During my four years of residency in Psychiatry, it was pretty rare for me to come across an adult with ADHD (Attention Deficit Hyperactivity Disorder) so I understand the skepticism that some people have (including some mental health professionals) regarding the validity of ADHD. The skeptics have a perspective that ADHD is a manufactured condition – a product of pharmaceutical marketing strategies and the artificial “pathologicalization” of the normal human response to a changing and stimulation seeking society. There’s also evidence of the negative consequences of the existence of the diagnosis and its primary treatments. For instance, there are recent data from the CDC that show that stimulants (the primary medication type used for the treatment of ADHD) are being prescribed to toddlers for behavioral problems in all demographics, but especially in poorer and minority populations. There are also statistics that show that stimulants are commonly being abused at the college level. One recent survey showed that 20% of all college students have inappropriately used someone else’s stimulant medication at least once. Also of concern is that stimulants belong to a class of medications that can have a high potential for abuse. The number of school aged children being diagnosed with ADHD has continued to rise over the last two decades, and along with that comes more prescriptions being written. There’s even for-profit clinics with proprietary evaluations and treatments that will charge thousands of dollars to use a brain scanner to not just diagnose ADHD, but also tell you which of the six subtypes you have – and that’s just for the evaluation while treatment costs extra.
But despite all of the above, over the past 10 years in practice I have since seen many people with ADHD that I’ve evaluated and helped. What has been affirmed through my experience is that ADHD is real, exists outside of the context of “normal” distractibility, and that it causes true disability. Thankfully, the evaluation is pretty simple and uncomplicated, generally only requiring a reliable history. Further confirmation can be done with standardized psychological and educational testing. No other tests are needed for diagnosis, including unnecessary brain scans which have not been validated as reliable enough as a diagnostic tool. The core symptoms of ADHD are: 1) circumstantial challenges with maintaining attention, 2) distractibility, 3) impulsivity, and 4) poor working memory – the type of memory used for real-time but transient processing of information, not the type that we store for recall later. These symptoms are persistent and not episodic, and have always been present since early childhood. This unique set of symptoms, its persistent nature, and the presence since childhood make this condition readily distinguishable from other diagnoses, conditions, or circumstances. Also, the treatments available for ADHD can also be very straightforward, are safe, and the benefits are usually immediate and meaningful for individuals and their families. But why so much controversy then?
One issue is that the most common treatment for ADHD is daily medication, and as most people are diagnosed as children, it’s a daily medication for children. And not just any medication, it’s an amphetamine, a controlled substance regulated by the DEA because of its potential for abuse. In addition, compared to other diagnoses that can be made for children, such as Depression or Anxiety disorders, in those situations psychotherapy is usually the first line of treatment instead of medication. Okay, so why is medication the first option with ADHD?
First of all it’s because it is very helpful and usually the benefits are close to immediate. About 80% of people with ADHD have meaningful improvements when taking a stimulant. Though these medications modify the flow of the brain chemicals norepinephrine and dopamine, the prevailing model of how they help in ADHD is that these changes actually function to better regulate the flow of another transmitter, glutamate, in two separate regions of the brain – one that controls the persistence of attention, and another region that filters out “noise.” So unlike the more commonly held but false belief that these stimulants stimulate a “bored” brain, what is more accurate is to think of these medications not as stimulants but as neuromodulators, working not on increasing brain activity, but balancing and coordinating activity in the prefrontal cortex in regions needed to appropriately modify focus and task switching. In fact, for the doses typically prescribed, the amount of medication that reaches the brain is actually too little to cause much stimulation.
Secondly, studies have demonstrated consistently and convincingly that a treatment strategy that includes medication is significantly better than non-medication options. This was first demonstrated through a series of studies in the 1970’s comparing methylphenidate (Ritalin) to behavioral strategies, individually and in combination, and more recently through the landmark MTA Cooperative Group study comparing medication, behavioral therapies, combined treatments, and community care (which turned out to be primarily medication in two-thirds of children in this group) (MTA Cooperative Group, Arch Gen Psych, 1999; MTA Cooperative Group, Pediatrics, 2004). So unlike Depression and Anxiety, where in both children and adults studies generally show that medication and therapy are equally effective, in ADHD medication interventions are actually better.
