How do you treat ADHD?

Multimodal treatment is best. The place that everybody often at least explores and starts with is medication. Medications help level the neurologic playing field, so that the person can have an equal shot at success. Now, medication is not a panacea. Pills don't give skills. But what it does is it gets the person in the door, so that then they can do all the remedial work that they need to do. They need to get caught up on their schoolwork, where they couldn't do it before, because they couldn't pay attention or they couldn't sit still long enough to study. And they need to go back and pick up skills in the social realm. . . . They have to go back and learn organizational skills, because these folks are terribly disorganized. There are a number of things that they have to learn, but the medication makes it possible. . . .

Over the last 20 years, if you read the literature, there are two great trends. One is validating the diagnostic criteria to say that this is a valid, reliable set of criteria if you apply them in order. The other one is saying what works in treatment. There are now over 170 double-blind control studies showing that the stimulant class of medications is effective. . . .

There are also a whole bunch of studies that show that a whole bunch of other things have an effect. And so the federal government, about six years ago . . . established the Multimodal Treatment Study of ADHD--the MTA--which was published in December,1999. That's the largest study ever undertaken of a mental health disorder in children. It's a huge study.

They took 579 elementary school-aged boys and girls who had the combined type of ADHD. And they broke them into four different treatment arms. The first group got just medication, and the medication was fine-tuned to the . . . child. The second group got intensive behavior management. By intensive, I mean two months of an immersion summer camp program--12 weeks of somebody coming in every day into the school to work with the teachers; 26 weeks of parent training, so the parents could use these techniques at home; 26 weeks of the kids getting individual and group treatment. In other words, a very money-, labor-, and time-intensive treatment. A third group got medication plus behavior management. And a fourth group, armed with world class work-ups, got referred out into their communities to see what would happen.

At the end of the study in 14 months, more than a year, the results were striking. . . . The two groups that got medication did wonderfully. They did exceptionally well. Adding the behavior management component did not improve the outcomes, unless you had an anxiety disorder, a co-existing condition, or you came from a single-parent family; then it made a difference. But it didn't make a huge difference. It didn't make a detectable difference in the outcome for ADHD.

And down from those was the intensive behavior management program. . . . It was nowhere near as effective as medication was. The big disappointment was that, when they came back after the intensive behavior management program had ended, there was no evidence that it had ever occurred. The hope had been that these techniques would be internalized by the children and that eventually, this very expensive treatment could be attenuated and ultimately stopped. What they found was that, as soon as the treatment stopped, so did the benefits.

If you have a choice of what to do for somebody who has ADHD, isn't the medication the first and best choice?

It is where most people--a vast majority of people--should start. But it is not where they should end. . . .

I've talked to a lot of pediatrician psychologists and psychiatrists who say that these stimulant medications do help, that they do improve performance of just about everybody--not just those with ADHD.

. . . Stimulant-class medications will enhance the performance of just about anybody, mostly through reaction time and vigilance. But it doesn't give the huge and drastic changes that you see in people with ADHD.

I worked with a parent who said very much those same things. And so I said, "Let's go ahead and see if that's true. I will bet you my fee that it's not true." We sat down and the parent went through and did a computerized test of their attention and impulse control. They did exceptionally well. We gave them five milligrams of Ritalin, and they came back in an hour and a half later, and did exactly the same test. Their reaction time increased somewhat--not dramatically--but increased. But their impulsivity just went wild in terms of their twitchiness when taking the test.

That parent had to see that, yes, it does increase vigilance and reaction time. But it actually causes a decrease in performance in terms of impulse control. And that's far more typical of people who don't have ADHD. The people who do have ADHD have fundamentally different nervous systems. And the medications behave in totally different ways for those people.

. . . We're in the midst of a revolution. We've got a set of drugs treating ADHD. If the prevalence rates are as high as I think you've argued, as much as anywhere between 5-12 percent, this should have an enormous impact on our society--if people are treated for something in the future that they weren't treated for before.

Right.

You would agree that this is a real revolution? In what way?

Yes, it is a revolution; it's very slow in coming. Our diagnostic criteria have been around 25 years. . . . Amphetamine has been used for 63 years, Ritalin for 32 years.

Right. But it's only been since 1990 that we've seen a real increase. Why is that?

Our understanding of the disorder continues to evolve. . . . Twenty years ago, the only child who was going to be identified, and therefore treated, was the hyperactive child who was pinging off the wall, who was aggressive, uncontrollable, and obnoxious. And so this was the child who was referred for evaluation. This was the child that everybody could agree was hyperactive and who would benefit from medication.

