Talk:Attention deficit hyperactivity disorder/Archive 24

Benefits of Adult ADHD
I'd like to add a small-to-medium section with some oft cited and well documented characteristics that are more common among Adults with ADHD than the general population. It might be most effective to pick 3-5 characteristics with a one-liner explanation, if necessary. For example, extroversion, creativity, and hyperfocus have all been associated with Adult ADHD. There seem to be many sources to pick from; I've found a bunch just by going through all the articles that can come up in a Google search and looking at the sources they cite. You'll see several at the bottom of this article: http://www.webmd.com/add-adhd/features/positives.

It seems like our description of the disorder would be incomplete without some indication that ADHD helps many adult succeed; indeed, some of the most successful people in the world are diagnosed with ADHD. Please let me know if it's OK to add this. I made a few minor edits, but this seemed like it would be too big and somewhat different from the rest of the article. ,Wil (talk) 09:07, 16 June 2014 (UTC)


 * I like the idea. Maybe also add a category and list of famous people with ADHD such as there is for: List of people on the autistic spectrum, Asperger syndrome and People on the autistic spectrum Or this: People with Asperger syndrome Raquel Baranow (talk) 14:57, 16 June 2014 (UTC)
 * I actually was compiling a list of famous ADHDers years ago, but I never got around to finishing it. ;) ,Wil (talk) 05:11, 17 June 2014 (UTC)


 * Responses: Like all articles that deal with medical diagnoses, please ensure that any additional information is sourced to appropriate medical research; see WP:MEDRS for some further information, and Wikiproject Medicine may also be of assistance there. As to the list, I'm rather disturbed that it exists; I'm not persuaded that it is really of benefit for a general encyclopedia to create articles solely based on people's diagnoses, even if self-declared. It may be appropriate in the article of the individual. Risker (talk) 20:43, 16 June 2014 (UTC)
 * Hi, Risker, it a bit refreshing to run in to each other while working on an encyclopedia for a change. :) I agree that if the individual has stated that he or she has benefited from ADHD, it is easily significant enough to include in their article. I also believe that a list of notable individuals with ADHD would be appropriate. I see a lot of use cases for such a reference of successful people with ADHD. For example, imagine someone is writing a new article about ADHD and he or she would like to illustrate some of the positive traits of ADHDers. Depending on the intended audience, some forms of success may be more relevant than others. Without mentioning names yet, I know that a list of notable individuals who have cited ADHD as a factor of their success would include top athletes, CEO's of Fortune 500 companies, actors, artists, musicians, scientists, . . . I know it's a pretty long list, because I started to compile one years ago. Now how would the author navigate to the best example for his/her audience currently? To catch all possible biographies in which ADHD is mentioned, this was the best advanced search I could figure out: [| all articles with the string "ADHD"]. You might know of a better search. In any case, those search results are far from optimal for someone looking for successful people with ADHD. Does this persuade you that it would be beneficial? Does precedent matter? We currently have thousands of lists of individuals that share certain attributes; I don't see why this list wouldn't be consistent with current practices. Thanks! ,Wil (talk) 05:11, 17 June 2014 (UTC)


 * Might be worth noting first that adult ADHD exists as a child article of this one.  Seppi  333  (Insert 2¢ &#124; Maintained) 22:55, 16 June 2014 (UTC)
 * WebMD is not a great source. A review article that is recently published and of high quality is much better. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 01:12, 17 June 2014 (UTC)
 * I was actually referring to the sources listed at the bottom of the WebMD article. But it sounds like you guys/gals are OK with the addition if suitable medical studies are provided as secondary sources. I'll try to find some and list them here; I just didn't want to make a big effort of it until I knew that this section would be appropriate for the article. Wikipedia's kinda keeping me busy right now. ;) ,Wil (talk) 05:11, 17 June 2014 (UTC)
 * Agree that the adult ADHD article would be best for this proposed content. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:25, 17 June 2014 (UTC)
 * Is this article about childhood ADHD? Adult ADHD is not a different disorder, and the benefits we'd like to add are associated with ADHD; they manifest in childhood just like all the other symptoms. ,Wil (talk) 05:47, 17 June 2014 (UTC)
 * Sure what is most important is that refs that comply with WP:MEDRS are used and pertain to the subject matter at hand. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:52, 17 June 2014 (UTC)
 * OK, cool. I'll look through those guidelines and come back with some good sources. Thanks for the help! ,Wil (talk) 06:49, 17 June 2014 (UTC)
 * The scope of this article is ADHD in the general population. Child articles like ADHD management, adult ADHD, and ADD are ideally supposed to be summarized in a section in the parent article (this one) with a link to that article in the section hatnote (usually via main). See WP:SUMMARYSTYLE.  Seppi  333  (Insert 2¢ &#124; Maintained) 08:23, 17 June 2014 (UTC)

TAAR1 and ADHD
 Seppi  333  (Insert 2¢ &#124; Maintained)
 * TL;DR version - I've come to the conclusion that it's premature to add this content based upon the third review.

Hey Doc - I want your perspective on this. Do you think any part of these refs from trace amine is worth summarizing and including in this article?
 * Edit: I apparently missed 1 that actually is in the MEDDATE window, but it's probably premature to add content on TAAR1 and ADHD; researchers haven't bothered to write anything on this in spite of the fact that amphetamine and phenethylamine's pharmacodynamics in human CNS dopamine neurons was established in . I've bolded the relevant statement about this in the new review.  Seppi  333  (Insert 2¢ &#124; Maintained) 12:05, 25 May 2014 (UTC)

Unfortunately, these two reviews are the newest ones available on trace amine receptors in relation to neuropsychiatry. I'm actually kind of puzzled as to why there isn't more activity in TAAR (particularly TAAR1) research... (emphasis added only as highlights)

If you happen to be interested in reading the full version of either paper, I can give you a download link or email you the pdf. The first one covers a lot more than just ADHD.

Best regards,  Seppi  333  (Insert 2¢ &#124; Maintained) 02:26, 25 May 2014 (UTC)
 * Maybe in a section at the end on research. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 13:03, 25 May 2014 (UTC)


 * I found some newer reviews - one on ADHD biomarkers and another on PEA - that better supported this. The biomarker review indicated an interesting relationship between ADHD and trace metals, namely zinc and iron, as well.  Pasted from my sandbox:"Reviews on ADHD and phenethylamine indicate that several studies have found abnormally low urinary phenethylamine content in ADHD individuals when compared with controls. In treatment responsive individuals, amphetamine and methylphenidate greatly increase urinary phenethylamine content."
 * You think its worth including content on ADHD biomarkers?  Seppi  333  (Insert 2¢ &#124; Maintained) 13:32, 30 June 2014 (UTC)


 * In the section on research maybe. The second source is not listed as a review. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 22:22, 30 June 2014 (UTC)

Alright, I'll work on that soon then. In any case, I know better than to cite primary sources for medical articles; I'm not sure why pubmed didn't mark it as a review, but like it's abstract states – "This review article summarizes what is known about PEA" - the paper simply reviews the existing literature on the chemistry, pharmacology, and industrial aspects of PEA. There's no original research in it.  Seppi  333  (Insert 2¢ &#124; Maintained) 22:37, 12 July 2014 (UTC)

Causes -- Society
Under Causes --> Society, should some of the content be moved to diagnosis or Society --> Controversies? For one, the section begins with "The diagnosis of ADHD," which implies information about the diagnosis rather than the cause of the actual disorder. I guess my question is, on medical/scientific pages does a "Causes" section generally contain any discussions related to the philosophical/sociological existence of a disorder or disease? Additionally is misdiagnosis ever a "cause" of a disease or disorder? Does a false positive for hepatitis mean bad diagnosis is a cause of hepatitis? — Preceding unsigned comment added by Jandjorgensen (talk • contribs) 21:22, 12 July 2014 (UTC)
 * I haven't read the section to which you're referring, but I figured it's worth pointing out the following. The controversy surrounding ADHD as a sociological/cultural construct has essentially been rendered moot by systematic reviews of all the recent MRI neuroimaging literature involving psychostimulant-medicated individuals, unmedicated ADHD controls, and healthy controls. In a nutshell, there's observable differences in brain structure and function between healthy and ADHD individuals; stimulants reduce this disparity (increase gray-matter density in affected areas) with long-term treatment. This is mentioned in the article, but only in passing in one sentence in the treatment section.
 * Unfortunately, fMRI isn't yet a suitable tool for diagnosing ADHD variants.  Seppi  333  (Insert 2¢ &#124; Maintained) 22:37, 12 July 2014 (UTC)
 * What is deemed normal versus abnormal and were we draw the line for continuous variables is partly a social decision. We know that different personalities and different feelings can be picked up by neuroimaging. This includes personalities and feeling which we could not call a disease / disorder. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 20:03, 16 July 2014 (UTC)

Pathophysiology needs to be updated
The pathophysiology section reads like there are three different explanations for ADHD. All three sections actually just represent one aspect of the same model. In a nutshell, the brain structures listed are connected via dopaminergic and noradrenergic pathways from the ventral tegmental area and locus coeruleus; activity in these pathways is directly responsible for the modulation of cognitive control (i.e., executive function) and other behaviors. Reduced brain structure volume reflects the impairments in pathway function, which in turn results in executive function impairments. I figured I should probably link the reference; these are images of the textbook: image files. This is the textbook the images are from.  Seppi  333  (Insert 2¢ &#124; Maintained) 17:03, 16 July 2014 (UTC)
 * Do you want to add a sentence or two right after the "pathophysiology heading" to give a general overview of how these three related? Doc James  (talk · contribs · email) (if I write on your page reply on mine) 20:07, 16 July 2014 (UTC)


 * With pathophysiology updated, this section now makes sense. In any event, you think anything should be changed?  I've never written a section like this before, but everything is cited by a recent review.  Miller uses the term "neuropsychiatric disorders" without referring to ADHD in his paper on TAAR1, but it's pretty obvious he had it in mind based upon a previous paper he wrote:.
 * (Repeating refs cited outside the new section for reflist - )


 * Research directions

As stated previously, one line of research that seems to be ongoing is on the pathophysiology of ADHD using larger models that include more neurotransmitter pathways and therefore link to additional brain structures that appear abnormal in ADHD individuals compared to controls.

Recent discoveries involving a group of endogenous amines present in trace quantities in the human brain, so called trace amines, has opened a new line of research on ADHD and similar neuropsychiatric disorders. Reviews on ADHD and phenethylamine indicate that several studies have found abnormally low urinary phenethylamine content in ADHD individuals when compared with controls. In treatment responsive individuals, amphetamine and methylphenidate greatly increase urinary phenethylamine content. In 2011, a medical review on trace amine-associated receptor 1 (TAAR1) determined that amphetamine and trace amines, which includes phenethylamine, activate this receptor in humans. Consequently, it is now known that these two compounds produce analogous effects in the brain's dopamine pathways. This evidence suggests that trace amines (especially phenethylamine) and their receptors may play an important role in the pathphysiology of ADHD and other neuropsychiatric disorders. Future research seems to be headed in this direction, although the number of recent studies involving ADHD and phenethylamine or TAAR1 is lacking.

 Seppi  333  (Insert 2¢ &#124; Maintained) 06:23, 17 July 2014 (UTC)

Add "Hypokalemic sensory overstimulation" to article!
So after doing research, and then having a thought wondering about ADHD and potassium channels, upon googling the two I found that there was indeed a subtype associated with potassium issues, and [Hypokalemic sensory overstimulation|a wikipedia article already written for it]. The fact that I haven't heard about it until now is very odd, as I have done extensive research on the subject. I strongly think it should be mentioned and linked to within this article.LiamSP (talk) 05:09, 25 August 2014 (UTC)
 * We would need a high quality secondary source. The main article used as a ref in that page is a case study. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 09:04, 25 August 2014 (UTC)

False and distortive information (unreferenced) on Wikipedia ADHD article re high IQ and oppositional defiant disorder
The following unreferenced claims are made in the article.
 * (Unreferenced and probably untrue allegation): Most studies have found similar impairments regardless of IQ with higher rates of repeating grades and having social difficulties.
 * Additionally, more than half of people with high IQ and ADHD experience major depressive disorder or oppositional defiant disorder at some point in their lives.

For the second allegation, I found a study of TEN kids. Is that generalizable to the overall population? I think not. What the study proves is that people with high IQs, HAVE ADHD.

Why is this article locked down?

ClarificationRequired (talk) 14:58, 27 August 2014 (UTC)
 * it is only semi protected, and for the usual reason: it had been long subject to vandalism and other problem edits, mostly from unregistered users. It would be helpful if you can find wp:MEDRS secondary sources that address the topics you wish to revise. LeadSongDog come howl!  20:59, 27 August 2014 (UTC)
 * The ref that supports it appears to be this one https://www.ncbi.nlm.nih.gov/pubmed/19072757 Doc James  (talk · contribs · email) (if I write on your page reply on mine) 05:28, 28 August 2014 (UTC)

Pre - FAC feedback
The Controversies section should be integrated into diagnosis - the biological vs psychological debate is intrinsic to understanding the controversy and discussion of it should be in the segment directly under cause. Media commentary on effectiveness on treatment could be in teatment section or otherwise relegated to daughter article. Cas Liber (talk · contribs) 01:53, 7 October 2014 (UTC) Also, I'm going to delete refs that are over a decade old and replace them with mcn.  Seppi  333  (Insert 2¢ &#124; Maintained) 03:29, 3 November 2014 (UTC)
 * Thanks for the feedback Cas!
 * Note to all: I'm going to be reformatting every citation in the article over the next day or two to establish a consistent citation format, since I intend to FA-nominate this article after I work on it (will begin in a month or so). The format I'm going to use is the same as the current citation formatting used in amphetamine for cite book, cite journal, and cite web.  I.e., authors and academic journals will use the abbreviated formatting that Boghog's citation template tool outputs for a given pmid (book/web authors will also use this formatting for consistency), editors will follow the same format as used for authors, ISBNs will be the 13 digit version w/o dashes, page ranges will be expanded instead of using the truncated version (e.g., will use 501–509 instead of 501–9), all dates will use DMY w/ expanded month names, etc.  I'll likely end up changing/adding parameters to existing cite web templates since these are often pretty sloppy.

Assessment and Diagnosis Sandbox Edits for Attention Deficit Hyperactivity Disorder
Hello all, I have made changes in my Sandbox about this topic focusing on evidence-based assessment and diagnosis. It would be great if people would look at it and leave comments on my talk page before I post it on the article.

The sandbox link can be found here (https://en.wikipedia.org/wiki/User:Sdard/sandbox).

