A few months ago, a friend gave me an article in the American Bar Association's Student Lawyer magazine discussing "Mental Doping" and the use of ADHD stimulant medication among students in law school. Some of these individuals legitimately have ADHD and need the medication - a situation which the article has compared to a person using glasses to correct a vision problem. In addition to this group of ADHD patients, there are also those who have both sought out an ADHD diagnosis by manipulating a screening, as well as those who have acquired the drugs through other illegitimate practices.
I interviewed ADHDCentral expert and clinical neuropsychologist Robb Mapou, Ph.D. ABPP to help me answer some questions about the prevalence of this activity.
What exactly is ADHD? How does medication help treat it?
The most recent theory about ADHD, which is supported by research, is that it is due to the dysfunction of the frontal lobes of the brain. The frontal lobes are involved with planning and looking at a goal ahead in time, figuring out how to get to that goal, and maintaining a direction toward that goal. They also enable people to inhibit responding to something that is unrelated to the goal. For people with ADHD, as Russell Barkley writes, it's disproportionately difficult to inhibit a response to something that is reinforced in the moment rather than work toward a long-term goal. For example, a student with ADHD may do anything but work on a paper that's due in three weeks. Stimulant medications help by increasing the availability of dopamine, one of the neurotransmitters in the brain which is presumed to be deficient in individuals with ADHD. The frontal lobes, especially, rely on dopamine for efficient functioning, so by taking a stimulant, more dopamine is available. The frontal lobes can then function more effectively, and people with ADHD can avoid distractions, focusing instead on what they are supposed to be doing.
What happens in a patient with ADHD when they take medication? What does this person feel when taking medication?
I must preface this by noting that I am not a physician and do not prescribe medication. Physicians who treat ADHD in adults have told me that the correct way to do a medication trial is to start with a low dose, and gradually push it up. People may then have the "a-ha" moment at the right dose, suddenly noticing that they can focus the way most people do. If the dosage is too high, however, they may feel very jittery and anxious.
Yet, even in people without ADHD, stimulants can boost cognitive performance. Consequently, it is being used by students and others without ADHD, much the way people used to use speed in the 1970s. In fact, what was called speed was amphetamine, which is what is in the drugs Adderall and Dexedrine. There was an article a year or so ago in the New Yorker about people using ADHD medications to gain an edge which explained just this issue, sometimes referred to as cognitive or neuro enhancement.
Is the problem that these medications are being prescribed too much? Is the testing for ADHD not stringent enough to weed out abusers?
I am not convinced that people are prescribed the medication too much. In fact, a large study several years ago found that there are many adults with ADHD who are really struggling, but, for whatever reason, do not take medication. However, there are websites that tell you how to fake ADHD, which is why, if I am going to make a diagnosis, I will do a very comprehensive evaluation. I also need input from a parent and academic records. The way of diagnosing ADHD should not differ from doctor to doctor - there are specific symptoms that need to be reviewed. However, diagnosis should always be based on more than an individual's self-report, because this is prone to bias or manipulation. Also, individuals who are using medication as a crutch are probably getting it through other ways, often illegally and not necessarily with a prescription after a manipulated test.
Do individuals come in with a diagnosis in mind?
Adults sometimes come in with a diagnosis in mind; adults may be more prone to self-diagnosis than children. As far back as 1994, a psychiatrist wrote that ADHD seems to be the most self-diagnosed condition in his practice. I find this is still the case, as adults are looking to explain the short-comings in their lives and think ADHD will be a simple way to do that. For kids, the parents are going to bring them in, sometimes unwillingly, because they are struggling in school and at home.
Is there any fear that some people may come in looking for a prescription?
Sure. But, I build many checks into my evaluation, to be sure. In my own practice, it is rare that the folks who are coming in are not legitimate. They typically come in with a long history of problems. We also charge a lot; so people may be less likely to waste the money and the time, especially when I tell them that I will not automatically confirm a diagnosis. I have become more attentive to this in the last few years. In addition, a problem with attention and work completion could be due to something else. People think treating ADHD with a pill will be a quick fix - they may be reluctant to admit they are not getting enough sleep, they are depressed, they are anxious, they are having family difficulties, etc. They may be looking for a diagnosis to explain what is going on, and they think ADHD is a better or "cooler" diagnosis to have.
The opposite case is that of the student or young adult with significant history of ADHD who does not want medication or support. I tell them my experience is that students find it useful, and that it can be very helpful. Ultimately, it is their choice, but they could be doing better with medication and academic support.
I would question the ethics of any doctor who prescribes to individuals without doing a thorough evaluation and without evaluating the possibility that the patient is "shopping" for a diagnosis. I would certainly not recommend prescribing without significant indications and a very clear history. ADHD goes way beyond affecting attention - you can't prescribe just based on attention problems, reflected by a young adult who is struggling with tests or is reporting problems paying attention in class. Making a diagnosis is based on history and not only current symptoms. Research has indicated that ADHD has to show onset by the teens - someone may do well in elementary school, but once organization and planning become more important, they can begin to decline in middle school and early high school. I am skeptical of anyone who comes in during college and claims to have ADHD or a learning disability, without having had any obvious problems before then. There are also "embedded indicators" during testing that indicate a person is being deceptive- I look closely at that, as do other neuropsychologists during their assessments.
Do you prefer one drug over another to treat ADHD?
Again, I am not a physician. I understand that one drug is not necessarily more effective than another, but prescribing is an art more than a science. Some people simply respond better to one medication than to another, with fewer side-effects. When someone does not respond to one medication, the physician can try another. Not everyone reacts in the same way.
Are there any side-effects, particularly long-term, that would dissuade people from using ADHD medication?
There are some potential side-effects. Individuals taking the medication can and should be monitored by their physician -- specifically cardiac heart rate and blood pressure, which can increase with stimulant treatment. The drugs can cause problems with sleep and reduced appetite. They may lower mood, and they temper impulsivity, which some people do not like as they complain they are less spontaneous. In terms of long-term side effects, Ritalin is probably the psychotropic drug that has been out there the longest - since the 1940s - and so we know a lot about it. Research has not shown any significant long-term side effects. In children, however, there are concerns it may depress growth a little. Yet, there is no research on alternative treatments. The tried and true method of treatment is with medication, along with behavioral supports that include cognitive-behavioral therapy and coaching.
The material presented here is for educational and informational purposes only. It is not to be taken as psychological or medical advice. Diagnosis of learning disabilities and ADHD (or other conditions) and recommendations for treatment should be made only after a comprehensive evaluation by a qualified and licensed professional.
Published On: May 27, 2010