Attention Deficit Disorder – Conceptions and Misconceptions
Written by Moss David Posner, M.D. *
It seems that every day we open the newspaper or go online we see another article about Attention Deficit Disorder[i]. The subjects and titles of the articles vary from condemnation of the very notion of the existence of such an entity, to natural treatments for the problem, to warnings of dire consequences ranging from insanity to addiction with the use of medications, to attacks on the drug companies as having created the notion in the first place, to congratulations to those who are blessed with the gift of the disorder, and to treatments, from medications, to meditation, to physical therapies, hypnosis, and prayer.
Organizations abound, from those which are support groups, information sources, medical education sources, and sources of natural treatments. There are web sites for clinics that have professional and comprehensive treatment plans for those who have the disorder, including physicians, psychologists, social workers and coaches.
Attention Deficit Disorder (which hereinafter I shall refer to as ADHD, is rather unique for several reasons:
- First, it is most commonly seen in childhood, and commonly presents as behavior problems in school in the classroom, and with parallel problems at home. Often the sufferers are children who are referred to variously as restless, fidgety, trouble-makers, wild, uncontrollable, and so on, and so forth. Common to both settings are incredible disorganization, inability to follow-through on homework and projects, uncontrollable behavior, rebelliousness, unreliability, and even violence. These behaviors can be seen in different combinations, measures and degrees in different children.What makes this aspect unique is that virtually all of these descriptions of behavior can be observed in otherwise normal children, who most often will grow out of them in time, and therein lies the difficulty: How does one know if the behavior is simply that which is treated by discipline, or that which requires help from the medical and allied professions? Tragically, by the time the disorder is suspected or confirmed, enormous mental suffering and damage has occurred on all sides. Moreover, a teacher or parent is operating under enough stress to begin with, and initially does not have the inclination to look for more complex answers to what, on its face, looks like a simple problem of discipline.
- Second, there is no concrete physical or other finding that by itself will differentiate ADHD, and therefore clinch the diagnosis definitively. There are sophisticated tests that can accomplish this, and we’ll discuss then later on.
- Third, there are various forms of the disorder, and they are not so easily recognized. To confound the problem further, these other types often are similar in their appearance to other mental disorders. Dr. Daniel Amen has defined eight sub-types, including the depressive type and the mixed type, this latter type, which can contain combinations of the other types.
- Fourth, the disorder can present differently in each sex, and in different age groups: Girls and women, for instance, can have more subtle or apparently unrelated problems, such as dropping out of school often for a year or more, or as sexual promiscuity.Hyperactivity and acting out are more commonly recognized in children, whereas adults may present more with disorganization of thought and executive function, and may, with age, demonstrate less physical symptomatology.The changes with age are at least in part due to the fact that the endocrine system is more stable in adults, and also often adults may have found ways of adapting or compensating ways which even they themselves may not be aware of. These can include hiring on secretaries to assist with organization, and going into professions that are more suited to those who have the disorder: The vast majority of comedians have ADHD, and it is commonly seen in artists. It is not clear whether these latter two are due to genetics or are choices allowing for adaptation by their very nature. ADHD is more common in Emergency Room physicians as compared to Internal Medicine specialists.
- Fifth, in addition to being similar in their presentation to other mental disorders, these other mental problems in their pure forms are often seen more in common with ADHD. This is called co-morbidity: Disorders such as Obsessive-Compulsive Disorder (OCD) and Bipolar disorder, (also known as Manic-Depressive Disorder) in their classic forms are more commonly found in people with ADHD than they are in the general population. This true co-incidence is probably genetic.
- Sixth, it is very common seen in families, with different members having different presentations, or having related disorders: Oppositional-defiant disorder is thought to be a variant form of ADHD. In taking a history from a patient, the astute physician will ask questions about the other family members, both in an attempt to assist the patient as well as the others in the same family.