I appreciate it! YenLingChen (talk) 20:36, 3 November 2014 (UTC) In any event, I agree that the lack of in-line citations is a problem; but, since they're listed before/after each section, these could be added easily enough. Every ref that I spot-checked satisfies MEDRS, so I actually think some of the content on that page could be useful in this article after some minor ref reformatting and copyediting. The DSM criteria (with some minor copyediting) would be a useful addition to the article (IMO) if reformatted neatly in a wikitable - would also improve coverage of the DSM 5's model, which is lacking at the moment. Some of the content on behavioral interventions would also be useful for updating/expanding upon the behavioral therapy section. Again, needs some minor copyediting/reformatting here too. I'll probably adapt parts of that page for use in the article when I start working on the article text within the next month or so.  Seppi  333  (Insert 2¢ &#124; Maintained) 23:18, 3 November 2014 (UTC)
 * Thanks for the heads up, . feedback:
 * I don't see in-line sourcing anywhere in that draft content. I would revert that immediately, if you added it to the article
 * in general a lot of this is technical (for example "A cut scores", "B cut scores", with no explanation of what that means) and I suspect there is a lot of copyright violation in it. (without sources it would be a lot of work to tell)  Per WP:MEDMOS things should be written in plain English.
 * with regard to sections, please do see WP:MEDMOS
 * with regard to "local resources", you are doing part of what wikipedia is not - namely we are not a directory and we are not a self help guide. Please don't add that section to WP
 * there is some feedback. Jytdog (talk) 21:02, 3 November 2014 (UTC)
 * Worth pointing out that the sandbox is for a class, so there might be a particular formatting requirement.
 * please note that the original post was a request for feedback, before they add the content to the article. Jytdog (talk) 00:15, 4 November 2014 (UTC)
 * and see User_talk:YenLingChen Jytdog (talk) 00:19, 4 November 2014 (UTC)

What is "high normal activity"?
The end of the second paragraph reads: "The condition can be difficult to tell apart from other disorders as well as that of high normal activity." There does not appear to be a definition for "high normal activity" (or even "high normal") anywhere, and the reference cited appears to be a dead link. This sentence needs clarification; it's a potentially "loaded" statement to begin with, but the fact that it is topped off with abnormal terminology and a rotten link makes it difficult to understand what the purpose of the sentence is in the first place.

--CoolOppo (talk) 00:48, 21 November 2014 (UTC)

Semi-protected edit request on 10 December 2014
I wish to add different medications and the symptoms and add sites that explain percentage of kids and adults who have harmful side effects or felt dramatic side effect but all in all add the list from web Md is a diagram of the most known and used maybe all the medications and there classifications along with all known general side effects

Darienwillis (talk) 03:24, 10 December 2014 (UTC)
 * If you could please list a reliable source (conforming with Wikipedia's medical sourcing guidelines), and suggest the text you wish to add, someone will have a look. Sandy Georgia  (Talk) 03:26, 10 December 2014 (UTC)


 * I think they're referring to the chart in this hyperlink: http://www.webmd.com/add-adhd/guide/adhd-medication-chart
 * We have something like that at Attention deficit hyperactivity disorder management, namely this table:

 Seppi  333  (Insert 2¢ &#124; Maintained) 04:07, 10 December 2014 (UTC)

PMT
See parent management training for a 2011 Cochrane review,. Sandy Georgia (Talk) 01:40, 20 December 2014 (UTC)
 * But, I don't have the full text of this:   Sandy Georgia  (Talk) 02:18, 20 December 2014 (UTC)

Adults with ADHD
I just read the source referenced claiming that 25 % of the people with the disorder still have it. And 75 % of the adults grow partially out of it. (in the section for adults with adhd)

Let me quote the relevant passage:

Numerous follow-up studies of children with ADHD show that the disorder persists during adolescence and adulthood in around two-thirds of individuals [3-11] either as the full blown disorder or in 'partial remission' with persistence of some symptoms associated with continued clinical and psychosocial impairments. In the meta-analysis of these data from Faraone and colleagues it was concluded that about 15% retain the full diagnosis by age 25 years, with a further 50% in partial remission [12], indicating that around two-thirds of children with ADHD continue to have impairing levels of ADHD symptoms as adults.

Although in some cases the symptoms of ADHD may appear to diminish during adolescence, this may not be the case relative to controls and does not mean that functioning is unimpaired. In a follow-up study of 119 boys of 19 years of age with childhood onset ADHD, symptom levels seemed to be lower than in childhood but 90% still did not function well [13].

We have various claims. Here, and not really clear figures. By 12, we would have only 50 % that grow partially out of it, 35 % who no longer quality, and 15 % who have the full diagnosis. That said, [12], is 2006, and pre DSM V, the criterions for adults have been lowered, for various reasons that I will not get into. (This increase the number of people who have the full diagnosis and do not quality)

Currently, I object to the precise figure, that also avoid the possibility of total remission.

I would suggest going with the figure at [12] despite my objections, since it is the only meta-analysis quoted, while the article quoted in wikipedia is only relevant for this information, in so far as it quotes other sources, and is not in itself a meta-analysis of adults having adhd.

After looking at [12], I found out that the article, "Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type." has 1020 citations,. Considering this is much higher than the article given. I strongly urge to consider it, rather than the currently used: European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD", that has 270 citations.  The European concensus was only used to quote the other articles, including the meta-analysis, while not itself going in depth on the topic.  It might also be worth digging more seriously into the meta-analysis.

Comments? Discuss? — Preceding unsigned comment added by 192.0.228.190 (talk) 20:22, 10 March 2015 (UTC)

Medications - long term effects
There has been statements saying that ADHD is fraud and was only developed to make more money for the companies and the psychiatrists that prescribe it. Read more at PBS. — Preceding unsigned comment added by 2A00:1A28:1171:9:0:0:0:1004 (talk) 05:47, 8 April 2015 (UTC)

In the introduction, it states that the long term effects of medication are not known.

That may be true for some of the newer medicines, perhaps atomoxetine, but not all. Methylphenidate (trade names: Ritalin, Concerta and many others, inc 'generic' versions) has been in use for several decades. The evidence on both efficacy and safety for methylphenidate is considerable.

Not sure why, but I can't edit the intro, only the part following it. I hope someone who can edit it will take a moment to simply delete this sentence. The issue is too complex to cover in the intro. In stark contrast to most 'physical' health problems, there is huge controversy over the use of medicines to treat ADHD - as can be seen on numerous websites / social media forums.

This article is otherwise very good at presenting the facts in about ADHD meds impartially, despite being somewhat US-centric (NB Adderall isn't available in many countries outside the USA, inc the UK). I feel that this line in the intro does harm to the rest of the article. If it can be reworded to something more accurate, great. I see no reason not to just delete it though.

Thanks in advance for any help others can give with this. Zctyp18 (talk) 00:29, 15 March 2015 (UTC)
 * The long term effects are not known as they have not been studied. The longest RCT is 18 months which is medium term. Doc James  (talk · contribs · email) 01:46, 15 March 2015 (UTC)


 * Eh...he actually does have a point. We just haven't updated the evidence in this article.  I tried to point this out earlier, but I just didn't feel like pushing the issue.  The last time I looked for reviews of RCTs or stimulant-induced structural plasticity neuroimaging, I wrote the relevant passages from in the amphetamine article:


 * The top paragraph's reviews/meta-analyses indicate that therapeutic stimulant use over the course of adolescence to adulthood is associated with healthy functional improvements and structural neuroplasticity (structural growth - doesn't specify a form, e.g., if it's neurogenesis, synaptic plasticity, gliogenesis, etc) in brain structures in which ADHD stimulants exert an effect. The bottom paragraph covers long-term use, as noted in the title of three of the review citations.    This is a link to reference #5 which is paywalled.  The ref 6 RCT is 36 months.  Seppi  333  (Insert 2¢ &#124; Maintained) 04:32, 15 March 2015 (UTC)


 * We have this 2011 and 2014 Cochrane reviews that mention only short term benefits have been shown in adults.
 * We need patient oriented benefits not surrogate markers such as changes in brain structure. Doc James  (talk · contribs · email) 05:36, 15 March 2015 (UTC)

We also have this 2011 review that states https://www.ncbi.nlm.nih.gov/pubmed/21519262 "Two peer-reviewed studies and one published report have attempted to address the issue of long-term effects of psychostimulant medication. One is favourable, one found no benefit, and the third showed harm." Doc James (talk · contribs · email) 05:40, 15 March 2015 (UTC)
 * A 2013 review "This review has highlighted the paucity and limitations of the evidence investigating the long-term outcomes of recommended interventions for managing ADHD symptoms. There is little evidence to suggest that the effects observed over the relatively short term are maintained throughout longer periods of impairment. Furthermore, much of the existing evidence examining effectiveness beyond 12 months does not include newer medications currently available" https://www.ncbi.nlm.nih.gov/pubmed/24082796 Doc James  (talk · contribs · email) 05:45, 15 March 2015 (UTC)

Hum per your sentence "Reviews of clinical stimulant research have established the safety and effectiveness of long-term amphetamine use for ADHD"

First ref is not RCT trial data for medications "While most included studies were observational open-label studies, in the 5 RCT studies, individuals were randomized to receive non-pharmacological treatment or no treatment: four (57%) of the 7 total outcomes were reported to improve with treatment. "

Second ref states "However, most medication trials for ADHD have been short term and thus have not provided information on the long-term outcomes of ADHD treatment. Since the medical treatment of many children with ADHD, especially those with more severe symptoms or co-morbid disorders, has to be continued for several years, recent studies have shifted their focus from the acute effectiveness of stimulants or non-stimulant drugs to the long-term outcomes of medications for ADHD. Evidence has shown that stimulants, along with the non-stimulants atomoxetine and extended-release guanfacine, are continuously effective for 24-month treatment periods with few and tolerable adverse effects"

The third ref states "This review has highlighted the paucity and limitations of the evidence investigating the long-term outcomes of recommended interventions for managing ADHD symptoms. There is little evidence to suggest that the effects observed over the relatively short term are maintained throughout longer periods of impairment."

Doc James (talk · contribs · email) 05:53, 15 March 2015 (UTC)


 * (Cochrane) involves a subset of the total population of ADHD individuls, which is what (2011 long-term) covers, thus the former can't be used to say anything about the ADHD population as a whole; i.e., it's not even relevant in this context because the statements made aren't discussing the adult subset (the technical reason is that a sample of the adult ADHD population is a nonprobability sample for the entire ADHD population; it's spurious/invalid to generalize to the entire ADHD population from the adult population).  The same goes for the MPH Cochrane review, ; generalizing the results of that study to the ADHD population as a whole is an invalid statistical inference. In addition, because it covers fewer RCTs (adult ADHD RCTs only vs all ADHD RCTs), it has reduced statistical power compared to general ADHD population reviews.
 * W.r.t. the 2013 long-term review about ADHD interventions in general, the first excerpt that follows does not contradict the second, since it is not discussing stimulants in particular; the scope of these statements is highlighted. The third excerpt that follows, especially the highlighted portion, is what the first excerpt is summarizing.






 * Lastly, the 2015 systematic review,, has the most statistical power out of all of these (systematic) reviews, simply because it covers 2+ years of RCTs than the next most recent review and/or covers a much more general ADHD population than the other reviews (i.e., the Cochrane ones). This review is what should be reflected in the article even if the other systematic reviews had inconsistent conclusions about stimulants (as I've pointed out, they're not inconsistent) for that reason alone. Because reviews which are several years outdated have far less statistical power than a new review, it is misleading and an incorrect use of statistical inference to place equal weight on their conclusions (it violates WP:UNDUE).


 * All that said, what I wrote in the amphetamine article is fully consistent with the specific conclusions on pharmacological interventions in every one of these reviews.  Seppi  333  (Insert 2¢ &#124; Maintained) 08:04, 15 March 2015 (UTC)
 * Sure so we disagree. One ref says "There is little evidence to suggest that the effects observed over the relatively short term are maintained throughout longer periods of impairment" -> ie no good evidence of long term effects. The third ref says "little is known regarding the long-term effectiveness"
 * How one gets "Reviews of clinical stimulant established the effectiveness of long-term amphetamine use for ADHD" beats me
 * What we have is one RCT of 14 months. That is the longest trial that has been ever done. Doc James  (talk · contribs · email) 14:02, 15 March 2015 (UTC)
 * You're quoting completely out of context to stimulants. If you actually realize you're doing that, that's some pretty fucked up behavior. If not, read the paragraph in which you read a sentence. These reviews are not just about stimulants.
 * "Reviews of clinical stimulant established the effectiveness of long-term amphetamine use for ADHD" is nearly verbatim from the textbook reference. I changed the statement from passive to active voice. Seppi  333  (Insert 2¢ &#124; Maintained) 18:45, 15 March 2015 (UTC)
 * You even highlighted " little is known regarding the long-term effectiveness"? Doc James  (talk · contribs · email) 14:25, 15 March 2015 (UTC)
 * I've highlighted the context and bolded the statement.  Seppi  333  (Insert 2¢ &#124; Maintained) 18:45, 15 March 2015 (UTC)
 * But that bit is about "nonpharmacological interventions" in that paper. That bit does not comment on long term benefits of pharmacological treatment. Doc James  (talk · contribs · email) 19:32, 15 March 2015 (UTC)
 * What I said in the collapse tab below is not correct. The review defined "long-term" as beyond 1 year. The first 2 excerpts above, taken together, suggest that it has "long-term" effectiveness (beyond 12 months) until 14 months; after 14 months little is known about "longer-term" effectiveness. The authors did a pretty bad job at clarifying this. It seems to be intentionally avoided making a concrete statement about "long-term" (as opposed to "longer-term") pharmacotherapy effectiveness.

Both of these excerpts are referring exclusively to nonpharmacological interventions. I've modified the quotes with highlights to illustrate what interventions in this review are being "recommended" and I've used different forms of emphasis to indicate the equivalent statements in the excerpts. I've de-emphasized the less important contextual statements with small text:"This review has highlighted the paucity and limitations of the evidence investigating the long-term outcomes of recommended interventions for managing ADHD symptoms. There is little evidence to suggest that the [recommended interventions] effects observed over the relatively short term are maintained throughout longer periods of impairment""There is high level evidence suggesting that pharmacological treatment can have a major beneficial effect on the core symptoms of ADHD (hyperactivity, inattention, and impulsivity) in approximately 80% of cases compared with placebo controls, in the short term.22 However, although pharmacological treatments are relatively safe, these treatments are not without adverse side-effects, such as, suppression of growth, sleep problems, tiredness, loss of appetite, stomach upset, headaches, nausea, and increases in heart rate and blood pressure.12,23–27 Nonpharmacological interventions, such as psychoeducational programs, behavioral interventions, and cognitive behavioral therapy are also recommended .28–30 Although there is moderate-to-high-level evidence that nonpharmacological interventions can be effective  in managing the core ADHD symptoms, conduct disorders, social skills, self-efficacy, and emotional outcomes at 6 months follow up, 28 little is known regarding the long-term effectiveness." In a nutshell, the first excerpt statement, "There is little evidence to suggest that the effects observed over the relatively short term are maintained throughout longer periods of impairment" is referring to "recommended interventions"; the review indicates what these "recommended interventions" are in the 2nd excerpt - they're specific nonpharmacological interventions (see the italicized small text).
 * Also note that it doesn't state that pharmacotherapy is "recommended" anywhere in the text, which is probably because pharmacotherapy is the standard treatment.


