Tuesday, September 13, 2016

"ADHD Nation" Perpetuates ADHD Myths & Half-Truths

The recent book, "ADHD Nation", by Alan.Schwarz, MD and the WSJ story, "The Ritalin Generation", by Sally Satel, MD, perpetuate the existing myths and half-truths about ADHD.

Here's a list of some of those myths/half-truths along with the REALITY as I know it from 40+ years as an ADHD specialist.

1. There's an epidemic of over-diagnosis and the blame lies with:
Overzealous Physicians  -  FALSE.
     REALITY:  The vast majority of ADHD diagnoses are done by primary MD's who are poorly trained and poorly informed about ADHD.  Furthermore, most of them tend NOT to follow AMA guidelines for diagnosing or treating ADHD.  A study by AAP in 2014 confirmed this at a level of 92%!  By a very wide margin, MD's have more influence than any other single entity over how and whether ADHD is diagnosed and how treatment is done.
Nervous Parents  -  SLIGHTLY TRUE.
     REALITY:  The vast majority of parents tend to follow the family physicians' advice.  Thus, most parents are as badly misinformed as the their physicians.
Schools Looking to Rein in Troublemakers  -  SLIGHTLY TRUE.
     REALITY:  Most school staff (public or private) tend to be as misinformed about ADHD as most physicians.  The Federal Gov't. sets the rules by which ADHD students are assessed and taught. Many of those rules are inconsistent with evidence-based research about ADHD. Also, a substantial portion of ADHD students are not "troublemakers."  However, they are either struggling or failing academically and often go unidentified.
Pushy Drug Companies  -  PARTLY TRUE.
     REALITY:  Many pharmaceutical firms that market ADHD medications are clear examples of "bad capitalism", i.e., their profit motive has overtaken their ethical obligations to patients with ADHD.  However, again, physicians have much more influence over who is diagnosed with ADHD, how, and what treatment approaches are used.
     REALITY:  The REAL epidemic is one of mis-diagnosis and mis-treatment by primary MD's with insufficient knowledge about ADHD diagnosis and treatment; and failure to make appropriate referrals to ADHD specialists.
2. Many experts agree that the prevalence of ADHD is about 5%  -  SOMEWHAT TRUE.
     REALITY:  Most experts agree that we have no idea of the actual prevalence of ADHD.  Many "experts" believe that the prevalence is significantly higher than 5%.  ADHD is a "spectrum" disorder just as Autism and most other mental disorders.  This means that there are some people who definitely meet the full clinical criteria and that there are others who's symptoms are somewhat below full-clinical-criteria, but who none-the-less have significant difficulty functioning in life.  It is important to note that in recent years epidemiologists have conceded that the prevalence of OCD and Bipolar Disorders have been vastly under-estimated for decades.
3. Diagnosis of ADHD is commonly determined by a checklist  -  PARTLY TRUE.
     REALITY:  A large percentage of primary physicians reportedly do use checklists as their main or only means of diagnosis.  Overwhelmingly, those clinicians who specialize in ADHD adhere to AAP or AACAP guidelines for ADHD diagnosis.  Those guidelines are rigorous and exhaustive.  Few primary MD's refer potential ADHD patients to ADHD specialists.
4. Medication is the default treatment option  -  PARTLY TRUE.
     REALITY:  More primary MD's are recognizing the importance of behavioral/family therapy as a FIRST treatment choice.  However, many do continue to "default" to medication.  There have been several recent studies confirming the value and effectiveness of therapy first.
5. It's easy to fake ADHD symptoms in order to get medication.  -  FALSE.
     REALITY:  For the "trained observer" (i.e., ADHD Specialist) this is generally untrue.  For the common primary MD, with minimal knowledge about ADHD and a very busy schedule this a distinct possibility  - but it needn't be!
6. Horrible reactions and side-effects to ADHD meds. are common.  FALSE.
Case examples given in the above publications are of the "horror story" type, e.g., patient is diagnosed with ADHD, put on medication and later develops addictions to various licit and/or illicit substances
     REALITY:  Those cases are in the minority and largely develop as a direct result of improper physician diagnosis and/or treatment, e.g., primary MD's rarely have the time or inclination to perform the necessary follow-up needed with ADHD patients.  Without proper F/U bad things are bound to happen.
7.  C. Keith Conners, "Father of ADHD", has decried the "over-diagnosis" of ADHD in "epidemic" proportions.  -  FALSE.
     REALITY:  Dr, Conners' persona as the "Father of ADHD" and his recent comments are being misused to dramatize certain statistics about ADHD diagnosis and medication prescription  -  data whose meaning and true causes are still under debate.  This is being done by those who want to force the beliefs of "over-diagnosis" and "Bad Big Pharma" onto the public.  Dr. Conners actually expressed more concern about mis-diagnosis and consequent mistreatment.  The misuse of Dr. Conners in this manner only serves to side-track clinicians from a focus on patient-centered-care and evidence-based practice.  

