I have been following this story in the online news. It seems quite surprising to me…

From what I can gather, a 20 year old young man got charged, convicted and sentenced to jail for charges of assault and an indecent act. This young man had been diagnosed with ADHD, and was treated with Ritalin from the ages of 6-16. Judge Conlon reportedly said that he believes that the use of Ritalin has created a whole generation of violent youth. Apparently a psychiatrist testified that ritalin caused brain damage.

Here is a link to the original article.

My surprise comes from the fact that misinformed (and frankly ignorant) opinions about ADD and ADHD are in the courts in Australia. This is now getting to be a debate in the Australian Government. I urge the Medical Community in Australia, as well as the parent support groups to step forward and break down these wrong ideas.

Ritalin doesn’t cause brain injury. Generally, it is not overprescribed. Research shows that treating with Ritalin (or other ADHD medication) actually reduces aggression and criminal acts, and doesn’t cause this.

I have submitted a comment to this newspaper article posted above. They have to approve the comment. It will be interesting to see if they do. I am posting it here for you to see my response, and I will come back and let you know if they do allow this comment to go on their website.

Dr. Kenny

Here is the comment I entered into their site:

I am sorry to see that such a controversy is going on in Australia over medications for ADD/ADHD.

It has been clearly studied and documented that Ritalin does not in fact cause brain injury. I reference Dr. Castellanos’s research from the American NIMH, which documented no change in children’s brains with the ADHD medication.

Ritalin, however, when taken, can significantly improve the risk of impulsivity, which can often be the cause of criminal behaviour.
Although I don’t know details of this 20 year old’s actions, the facts are that about 70% of kids and teens with ADHD, still have it when they are adults. If he wasn’t taking his medication, then his ADHD was uncontrolled, and this could have been a contributing factor to his criminal behaviour.

Ritalin was not the causal agent for this man’s criminal acts, but it could have been a factor to prevent that from happening.

I urge scientific facts to enter this controversy in Australia, rather than ill informed opinions.
Please visit my blog to learn more about ADD/ADHD: www.ADDADHDBlog.com

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It was just reported today in Australia, that the non-stimulant medicine Strattera (Atomoxetine) will be funded under the Pharmaceutical Benefits Scheme, starting July 1, 2007.

Prior to this, the only options covered under the plan are stimulant medicines.

Strattera is the first non-stimulant indicated for ADHD. In Canada and the USA, it is indicated in the treatment of ADD/ADHD in children aged 6 and older, teens, as well as adults with the disorder.

To read more about the story in Australia, visit here.
To read more about Strattera, visit here: Strattera for ADHD.

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I came across a great article and online video about Chris Kaman, the LA Clippers Center. He has ADHD.

Chris is having a great season, and is thought to be one of the up and coming star players. He was brave enough to let people know that he has ADHD.

I am happy to see that another celebrity is coming forward to share his experiences. My hope is that he can be a great role model for kids out there who may be struggling with ADD or ADHD.

Previously, I wrote about Ty Pennington having ADHD, and I hope that we can see more celebrities sharing their personal experiences with this disorder, and how they succeed with it.

To see the full story, (and to watch a video) visit: Chris Kaman

Please forward this article to any kids who love basketball, and have ADD or ADHD themselves.

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This article comes from two different subscribers’ questions. The first is: “Dear Dr. Handelman - I wanted to ask you why would a child at ten years old with ADHD push his mother into counters and walls when he is upset and not getting his way?”

The second question is “Dear Dr. Handelman - I wanted to ask you if my daughter has ADHD because she gets into trouble a lot at school by not concentrating, disrupting and blurting out and fighting a lot and she never shuts up. She gets hyper nearly every day and she can become very stressed and emotional and aggressive. She can get hyper on anything she eats.”

I appreciate both of these questions, because it is not easy to talk about such difficulties.

I will use both of these questions to teach you an important point. It relates to the fact that both of the descriptions above suggest that these kids have ADHD plus something else.

There is a concept in ADHD called comorbidity. You can review comorbidity by reviewing a previous article - comorbidity in ADHD. In summary, comorbidity means that there is a co-existing disorder that causes more ‘morbididty’ or in other words difficulties in one’s life.

While I cannot diagnose these children based on so little information, the comorbid condition which comes to mind is: Oppositional Defiant Disorder. This is often referred to as ODD.

Certainly in the first question where a ten year old boy is pushing his mother into the counters and walls when he’s upset and not getting his way - that’s more than ADHD - that’s a behavior problem. It is very uncommon for a child with ADD or ADHD to act in such a manner.