 * This paper did a really bad job at making a clear statement on long-term pharmacotherapy effectiveness.  Seppi  333  (Insert 2¢ &#124; Maintained) 21:08, 15 March 2015 (UTC)

Looking at what you have quoted
 * "There is high level evidence suggesting that pharmacological treatment can have a major beneficial effect on the core symptoms of ADHD (hyperactivity, inattention, and impulsivity) in approximately 80% of cases compared with placebo controls, in the short term.22"

This is a comment on short term pharmacological treatment not long term. So doesn't support the text in the amphetamines article. The other refs to not claim long term effectiveness and what you have quoted here does not either. Doc James (talk · contribs · email) 19:26, 15 March 2015 (UTC)
 * That quote supports the statement: "Approximately 80% of those who use these stimulants see improvements in ADHD symptoms. ". This statement is made after the material I quoted earlier in amphetamine.  Seppi  333  (Insert 2¢ &#124; Maintained) 21:08, 15 March 2015 (UTC)

Recent revisions
I made a few revisions to the article for language clarity, MOS compliance, and grammar... I also revised the statements concerning the "long-term" issue using similar language to your revision in the amphetamine article. I'm perfectly open to rephrasing the text I added if you'd prefer it.  Seppi  333  (Insert 2¢ &#124; Maintained) 23:12, 23 March 2015 (UTC)
 * Have restored some of it as that 2015 study did not find strong evidence of long term benefit. They found low quality evidence and other reviews have found mixed findings. Doc James  (talk · contribs · email) 15:03, 24 March 2015 (UTC)
 * http://www.caddra.ca/cms4/pdfs/caddraGuidelines2011Chapter07.pdf - this ref that you restored doesn't mention 80% prevalence anywhere.  Seppi  333  (Insert 2¢ &#124; Maintained) 15:06, 24 March 2015 (UTC)
 * In an airport will look when I get home. Doc James  (talk · contribs · email) 03:43, 25 March 2015 (UTC)
 * Corrected. Doc James  (talk · contribs · email) 11:29, 26 March 2015 (UTC)

CDC Apr 1st 2015 states "We do not know what the long-term effects of psychotropic medication are on the developing brains and bodies of little kids. What we do know is that behavioral therapy is safe and can have long-term positive impacts on how a child with ADHD functions at home, in school, and with friends,"  Doc James  (talk · contribs · email) 10:45, 4 April 2015 (UTC)

ADHD Diagnoses in Girls
With the main focus usually being on boys, the diagnosis of ADHD in girls has gone unnoticed, with the effects of the diagnosis on girls slipping under the radar. In an article by Skogli et al. (2013), the researchers literally state “girls may be consistently under identified and underdiagnosed because of differences in the expression of the disorder among boys and girls”. In plain terms, the criteria for the diagnosis of ADHD does not fit the ways which most girls are socialized or how the disorder fits them specifically. There is a large amount of information in the article by Mahone and Wodka (2008) about the neurological differences between boys and girls, and the effects these differences might have in the decreased representation of girls with ADHD. Rucklidge (2010), mentioned the importance of changing the criteria of ADHD to better accommodate proper diagnosis of girls. Rucklidge (2010), also makes a great case about how girls diagnosed with ADHD are often misunderstood. Misunderstood in this case meets multiple possibilities. Girls with ADHD are often misunderstood by their peers, teachers, parents, and even themselves. . Girls diagnosed with ADHD are commonly observed showing signs of internalization (Graetz, Sawyer, Baghurst, & Hirte, 2006). These researchers went on further to explain that the most common identifications of the internalization behaviors were depression and anxiety. An article by Becker, McBurnett, Hinshaw, and Pfiffner (2013) also agreed that girls were more likely to internalize their symptoms. The article explained how girls with ADHD would report significantly higher levels of anxiety compared to boys with ADHD. One of the important topics discussed by researchers concerning the diagnosis of ADHD in girls is underdiagnoses. Waite (2007) observed that the inequality of diagnosis in girls is that they do not typically show the common symptoms of ADHD, causing girls to be so frequently misdiagnosed. Researchers have discussed how the criteria for ADHD is predominantly focused on the symptoms displayed in boys (Rucklidge, 2010; Waite, 2007). Researchers have also debated whether or not the criteria for ADHD should be improved to include the specific gender differences between girls and boys with ADHD. Researchers have come to the conclusion that the diagnostic criteria from ADHD should be altered based on gender and the symptoms should be lowered to adequately assist girls with ADHD (Rucklidge, 2010). Correctly diagnosing children is a hard task, so it is important to look at age-related children and comparing them that way. However, it is rather important for clinicians to most accurately diagnose children regardless of their gender. Waite (2007), speaks directly to this saying, “the DSM-IV-TR criteria have a limited scope and lack of gender specificity, which precludes many women from being properly diagnosed”. Correctly diagnosing and treating girls with ADHD can lead to many positive social and personal experiences. If the correct diagnosis and treatment is not given to girls with ADHD there could be significant disabilities in the psychological functions and academic progress in girls with ADHD (Quinn, 2005).

— Preceding unsigned comment added by Aliciarj123 (talk • contribs)


 * Hi, ; if you are proposing to add this text here, it will need considerable cleanup and editing before it is ready for publication. One of the first things you might do is look up PubMed identifiers (the PMID number), and add them to your citations with a PMID parameter ... then we can evaluate your sources, and go on from there to work on the content.  Sandy Georgia  (Talk) 20:27, 4 May 2015 (UTC)
 * , Digital object identifier (DOI) is equally helpful, and it's sometimes easier to locate than the PubMed identifier (PMID). I'm also interested the gender differences in ADHD diagnosis, so feel free to drop a note on my talk page if I can lend a hand. —Shelley V. Adams ‹blame credit › 17:25, 5 May 2015 (UTC)
 * Yes, but if Aliciarj123 would understand PMIDs, then she would know how to read the fields at PubMed entries that explain primary sources vs. secondary reviews; looking up 12 sources to help someone understand WP:MEDRS is a lot of work, particularly when supplies no dates, so we don't even know on the surface if her sources are recent.  And often, sources that aren't Pubmed-indexed (that is, have a DOI but not a PMID) are not high quality.  For example,  is a recent review that should be/could be  used for whatever text is written about ADHD in girsl, removing the need to work to sort out Alicia's sourcing.   Sandy Georgia  (Talk) 17:34, 5 May 2015 (UTC)
 * There are duplicates, so it's only seven.
 * Skogli, et al. is a comparative study.
 * Mahone & Wodka is a good review article from 2008.
 * Rucklidge is a 2010 review.
 * Becker, et al. is a randomized controlled trial.
 * Waite is a 2007 review.
 * Graetz, et al. is a comparative study. It's in a journal not indexed by PubMed.
 * Quinn is a case report. —Shelley V. Adams ‹blame credit › 19:40, 5 May 2015 (UTC)

See also:  Sandy Georgia  (Talk) 20:48, 4 May 2015 (UTC)
 * Yes this text needs lots of work. This for example would need an exceedingly strong source to support it "the diagnosis of ADHD in girls has gone unnoticed". Doc James  (talk · contribs · email) 11:26, 5 May 2015 (UTC)

Incorporate gender please
Can someone who has access to the full text incorporate something from: This is a GA, but it's citing very old sources on gender differences. Sandy Georgia (Talk) 17:37, 5 May 2015 (UTC)
 * A couple 2014 review articles that look promising
 * Both are free to access in PubMed Central. —Shelley V. Adams ‹blame credit › 19:47, 5 May 2015 (UTC)
 * Both are free to access in PubMed Central. —Shelley V. Adams ‹blame credit › 19:47, 5 May 2015 (UTC)
 * Both are free to access in PubMed Central. —Shelley V. Adams ‹blame credit › 19:47, 5 May 2015 (UTC)

Semi-protected edit request on 13 August 2015
Those that complain of easy fatigability and physical pain many, relationship between autonomic imbalance are discussed.

YTMX (talk) 01:35, 13 August 2015 (UTC)
 * Red question icon with gradient background.svg Not done: it's not clear what changes you want to be made. Please mention the specific changes in a "change X to Y" format. Stickee (talk) 03:58, 13 August 2015 (UTC)
 * What does that even mean? Please cite a source. Andrea Carter (at your service &#124; my good deeds) 11:46, 19 September 2015 (UTC)

AACAP practice parameter
Hi all! I added a citation for the recent AACAP practice parameter on ADHD. Practice parameters are highly useful tools for diagnosis and treatment, and it's definitely worth mentioning in the diagnosis section. Let me know if any issues arise! — Preceding unsigned comment added by Kennyle78 (talk • contribs) 18:43, 5 October 2015 (UTC)


 * Thanks for making this edit! I noticed that you moved the citation for the American Academy of Child and Adolescent Psychiatry practice parameter and linked it to the New Zealand practice parameters. I also noticed that you cut part of the stuff that was inserted. I think there is value in having separate links for practice parameters for New Zealand and USA, so I've made separate links to both of them. Let me know your thoughts! Ongmianli (talk) 16:08, 9 October 2015 (UTC)

Treatment of ADHD
In the therapy section, evidence-based practice, techniques that are supported by science, can be used to further back up the claims that behavioral therapies have been shown to give the best results when treating ADHD. "Effective Child Therapy lists behavioral treatments such as, behavioral parent training, behavioral classroom management, behavioral peer interventions, combined behavior management interventions, and organization training, as the most well-established treatments for ADHD in children. These treatments are considered to be the most efficient because they are backed up by science; these treatments are considered to be evidence-based practices." This information would give way to a great resource for parents about evidence-based practice, aka the most scientifically backed up treatments. --Mktayloe (talk) 22:24, 13 October 2015 (UTC)

Non-pharmacological treatments for ADHD
Based on a meta analysis published on the Non-pharmacological treatments for ADHD published in the journal of attention disorders (DOI: 10.1177/1087054712444732) I recommend that in the "behavioral therapies" subsection of Management, information be added on the most efficacious non medical treatments for ADHD. The meta analysis concluded thatbehavioral management and neurofeedback training are the most effective non medical treatments for ADHD. The wiki page mention thats parent training and education have short term results, however the meta analysis concluded that there is no statistically significant benefit to these treatments. The wiki page should be updated to reflect this conclusion.

Additionally, the meta analysis concluded that behavioral treatments are generally more effective for girls.

Finally, it should be made clear in the prognosis section of this page that the combined ADHD subtype (inattentive and hyperactive) is associated with the worst outcomes in regards to non pharmacological treatment.

Jogunk07 (talk) 16:01, 13 October 2015 (UTC)Jay 10-13-2015
 * Added a bit on which is most effective. User:Jogunk07 other reviews support parent training. Best Doc James  (talk · contribs · email) 22:23, 13 October 2015 (UTC)

g yuergtuiwerfghrgfo — Preceding unsigned comment added by 71.184.98.9 (talk) 18:26, 21 October 2015 (UTC)

Text
I have reverted the following addition as the ref does not support the changes  Doc James  (talk · contribs · email) 19:47, 22 November 2015 (UTC)

Tom Cruise?
No sure that Tom Cruise's comments should be included on the page given that he is a well known puppet for scientology which has a confirmed bias/agenda against pharmaceuticals and would prefer that people joined their religion and be crazy there.

Neither should the rebuttal. Giving either comment gives weight to an invalid, obviously biased argument that has no place in a general media discussion. — Preceding unsigned comment added by Soulstudios (talk • contribs) 00:25, 23 October 2015 (UTC)
 * I have mixed feelings about this issue. I fully agree that Cruise has no more expertise than any other celebrity and that it's problematic when his comments are given weight on Wikipedia. On the other hand, he gets a lot of public attention from his comments on this and other medical issues, so mention of the scientifically sound rebuttal of his irresponsibility has some merit. I'm curious what others think. Sundayclose (talk) 20:04, 22 November 2015 (UTC)

Worth adding at some point
... whenever I get around to it.  Seppi  333  (Insert 2¢) 08:39, 18 July 2015 (UTC)

Also, possibly worth adding to the section on prognosis. A meta analysis of follow up studied on children diagnosed with ADHD found that evidence of symptoms associated with ADHD lessens with age. Jogunk07 (talk)jogunk07
 * Your citation is a dead link. And it's much better to cite the actual journal article than an abstract. Sundayclose (talk) 01:05, 29 November 2015 (UTC)
 * This one http://www.ncbi.nlm.nih.gov/pubmed/?term=16420712 Doc James  (talk · contribs · email) 10:05, 29 November 2015 (UTC)

Methylphenidate as Medication
This section mentions that methylphenidate appears to improve symptoms as reported by teachers and parents. This may be true, however a recent Cochrane review suggests that methylphenidate causes an increase in sleep problems, as well as decreased appetite. This review also suggests that because of the low quality evidence, we can not be so sure of the magnitude of the effects that this medication has. This is definitely something that should be added to this section. Kcwiley12 (talk) 15:23, 5 December 2015 (UTC)
 * The Cochrane review is already cited in the article. I think more specific details belong in the Methylphenidate article. Sundayclose (talk) 16:27, 5 December 2015 (UTC)

Assessment of ADHD
Adding more information regarding assessment techniques for diagnosing ADHD would be beneficial to this page. "While the DSM is the primary tool used by clinicians to diagnose ADHD, there are different assessments used, that when applied to the DSM criteria, can help determine the severity and type of ADHD an individual possesses. Examples of these assessments are the ADHD Rating Scale, the Vanderbilt ADHD Diagnostic Rating Scale, and the Swanson, Nolan and Pelham Teacher and Parent Rating Scale." These Wikipedia pages should be enough citation and resources to back up these assessment types, and this information should be included in the diagnosis section of the page.

Reference outdated
Reference 32 seems to be outdated, or so says the site it links to. I haven't yet found the correct one, in case it was just moved or updated. --37.60.1.66 (talk) 00:14, 8 December 2015 (UTC)

Semi-protected edit request on 8 December 2015
I've noticed that there could be a more thorough expansion when it comes to the difference between genders and how each experience ADHD, I am partially doing this for a university project and I would like to be able to create some new sections. In Section 4 Diagnosis I would like to add three new sections the first: 4.5 Sex and ADHD, the second: 4.6 Difficulties in Diagnosing, and third: 4.7 Differences Between Sexes

4.5 Sex and ADHD
Attention deficit hyperactivity disorder is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age (Attention-Deficit/Hyperactivity Disorder ADHD). Currently, most literature and research focuses on Caucasian males which indicates that data on women with ADHD, specifically women of color, has to a great extent been absent from literature and research. For girls and women, ADHD is often a hidden disorder that is ignored or misdiagnosed which leads to psychological and academic impairments. Because ADHD is so common (3% to 5% of school children) and chronic (lifelong in many cases), even a small proportion of females multiplied by such a large base means hundreds of thousands of girls and women are living with ADHD, a significant public health problem. Minorities are often left by the wayside when it comes to diagnosing, so women of color are at even more of a disadvantage, facing both sexist and racist complications. Lack of recognition can partially be explained because the symptoms are less overt in females and partially because coexisting disorders in females are often different from those seen in males who have ADHD. Clinicians are frequently challenged with disentangling the symptoms of ADHD from symptoms of coexisting conditions as well as fluctuating hormone levels which may affect symptoms and treatment in females.

