Thoughts On the Medical Treatment of ADD/ADHD: A Physician's Perspective

Written by Theodore D. Mandelkorn, M.D.

Human beings are rarely created in perfect form, so the great majority of us arrive in this world with unique differences. Some differences are blessings; others are handicaps. Poor vision, for example, is a common handicapping condition that affects millions of people throughout the world. I consider poor vision a condition of "human-ness." People can also have other conditions such as diabetes, asthma, thyroid conditions, ADHD, etc.--all well recognized differences that can impair the pursuit of a normal life if not dealt with in some manner.

ADHD is characterized by a prolonged history of inattention, impulsiveness, and variable amounts of hyperactivity. It is important to emphasize that all of these symptoms are normal human characteristics. All of us are forgetful and inattentive at times. We all at times become nervous and fidgety, and we certainly are impulsive to some degree. It's part of our "human-ness." ADHD, then, is not diagnosed by the mere presence of these normal and characteristic human behaviors, but from the DEGREE to which we manifest these symptoms. ADHD people have an overabundance of these normal human characteristics.

WHO SHOULD TAKE MEDICATION, AND WHY?

Returning to the vision analogy, there are a number of options open to an individual who has bad eyesight. One option is to attempt to correct the problem. This could involve wearing glasses to correct the visual deficiency. Perhaps glasses can totally correct the problem, or perhaps they can only partially help. After the glasses are in place, we are in a position to assess what further problems are interfering with success. Then we can address these issues as well.

ADHD is a medical condition. Dr. Alan Zametkin has clearly demonstrated that there is something uniquely different about the metabolism of the brain affected by ADHD. If a person meets the criteria for a diagnosis of ADHD and is not succeeding academically or socially up to expectations, medication should be a PRIMARY OPTION of therapeutic intervention. The opportunity to eliminate the symptoms- toms of a medical condition partially or completely should be available to all. Many children benefit enormously from the use of medication. Many families who understand ADHD and its clinical manifestations prefer to try medication as a PART of their treatment plan. As many as 80% of individuals will show a positive response to one of the medical treatments.

Since it is impossible to determine who will respond favorably to medication, I always offer a trial of medication to each diagnosed patient. If medication will help alleviate the symptoms and does not elicit any unfavorable effects, then the patient may choose to utilize medication as one part of therapy for ADHD.

WHAT IMPROVEMENT SHOULD BE SEEN?

In the early 1930's, Dr. Charles Bradley noted some dramatic effects of stimulant medications on patients with behavior and learning disorders. He found that the use of stimulants "normalized" many of the systems that we use for successful living. People on medication IMPROVED their attention span, concentration, memory, motor coordination, mood, and on-task behavior. At the same time they DECREASED daydreaming, hyper- activity, anger, immature behavior, defiance, oppositional behavior. It was evident that medical treatment allowed intellectual capabilities that were already present to function more appropriately. When medication is used appropriately, patients notice a significant
improvement in control. Objective observers should notice better control of focus, concentration, attending skills, and task completion. Many children are able to cope with stress more appropriately, with fewer temper outbursts, less anger, and better compliance. They relate and interact better with siblings and friends. Less restlessness, motor activity and impulsiveness are noted.

It is very important to remember what medicine does and does not do. Using medication is like putting on glasses. It enables the system to function more appropriately. Glasses do not make you behave, write a term paper, or even get up in the morning. They allow your eyes to function more normally IF YOU CHOOSE to open them. YOU are still in charge of your vision. Whether you open your eyes or not, and what you choose to look at, are controlled by you. Medication allows your nervous system to send its chemical messages more efficiently, and thus allows your skills and knowledge to function more normally. Medication does not provide skills or motivation to perform. ADHD individuals often complain of forgotten appointments, incomplete homework, miscopied assignments, frequent arguments with siblings and parents, excessive activity, and impulsive behaviors. With medication, many of these problems dramatically improve. Patients successfully treated with medication typically can go to bed at night and find that most of the day went the way they had planned.

WHO SHOULD PRESCRIBE MEDICATIONS?

Medications can be prescribed by a licensed physician only. This person may serve as a coordinator to assist with the multiple therapies often needed, such as educational advocacy, counseling, parent training, and social skill assistance. Parents and adults should look for a physician who has a special interest and knowledge in dealing with ADHD individuals.

MEDICAL TRIALS

It is necessary to establish a team for an appropriate evaluation of the medication trial. I gather information from sources who spend time with my patients. This might include parents, teachers, spouses, friends, co-workers, grandparents, tutors, piano teachers, coaches, etc. As gradually increasing dosages are administered, input is gathered from these observers. Various rating scales are available to assist in gathering factual data. However, the true assessment is whether the ADHD patient's quality of success in life has improved. For this information, I find no scale takes the place of conversations with observers.

When evaluating patients during a trial of medication, I will treat them throughout the day, seven days a week. Treating them only at school or only at work is totally inadequate. I need all involved observers, assisting in the evaluation process. Furthermore, I want to know if treatment has an effect on non- academic issues. After the trial of medication, if positive results are evident, then the family and/or the patient can make informed decisions as to when the medication is helpful. Many patients find the medication is helpful throughout all waking hours. Others may need it only during certain times of the day.