What’s New About Attention Deficit/Hyperactivity Disorder? – Dale Mortimer, M.D.

Is Attention Deficit/Hyperactivity Disorder (also known as “ADD or “ADHD”) a fad, or a valid medical disorder? Don’t we all have some symptoms of attention–deficit/hyperactivity disorder? Isn’t attention–deficit/hyperactivity disorder just an excuse to escape culpability for blatantly rude or even criminal behavior? Just how effective are EEG neurobiofeedback, play therapy, gluten–free diets, various vitamins, caffeine, “energy drinks,” or herbs for the treatment of ADHD? Should those with ADHD receive effective treatment only during school days and school hours, or should these persons with impairing ADHD be treated throughout the waking day, 365 days a year? Why do some ADHD individuals do well with a very low dose of medication, while others prescribed the same dose show no response – even if the ADHD individuals are of the same weight and age? What is the risk of addiction from taking prescribed stimulants? Should those with past substance abuse ever be prescribed stimulants? Is there an absolute maximum daily stimulant dose?

In June, 2001, at the annual meeting of the Oregon State Pharmacists Association, Vancouver Child & Adolescent Psychiatrist Dale Mortimer, M.D., addressed these questions and more during his presentation on attention deficit/ hyperactivity disorder.  More than 80 pharmacists from Oregon, Washington and Idaho traveled to Oregon’s Sun River Resort to listen to Dr. Mortimer’s keynote presentation. Because of the enthusiastic response to his 2001 presentation and subsequent summary, Dr. Mortimer has provided the reader with this update.

History OF ADHD. Back in 2001, Dr. Mortimer began his Sun River presentation by reciting a poem – which is known in English as Fidgety Phil. In one translation, the poem goes something like this:

“Phil, stop acting like a worm.

The table is not a place to squirm!”

Thus speaks the father to the son.

Severely speaking, not in fun.

Mother frowns

And looks around.

But Phillip will not heed the advice.

He’ll have his way at any price.

He turns and churns.

He wiggles and giggles.

“Phil these twists I cannot bear!”

Phillip then tips backward and out of his chair.

This poem was written in about 1848 by German physician Heinrich Hoffman who lived from 1809 to 1894. In this poem, Dr. Hoffman describes a boy with what would now be an example of the “hyperactive/impulsive subtype” of ADHD. A second poem by Dr. Hoffman, entitled [in English]

Harry Stare at the Clouds, describes a boy with the inattentive type of ADHD. In English translation, the poem goes something like this:

  As he trudged along to school,

  It was always Harry’s rule

  To be looking at the sky

   And the clouds that floated by;

   But what just before him lay,

   In his way,

   Harry never thought about;

   So that every one cried out

   "Look at little Harry there,

   Little Harry Head-In-Air!"

   Running just in Harry’s way

   Came a little dog one day;

   Harry’s eyes were still astray

   Up on high,

   In the sky;

And he never heard them cry

   "Harry, mind, the dog is nigh!"

   Bump!

   Dump!

   Down they fell, with such a thump,

   Dog and Harry in a lump!

Dr. Mortimer added: “From reading some descriptions about Dr. Hoffman’s own childhood, I suspect that Hoffman himself suffered from what would now be called untreated attention–deficit/hyperactivity disorder. For example, young Heinrich Hoffman was described as ‘lazy and easily distracted, gregarious, and struggling in school.’ Fortunately, Heinrich’s ‘stern father’ provided Heinrich with enough structure to permit him to eventually graduate from medical school.”

Dr. Mortimer made several observations and conclusions: “The name of what is now known as Attention Deficit/Hyperactivity Disorder has gone through a change of name [and a slight change in diagnostic criteria] every decade or so. In 1902, Sir George Still named this condition Still’s Disease, of course. In the early 1900s, the condition was renamed Disorder of Moral Control. In 1937, its name changed to Minimal Brain Damage. Since no gross brain pathology could be identified on autopsy, in 1960, the name was changed to Minimal Brain Dysfunction. Then in 1968, the name changed again to Hyperkinetic Reaction of Childhood. In 1980, the name changed again – this time with subtypes: Attention Deficit Disorder with or without Hyperactivity [i.e., “ADD with or without H”]. In retrospect, this sub–classification was as useful as subtyping hypertension based on a patient’s eye color. In 1987, the name changed again slightly to Attention Deficit Hyperactivity Disorder – without the subtypes. Most recently, since 2013, the subtypes are now back in fashion, and there is now a vergule between “Deficit” and “Hyperactivity.” So we currently have ADHD [for stylistic purposes, I am omitting the vergule here] with five subtypes: (1) ADHD, predominately inattentive type; (2) ADHD, predominately

hyperactive/impulsive subtype; (3) ADHD, combined subtype; (4) ADHD Not Otherwise Specified; and (5) ADHD, in partial remission. [For the current, “official” diagnostic criteria, please see Appendix A.]

Dr. Mortimer summarized: “My introduction above may be tedious, but here is my point: childhood–onset, chronic problems with attention, concentration, impulsivity and/or motivation is not a new condition. The name of the condition changes, but the ‘deck of cards” [each metaphorical card listing a single ADHD symptom] has remained still pretty much the same cards (or symptoms) for the past 160 years. Every ten or twenty years, the deck of cards is reshuffled, and, with each new edition of the Diagnostic and Statistical Manual of Mental Disorders, or “DSM” (since 2013, we have been currently using the fifth edition of the DSM), the name of the disorder is ‘tweaked.’”

Prevalence. Community prevalence is the number of persons with attention–deficit/hyperactivity disorder in a representative population sample, according to pre–defined diagnostic criteria. Dr. Mortimer continued: “Please also note that what is now defined as ADHD was described in the medical and pediatric literature over 150 years ago – long before the invention of TV, computer games, fluorescent lights, and food additives. Furthermore, what is now called ADHD is not a disorder that is limited to the United States (– remember that Dr. Hoffman lived in what is now known as Germany). We also know from international epidemiological studies that ADHD is a common medical disorder with a world–wide distribution. More recent studies place the prevalence of ADHD at 8.9% of all children and 13.1% of all adults. Previous and lower prevalence estimates of the diagnosis of ADHD in adolescence and in adults is misleading for several reasons. This is because of the quirky statistical consequences of writing the diagnostic criteria in order to identify ADHD children. Now, in the vast amount of cases, children with ADHD don’t ‘outgrow it.’ Instead, their symptoms change over time as their brains [and, especially, their frontal lobes] mature. The ADHD adult (or the spouse) might focus his or her complains on inefficiencies at work, problems with completing projects, difficulty sitting through meetings, driving a car too quickly, or talking excessively and making inappropriate comments. But it is the inattentiveness of ADHD that tends to remain in adulthood – which when ADHD is undiagnosed in adults, is much more difficult to identify by general adult psychiatrists, correctional psychiatrists, geriatric psychiatrists (– the majority of whom are not trained in child & adolescent psychiatry), or by the ADHD adults themselves.”

Orphan Adults. Where did all these “ADHD adults” suddenly come from? Is this just the latest fad? Dr. Mortimer explained that it wasn’t until 1995 before anyone saw a book on attention–deficit/hyperactivity disorder which had a chapter devoted to ADHD in adults. Until that time, ADHD in adults was an “orphan” medical condition, without any medical specialist “claiming” this group of patients as theirs. Those physicians most familiar with diagnosis and treatment of ADHD (i.e., pediatricians, child & adolescent psychiatrists, and pediatric neurologists) typically exclude adults from their patient population. General adult psychiatrists and general adult neurologists are usually not trained to identify (or even think about the possibility of) ADHD in adults.

A Fad? Being “thoroughly” familiar with the pediatric, genetic, neurological, and psychiatric literature on attention–deficit/hyperactivity disorder, Dr. Mortimer summarized: “ADHD is a valid medical disorder. It is one of the best–researched conditions in all of medicine. The overall data on its validity are far more compelling than is the case for most mental disorders – and even for many medical conditions.” While there is currently a lack of independent diagnostic tests for ADHD, “The evidence supporting the validity of the disorder in children, adolescents and adults includes: family, twin, and adoption studies; cross–national studies; long–term developmental course of ADHD over time; brain imaging studies; and segregation and molecular genetic analyses., Those who claim that ADHD is just a fad, and that it is an invalid diagnosis have not done their homework – nor have they had the frustrating and sometimes ‘hellish’ experience of living with someone with untreated ADHD.”

A sampling of the evidence for ADHD being a legitimate medical disorder. First, there is the genetic evidence. A number of twin studies have established that attention–deficit/hyperactivity disorder is among the most heritable of neuropsychiatric disorders.  Second, there is the brain imaging evidence. Structural brain imaging studies have found that total gray matter volume in the brain is decreased by 2% to 3% in children with ADHD compared with typically developing children, with more pronounced decreases and atypical age–related changes in the brain’s frontal–striatal system. The striatum and its frontal lobe connections are rich in dopaminergic neurons, and ADHD symptoms are believed, at least in part, to stem from dopaminergic and noradrenergic imbalances. Functional connectivity analyses (conducted on data obtained during functional magnetic resonance imaging) have demonstrated decreased connectivity in the brain networks supporting sustained attention and working memory, spanning the prefrontal cortex, striatum, parietal cortex, and cerebellum, specifically identifying brain regions in the right thalamus, left occipital gyrus and cerebellum. A recent study by Li et al places the pulvinar nuclei of the thalamus at the center of dysfunctional attentional networks in those with ADHD. (The pulvinar nuclei are the largest group of nuclei within the thalamus, and act as an “umpire” adjudicating which items in a crowded visual environment win focused attention.)

Heritability and Genetics. Until very recently, medical insurance companies attempted to deny medical coverage for the medical treatment of attention–deficit/hyperactivity disorder by asserting that it is an educational or behavioral problem which does not belong in the physician’s domain of medically treatable problems. Dr. Mortimer responded: “There is, in fact, no controversy in the professional medical literature on this point: ADHD is one of the most strongly inherited neurological disorders in all of medicine. Those who claim otherwise are either not familiar with the voluminous research published over the past three or more decades – or they are simply liars.” While the specific genes causing ADHD remain elusive,, we know that twin, adoptive and family genetic studies have found the heritability of ADHD to be between 60% to 90%, meaning that somewhere between 60–90% [the most common number quoted in recent articles is 75%] of the variance in ADHD symptoms is accounted for by genetics. “In other words, in about 3 out of 4 cases of ADHD, there will be a genetic family history for ADHD. Thus, ADHD is one of the most strongly inherited medical conditions is all of medicine – the heritability of ADHD is as strong or even stronger than it is for ultimate height.”