4.6 Difficulties in Diagnosing
As described in the book A Comprehensive guide to Attention Deficit Disorder in Adults Research, Diagnosis, and Treatment particular issues that may add to, or detract from, our ability to detect ADD in women are neurobiological, "as gender-related neurobiological tendencies may make diagnosis more difficult; they are psychological, as a woman's trend toward internalization rather than externalization and acting out makes diagnosis more complicated; they are social and cultural, as gender-related norms and expectations not only affect a woman’s own ability to recognize ADD but these stereotypes also shared by women and clinicians, as well as the different manifestations of ADD symptoms, preclude or delay the diagnosis of ADD in girls and women" .The recognition of attentional problems and the diagnosis of ADD in women elude clinicians partially because women often lack the typical symptoms of "hyperactivity" and "impulsivity" in childhood or adulthood, and partially because the societal constructs surrounding the way in which womens behavior is interpreted often changes the way in which certain symptoms are recognized. In her book Women with Attention Deficit Disorder, Sari Solden MS, LMFT, addresses these cultural stereotypes that we have for women: “Because they are nice, quiet, or shy, they meet cultural expectations so people either don’t notice or are not as concerned with their subtle information processing problems”. Conflicting results reported in the salient literature on females diagnosed with attention deficit hyperactivity disorder gave credence to a study published in the Journal of Attention Disorders that looked at specific neuropsychological test data, assessing various aspects of attention, memory, personality adjustment, and psychiatric symptomatology. The study, undertaken in an effort to illuminate the presentation of ADHD in adult women, addressed substantial evidence that suggests under diagnosis and treatment of the disorder in females and the possible, consequent negative implications for their lives. Results indicate that females had higher scores on cognitive tests, greater degrees of anxiety and depression than males and because of their higher rates of depressive and anxiety symptoms they may as a group be underdiagnosed.

4.7 Differences Between Sexes
An NIMH conference on Sex Differences in ADHD on November 16-17, 1994, concluded that the difference between sexes may reflect either a difference in susceptibility or that women with ADHD are less likely to be diagnosed than males. The Canadian Journal of Psychiatry reveals that retrospective studies, clinical studies, and epidemiologic studies show the overall rate of comorbidity among adults with ADHD is high and the studies which looked at ADHD subtypes showed females with ADHD were more likely to have depression or dysthymia (Cumyn, French, and Hechtman 675). As well the same studies found that more women with ADHD (68.18%) had current panic disorder than men (31.82%), there were more men (66.67%) with drug abuse issues than women (33.33%), 85% of women had a history of past anorexia, compared with 14.92% of men, and that 62% of women with ADHD had a history of past bulimia, compared with 12.5% of men (675). In addition, Volume 56 of the Clinical Psychology Journal (A study in Attributions and Perceptions of Childhood in Women with ADHD Symptomology) concluded that women with ADHD symptomatology had “more uncontrollable, and global attributions, reported more dissatisfaction in their childhood parent, peer, and teacher relationships, and felt less in control of negative childhood events suggesting that negative perceptions and attributions are more than reflections of current thinking and mood with symptomatology also an important risk factor for maladaptive attributions”. Peer rejection increases as the behavior of ADD adolescent girls appears more divergent from an accepted standard. Men with ADD have low self-esteem as well, but this is mostly due to an inability to find steady employment and a tendency to externalize performativity issues such as achievement instead of rejection from their peers. Research suggests that women are much more likely to feel shame and to be ostracized regarding impulsive actions than men because the culture in which these women participate in produces a certain humiliation that can also be procured internally. Saakvitne and Pearlman in 1993 reported that generally both the media and popular culture stigmatize women who behave impulsively, while tolerating or even celebrating impulsivity as an attribute in males. Furthermore in 2012 Dr. Stephen Hinshaw, chair of the psychology department at UC Berkley published a study showing that girls with combined-type ADHD have significantly higher rates of attempted suicide and self-harm, even though 40 percent of them have outgrown their hyperactive and impulsive symptoms in adolescence.

I would also like to request another section '''5.3 Research. '''

5.3 Research
The Child & Adolescent Disorders Research Brand of the Division of Clinical & Treatment Research of NIMH suggests that researchers focus on if the same instruments and diagnostic criteria used for males are also appropriate for females as well as how males and females with ADHD differ genetically, neurologically, physically, phenomenologically, and in treatment response .. ADHD is manageable with a proper diagnosis and with advances in research and advocacy a Gender-sensitive diagnosis and treatment allows clinicians to address and combat the public health concern posed by the under diagnosis of ADHD in females.

Hope Im doing this right, I'm new to this process. Please get back to me. Thanks!

Satans-doyly (talk) 01:04, 8 December 2015 (UTC)
 * This seems to be a fairly close copy of this source. Seems too close and would be a copyright violation. Stickee (talk) 02:03, 8 December 2015 (UTC)

Semi-protected edit request on 8 December 2015

 * I have made changes to the sections I’ve told were “too close to a cited source”… Please take another look. I'm simply relaying facts and studies so not too sure what else I can do to make it less similar. I’ve changed all the wording. Anyways, there needs to be a more thorough expansion when it comes to the difference between genders and how each experience ADHD.

Once again in Section 4 Diagnosis I would like to add three new sections the first: 4.5 Sex and ADHD, the second: 4.6 Difficulties in Diagnosing, third: 4.7 Differences Between Sexes and fourth: 5.3 Research

4.5 Sex and ADHD
Attention deficit hyperactivity disorder is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age (Attention-Deficit/Hyperactivity Disorder ADHD). Currently, most literature and research focuses on Caucasian males which indicates that data on women with ADHD, specifically women of color, has to a great extent been absent from literature and research. For girls and women, ADHD is often a hidden disorder that is ignored or misdiagnosed which leads to psychological and academic impairments. Because ADHD is so common (3% to 5% of school children) and chronic (lifelong in many cases), even a small proportion of females multiplied by such a large base means hundreds of thousands of girls and women are living with ADHD, a significant public health problem. Minorities are often left by the wayside when it comes to diagnosing, so women of color are at even more of a disadvantage, facing both sexist and racist complications. Lack of recognition can partially be explained because the symptoms are less overt in females and partially because coexisting disorders in females are often different from those seen in males who have ADHD. Clinicians are frequently challenged with disentangling the symptoms of ADHD from symptoms of coexisting conditions as well as fluctuating hormone levels which may affect symptoms and treatment in females.

4.6 Difficulties in Diagnosing
As described in the book A Comprehensive guide to Attention Deficit Disorder in Adults Research, Diagnosis, and Treatment particular issues that may add to, or detract from, our ability to detect ADD in women are neurobiological, "as gender-related neurobiological tendencies may make diagnosis more difficult; they are psychological, as a woman's trend toward internalization rather than externalization and acting out makes diagnosis more complicated; they are social and cultural, as gender-related norms and expectations not only affect a woman’s own ability to recognize ADD but these stereotypes also shared by women and clinicians, as well as the different manifestations of ADD symptoms, preclude or delay the diagnosis of ADD in girls and women" .The recognition of attentional problems and the diagnosis of ADD in women elude clinicians partially because women often lack the typical symptoms of "hyperactivity" and "impulsivity" in childhood or adulthood, and partially because the societal constructs surrounding the way in which womens behavior is interpreted often changes the way in which certain symptoms are recognized. In her book Women with Attention Deficit Disorder, Sari Solden MS, LMFT, addresses these cultural stereotypes that we have for women: “Because they are nice, quiet, or shy, they meet cultural expectations so people either don’t notice or are not as concerned with their subtle information processing problems”. Conflicting results reported in the salient literature on females diagnosed with attention deficit hyperactivity disorder gave credence to a study published in the Journal of Attention Disorders that looked at specific neuropsychological test data, assessing various aspects of attention, memory, personality adjustment, and psychiatric symptomatology. The study, undertaken in an effort to illuminate the presentation of ADHD in adult women, addressed substantial evidence that suggests under diagnosis and treatment of the disorder in females and the possible, consequent negative implications for their lives. Results indicate that females had higher scores on cognitive tests, greater degrees of anxiety and depression than males and because of their higher rates of depressive and anxiety symptoms they may as a group be underdiagnosed.

4.7 Differences Between Sexes
An NIMH conference on Sex Differences in ADHD on November 16-17, 1994, concluded that the difference between sexes may reflect either a difference in susceptibility or that women with ADHD are less likely to be diagnosed than males. The Canadian Journal of Psychiatry reveals that retrospective studies, clinical studies, and epidemiologic studies show the overall rate of comorbidity among adults with ADHD is high and the studies which looked at ADHD subtypes showed females with ADHD were more likely to have depression or dysthymia (Cumyn, French, and Hechtman 675). As well the same studies found that more women with ADHD (68.18%) had current panic disorder than men (31.82%), there were more men (66.67%) with drug abuse issues than women (33.33%), 85% of women had a history of past anorexia, compared with 14.92% of men, and that 62% of women with ADHD had a history of past bulimia, compared with 12.5% of men (675). In addition, Volume 56 of the Clinical Psychology Journal (A study in Attributions and Perceptions of Childhood in Women with ADHD Symptomology) concluded that women with ADHD symptomatology had “more uncontrollable, and global attributions, reported more dissatisfaction in their childhood parent, peer, and teacher relationships, and felt less in control of negative childhood events suggesting that negative perceptions and attributions are more than reflections of current thinking and mood with symptomatology also an important risk factor for maladaptive attributions”. Peer rejection increases as the behavior of ADD adolescent girls appears more divergent from an accepted standard. Men with ADD have low self-esteem as well, but this is mostly due to an inability to find steady employment and a tendency to externalize performativity issues such as achievement instead of rejection from their peers. Research suggests that women are much more likely to feel shame and to be ostracized regarding impulsive actions than men because the culture in which these women participate in produces a certain humiliation that can also be procured internally. Saakvitne and Pearlman in 1993 reported that generally both the media and popular culture stigmatize women who behave impulsively, while tolerating or even celebrating impulsivity as an attribute in males. Furthermore in 2012 Dr. Stephen Hinshaw, chair of the psychology department at UC Berkley published a study showing that girls with combined-type ADHD have significantly higher rates of attempted suicide and self-harm, even though 40 percent of them have outgrown their hyperactive and impulsive symptoms in adolescence.

5.3 Research
The Child & Adolescent Disorders Research Brand of the Division of Clinical & Treatment Research of NIMH suggests that researchers focus on if the same instruments and diagnostic criteria used for males are also appropriate for females as well as how males and females with ADHD differ genetically, neurologically, physically, phenomenologically, and in treatment response .. ADHD is manageable with a proper diagnosis and with advances in research and advocacy a Gender-sensitive diagnosis and treatment allows clinicians to address and combat the public health concern posed by the under diagnosis of ADHD in females.

Is this sufficient?

Satans-doyly (talk) 03:57, 8 December 2015 (UTC)
 * Still seeing content copied and pasted from the sources so no it is not sufficient. There are also a lot of other issues. Best to use sources from the last 5 years. Refs go after punctuation. Where were you previously told their was problems? Doc James  (talk · contribs · email) 08:11, 8 December 2015 (UTC)
 * No answer from OP. Changing answered parameter to yes. --Stabila711 (talk) 07:35, 23 December 2015 (UTC)

Semi-protected edit request on 11 December 2015
There needs to be a more thorough expansion when it comes to the difference between genders and how each experience ADHD. I have re-written each of the sections I have previously proposed and found all new sources which meet the criteria for editing medical articles. Please take another look and get back to me if need be.

In Section 4 Diagnosis I would like to add three new sections the first: 4.5 Sex and ADHD, the second: 4.6 Difficulties in diagnosing, third: 4.7 Differences between sexes and fourth: '''5.3 Research. '''
 * We should be basing content on high quality secondary sources rather than MedScape summaries of primary sources. Doc James  (talk · contribs · email) 13:56, 11 December 2015 (UTC)

Sex and ADHD
Attention deficit hyperactivity disorder is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age.

Currently, most literature and research focuses on Caucasian males which indicates that data on women with ADHD, specifically women of color, has to a great extent been absent from literature and research. The risk of institutional racism is a reality within diagnosis because of the often ignored issues of gender distribution, differences in diagnosis of ethnicity, and different meanings attached to symptoms in other societies. Along with racial disparities, other factors are connected with low rates of ADHD treatment among children such as lower average expenditures delegated to special education programs in schools, education levels, poverty rates, and rural areas. A study showcasing racial and ethnic disparities in ADHD diagnosis from kindergarten to eighth grade of more than 17 000 children deduced that non-white children such as African American and Hispanic populations experienced rates of ADHD that were up to 50% lower, respectively, than rates among white children. Women of color within these populations are at an even more of a disadvantage, due to the focus on male symptomology. By only focusing on a certain set of cultural views, communities with differing practices and beliefs are left with a very rigid and specific perspective on childhood and its problems. As well clinicians are frequently challenged with disentangling the symptoms of ADHD from symptoms of coexisting conditions coupled with fluctuating hormone levels which may affect symptoms and treatment in females. However, sex differences related to comorbid psychiatric conditions that show symptoms of agitation and impulsivity overlap with ADHD in women and men. But with this said, women are shown to have a higher capacity to seek treatment because they more readily 'medicalize' their symptoms. At present there is a referral bias which is reflected in the lack of a difference between men and women that has resulted from the absence of data to suggest different sex-specific rates of remission.

Difficulties in diagnosing
As described in the book A Comprehensive guide to Attention Deficit Disorder in Adults Research, Diagnosis, and Treatment particular issues that may add to, or detract from, our ability to detect ADD in women are neurobiological. When it comes to issues surrounding medication for women with ADHD it is frequently more complicated than for men not only because women suffer from certain comorbidities such as anxiety and depression so their treatment also has to deal with how those disorders mingle with ADHD symptoms but they are also complicated by hormone fluctuations whenever estrogen levels fall during their life span including menstrual cycles, puberty, and menopause. For women with perimenopause, it's not unusual to have difficulty with word retrieval, memory and cognitive skills. Pregnancy and post-partum depression along with the drastic changes in hormone levels and iron deficiency during menstruation already leads to strenuous issues with mental health before ADHD symptoms are even considered. Often hormone replacement is coupled with medication. Consideration of all the aspects of a patient’s life not limited to substance abuse, and disordered eating need to be addressed to effectively treat women with ADHD. Many disorders have similar symptoms and because women with ADHD have a tendency to couple these disorders with ADHD (as well as the fact ADHD tends to aggravate the symptoms of other maladities) many are mis-diagnosed. . Other factors such as history of physical abuse can be prone to ADHD-like symptoms which complicates the identification of the disorder. . The interplay of all of these conditions needs to be more accurately examined due to the fact that research has for too long focused only on male populations because masculine subject positions are privileged in social and educational settings which results in more interventions and special resources allocated and aimed at boys which in turn serves to perpetually re-enact male dominance within the treatment of ADHD. The diagnosis of ADHD is also influenced by gender stereotypes. These gender-related norms and expectations not only affect a woman’s own ability to recognize ADD but these stereotypes are also shared by clinicians. A study which provided participants (specialists in child and adolescent mental health including social workers, child psychologists and psychiatrists) with information about the minimal and optimal behavioral symptoms to diagnosis ADHD were told to indicate which children had ADHD from a series of vignettes. Approximately 20% of clinicians diagnosed ADHD when the criterion was not fulfilled. Kathleen Nadeau, a clinical psychologist and director of the Chesapeake ADHD Center of Maryland in Silver Spring, explains that the societal expectations placed upon women makes dealing with their ADHD more difficult because of a continuation of traditional societal roles. Many women and their families see their difficulties as merely a part of the stress of modern-day living. In her book Women with Attention Deficit Disorder, Sari Solden MS, LMFT, addresses these cultural stereotypes that we have for women: “Because they are nice, quiet, or shy, they meet cultural expectations so people either don’t notice or are not as concerned with their subtle information processing problems”.

