The Latest Controversy about ADHD

Attention deficit hyperactivity disorder has been around and known by different names since the early 1900’s when in the Boston area, the first child behavioral (psychiatric) established by the then family/child court system of Boston started to have to deal with behaviorally out of control, hyperactive [thought that term came into use later] children in sudden new higher numbers after World War I. Most medical historians feel that ADHD has always been with us but the time after WWI saw an increase in children who had unfortunately suffered mild brain damage from what was known then as “Von Economo’s Encephalitis.” This was the CNS manifestation of the “Spanish flu pandemic” that swept the world shortly before the end of WWI and through somewhere around 1920-1921. This was the first great known documented influenza pandemic and many books in the last 20 years have documented beautiful this pandemic as the modern scientific and public world began to become interested in infectious diseases, emerging diseases, largely set off the AIDS epidemic that rose to public awareness in the late 1970’s and especially the 1980’s.[ For the very best book on the start of the AIDS epidemic, the reader is referred exclusively to the now dated book AND THE BAND PLAYED ON by the late San Francisco newspaper reporter Randy Shilts.]

To explain what happened in the Spanish Flu pandemic, the influenza virus is capable in anyone of producing an “encephalitis,” a viral infection of the brain. Nowadays we are acquainted unfortunately with annual “equine encephalitis” outbreaks in various parts of the country. Any of these viral infections of the brain can cause real brain damage, paralysis, loss of virtually any brain function or capacity. Strikingly though, this viral outbreak that was part and part of the Spanish Flu pandemic produced as it were, “artificial,” causes of Parkinsonism by the thousands as an aftermath residual symptom of having the influenza brain viral infection. Patients young and old had the visible and even in those days nearly 100 years ago now, the tremors, halting gait, imbalance and slow gait of the adult Parkinsonism patient. But in the young people they seemed more likely to develop sudden hyperactivity, wild difficulties with impulse control, poor or absent concentration and focus. Sound familiar? They got into all kinds of behavioral, legal and delinquent behaviors and turned by the dozens, then hundreds, in the Judge Baker juvenile court, one of, if not the first of its kind in the country. The court and this jurist were wise and recognized that these were not criminal youth, but that something had altered them self-control and resulting behavioral styles drastically for the worse. It was a tough time as there was really NO treatment for this new avalanche of a patient cohort with a new condition not seen before. But that is likely the historical start of the recognition of ADHD. It came to be then appreciated in the school systems that there were other youths who had much the same behaviors, but who had NOT had the influenza nor Von Economo’s encephalitis. Thus, the concept of the “hyperkinetic” child started in the decades after World War I.

It was not until World War II and after that we started to have the first successful agents that reduced those ‘hyperkinetic’ symptoms. And that is the early “teaser” in this post that I will address next in the subsequent post once I take the reader through this brain correction ADHD medication controversy.

And of course now we have the ongoing dramas about measles and the Ebola virus.

But ADHD while being controversial since its evolving discovery and description, treatment options and growing body of research confirmation that is real, is NOT an infectious disease but nonetheless fairly common. And literally everything about ADHD has been not only debated, but hotly disputed, contested, reviled and even fought over. I recall in my earlier days as a child psychiatrist especially in the 1980’s when national child psychiatry meetings, were routinely invaded and disrupted by protesters, demonstrators and fierce fervid opponents of the concept of ADHD often sponsored by a few nationally organized groups for whom ADHD was one of their central organizing rallying points. I recall having to tolerate their outbursts, taking time in our meetings to permit them to speak and giving them due free speech rights some rein. But always they would get carried away and push in an aggressive manner until ‘security’ always had to cart them away as they imitated the passive sit in protesters of the Civil Rights days in this country. All of us resigned ourselves to these disruptive and irritating events as part of the social contract we abide by in this country to preserve free speech. Many of us felt a kind of intellectual sorrow for these, in our views, misguided folks, and worried about if they had children that had ADD/ADHD and were not being treated, or worse, in those days, were receiving bogus sometimes expensive time wasting treatments.

Now to the latest stimulus for another controversy about this disorder. Recently in the Journal of Clinical Psychiatry, a reputable, refereed scientific journal in psychiatry has published article jointly authored by a group of credible Harvard Medical School reputable researchers entitled: “Effect of psychostimulants on brain structure and function in ADHD: a qualitative literature review of magnetic resonance imaging-based neuroimaging studies.” It is published for review in J Clin Psychiatry. 2013 Sep;74(9):902-17, through the National Institutes of Health site in the National Library of Medicine via its online medical reference publication database open to anyone, PubMed. A much more readable, simple and clearer article describing the issues written by Katherine Ellison, entitled “Can Attention Deficit Deficit Drugs ‘Normalize’ a Child’s Brain?” on February 2, 2105 in the New York Times will help to make the issues clearer and is available at this website link.