If a child meets criteria for attention–deficit/hyperactivity disorder, there is a 25% likelihood that a sibling will also be found to meet diagnostic criteria for attention–deficit/hyperactivity disorder, and there is an 80% likelihood that one or both parents will also meet diagnostic criteria for ADHD. If a parent meets criteria for attention–deficit/hyperactivity disorder, there is a 50% likelihood that their child will also meet criteria for ADHD.

“Once I am convinced a child meets criteria for attention–deficit/hyperactivity disorder, I next wonder which parent also meets ADHD criteria. Often, it makes more sense to treat the disorganized, inattentive, impulsive, or forgetful parent first before attempting to enlist the ADHD parent’s cooperation in administering and supervising the medications prescribed to treat the ADHD child or adolescent.”

Environmental contribution. Environmental factors also influence our genes. Epigenetic changes have been identified in a number of attention–deficit/hyperactivity disorder children with histories of exposure to such environmental stressors as prenatal nicotine and alcohol exposure, lead exposure, maternal malnutrition, prematurity, lower birth weight, stress violence, or severe psychosocial trauma.

Maturational delays and responsibility levels. Dr. Mortimer next referred to longitudinal neuroimaging studies of the brains of children with attention–deficit/hyperactivity disorder children compared to brains of normal controls. Some brain studies have shown a 2– to 3–year delay in maturation of prefrontal cortex and associated pathways in children with ADHD. Other brain studies have demonstrated frontal lobe subcortical and cerebellar dysfunction with smaller striatal structures in particular. In MRI studies, difficulties have been found with the differential maturation of important neural circuits, along with the persistence of cortical thickening where it should be thinning over time. “The important thing to keep in mind is that children and adolescents are moving targets. Their brains continue to myelinate with time, allowing more “computer application programs” to go “on line” in their brains. You just have to be very, very patient, and realize that developmental disorders such as ADHD unfold in a nonlinear fashion over time. The life trajectory for those with untreated ADHD is curvy, not a straight line.”

Dr. Mortimer has found the following formula from psychologist Russell Barkley, Ph.D. to be very useful for parents’ decision–making: For a child or adolescent with untreated attention–deficit/hyperactivity disorder, multiply the youngster’s age (in years) by 70%. This will give the parent a “ball park” understanding of the youngster’s current level of emotional maturity and responsibility. Would you trust a normal 14 year–old to baby–sit your children? Yes, probably. OK, would you trust a 14 year–old with untreated ADHD to baby–sit you children? Well, 14 years old times 70% yield a level of emotional/maturity of a 9.8 year–old child. So no, you shouldn’t expect a 14 year–old with untreated ADHD to responsibly baby–sit your children. Would you trust an 18 year–old normal adolescent with a driver’s license to drive your car safely. Well…yes, I suppose. Consider next the situation of an 18 year–old with a driver’s license who takes ADHD medication but the benefits of the ADHD medication are gone by 6PM? Would you allow him or her to drive your car after supper? Well, let’s see: 18 years old times 70% results in an emotional/maturational level equivalent of 12.6 years old. So no; this ADHD adolescent must not be allowed to drive a car after 6PM without taking effective ADHD medication at an effective dose late enough in the day to allow him or her to drive responsibly and safely in the evening. Would you expect a normal 18 year old adolescent to be responsible and mature enough to live on his or her own? Yes, probably. How about an 18 year old with untreated ADHD? Well, 18 years times 70% results in an emotional/maturational level equivalent to 12.6 years old, so no – the adolescent’s parents should anticipate providing supervision for their young adult with untreated ADHD until sometime around age 26 (i.e., 26 years times 70% results in an emotional/maturational age of 18.2 years old). Good luck with that!

Co–Occurring Medical Disorders (comorbidities). Not only is attention–deficit/hyperactivity disorder strongly genetic, ADHD is also a highly comorbid condition, with at least 50% of ADHD children, and 70% of ADHD adults having  at least one additional mental disorder, learning disorder or developmental disability –  e.g., major depression; bipolar disorder; obsessive compulsive disorder; a reading disorder [e.g., “dyslexia”]; a tic disorder; difficulties with sensory integration; problems with working memory; speech and language delay; and/or substance abuse [most commonly, nicotine dependence].,

“Identifying whether or not a person meets diagnostic criteria for attention–deficit/hyperactivity disorder is often the easiest part of the physician’s task. It is often more difficult for the physician to sort out – for example – whether the ADHD person’s demoralization and worries are separate disorders, or whether these symptoms are the consequence of the ADHD person’s accurate assessment of his or her current woefully inadequate difficulties with performance. Another diagnostically challenge is to sort out ADHD from bipolar disorder. ” This notion of comorbidity is important to keep in mind since the presence of additional, mental disorders (e.g., oppositional defiant disorder, a tic disorder, bipolar disorder) or the presence of non–ADHD general medical conditions (e.g., sleep apnea, an underactive thyroid, inadequate testosterone production in adolescents and adults, substance abuse, other unidentified medical illness) can greatly interfere with reaching a satisfactory treatment outcome.

Sleep and ADHD. Studies are finding that as many as 77% of children with attention–deficit/hyperactivity disorder have sleep disturbances, irrespective of medication status. Difficulty falling asleep (possibly a manifestation of a circadian sleep disorder with a phase delay) is common in ADHD patients of all ages. Several studies have shown an association between ADHD and sleep–related motor disorders, with 44.% with restless legs syndrome (compared to 10% of the general population); 40.4% with periodic leg movements associated with sleep; 21.8% with sleep–related rhythmic movement disorder; and 32.7% with bruxism. Studies of ADHD adults have found 60–80% of ADHD adults having comorbid sleep disorders such as daytime sleepiness, insomnia, delayed sleep–phase syndrome, fractured sleep, restless legs syndrome, and sleep–disordered breathing [e.g., primary snoring; upper airway resistance syndrome; obstructive hypoventilation; and obstructive sleep apnea].  Actigraphy and polysomnography data have shown that ADHD patients have lower sleep efficiency and higher stage shifts per hour of sleep; increased nocturnal movements; decreased time spent in REM sleep, are more sleepier during the day; and have longer daytime reaction times.,,

Just to make it interesting for the clinician, untreated adults with a diagnosis of attention–deficit/hyperactivity disorder will frequently complain to a general adult psychiatrist about the “random noise in my head” of mostly negative and pessimistic self–talk, during which time the untreated ADHD adult ruminates about what he or she said or didn’t say to others that day, or what the ADHD adult didn’t accomplish that day. Historically, the “noise in my head” was often misattributed as “racing thoughts” (– a diagnostic symptom of bipolar disorder), and – along with being easily distracted and often “on the go,” many general adult psychiatry–trained psychiatrists then misdiagnosed adults with ADHD with bipolar disorder. The good news is that now there is at least one adult psychiatry training program (at OHSU in Portland, Oregon) which trains its residents in identifying and treating adults with ADHD.

Although difficulty falling asleep is a chronic problem in most children, adolescents and adults with untreated attention–deficit/hyperactivity disorder, a common confusion arises when the ADHD patient (or the patient’s parent) forgets that the onset of sleep problems predated onset of ADHD treatment with stimulants. Consequently, the stimulant medications are often unjustly accused of causing sleep difficulties.

Longitudinal Course of Those with Untreated ADHD. In the 1960s, there was an unsubstantiated belief (which apparently became “gospel” after pediatrician Brian Laufer, M.D. publicly speculated about the longitudinal course of children with attention–deficit/hyperactivity disorder) that all individuals with ADHD “outgrew” their symptoms at the onset of puberty. We now know that this is not the case ( “…since when does anything improve with puberty?” asks Dr. Mortimer with a wry smile). Virtually all prospective studies of ADHD school-age children show persistence of symptoms through puberty and into adulthood. Since hyperactivity symptoms diminish with age, this may account for the long–held belief that children with ADHD outgrow the disorder during adolescence. However, the “core” ADHD symptom of inattention usually persists into adulthood. And it is often this profoundly impairing inattention which causes so many vocational, educational, medical, legal, and social problems.

“For the vast majority of attention–deficit/hyperactivity disorder individuals, this is a life–long, inherited disorder. ADHD is ‘with’ the person 24 hours a day, 365 days a year. That is, ADHD is a chronic medical disorder, probably present in the majority of ADHD individuals since birth. Yet, despite this knowledge, many primary care physicians continue to prescribe medications that cover ADHD symptoms for only 4 hours a day, and only during school days. This prescribing strategy makes as much sense to me as trying to read in the afternoons or on weekends without my eyeglasses. Optimal treatment must cover as much of the waking day as possible every day of the year.”

Psychiatric Assessment of ADHD. Since attempts to demarcate attention–deficit/hyperactivity disorder vs non– attention–deficit/hyperactivity disorder along a continuum of behavioral inhibition and self–regulation causes problems similar to those of trying to precisely determine when day ends and night begins, and since everyone sometimes has ADHD–type impairments [just as everyone is occasionally sad, but not everyone meets diagnostic criteria for a major depressive episode], “...experienced clinical judgment is essential in distinguishing those who do and those who do not meet ADHD criteria.” A considerable amount of information must be collected in order to: accurately rule in or rule out a diagnosis of ADHD; identify other, co–existing mental disorders; and develop an effective, practical treatment plan. “A thorough evaluation may require three or more hours of face–to–face time with the family – in addition to reviewing as many medical and academic records as can be retrieved. Performing an ADHD evaluation is not something that a physician can competently accomplish during a fifteen minute office visit.”