- Last, untreated or unrecognized ADHD can evolve into other disorders over the years, and is generally harder to treat with age. Hyperactivity can evolve into Conduct Disorder, in an adolescent, which can get the individual into trouble with others and with the law; and if untreated, this can progress to a true anti-Social Personality Disorder (ASPD) with imprisonment, tragically, being the final outcome.
It has been estimated that at least fifty percent of prisoners in state institutions have untreated ADHD. This is a tragedy beyond description. As one who works in the Correctional System in the State of California, I can attest to this first-hand. This last fact is a compelling reason why mass screening could be done in school. This would avert the tragedy of lives destroyed by ADHD, as well as protect society itself.
There are studies that have been done and more underway to demonstrate the magnitude of the relationship between criminal behavior and ADHD. The combination of ADHD and a right temporal lobe seizure focus, if untreated, is a strong predictor of future criminal behavior. My personal experience has shown me that there is little inclination in the Correctional System to treat ADHD, although it is often recognized.
The very best article I have seen to date on the subject of ADHD unrecognized and subsequent criminal behavior is in an article by T. Dwaine McCallon, M.D., Medical Director, Buena Vista Correctional Facility, and the Assistant Chief Medical Officer of the Colorado Department of Corrections. It is entitled, “If He Outgrew It, What’s He Doing In My Prison?”[ii] I cannot recommend it too highly. It is a must-read for anyone with an interest in ADHD.
I just cannot emphasize too strongly how important it is to diagnose and to treat this disorder. The greatest problem is to get people to take this seriously. This problem is also common to the other personality disorders (OCD, BPD) as well: The individuals just rationalize the necessity. This fact is also symptomatic of these disorders.
In addition to the tentative diagnosis made by a skilled interviewer, one or both of two major tools used to accomplish diagnosis of this disorder are: psychometric testing, and specific brain scans:
There are several conventional tests that will quite quickly and definitively show the presence of ADHD. The individual or family member can use them, but ultimately the diagnosis has to be confirmed by a professional who is specifically trained to do just that. As to professionals, I strongly recommend a Psychiatrist who specifically has had training in ADHD.
Unfortunately, there are numerous others, physicians and psychologists, who claim to have such experience, but they simply do not. There is a push now to train family practitioners to do this; and while I am sure there are many talented individuals who can do this, there are more than cannot, and don’t know it. This is too important an issue to leave to anybody but to those whose major preoccupation is the diagnosis and treatment of ADHD.
Specific brain scans include fMRI (functional MRI) and SPEC scans, (Single Positron Emission scan.) Both are functional tests, in that they measure brain function, not structure per se.
A specific amount of glucose tagged with a harmless and small amount of a radioisotope with a short half-life, is injected right after the subject has done a task that requires concentration.
In normal individuals, with increased mental concentration on a task, the isotope with the glucose (sugar) will concentrate in the pre-frontal cortex of the brain, the area which, with concentration to a task, requires more energy (glucose.) In individuals with ADHD, this area will show decreased uptake in the pre-frontal cortex, and often a paradoxical increased uptake in an area known as the cingulate gyrus, a finding which, interesting enough, is associated with obsessive thoughts and behaviors.
There is a skill in reading these scans; but with a skilled trained operator, these tests serve both to confirm the diagnosis made on the basis of testing and interview, and may also show other “defects” brain injuries, and the damage of drug use” as well.
Finally, treatment of ADHD takes time and patience, and involves the whole family or it should. Other members must understand how to live with the individual with ADHD, and is even more urgent when other members have the disorder as well.
Treatment in part depends upon the cause.
Let me explain: We don’t know all there is to know about what is the cause of ADHD. It is clear from the literature that there is a strong genetic predisposition in many if not most all cases. Other postulated causes include neonatal or birth injuries, resulting in decreased blood supply and oxygen to the brain, possibly some drugs, and in a few documented cases, specific food allergies.