Thursday, February 04, 2016

ADHD Meds.: Complaints & Solutions


ADHD Medications:  Typical Complaints & Solutions

Not eating - Allow healthy snacks; during summer break they often make-up for lost growth; eat by the  clock vs. hungry; if still OK on growth chart, don't worry.
Mid-late morning behavior problems - Adjust dose timing - at-home + mid-morn. doses; change to longer lasting medication.
After school behavior problems - Was noon dose given?; Change to long-lasting form.
Very irritable mid-late afternoon - Same as just above.

After 4-6 weeks meds. not working as well – Called “acclimation phenomenon”; increase dose

Trouble falling asleep - Make dosage time earlier, or, amount smaller.

Still can’t get up, wake-up mornings - Give pre-awakening dose; re-review sleep problems for possible solutions.

More withdrawn, crying, angry - Lower dose or change medication.

Too zoned-out; very tired - Same as just above.
Headaches; stomach pain - Try Tylenol and/or Pepto-Bismol, wait 1 week; maybe just initial reaction (not uncommon).

Refuses to take it - Do more education; discuss their resistance: Stigma?; How it makes them feel?; Trouble swallowing pills?; Feel it's "controlling" them?
Nothing happened after 1 month! - Should have increased dose after 1-2 weeks!

Uncertain what to expect? - Get education from doctor, Internet.
Helped some problems, not others - Depends on which symptoms it helped and which it didn't; Discuss with doctor; Consider different medication or second medication.  Re-check diagnosis.

Medication effects don't last long enough - Dose maybe too low; Consider longer lasting form; most meds. last from 6 to 12 hrs.; individual metabolism varies & effects med. duration.
Feel too "revved-up", or shaky - Dose too high; Wrong med.?

Skin itches a lot - Dose too high; Wrong med.; try lotion or Vit. E capsules; stimulants can cause skin dryness.
Everything is much worse - Wrong med.; re-check diagnosis; most ADHD people have at least one co-occurring condition.

Can't swallow pills! - Try new liquid form or patch; if capsule, try sprinkling over food.
Pharmacist says ADHD meds. are all the same, or, all forms of Ritalin (methylphenidate) are the same - Absolutely FALSE!  Different ADHD people tend to respond best to different meds., and, to different formulations of the same med., e.g., Concerta vs. Ritalin LA.

Don’t have insurance; can’t afford meds. – Look on drug manufacturer web site for “Patient Assistance Program” (PAP), or, call their 800#.  PAP’s provide meds. at low cost depending on income.
I’m afraid about what others say about side-effects – All substances, whether prescribed meds. or “supplements” have side-effects.  The vast majority of truly problem side-effects from ADHD meds. occur due to incomplete or mis-diagnosis, and lack of prescriber knowledge about ADHD and how ADHD meds. work.  If your prescriber is a specialist in ADHD or very knowledgeable about ADHD and how ADHD meds. work, you should be able to avoid most if not all side-effects.

I’m concerned about long-term effects of ADHD Meds. – Ritalin has been on the market since 1954.  Amphetamines have been used to treat ADHD about as long or longer.  Although more well-done studies on long-term effects are needed, no significant problems have been documented to date.  The very negative life-costs of not taking ADHD meds. has been well documented, e.g., higher rates of divorce, unemployment, injury, lower income.
KEYS TO SUCCESSFUL ADHD MEDS. TRIALS:

1.       Going to see an “ADHD Specialist.”  Not just any old “doctor” or mental health professional will do.

2.       Thorough diagnosis; including co-occurring conditions.

3.       Monitoring responses.

4.       Patience.

5.       Sticking with a “Specialist.”

6.       Always consider diagnosis review/update.

Monday, November 09, 2015

Traditional Classroom Model - Not for ADHD Students!



   

      

Doesn't Work for ADHD Student                            Best for ADHD Student

30+ students per classroom                                  Less than 20 Students
Whole word learning                                             Phonics
Rows                                                                  Work/Study Groups
Level playing field idea                                          Learning differences accepted
Low stimulation room                                            High stimulation room
Primarily auditory methods                                    Multi-Sensory Methods
ADHD = “Developmental Lag”                                ADHD = Neuro-Biological Disorder
Children are "little adults"                                      Each child an Individual
ADHD Child - “immature”                                       Teach appropriate behaviors
"Goals and Objectives" Emphasis                          Evidence-Based Remedial Methods
Motivation/Responsibility assumed                         Teach Motivation/Responsibility 
                                                                                        (ADHD student’s core problem)


Tuesday, February 03, 2015

What Does ADHD Look Like in School?