Although when it comes to seeking treatment males generally combat more variables impacting their treatment seeking than females in compliance with the findings of Elias Dakwar, MD, and assistant professor of psychiatry, for Columbia University. Researchers have found that delayed treatment seeking among men is influenced by socioeconomic status, and demographic factors such as having a lower education level, having antisocial personality disorder and being African American, whereas the desire to seek treatment earlier is linked to specific psychiatric comorbidities and addiction issues such as alcohol dependence. But because teachers and parents are the ones who seek treatment for ADHD children the more disruptive the behavior the more likely it is that they will notice which tends to result in more clinical attention for boys initially than girls where this behavior goes unnoticed. In adolescence this starts to change possibly because of the decreased role parents and teachers have.

Differences between sexes
A study by David Muzina, an MD, psychiatrist and vice president of Express Scripts, a pharmacy based company, conducted research on prescription medications to treat adult attention-deficit/hyperactivity disorder and found that it increased in the United States in 2008 to 2012 by 53.4%; with 85% of that increase involving women aged 26 to 34. His study concluded that women received treatment more frequently than men because of a delay in diagnosis until adulthood and as well that women were using an unsuitable amount of stimulants possibly because of a desire to reduce appetite. Whereas in childhood boys outnumber girls in the use of medications to treat ADHD by 2:1 this swaps during adulthood. Women then represent a more significant proportion of adults with ADHD. Patricia Quinn, director of the National Center for Gender Issues and ADHD, specifies that women often” develop strategies to hide their deficiencies, but in the process, feel ashamed and have low self-esteem”. Rather than be disruptive, girls show their symptoms in a more socially acceptable way where it isn’t uncommon for them to take up extra responsibility in classroom settings as monitors or by becoming extremely social. Girls are also more likely to develop anxiety due to their general need to be “people pleasers”. As adults many women and in turn their families see their symptoms as simply the stress of contemporary living.

There is also a difference in self-reported symptoms where men focus more on stress, lacking social skills, and issues with conduct and learning. Stephanie Sarkis, a psychotherapist in Boca Raton, Florida, reports that men with ADHD tend to have more substance abuse issues, discipline issues (school suspensions), car accidents, and anger/behavioral issues compared to women with ADHD. Women on the other hand are concerned with dysphoria although they too have trouble with conduct problems, impulsivity, organization and attention. Women project more control over external symptoms and show less cognitive challenges but report lower self-esteem and self-image issues and fewer assets than males. They are also more susceptible to eating disorders, and obesity. Peer rejection for girls starts early and only increases with age. This ingrained and internalized low self-regard results from societal criticism of impulsive and risk taking behavior where women deal with a larger maternal criticism of ADHD behavior which is more likely to result in long-term psychological damage. In corroboration with these findings, Volume 56 of the Clinical Psychology Journal (A study in Attributions and Perceptions of Childhood in Women with ADHD Symptomology) concluded that women with ADHD symptomatology had “more uncontrollable, and global attributions, reported more dissatisfaction in their childhood parent, peer, and teacher relationships, and felt less in control of negative childhood events suggesting that negative perceptions and attributions are more than reflections of current thinking and mood with symptomatology also an important risk factor for maladaptive attributions”. According to the research of Anthony Rostain, a professor of psychiatry and pediatrics at the University Of Pennsylvania School Of Medicine, men are more likely to see problems in their professional lives whereas women are more likely to see their ADHD manifest as conflicts in the domestic space. This can also account for the way in which women’s ADHD is sometimes overlooked until later in life, when they start to show decreased self-regulation and management.

The difference between gender shows clearly in the statistics illustrated by The Canadian Journal of Psychiatry which revealed that retrospective studies, clinical studies, and epidemiologic studies found that more women with ADHD (68.18%) had current panic disorder than men (31.82%), there were more men (66.67%) with drug abuse issues than women (33.33%), 85% of women had a history of past anorexia, compared with 14.92% of men, and that 62% of women with ADHD had a history of past bulimia, compared with 12.5% of men. Another study in Sweden of 25, 000 individuals with ADHD showed that the risk of committing a crime decreased by 32% among men and 41% among women during treatment periods for ADHD rather than untreated periods. Furthermore in 2012 Dr. Stephen Hinshaw, chair of the psychology department at UC Berkley, published a study showing that girls with combined-type ADHD have significantly higher rates of attempted suicide and self-harm, even though 40 % of them have outgrown their hyperactive and impulsive symptoms in adolescence.

Research
Gender sensitive profiles and answers regarding the different ways in which ADHD manifests according to gender have been slow-moving as much still remains to be answered. The Child & Adolescent Disorders Research Brand of the Division of Clinical & Treatment Research of NIMH suggests that researchers focus on how males and females with ADHD differ genetically, neurologically, physically, phenomenologically, and in treatment response. The US Agency for Healthcare Research and Quality found that, particularly boys, exhibited better behavior when treated with stimulants and that women tended to engage in more emotion-oriented versus task oriented coping strategies. Currently the adherence to diagnostic criteria put in place limits the results of diagnosis in females to women who most resemble men with ADHD. The development of more gender sensitive treatment is the only way to appropriately address the under-diagnosis of ADHD in females. Screening tools and routinely incorporating questionnaires into clinician evaluations to detect ADHD among older adolescents could help combat the many adults who do not receive treatment for their symptoms. There has been speculation, from such psychiatrists as Joseph Austerman, head of the Section of Child and Adolescent Psychiatry at Cleveland Clinic Children's Hospital, in Ohio, that the rise in medicating adults for ADHD signals an over-diagnosing of the adult population although it cannot be refuted that there are adults who require this medication to thrive in their private and professional lives.

Satans-doyly (talk) 06:50, 11 December 2015 (UTC)

ADHD- natural remedies
In reading over the information on ADHD treatments, I didn't find that there was much information on natural remedies or dietary restrictions. Here's some stuff I think would be helpful!

There is evidence supporting the use of nutritional supplements in helping to control ADHD, especially in young children. For example, supplements including omega-3 polyunsaturated fatty acid compounds and minerals have been found to improve ADHD symptoms.

While prescription drugs have been found to have positive effects on ADHD symptoms, there is also research supporting the use of nutritional supplements. While the findings have not been proven sufficient enough to draw generalized conclusions, they have shown that adding supplemental nutrients to an individual’s daily diet may indeed help with the symptoms associated with ADHD. Among the supplements tested are omega-3 fatty acid compounds (also known as fish oil), iron supplements, and zinc supplements. While these supplements have been researched, it is also important to consider the removal of certain components of a diet when treating the symptoms of ADHD. For example, because hyperactivity and issues with concentration are such a significant part of the problematic symptoms, sugar is often removed (or at least limited) when using natural remedies for such symptoms.

-- — Preceding unsigned comment added by Cevance  (talk • contribs) 02:32, 9 March 2016‎ (UTC)
 * Wikipedia does not hype things that "may" work. There is either evidence that they are safe and effective enough, or not. Please read that source again.  You are not representing it accurately. Also please avoid giving medical advice.  You may want to read WP:MEDMOS.   Jytdog (talk) 02:35, 9 March 2016 (UTC)

Intervention studies in an academic setting
A systematic review in 2015 looked at four groups of studies that measured the efficiency of non-medicinal treatment strategies, resulting from modification of the behavior in children within their school environments. I'm hoping that another editor can share their thoughts on the review. Richardson M, Moore DA, Gwernan-Jones R, Thompson-Coon J, Ukoumunne O, Rogers M, et al. Non-pharmacological interventions for attention-deficit/hyperactivity disorder (ADHD) delivered in school settings: systematic reviews of quantitative and qualitative research. Health Technol Assess 2015;19(45). http://www.journalslibrary.nihr.ac.uk/__data/assets/pdf_file/0011/146684/FullReport-hta19450.pdf

I'll leave it to another editor to decide whether to add this review to the references, or perhaps to the page itself. I believe the findings would fit in the environmental section, societal section, or in a subsection about intervention therapies. I'm happy to write a section on the findings of this review; just wanted to check with the ADHD page community before possibly stepping on anyone's toes. Thanks for the feedback! Zharris24 (talk) 05:18, 9 March 2016 (UTC)
 * that is a very high quality source. nice find.  it basically says that "we don't know."  it says effect sizes were small, outcomes were qualitative, and they cannot tell which intervention caused which outcome. the state of research is messy. Jytdog (talk) 05:46, 9 March 2016 (UTC)

Seminar
Lancet 10.1016/S0140-6736(15)00238-X JFW &#124; T@lk  23:52, 19 March 2016 (UTC)

Gluten and ADHD
The following were added today:

At "Causes: Environment":

An association of ADHD with gluten intolerance, both celiac disease and non-celiac gluten sensitivity, has been found. ADHD may be the only symptom of these two diseases, even in absence of gastrointestinal symptoms.

and later a subsection under Management "Gluten-free diet" was created: People with undiagnosed celiac disease or non-celiac gluten sensitivity may develop ADHD, which may be the only symptoms in absence of gastrointestinal complaints. Gluten-free diet often improves them. In one study, the majority of patients (74%) chose to continue the gluten-free diet due to significant relief of their symptoms after six months of gluten withdrawal.

The Fasono source from 2015 is a) very clear about gluten-free being faddish, and b) is tentative on the gluten hypothesis: "Children with NCGS mainly have intestinal symptoms such as abdominal pain and chronic diarrhea without weight loss. Less frequently, they present with extraintestinal manifestations, including fatigue and attention-deficit disorders. Of particular interest is the relationship between NCGS and neurologic and neuropsychiatric disorders, including autism, schizophrenia, and peripheral neuropathy. However, it is not clear how gluten might contribute to these disorders." The older 2012 Jackson paper (which we don't need at all, since we have the Fasano review) is also tentative, noting " few studies have suggested that Attention Deficit Hyperactivity Disorder (ADHD) may be associated with gluten intolerance as well. A study measured ADHD symptoms in CD patients and found that these symptoms are “overrepresented” as compared to the general population. A 6-month gluten-free diet was reported to improved ADHD symptoms and the majority of patients (74%) in this report wanted to continue the gluten-free diet due to significant relief of their symptoms" And if you look at that clinical trial  it is 10 years old, and is a single arm study of people with celiac, looking for ADHD-like symptoms. The proposed content doesn't represent the sources and additionally appears to be UNDUE to me. Jytdog (talk) 12:48, 24 March 2016 (UTC)
 * It is certainly troubling that Schuppan is both an author of the (primary sourced) FasanoSapone2015 paper and an editor of the special issue which published it. Not to mention having a declared COI. I think we could afford to stick to the (almost secondary) source per wp:MEDRS. Note that Fasano is both reviewing and reviewed in that paper. It, however, does not present evidence to associate ADHD with GS, just with CD (per ref 34 to that paper). It does speculate that GS may be associated with ADHD, but does not present this as anything more than a possibility to be investigated. Given the well-documented connection between CD and B12 deficiency (particularly but not entirely before diagnosis) the whole question of how CD impacts neurology may be difficult to chase down, likely with multiple insults playing a role. We likely should give this some more time for the literature to shake out. LeadSongDog come howl!  16:32, 24 March 2016 (UTC)


 * , I hope you're not trying to bias the information WP:NPOV.


 * You said: "The Fasono source from 2015 is a) very clear about gluten-free being faddish," "Very clear" about gluten-free being faddish??? Just opposite! All paper is a complete review of current knowledge about non-celiac gluten sensitivity, a real health  disorder that is not a "fad", and Fasano states:


 * You extracted from Fasano source: "Less frequently, they present with extraintestinal manifestations, including fatigue and attention-deficit disorders." Children People who develop ADHD symptoms because of non-celiac gluten sensitivity, whether a majority or a minority, have no right to cure or improve...? There is no reason to hide this information. WP:NPOV


 * You said: "And if you look at that clinical trial it is 10 years old, and is a single arm study of people with celiac, looking for ADHD-like symptoms." Gluten-free diet resolves or improves digestive and extraintestinal symptoms, and associated diseases, now and 10, 20, 30... years ago. The cause of celiac disease remains the same: gluten intolerance. Gluten-free diet is in fact the only available treatment. I cited this because of is included in a secondary source, per WP:MEDRS. But this is not a single study. There are other reports:


 * Front Hum Neurosci. 2013 Jan 4;6:344. doi: 10.3389/fnhum.2012.00344. eCollection 2012. Gluten- and casein-free dietary intervention for autism spectrum conditions. Whiteley P, Shattock P, Knivsberg AM, Seim A, Reichelt KL, Todd L, Carr K, Hooper M




 * - (Pelsser et al., 2011) Lancet. 2011 Feb 5;377(9764):494-503. doi: 10.1016/S0140-6736(10)62227-1. Effects of a restricted elimination diet on the behaviour of children with attention-deficit hyperactivity disorder (INCA study): a randomised controlled trial. Pelsser LM1, Frankena K, Toorman J, Savelkoul HF, Dubois AE, Pereira RR, Haagen TA, Rommelse NN, Buitelaar JK.


 * - (Niederhofer, 2011) Prim Care Companion CNS Disord. 2011;13(3). pii: PCC.10br01104. doi: 10.4088/PCC.10br01104. Association of attention-deficit/hyperactivity disorder and celiac disease: a brief report. Niederhofer H.


 * Prim Care Companion CNS Disord. 2011;13(3). pii: PCC.10br01104. doi: 10.4088/PCC.10br01104. Association of attention-deficit/hyperactivity disorder and celiac disease: a brief report. Niederhofer H.


 * BMC Pediatr. 2011 May 27;11:46. doi: 10.1186/1471-2431-11-46. Compliant gluten-free children with celiac disease: an evaluation of psychological distress. Mazzone L, Reale L, Spina M, Guarnera M, Lionetti E, Martorana S, Mazzone D




 * 12. Lionetti E, Francavilla R, Maiuri L, Ruggieri M, Spina M, Pavone P, Francavilla T, Magistà AM, Pavone L. Headache in pediatric patients with celiac disease and its prevalence as a diagnostic clue. Journal of Pediatric Gastroenterology and Nutrition. 2009;49(2):202–7. doi: 10.1097/MPG.0b013e31818f6389.
 * 13. Pynnönen P, Isometsä E, Aronen E, Verkasalo MA, Savilahti E, Aalberg VA. Mental disorders in adolescents with celiac disease. Psychosomatics. 2004;45(4):325–35. doi: 10.1176/appi.psy.45.4.325.
 * 14. Pynnönen PA, Isometsä ET, Verkasalo MA, Kähkönen SA, Sipilä I, Savilahti E, Aalberg VA. Gluten-free diet may alleviate depressive and behavioural symptoms in adolescents with coeliac disease: a prospective follow-up case-series study. BMC Psychiatry. 2005;5:14. doi: 10.1186/1471-244X-5-14. [PMC free article]
 * Niederhofer H, Pittschieler K. A preliminary investigation of ADHD symptoms in persons with celiac disease. Atten Disord. 2006;10:200–4. doi: 10.1177/1087054706292109.


 * Pediatrics. 2004 Jun;113(6):1672-6. Range of neurologic disorders in patients with celiac disease. Zelnik N, Pacht A, Obeid R, Lerner A.


