Treating ADHD: What Really Works Best?
“Just tell me one thing so I can get this
straight: How much of treating ADHD is
medications, and how much is everything
else? Is it 50-50? 80-20? Give me a number, so
I can wrap my mind around it.” Alex wanted
Oren Mason, M.D., a family physician in
Grand Rapids, Michigan, to cut to the chase.
Alex’s ADHD treatment plan 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 medication
sounded promising to him, but the trials
needed to find the right dose of the right
medication could take months.
“How much bang for the buck do these
treatments give?” is a fair question. People
with ADHD have already tried dozens of
strategies to improve attention and efficiency that, over time, fizzled out.
On one hand, if non-medication therapies
were going to successfully treat Alex’s ADHD,
they would have done that. He had worked
with tutors, therapists, and dieticians,
and read self-help books, but he still had
inattention and self-control issues. Medica-
tion response can be remarkable, but it isn’t
the whole story. Physicians can’t prescribe
pills and assume a patient’s ADHD will get
Many doctors lack personal experience
with ADHD, and don’t understand how
much more rigorous the treatment is than
the oft-heard “just pop a pill.” Investigators
define successful treatment in scientifically
accurate terms such as “a 40 percent or bet-
ter reduction of investigator-rated DSM-V
symptomatology, along with a CGI-I score of
at least +2.”
Patients, bless them, don’t talk like that.
They tend to have goals for successful treatment, such as “get more organized,” “study,”
“work to my potential,” and “be more
thoughtful” or “be less frustrated with my
children.” These goals are hard to express in
numbers. They have an “It’s hard to describe,
but I’ll know it when I see it” endpoint.
Alex wasn’t asking Dr. Mason to quote
studies, just to help him reach some of his
goals. Dr. Mason was about to say “ 50-50,”
to emphasize that the effects of medica-
tion and non-medication therapies are both
important, but what came out was, “They’re
both essential. It’s 100-100. Neither of them
matters much without the other.”
Researchers have worked on that ques-
tion and have tried to give us more accurate
numbers, even if they aren’t exact. It turns
out that you get about 30 percent of what
researchers call “the potential response”
with medications alone, and about the same
from evidence-based non-medication thera-
pies. Using only one therapy alone misses
70 percent of the potential improvement. In
other words, if your ADHD were a pie, one
evidence-based therapy would eat about
one third of it. Use another therapy and 30
percent more would be gone, and so on.
Which is best: medication or the non-
medication therapies? The 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. —TAMARA
ROSIER, PH. D.
attentional lapses. People with ADHD can instruct their focus
control system to pay attention to the task at hand—say a pile
of bills that need to be paid—but the circuits that connect to
the DMN fail to send the instructions to quiet down. When
the DMN notices a new magazine lying next to the pile of bills,
emotional interest centers light up and overwhelm the weak
voice of the cognitive centers.
We have come a long way from our earliest concepts of
ADHD as hyperactivity to a dysfunction in the control pathways, but much remains to be studied. Finding which therapies strengthen control centers, which ones improve communication between control centers and action centers, and
which ones bypass typical pathways will help adults with the
disorder become more productive and confident. A
TAMARA ROSIER, PH. D., is co-founder of Acorn Leadership Coaching.
Connect with Tamara at firstname.lastname@example.org. OREN MASON,
M.D., has been a family physician in Grand Rapids, Michigan, for 20 years.
Author of Reaching for a New Potential, Mason founded Attention MD in
2008, a clinic dedicated to the diagnosis and treatment of children, adolescents, and adults with ADHD. You can reach Dr. Mason at attentionmd.com.
mind-wandering, contemplation, and reflection. It comprises
the precuneus/posterior cingulate cortex, the medial prefrontal cortex, and the lateral and inferior parietal cortex. The
DMN is more active when individuals are at wakeful rest, engaged in internal tasks, such as daydreaming, recovering
memories, and assessing others’ perspectives. Conversely,
when individuals work on active, willful, goal-directed tasks,
the DMN deactivates, and attentional pathways engage. The
DMN and cognitive control networks work in opposing directions to accommodate attentional demands.
In ADHD, the daydreaming brain doesn’t quiet down when
the attention circuits turn on. Several studies have focused
on the connectivity of the DMN in individuals with ADHD.
Weak connections between control centers and the DMN cause
an inability to modulate DMN activity. Many studies of children, adolescents, and adults with ADHD, taking and not taking
medication, have found that the balance between the cognitive
control network and the DMN is either reduced, or absent, in
those with ADHD.
The lack of separation between the cognitive control network and the DMN in the ADHD brain suggests why there are
YOUR AMAZING ADHD BRAIN