ADHD Checklists. Many physicians use symptom and behavior checklists, and some checklists are more helpful than others. Dr. Mortimer summarized: “For children with suspected attention–deficit/hyperactivity disorder, I prefer using the CAP (Child Attention Problems) checklist since it is short, normed, not copyrighted, and allows teachers to leave rich, descriptive written comments. For about the past 25 years or more, I have been using the Brown Attention Activation Disorder Scale (BAADS) and Paul Wender’s Utah Rating Scale (WURS) to screen for ADHD in adults. Other clinicians frequently use the World Health Organization–supported Adult ADHD Self–Report Scale (ASRS). However, despite the availability of these updated and normed symptom/behavioral checklists, I still cringe when I see pediatricians who are still using the archaic Vanderbilt ADHD Parent Rating Scale to rule in or out a diagnosis of ADHD. Alas, despite the Vanderbilt being insensitive and despite the Vanderbilt being incompatible with the current official diagnostic criteria for ADHD, the Vanderbilt is still widely used by pediatricians – probably because the Scale was devised by a pediatrician and also probably because the Scale isn’t copyrighted.” Dr. Mortimer summarized: “The Vanderbilt ADHD Parent Rating Scale checklist's utility in accurately identifying ADHD in children simply sucks. It isn’t a sensitive ADHD screening instrument: and it especially misses too many children who have more subtle – but still disabling – forms of ADHD.”

Elementary School Report Cards. “In addition to clinical interview, what is usually most useful for helping to identify attention–deficit/hyperactivity disorder in any age is a careful review of the patient’s elementary school reports cards – from kindergarten onward – even if the identified patient is seventy years old or older. For the purposes of assessing for ADHD, I care less about the actual letter grades, and look for a pattern to teachers’ hand–written comments. Experienced teachers have a good “feel” for a child’s normal range of behavior for any specific age and sex. If teachers repeatedly comment over multiple school years in elementary school that the student is polite, but is: too social, not working up to his ability, needs to improve his time management skills, or needs to show more consistent effort, then the diagnosis of ADHD becomes much more likely.”

When the new patient is a child or an adolescent, the first office visit with Dr. Mortimer is for the parents alone. During this first meeting, among other things, Dr. Mortimer asks the parents about the patient’s biological relatives, the history of the child’s development,  – as well as the child’s school and family situation. “I want to hear about what could be better in the child’s life, and what interventions have been tried. But I also want to know what the child is doing well. We build on our strengths, not on our weaknesses.”

Diagnostic Criteria for ADHD. Dr. Mortimer reviewed the diagnostic criteria for attention–deficit/hyperactivity disorder as defined in the latest version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V), and then discussed problems with the currently accepted diagnostic criteria. First, the good news. The latest edition of the DSM acknowledges that previous editions of the ADHD criteria more readily identify ADHD children, and often completely miss impairing ADHD in adolescents and adults. In addition, longitudinal studies of ADHD children followed into adulthood by Russell Barkley, Ph.D. and others have shown that ADHD adults had difficulty remembering symptoms dating back to early childhood, and therefore the DSM–V diagnostic criteria have been modified to reflect this. Secondly, the latest DSM version also acknowledges that not only do the ADHD symptom manifestations change with age, but a lower number of symptoms should be considered indicative of the diagnosis in both adolescents and adults. Thirdly, “The diagnostic criterion in early version of the DSM asserted (without any research to support this claim) that ADHD symptoms must be present by the age of 7 years. This cut–off has been found to be completely arbitrary. The committee members who selected this age limit for ADHD have been the first to admit this. While, in the latest edition of the DSM, the age–limit cut off for onset of at least some ADHD symptoms is now 12 years old – which was also selected without supportive research – this is a step in the right direction. Those with mild ADHD, and those with the predominately inattentive type plus high IQ may not show impairment until later adolescence when academic demands increase – yet they may still respond as robustly to the common ADHD treatments.”

ADHD, High IQ and/ or Learning Disorder. While – on average – the IQ of youth with attention–deficit/hyperactivity disorder is nine points lower than those of typically developing peers, how many times has Dr. Mortimer heard the following? “My son [or daughter] doesn’t have ADHD – the teacher doesn’t know how to teach – and the classes are all boring!” Well, maybe. This is where a seasoned clinician’s judgment is especially important. In some cases, the parent is right, but sometimes, the child has ADHD – plus high IQ. “Thus, even though an undiagnosed and untreated ADHD student might be daydreaming in the classroom 80% of the time, if the student’s IQ is high enough, he or she can deduce what the teacher must have been discussing when the teacher attempts to “catch” the student in a daydream through an unanticipated question. “In the high–IQ child whom you suspect also has ADHD, the clinician may have to examine the pervasiveness of the student’s boredom in different situations. The clinician may need to examine the school situation very carefully to sort out  ADHD vs legitimate classroom tedium.”

There is another potential problem in sorting out whether or not a student has high IQ, has high IQ plus attention–deficit/hyperactivity disorder, or has high IQ plus a learning disorder.  Because of normal variation, some students will have some academic weakness in relation to his or her IQ, and those weaknesses may seem to be more prominent, and more discrepant in those with higher IQ. So there is some controversy over whether that constitutes a true disability. Can you actually have a disability if you are doing better than 50% of the population? “Well…yes! I see this all the time in my patients whose IQ is well above average. This is a situation when a psychologist can be very helpful in uncovering an unidentified learning disorder – such as what is now being called sluggish processing tempo.”

Undiagnosed ADHD in the Geriatric Population. While there is scant research focusing on attention–deficit/hyperactivity disorder in the geriatric population, the current consensus is that ADHD symptoms persist into adulthood in at least 67% of childhood ADHD cases. And a recent Dutch study of non–institutionalized adults over the age of 60 years old estimated the prevalence of ADHD in this population at 2-4%. Dr. Mortimer summarized: “Older ADHD adults are especially prone to be misdiagnosed because they and their physicians are mostly likely more concerned about the possibility of a neurodegenerative disorder (e.g., dementia) instead of a life–long neurodevelopmental disorder such as ADHD. Thus, most geriatric patients with ADHD will not be correctly identified – or ever correctly treated.”

Teflon and Fog. “Having untreated attention–deficit/hyperactivity disorder is like  being covered with ‘psychic Teflon.’ Nothing sticks! The person with untreated ADHD is praised, and it doesn’t make a difference. The untreated ADHD person is punished, and the same maladaptive behaviors continue unchanged. It’s as if the person with untreated ADHD doesn’t learn from experience.” Using another simile, Dr. Mortimer said: “Those with ADHD are like airplane pilots who are born in a fog, fly their airplanes in a fog, repeatedly crash their planes while flying in the fog, and remain bewildered by it all. What they do know is that their [non–ADHD] peers are learning more quickly, and performing better in flight school – and are often able to perform better with much less effort. They know something is wrong, but don’t have a clue about what exactly is the cause of their recurring difficulties with paying attention, anticipating, and impulse control.”

Solvents and Defoggers. Dr. Mortimer likened effective medications for the treatment of attention–deficit/hyperactivity disorder to solvents. Referring  to an earlier image, effective ADHD medications taken at effective doses temporarily dissolve the Teflon so that those with ADHD can then learn from the consequences of their behavior. In his second simile, the medications are likened to windshield defogging agents, allowing the ADHD “pilots” to see blue sky for the first time in their lives. “With effective medications, just about everything becomes infinitely easier. Of all medical disorders and diseases, this is one of the most gratifying to treat.”

Dr. Mortimer hastened to add: “This is not to say that psychosocial treatment interventions – such as academic tutoring, social skills training, individual therapy, and family therapy – are not useful. However, without first initiating effective medication at effective doses which manage symptoms throughout the entire day, these psychological interventions are largely a waste of time, precious resources, professional efforts, and money.”  

Prescription Medications are Essential for Effective ADHD Treatment. One common treatment goal for those with ADHD is to alter their catecholamine tone in their brain’s prefrontal cortex. This part of the brain has evolved to help guide our thinking toward distant goals and to metaphorically navigate us successfully through the world around us. The prefrontal cortex of the brain allows us to inhibit actions that are task–irrelevant or are not serving our long–term goals. The prefrontal cortex also enables us to regulate our emotions. When our prefrontal cortex is operating optimally, we have guided attention and our responses to the world are appropriate. We can listen, understand, make sense of the world and deviate or shift direction if something gets in the way of our goals. Our responses are flexible. We can say: “Since that didn’t work, I’ll try something else.” The only treatment that is effective in achieving this goal is prescription medication. Thus, prescription medications are the cornerstone of effective treatment of attention–deficit/hyperactivity disorder. The MTA study has conclusively demonstrated this. ADHD medications are substantially much more effective than non–pharmacological treatments such as: dietary changes (e.g., restricted elimination diets; artificial food color exclusion; free fatty acid supplementation with omega–3 and /or omega–6 supplements); sunlight exposure; or psychological treatments (e.g., cognitive training; neurofeedback; or behavioral interventions such as parent training or teacher training).

Effective medical treatment can make a dramatic difference in a person’s life. Here are two cases typical of what I see in my office: Several years ago, when we first met, one of my eighth grade girls with attention–deficit/hyperactivity disorder had a GPA of 1.7. With an optimally dosed ADHD medication –  plus adding effective study strategies –  in less than six months, this girl’s GPA increased to 3.7! More recently, I had a high school student who presented to me with severe, untreated ADHD. His baseline cumulative GPA was zero. With effective ADHD treatment, his semester GPA improved to over 3.0!”

The Prescription Stimulant Options. In 1937, Rhode Island pediatrician Charles Bradley reported an immediate and frequently dramatic improvement in the conduct and academic performance of a group of children with behavioral disturbances when they were treated with Benzedrine (i.e., racemic amphetamine). Since that time over seventy years ago, prescription stimulant medications have remained the cornerstone (i.e., the “first line” pharmacological treatment options) for treatment of attention–deficit/hyperactivity disorder. The stimulants prescribed for ADHD have some of the highest effect sizes of any medical intervention.  And for most individuals with ADHD, the stimulants (e.g., dextroamphetamine, methamphetamine, methylphenidate, and dexmethylphenidate) are the treatments of first choice. However, that response to specific medications is highly individual. An ADHD patient may respond well to a methylphenidate preparation but may fail to respond to or may have significant adverse effects with an amphetamine preparation. Some ADHD patients respond equally well to either class, while other ADHD patients have a preferential response to either a methylphenidate preparation or an amphetamine preparation.