It has only been in the last ten to twelve years that we see that actually, the hyperactive aggressive child makes up only a small percent--20 percent or 25 percent--of people who have ADHD. There are far larger numbers of people who don't have any hyperactivity at all, and they are purely the inattentive subtype. . . .

The inattentive and impulsive symptoms continue unabated for a lifetime. And so it is this recognition--that there are a lot of people out there who have purely inattentive symptoms, who aren't hyperactive, who are not aggressive or obnoxious--who also have this disease. And this is where we start picking up females. When I was in medical school, I was taught that women did not get Attention Deficit Disorder. It turns out that women get it just as often as men do. The assumed prevalence is about one to one, male to female. It's that it's exceedingly rare for a woman to be hyperactive. . . . And so now what we're doing is doubling the apparent prevalence rate by recognizing that the quiet, inattentive child who daydreams in the back of the class also has Attention Deficit Hyperactivity Disorder, just without the hyperactivity. . . .

So that's why we have such a rapid increase in the prescription rates?

Dr. James Swanson in California did a study of that. And we are seeing an increase in the number of people who are being diagnosed and treated. But the biggest increase in the number of prescriptions, according to Swanson, is that people are being treated for longer periods of time. Once a person starts on the medication, we now recognize they'll benefit from the medication their entire life. They're being treated for more days--not just Monday through Friday while they're in school. They're being treated 7 days a week, 52 weeks a year.

There is more of an acceptance of the disorder. People are more willing to give their children a trial on medication. And there's more of an awareness in teachers and Girl Scout leaders and doctors, in people who work with children, to recognize the disorder, and to suggest to parents that they might want to have it looked into.

Lots of people say there's also over-diagnosis--that a certain hysteria is taking over that it has become the disorder of the decade.

The diagnosis is still missed two out of three times, and even when it is made, it is under-treated. The fourth treatment arm in the MTA study was one in which the children, armed with world-class evaluations that said this person very definitely has ADHD, were referred out into the six communities of the study. There, one in three got no medication, got no services whatsoever. Those that did get medication got medication at lower dosages than the study indicated that they probably would've found optimal benefit from. . . . When you actually go out there and you say, "I want facts, rather than opinion," the facts are that the diagnosis is still missed more than half the time. And even when the diagnosis is made, it is grossly under-treated.

Is there a danger that it's being over-diagnosed in certain communities and under-diagnosed broadly in other social classes, thereby making the difference?

There are two case reports out of Virginia showing that, in two counties, there was a very high prevalence of a diagnosis of ADHD, higher than the national average. They did not go in there to see whether or not these were accurate diagnoses. . . .

How does the ADHD diagnosis differ between social classes?

The disorder is found pretty much equally through different socioeconomic groups. ADHD is found in every culture, in every socioeconomic group, in pretty much the same prevalence. . . . I'm aware of one study that showed that black inner-city males were diagnosed with ADHD more commonly than you would expect from the general population. But again, this could be clustering. It could very well be a valid diagnosis.

. . . Where is the controversy?

. . . It's not just ADHD that is controversial. The vast majority of people in this country don't want to acknowledge that children have major mental illnesses of any sort. They don't want to acknowledge that there's childhood schizophrenia, that there's childhood manic depression. They don't like to acknowledge that some children murder other children. They don't like the fact that there are childhood sociopaths. And yet, those things exist.

The NIMH study that Peter Jensen authored concludes that all mental disorders in children are under-diagnosed and grossly under-treated. . . .There is just a fundamental aversion in this country to acknowledging that children can be mentally ill.

Then why would we have such a rapid increase in the prescription rates for ADHD?

There is a rapid increase. But if you start at a very low recognition rate and it increases, yes, it's going to be rapid. But you're still missing at least half.

. . . We're talking about large numbers of kids receiving prescriptions. Is that correct?

But it's still a small percentage of those who should. We're still missing the majority. In Germany, for instance, when they did the prevalence studies to validate the shift in diagnostic criteria from the DSM-III to the DSM-IIIR, they went out and they screened every child in an entire city in Germany. . . . And there, they found that 17.7 percent fulfilled all diagnostic criteria for ADHD. They did the same study in an entire county in Tennessee, and there they found that 12.7 percent fulfilled the full diagnostic criteria.

. . . Every time they look for ADHD anywhere in the world, they have found it in pretty much the same prevalence. . . . Is it treated the way it is in the United States? No, it's not. . . . We're at a cusp in history in which people are beginning to recognize, "Wow, this has been around forever." We have a great treatment for it, so more and more people are taking advantage of that treatment. . . .