Oppositional Defiant Disorder is defined as having 4 out of 8 diagnostic criteria on a regular basis, over a period of at least 6 months.

The criteria of ODD include(from the DSM-IV-TR):

• Often loses temper
• Often argues with adults
• Often actively defies or refuses to comply with adults’ requests or rules
• Often deliberately annoys people
• Often blames others for his or her mistakes or misbehaviors
• Is often touchy or easily annoyed by others
• Is often angry and resentful
• Is often spiteful or vindictive

The DSM-IV-TR explains that these symptoms have to be present much more than would be expected for the individual’s developmental age.

Furthermore, the symptoms have to cause significant impairment - in social, academic, or occupational realms.

Conceptually, ODD is like a child going “up to the line”, which is put in place by parents or other adults and testing that line. Or tormenting the person holding the line. Or stepping over the line but coming back very quickly.

ODD doesn’t include clearly crossing the line. That moves into the realm of Conduct Disorder.

Now when a child has ODD with ADHD it can be a lot more complicated to deal with. It can really depend on the severity of the ODD. With mild ODD, it can be challenging for parents and teachers, but it can be like just an extra spirited child. Severe ODD can tear families apart and disrupt the school significantly.

So what do we do to treat Oppositional Defiant Disorder (ODD)?

Well as with all psychiatric disorders, there are medication approaches and there are behavioral approaches.

The medication approaches: there are no medications specific for ODD. Since ODD is mostly present with ADHD, then treating the ADHD well will often improve the ODD. This has been shown in multiple studies with stimulant medicines (Ritalin, Concerta, Adderall, Metadate, etc) and the non-stimulant - Strattera.

The non-medication approaches include behavioral and psychological techniques to help manage the ADHD and ODD. Parents need to learn to structure the environment very well for them to help them to keep on track. Parents need to get a ‘Ph.D. in parenting’ if you will. They need to learn specialized techniques and abilities to handle their child’s difficulties. A good resource for this is Dr. Tom Phelan’s work - including 1,2,3 Magic and Surviving Your Adolescents.These books can be found at The ADHD Bookstore.

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There is a very important concept in ADHD called comorbidity. Comorbidity means that there is a co-existing disorder that causes more ‘morbidity’, or in other words difficulties in one’s life.

It is very common for people with ADHD to have comorbid (or co-existing) conditions. Only about 25-40% of kids and teens with ADHD have ADD or ADHD alone. Most of the time (i.e. 60-75% of the time), there is a second, or third diagnosis as well.

The most common comorbid conditions with ADD or ADHD in kids and teens are: Learning Disabilities, Behavior Disorders (including Oppsitional Defiant Disorder and Conduct Disorder), Anxiety Disorders, Mood Disorders (commonly Depression, rarely Bipolar Disorder), tic disorders (like tourette’s), etc.

In adults - comorbidity in ADHD is very common. Research has shown that only about 14% of adult ADHD is simple ADHD, meaning that 86% of adults with ADD or ADHD actually have a second or third disorder.

While the list of comorbid conditions in adults is similar to the one in kids, it is important to note that there are some significant additions. These include: substance abuse and dependences (i.e. drug and alcohol addiction/dependence), and personality disorders. Adults still have high rates of Learning Disabilities, Behavior Disorders, Anxiety Disorders, Depression and even Bipolar disorder.

The reason that comorbidity in ADD or ADHD is so important relates to the fact that often times, the comorbid condition can be so important that it can completely dominate or change the treatment for the whole condition.

For example, if one has ADHD and an Anxiety disorder, there is research that shows that the response to medication may be different. For example, some studies show that the use of a stimulant (like Concerta, Ritalin, Adderall, Biphentin or Metadate CD) may actually worsen the anxiety. There are other studies that show that they don’t worsen the anxiety, but don’t help it. However, Strattera, the non stimulant for ADHD, has been shown to help the anxiety and the ADHD at the same time.

Another example is if a child has ADD and a Learning Disability. If this occurs, one needs to treat both in order to get a good effect. If one were to only treat the concentration, then there could still be problems with processing information (i.e. the learning disability). If there were academic supports and treatment put in place for the learning disability, but there was not effective treatment in place for the ADHD, then the child could struggle to pay attention in order to benefit from the help in place for academics.

The bottom line: a thorough assessment for ADD or ADHD will review whether there are any comorbid (or co-existing) conditions present. Knowing about these comorbid conditions is crucial because it can actually affect the primary treatment of the ADD or ADHD.