Dr. Mortimer then summarized: “There have been at least 3,000 studies in the past 100 years, plus over 180 controlled studies of at least 6,000 children, adolescents, and adults which have documented the efficacy of stimulants in the treatment of attention–deficit/hyperactivity disorder. With a history of over eighty years of clinical data, tens of millions of ADHD children, adolescents and adults have now been effectively and safely treated with the stimulants. Those with ADHD can be safely treated with stimulants even in the presence of co–existing depression, anxiety, eating disorders, chemical dependence, and bipolar disorder – that is, if these clinically complex persons are treated by an experienced and knowledgeable physician.”

Prescription Stimulant Selection. “There is not yet any widely accepted algorithm that can be used to justify the selection of one prescription stimulant over another. As is the case with many medical disorders, but especially in the case of those with attention–deficit/hyperactivity disorder, a person’s treatment response to any one medication can be idiosyncratic. While I will often have a satisfactory result with either the first or the second prescription medication we try, studies have been unable to identify a reliable way to predict a priori the best medication or the best dose of a prescription stimulant for a particular ADHD individual. The optimal stimulant dose for a particular ADHD patient is not correlated with age, sex, height, weight, body mass index, severity of symptoms, stressors, socioeconomic status, neurological soft signs, EEGs, auditory-evoked potentials, or neurochemical measures. Nothing!”

“Essentially, the prescription stimulants are all equally effective. However, their mode of action, likelihood of side effects, and effective duration of action will differ. And about one–third of those with attention–deficit/hyperactivity disorder will respond better to one medication than they will to another prescription ADHD medication.”

Listed below are the most of the current, first–line treatment options for attention–deficit/hyperactivity disorder. All the medications below are all classified as stimulants. Not all of the stimulants are “amphetamines.” [And while it is a stimulant, do be aware that caffeine is completely ineffective in managing the core symptoms of ADHD!] In about 95% of Dr. Mortimer’s patients, the duration of each prescription stimulant  benefit to be as follows:

Dexedrine (dextroamphetamine) brand immediate release and Dextrostat (dextroamphetamine) generic tablets have a benefit for ADHD management which lasts no longer than 4 hours per dose.

Zenzedi is a newer, immediate–release dextroamphetamine which – in comparison to the old dextroamphetamine (Dextrostat) tablets – is lasting 5–6 hours in most of Dr. Mortimer’s ADHD patients.

Dexedrine Spansules (a very old, first attempt at making a time–release stimulant medication) provides a benefit for the management of ADHD which lasts no more than 5 hours per dose.

Vyvanse is a newer dextroamphetamine time–release preparation, first available for prescription in 2007. In about 90% of Dr. Mortimer’s ADHD patients, the Vyvanse benefit for ADHD management continues for the entire waking day (i.e., about 16 hours per dose). In the other 10% of Dr. Mortimer’s ADHD patients, the benefit lasts about 8 hours per dose.

Adderall IR (“immediate release”) is a mixed amphetamine salt preparation which provides a benefit in the management of ADHD for 4 to 7 hours, depending on the individual patient’s genetics.

Adderall XR is a double–beaded, time–release preparation of Adderall (“amphetamine mixed salts”) which provides a benefit for the management of ADHD for 8 to 10 hours per dose.

Adzenys XR ODT is an instant–dissolve–on–the–tongue preparation of Adderall XR which is designed to duplicate the benefit and duration of Adderall XR.

Mydayis (manufactured by Shire Pharmaceuticals) first became available for prescription in the summer of 2017. It is a triple–beaded, longer–acting preparation of Adderall XR and provides

a benefit for the management of ADHD of 14 or more hours, thus rivaling the duration of benefit of Vyvanse (which is also manufactured by Shire Pharmaceuticals).

Evekeo is a racemic mixture of dextroamphetamine and levoamphetamine (this used to be known in the 1960s as Benzedrine) which provides a benefit for the management of ADHD of 4 hours per dose. Evekeo is too new for Dr. Mortimer to have a good “feel” for how long it lasts in his patient population.

Methamphetamine (Desoxyn) immediate release tablets has been available for prescription since probably the 1940s. Desoxyn (or methamphetamine) provides a duration of benefit for the management of ADHD of 7–8 hours per dose.

Methylphenidate (generic name for “Ritalin”) is available in a 4–hour immediate release preparation (also known as Ritalin immediate release and Methylin immediate release).

Ritalin SR is a very old and early attempt to develop a time–release methylphenidate. This is, in effect, a 5–hour preparation of methylphenidate that “because you can’t cut the tablet, almost no–one prescribes this now.”

Metadate CD and Ritalin LA are competing methylphenidate time–release preparations which provide a benefit for the management of ADHD of 8–10 hours per dose.Concerta is a 14–hour time–release capsule (plastic, uncuttable capsule) of methylphenidate.

Focalin IR (or dexmethylphenidate tablets), the immediate release dextro–isomer tablet of methylphenidate, provides a benefit for the management of ADHD of 5–6 hours per dose.

Focalin XR (dexmethylphenidate), the newer time–release form of Focalin, provides a benefit for the management of ADHD for 10–13 hours.

Daytrana is the time–release methylphenidate which is available as a patch. It provides a benefit for the management of ADHD from the time it is applied to the skin until the patch is removed – or until bedtime, whichever occurs first. Thus, Daytrana can potentially provide a benefit for the treatment of ADHD for up to 24 hours per dose.

Quillivant is time–release methylphenidate in a liquid suspension. Its reported duration of benefit for the treatment of ADHD is 8–10 hours per dose.

Cotempla XR ODT tablets is a newer, instant –dissolve–on–your–tongue, time–released methylphenidate. Its reported duration of benefit for the treatment of ADHD is 12 or more hours per dose.

If a particular stimulant for the treatment of attention–deficit/hyperactivity disorder decreases appetite or interferes with sleep, the problem can often be resolved by switching to another ADHD medication – or adding an antidote. “The most common and predictable stimulant side effects (decreased appetite and difficulty falling asleep) can usually be managed satisfactorily with adding one of my favorite antidotes: cyproheptadine (Periactin), mirtazapine (Remeron), hydroxyzine (Vistaril), clonidine (Catapres) or risperidone (Risperdal). Similarly, if other medication side effects occur, psychiatrists can usually find a way to manage the side effects while still being able to maintain the medication’s benefits. This is where the art of medicine comes in – similar to what a chef does in the kitchen (– or what a master chemist does in his lab). The master chef knows what he wants for a result, so he mixes and blends the available ingredients together in an artful way so that the end result for his customer [or patient] is both as elegant in its presentation and as enjoyable an experience [without, in the case of stimulants, causing euphoria, of course] as possible.”

Prescription medication dosing. Do keep in mind that just because the number of milligrams in two different prescription stimulant preparations are equivalent does not mean the responses will be identical. In over 90% of his clinical population, Dr. Mortimer has found the following dosing equivalences to be accurate: 10 mg of methylphenidate immediate release (e.g., Methylin, Metadate, and regular Ritalin) is equivalent in benefit – but not necessarily duration – to a:

5 mg     Focalin immediate release (“IR”) tablet

5 mg     Dextroamphetamine (Dextrostat tablet or Dexedrine Spansule capsule)

5 mg     Evekeo tablet

5 mgZenzedi tablet

5 mg       Methamphetamine (Desoxyn) tablet

5 mg       Adderall immediate release  (“IR”) tablet

6.3 mg    Adzenys XR ODT orally disintegrating tablet

8.6 mg Cotempla tablet

10 mg    Adderall extended release (XR) double–beaded capsule, or a 10 mg Metadate

controlled release (“CD”) capsule

10 mg    Focalin extended release (“XR”) capsule

15 mg    Mydayis triple–beaded capsule

20 mg    Ritalin sustained release (“SR”) capsule

36 mg    Concerta tablet (but Concerta is not really a tablet - the methylphenidate in Concerta is

contained in an uncuttable plastic capsule; if it is a tablet, it is ineffective generic crap!)

There is not a reliable conversion algorithm for quickly switching from Vyvanse, Mydayis or Daytrana to any of the medications listed above or vice versa. Dr. Mortimer added: “…and at this point, having prescribed Vyvanse, Mydayis, and Daytrana to over 600 patients, I doubt that a conversion algorithm will ever be identified and published. However, this has never been much of a problem for me. When switching to or from Vyvanse, Mydayis, or Daytrana to another stimulant (or vice versa), I can usually ‘ballpark estimate’ the optimal dose. We can then use a computer test [MedChek] which I have been using since about 1991 to quickly and accurately ‘nail down’ the optimal dose of any of these medications for any specific patient.”

“While certainly not always the case, sometimes in order to optimally control attention–deficit/hyperactivity disorder symptoms, specific doses may need to exceed FDA–approved manufacturers’ advertising daily dosage limits. One commonly used strategy that many physicians follow is to choose a stimulant, start at the medication’s lowest dose size, and increase the dose to the optimal or maximum tolerated dose – whichever comes first. If the patient does not demonstrate a robust response, then the physician will switch to the next stimulant on his or her list of options. If all the stimulants are given a trial as first–line therapy for ADHD, then the overall treatment response rate should be greater than 95%.” True non–responders to stimulant therapy are rare but this possibility increases with the presence of additional mental disorders (e.g., those with an additional anxiety disorder such as obsessive compulsive disorder; those with a chronic tic disorder such as Tourette’s disorder; or in those who experience the roller coaster ride of bipolar disorder.)

“The FDA-approved stimulant dosage guidelines were developed from the results of studies of attention–deficit/hyperactivity disorder patients without significant additional mental disorders. These dosage guidelines are, thus, largely inapplicable for the clinically complicated patient populations that medical specialists (like general adult psychiatrists), or medical subspecialists (such as child and adolescent psychiatrists) are most likely to see.”

