How do you treat ADHD?
Multimodal treatment is best. The place that everybody often at least
explores and starts with is medication. Medications help level the neurologic
playing field, so that the person can have an equal shot at success. Now,
medication is not a panacea. Pills don't give skills. But what it does is it
gets the person in the door, so that then they can do all the remedial work
that they need to do. They need to get caught up on their schoolwork, where
they couldn't do it before, because they couldn't pay attention or they
couldn't sit still long enough to study. And they need to go back and pick up
skills in the social realm. . . . They have to go back and learn
organizational skills, because these folks are terribly disorganized. There
are a number of things that they have to learn, but the medication makes it
possible. . . .
Over the last 20 years, if you read the literature, there are two great trends.
One is validating the diagnostic criteria to say that this is a valid,
reliable set of criteria if you apply them in order. The other one is saying
what works in treatment. There are now over 170 double-blind control studies
showing that the stimulant class of medications is effective. . . .
There are also a whole bunch of studies that show that a whole bunch of other
things have an effect. And so the federal government, about six years ago . . .
established the Multimodal Treatment Study of ADHD--the MTA--which was
published in December,1999. That's the largest study ever undertaken of a
mental health disorder in children. It's a huge study.
They took 579 elementary school-aged boys and girls who had the combined type
of ADHD. And they broke them into four different treatment arms. The first
group got just medication, and the medication was fine-tuned to the . . .
child. The second group got intensive behavior management. By intensive, I
mean two months of an immersion summer camp program--12 weeks of somebody
coming in every day into the school to work with the teachers; 26 weeks of
parent training, so the parents could use these techniques at home; 26 weeks of
the kids getting individual and group treatment. In other words, a very
money-, labor-, and time-intensive treatment. A third group got medication
plus behavior management. And a fourth group, armed with world class work-ups,
got referred out into their communities to see what would happen.
At the end of the study in 14 months, more than a year, the results were
striking. . . . The two groups that got medication did wonderfully. They did
exceptionally well. Adding the behavior management component did not improve
the outcomes, unless you had an anxiety disorder, a co-existing condition, or
you came from a single-parent family; then it made a difference. But it
didn't make a huge difference. It didn't make a detectable difference in the
outcome for ADHD.
And down from those was the intensive behavior management program. . . . It was
nowhere near as effective as medication was. The big disappointment was that,
when they came back after the intensive behavior management program had ended,
there was no evidence that it had ever occurred. The hope had been that these
techniques would be internalized by the children and that eventually, this
very expensive treatment could be attenuated and ultimately stopped. What they
found was that, as soon as the treatment stopped, so did the benefits.
If you have a choice of what to do for somebody who has ADHD, isn't the
medication the first and best choice?
It is where most people--a vast majority of people--should start. But it is
not where they should end. . . .
I've talked to a lot of pediatrician psychologists and psychiatrists who say
that these stimulant medications do help, that they do improve performance of
just about everybody--not just those with ADHD.
. . . Stimulant-class medications will enhance the performance of just about
anybody, mostly through reaction time and vigilance. But it doesn't give the
huge and drastic changes that you see in people with ADHD.
I worked with a parent who said very much those same things. And so I said,
"Let's go ahead and see if that's true. I will bet you my fee that it's not
true." We sat down and the parent went through and did a computerized test of
their attention and impulse control. They did exceptionally well. We gave
them five milligrams of Ritalin, and they came back in an hour and a half
later, and did exactly the same test. Their reaction time increased
somewhat--not dramatically--but increased. But their impulsivity just went
wild in terms of their twitchiness when taking the test.
That parent had to see that, yes, it does increase vigilance and reaction time.
But it actually causes a decrease in performance in terms of impulse control.
And that's far more typical of people who don't have ADHD. The people who do
have ADHD have fundamentally different nervous systems. And the medications
behave in totally different ways for those people.
. . . We're in the midst of a revolution. We've got a set of drugs treating
ADHD. If the prevalence rates are as high as I think you've argued, as much as
anywhere between 5-12 percent, this should have an enormous impact on our
society--if people are treated for something in the future that they weren't
treated for before.
You would agree that this is a real revolution? In what way?
Yes, it is a revolution; it's very slow in coming. Our diagnostic criteria
have been around 25 years. . . . Amphetamine has been used for 63 years,
Ritalin for 32 years.
Right. But it's only been since 1990 that we've seen a real increase. Why
Our understanding of the disorder continues to evolve. . . . Twenty years ago,
the only child who was going to be identified, and therefore treated, was the
hyperactive child who was pinging off the wall, who was aggressive,
uncontrollable, and obnoxious. And so this was the child who was referred for
evaluation. This was the child that everybody could agree was hyperactive and
who would benefit from medication.