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In a previous article, I discussed how people with ADD or ADHD actually do not always have a ‘deficit’ of attention, but rather a difference.

One big difference in the attentional abilities of people with ADD or ADHD is the ability to hyperfocus.

What is hyperfocus?

My definition of hyperfocus is: the ability to completely and utterly focus on one topic or issue, often to the exclusion of others, with precise and productive concentration, until the end result is achieved.

“Wait…” you may say. “That sounds really productive. That sounds like tremendous concentration!”

It is.

Yes, people with ADD or ADHD can actually hyperfocus and create tremendous focus, achievements and results.

How?

They need to develop the skill of hyperfocus.

Hyperfocus can actually come out if there is a natural crisis. This could be someone is in danger and you need to pay attention to save them. This could be that the boss needs a report done last minute and you are the only one who can help to save the team.

In a school setting, often times procrastination leads to a ‘crisis’, which then lends itself to the increased stimulation needed to get the job done, and this paves the way for hyperfocus to come out and help out.

How can you use hyperfocus regularly to improve your functioning?

• Set little deadlines, and focus on achieving them.
• Use a timer to keep you going for a set period of time.
• Make yourself accountable to others - so that getting something done as you’ve said you would becomes a matter of pride or honor.
• Keep a journal to keep track or multiple goals your are aiming for - so that if and when you do start hyperfocusing, you won’t let other priorities become major crises.

The important point here is that when people have ADD or ADHD, there is actually more of a difference than a deficit in attention and one needs to learn to harness this difference to improve functioning.

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This article comes from a subscriber’s question: “Dr. Handelman: I wanted to ask you my son has been diagnosed with ADHD but I have trouble accepting it. He is able to read books for a long time and he can play Nintendo for hours. How can they say that he’s got ADHD when he can pay attention?”

This is a great question and I’m glad that it’s been brought up because people with ADHD can pay attention.

Let me repeat that: People with ADD or ADHD still can pay attention.

The issue is that they are very inconsistent in their ability to pay attention.

Someone without ADHD can be consistent in their ability to pay attention. For example, a student with ADHD can be consistent paying attention to math in the morning, English late morning, and Science in the afternoon. For the student without ADHD, he or she can pay attention reasonably consistently on whichever day, at whatever the time.

Someone with ADHD can find it very hard to be consistent with paying attention. On a day to day basis, paying attention can be hit or miss. The level of attention can vary based on how interested the student is to the material, how important the material is, etc.

Even if he or she has trouble paying attention to a specific subject - i.e. Mathematics, if there is a big test coming up - he or she could put a lot of attention into paying attention for that test. However, if the next class is English (which is often easier to pay attention to for that person…) he or she could be totally distracted because all of the attention was ‘used up’ in the last class.

The important thing is that attention is inconsistent. I suggest that instead of thinking of an ‘Attention Deficit’ - you should think of an ‘Attention Difference’. People with ADHD can pay attention to things but they do it in a different way than people without ADHD.

One other angle with this issue is that ADHD symptoms are much less of an issue when someone is doing something that she likes, or in a small setting such as one on one. ADHD symptoms are much more significant when the individual is doing something she doesn’t like in a large group setting.

When I’m interviewing parents in my office about their children and the symptoms they have, I need to keep this in mind. If I ask: “Does your child have trouble paying close attention to details?” Some parents will say, “it depends”.

I then clarify - by asking: “Tell me what it’s like in a larger class in a subject they don’t like - or in a large group setting”. It then may be easier for a parent to recognize the difficulty.

The analogy here is cardiac disease. If someone has blocked heart arteries, he may not have symptoms sitting in front of the TV relaxed. But, if you make him run up two flights of stairs, he may get chest pain. When he is sitting on the couch, does that mean he doesn’t have cardiac disease? Of course not. The same applies in ADHD. If one is doing something fun, stimulating, easy and in a small group, it is easy. However, under ’stress test’ conditions, the symptoms come out.

And why can just about all kids with ADHD spend hours playing video games (if you let them)?

Because video games are designed to be tremendously stimulating. In fact, they are designed in such a way that the ADHD brain may excel - compared to non-ADD’ers.

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In reviewing how common adult ADD/ADHD is, we can look at it from two angles. The first is ‘ADHD kids grown up’, and the second is the rates of adults with ADD/ADHD.