Finding the Optimal Dose. Suppose the first medication tried improves attention, motivation and impulse control. How does one determine if this is the optimal medication, and –  if it is –  how does one determine the optimal dose? “Since this is a disorder present from birth, the person with attention–deficit/hyperactivity disorder often doesn’t not know what is normal. Treatment with any of the stimulants usually results in profound improvements in attention, concentration, planning, impulse control and motivation. Here, though, is the challenge for the clinician: since the ADHD person has been in a fog all of his life, an effective ADHD medication may result in the best performance that the ADHD person has ever demonstrated – but there may still be much room for improvement. This is why it is so important to solicit the observations from reliable, non–ADHD significant others (e.g., teachers, parents, spouses, and siblings). Additionally, a computerized continuous performance task can be very helpful in objectively assessing treatment response. I can be as powerfully efficient as I am in determining optimal ADHD treatment because I use a sensitive continuous performance task computer program.” (Since 1999, Dr.  Mortimer has been the principle beta tester for the MEDChek computerized continuous performance task program.)

Dose Sculpting. While Dr. Mortimer emphasized keeping medication treatment as simple as possible, “Sometimes a particular medication is profoundly effective, but side effects might sometimes turn out to be clinically significant for a particular patient – such as a stimulant causing appetite suppression throughout the day (which then leads to significant weight loss). If this is the case, I may take advantage of the different durations of action of different stimulant medications or time–release stimulant preparations to ‘sculpt’ the dosing schedule for a particular patient with attention–deficit/hyperactivity disorder. For instance, one ADHD patient might do well with a 4-hour duration Ritalin or 4–hour duration Dextrostat after breakfast. The medication’s effect on appetite suppression should then abate by lunch time. After eating a hearty lunch, this ADHD patient could then take a longer–acting prescription stimulant medication such as Adderall IR or Desoxyn to cover the afternoon, with its appetite–suppressing effects wearing off by supper time. Then, if a medication is needed to improve attention for evening events or for late–night studying,  a 4–hour duration stimulant medication could be taken after supper. For other ADHD patients, a  long–acting medication (e.g., Adderall XR, Concerta, Focalin XR, or Ritalin LA) taken just in the morning might last long enough to achieve optimal symptom control throughout the waking day.”

Keep in Mind that Females are the Superior and the More Resilient Sex. Dr. Mortimer made the following observation:Females are naturally more resilient than males. More boys than girls are stillborn; severe mental retardation is more prevalent in boys than in girls; autistic spectrum disorder (and what used to be considered Asperger’s syndrome) is more prevalent in boys than in girls; and attention–deficit/hyperactivity disorder is four times more prevalent in boys than in girls.”  During her time as Dean of St. John’s College, Dr. Mortimer recalls Eva Brann, Ph.D. commenting to him that when an adolescent college male is “dumped” by an adolescent college female, he is devastated and is likely to say to Ms Brann: “My life is over.” However, if an adolescent college female is “dumped” by an adolescent college male, she is more likely to shrug her shoulders and say to Ms Brann: “Oh well…No big deal…there are plenty of other boys that I can still date.”

Thus, if a boy inherits a small number of attention–deficit/hyperactivity disorder genes from either ADHD parent, he will very likely show symptoms consistent with a diagnosis of ADHD. However, if a girl inherits the same “genetic load” from an ADHD parent as her brother, there is less likelihood that she will herself demonstrate any ADHD symptoms. This, then, is the most likely reason for the four–to–one ratio in the prevalence of ADHD in boys versus girls. Conversely, if a girl shows ADHD symptoms, this means that – everything else being equal – she has inherited a very large number of all the twenty or more purported genes for ADHD, and the clinician (and parent) should not be surprised to learn that the girl requires a much higher stimulant dose to optimally control her ADHD symptoms than a boy with the same ADHD symptoms severity.

As another consequence of females being more resilient, attention–deficit/hyperactivity disorder should be more prevalent in the relatives of females with a diagnosis of ADHD than in the relatives of males with a diagnosis of ADHD; and the co–twins of females displaying an extreme degree of characteristic ADHD behaviors should display more such behaviors themselves than do the co–twins of males showing an extreme degree of ADHD traits. Furthermore, co–twins of females with particularly high ADHD trait scores should be more likely to display an extreme degree of ADHD behaviors than should the co–twins of males. Relatives of females with ADHD are more likely to exhibit ADHD symptoms than relatives of males with ADHD.  And females with ADHD are more likely to display more emotional difficulties than males with ADHD. And this turns out to actually be the case.

Stimulant Safety. The popularity of the stimulant medications is, in part, due to their wide ratio of therapeutic dose to toxic dose, with a margin of safety of at least 100 to 1. For example, published studies have found the LD50 (the lethal dose for 50% of a study population) of dextroamphetamine in rats to be 55 mg/kg of a rat’s body weight. The LD50 for methylphenidate in other animals is 367 mg /kg of these other animals’ body weight.

“Curiously enough, however, stimulant toxicity findings in animals have not been replicated in humans. There simply aren’t any reputable studies showing that stimulants prescribed at therapeutic levels are associated with significant toxicity. In fact, studies using doses up to 4,000 mg of methylphenidate in human volunteers have been without clinically significant adverse effects. And in Dr. Nora Volkow’s published PET scan study, methamphetamine addicts were included in her study if their average methamphetamine use involved at least 500 mg methamphetamine administered intravenously at least five days per week for at least two years. Volkow found fifteen subjects who met her study’s criteria. I want to point out that these fifteen subjects had read her newspaper ad, answered her newspaper ad, drove to her laboratory in rural Long Island without getting lost, and arrived on time for their appointments. Their average daily intravenous methamphetamine dose was 1,600 milligrams (“mg”), with a range of 300 to 10,000 mg daily. These doses of methamphetamine are astronomical! The equivalent Ritalin (methylphenidate) dose of 1,600 mg of methamphetamine is 3,200 mg of methylphenidate. And yet these methamphetamine addicts kept their interview appointments with Dr. Volkow’s staff. This is simply amazing!”

Cardiovascular Risk? The effects of stimulants used in the treatment of attention–deficit/hyperactivity disorder on the cardiovascular system of healthy individuals are well established. In therapeutic doses, these stimulant medications increase blood pressure and heart rate, but such changes are not clinically meaningful. Furthermore, since 2009, there have been at least seven large–scale studies,,,,,, looking into the association between stimulant use and sudden cardiac death. None of the studies found any statistical association between use of stimulants for the treatment of ADHD and sudden death. Healthy persons, in particular children and young adults, who do not have a diagnosed and significant cardiovascular illness (e.g., such as having had a previous stroke, or a previous myocardial infarction) do not require specific cardiac testing before starting treatment.

Risk of Addiction. Dr. Mortimer summarized: “Despite some in the chemical dependence treatment community arguing otherwise, there is no credible evidence that prescribing stimulants commonly used in the treatment of attention–deficit/hyperactivity disorder, major depression, narcolepsy, or chronic pain syndromes ever causes euphoria or chemical dependence. There is no evidence that properly monitored prescribed stimulants results in drug abuse. Lastly, tolerance to a particular stimulant dose rarely if ever occurs.”

Dr. Mortimer then referred to a recently published review of medications for the treatment of attention–deficit/hyperactivity disorder: “Despite the concern that ADHD may increase the risk of abuse in adolescents and young adults (or their associates), there are simply no scientific data confirming the abuse of prescribed stimulants by ADHD children who are receiving appropriate diagnosis and careful follow-up. Moreover, other studies have shown that the most commonly abused substances in untreated ADHD adolescents and adults are cigarettes, marijuana and alcohol –  not the stimulants.”

Lastly, Dr. Mortimer pointed out that rather than stimulants increasing the likelihood of future substance abuse, the contrary has been found. “There are now enough longitudinal studies of attention–deficit/hyperactivity disorder to demonstrate conclusively that treatment of ADHD with stimulants actually provides a protective effect in preventing future substance abuse."

Those ADHD Patients with a History of Past Substance Abuse. Regarding the question of prescribing stimulants to those with a prior history of substance abuse, Dr.  Mortimer referred to published works of four ADHD authorities. First, quoting from Paul Wender, M.D.: “The failure – or reluctance – to offer ADHD patients a trial of the amphetamines or methylphenidate often does not have a scientific basis but is related to the fact that these are Schedule  II drugs. Physicians are afraid to prescribe them not because of concern about toxicity or producing an iatrogenic addiction but because of the regulatory agencies. However, just as it is possible to employ methadone in a special administrative setting, it should be possible to work out a method of dispensing stimulants to ADHD adults that will relieve physicians of this extraneous concern. Comparably effective drugs would never be used so sparingly in internal medicine.”

Next, quoting from Dr. Josephine Elia’s study: “Stimulant–drug treatment as a specific risk factor for the ultimate use of or dependence on drugs, alcohol, or any other substance is unsupported by evidence from clinical studies.” Lastly, Dr. Mortimer then modestly referred the interested listener to two,  of his favorite articles on effective, non–abusable ADHD medication options for use in special clinical populations and special clinical circumstances.

ADHD and Fad Diets. Restriction and elimination diets have been studied for decades in the treatment of ADHD. “For probably the past sixty years, you hear and see claims that special diets such as gluten–free or additive–free diets are effective for the treatment of attention–deficit/hyperactivity disorder. This claim has been repeatedly shown in controlled studies to be complete bullshit. Most recently, in 2015, Pliszka and colleagues reported that in his five week study with two groups of ADHD children, both groups treated with stimulants, those on a gluten–and additive–free diet who were then given a daily snack of a cookie (– which was inconsistent with the prescribed diet) still showed behavioral improvement to the same extent as those ADHD kids treated with stimulants who were on regular diets.” Dr. Mortimer summarized: “No one is going to assert that junk food, candy and highly processed foods are preferred over spinach, parsley and carrots, but those who claim that diet restriction is an effective treatment for attention–deficit/hyperactivity disorder is simply psychotic nonsense. The cornerstone of ADHD treatment remains appropriately prescribed and monitored prescription stimulant medication.”