In any event, regardless of cause, there is good evidence that the brains of those with ADHD have insufficient amounts of either or both of dopamine and norepinephrine. These compounds are cyclic amines and are critical to nerve conduction in the brain.
Current statistics indicate that some 7% of children have the disorder, that of these, 60% persist into adulthood, and that 5% of adults can be seen to have the disorder. My personal professional opinion is that these statistics are far too optimistic, in that most cases persist into adulthood but are far too seldom recognized.
It is also known that 20-65% of sufferers do not continue on medication, simply as a typical manifestation of the disorder, and not because of any side effect of medication. In fact, most of these people will tell you, to your amazement, that they don’t have it and that therefore they don’t require treatment.
Finally, please do try to leave emotional reactions and others opinions out of your decisions. And avoid other natural or miracle therapies, such as various nutriments, vitamins, worse yet, chelation therapy and EMDR. If someone presses you in this regard, ask them what are their credentials and training, and find out if they are willing to take responsibility if their treatment fails.
The most proven and definitive treatment consists of the amphetamine derivatives and related compounds. Dexadrine is the best-known and proven therapy for the disorder. Ritalin (methylphenidate) is another.
Side effects are really minimal at the appropriate doses. Insomnia or hyperactivity, restlessness and rarely anorexia or mild nausea has been reported. Ironically, these medications appear to have the exact opposite of some of the effects in patients with ADHD it calms them down, even occasionally putting them to sleep. Adderal is a combination of dexadrine salts and is very effective as it is long acting with a very predictable and steady release of the compound. Similarly Concerta is an effective long-acting form of Ritalin. Finally, Daytrana is a very recent and effective once-a-day skin patch of Ritalin.
Atomoxatine (Strattera) is a non-restricted compound of an entirely different class; however unfortunately recent studies have shown it to be less effective overall. In some people however, it still has a place. Cylert (Pemoline) is effective but has fallen out of favor because of certain serious side effects. Provigil (Modafinil) has shown promise and has been used for certain types of depression, but this is the testing stage. Many of these medications are also helpful in the treatment of depression, sleep apnea and narcolepsy, which are also often marked by inadequate or ineffective dopamine production.
Tragically, many of those individuals who are incarcerated, often because of drug use, were using drugs illegally which can, in the appropriate form and dosage, treat ADHD; and as many of these individuals have the disorder, which had contributed to their conviction for drug abuse, they may very well intuitively have been using the drugs because they did, in fact, obtain relief.
I hasten to say that there are some promising therapies, none of which by the way claiming to be an exclusive treatment, but which have shown definite positive results.
- One such treatment is the DORE treatment.
- Neurofeedback is promising but needs more research.
- A combined approach by a treatment team is the best choice of all. It consists of the physician, a psychologist or LCSW either or both with specific training, and often a coach. The use of coaches specifically for ADHD is believed to help sufferers re-organize their lives, and to show them coping strategies the nuts and bolts of everyday living.
In summary, ADHD is a very real disorder, and is incapacitating to those who suffer from it, as well as their families and friends. It can severely limit education, as well as stunt the development of many would-be high achievers. It is treatable, primarily with early diagnosis. Recognition of ADHD can save sufferers from privation and incarceration and give them their opportunity for happy and productive lives.
[i] It is also known as ADD (Attention Deficit Disorder) or ADHD (Attention Deficit Hyperactivity Disorder) and now more recently as AD/HD. The progression in nomenclature indicates the progress in our understanding of the disorder.
[ii] The article can be found at the Attention Deficit Disorder Association website in their archives. It also has links to other useful sites.
About the author
Moss David Posner, M.D. is a physician currently in practice in the California Department of Corrections. He is prolific as well as versatile, and writes on a number of subjects, including philosophy, religion, and the state of medical care in the California Department of Corrections. Dr. Posner has published articles in a variety of publications, including a Journal of Transcription and the Department of the Navy. He lives in Fresno with his son Aaron, a budding Mechanical Engineer.
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