Focusing on ADHD for Forty Years

[[{"type":"media","view_mode":"media_crop","fid":"17480","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7760993925813","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"982","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]It is the beginning of the school year and, besides school supplies, ADHD comes to mind for many. Hopefully, evaluating or reassessing ADHD has already been done or is soon about to be for those students who seem to have trouble with attention.

In one way or another, I have been involved with evaluating and treating ADHD for about 40 years. It started in 1971, when I began an internship at the infamous Los Angeles county hospital system. Half of that internship was general medicine, and the other half was child and adolescent psychiatry.

As became common, my wife led the way. While I was in medical school at Yale from 1967 to 1971, she became one of the first learning disability teachers in the nation. On occasion, she would teach me about the role of the stimulant methylphenidate (Ritalin, Concerta, Metadate, Methylin), which was often used when full-blown ADHD was responsible for learning problems.

Until then, my experience with stimulant medications encompassed treating addiction in the drug abuse era of the 1960s, often leading the vulnerable to paranoia, depression, or even precipitating schizophrenia. In fact, one test for diagnosing schizophrenia was to administer a small dose of an amphetamine and see if the thinking of the patient became more disorganized. I wondered at that time how a stimulant could calm someone down with ADHD, but cause agitation in "normal" patients or those with certain mental disorders. Little did I realize the answer to this question would challenge us 40 years later.

After my psychiatric residency from 1972 to 1975, I had to spend 2 years in the Army. There, I moonlighted as a medical director of a community mental health center, where my wife worked in the child psychiatry department. Those were “the good old days” of comprehensive centers, where consultation and education to schools was part of federal funding and expectations.

Given that successful experience, my wife suggested that we open a clinic focused on ADHD. However, I yearned for something broader and felt an ethical need to serve the underserved, so I went on to work in academic psychiatry, while my wife privately taught students with learning disabilities for many years.

In retrospect, perhaps she was right yet again. Given that I never did the full fellowship training in child and adolescent psychiatry, I did not often treat patients with ADHD until it became recognized that perhaps a majority of children did not “outgrow” ADHD, as was once thought. Consequently, by the late 1990s, I started to treat many adults who seemed to have ADHD, even if the hyperactivity symptoms they experienced when they were children died down.

And the initial results? The closest to a cure I had ever experienced-but the cure only lasted as long as the medication was taken. Work and relationships improved. More stimulant medications became available, including some that lasted a whole day. But, alas, I learned quickly not to be casual about the diagnosis. Stimulants, the most effective kind of medication for ADHD, could also be abused, diverted, cause problematic side effects, and even contribute to suicide. The best dosage was subjective. In fact, how could you really be sure that an adult had ADHD? Even if they did have ADHD, had they successfully learned enough coping strategies? Perhaps even to use their tendency to be distracted in a creative way?

A patient of mine once blamed me for becoming psychotic and paranoid on high doses of Ritalin. I then decided that new patients should have sophisticated ancillary psychological testing and family input. Given that such tests were expensive, often not covered by insurance, and not readily available, this was perhaps an overreaction on occasion.

Given my interest, as well as the increasing brain research showing differences in patients with ADHD, I suggested that a clinic be set up in our academic setting. Not only was that turned down, but some sort of suspicion led to my prescribing of stimulant medication to be secretly reviewed. I only found this out years later. No problems were discovered.

I was discovering more complications of treating ADHD in my own practice. There seemed to be a complex and challenging relationship among the disorder itself, stimulant medications, substance abuse, and criminality. For instance, from 2009 to 2012, I worked in a state prison for men. There, stimulants were taken off the formulary because the inmates were skilled in manipulation to obtain these medications, both from physicians and from other inmates. Unfortunately, alternative medications did not work nearly as well, especially for the core symptoms.

For many patients with ADHD, the risk of substance abuse seemed to become less of a risk when they were properly treated with stimulants. This is not always the case. In her interview on August 18 with Oprah Winfrey on “Oprah’s Next Chapter,” Lindsey Lohan claimed that what was different now, after many relapses with substance abuse, was that she was no longer taking the stimulant Adderall for presumed ADHD. She claimed to be calmer without it, although time will tell if this medication was unnecessary or even harmful for her.

Another recent case seemed to cause my history with ADHD to come full circle. In a series of front page articles in the Milwaukee Journal Sentinel on the crisis in mental healthcare in the city of Milwaukee, the reporter had asked me about a particularly challenging and worrisome case.¹ A mother had been trying to get care for her 25-year-old son, who had been diagnosed with schizophrenia, but was in and out of hospitals with poor medication compliance and behavior that was becoming ever more threatening. What struck me was that he also seemed to have much difficulty with impulsivity, hyperactivity, and focus. Those symptoms, coupled with the prescribing of Ritalin during his childhood, made me wonder if he also had ADHD, which could be partially responsible for the failure to get him adequate help. If so, the major challenge would be to get the symptoms of schizophrenia under enough control before attempting to use any medication for ADHD, which otherwise could make him more psychotic, just like it did with those patients 40 years back who were given stimulants to see if they really had schizophrenia!

Over 40 years, I have learned that sometimes the diagnosis of ADHD is clear, treatment with medication successful, education specialists and supportive psychotherapy helpful, and all becomes well. However, the complications are common, so the utmost care must be made with the diagnosis, medications carefully prescribed, and the public educated better of the benefits and risks. Schools at all levels need to know about the risks of diversion. In persons without ADHD, stimulant medication indeed helps focus and lessens the need for sleep, at least for a time. Pediatricians and family practitioners should be very cautious about prescribing stimulants. Without supplemental education, even psychiatrists should be cautious. Treating ADHD may need its own special attention.

References:

1. Kissinger M. A mother, at wits’ end, sets out to find help for her sick son. Milwaukee Journal Sentinel. July 20, 2013. http://www.jsonline.com/news/milwaukee/chronic-crisis-out-of-options-in-milwaukee-county-mother-searches-for-mental-health-care-in-California-for-son-215702231.html. Accessed September 9, 2013.