Focusing on ADHD for Forty Years
Focusing on ADHD for Forty Years
It is the beginning of the school year and, besides school supplies, ADHD comes to mind for many. Hopefully, evaluating or reassessing ADHD has already been done or is soon about to be for those students who seem to have trouble with attention.
In one way or another, I have been involved with evaluating and treating ADHD for about 40 years. It started in 1971, when I began an internship at the infamous Los Angeles county hospital system. Half of that internship was general medicine, and the other half was child and adolescent psychiatry.
As became common, my wife led the way. While I was in medical school at Yale from 1967 to 1971, she became one of the first learning disability teachers in the nation. On occasion, she would teach me about the role of the stimulant methylphenidate (Ritalin, Concerta, Metadate, Methylin), which was often used when full-blown ADHD was responsible for learning problems.
Until then, my experience with stimulant medications encompassed treating addiction in the drug abuse era of the 1960s, often leading the vulnerable to paranoia, depression, or even precipitating schizophrenia. In fact, one test for diagnosing schizophrenia was to administer a small dose of an amphetamine and see if the thinking of the patient became more disorganized. I wondered at that time how a stimulant could calm someone down with ADHD, but cause agitation in "normal" patients or those with certain mental disorders. Little did I realize the answer to this question would challenge us 40 years later.
After my psychiatric residency from 1972 to 1975, I had to spend 2 years in the Army. There, I moonlighted as a medical director of a community mental health center, where my wife worked in the child psychiatry department. Those were “the good old days” of comprehensive centers, where consultation and education to schools was part of federal funding and expectations.
Given that successful experience, my wife suggested that we open a clinic focused on ADHD. However, I yearned for something broader and felt an ethical need to serve the underserved, so I went on to work in academic psychiatry, while my wife privately taught students with learning disabilities for many years.
In retrospect, perhaps she was right yet again. Given that I never did the full fellowship training in child and adolescent psychiatry, I did not often treat patients with ADHD until it became recognized that perhaps a majority of children did not “outgrow” ADHD, as was once thought. Consequently, by the late 1990s, I started to treat many adults who seemed to have ADHD, even if the hyperactivity symptoms they experienced when they were children died down.
And the initial results? The closest to a cure I had ever experienced—but the cure only lasted as long as the medication was taken. Work and relationships improved. More stimulant medications became available, including some that lasted a whole day. But, alas, I learned quickly not to be casual about the diagnosis. Stimulants, the most effective kind of medication for ADHD, could also be abused, diverted, cause problematic side effects, and even contribute to suicide. The best dosage was subjective. In fact, how could you really be sure that an adult had ADHD? Even if they did have ADHD, had they successfully learned enough coping strategies? Perhaps even to use their tendency to be distracted in a creative way?
A patient of mine once blamed me for becoming psychotic and paranoid on high doses of Ritalin. I then decided that new patients should have sophisticated ancillary psychological testing and family input. Given that such tests were expensive, often not covered by insurance, and not readily available, this was perhaps an overreaction on occasion.
Given my interest, as well as the increasing brain research showing differences in patients with ADHD, I suggested that a clinic be set up in our academic setting. Not only was that turned down, but some sort of suspicion led to my prescribing of stimulant medication to be secretly reviewed. I only found this out years later. No problems were discovered.