Overdiagnosed? Many in the audience thought that more people were being treated for attention–deficit/hyperactivity disorder now than twenty years ago, and wondered if perhaps ADHD was being overdiagnosed. Dr. Mortimer responded that since the prevalence of ADHD in the United States general population is estimated at somewhere between 9 and 14%, “Prevalence studies have consistently found that at any one time, no more than 2.5% of the population is being treated for ADHD. Therefore, even taking an overly–conservative estimate of a five percent prevalence of ADHD, the majority of those with ADHD are never identified. From both reviewing the results of the MTA study, and from what I have seen clinically, here is what I think happens much too often: If those with ADHD are correctly identified, they are usually not prescribed an effective medication at all – that is, too many times the child’s pediatrician outright dismisses the legitimate concerns of the child’s parents and child’s teachers. In the too–infrequent case where ADHD youngsters are prescribed a medication known to be effective for the management of ADHD symptoms, the dose or duration of medication prescribed is a homeopathic dose and is not anywhere close to that required for optimal symptom control. And if the ADHD youngster is lucky enough to be treated with and optimal medication and dose, the ADHD youngster usually don’t continue taking the medication long enough to make a substantial improvement in his or her life trajectory. In fact, one recent study found that over half of prescriptions written for 30 days–worth of methylphenidate were not renewed a month later. ADHD is a woefully under–diagnosed and inadequately treated common medical condition – and, as I explain below – when untreated or inadequately treated, it is a potentially lethal medical condition.”

To treat or not to treat. Rather than expatiate on this topic here, Dr. Mortimer simply referred to published comments from two acknowledged international ADHD experts: “Successful management of ADHD in children includes a decrease in symptoms or an improvement in the quality of life. However, with the exception of antibiotics for viral colds, most parents do not want their child on medication, so there is a market for “natural” medication. Besides the fact that some of these [“natural”] treatments are dangerous, what is often missed is that having ADHD is dangerous. By not giving a medication that has been well tested and tried, you are increasing the time during which the child grows up having negative developmental experiences and not getting proper treatment. The child thereby becomes subjected more often to peer rejection; school failure; involvement with drugs, sex, and alcohol; and other serious consequences. Thus, failing to give medications that are known to be effective is really detrimental to the children. In fact, several authorities have stated that the evidence supporting the use of approved medicines for ADHD is so strong that a clinician who does not address this issues is probably being negligent.”

Dr. Mortimer then refers the interested reader to a summary statement from John Werry, M.D., Professor Emeritus of Child Psychiatry:

“…in any other medical or psychiatric condition where the evidence for drug efficacy is this substantial and for drug side effects is this benign, the failure of a physician to consider medication treatment for the disorder would be considered tantamount to malpractice. Yet somehow many less–informed individuals have come to believe that it is the withholding of stimulant medication treatment for those with ADHD that is the more noble, ethical, and humane approach. Clearly, this can now be seen to be largely the result of naïveté or even a misunderstanding, unintentional or otherwise, of the extant scientific literature on ADHD and these medications.”

Treatment Duration. “Let’s say there’s a child who has failed each of his first five years of school. Eventually, he finds his way to an optometrist. A visual acuity problem is identified. The optometrist then prescribes corrective lenses, and with the glasses, the child is able to see clearly for the first time ever. With considerable effort, the student’s grades that year (sixth grade) improve to B’s. But at the end of the sixth grade, the eyeglasses are removed (so that the student doesn’t become “dependent” on their use). Is the experience of seeing clearly for one year in elementary school going to be sufficient to carry the student successfully through to high school graduation? I don’t think so. I’ve been wearing eyeglasses for over ten years now, but whenever I remove them, printed words return to being as unreadable as they were when I first started wearing glasses. Short–term treatment interventions for a chronic disorder are unlikely to return the individual to a healthy, maximally productive and satisfying life trajectory. ADHD is a chronic medical condition. To make a difference, those who treat attention–deficit/hyperactivity disorder must adopt a longitudinal, multi–decade perspective.”

In addition to looking for overall improvement in symptoms of attention–deficit/hyperactivity disorder with effective treatment, it is important to remember that the treatments must deliver symptomatic improvement at the times during the day where functional impairment is occurring. Alas, studies by Salee, Whalen, Mattingly and others have shown that physicians primarily focus on the consequences of untreated ADHD during school and work, while overlooking impairments that occur at the beginning and end of the day.,, Salee found that 79% of caregivers have discussed early morning functional impairments, such as getting out of bed on time, getting dressed efficiently, self–hygiene, eating breakfast, packing their backpack, and being able to catch the bus on time, as being some of the most impairing issues for their ADHD children. Of these caregivers, 48% reported they had to wake up early in the morning themselves to personally administer their child’s ADHD medication before their child’s normal waking time because of the functional difficulties experienced in the home before their child’s medication had taken effect.

There is also the issue of transitioning from child & adolescent psychiatric services to adult psychiatric services. Children and teens who might have their attention–deficit/hyperactivity disorder under optimal symptom control can fall apart when they transition from adolescence to adulthood and are no longer treated by the most experienced group of ADHD specialists: pediatricians, pediatric neurologists and child & adolescent psychiatrists. Many adult mental health practitioners have little experience and training in the management of ADHD, and many have negative and skeptical attitudes towards ADHD as a condition that warrants intervention. The transition from adolescent to adult psychiatric services poses particular challenges because of differences in training, symptom severity thresholds needing to be reached before treatment is offered, and focus between child and adult psychiatric services, leaving a proportion of young adults with ADHD without a clear treatment pathway. Young adults in general often face multiple other transitions around that time that adolescent medical services are withdrawn, and given the nature of ADHD, many young adults with ADHD struggle to organize themselves adequately in order to arrive on time for follow–up appointments and continue ADHD treatment.

FDA Dosing Guidelines. Some pharmacists expressed concerns about the relatively high–dose stimulant prescriptions they were occasionally asked to fill. Dr. Mortimer acknowledged this as a legitimate concern. “We should always keep in mind the potential for diversion of medications, but this has not been a significant problem either locally or nationally.” Dr. Mortimer then added: “However, I am more concerned with the number of ADHD individuals I see receiving ineffective treatments – or potentially effective ADHD treatments at clearly ineffective, sub–therapeutic doses. While some ADHD individuals might do best on 5 milligrams of a particular medication, others might not find their ADHD symptoms under optimal control until they reach a much higher dose. In addition to needing sufficient clinical experience to make an accurate diagnosis  and identifying an optimal treatment response, using a sensitive continuous performance task (CPT) program can, again, be very helpful both clinically and forensically.”

Dr. Mortimer believes that molecular genetics studies of proteins involved in dopamine transmission provides a compelling model for why there is such inter–individual variation in dosing in those with attention–deficit/hyperactivity disorder, and why some patients might need a relatively higher stimulant dose to optimally control their symptoms. “As seasoned physicians know, dogmatism about doses is generally incompatible with good medical practice. There is tremendous inter–individual variability in determining doses of many psychiatric medications – not just the stimulants. For example, while most tricyclic antidepressants are generally recommended in a daily dose of 150 to 200 mg/ day, some patients require a doubling of this dose, while others respond favorably and even have therapeutic serum concentrations with daily doses of only 10 mg. Some ADHD patients do best with low stimulant doses, others do best with doses above the FDA–approved single or daily dose limits. But do remember that FDA dosing limits are for the purpose of regulating pharmaceutical companies’ claims about their medications, not what physicians can safely and responsibly prescribe.”

Dr. Mortimer added: “The Food and Drug Administration itself is clear on this issue, with its own publication stating: ‘Under the Federal Food, Drug, and Cosmetic Act, a drug approved for marketing may be labeled, promoted, and advertised by the manufacturer only for those uses for which the drug’s safety and effectiveness have been established and which the FDA has approved. The Act does not limit the manner in which a physician may use an approved drug. Once a product has been approved for marketing, a physician may prescribe it for uses or in treatment regimens or patient populations that are not included in approved labeling. Accepted medical practice often includes drug use that is not reflected in approved drug labeling.’ ”

Neurotransmitters. There is  a substantial body of evidence from molecular genetics that points to catecholamine neurotransmitter dysfunction in those with attention–deficit/hyperactivity disorder. That is, abnormalities in the brain have been identified in both dopamine and norepinephrine neurotransmitter systems. More specifically, ADHD studies have found genetic and structural variations in both the dopamine transporter protein (SLC6A3, commonly known as DAT1) and at least one dopamine receptor protein (DRD4). The dopamine transporter gene (DAT, or SLC6A3) produces a protein that transfers dopamine from the neuronal synapse back into the presynaptic dopaminergic neuron. The dopamine receptor protein (i.e., DRD4) on the post–synaptic side of the synaptic cleft and is analogous to the back side of the “lock” into which the dopamine “key” inserts when a dopaminergic signal is sent down a neuronal pathway.

Locks and Keys. First to be found was an association between a variant of the dopamine receptor protein DRD4 and attention–deficit/hyperactivity disorder. Normally, when the post–synaptic DRD4 receptor is stimulated by dopamine neurotransmitter, the cytoplasmic loop component of the receptor efficiently binds to a guanine nucleotide regulatory protein. In turn, this “G protein” inhibits cyclic–AMP synthesis, which then causes changes in protein kinase enzyme activity, which then might change the rate of the flow of calcium or potassium through neuronal membrane ion channels, or alter neuron cell nucleus gene activation. Dr.  Mortimer used the following metaphor. “The dopamine transmitter serves as a key which inserts into a post–synaptic neuronal receptor lock. When activated, the internal portion of the lock apparatus triggers a series of cascading intracellular events that transmits the dopamine signal along neurons from one part of the brain to another – just as a twist of the key in the lock causes a cascade of levers to move to their ‘open’ position inside the door.” A particular segment of the third cytoplasmic protein loop of the DRD4 dopamine receptor is normally repeated four times, but in some ADHD individuals, it is repeated seven times. “This 7–repeat leads to a ten–fold blunted intracellular dopamine response. This is an important finding, and offers us a way to make sense of the observed differences in the individual responses that ADHD persons have to medication dosing.”  