Why does it remain extraordinarily controversial?

. . . In this country, there is a tenet of faith that says that any difficulty in life can be overcome if you have a good character, if you try hard enough and long enough. And so they don't like that tenet of faith challenge, that there are some children who come from the womb genetically predisposed to being inattentive, compulsive, somewhat reckless, and perhaps aggressive. No matter how hard they try, trying harder is ineffective.

These people confuse an explanation for misbehavior and failure with an excuse. In point of fact, when people are diagnosed with ADHD, more is expected of them, not less. Now that you've got the diagnosis, now that you're on medication, our expectations for your performance in life are going to increase. But there are a lot of people who say, "I don't want to let the person off. I don't want this to be an excuse." But it's not an excuse. It's an explanation. . . .

Most people think we're talking science here. In fact, we know that this drug has an effect on children and adults who display certain syndromes, but we don't know what it is. Does that disturb or concern you?

It doesn't concern me. I'm curious and I want to know why it works, because once we know why it works, we can probably develop better medications and better treatments. We did find, totally by accident, that these medications work. The original reason that they were used back in 1937 was due to their anti-seizure properties. They found that they had a much more dramatic effect upon behavior and attention and impulsivity. . . .

If you look at the history of medicine use in psychiatry, until Prozac came along in 1988, every single medication in psychiatry was discovered by accident. They were using the medication for some other purpose and they found that mental health symptoms improved when you used that medication. I don't have to know how a medication benefits my patient. All I need to know is that it does. I won't wait around until some good hard-edged scientist can tell me the how. . . .

. . . Another concern people have is that "amphetamine" sounds like it's a street drug.

Many people mistake methamphetamine, which is a street drug and which has a powerful euphoric affect, for simple amphetamine, which doesn't. Simple amphetamines, simple methylphenidate, do not have much abuse potential. They don't produce a euphoric high. Other stimulants do. Cocaine does. Methamphetamine does. Ecstasy does. But these simple compounds, like simple amphetamines, simple methylphenidate, have very little abuse potential . . . .

. . . But what if the parents say, "I don't want to take away my child's personality, his spirit, his uniqueness?"

Properly adjusted medication does not change the child's personality any more than eyeglasses will change their personality. Eyeglasses help you to focus. The medication helps you to focus. It is true that, if a dose is too high, the child will have side effects. They will, perhaps, get what they call the "zombie syndrome," in which they do become dull. But that can be removed almost immediately by lowering the dose.

In and about the controversy, there are people who feel that the increase in the prescription rates has to do with the HMOs wanting quick, cheap fixes. Is there any validity to that?

. . . Over the last ten years, there has been extraordinary pressure within the medical field to deliver all medical care much more quickly and, therefore, much more cheaply, than it ever has been delivered before. And so there is a lot of economic pressure to diagnose and treat all disorders, medical or psychiatric, more cheaply and more quickly. So surely, yes, that's going to trickle down to the diagnosis of ADHD.

Can ADHD be diagnosed in a 15-minute well-baby check-up at the pediatrician? No way. In order to do a good, adequate evaluation, you need several hours: to do the evaluation: to rule out all the things that might mimic ADHD; to thoroughly evaluate all the things that can co-exist within ADHD; to educate the parents about the use of medication, and about the ancillary treatments that are going to be necessary; to do a quick screening for learning disabilities. A good, thorough evaluation takes time.

But we're not set up to do that?

We're set up to do it. It's that ADHD and managed care just don't go together. Managed care wants it done quickly and cheaply, and ADHD can't be done quickly and cheaply.

Another controversy is the role of the pharmaceutical companies in marketing these drugs. . . . The pharmaceutical companies make profits off of the sale of Ritalin or Adderall or Concerta. They're companies. They can strategize and put out a marketing message. The alternative therapies--such as behavioral therapy or psychotherapy--don't have that kind of lobbying muscle or marketing muscle. Therefore, it tilts the balance in favor of medication over other therapies.

Physicians tend to be very pragmatic people. They do what works, what gives the best outcome for the patients. And that's why there has been controversy, and why the federal government spent $17.7 million to do the MTA study to try and figure out where they were going to spend the money that they spend on insurance. The federal government insures one out of six people in the United States.

. . . This study is not funded by drug companies. It's funded by the federal government. And what they found is that medication is more effective--that if you stop either medication or behavioral management, the benefits end. . . .