It has only been in the last ten to twelve years that we see that actually, the
hyperactive aggressive child makes up only a small percent--20 percent or 25
percent--of people who have ADHD. There are far larger numbers of people who
don't have any hyperactivity at all, and they are purely the inattentive
subtype. . . .
The inattentive and impulsive symptoms continue unabated for a lifetime. And
so it is this recognition--that there are a lot of people out there who have
purely inattentive symptoms, who aren't hyperactive, who are not aggressive or
obnoxious--who also have this disease. And this is where we start picking up
females. When I was in medical school, I was taught that women did not get
Attention Deficit Disorder. It turns out that women get it just as often as men
do. The assumed prevalence is about one to one, male to female. It's that
it's exceedingly rare for a woman to be hyperactive. . . . And so now what
we're doing is doubling the apparent prevalence rate by recognizing that the
quiet, inattentive child who daydreams in the back of the class also has
Attention Deficit Hyperactivity Disorder, just without the hyperactivity. . .
So that's why we have such a rapid increase in the prescription
Dr. James Swanson in California did a study of that. And we are seeing
an increase in the number of people who are being diagnosed and treated. But
the biggest increase in the number of prescriptions, according to Swanson, is
that people are being treated for longer periods of time. Once a person starts
on the medication, we now recognize they'll benefit from the medication their
entire life. They're being treated for more days--not just Monday through
Friday while they're in school. They're being treated 7 days a week, 52 weeks
There is more of an acceptance of the disorder. People are more willing to
give their children a trial on medication. And there's more of an awareness in
teachers and Girl Scout leaders and doctors, in people who work with children,
to recognize the disorder, and to suggest to parents that they might want to
have it looked into.
Lots of people say there's also over-diagnosis--that a certain hysteria is
taking over that it has become the disorder of the decade.
It is very common for people to say very emphatically that the diagnosis is
being too easily made. But there's very little evidence to support that point
of view. And there's a lot of evidence to support the exact opposite point of
view. In 1995, the National Institute of Mental Health did a study, not only of
ADHD, but of all childhood mental disorders. They found that, in the previous
year, only one in eight children who had ADHD received any services--medication
The diagnosis is still missed two out of three times, and even when it is made,
it is under-treated. The fourth treatment arm in the MTA study was one in
which the children, armed with world-class evaluations that said this person
very definitely has ADHD, were referred out into the six communities of the
study. There, one in three got no medication, got no services whatsoever.
Those that did get medication got medication at lower dosages than the study
indicated that they probably would've found optimal benefit from. . . . When
you actually go out there and you say, "I want facts, rather than opinion," the
facts are that the diagnosis is still missed more than half the time. And
even when the diagnosis is made, it is grossly under-treated.
Is there a danger that it's being over-diagnosed in certain communities and
under-diagnosed broadly in other social classes, thereby making the
There are two case reports out of Virginia showing that, in two counties, there
was a very high prevalence of a diagnosis of ADHD, higher than the national
average. They did not go in there to see whether or not these were accurate
diagnoses. . . .
How does the ADHD diagnosis differ between social classes?
The disorder is found pretty much equally through different socioeconomic
groups. ADHD is found in every culture, in every socioeconomic group, in
pretty much the same prevalence. . . . I'm aware of one study that showed that
black inner-city males were diagnosed with ADHD more commonly than you would
expect from the general population. But again, this could be clustering. It
could very well be a valid diagnosis.
. . . Where is the controversy?
. . . It's not just ADHD that is controversial. The vast majority of people in
this country don't want to acknowledge that children have major mental
illnesses of any sort. They don't want to acknowledge that there's childhood
schizophrenia, that there's childhood manic depression. They don't like to
acknowledge that some children murder other children. They don't like the fact
that there are childhood sociopaths. And yet, those things exist.
The NIMH study that Peter Jensen authored concludes that all mental
disorders in children are under-diagnosed and grossly under-treated.
. . .There is just a fundamental aversion in this country to acknowledging that
children can be mentally ill.
Then why would we have such a rapid increase in the prescription rates for
There is a rapid increase. But if you start at a very low recognition
rate and it increases, yes, it's going to be rapid. But you're still missing
at least half.
. . . We're talking about large numbers of kids receiving prescriptions. Is
But it's still a small percentage of those who should. We're still missing the
majority. In Germany, for instance, when they did the prevalence studies to
validate the shift in diagnostic criteria from the DSM-III to the DSM-IIIR,
they went out and they screened every child in an entire city in Germany. . .
. And there, they found that 17.7 percent fulfilled all diagnostic criteria for
ADHD. They did the same study in an entire county in Tennessee, and there they
found that 12.7 percent fulfilled the full diagnostic criteria.