Dr. Mortimer likened the genetic polymorphisms and resulting excess protein receptor loop material to the presence of bubble gum in a door locking mechanism. “Because of the extra loops in the internal side of the receptor lock, those with attention–deficit/hyperactivity disorder need a stronger dopamine signal to engage the brain’s frontal lobe’s motivation and planning programs. ADHD medications accomplish this by providing more torque to turn the dopamine keys in the sticky door locking mechanism of the post–synaptic neuronal cellular mechanism.”

Bungy Cords. Researchers specializing in attention–deficit/hyperactivity disorder have also found a second polymorphism (i.e., another variation in the genetic code for the structure of a dopamine–related protein) in the presynaptic dopamine transporter gene DAT1. This transporter protein is responsible for terminating the action of dopamine released into the inter–neuronal synapse. It does this by recycling the dopamine back into the presynaptic neuronal membrane. “That is, when you’ve completed the task of opening the door, you then pull the key out of the lock.” In at least some persons with ADHD, this DAT1 protein has been linked to increased dopamine reuptake, so that in those with this DAT1 polymorphism, binding between dopamine and its transporter is too efficient. “It’s as if there is a bungy cord attached to the dopamine. In those with ADHD, the transporter protein yanks the dopamine out of the receptor before the locking mechanism has been fully activated.” This structural variation of the DAT1 protein decreases the efficiency with which dopamine signals are sent through the brain to the motivation, inhibition, and executive planning areas of the brain. “Finding an effective medication at the optimal dose maximizes the person’s ability to route instructions to various processing areas of the brain. And, again, finding the best medication and the best dose are determined empirically.”

Noisy Norepinephrine. Studies are also finding an overactive norepinephrine system in the brains of some with attention–deficit/hyperactivity disorder. Due to a lack of inhibition of certain neurons originating in the locus coeruleus in the brainstem (the brain’s “panic center”), there is excess norepinephrine transmission. This increases the “noise” in the dopaminergic neurotransmission lines as well, thus decreasing the “signal–to–noise” ratio of dopamine to norepinephrine. In addition to enhancing dopamine neurotransmission, the stimulants used in ADHD treatment act via alpha2-adrenergic receptors on the locus coeruleus to reduce spontaneous firing. Clonidine and guanfacine are non–stimulant ADHD medication options. They act on these alpha2 receptors to decrease the “noisy norepinephrine” that interferes with the dopamine signals. “Some with ADHD have tremendous difficulty with impulse control. Medications can often make a tremendous difference. Or, as internationally published child & adolescent psychiatrist Robert Hunt, M.D. describes it, if you have a hyperactive ADHD locomotive engine, the stimulants apply the brakes harder, while clonidine and guanfacine decrease the heat in the engine.”

Executive Functions and Executive Control. Some of the more intriguing recent thinking about attention–deficit/hyperactivity disorder involves the functions of the brain’s frontal lobes – particularly executive functions (i.e., those parts of the brain that are responsible for: engaging motivation; planning; organizing; and weighing options – including philosophizing). Some authorities are now describing ADHD as being primarily a disorder of motivation and planning, rather than one of distractibility, impulsivity, or fidgetiness.Referring to a recent book authored by Russell Barkley, Ph.D., executive function can be defined as “the use of self–directed actions so as to choose goals, and to select, enact, and sustain actions across time toward those goals, usually in the context of others, often relying on social and cultural means for the maximization of one’s longer–term welfare as the person defines that to be.”  There are thought to be at least five of these Executive Functions that appear to be involved in self–regulation. Research suggests that most of the five executive functions – and probably all of these five executive functions – are implicated in attention–deficit/hyperactivity disorder. The first of these five Executive Functions is the ability to inhibit our behavior – to stop what we are doing in order to allow the other executive functions to be able to take over and  guide our behavior toward the future.The second of these five Executive Functions is the ability to use visual imagery. This is often called non–verbal working memory. Humans have the ability to hold images in mind about what they are proposing to do. We use those images as mental maps to guide our behavior toward the intended target. We also use those images to remember the sequence of steps that is necessary to accomplish that goal or that task. Out of this executive ability also comes our sense of hindsight, foresight, and overall our subjective sense of time. We would expect all of this Executive Function to be impaired in those with ADHD, and so this seems to be the case. The third executive ability is the ability to talk to ourselves in our minds as a form of self–guidance.Throughout the day, all of our waking moments include a voice in our head that we use not just to converse with ourselves, but also to give ourselves instructions – and even to question ourselves when we face a novel situation or a problem. This mind’s voice is often called verbal working memory and it is another form of self–control that humans use to guide behavior over time to accomplish goals. The fourth executive ability is the ability to control our own emotions and with it, our motivations. It is out of this fourth Executive Function that we get emotional self–control – the ability to inhibit strong emotion that is being elicited by things around us, and the ability to moderate those emotions so that they are more in keeping with our long term welfare and our long term goals.Then finally there is the ability to plan and problem solve. This Executive Function involves mental play. This Executive Function provides us with the ability to manipulate information in mind in order to discover novel combinations that might serve to overcome obstacles toward our goals and allow us to accomplish our tasks and goals as we aim our behavior toward the future. These five Executive Functions by adulthood serve as a set of mind tools –  as Russell Barkley, Ph.D. describes it, they are a veritable Swiss Army Knife of mental faculties that allow people to regulate their own behavior over time for their own long–term welfare.

“The vast majority of those with attention–deficit/hyperactivity disorder don’t need another class or book on time management. They know what they have to do. The problem is that they just don’t – or can’t – do it. This isn’t to say that those with untreated ADHD should be excused from the consequences of execrable behaviors. All of us have some tasks that are harder for us to do than others. What I am presenting here is a way of understanding ADHD, not excusing it.”

While the brain’s motivation programs are intact in those with attention–deficit/hyperactivity disorder, these ADHD individuals often have difficulty “booting up” these programs without the help of adrenalin – or effective ADHD treatment. “I see many unidentified and untreated ADHD adults who gravitate to careers and environments where they can use novelty (their tasks or work locations are different every day) or terror (bosses, teachers, and others screaming about completing projects by their deadlines) to help them compensate for their motivation problems. However, relying exclusively on one’s environment to activate one’s motivation and executive planning programs may be clever, but it is not always the most efficient strategy to use in managing one’s otherwise untreated ADHD.”

Dopamine. For some with untreated or sub–optimally treated attention–deficit/hyperactivity disorder, the difficulty in “booting up” the brain’s executive functions programs located in the brain’s frontal lobes leads to chronic problems with: motivation, poor time management, impulsiveness, and paying adequate attention to boring but important task details. Dopamine is the primary neurotransmitter involved in ADHD, motivation and behavioral reinforcement; the frontal lobes are rich in dopamine neurons; and the stimulants can boost dopamine signals. However, there are also dopamine–enhancing, non–stimulant medications which can be effective in treating individuals with ADHD. These medication options include amantadine (Symmetrel), atomoxetine (Strattera), bupropion (Wellbutrin IR, SR and XL; and Forfivo XL), clonidine (Catapres tablets and patch; Kapvay); and guanfacine (Tenex; Intuniv).

RAM Chips. “In 1990, when I first started using a computer, I often found myself wanting to keep both Word and FileMaker applications open at the same time. However, since my little Apple computer didn’t have enough RAM to have both applications open at the same time, the computer would almost always freeze. I would then have an emotional reaction when confronted by this frustration. The RAM chip is analogous to our brain’s working memory, and a similar thing happens when those with untreated attention–deficit/hyperactivity disorder try to manage the complexity of the demands one typically encounters in everyday life. That is, many with ADHD appear to have “thin skins:” they are exquisitely sensitive to rejection, criticism and teasing. They often react to daily stressors with paralyzing anxiety, panic attacks, or explosive rages.”          

Some of the newer medications being used off–label for the treatment of attention–deficit/hyperactivity disorder” were first developed to enhance the efficacy of acetylcholine –  which is the brain’s main memory neurotransmitter. These “working memory–enhancing” medications include donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl) and memantine (Namenda). “When medications improve ADHD symptoms in certain individuals, they appear to me, in effect,  to be increasing the size of the brain’s RAM chip – at least temporarily while the medication is active – so that those with ADHD can more adaptively respond to the multifarious demands on their attention throughout their day without their human biocomputer freezing.” Indirectly, these medications may manage ADHD symptoms by indirectly improving the “signal to noise ratio” of dopamine relative to norepinephrine.”

Lack of Consensus.  Despite over 80 years of research on attention–deficit/hyperactivity disorder, a consensus on ADHD treatment or ADHD prevention does not yet exist. In a recent survey, only 19% of general and child and adolescent psychiatrists followed published practice parameters for the assessment and treatment of ADHD. Dr. Mortimer then quoted from Greenhill: “There is no empirically proven threshold of ADHD symptoms that can be used to initiate stimulant treatment. There are no universally recognized dosage guidelines, nor are there blood tests to confirm that a patient’s dose is in the therapeutic range. There are no systematically gathered data on whether practitioners follow the FDA guidelines or use lower or higher stimulant doses in practice. Research based weight–adjusted guidelines, which suggest that doses of 0.3 mg per kg [of body weight] show optimal effects, have not been supported by studies of dose response curves for children with ADHD. Most published randomized control trial data showing stimulant efficacy are group–based and do not help the clinician select the best dose for the individual patient. Important issues facing the practitioner are not found in most practice parameters articles.”

Mere Clinical Response, or Optimal Treatment? Studies with all three classes of medications (i.e., methylphenidates, amphetamines and non–stimulants) have highlighted that is is all too easy for physicians to settle for a partial improvement in symptom control of attention–deficit/hyperactivity disorder, while still leaving ADHD patients with ongoing, clinically compromising symptoms and impaired quality of life. Clinical response in Phase III clinical drug trials is often defined as a 25–30% improvement in symptoms from baseline, but this still leaves patients with ongoing and significant symptomatic and functional impairment. Long–term trials with sustained–release stimulants have shown that 90–95% of ADHD patients will achieve a 30% improvement in symptoms in the clinical trials. However, physicians then interpret the 30% symptom improvement as “much” or even “very much improved” on global clinical outcome measures.,,,

Patients and physicians may be tempted to be satisfied with a 30% improvement in attention–deficit/hyperactivity disorder symptoms, even though the evidence is clear that such minimal improvement in ADHD symptom management almost inevitably means continued functional impairment. For almost all ADHD patients, further improvement in functioning and quality of life is still possible. Long–term trials have demonstrated that if the patient and physician is willing to pursue optimal symptom control, then 75–80% of ADHD patients can achieve at least a 50% reduction in symptom impairment (as measured by such ADHD research scales as the ADHD Rating Scale) to reach symptomatic remission.

