By Henry David Abraham MD
If you harbored any doubt that ADHD is real, take a look at the time-lapsed photo below. It comes from Duke University where they are trying to define ADHD on a molecular level. The mouse in the left test-tube is normal. The one in the middle is missing a certain gene. The one in the right tube is missing a pair of those genes. The blurred image tells the story. Hyperactivity is for real, at least in mice.
But if you or your child has suffered from attention deficit-hyperactivity disorder you don’t need evidence from a lab. The classroom tells the story well enough. The ADHD child is the one who can’t keep his seat, who runs and climbs at the wrong times, who can’t wait his turn or keep from talking. A more subtle form is found in the kid who can’t pay attention, can’t organize, is forgetful, distractible, and forever losing things. This is the inattentive type of ADHD. Kids with poor attention have trouble reading. Kids with hyperactivity have trouble listening. Some kids have both types.
We even know where it comes from, sort of. Genes have been identified. Smoking in pregnancy increases the chances a baby will have ADHD. Even Tylenol in pregnancy increases the odds somewhat. The problem is that there is no simple test that clinches the diagnosis. It’s more a matter of a consensus between parents, teachers and doctors that seals the deal. Knock one of those out of the discussion, and you open the door to years of error.
Consider a short list of some of the other problems that can cause hyperactivity without ever being ADHD: learning disabilities, autism, mood disorders, drug abuse, caffeine, thyroid disease, asthma medication, to say nothing of a new sibling, new school, divorce, or death of a parent or grandparent. If there is one take home lesson, it’s that diagnosis should drive treatment, not the other way around.
When people agree on the diagnosis, treatment should follow two principles. The first is to create a state in the child of what AJ Martin calls “academic buoyancy.” That’s when a student develops the capacity to overcome setbacks that are typical of ordinary life at school. In severe cases medication is nearly always essential, since a strictly behavioral program is not likely to succeed alone. But behavioral steps in class and at home are essential. These children are not simply going to be cured by a pill. Needed as well are getting classroom accommodations, building classroom citizenship, making and keeping friends, and seeking schoolhouse victories in class and after school.
This brings up a second principle. Treatment must protect the children from us- the swarm of well-meaning parents, teachers, counselors and doctors who all want to do something about this whirling dervish of a child. Too often an overly aggressive treatment plan labels the child as trouble, a poor learner, not normal. The result is stigma, social isolation, and the continual drumbeat of inadequacy that the child hears and comes to believe. It’s not that you should do nothing. But whatever is done has to be done carefully. Note that on the average, symptoms diminish by about 50% every 5 years between the ages of 10 and 25. It’s fair to ask if a child’s problems are likely to disappear by adulthood, why treat in the first place? Because they may not, and without treatment she is in for a childhood surrounded by handwringing adults. This is not good for anyone.
What about the child with mild or moderate ADHD? They look OK for the most part, like the mouse in test-tube 2, but they still stand out by being inattentive rather than hyperactive, girls rather than boys. They are also annoying, irritable, friendless, indifferent to school work, anxious, or depressed. They may be helped by classroom accommodations, tutoring in tough subjects, and a little more parental involvement. Medications may be an option if behavioral approaches don’t do the job.
Medication is a big stick, and there are risks as well as benefits. Medications for the most part are stimulants. They are abusable, addictive, and with unpleasant side effects like insomnia, anxiety, and weight loss. In large doses they cause paranoia and psychosis. On tests and papers they can result in blithering. Worse, in a Dutch study of heroin addicts, fully one quarter of them had ADHD. And among ADHD patients, the risk for drug abuse was increased seven times.
So why has the sales of stimulants for ADHD quintupled in the last ten years? The answer is vividly described by Alan Schwarz’s recent piece in the New York Times, “The Selling of Attention Deficit Disorder.” The sale of stimulant drugs is big business. Shire, the world’s biggest producer of ADHD drugs, just recorded some of its highest profits, largely based on sales of its stimulant Vyvanse. Shire even supports an on-line six question self-quiz to tell you if you suffer from their favorite disease. Nearly half the people who took the quiz for the Times were classified as possible ADHD cases. (Trouble wrapping up a project? Sounds serious. Call your doctor!) Stimulants have a ready market among desperate parents, hurried doctors, and students willing to divert their drug supply to friends who want to pull an all-nighter. The medications also have a thriving after-market among addicts. Heroin may have killed Philip Seymour Hoffman, but stimulants helped. A reporter for Al Jazeera asked me recently if normal college kids should use stimulants to enhance their school performance. Brave new world, that has such questions in it.
Henry David Abraham, M.D.
Dr. Henry David Abraham is a psychiatrist in Lexington, MA. He is the author of several books on drug education, including What’s a Parent to Do: Straight Talk on Drugs and Alcohol, and the e-book for teens, The No Nonsense Book on Drugs and Alcohol, available on Amazon.com and BN.com.
