contd. from

Skeptics say that there's no biological marker--that it is the one condition out there where there is no blood test, and that no one knows what causes it.

Well, people say that ADHD can't be real--that it can't be a valid disorder--because there's no lab measure for it. But that's tremendously naïve, and it shows a great deal of illiteracy about science and about the mental health professions. A disorder doesn't have to have a blood test to be valid. If that were the case, all mental disorders would be invalid--schizophrenia, manic depression, Tourette's Syndrome--all of these would be thrown out. They wouldn't be considered valid disorders; they'd all be fakes. There is no lab test for any mental disorder right now in our science. That doesn't make them invalid.

I might also point out, by the way, that there are no lab tests for all of all the disorders that we treat in medicine. There is no lab test for multiple sclerosis, for Alzheimer's disease, or for epilepsy. We may be able to use lab measures of them when they're in their most severe stages. But in their early stages, there are no lab measures. They're based on the same way we approach the diagnosis of ADHD. They're based on history, on your presenting complaints, how consistent those symptoms are with what we know about the disorder, and being able to rule out other possible explanations for your symptoms. And as long as we can do those things, we can come to the conclusion that you have this disorder and that it's a valid disorder.

I find these criticisms that there's no biological marker for the disorder to be a bit lame, quite frankly. They're actually kind of boring, because people really haven't gone to the library to do their research. If you're saying that we don't understand ADHD down to the level of molecules and cells and proteins within the brain, well, that's true. But that's true of many disorders in medicine and in all of psychology. But they're still valid disorders. . . .

How do the medications work?

Stimulants seem to work by increasing activity within certain brain regions. By increasing or stimulating these brain regions, they result in greater powers of inhibition. The individual is able to stop and is able to engage their processes before they act. . . . What the stimulants do is to activate these critical brain regions that are involved in inhibition.

Now, as far as what they're doing at the level of chemistry and proteins, we're not quite sure yet. We do have some indications that the stimulants are achieving an increase in the amount of dopamine that is within the synapses between brain cells--those critical gaps between the brain cells where the neurotransmitters are supposed to do their job. Evidence indicates that drugs like Ritalin slow up how much of that chemical is being reabsorbed into the nerve cell, so that more is left in the synapse. Other medications, like Dexedrine, may just increase the production of dopamine within these nerve cells.

However they do it, the stimulants all have in common that more dopamine seems to be available within these critical brain regions to allow them to be more active, and to do the job of inhibiting behavior that they're supposed to do.

Why are these drugs compared to cocaine?

The drugs are compared to cocaine because chemically, they are similar to cocaine. That doesn't mean that they act like cocaine. For a drug to be similar doesn't mean that it's identical or that it does the exact same things that cocaine happens to do. Many critics of the stimulants have badly misled the public into thinking that, because the drug is chemically similar, it is identical--and that's misleading. What makes a drug like cocaine addictive is how quickly it enters and clears the brain. Cocaine, because it is inhaled through the sinus passages, is rapidly absorbed into the bloodstream and taken immediately into the brain. There is a rapid change in consciousness. And it's that rapid change in consciousness that humans perceive as addictive, as so seductive to them.

On the other hand, drugs like Ritalin and the other stimulants are taken orally. They're absorbed very gradually through the intestine. They enter the bloodstream in very slow, gradual amounts. Therefore, they're entering and leaving the brain in a very controlled and subdued fashion. As a result, they are not addictive whatsoever when they are taken orally. All of the evidence points to these being non-addictive drugs when taken as prescribed.

Of course, if you were to crush a tablet of a stimulant medication and inhale it, you might well become psychologically dependent, and possibly even addicted to inhaling this medication. But, of course, you can do that with airplane glue and paint thinner and gasoline. But I don't see anybody requiring these being prescribed monthly the way we control access to the stimulants. Any drug can be abused if you administer it through a different route than the way it's intended to be used. But, used as prescribed, the stimulants are not addictive.

So you don't believe they should be classified as Schedule II?

. . . I've taken a position that they should be removed from the Schedule II controlled substances and allowed to be Schedule III drugs--where you don't have to go to a physician every month to get a new prescription, and they can be used like other psychiatric drugs--you can be given multiple prescriptions that you can renew. But I understand why some people might be a bit concerned about that, and not because the drugs are being abused by a large percentage of people or because they are addictive.

The concern arises about the potential for abuse--if you allow the drugs to be prescribed more easily, would they be abused more by the general population than they are now? That's an empirical question. We haven't tried that experiment to see whether or not our concerns are well founded. I happen to believe that the convenience that would come to families of ADHD children and the lowering of medical costs that would come with rescheduling these drugs into the non-addictive category would outweigh the abuse potential that some people think might be there. . . .

These meds are performance-enhancers. Are they also life-enhancing?

Well, many medications can be considered life-enhancing or performance-enhancing medications. Prozac, for instance, when it first came on the market, was criticized, because people were taking it to fine-tune some of the edges of their personality when they really didn't have major depression. And undoubtedly some people are taking stimulant medications, not because they have ADHD, but because they want to stay up and get more work done; or they're truck drivers who want to be driving longer hours without sleep than they ought to be; or they're people like Bob Fosse, the choreographer, who was so involved in his profession and didn't sleep much and was taking stimulants in order to be a more productive individual.

There are certainly people who can misuse the stimulants as performance enhancers. But the fact is that the largest percentage of prescriptions for the stimulant medication are being prescribed for the disorder, for a valid condition, and are being prescribed appropriately. There's always going to be a certain small percentage of the public who wants to try a medication to tweak their personality a little bit, to see if it makes them more competitive in this competitive environment that we live in. I don't think you're going to be able to stop that. But that's no reason to keep people with a legitimate mental disorder from having access to treatments that are well established and that are safe and effective for them.

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Written 2000. Updated 2001. Reviewed: 02/2006