Maximum Dose? Is there a maximum stimulant dose beyond which one should never prescribe? Dr. Mortimer responded: “Absolutely not. In reality, there are no credible, published clinical studies indicating that there is an absolute maximum single or daily stimulant dose for the treatment of attention–deficit/hyperactivity disorder in children, adolescents, or adults. I think that the reason that national ADHD experts will not address this issue publicly is for political reasons. However, privately, all of the ADHD experts with whom I have consulted over the past twenty–nine years have acknowledged this lack of an absolute stimulant dose maximum.” And most recently, there have now been published a number of studies looking at whether or not prescription stimulant use increases the risk of sudden death. The result: there was nothing to suggest that this was the case. Dr. Mortimer adds: “In fact, there was statistical evidence in one of the epidemiological studies to support the idea that stimulants actually have a protective effect on cardiac health. That is, compared with those with a diagnosis of ADHD who don’t take medications, those persons with a diagnosis of ADHD who take their medications consistently are less likely when driving an automobile to run a red light – which then increases the likelihood of a sudden, adverse cardiac event (i.e., sudden cardiac death from a motor vehicle accident).”

Hobbesian Outcome without Effective Treatment. In addressing the topic of outcomes of those with ADHD who do not receive appropriate treatment, Dr. Mortimer reminds his audience of the most quoted sentence in Thomas Hobbes’ political philosophical treatise, The Leviathan , published in 1651 in which Hobbes describes: “…the life of man, solitary, poor, nasty, brutish and short.”  Dr. Mortimer then summarizes: “Attention–deficit/hyperactivity disorder is not a trivial condition. Compared with normal controls, those with untreated ADHD are at a much greater risk for:  lower educational attainment (by 2.5 less years of education); academic failure (i.e., increased high school and college drop–out rates); risky sexual behavior (e.g. younger initiation of sexual activity, more casual sex, more sexual partners, and no use of condoms); unplanned pregnancies (i.e., untreated ADHD youngsters are more sexually impulsive and less likely to carry condoms; and the ADHD girls are both more impulsive, and less likely to either use condoms, and less likely to remember to consistently take oral birth control pills); more children (on average, untreated ADHD males sire more than three children; and, on average, untreated ADHD females give birth to more than four children); criminal behavior/ antisocial personality disorder (– what Dr. Mortimer calls “Future Felons of America” now grown up); substance use disorders (including over twice the rate of nicotine dependence compared to the general population); psychiatric hospitalizations; head injuries (from more fights and more motor vehicle accidents in those with untreated ADHD compared to the general population); more frequent divorce; more frequent job changes; lower occupational achievement; decreased lifetime earnings; increased difficulties with financial management (e.g., not paying bills on time); lower socioeconomic status; lower social functioning/increased difficulties in interpersonal relationships; more incarcerations (i.e., in one prison study, the prevalence of ADHD in male prison inmates was found to be 25.5%); more social isolation (from dramatically increased difficulties maintaining ongoing friendships and romantic relationships); development of additional mental disorders (pessimistic explanatory style, major depression, bipolar disorder, tic disorders, various anxiety disorders; nicotine dependence; other substance abuse); and more frequent and more expensive motor vehicle accidents (47% increased risk of untreated ADHD men having a traffic crash; 45% increased risk of untreated ADHD women having a traffic crash). This all leads, naturally, to finding significantly lower evaluations of self–esteem and self–worth in those adults with untreated ADHD. Studies are also finding that – compared with the general population – those with untreated ADHD have higher rates of premature death from homicide, suicide,, general medical disorders – with double the rate of death from motor vehicle accidents.,  

Attention–deficit/hyperactivity disorder is thus a chronic medical condition which – if untreated or undertreated –  can lead to a prematurely fatal outcome. For example, utilizing the Danish birth registry, Dalsgaard found that on a nationwide basis, untreated ADHD persons had dramatically increased death rates compared to the general population: ADHD pre–schoolers had an 86% increased mortality rate; school–aged students had a 58% increased mortality rate; and adults with untreated ADHD had a 325% increased mortality rate relative to non–ADHD individuals within the same population, with accidents being the most common cause of death.,  The good news is that with effective ADHD treatment, there was an overall decrease in accidental injury and medical utilization due to accidents and trauma. On a national–wide basis, Dalsgaard et al found a  25–37% decrease in emergency room utilization among ADHD persons receiving treatment versus those not receiving treatment.”

“There are still too many well–intentioned but misinformed individuals who actively discourage parents and other family members from pursuing competent medical assessment of and treatment for attention–deficit/hyperactivity disorder. This irresponsible behavior of unenlightened others leads those with untreated ADHD on to an increasingly dysfunctional life trajectory. Unfortunately, without ever receiving effective treatment, the lives of some of these ADHD individuals will result in a solitary, poor, nasty, brutish, short, violent, premature Hobbesian death."

“With what we now know from longitudinal studies, there is now another item that physicians can add to their increasingly long list of potential legal pitfalls: physicians who refuse to treat an ADHD individual and refuse to refer an ADHD individual to a physician competent in assessment and treatment of ADHD now run the risk  of a medical malpractice lawsuit, disciplinary action by the state’s medical licensing board – or both.”

Summary.  Attention–deficit/hyperactivity disorder is a highly genetic, common neuropsychiatric condition, and it affects numerous cortical and subcortical pathways that coordinate information processing, impulsivity, emotional modulation, and neurochemical pathways which modulate communication between these cortical regions. Both the data on the validity of the diagnosis of ADHD, and the evidence of the efficacy and safety of using stimulants in the treatment of ADHD is overwhelming. If stimulants are not an option in a particular clinical situation, there are a variety of safe, effective non–stimulant treatment choices available. Effective medical treatment can result in a profound improvement in the quality of life for not only the individual with ADHD, but also for the ADHD patient’s families – and the general public.

Dr. Mortimer concludes with this conundrum: “If my understanding of attention–deficit/hyperactivity disorder is accurate, then those with ADHD who have thus far not been treated with effective medication at an effective dose will not be able to sit still long enough to either read or understand many of the implications of the information contained in these thirty–plus pages. So, recalling Aristotle’s introduction to his Nicomachean Ethics, we might ask who, then, is the intended audience? – Well, it is mostly those without ADHD.”

Successfully publicly defending his Senior Essay (– a commentary on Darwin’s Origin of Species), Dr. Mortimer received his undergraduate degree (Bachelor of Arts) in Liberal Arts from St. John’s College in Annapolis, Maryland. Subsequently earning his medical degree from Oregon Health Sciences University in 1985, Dr. Mortimer continued at OHSU to complete general adult psychiatry training, and then a two–year child & adolescent psychiatry fellowship training program. Dr. Mortimer is, thus, not only a fully trained general adult psychiatrist, but Dr. Mortimer is also a fully–trained child & adolescent psychiatrist. The value of having such broad, developmental psychiatric training first became readily apparent when Dr. Mortimer served as the principle psychiatrist for the Oregon Department of Corrections from 1990 to 1997. During this time, Dr. Mortimer evaluated 1,304 adult male and female inmates (ages 16 to 80 years old). Using his extensive medical and psychiatric training to make clinical sense of these inmates’ developmental trajectories “from play pen to state pen,” Dr. Mortimer was then able to provide – sadly, often for the first time in their lives – safe and effective psychiatric treatment for many psychiatric and some medical conditions the symptoms of which had been present (but too–often ignored or dismissed by teachers, pediatricians, parents and others) since their early years in elementary or middle school.

Among Dr. Mortimer’s professional medical accomplishments, Dr. Mortimer is a diplomate of (– that is, he has a diploma in general adult psychiatry from) the American Board of Psychiatry and Neurology (i.e., Dr. Mortimer is “Board Certified in Psychiatry”). Dr. Mortimer has also been on the clinical teaching faculty for Oregon Health Science University’s Department of Psychiatry, and for the Family Practice Training Program at Eastmoreland Osteopathic Hospital in Milwaukie, Oregon. Dr. Mortimer has served as both a principle investigator and as a clinical investigator for phase III clinical drug trials, several of which investigated stimulants in the treatment of ADHD; in other clinical drug trials, other medications were investigated for their efficacy in such psychiatric disorders as social anxiety disorder, and in post–traumatic stress disorder. Over the past 31+ years, Dr. Mortimer has enjoyed seeing some of his many clinical writings published in peer–reviewed international medical journals.

Saying a fond farewell to the State of Oregon, Dr. Mortimer is currently licensed to practice medicine only in the State of Washington, maintaining a full–time, solo private practice in child, adolescent, and general adult psychiatry in the non–incorporated Hazel Dell neighborhood of Vancouver, Washington. Also of perhaps some interest: Dr. Mortimer currently enjoys the distinction of having the longest–surviving, private practice in child & adolescent psychiatry in the county.

DSM V DIAGNOSTIC CRITERIA FOR ADHD

1 Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

• Often has trouble holding attention on tasks or play activities.

• Often does not seem to listen when spoken to directly.

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

• Often has trouble organizing tasks and activities.

• Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

• Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

• Is often easily distracted

• Is often forgetful in daily activities.

2 Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

• Often fidgets with or taps hands or feet, or squirms in seat.

• Often leaves seat in situations when remaining seated is expected.

• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

• Often unable to play or take part in leisure activities quietly.

• Is often “on the go” acting as if “driven by a motor”.

• Often talks excessively.

• Often blurts out an answer before a question has been completed.

• Often has trouble waiting his/her turn.

• Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.

• Several symptoms are present in two or more setting, (e.g., at home, school or work; with friends or relatives; in other activities).

• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.

• The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. The symptoms are not better explained by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months

Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months

Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.

Because symptoms can change over time, the presentation may change over time as well.