This morning I read an article linked by Steve Silberman about adult ADHD. The article was about a study from Sweden of stimulant treatment of adults with diagnosed ADHD. This article said, basically, it’s a good thing to do, as it helps the patients function better, with relatively few and minor unwanted effects.
Sounds great, right?
Important too, given that apparently it’s estimated that 3-4% of adults have ADHD.
Some people take issue with the very notion of adult ADHD. It used to be thought that ADHD kind of disappeared, or “burnt out” by adulthood, and consequently there was no thought given to diagnosing it in adults – let alone treating it. I accept that that’s probably wrong; there’s not really any justification for thinking that ADHD as a neurobiological entity would just … stop.
However, I don’t know how much of what we call – and treat as – ADHD is true neurobiological disorder, and how much is behavioural manifestation of other problems (such as environmental/family factors). Those other childhood problems could lead to the ongoing problems described in adults with “ADHD” – without the existence of the biological disorder.
So what?
So other strategies than medication should really be employed in that instance, in order to target what’s really going on. Now the child psychiatrists I know do in fact do that as best they can. One has even lamented to me that he spends most of his time trying to persuade parents away from the idea of medication (despite what the scientologists et al believe).
Adults however, don’t see child psychiatrists. Mostly they don’t see adult psychiatrists either; they see general practitioners in 10-15 minute slots. Are psychological and social interventions as likely to be considered when the GP can run through a diagnostic checklist and send the patient away with a prescription and a smile? Nothing against GPs, mind; this is just the way of it.
Some psychiatrists (in privat practice) do see patients with adult ADHD, but the thin is they seem to display the characteristics of the “brave maverick doctor” who knows something the rest of us don’t, and really that is the answer to everything. That’s something that always makes me look askance, as I really doubt that there is any one thing that is “the answer”.
Or The Secret…
Anyway, why would I think this is a problem anyway? If people feel better, isn’t that what it’s all about? Doesn’t the study mentioned above indicate it’s a good thing?
Clinical trials are funny beasts (bear with me). In order to weed out confounding factors and focus in on specific effects of a single intervention on a specific problem (which is very necessary) study populations are highly-selected. People with multiple problems? Excluded. People with chronic problems? Often excluded. People with drug abuse? Almost always excluded. That gives us a clean picture of the potential of a treatment in a clean uncomplicated disorder – but reality ain’t like that.
I work in an acute outpatient psychiatric service in one of the most deprived areas in New South Wales, Australia. We have a population with many problems – including, significantly, a high prevalence of drug use. Whatever problems a person comes to us with (and I have to also say that given the resource constraints in the public system, and the sheer volume of work, someone presenting with attentional problems alone is almost certainly not going to get seen), am I really likely to send them off with a prescription for amphetamines?
Ummm … let me think about that for a nanosecond …
Hell. No.
That’s where reality intervenes. ADHD isn’t something that the public service can really afford to look at, and even if we did, given the reality of the world (comorbidity, drug abuse and so on) treating these people with stimulants is really not a goer.
… Leaving aside completely the question of what it really “is” that we’re diagnosing and treating.
Popularity: 6% [?]
I wouldn’t say no to some cheap speed.
Raphael,
I am a 49 year old General Practitioner, treated for ADHD with stimulants form October 2008 to June 2010. I finally mastered my ADHD through meditation- but would never have got stable enough to do this without medication.( Dexamphatamine 10mg q4h- 5 doses per day).
My ADHD very nearly killed me, and left me in a state where I was inflicting accidental harm on my kids every day.
I will say this quite bluntly- not to diagnose and treat ADHD properly is simply Medical Negligence- pure and simple.
I will also say that “speed” and “drug abuse:” are quite frankly ridiculous terms to use in relation to people who are taking medication in order to live a more functional and helpful live, one that is kinder on their loved ones. For heavens sake grow up and look at the ample evidence that supports the utility of the diagnosis, and the huge number of people who are greatly assisted by medication.
I look forward to the day when a successful negligence case for “failure to diagnose ADHD ” is brought against a psychiatrist. It is well overdue.
You talk about environmental issues in ADHD- however- if you look at the DSM definition- there is NO mention of causation. I know hundreds of people with ADHD- and I do not know a single one whose life was such a rose garden that paying direct attention to it was anything less than a tall order. However that is not part of the definition.
Equally- the concept of ADHD as a “neurobiological disorder” is also not part of the definition. It is part of the mythology of current biomedical science- but these people are well behind the leading edge of scientific thought, are over specialised, and are financially beholden to Big Pharma. They don’t impress me, their arguments are flawed, and I most certainly do not accept the idea that there is anything wrong with my genome.
I would also add that I am 100% with you on the failings of 15 minute medicine, 15 minute psychiatry, and drug only intervention. In fact quite a few ADHD patients will do very well without medication. ADHD is not a stimulant deficiency syndrome.
However, naming the problem for what it is does open the window to a raft of attention targeted treatment, from stimulants, to mediation, to exercise, to management of sleep problems, to management of oculomotor problems, auditory processing disorder, anger problems, to assistance with personal crises and concessions with study, to dietary modification. ( How much do you know about the methylation pathways for instance- and why would you even be interested in them if you had not already understood that your patient had an attention problem?)
Sorry MEDITATION– not mediation. The last residues of ADHD are difficult to eradicate.
As a final comment- as a medical practitioner with 26 years experience- I do not think the argument of "what the public system " can afford to look at tells us anything more than the need for private health insurance..The public system was pretty patchy when I was a resident doctor in the eighties, and in Australia at least it is going downhill at an alarming rate.
Again, for those prepared to do their homework, the theory that ADHD is a "foundational disorder" and is in fact the state that is the driver of much of the psychopathology we see- is now gaining currency. That makes sense to me- it is easy enough to delineate to anyone prepared to take a thorough history. True- it doesnt pay well- but a job well done is it's own reward.
But it’s not one thing, one problem. We see a pattern that sometimes *is* neurobiological disorder, sometimes is environmentally mediated, sometimes is probably simply to do with basic hard-wiring, temperament, and goodness of fit with demands of school/work/society/whatever. And probably more, and certainly mixtures of all. Saying that a presentation, a syndrome, with multiple underlying aetiologies, is itself the cause underlying most other psychopathology, makes no sense.
I know some believe they know exactly what ADHD “is”, what causes it, and how it causes *everything* else, but they are not in line with the evidence or the overall body of knowledge and expert opinion. Consequently, I don’t accept their claims of what almost seems to amount to a “unified psychiatric theory” – as much as they claim to be the only ones at the leading edge, or not in thrall to “Big Pharma”.
And I also think you missed my main point. As the title of the post reads: ” …the problem is reality”. In reality it is not reasonable or practicable to treat people with this set of symptoms – at least in the public system. Sorry, but that really is the long and the short of it. No matter what the entity/ies might be, no matter how important at base (and I don’t take issue with that at all), we simply cannot do anything for these people – see my recent post about the mental health monies in the recent Budget.