.

The team cautioned, “There is a potential risk of surveillance bias as women diagnosed with ADHD are more likely to have repeated visits to psychiatric care and might have an enhanced likelihood of also being diagnosed with depression and anxiety disorders postpartum, compared to women without ADHD.”

Nevertheless, they concluded, “ADHD is an important risk factor for both depression and anxiety disorders in the postpartum period and should be considered in the post- pregnancy maternal care, regardless of sociodemographic factors and the presence of other psychiatric disorders. Parental education prior to conception, psychological surveillance during, and social support after childbirth should be provided to women diagnosed with ADHD.”

December 22, 2023

Meta-analysis suggests acupuncture might offer effective treatment for ADHD, but suffers from methodological flaws

Meta-analysis suggests acupuncture might offer effective treatment for ADHD, but suffers from methodological flaws

Noting that previous “systematic reviews concluded that currently available data on the clinical effectiveness of acupuncture for treating ADHD are yet to be sufficient to support its routine use,” a South Korean study team conducted an updated systematic search of the medical literature for randomized controlled trials (RCTs) comparing acupuncture with drug treatment for children and adolescents with ADHD. There were no restrictions on language or publication type.

Only two of the meta-analyses involved more than two RCTs. 

One of them, of six RCTs with a combined 541 participants, reported total treatment efficacy of acupuncture to be at least equal to that of conventional treatment with ADHD medicines. 

Another, of five RCTs with a total of 351 participants, reported total treatment efficacy of combined acupuncture and ADHD drugs to be at least equal to that of conventional treatment with ADHD medicines.

Two RCTs with a Noting that previous “systematic reviews concluded that currently available data on the clinical effectiveness of acupuncture for treating ADHD are yet to be sufficient to support its routine use,” a South Korean study team conducted an updated systematic search of the medical literature for randomized controlled trials (RCTs) comparing acupuncture with drug treatment for children and adolescents with ADHD. There were no restrictions on language or publication type.

Only two of the meta-analyses involved more than two RCTs. 

One of them, of six RCTs with a combined 541 participants, reported total treatment efficacy of acupuncture to be at least equal to that of conventional treatment with ADHD medicines. 

Another, of five RCTs with a total of 351 participants, reported total treatment efficacy of combined acupuncture and ADHD drugs to be at least equal to that of conventional treatment with ADHD medicines.

Two RCTs with a combined 152 participants reported a large effect size improvement in hyperactivity/impulsivity symptoms from acupuncture treatment versus conventional drug treatment.

From this one could superficially conclude that acupuncture is at least as effective for treating ADHD as the medicines currently considered to be the standard of care, and that there is no need to combine acupuncture with drug treatment.

However, there were numerous methodological shortcomings:

  • No effort was made to look for publication bias.
  • There were few RCTs, and the combined number of participants was relatively small.
  • Only one of the six RCTs in the first meta-analysis and none of the five RCTs in the second meta-analysis was rated “low risk of bias.”
  • Though nowhere stated in the journal article, there may have been cultural bias as well. All studies included in the meta-analyses were conducted in China. As China has emerged as a global superpower, it has been eager to portray its traditional medicine as at least equal if not superior to forms of medicine originating elsewhere.
  • The authors noted, “the quality of the studies included in this systematic review was poor. Assessing the blinding of studies is a major aspect in determining the risk of bias of a study, but most of the studies did not provide any relevant information.” 

The authors concluded, “The current evidence on AT [acupuncture treatment] is still too limited to support its routine use in treating ADHD.”

152 participants reported a large effect size improvement in hyperactivity/impulsivity symptoms from acupuncture treatment versus conventional drug treatment.

From this one could superficially conclude that acupuncture is at least as effective for treating ADHD as the medicines currently considered to be the standard of care, and furthermore that there is no need to combine acupuncture with drug treatment.

However, there were numerous methodological shortcomings:

  • No effort was made to look for publication bias.
  • There were few RCTs, and the combined number of participants was relatively small.
  • Only one of the six RCTs in the first meta-analysis and none of the five RCTs in the second meta-analysis was rated “low risk of bias.”
  • Though nowhere stated in the journal article, there may have been cultural bias as well. All studies included in the meta-analyses were conducted in China. As China has emerged as a global superpower, it has been eager to portray its traditional medicine as at least equal if not superior to forms of medicine originating elsewhere.
  • The authors noted, “the quality of the studies included in this systematic review was poor. Assessing the blinding of studies is a major aspect in determining the risk of bias of a study, but most of the studies did not provide any relevant information.” 

The authors concluded, “The current evidence on AT [acupuncture treatment] is still too limited to support its routine use in treating ADHD.”

January 4, 2024