But isn't the system set up to prejudice us towards the development of better and better pharmaceuticals rather than other therapies, just because of the amount of money that is spent is disproportionately in favor of the drug? That's where the profits are. Is this a place where our system is perhaps not serving us well?

Everything in the United States is driven by the profit motive. We get better cars because we have a private enterprise of car manufacturers, who continue to improve their product in hopes of making more sales and making more money for their investors. That's the set-up we have in the United States. If people could demonstrate clear effectiveness from the treatments that didn't involve medication, I think that there would be a lot of people beating a path to their door. The fact is that they haven't been able to demonstrate that. . . .

I don't think that . . . just because there is a profit motive that pushes the development of drugs, you can therefore say whatever else is done is inadequate. There's also a profit motive there, because people do get paid to this type of treatment. There are teachers who do get paid to be special education teachers. . . . All of these things need to be done to treat ADHD. Just because one happens to spend more money does not invalidate the others.

Can you give me a description of what your relationship is with Shire-Richwood, the makers of Adderall?

Sure. I go out and I do educational presentations, and they pay a speaking fee, and they pay my expenses.

Are you on a staff basis? What's the nature of your contract with them?

I don't have a contract with them. They ask me if I'd be available to go and do an educational presentation somewhere. I go, I do it, and they pay for my time.

Would it be fair to say you're a spokesperson for Shire Richwood? How would you describe it?

No, because my presentation is entirely on ADHD, its treatment, and how the research that's out there can be applied to daily practice. I talk to pediatricians, neurologists, and psychiatrists about how the research can be applied to daily practice.

There are studies showing that money fronted in free samples and trips does have an influence on doctors' opinion. It changes your prescription habits.

If it did not change prescription habits, most drug companies wouldn't do it.

You have a financial relationship with a manufacturer of a major stimulant medication, knowing that it's going to very possibly skew your prescription habits.

I do presentations for a number of drug companies. For instance, I do some presentations for Pfizer. And yet, the antidepressant that I write for by far the most often is Prozac, which is made by Eli Lilly. My job is to be an educator. Docs are very independent people. If you try to influence them and tell them what to do, very often you get a backlash.

But you did confirm that prescription habits are affected by the sponsorship, free samples, perks, whatever. When your patient comes in here, do they know up front that you are representing and making speeches on behalf of Shire-Richwood?

A few do; most do not.

Is it a problem? You don't see it as a problem?

No, I don't. For the three drug companies that I do presentations for now, I have never once had anybody ever ask me what I was going to say, or ask me to skew it in one direction. What they want is a chance to meet with physicians and present their materials. And what they want is something the doctors will show up for.

What do you say to those people that criticize this kind of taking money from drug companies?

That it allows me to leave my practice, allows me to do the education that desperately needs to be done to bring docs up to speed without my taking a tremendous financial hit. And, in point of fact, right now I lose money every time I go out and do a speech. Financially, I would do significantly better if I stayed here and saw patients and charged them for my time.

Would you object to the statement that we're re-engineering the personalities and behaviors of a percentage of our children in order to make them function better in our society?

You present that as if it's a bad thing.

Some people would say we should be leaving them alone--that we should be loving them and supporting them--but that to give them medications that alter their brains is dangerous; that we're playing God; that we don't know what we're doing. We don't know the cause of the disease, and we don't know the effects and how the drugs work.

We don't know how the drugs do work, but we do know that they're safe. Amphetamine was invented over 100 years ago. We have people who have taken amphetamine every day of their lives--usually for narcolepsy, but also for ADHD--for 60 years. We've had people who have taken Ritalin every day of their lives for 32 years with no adverse affects, and with lots of benefit.

. . . For people who say, "Let's leave this well enough alone," or, "Let's be more cautious," without defining what "more cautious" would mean, I would ask those people to prepare themselves for that day 15 or 20 years from now when their child comes to them and says the following, "Now, let me get this straight. You saw that I was struggling. You saw that I was failing in school. You saw that I couldn't fall asleep at night. You saw that I was having trouble with my interpersonal relationships. You knew that it was ADHD. You knew that it had a good safe treatment. And you didn't even let me try? Explain that to me."

Those folks had better start working on their answer right now, because they're going to need 15 or 20 years to come up with a compelling answer for their child who asks them that question. "You saw me struggling and you did nothing?" That's a good question. And to me, it's a far more compelling one than saying, "We don't have perfect answers, therefore, let's do nothing." . .

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Written 2000. Reviewed: 05/2008