. . . Every time they look for ADHD anywhere in the world, they have found it
in pretty much the same prevalence. . . . Is it treated the way it is in the
United States? No, it's not. . . . We're at a cusp in history in which people
are beginning to recognize, "Wow, this has been around forever." We have a
great treatment for it, so more and more people are taking advantage of that
treatment. . . .
Why does it remain extraordinarily controversial?
. . . In this country, there is a tenet of faith that says that any difficulty
in life can be overcome if you have a good character, if you try hard enough
and long enough. And so they don't like that tenet of faith challenge, that
there are some children who come from the womb genetically predisposed to
being inattentive, compulsive, somewhat reckless, and perhaps aggressive. No
matter how hard they try, trying harder is ineffective.
These people confuse an explanation for misbehavior and failure with an excuse.
In point of fact, when people are diagnosed with ADHD, more is expected of
them, not less. Now that you've got the diagnosis, now that you're on
medication, our expectations for your performance in life are going to
increase. But there are a lot of people who say, "I don't want to let the
person off. I don't want this to be an excuse." But it's not an excuse. It's
an explanation. . . .
Most people think we're talking science here. In fact, we know that this
drug has an effect on children and adults who display certain syndromes, but we
don't know what it is. Does that disturb or concern you?
It doesn't concern me. I'm curious and I want to know why it works, because
once we know why it works, we can probably develop better medications and
better treatments. We did find, totally by accident, that these medications
work. The original reason that they were used back in 1937 was due to their
anti-seizure properties. They found that they had a much more dramatic effect
upon behavior and attention and impulsivity. . . .
If you look at the history of medicine use in psychiatry, until Prozac came
along in 1988, every single medication in psychiatry was discovered by
accident. They were using the medication for some other purpose and they found
that mental health symptoms improved when you used that medication. I don't
have to know how a medication benefits my patient. All I need to know is that
it does. I won't wait around until some good hard-edged scientist can tell me
the how. . . .
. . . Another concern people have is that "amphetamine" sounds like it's a
Many people mistake methamphetamine, which is a street drug and which has a
powerful euphoric affect, for simple amphetamine, which doesn't. Simple
amphetamines, simple methylphenidate, do not have much abuse potential. They
don't produce a euphoric high. Other stimulants do. Cocaine does.
Methamphetamine does. Ecstasy does. But these simple compounds, like simple
amphetamines, simple methylphenidate, have very little abuse potential . . .
. . . But what if the parents say, "I don't want to take away my child's
personality, his spirit, his uniqueness?"
Properly adjusted medication does not change the child's personality any more
than eyeglasses will change their personality. Eyeglasses help you to focus.
The medication helps you to focus. It is true that, if a dose is too high, the
child will have side effects. They will, perhaps, get what they call the
"zombie syndrome," in which they do become dull. But that can be removed
almost immediately by lowering the dose.
In and about the controversy, there are people who feel that the increase in
the prescription rates has to do with the HMOs wanting quick, cheap fixes. Is
there any validity to that?
. . . Over the last ten years, there has been extraordinary pressure within the
medical field to deliver all medical care much more quickly and, therefore,
much more cheaply, than it ever has been delivered before. And so there is a
lot of economic pressure to diagnose and treat all disorders, medical or
psychiatric, more cheaply and more quickly. So surely, yes, that's going to
trickle down to the diagnosis of ADHD.
Can ADHD be diagnosed in a 15-minute well-baby check-up at the pediatrician?
No way. In order to do a good, adequate evaluation, you need several hours: to
do the evaluation: to rule out all the things that might mimic ADHD; to
thoroughly evaluate all the things that can co-exist within ADHD; to educate
the parents about the use of medication, and about the ancillary treatments
that are going to be necessary; to do a quick screening for learning
disabilities. A good, thorough evaluation takes time.
But we're not set up to do that?
We're set up to do it. It's that ADHD and managed care just don't go together.
Managed care wants it done quickly and cheaply, and ADHD can't be done quickly
Another controversy is the role of the pharmaceutical companies in marketing
these drugs. . . . The pharmaceutical companies make profits off of the sale
of Ritalin or Adderall or Concerta. They're companies. They can strategize and
put out a marketing message. The alternative therapies--such as behavioral
therapy or psychotherapy--don't have that kind of lobbying muscle or marketing
muscle. Therefore, it tilts the balance in favor of medication over other
Physicians tend to be very pragmatic people. They do what works, what gives
the best outcome for the patients. And that's why there has been controversy,
and why the federal government spent $17.7 million to do the MTA study to try
and figure out where they were going to spend the money that they spend on
insurance. The federal government insures one out of six people in the United
. . . This study is not funded by drug companies. It's funded by the federal
government. And what they found is that medication is more effective--that if
you stop either medication or behavioral management, the benefits end. . .