Thirdly, because despite the theoretical concerns about the medication, in practice these medications are well tolerated and have minimal side effects in both short term and long term use. Methylphenidate and other stimulants have been used routinely in children for over 40 years so there’s decades of real world experience and knowledge. The most common side effects are appetite suppression and sleep difficulties, and in some cases there is irritability when the medication wears off. Though these side effects can be challenging, they are not dangerous, and in most cases they improve over time. Previous concerns about stunting children’s growth have not been shown to be true over the long term. Nor have concerns about the potential for addiction. In fact, there are long term studies that show that without treatment, people with ADHD are at higher risk for substance abuse, and this risk is meaningfully decreased when prescribed stimulants (Wilens et al, Pediatrics, 2003). To better understand why these potentially “addictive” medications don’t actually cause addiction, we can explore the differences as to how our bodies respond to anything in small doses versus large doses. A comparable analogy would be to think about how in a healthy diet our blood sugar levels are regulated easily by the normal mechanisms of our metabolism, but a diet high in sugar and simple carbohydrates overwhelms these systems and causes dysfunctional changes in our bodies and brain such as carbohydrate craving, fat retention, and Type 2 Diabetes. Even drinking excessive amounts of water (such as in psychogenic polydipsia) can be toxic to the human body for similar reasons, where the normal processes to regulate blood volume and concentration can become overwhelmed. So the small doses of stimulants normally prescribed optimize brain functioning within the range of normal for people with ADHD, and only very high doses (which occurs only with deliberate misuse) causes harmful changes in the brain.
The next controversy is that some believe that the diagnosis of ADHD is a modern invention to explain away the natural outcome of an ever increasing stimulus driven society. One that children are particularly overexposed to through digital devices and electronic media, while at the expense of free play and time outdoors. As a father of two young children, I don’t totally disagree about the observation about the changing times. However, in regards to ADHD as a “modern” invention and societal avoidance strategy at the expense of our children, that’s harder for me to accept. For one, read the following excerpt taken from a medical textbook in 1798, written by physician Sir Alexander Crichton:
The morbid alterations to which attention is subject, may all be reduced under the two following heads:
First. The incapacity of attending with a necessary degree of constancy to any one object.
Second. A total suspension of its effects on the brain.
The incapacity of attending with a necessary degree of constancy to any one object, almost always arises from an unnatural or morbid sensibility of the nerves, by which means this faculty is incessantly withdrawn from one impression to another. It may be either born with a person, or it may be the effect of accidental diseases.
When born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate, it is generally diminished with age.
To me that sounds like ADHD existed over 200 years ago as well, and they didn’t have a societal overstimulation problem then. Also, Dr. Crichton seemed like a pretty observant fellow, both in his description of the attention challenges as well as his observation regarding the individual’s personal history. This also reinforces that a diagnosis can be made readily by taking a detailed history alone. Some of his observations about the typical history of someone with ADHD are very true. It is a condition that essentially always has been there with an individual, so a focused childhood history should reveal a persistent pattern of attention difficulties, impulsivity, and distractibility. School tends to be much harder for kids with ADHD, but it’s not so disabling that they totally fail either. It is also true that about one third of people with ADHD as children will outgrow their symptoms by their mid-20’s, while another third will see meaningful improvement but may have residual symptoms throughout their adult lives. The remaining third will have a relatively fixed level of symptoms throughout their lifespan. If you’re a pessimist, you’ll interpret that as two-thirds of people diagnosed with ADHD as having symptoms for their whole lives. If you’re an optimist, you’ll interpret that as two-thirds of people will outgrow their symptoms to some degree. These statistics also pan out in terms how commonly ADHD is seen in the general population, roughly 9% of school aged children and about 6% of adults – exactly two-thirds. That means in the average-sized classroom, you’ll see about three kids that are dealing with ADHD, and two of them will still have some symptoms when they become adults.
Okay, so hopefully we’ve confounded the notion that ADHD is “fake” but we can agree that there is something about our modern society that does contribute to the difficulties of living with ADHD, which I will discuss at great length in part 2. If I have your full attention, then please read on.