November/December 2005

Kidz ‘n speed

By MARC RINGEL, MD

I confess. I give speed to children; not to all kids, just to ones who have attention deficit hyperactivity disorder (ADHD). It was years before I got up the nerve to write my first prescription for methylphenidate (Ritalin) for a schoolchild. Up until then, I had reasoned that these difficult children were merely normal kids who fell toward one end of the behavioral spectrum and had gotten themselves labeled as problems by an uncompromisingly competitive culture. I was not about to hang a diagnosis like ADHD on a child, then give him a serious drug to affect his behavior, until I was convinced that there really was such a disease.

The failure of scientists to identify a clearly-defined anatomical or biochemical defect that characterizes ADHD leaves huge room for doubt about the validity of the diagnosis, let alone grounds to criticize treating such an ill-defined condition with major psychoactive drugs. Advanced brain imaging techniques do suggest real structural differences between the brains of patients with and without ADHD. And studies of twins indicate about 70 percent heritability of ADHD (greater than IQ and less than stature). So there is credible evidence that what we call attention deficit hyperactivity disorder is rooted in biology.

Still, the diagnosis must be made purely on clinical grounds. There is no blood test nor radiologic study that can tell a doctor if a patient has ADHD or not. There is only the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, a compendium of checklists of characteristics for the whole spectrum of psychiatric maladies. According to the DSM, to diagnose ADHD the professional must check off six or more symptoms of inattention that have persisted for at least six months—such as making frequent careless mistakes, showing difficulty sustaining attention in play, having trouble following instructions, not listening, disorganization, persistently losing things—or six or more symptoms of hyperactivity: impulsivity such as fidgetiness, excessive running and climbing, a tendency to blurt out answers or having trouble waiting one’s turn.

Admittedly, arriving at a diagnosis by checklist is much less satisfactory than, for example, diagnosing diabetes based on an elevated blood sugar or a fractured wrist because you can see broken bones on an x-ray. Nevertheless, my experience does tell me that ADHD really, really does exist. Biological diagnosis or not, I do know that there is a large cohort of children and a few adults whom I have helped by treating them with stimulants. After getting them on an adequate dose of medication, these patients have described to me how wonderful it feels, for some of them for the first time ever, to sit still and pay attention.

Reams of medical studies have measured how hard life is for people with ADHD. These folks do worse in school, have fewer friends, sustain more injuries (and more serious ones), spend more time in jail and in the hospital, have more traffic accidents and more trouble with drugs and alcohol, suffer more divorces, have a higher rate of unemployment and work in lower quality jobs. All of these problems tend to normalize with proper diagnosis and treatment. Even drug and alcohol abuse problems are less frequent in ADHD patients who are treated with stimulants than in those who aren’t treated. Paradoxical though it may seem, studies have demonstrated that giving speed to a person with ADHD can actually help him avoid falling prey to drugs of abuse.

Before I wax too eloquent about the wonders of modern psycho-pharmacology, I need to backtrack. I don’t like calling attention deficit hyperactivity disorder a disease. And the diagnosis would still not sit quite right with me even if tomorrow scientists were to discover that a specific piece of the brain is smaller in people with ADHD or to identify a particular enzyme missing in the brain cells of these patients. To be sure, it is harder for people with this constellation of symptoms to get along in school, home and the workplace. But there is also something unique and valuable to their way of being, as there is in every way of being. It’s the old argument about whether to call folks “dis-abled” or “differently-abled.”

I have a very good friend with ADHD. He has a twisted sense of humor that reflects what I call his skewed view of the world—skewed in part, I’m sure, because of the ADHD. The world would be a less rich place without that man’s wit.
I sent my buddy a copy of some professional education stuff I’d written on his disease. Here’s what he had to say about it:
“Because I suffer from this, I only glanced at your material. It is too tedious to read the whole damn thing (seriously). As an ADHD symptom-holder I am never quite satisfied by a non-sufferer’s explanation. Often others see outcomes measured in norms of behavior and not much of either the beauty or the value of the underlying personality traits. I do not any more think I suffer from a disease. I now truly believe it is a world perspective that is valuable and is a trait of some, much like mathematical ability or musical ability, but one whose manifestations do not make the bearer of that trait want to dance or to make rockets. Rather, people with ADHD seem to cause some societal irritation because of the simple fact that we are on the edge of a spectrum of perceiving... I see things in fragments and in bits and pieces, not in any continuum of thought. Yet even this perspective lends a view of the universe that is quite valuable. It is just hard for a non-ADHD person to get what I am seeing. Optimistically, I trust researchers will notice that ADHD is not so much a malady as it is a different angle on life.”

I suppose if we lived in a world where kids didn’t have to get along in school and adults on a job, and we all didn’t have to keep track of our jackets, there would be no need to diagnose or treat ADHD. Even my friend takes methylphenidate when he needs to concentrate on a big project at work.

Whether we like it or not, we do live in a world in which certain behaviors, such as the ability to sit still and not disrupt a classroom or a business office, are required. I’ve seen so many people’s lives made so much better because, with the aid of prescription drugs, they could meet the exigencies of modern life. I’d never deny such patients the medication that can help them to get along.

The other day, in the midst of a discussion about our aging bodies, a friend asked me that familiar old question, “If you could go back to being x-years-old, would you?” And we both promptly answered, “Only if we could bring along what we’ve learned so far in our lives.” One of those things I’ve learned, that I don’t see how I could have figured out any other way than by living long enough, is how to pick my battles. Given the choice between railing against a world that does not easily accommodate people with the symptoms of ADHD and helping those people to get along in this world, flawed though it is, I’ve come around to prescribing stimulants.

There are many alternative therapies for ADHD, including the Feingold carbohydrate elimination diet, electroencephalographic biofeedback, megavitamin and mineral supplements, yeast avoidance, applied kinesiology, optometric vision training and vestibular training. In my heart of hearts, I sorely wish that they really worked. And maybe some of these therapies do work in some patients. But there is still no reliable evidence that shows anything to be nearly as good as stimulants for controlling the symptoms of ADHD.

So, I’ll say again, though still a little sheepishly, “I give speed to children.”

Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.