 * Two interesting papers:


 * Child Adolesc Psychiatr Clin N Am. 2014 Oct;23(4):937-53. doi: 10.1016/j.chc.2014.05.010. Epub 2014 Aug 10. Restriction and elimination diets in ADHD treatment. Nigg JT, Holton K




 * Nutr Res Rev. 2014 Dec;27(2):199-214. doi: 10.1017/S0954422414000110. Epub 2014 Jul 8. Autism and nutrition: the role of the gut-brain axis. van De Sande MM, van Buul VJ, Brouns FJ.




 * Anyway, Jytdog and, I agree to take another approach, include a text much shorter and eliminating the mention in the treatment section.


 * Best regards. --BallenaBlanca (talk) 19:25, 24 March 2016 (UTC)
 * Ballena. Please strike your first sentence, and then I will be happy to reply. Jytdog (talk) 20:44, 24 March 2016 (UTC)


 * Sorry, . It was not my intention to offend you. I've already done it. Now, let's talk. You reverted once again... Best regards. --BallenaBlanca (talk) 22:19, 24 March 2016 (UTC)
 * Great. Now. What I actually wrote was "The Fasono source from 2015 is a) very clear about gluten-free being faddish, and b) is tentative on the gluten hypothesis:." I left off, "with regard to the relationship between gluten and ADHD".  Sorry for eliding that.  Jytdog (talk) 22:32, 24 March 2016 (UTC)

FWIW, a positive correlation between celiac disease or gluten intolerance and ADHD could be mediated entirely at a genetic level, in which case gluten itself has nothing to do with ADHD in otherwise healthy individuals. All that association suggests is that celiac disease/gluten intolerance and ADHD are comorbid disorders. I doubt gluten itself has anything to do with ADHD pathology in individuals without a gluten sensitivity, especially because this unfiltered search returned nothing.  Seppi  333  (Insert 2¢) 22:43, 24 March 2016 (UTC)


 * , you are misinterpreting. You say that Fasano is "very clear about gluten-free being faddish ... is tentative on the gluten hypothesis ... with regard to the relationship between gluten and ADHD". If you read the rest of the paper, you'll see that he doesn't say nothing like this! Fasano says "However, it is not clear how gluten might contribute to these (neurological and psychiatric) disorders." because actually we don't know the exact pathogenesis of non-celiac gluten sensitivity: besides gluten, other proteins present in gluten-containing cereals (ATIs) seem to play a role in the development of symptoms, both digestive and extraintestinal symptoms :




 * ATIs are proteins that induce an immune response, not a "fad". And they are also present in commercial gluten...:




 * ...and some people with celiac disease / non-celiac gluten sensitivity may develop ADHD symptoms which often improve with a gluten-free diet (gluten-free diet removes all gluten-containing cereals and therefore removes gluten and ATIs). This is a reality that we must state, best if we add that "the underlying mechanism is not clear"; as we state, for example, that "Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk; however, the evidence is not conclusive.[82]" or "Some children may react negatively to food dyes or preservatives.[87] It is possible that certain food coloring may act as a trigger in those who are genetically predisposed but the evidence is weak.[88]"


 * Best regards. --BallenaBlanca (talk) 01:25, 25 March 2016 (UTC)
 * Your comments here are far too long. The Fasano article is extremely clear that there is faddism around gluten and it is tentative with regard to connections between gluten and ADHD.  Yes it does say that some people with celiac non-celiac gluten sensitivity have ADHD-like symptoms.  It does not discuss the very old, single arm trial at all.  We rely on recent reviews per WP:MEDRS and there is no reason to mention the older review nor to provide any detail about that small and quite useless old trial. Jytdog (talk) 01:33, 25 March 2016 (UTC) (correct error Jytdog (talk) 02:32, 25 March 2016 (UTC))


 * Link to download full text of Fasano source: Fasano A, Sapone A, Zevallos V, Schuppan D (May 2015). "Nonceliac gluten sensitivity". Gastroenterology (Impact Factor: 16.72). 01/2015; 148(6). DOI: 10.1053/j.gastro.2014.12.049 - RESEARCHGATE
 * I have read the whole source. I would not be writing here, if I had not. Jytdog (talk) 02:26, 25 March 2016 (UTC)
 * Don'worry, I've noticed that you have the paper. The link is so that other users can review it. Best regards. --BallenaBlanca (talk) 02:42, 25 March 2016 (UTC)
 * The only other source that seems possibly relevant and MEDRS compliant that you introduced was ; I just read that too and it only talks about gluten as a paradigmatic elimination diet. It focuses on diets eliminating food colorings etc as possible ADHD treatments and gives no attention to gluten after the brief description I just mentioned.  It is a review on elimination diets for ADHD and if those authors thought the gluten-elimination approach was noteworthy or significant for ADHD, they had every opportunity to discuss it, and they didn't.  This is exactly what we rely on MEDRS-sources to do for us.    Otherwise the sources you mention above are not MEDRS compliant. Jytdog (talk) 02:44, 25 March 2016 (UTC)

The conclusions of this source are: "The literature clearly demonstrates that a minority of children with ADHD will benefit from an elimination diet. Research funders, scientists, and clinicians would do well to re-invigorate investigation of this intervention, while avoiding both excessive skepticism (clearly, it may work for some), and excess optimism (it probably only works for a minority) ... dietary intervention for ADHD was abandoned too quickly in North America. Although it is likely that only a minority of children with ADHD will respond to dietary intervention, the evidence persistently suggests that for some children such intervention can be quite effective. ". Diets are not profitable for pharmaceutical companies....

I did not say that a gluten-free diet may work for everyone, just for one subgroup (people with CD or NCGS), and it is documented although they are few studies (dietary intervention for ADHD was abandoned too quickly...). And I repeat: this minority of people who develop ADHD symptoms because of celiac disease / non-celiac gluten sensitivity have no right to cure or improve, or to know this information...? Are "minorities" have no right?

Elimination diets reinforce the idea that wheat ("gluten and ATIs") may be involved. Also, very often in gluten-free diet is not enough to remove only gluten, more food must be removed, especially in cases with long delays in diagnosis (which is usual, there often are delays of many years, including children). Intestinal permeability and mucosal damage caused by gluten are responsible for the appearance of more food allergies and intolerances, which are often reversible after months or years of strict GFD, and avoidable with an early diagnosis. But researchers are badly lost and disoriented, generally uninterested or they do not get money to fund the studies (diets are not profitable for pharmaceutical companies).

Authors of this paper, when summarizing the results, talk about of all elimination diets in general terms.

Best regards. --BallenaBlanca (talk) 11:05, 25 March 2016 (UTC)
 * Could we summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both."? Doc James  (talk · contribs · email) 13:27, 25 March 2016 (UTC)


 * I agree, . Best regards. --BallenaBlanca (talk) 14:16, 25 March 2016 (UTC)
 * User:Doc James this is an article on ADHD. That summary goes beyond what the source says; this whole "may improve" thing is the language that advocates throughout Wikipedia try to use to get fringe-y treatments into the encyclopedia. There is no clear biological connection between gluten and ADHD (like there is no link between say magnetic bracelets and cancer) and the clinical evidence is scant.  As I noted above the most recent review on dietary interventions for ADHD  doesn't mention gluten restriction as a treatment for ADHD at all. Jytdog (talk)
 * Not as a treatment for all cases, of course. Nobody is saying that. This is to state objectively that GFD improves ADHD symptoms in celiac patients.
 * It would be good to add, in addition to GFD in CD, a brief mention to elimination diets, supported by that source, including it on a "Diet" sub-section. Wording from these two paragraphs: "Food elimination diets vary in their specific content, but take 3 main forms. A single food exclusion diet excludes one suspected food, such as eggs. A multifood exclusion diet, such as the 6-food elimination diet, eliminates the most common food allergens: cow-milk protein, soy, wheat, eggs, peanuts, and seafood. A “few foods diet” (also called an oligoantigenic diet) restricts a person’s diet to only a few less commonly consumed foods (eg, lamb/venison, quinoa/rice, pear, and others with low allergenic potential). The “few foods diet” must be overseen by a properly qualified professional (eg, dietitian) to avoid nutritional deficiency, but is effective at identifying multiple food allergies in an individual.11 Much of the use of these diets in the medical literature is targeted at single specific food allergies (eg, cow’s milk12 or physical symptoms thought to potentially be related to food allergies, such as esophagitis).13" .... "Referral to an immunologist who can conduct skin prick allergy testing may also be beneficial, but dietary response may occur even with a negative skin prick test, if the response is due to a food intolerance rather than to an allergy. It remains unclear whether the presence of food allergy symptoms or allergy skin prick findings increase the likelihood that ADHD symptoms will respond to an elimination diet." ..... " The literature clearly demonstrates that a minority of children with ADHD will benefit from an elimination diet. Research funders, scientists, and clinicians would do well to re-invigorate investigation of this intervention, while avoiding both excessive skepticism (clearly, it may work for some), and excess optimism (it probably only works for a minority). "
 * Best regards. --BallenaBlanca (talk) 20:41, 25 March 2016 (UTC)
 * There is insufficient sourcing to justify including discussion of a gluten-free diet in this article. Jytdog (talk) 22:02, 25 March 2016 (UTC)

Ref says "an elimination diet produces a small but reliable aggregate effect" The ref comments on celiacs but makes no claim that it improves ADHD symptoms I agree. Doc James (talk · contribs · email) 09:57, 26 March 2016 (UTC)
 * Well, there's no doubt about this reference, we all agree, and I will include two brief sentences, without talking about gluten, nor gluten-free diet. I respect the discussion.
 * Regarding the mention to gluten-free diet in celiacs, which is the issue of this discussion,, you said: Could we summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both."? supported by these two other sources. I agree to eliminate Fasano's source. What do you think?
 * Best regards. --BallenaBlanca (talk) 00:41, 27 March 2016 (UTC)
 * With which ref to support again? Doc James  (talk · contribs · email) 11:16, 27 March 2016 (UTC)
 * We have another ref that says elimination diets are not supported. So obviously they are controversial. Balanced the two. Doc James  (talk · contribs · email) 11:14, 27 March 2016 (UTC)
 * I agree. I have adjusted a bit.
 * With which ref to support again? This reference is perfectly valid . As we have seen above, in the literature are a few studies on the improvement of ADHD symptoms with a gluten-free diet in people previously undiagnosed of CD. This article extracts the results of one of them, but is not the only one. We can write, as is customary in these cases, something like this: A few studies in patients with undiagnosed celiac disease showed an improvement of symptoms of ADHD when starting a gluten-free diet.''
 * Neurologic and psychiatric manifestations of celiac disease and gluten sensitivity.
 * Best regards. --BallenaBlanca (talk) 18:08, 27 March 2016 (UTC)
 * Best regards. --BallenaBlanca (talk) 18:08, 27 March 2016 (UTC)

Break

 * Hi, . Perhaps you didn't read my last message. You proposed summarize this as "A gluten free diet in those with CD and ADHD may improve the symptoms of both." and I proposed something like this, to adjust and be more precise: A few studies in patients with an undiagnosed celiac disease showed an improvement of symptoms of ADHD when starting a gluten-free diet. Which of the two we choose?
 * The Psychiatric Quarterly is a peer-reviewed medical journal that was established in 1915, with an impact factor of 1.26 (5-year impact: 1.39).
 * Best regards. --BallenaBlanca (talk) 10:01, 3 April 2016 (UTC)
 * Added. Doc James  (talk · contribs · email) 14:16, 3 April 2016 (UTC)
 * I've gotten the full paper of the newly added source . It is a good source, published on Journal of Attention Disorders (current impact factor of 3.78). I will expand, supported by this source, and I will try to be as brief as possible. The text I will add is on the same line that the text has been discussed and approved above, that led to the inclusion of this text by Doc James: (There is no clear relationship betwen ADHD and CD, but is not incompatible with the fact that CD patients with ADHD improve with GFD). I hope you agree and I wait your opinions. Best regards. --BallenaBlanca (talk) 10:38, 13 April 2016 (UTC)
 * Have adjusted it some. Let me know what you think. Remember to use "person with ADHD" rather than "ADHD patient" per the WP:MEDMOS. Doc James (talk · contribs · email) 19:09, 13 April 2016 (UTC)


 * Remember to use "person with ADHD" Oops...! Sorry! I will remember.
 * I like the adjustments you made, minus the last sentence: "People with ADHD and a broad range of physical symptoms should be tested. [158]" This implies that people with CD and ADHD have always a large number of other symptoms. The meaning is very different. The authors say literally: "Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD" because they previously explained the wide variety of symptoms (digestive and/or extra-digestive) that can present CD and make it difficult to identify. What it means is that physicians have to evaluate a wide range of symptoms, because the presence of any of them (perhaps only one, or two, or more... all is possible) may be  the track to identify an undiagnosed CD. I realize that my previous text was confused, wanting to do so shortly.
 * It is clear that it is better to add a clarification, for everyone can understand it, without reading the entire reference, because out of context it is confusing.
 * I will adjust. Tell me if you like the result.
 * Best regards. --BallenaBlanca (talk) 21:10, 13 April 2016 (UTC)
 * The exact symptoms of celiacs belongs in the celiac article IMO as those symptoms are complicated. How about "In people with ADHD, those with any of a range of physical symptoms should be tested to identifying unrecognized celiac disease"? Doc James  (talk · contribs · email) 12:47, 14 April 2016 (UTC)

People with symptoms of any mental health problem should always see their PCP to rule out likely physical ailments first. Celiacs is not unique in having some overlapping symptoms with ADHD and it's far from the most common. It not in the top 5. This reads like doctors have no idea ADHD symptoms could be caused by something else. We can't/shouldn't attempt to address every other issue that might present like ADHD and if we're going to mention some things that should be ruled out first, it should be the most common: seasonal allergies, asthma hearing or vision disorders, anemia, hashimotos/thyroid issues, tonsil/adenoid issues, sleep apnea and other sleep disorders, brain injury, elevated lead levels...  and that's not even mentioning things like learning disabilities, other mental illnesses, and having crappy parents. If your pediatrician isn't ruling out other likely possibilities before officially diagnosing your kid with anything, you need a new pediatrician. As far as celiacs goes, it would encompassed with due weight in sentence like, "doctors should always rule out potential physiological explanations for attentional issues as part of a thorough ADHD evaluation." More sources talking about common things to rule out in patients with ADHD symptoms that don't mention celiacs:    PermStrump (talk)  15:02, 14 April 2016 (UTC)


 * Hi, . Your comments are very interesting and you are quite right. There is already a Differential diagnosis section which mentions most of the diseases that you are listing Attention_deficit_hyperactivity_disorder but I agree your observation: "doctors should always rule out potential physiological explanations for attentional issues as part of a thorough ADHD evaluation." IMO, this sentence should be on first place in the Diagnosis section, because it must be the first step, prior to psychiatric evaluation and ADHD diagnosis, searching a good source to support it. What do you think?
 * In the case of the section Diet, the objetive is to reflect the results of the studies with neutrality, explaining all conclusions. Perhaps the best thing is to modify a little again, to reflect what the authors mean in other words, compatible with the existence of a differential diagnosis section. I will do it. Let me know if you agree.
 * If your pediatrician isn't ruling out other likely possibilities before officially diagnosing your kid with anything, you need a new pediatrician. It could not have said it better! How right you are! And not only pediatrician, ADHD affects both children and adults.
 * Best regards. --BallenaBlanca (talk) 18:09, 14 April 2016 (UTC)


 * Doc James thanked me by this edit, reverted by  "Uh, this is even more incorrect and misleading... " I don't understand why this is "even more incorrect and misleading". It seems that the problem is to say that celiac disease "may present with mild or absent gastrointestinal complaints". Currently, it has changed the understanding of the presentation of CD. Non-classical CD presentation (with mild or absent gastrointestinal symptoms and extra-intestinal manifestations) is more common than classical presentation (with malabsorption and chronic diarrhea). Really, is even more adjusted to say that often present with mild or even absent gastrointestinal symptoms. Let's see two sources (NOTE: Non-classical and atypical refer to the same presentation and are interchangeably. Also, classical and typical are synonymous):


 * World Gastroenterology Organisation Global Guidelines on Celiac Disease
 * Many patients with CD have few symptoms or present atypically, whereas a minority of patients have malabsorption (classical CD).


