Joseph Biederman, MD
In the mid-1800s, German physician Heinrich Hoffman wrote a children’s book called The Story of Fidgety Philip, about a boy who giggled, wriggled, and rocked in his chair—thus providing the first published description of what is now known as attention deficit hyperactivity disorder (ADHD).
The disorder was not officially recognized as a clinical entity until 1902, when English pediatrician George F. Still published a report in The Lancet in which he described a cluster of disruptive behaviors that he had observed in a number of his young patients, such as impulsivity and an inability to pay attention.
In the years since, physicians and researchers have learned much more about the basis of ADHD and how to treat it. Yet surprisingly this disorder, which affects anywhere from eight to twelve percent of the children pediatricians see in clinical practice, remains encumbered by stigma and misunderstanding. Some people doubt that it is a real medical condition; others ascribe it to bad parenting or blame it on undisciplined children.
Dr. Biederman at Massachusetts General Hospital aims to dispel those notions. He has spent much of his career refuting such myths and publishing evidence-based insights into ADHD. He speaks and writes with the authority of someone who is both a clinician and a researcher. He is clearly passionate about the subject. Dr. Biederman heads a clinical program that treats more than two thousand children, adolescents and adults with ADHD each year. His research team publishes more than thirty scientific papers a year on a range of childhood psychiatric disorders, including ADHD. Together with colleagues Tom Spencer, MD, Janet Wozniak, MD, Eric Mick, ScD, Timothy E. Wilens, MD, Alysa E. Doyle, PhD, Michael C. Monuteaux, ScD, Stephen V. Faraone, PhD, and Larry Seidman, PhD, Dr. Biederman is providing sometimes surprising insights into ADHD.
One persistent myth is that ADHD is a childhood disorder that people eventually grow out of. “Although the prevalence of ADHD falls with age, at least half of children with the disorder will experience impairment into adulthood,” says Dr. Biederman. In its most recent recommendations on treatment for ADHD, the American Academy of in endorsing the view that ADHD is a chronic health condition. Dr. Biederman’s studies report that typical problems include learning difficulties, peer and family conflicts, poor occupational performance, and an increased risk for smoking and substance abuse. Dr. Biederman says that is why it is so important for pediatricians to educate parents about potential adverse outcomes associated with the disorder, and to work with them to develop a treatment plan that not only controls symptoms in the short-term, but can also prevent additional problems later.
Another myth is that ADHD is primarily a problem that affects boys. In fact, in research published over the past few years, Dr. Biederman and his colleagues reported that the disorder is as common in girls as in boys and causes much the same symptoms. “We’ve studied ADHD both in the psychiatric setting and the pediatric setting. In clinics, the ratio of boys to girls being treated is up to ten to one. However, in real life, it’s probably not greater than two to one,” notes Dr. Biederman.
This discrepancy suggests that girls with ADHD are likely underdiagnosed and undertreated. Although the reasons for this are not clear, it could be due to referral bias, says Dr. Biederman. “Boys with ADHD tend to be disruptive at earlier ages than girls with the disorder. And it’s probably the disruptive behavior that is leading to referrals.” But that also means girls with ADHD are not being diagnosed and treated as often as they should.
About half of the children with ADHD develop comorbidities, such as learning disabilities, disruptive behavior, and mood and anxiety disorders, which are distinct from ADHD. These comorbidities not only need to be addressed separately, but also considered when developing an overall treatment plan. For example, one mainstay of ADHD treatment—stimulant medications such as Ritalin—may worsen tics and mania. To aid pediatricians in diagnosing comorbidities, Dr. Biederman and his colleagues have used a self-report scale that parents can fill out in the waiting room. This simple tool can help pediatricians better identify children with ADHD who are exhibiting symptoms of comorbidities, and help them determine what type. (A paper describing this tool is in press in the Archives of Pediatrics.)
“Early diagnosis and appropriate treatment are essential so that ADHD can be managed, giving patients and parents a sense of control and peace of mind,” emphasizes Dr. Biederman. The American Academy of Pediatrics recommends stimulant medication to treat core symptoms combined with behavior therapy to improve functioning. Although some parents worry that medicating a child for ADHD may only encourage that child to use illicit drugs later on, Dr. Biederman and his MassGeneral colleagues have conducted studies suggesting the exact opposite. They authored one widely quoted 1999 paper in Pediatrics, for instance, which showed that children with ADHD who were treated pharmacologically in childhood were three times less likely to develop substance abuse four years later in adolescence than those who were not treated. In the years since, they have published additional research—including a 2003 meta-analysis in Pediatrics— documenting how treatment for ADHD significantly reduces the risk of alcohol and drug abuse later on.
Dr. Biederman and his team are now conducting research to better understand what causes ADHD and how it develops. “Twin, adoption, and molecular genetic studies show ADHD to be highly heritable,” says Dr. Biederman, “so we’re conducting molecular-genetic studies to better understand how this disorder is transmitted and how it develops.”
Dr. Biederman’s team also is using advanced imaging techniques such as functional magnetic resonance imaging to identify areas of the brain that are abnormal in ADHD. “We’re documenting the chemical and structural differences in the brains of children with ADHD to determine the underlying pathology involved in this disorder,” says Dr. Biederman. The long-term goal of this work is to improve treatments and outcomes for young patients.
Joseph Biederman, MD, is professor of psychiatry at Harvard Medical School and chief of Clinical and Research Programs in Massachusetts General Hospital’s Department of Pediatric Psychopharmacology. He is the recipient of prestigious awards from the American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder), among other organizations. A member of the editorial board of multiple journals, Dr. Biederman is also the author and co-author of seventy book chapters, more than 450 scientific abstracts, and almost five hundred papers and scientific articles.