We know reliably that ADHD occurs in about 5-7% of children. We also know that about 70% of those individuals carry on with their ADHD into adult life. So, we’re talking about approximately 3-4% of adults having ADHD.

Research was recently published documenting results of an epidemiological study. An epidemiological study is one which looks at rates of disorders in the community. It was very well designed and the results can be trusted. It documented that 4.4% of the American adult population have Adult ADD/ADHD. This type of study has not been done in other countries or cultures, but it is nonetheless a very important study to understand the rates of adult ADD/ADHD.

Now, we don’t recognize and treat 4.4% of adults in the general American population with ADHD so there are a lot of people out there who don’t know about this. This relates to the fact that recognizing and treating Adult ADHD is still in its infancy.

It is really only about the past 10-15 years that research about Adult ADHD has become more common, and that practitioners are recognizing that ADHD can go beyond 18 years of age.

Where are all of the adults with ADHD who aren’t diagnosed or treated?

Some are very successful - if they have learned to harness their creativity and energy for their own success.

Some are doing reasonably well, but struggling more than they should.

Some are doing very poorly, with multiple difficulties.

From a doctor’s perspective - I expect that we will find many of the adults with Adult ADHD in the other psychiatric clinics. Research shows that about 80% of adults with ADHD have at least one other co-existing (the medical term for this is ‘comorbid’) disorder, and 60% have two or more disorders.

Which disorders come with Adult ADHD?

It can really be almost any psychiatric disorder - but it is commonly mood disorders like depression, anxiety disorders, substance abuse disorders, etc.

I hope that the adult psychiatrists will learn more about adult ADHD, and start to include it as part of their assessments, particularly when dealing with individuals with difficult to treat mood disorders, anxiety disorders or substance use disorders.

One final comment - the fact that two different research sets show the same rate of adult ADD/ADHD is very strong data. By this I mean that if we use the rates of kids with ADHD grown up - we start with about 7%, and then only 70% still have it, yielding a rate of 4-5%. The recent epidemiological study gave a rate of 4.4%. Thus this number is reached by two different lines of research. This makes the finding that much stronger, because it is from ‘converging data’. This means that two separate research approaches yielded the same results. Very strong data indeed, meaning that we can be confident in the results.

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This article comes from a question from three of my subscribers. It was asked three different ways:

1. What is the prognosis of ADHD?
2. Can one outgrow ADHD?
3. When will my son outgrow ADHD or at least outgrow the need for medication?

These are very important questions especially for people dealing with kids and teens with ADHD.

Research shows that when individuals with ADHD are followed from childhood into adolescence and then into adult life about 30% or so of adults will have outgrown their ADHD. That means they will no longer meet a formal diagnosis of ADHD.

That means that about 70 percent of kids and teens who have ADHD will still have the full diagnosis as adults. Research also suggests that the people who don’t have the full diagnosis still have some of the ADHD criteria present and may in fact still have some impairment from their ’subthreshold’ ADHD. ‘Subthreshold’ means that their symptoms are not severe enough to merit the full diagnosis, but they are close to the threshold of meeting the diagnosis.

The second part of the question is: ‘can he at least outgrow the need for medication?’

This is a very important question.

Does a person with ADHD going into adult life necessarily need medication for many years?

The answer depends on many factors. It depends on the individual’s strengths and weaknesses; it depends on whether they have been able to find support in their family, in their education, in their career, and it depends on their personal strengths and weaknesses and their ability to adapt.

I like to think that if someone has an ADHD ‘friendly’ job and an ADHD ‘friendly’ spouse or friends etc., that he or she may do quite well without medication. Somebody with an ADHD unfriendly job may end up being very unhappy and being at risk of a lot of complications that can come with difficult ADHD if it’s not treated.

What is an ADHD friendly job? One which allows one’s strengths to come out. One which does not penalize the individual for his/her weaknesses. For example, often someone with ADD/ADHD may do well with a creative, high stimulation type of job; and he or she may do poorly with a low stimulation job like data entry.

To summarize, some people do need medication going into adult life with ADHD, and some people may not. It depends on their ability to find a situation that works well for them with the support that they need to function effectively. ADHD can bring out some tremendous characteristics in individuals- creativity - looking at the same thing that everybody else looks at - seeing it in a completely different way and thus yielding very different results. That can be a tremendous strength of ADHD and can be a very valued skill in a workplace.

However being disorganized, being late for things, missing meetings and not paying attention enough can be very difficult in a work place.

In summary, each adult with ADD/ADHD will have to assess whether he or she is functioning well enough to manage without medication.

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