 * Diagnosis and management of adult coeliac disease: guidelines from the British Society of Gastroenterology
 * Traditionally patients with CD presented with malabsorption dominated by diarrhoea, steatorrhoea, weight loss or failure to thrive (‘classical CD’),7 but over time the proportion of newly diagnosed patients with malabsorptive symptoms has decreased,31 and ‘non-classical CD’7 and even asymptomatic CD have gained prominence. Newly diagnosed patients with CD can present with a wide range of symptoms and signs, including anaemia,32 vague abdominal symptoms (often similar to irritable bowel syndrome (IBS)33), neuropathy,34 ,35 ataxia,36 depression,37 short stature,38 osteomalacia and osteoporosis,39 liver disease,40 adverse pregnancy outcomes41 and lymphoma.42


 * And let's see part of the text of the source used in ADHD. Really, the text currently included is very summarized, as there is much that can be written about it:
 * Untreated, CD has a wide range of clinical presentations. The “classical CD type” presents with mostly gastrointestinal symptoms such as abdominal pain, distension, chronic diarrhea, or failure to thrive. The “non-classic CD type” is characterized by fewer or no gastrointestinal symptoms and presents with extra-intestinal manifestations, such as neurologic, dermatologic, hematologic, endocrinologic, reproductive, renal, psychiatric, skeletal, and liver involvement (Celiloğlu, Karabiber, & Selimoğlu, 2011). The “asymptomatic or silent CD type” can present with no clinical symptoms and only positive serology (Bai et al., 2013). ...
 * Neuropsychiatric Symptoms in CD
 * Research on neuropsychiatric symptoms in patients with CD report age-related differences. In adult patients with CD, ataxia, epilepsy, peripheral neuropathy, inflammatory myopathies, myelopathies, headache, gluten encephalopathy, white matter abnormalities, anxiety disorders, depressive and mood disorders, ADHD, autism spectrum disorders, and schizophrenia have been reported (Jackson, Eaton, Cascella, Fasano, & Kelly, 2012). In children with CD, however, the risk of developing neuropsychiatric disturbances is only 2.6% (compared with 26% in adults; Ruggieri et al., 2008). This discrepancy may be due to shorter disease duration in children, earlier elimination of gluten from the diet, stricter adherence to a diet, or a different susceptibility to immune-mediated disorders (Lionetti et al., 2010; Ruggieri et al., 2008).
 * Discussion
 * ADHD-Like Behavior and CD 
 * Based on this review, there is no conclusive evidence for a relationship between ADHD and CD. However, attention difficulties, distractibility, chronic fatigue, and headache have been observed in patients with CD, especially prior to treatment or when noncompliant to GFD (Terrone et al., 2013). Newly diagnosed children with CD often complained of “aches and pains,” “easily tired,” “easily distracted,” and “trouble concentrating.” After 1 year of GFD treatment, scores on these items were reduced and remained low in GFD-compliant children (Terrone et al., 2013). Also in newly diagnosed adults with CD, a significant improvement in cognitive functioning, particularly verbal fluency, attention, and motor function, is noted after a 12-month adherence to GFD (Lichtwark et al., 2014). Thus, it is possible that in untreated patients with CD, neurologic symptoms such as chronic fatigue, inattention, pain, and headache could predispose patients to ADHD-like behavior (mainly symptoms of inattentive type), which may be alleviated after GFD treatment.
 * Possible Mechanisms
 * ''Possible mechanisms underpinning the relation between attention/learning problems and CD point to accumulative effects of multiple effects, including both nutritional and immunologic/inflammatory factors. However, more indirect factors, related to nonspecific effects of chronic disease, cannot be ruled out (Zelnik et al., 2004). With respect to nutritional factors, micronutrient deficiencies and anemia are frequently seen in untreated patients with CD (Kupper, 2005; Wierdsma, van Bokhorst-de van der Schueren, Berkenpas, Mulder, & van Bodegraven, 2013). These factors may also play a role in causing ADHD-like behavior. However, when studying iron and zinc deficiencies in patients with ADHD, results remained inconclusive and needed further elaboration (for a review, see Millichap & Yee, 2012). There is emerging evidence that immunological mechanisms may contribute to ADHD development and manifestation (Verlaet, Noriega, Hermans, & Savelkoul, 2014). CD may induce an immune dysregulation in the gut, leading to chronic inflammation, which on its turn may be the cause for developing ADHD-like symptoms (Esparham, Evans, Wagner, & Drisko, 2014). Studies on the brain level point to the possible implication of serotonergic dysfunction in developing neuropsychiatric disorders in CD. More specifically, these studies refer to an impaired availability of tryptophan and decreased serotonin and dopamine metabolite concentrations (Hernanz & Polanco, 1991; Jackson et al., 2012; Pynnönen et al., 2005). Neuroimaging studies show structural and functional brain deficits in adult patients with CD. Structural deficits include bilateral decrease in cortical gray matter and caudate nuclei volumes (Bilgic et al., 2013), bilateral decrease in cerebellar gray matter, and smaller volume in multiple cortical regions (Currie et al., 2012). Functional deficits include a hypoperfusion of cerebral regions, primarily in the frontal cortex in untreated adult patients with CD, but not in treated patients (Addolorato et al., 2004; Usai et al., 2004). Such brain abnormalities may induce problems in high-cognitive functions such as attention span. Further research is however needed to confirm this hypothesis. To our knowledge, there are no studies on structural and functional brain deficits in pediatric patients with CD. A final hypothesis relates to increased oxidative stress that has been described in both ADHD (Lopresti, 2015) and CD (Stojiljković et al., 2009). Therefore, oxidative stress may represent a possible mediator in the development of ADHDlike behavior in CD patients. However, it remains uncertain whether oxidative stress itself contributes to the development or exacerbation of ADHD symptoms or whether it is the result of environmental factors (Lopresti, 2015). Further empirical studies are needed to understand the mechanisms underlying the potential association between ADHD, ADHD-like behavior, and CD.''
 * Clinical Implications
 * Up till now, there is no conclusive evidence for a relationship between ADHD and CD. Therefore, it is not advised to perform routine screening of CD when assessing ADHD (and vice versa) or to implement GFD as a standard treatment in ADHD. Nevertheless, the possibility of untreated CD predisposing to ADHD-like behavior should be kept in mind. Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD.


 * Best regards. --BallenaBlanca (talk) 22:28, 14 April 2016 (UTC)

Full protection
I've just full-protected this page for 24 hours to prevent edit-warring and allow discussion to take place. I am happy for any admin to unprotect if they feel the problem has resolved. Cas Liber (talk · contribs) 00:33, 25 March 2016 (UTC)


 * I agree. Thanks, . It would be good than an administrator take a look at this issue, such as . Best regards. --BallenaBlanca (talk) 01:29, 25 March 2016 (UTC)

Executive functions
Why did you remove the statements about problems with executive functions in the lead a while back?  Seppi  333  (Insert 2¢) 10:43, 29 March 2016 (UTC) Attention deficit hyperactivity disorder (ADHD, similar to hyperkinetic disorder in the ICD-10) is a neurodevelopmental psychiatric disorder in which there are significant problems with executive functions (e.g., attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age.
 * To simplify the lead. IMO it is best to describe the symptoms. Than have the discussion of executive functions in the body of the text. Doc James  (talk · contribs · email) 10:44, 29 March 2016 (UTC)
 * Fair enough.  Seppi  333  (Insert 2¢) 10:47, 29 March 2016 (UTC)
 * Actually, would you be ok with adding "there are problems with executive functions that cause" before the list of symptoms? It's shorter than what was there previously (the underlined and struckout text is the part you deleted; I'm proposing that we only re-add the underlined text):
 * Rephrasing it this way doesn't seem (to me) to be overly technical for the lead.  Seppi  333  (Insert 2¢) 11:33, 29 March 2016 (UTC)
 * Your thoughts?  Seppi  333  (Insert 2¢) 23:09, 29 March 2016 (UTC)
 * The DSM defines ADHD by the signs and symptoms. The "cause" is unknown. So I do see this proposal as being more complicated.
 * The ref does not mention "executive function". I am not even clear how that word is defined.   Doc James  (talk · contribs · email) 09:35, 30 March 2016 (UTC)
 * The refs for that statement are in this article's section on that topic. An executive function is a particular kind of cognitive process; it's also defined in the section.  Seppi  333  (Insert 2¢) 11:57, 30 March 2016 (UTC)
 * IMO it makes the lead more complicated and is not central enough to be mentioned in the lead. Doc James  (talk · contribs · email) 13:10, 30 March 2016 (UTC)
 * Alright.  Seppi  333  (Insert 2¢) 12:54, 5 April 2016 (UTC)
 * Does alright mean that you are okay with having "ADHD involves deficits in cognitive control. Stimulants improve cognitive control. " in the body of the article which is were it is already? Cognitive control is basically the symptoms of hyperactivity, impulsivity and trouble paying attention. We already state this in the lead and that stimulants help with this in the paragraph on treatment.  Doc James  (talk · contribs · email) 12:21, 7 April 2016 (UTC)

No, it's my way of acknowledging "I have heard what you said." Arbitrarily adding it back into the lead instead of having a discussion is just me reflecting your behavior at MDMA in this article. FWIW, it also irritates me that instead of having a discussion on the talk page and arriving at some form of compromise version that suits both of us, you decide on an RFC to go with one version or the other when we have content disputes.  Seppi  333  (Insert 2¢) 12:43, 7 April 2016 (UTC)
 * A RfC to bring in a larger number of opinions is often useful. Doc James  (talk · contribs · email) 13:35, 7 April 2016 (UTC)
 * When you hold an RFC and frame a question that has only 2 options, you're soliciting a vote, not a discussion.  Seppi  333  (Insert 2¢) 13:48, 7 April 2016 (UTC)
 * You were reverting to one of those options until the RfC began. Doc James  (talk · contribs · email) 18:47, 7 April 2016 (UTC)
 * Yes, I was, and so were you, but that's not really relevant. I'm not talking about what we were doing in the article, I'm talking about having a discussion on the talk page in order to arrive at an agreeable compromise.  One can discuss what parts of an edit they take issue with and what parts they don't even during a full-blown edit war.  Seppi  333  (Insert 2¢) 19:00, 7 April 2016 (UTC)
 * As one who's read a lot on AD/HD, I say leave executive function out of the lead. Seppi333, I agree that it's relevant to the subject — there's abundant literature from researchers exploring the association between EF and AD/HD. However, I'm not convinced that it's essential to describing the disorder. Furthermore, the lead is already overly-detailed, and I agree with Doc James that it needs to be simplified. —Shelley V. Adams ‹blame credit › 19:35, 8 April 2016 (UTC)

This is a fairly moot issue because I'm not disputing the removal; I don't really care if it's in the lead or not. Nonetheless, ignoring any evidence supporting the characterization, the "AD" in ADHD is nominally an EF disorder. It's not essential to mention this in order to describe ADHD, I agree, but it is for any body of text that gives any serious weight to the pathophysiology of the disorder. The lead of this article is not such a body of text.  Seppi  333  (Insert 2¢) 20:25, 8 April 2016 (UTC)

Not a mental disorder / psychiatric disorder?
We have had in the article for some time that ADHD is both a mental disorder and a neurodevelopmental disorder. Not sure why there are attempts to remove that it is a mental disorder.. All the main listing in the DSM5 are mental disorders / psychiatric disorders. We all agree that it is also a neurodevelopmental disorder.

Doc James (talk · contribs · email) 06:11, 10 April 2016 (UTC)
 * Right, mental disorder is the umbrella category and then ASD and ADHD both fall under the subcategory called neurodevelopmental disorders. I guess it's might be kind of redundant but I think having both is fine. PermStrump (talk) 07:53, 10 April 2016 (UTC)
 * Yes mental disorder is a broader term and better understood than neurodevelopmental disorder. Doc James  (talk · contribs · email) 08:44, 10 April 2016 (UTC)


 * Okay so the issue here is that the nebulously-defined term "mental disorder" has somehow stretched to encompass neurodevelopmental disorders. However, calling ADHD a mental disorder is NOT supported by the majority of the scientific literature indexed in pubmed (at least according to a number of somewhat crude queries that I ran in pubmed's search), it is NOT supported by textbooks, books, and (many) journal articles that I've read, it is NOT supported by the DSM-V, it is NOT supported by the CDC, and it is NOT supported by Canadian practice guidelines for ADHD (haven't checked the US ones yet). The loose implication that ADHD may fall under the umbrella of mental disorders does not warrant a specific mention. Note that the autism page explicitly does not list the term mental disorder, even though as you say it is easier to understand (which is true, but it's still wrong).


 * After going through this page's history, I discovered some differences that were not preserved, so I compromised and used the old format with an updated wikilink (to mental disorders directly). I still don't agree that this is accurate, but at least this way it's clearer about the mental disorder's role without overtly misleading readers. However I would like to point out that including the mental disorder part on the page for at least one of the disorders mentioned on the mental disorder page (primary example: autism) would likely be very poorly received. Garzfoth (talk) 09:47, 10 April 2016 (UTC)
 * When those places refer to it as a "neurodevelopmental disorder" I don't think they're implying that it's not a mental disorder. In any case, I like the phrase "psychiatric disorder" better than "mental disorder," so personally, I'm fine with the revision in the lead. PermStrump (talk) 16:49, 10 April 2016 (UTC)
 * Mental disorder and psychiatric disorder mean the same thing. Do not have a strong feeling regarding which one we use.
 * And use the APA / DSM 5 consider autism to be a psychiatric disorder / mental disorder Doc James  (talk · contribs · email) 19:30, 10 April 2016 (UTC)
 * As far as I can tell the APA/DSM-V does not explicitly state that autism is a mental disorder. With ADHD, I found one or two pages on the APA site that explicitly calls it a mental disorder, neither of which were officially claimed to be the position of the APA (the pages were simplified descriptions intended for the public and apparently weren't maintained by the APA itself either). In short, the only hard evidence that we have is that you can infer all disorders in the DSM are mental disorders based on the title of the book. In pubmed, the term neurodevelopmental disorder (alone) is used most frequently. But I suppose I'm just being pedantic at this point, and I guess calling it a neurodevelopmental psychiatric/mental disorder is fine... However, I'm probably going to insert this term into the autism article(s) for continuity between articles (same rationale applies there), and then see how it's received. Garzfoth (talk) 21:07, 10 April 2016 (UTC)
 * Personally, I wouldn't do that if the only reason is to be consistent with the ADHD article. I imagine it could be contentious. I do think this wording is more accurate and, more importantly, more clear for people who might not know what a neurodevelopmental disorder is. But I was willing to weigh in on this article, because I'm not aware of an ADHD advocacy group that is specifically dedicated to saying ADHD isn't a disorder. For the autism article, I'm satisfied with it only saying "neurodevelopmental disorder" as long as the first sentence doesn't deny that it's a disorder. PermStrump (talk) 22:15, 10 April 2016 (UTC)

Source for gluten free diet not reliable
In the section on managing ADHD symptoms with diet, a literature review by Ertürk et al. (2016) is used to support this statement: "A 2016 review states that evidence does not support a clear link between celiac disease and ADHD, and that routine screening for celiac disease in people with ADHD and the use of a gluten-free diet are discouraged. However, untreated celiac disease, which often present with mild or even absent gastrointestinal complaints, could predispose to ADHD symptoms, especially those of inattentive type, which may be improved with a gluten-free diet." Now that I've had a chance to thoroughly read the paper, I don't think it's a reliable source for this statement. My issue is with the second sentence, because it was easy to find alternate sources to the support the first sentence alone, like Sethi and Hughes (2015). My issue with Ertürk et al.'s paper is that they contradict themselves in several locations and their conclusions are not supported by actual findings. Only 3 of the 8 studies they found a positive correlation between ADHD and celiacs and only 2 of those studies (both with the same lead author - Niederhofer) "showed" a decrease in ADHD-like symptoms after starting a GFD. All 3 were "low quality" with "very poor internal validity and small sample sizes" according to Sethi and Hughes.