The occasion for emerging in the news again, as the first study above, “Effects of psychostimulants…” etc., actually published in 2013, was the occasion of a nationally famous and respected authority on ADHD, Dr. Timothy Wilens, talking publicly about his growing feeling evidence is accumulating that the much maligned stimulant anti-ADHD drugs may indeed help to somehow reset the deficient self inhibiting areas of the brain that help in those of us without this condition to quiet, still ourselves, be able to wait more patiently, not have to fidget all the time, squirm in our chairs, maintain our focus and concentration, or do the multiple of “hyper” behaviors individuals with ADHD do.

A corollary to this that may serve as somewhat of an intellectual backdrop to this line of thinking is that there has been some research, though not an overwhelming amount, that seems to suggest the anti-depressants in general, and perhaps the modern second and third generation of the serotonin acting antidepressants, may indeed be “neuroprotective,” and help restore over time some aberrations of functioning of some of the neurotransmitter systems and signaling and traffic mechanisms in some of the many brain regulating areas that have to do with the resultant outward expression of depression.

In my humble opinion, the research on medications perhaps exerting an as yet unknown sort of ‘neuroprotective’ or corrective effect on functioning of the ADHD brain systems is more supported in long term clinical observations than in the general field of the treatment of depression. For instance, there has been data and longstanding observations that perhaps a fairly high percentage of children and adolescent can ‘graduate off’ anti-ADHD psychostimulant medications as their condition declines in intensity after some years of consistent maintenance on these medications.

I will give you my own clinical experience in this area. In the first third of my career I was in one setting and one practice community for nearly two decades so I had the wonderfully educational and edifying opportunity to follow patients over a period of almost 20 years. This was especially enjoyable for me, for at heart, I was and still am, a developmentally oriented child psychiatrist. My mission as I saw it in its ideal form and result, was to support development, I and parents were on a joint mission in our treatment alliance to strive and work as hard as possible, pulling together as many positive and developmentally nourishing resources as we could to ensure the best track of development of growth in all the typical areans of child development whether they be physical growth, social, educational, musical, artistic, even that of helping a child and teen to be a “good citizen,” which I still think is a supremely laudatory goal no matter what one’s viewpoint. Sometimes this helpful view of a child’s development was poignantly expressed to me by many parents who had been abused themselves as they fervently stated that they wanted “my child’s growing up experience to be better than mine.” No wiser words I ever heard and they always reminded me what constituted a “good parent.”

So in my nearly 20 years’ practice in my city where I had done my psychiatry training, I saw many youth through their developmental epochs, stage by stage, and had the chance to follow them long term which was crucially important. I did see about half of my ADD/ADHD patients be able to come of psychostimulants as they “matured out of” ADHD as it was commonly described back then. Others learned when they hit high school, university, technical school or community college settings, that they still DID need the medications especially in lecture settings. They “learned to manage” their ADHD and take their medication dose or doses a period of time before the block of lectures began so they could be at their best in classes, pay attention for up to two hours, take good notes and above all, more ably and accurately register and retain the information they had to sit through and listen to some, often not very dynamic or engaging lecturing professor with a microphone down in the well of the lecture hall shaped like an amphitheater droning through a microphone. I exaggerate, but not much as in the big prestigious universities that was and still is sometimes, the standard setting for the large required introductory freshman year courses. And ADHD folks tend to be more visual learners than sponge types who can soak up droning auditory material.

But there are caveats and limitations to everything. Most of the most severe ADHD individuals could not tolerate or perform in anything like a conventional educational setting and could not come off their medications at all. We did them a disservice nearly 40 year ago when it was still partial clinical unsupported lore that adolescents should come off their stimulant anti-ADHD medications by ages 16-17 and I remember being taught this in my training and thinking to myself of cases I was treating that I knew could not function without their medication maintenance and did not ‘cut them off’ from their function sustaining aid. Yes, we professionals too, in the early days were concerned about the long-term effects of psychostimulant medications as that line of practice was still in its infancy and we recognized we did not have complete knowledge about their effects. Now we have over a decade if not 15 years or more of good literature, drawing upon huge pooled numbers with true statistical power and confirmation, that one “neuroprotective” effect of the stimulants for the treatment of ADHD, is that they prevent the onset of drug abuse even at early ages in very high percentages of ADHD youth who receive good long-term treatment to support their development even through early adulthood!

The other hinted at “neuroprotective” possible effects of the old standard psychostimulants will have to wait a few more long term decades of research and follow up to see if this holds up in large populations, and, pinpointing the areas and structures that may be changed, and how these biological, functional and possibly structural changes in the central nervous systems of ADHD individuals changes for the good the course and all too often very achievement limiting effects of this all too common neurodevelopment condition.

Again, in the next post, to round out the early history of ADHD, I shall try to take the reader through the almost accidental, fortuitous, serendipitous discoveries of helpful agents for ADHD and its developmentally interfering symptoms. One of those substories about the early agents will help, I hope, to clue the reader into what I and many others consider the historical origin of the fears of the psychostimulant. Another interesting story to be sure, so stay tuned.

 

 

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2 thoughts on “The Latest Controversy about ADHD

    1. Thank you for your kind comments. I am a busy physician and sometimes post irregularly due to my typical MD schedule at the state hospital where I work which is a very place facility. But I try to post at least once a week or more but sometimes miss a week. In any case thanks for you comments.

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