But isn't the system set up to prejudice us towards the development of
better and better pharmaceuticals rather than other therapies, just because of
the amount of money that is spent is disproportionately in favor of the drug?
That's where the profits are. Is this a place where our system is perhaps not
serving us well?
Everything in the United States is driven by the profit motive. We get better
cars because we have a private enterprise of car manufacturers, who continue
to improve their product in hopes of making more sales and making more money
for their investors. That's the set-up we have in the United States. If
people could demonstrate clear effectiveness from the treatments that didn't
involve medication, I think that there would be a lot of people beating a path
to their door. The fact is that they haven't been able to demonstrate that. .
I don't think that . . . just because there is a profit motive that pushes the
development of drugs, you can therefore say whatever else is done is
inadequate. There's also a profit motive there, because people do get paid to
this type of treatment. There are teachers who do get paid to be special
education teachers. . . . All of these things need to be done to treat ADHD.
Just because one happens to spend more money does not invalidate the others.
Can you give me a description of what your relationship is with
Shire-Richwood, the makers of Adderall?
Sure. I go out and I do educational presentations, and they pay a speaking
fee, and they pay my expenses.
Are you on a staff basis? What's the nature of your contract with
I don't have a contract with them. They ask me if I'd be available to go and
do an educational presentation somewhere. I go, I do it, and they pay for my
Would it be fair to say you're a spokesperson for Shire Richwood? How would
you describe it?
No, because my presentation is entirely on ADHD, its treatment, and how the
research that's out there can be applied to daily practice. I talk to
pediatricians, neurologists, and psychiatrists about how the research can be
applied to daily practice.
There are studies showing that money fronted in free samples and trips does
have an influence on doctors' opinion. It changes your prescription habits.
If it did not change prescription habits, most drug companies wouldn't do
You have a financial relationship with a manufacturer of a major stimulant
medication, knowing that it's going to very possibly skew your prescription
I do presentations for a number of drug companies. For instance, I do some
presentations for Pfizer. And yet, the antidepressant that I write for by far
the most often is Prozac, which is made by Eli Lilly. My job is to be an
educator. Docs are very independent people. If you try to influence them and
tell them what to do, very often you get a backlash.
But you did confirm that prescription habits are affected by the
sponsorship, free samples, perks, whatever. When your patient comes in here,
do they know up front that you are representing and making speeches on behalf
A few do; most do not.
Is it a problem? You don't see it as a problem?
No, I don't. For the three drug companies that I do presentations for now, I
have never once had anybody ever ask me what I was going to say, or ask me to
skew it in one direction. What they want is a chance to meet with physicians
and present their materials. And what they want is something the doctors will
show up for.
What do you say to those people that criticize this kind of taking money
from drug companies?
That it allows me to leave my practice, allows me to do the education that
desperately needs to be done to bring docs up to speed without my taking a
tremendous financial hit. And, in point of fact, right now I lose money every
time I go out and do a speech. Financially, I would do significantly better if
I stayed here and saw patients and charged them for my time.
Would you object to the statement that we're re-engineering the
personalities and behaviors of a percentage of our children in order to make
them function better in our society?
You present that as if it's a bad thing.
Some people would say we should be leaving them alone--that we should be
loving them and supporting them--but that to give them medications that alter
their brains is dangerous; that we're playing God; that we don't know what
we're doing. We don't know the cause of the disease, and we don't know the
effects and how the drugs work.
We don't know how the drugs do work, but we do know that they're safe.
Amphetamine was invented over 100 years ago. We have people who have taken
amphetamine every day of their lives--usually for narcolepsy, but also for
ADHD--for 60 years. We've had people who have taken Ritalin every day of their
lives for 32 years with no adverse affects, and with lots of benefit.
. . . For people who say, "Let's leave this well enough alone," or, "Let's be
more cautious," without defining what "more cautious" would mean, I would ask
those people to prepare themselves for that day 15 or 20 years from now when
their child comes to them and says the following, "Now, let me get this
straight. You saw that I was struggling. You saw that I was failing in
school. You saw that I couldn't fall asleep at night. You saw that I was
having trouble with my interpersonal relationships. You knew that it was ADHD.
You knew that it had a good safe treatment. And you didn't even let me try?
Explain that to me."
Those folks had better start working on their answer right now, because they're
going to need 15 or 20 years to come up with a compelling answer for their
child who asks them that question. "You saw me struggling and you did
nothing?" That's a good question. And to me, it's a far more compelling one
than saying, "We don't have perfect answers, therefore, let's do nothing." . . .
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