For context, in Feb 2016, Ertürk et al. did a lit review of all of the trials ever published on ADHD and celiacs and they found 8 that discussed a possible association between CD and ADHD:
 * Ertürk et al. (2016)
 * Lahat et al. (2000) • Zelnik et al. (2004) • Pynnönen et al. (2004) • Niederhofer and Pittschieler (2006) • Ruggieri et al. (2008) • Niederhofer (2011) • Güngör et al. (2013) • Dazy et al. (2013)

After reviewing those 8 studies, these were their findings:
 * p2: Only one study considered ADHD as a possible onset manifestation of CD. However, no improvement was seen after starting a GFD treatment  (Diaconu, Burlea, Grigore, Anton, & Trandafir, 2013)

* Note Ertürk et al. didn't even mention if the 3 studies that showed a positive correlation between ADHD and celiacs found that GFD improved symptoms. In fact, Zelnik et al. explicitly found the opposite. According to other reliable sources, there's so much bias in the Niederhofer studies that they don't count.
 * 3-4: Only three out of eight studies reported a positive correlation between ADHD and CD: Two studies found an overall higher prevalence of ADHD in patients with CD (Niederhofer & Pittschieler, 2006; Zelnik et al., 2004), and one study reported an over representation of CD in patients with ADHD (Niederhofer, 2011). However, these studies show methodological limitations. The first study of Niederhofer (Niederhofer & Pittschieler, 2006) reported on ADHD symptoms rather than including a formal diagnosis of ADHD. In the other study (Niederhofer, 2011), only CD antibody serology was used to diagnose CD, without a confirmatory biopsy. In both studies, there was no control group (Niederhofer, 2011). The study of Zelnik et al. (2004) screened for combined ADHD and LD in patients with CD, without making a distinction between the presence of ADHD versus learning disorders in CD patients.

Yet, somehow Ertürk et al. came to the conclusion that: * Note that neither of the 2 studies cited in the conclusion were one of the 8 analyzed for the lit review. And if you look at those two studies, they don't support this statement. Lichtwak et al. (2014) weren't explicitly measuring ADHD or inattention symptoms, Lichtwak and all of the co-authors noted massive conflicts of interest, and their study was heavily criticized for bias and poor design by Lebwohl et al. (2014) for additional reasons. Terrone et al. (2013) also weren't testing for tru ADHD, just "inattention" in combination with other mental health issues like depression, anxiety, oppositional behavior, etc., and they were really vague about what inattention symptoms were reported and didn't show the before and after data. There's a reason they weren't included in Erturk or Sethi and Hughes lit reviews, so it's pretty shady for Erturk to turn around and act like those studies support their hypothesis when the actual studies they analyzed didn't.
 * p4: Newly diagnosed children with CD often complained of “aches and pains,” “easily tired,” “easily distracted,” and “trouble concentrating.” After 1 year of GFD treatment, scores on these items were reduced and remained low in GFD-compliant children (Terrone et al., 2013). Also in newly diagnosed adults with CD, a significant improvement in cognitive functioning, particularly verbal fluency, attention, and motor function, is noted after a 12-month adherence to GFD (Lichtwark et al., 2014). Thus, it is possible that in untreated patients with CD, neurologic symptoms such as chronic fatigue, inattention, pain, and headache could predispose patients to ADHD-like behavior (mainly symptoms of inattentive type), which may be alleviated after GFD treatment.

Sethi and Hughes (2015) also did a lit review of the published studies on celiacs and ADHD. They found 8 studies (with only one difference from Erturk - Chen et al. instead of Pynnönen et al.):
 * Lahat et al. (2000) • Zelnik et al. (2004) • Niederhofer and Pittschieler (2006) • Ruggieri et al. (2008) • Niederhofer (2011) • Güngör et al. (2013) • Dazy et al. (2013) • Chen et al. (2013)

This is what Sethi and Hughes found:





More importantly, beginning a gluten-free diet with out concrete biological markers for celiacs is contraindicated, so there's absolutely no reason we should be suggesting it might help ADHD symptoms. That suggestions should only come from their doctor after definitive diagnosis of celiacs.


 * According to the U.S. National Library of Medicine (2014): "You should NOT begin the gluten-free diet before you are diagnosed. Starting the diet will affect testing for the disease."


 * Also according to Sethi and Hughes (2015): "For several parents, even if serological tests for celiac disease are negative, they may insist on trying their child on an empiric trial of a gluten-free diet. In the absence of objective findings of celiac disease or gluten sensitivity, clinicians should advise against such practices and inform parents of the potential harms of a gluten-free diet. First, a gluten-free diet can be a significant financial burden for a family. Second, starting a child on a gluten-free diet can potentially adversely impact a child’s ability to participate in social activities such as school pizza lunches or birthday parties. And third, a gluten-free diet that is started empirically without first consulting with a dietician carries the risk of long-term nutritional deficiencies."

I propose this change: "A 2015 review states that evidence does not support a clear link between celiac disease and ADHD, and that routine screening for celiac disease in people with ADHD and the use of a gluten-free diet are discouraged." Another alternative would be not mentioning celiacs at all, which is my #1 preference. <b style="color:indigo;">PermStrump</b> (talk) 03:54, 15 April 2016 (UTC)


 * said "After reviewing those 8 studies, these were their findings: p2: Only one study considered ADHD as a possible onset manifestation of CD. However, no improvement was seen after starting a GFD treatment (Diaconu, Burlea, Grigore, Anton, & Trandafir, 2013)" This study is not included among the 8 of analysis (the reason is not specified).


 * Permstrump said: "*Note Ertürk et al. didn't even mention if the 3 studies that showed a positive correlation between ADHD and celiacs found that GFD improved symptoms. In fact, Zelnik et al. explicitly found the opposite. According to other reliable sources, there's so much bias in the Niederhofer studies that they don't count. " Sethi and Hughes (2015) is not a reliable source WP:MEDRS. Journal of Family Medicine & Community Health belongs to SciMedCentral publisher and SciMedCentral is included in Beall's List of predators journals]. So we let it out. The 3 studies that showed a positive correlation are:
 * Niederhofer & Pittschieler, 2006, CONCLUSION: The data indicate that ADHD-like symptomatology is markedly overrepresented among untreated CD patients and that a gluten-free diet may improve symptoms significantly within a short period of time. The results of this study also suggest that CD should be included in the list of diseases associated with ADHD-like symptomatology.''
 * Zelnik et al.,2004 in effect, states that in their study Therapeutic benefit, with gluten-free diet, was demonstrated only in patients with transient infantile hypotonia and migraine headache. but also "We conclude that the spectrum of neurologic disorders in patients with CD is wider than previously appreciated and includes, in addition to previously known entities such as cerebellar ataxia, epilepsy, or neuromuscular diseases, milder and more common problems such as migraine headache and learning disabilities, including ADHD."
 * Niederhofer, 2011 "CONCLUSIONS: Celiac disease is markedly overrepresented among patients presenting with ADHD. A gluten-free diet significantly improved ADHD symptoms in patients with celiac disease in this study. The results further suggest that celiac disease should be included in the ADHD symptom checklist."


 * And if we look at the Table 1 of the reliable systematic review, we see that only the two studies of Niederhofer evaluate ADHD prior to diagnosis and analyze results after GFD. Inclusion criteria of Zelnik study is CD on GFD. Really, of 8 studies included on this systematic review, only the two ones of Niederhofer apply the inclusion criteria previous to CD diagnosis. Thus, this conclusion "untreated celiac disease could predispose to ADHD symptoms, which may be improved with a gluten-free diet" are perfectly supported. In addition, they mention two other studies with the same conclusions. However, because of methodological limitations of all analayzed studies, they state "Up till now, there is no conclusive evidence for a relationship between ADHD and CD. Therefore, it is not advised to perform routine screening of CD when assessing ADHD (and vice versa) or to implement GFD as a standard treatment in ADHD.", which is also reflected on ADHD page.


 * Permstrump said: "More importantly, beginning a gluten-free diet with out concrete biological markers for celiacs is contraindicated, so there's absolutely no reason we should be suggesting it might help ADHD symptoms. " Nobody is recommending to start a gluten-free diet without a diagnosis of CD. "Untreated CD" means both CD diagnosed patients with lack of compliance with the diet and undiagnosed patients, prior to CD diagnosis.


 * And above all, Wikipedia is not a primary source, not an original research WP:NOR, we have to include conclusions of verifiable secondary sources and this source is a systematic review, published on Journal of Attention Disorders, with a current impact factor of 3.78. The effort of Permstrump reviewing this source is appreciated, but we must not forget that it is a peer-reviewed journal, the criteria for accepting and publishing articles are very strict (most are rejected) and that this review has already been rigorously evaluated by specialists. Therefore, the conclusions are supported and accepted. So I disagree removing the last sentence. We must reflect the conclusions with neutrallity, and not just what we like to say, per WP:NPOV.


 * Best regards. --BallenaBlanca (talk) 07:36, 15 April 2016 (UTC)


 * 6 out of 8 of the studies Ertürk et al. looked at did not support their hypothesis that GFD improves ADHD-like symptoms. The only 2 studies that supported it were both by the same person (Niederhofer). And we've decided to give equal weight to what Ertürk said about Niederhofer as we are to the other 6 authors. Equal weight is not NPOV (see WP:BALANCE). BallenaBlanca said, "Nobody is recommending to start a gluten-free diet without a diagnosis of CD. "Untreated CD" means by both CD diagnosed patients with lack of compliance with the diet and undiagnosed patients prior to CD diagnosis." That's what the article currently sounds like it's saying. <b style="color:indigo;">PermStrump</b> (talk) 07:55, 15 April 2016 (UTC)


 * You are confusing the results. If we analyze ADHD in CD treated patients, and there is no association, it doesn't mean that GFD doesn't improve ADHD symptoms, just the opposite, because the possible preventing role of the diet (In children with CD, however, the risk of developing neuropsychiatric disturbances is only 2.6% (compared with 26% in adults; Ruggieri et al., 2008). This discrepancy may be due to shorter disease duration in children, earlier elimination of gluten from the diet, stricter adherence to a diet, or a different susceptibility to immune-mediated disorders (Lionetti et al., 2010; Ruggieri et al., 2008).) In this review of 8 studies, 3 studies analyze treated CD people (CD on GFD), 3 studies analyze prevalence of celiac antibodies in people with ADHD, and 2 studies analyze people prior to CD diagnosis and after GFD (and found an improvement with a GFD, similar to other two studies not included among these 8 ones). Author's conclusions are the mentioned above and in the ADHD page.
 * Similar to your reasoning, we could insist on making the conclusion that gluten-free diet may prevent ADHD symptoms in CD people and include it (which moreover is reflected in the paper, so yes we could write it...).
 * We are Wikipedia editors and this systematic review is written, and already reviewed, by specialists (peer-reviewed). We must reflect the conclusions, that only are equal weight if we mention all of conclusions, and not only a part, because of the different methodologies of the studies analyzed.
 * Best regards. --BallenaBlanca (talk) 09:03, 15 April 2016 (UTC)
 * As wikipedia editors, when there's ONE review saying saying ONE other researcher made a certain finding that no one else has made, we can and should conclude that it's WP:UNDUE to include. No, we could not argue that a gluten-free diet may prevent ADHD symptoms because literally none of the studies said that. Moreover, Erturk et al. don't even say in the "clinical implications" section that GFD may improve symptoms, it's only mentioned earlier in the paper. At the end they conclude, "Up till now, there is no conclusive evidence for a relationship between ADHD and CD. Therefore, it is not advised to perform routine screening of CD when assessing ADHD (and vice versa) or to implement GFD as a standard treatment in ADHD. Nevertheless, the possibility of untreated CD predisposing to ADHD-like behavior should be kept in mind. Therefore, it is recommended for clinicians to assess a broad range of physical symptoms, in addition to typical neuropsychiatric symptoms, when evaluating patients with ADHD." This ADHD article is hyperfocusing on 1-2 sentences from Erturk et al.'s paper that do not accurately reflect the entirety of the paper and its overall conclusions. It sounds very much like we're telling people if their stomach is mildly upset and they get distracted easily, they should try eating a gluten free diet, which (a) isn't what any the studies found and (b) is the opposite of the medical recommendation. <b style="color:indigo;">PermStrump</b> (talk)  12:33, 15 April 2016 (UTC)


 * "No, we could not argue that a gluten-free diet may prevent ADHD symptoms because literally none of the studies said that." Non literally, but the authors of systematic review say "In children with CD, however, the risk of developing neuropsychiatric disturbances is only 2.6% (compared with 26% in adults; Ruggieri et al., 2008). This discrepancy may be due to shorter disease duration in children, earlier elimination of gluten from the diet, stricter adherence to a diet, or a different susceptibility to immune-mediated disorders", and ADHD is included among neuropsychiatric disturbances.
 * "It sounds very much like we're telling people if their stomach is mildly upset and they get distracted easily, they should try eating a gluten free diet" Well, now I understand your concerns. Let's specify, to avoid confusion, adding "which may be improved after diagnosis and treatment of celiac disease with a gluten-free diet" . I think now it is quite clear. What do you think?
 * Best regards. --BallenaBlanca (talk) 15:07, 15 April 2016 (UTC)
 * Oh! While I was writing this, made another edition.  I agree with the two options. --BallenaBlanca (talk) 15:14, 15 April 2016 (UTC)
 * Which two options are you referring to? Doc James  (talk · contribs · email) 18:40, 15 April 2016 (UTC)
 * (mine) and (yours). I prefer the second one (your latest edit): brief and clear. Best regards. --BallenaBlanca (talk) 18:53, 15 April 2016 (UTC)
 * , it seems that we can not be so brief, because of concerns of other users and   To avoid confussions, it seems that is better to expand the text. I will try.
 * Let me now if you agree. Best regards. --BallenaBlanca (talk) 12:46, 16 April 2016 (UTC)