What It Looks Like In School

*Spacing-out
*Absenteeism
*Excessive talking
*Off-task behaviors
*Distorted sense of time
*Disorganized or Perfectionistic
*Responds negatively to correction
*Often unprepared, loses materials
*Poor/conflicted peer relationships
*Disruptiveness, clowning, defiance
*Difficulty with Transitions/Changes.
*Physical restlessness or slow moving
*Careless mistakes, omissions, rushes
*Doesn’t seem to “get it” (cause-effect)
*Incomplete work, not finishing on time
*Misses and/or misinterpret social cues
*Poor recall, forgets, trouble memorizing
*Homework is missing; but it’s completed!
*Inconsistent performance (grades, behavior)
*Defiant and/or uncooperative, or overly submissive
*Relates better to older and younger children (not with peers!)

Academic Problems -
*Messy, stilted hand-writing
*Trouble copying from board
*Poor reading comprehension
*Difficulty reading; dislike of reading
*Written expression (getting it on paper)
*Difficulty with sequencing (auditory, visual)
*Math. concepts, word problems, times tables, algebra
*Poor grammar; sentence structure; punctuation; capitalization

But, often does well in PE, Art, Music, and/or Science

Not All symptoms need be present

Monday, November 24, 2014

5 trends driving global rates of ADHD


"5 trends driving global rates of ADHD"
Brandeis University
Peter Conrad and Meredith R. Bergey attribute ADHD’s growth to five trends:

1. Drug companies are effective lobbyists, and have spurred some countries to relax marketing restrictions on stimulants.
2. Psychoanalytic treatment with talk therapy is giving way to biological psychiatry—treating psychological problems with drugs.

3. More European and South American psychologists and psychiatrists are adopting the American-based Diagnostic and Statistical Manual (DSM) standards, which are broader and have a lower threshold for diagnosing ADHD.
4. Vocal ADHD advocacy groups work closely with drug companies to promote pharmaceutical treatment.

5. The easy availability of ADHD information and self-diagnosis online empowers consumers to ask for prescription treatment.
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I approached this story with great interest.  But the more I read the more annoyed and disillusioned I became.  It is written by a sociology professor and a doctoral candidate at Brandeis University.  One of Professor Conrad's areas of academic emphasis is the "medicalization of society".  Another is the "sociology of ADHD."  Ms. Bergey appears to be primarily a medical researcher, most recently from the University of Pennsylvania, with no apparent background in ADHD.  These factors are important as they directly underlie the basic theme of their "study", i.e., the international medicalization of ADHD.  So that's their bias.
My bias stems from being a 40+ year veteran of direct clinical practice and study of ADHD.  From my viewpoint, Professor Conrad and Ms. Bergey are academicians whose "theories" clearly emanate from the "ivory tower" of education.  Not the "real" world.  There are several clues within their "5 trends" to their cloistered perception of the world of ADHD  -

1. Drug companies do have a significant influence but are not a primary driver of ADHD diagnosis or of medication usage.  Stimulant medications are not "bad" in and of themselves.  Their appropriate prescription, management and usage are the key problems.
2. "Psychoanalytic treatment" never, ever was considered an appropriate treatment for ADHD.  One form of "talk therapy" called Cognitive Behavioral Therapy (CBT) along with Family Therapy are evidence-based treatments for ADHD.  There is no mass-movement from these latter therapies to "biological-psychiatry."

3. The "broader" diagnostic guidelines in DSM-V ARE research and evidence-based.     
4. Stating that, "ADHD advocacy groups work closely with drug companies", tends to imply some collusion.  For the most part, ADHD advocacy groups maintain a primary allegiance to consumers  -  parents, families and ADHD adults.

5. The easy and increased availability of ADHD information and screening tools on the Internet are primarily positive public education mechanisms.  The action of consumers asking physicians for prescriptions is a doctor-practice-management issue.  Perhaps THE most significant factor in both excessive and inaccurate ADHD diagnosis is the FACT that over 90% of physicians who first see potential ADHD patients do NOT follow accepted guidelines for diagnosis or treatment.
Prof. Conrad and Ms. Bergey appear to be out to make-their-mark in the current realm of ADHD controversies.  Their contribution is of dubious value.