ADHD/ADD Part I
When I entered practice in the 60′s the flood of new antibiotics and vaccines seemed destined to change pediatrics and we looked for new worlds to conquer. Behavioral issues took on a greater significance, none more than what became known as ADD, Attention Deficit Disorder (plus or minus an H for Hyperactivity). I’ve been immersed in this field for 45 years, dealing with it not only as a pediatrician but as a school doctor and father. If that qualifies me as an expert, I’ll let you decide.
Despite great advances, controversy continues. Some deny that ADHD exists, especially in L.A. where scientologists are taken seriously despite their medical ignorance. (It is beyond ironic that in the entertainment industry practically all successful people have ADD.) This first blog will cover some history and discuss where we are now; later I will tackle treatment and prognosis.
Just the term ADHD was a major advance, replacing dozens of older names that were offensive (e.g. Brain Damage, Minimal Brain Dysfunction, etc.) and implied an understanding of the disorder that we had not earned. Now MDs, mental health professionals and parents share a descriptive term that makes sense to all. I do agree with critics that we medicalize too much these days. If we get nervous before giving a speech, does it help to call it “Social Anxiety Disorder?” When we see a child terrorizing a grocery store, “Oppositional Defiant Disorder” is not the first thing to come to mind. It seems as though we find a new pill or procedure, then invent a disease to match (heard enough Sweaty Palms commercials?) But ADD/ADHD is all too real and pervasive, especially in boys.
Seventy years ago World War I veterans with brain injuries were found to improve attention spans when given the new stimulant Dexedrine (which was available over the counter as No-Doz in my college days!). In the 50′s Ritalin (methylphenidate) became a promising antidepressant for alcoholics. By the next decade researchers confirmed that children with hyperactivity, inattention, distractibility and impulsiveness (similar to the WWI vets) often improved on Ritalin. In recent years long-acting versions with better profiles have largely replaced Ritalin.
Working part-time in several L.A. schools early in my career I saw the battlefield close up. Because the disorder is largely genetic, these kids often came from chaotic, impoverished backgrounds with single parents or none at all. There was usually a family history of alcohol and drug abuse, psychiatric problems, and ADHD itself. Teachers back then resisted medical intervention as an affront to their abilities, tending to blame parents and demand more money and smaller classrooms. I learned later that parochial schools had more success despite larger classrooms and fewer dollars. Identifying cases was seldom difficult, but too many kids were lost to follow-up. For almost 40 years I was the physician to the youngsters at Hollygrove Childrens Home. Perhaps two thousand passed through and virtually all had been abused. (Marilyn Monroe, their most famous alumna, was before my time). Most of those children had ADHD and responded well to treatment, but returned to foster care or family and an uncertain future.
Parents, especially fathers, always ask if ADD treatment is addictive. If it were, we’d have no problem getting our teenagers to stay on therapy! Fact is research has shown that kids treated for ADD are less likely to tinker with street drugs than “normal” adolescents (is there such a thing?) When my son was 14 he decided he didn’t need his Ritalin any more. At 6’3″ and 225, he got his way.
Frontiers in ADHD include treatment of adults and identification of “co-morbidities”. Most ADD kids also have learning disorders such as dyslexia (did I mention I was a founding member of DAM – that’s Mothers Against Dyslexia)? ADD drugs help handwriting and organizational skills but a learning-disabled child typically needs tutoring as well. As children get older, some develop signs of bipolar or obsessive-compulsive disorders, the first sign of which can be an atypical response to ADD treatment.
Treating a child for ADHD/ADD is a major responsibility, usually a multi-year commitment. I never treat without an hour or more of discussion with parents, who often leave to think it over. My patients know me as a conservative doctor whose prescription pad seldom comes out of my back pocket. But in my long career, the impact of treatment on these children and their families gives me more satisfaction than anything else I’ve done professionally.
A recent study of CEO’s of major corporations showed that virtually 100% had ADHD symptoms as children but were able to channel their energy by getting the help they needed. Conversely, all studies of prison populations reveal a 70-80% prevalence of childhood ADHD, usually untreated. These kids can be like runaway trains, and medications can help keep them on the track to success. While we’re on metaphors, I like to compare kids with ADD to radios without condensers; i.e. they can’t tune in to one station (the teacher) because they’re picking up ALL of them.
Contrary to what you may have heard, treatment does not induce a zombie-like trance, teachers do not demand that students be treated (they may recommend and it’s thankful that they do), and we share information and work as a team. Our goal is not to induce “conformity” although if we refer to scholastic success, popularity, impulse control, peace at home and on the playground as “conformity” remind me what’s wrong with that.
Parents understandably balk at having their kids “labelled” with ADHD or any other name, but I find that a child who can’t learn or adjust socially already feels different, and that success leads to greater self-esteem, not the other way around.