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Hitting the Wall

When it's ADHD and not Bipolar or anything else.

Well, the new academic year is in full swing. Most of the children and adolescents and college students have moved up one grade and maybe one level. And with each successive promotion a remarkable number hit the wall.

Hit the wall? Yes. These previously good students; good grades, generally good behavior, good attitudes, begin to falter, fail, act up or act out, and get in trouble. They are accused of being lazy, not trying hard enough. Many begin to use drugs, particularly marijuana and tobacco. They are often diagnosed as depressed and much too frequently as bipolar. Then of course they are placed on SSRIs, heavy mood stabilizers, and atypical antipsychotics. In some cases the behavioral problems are diminished. In most cases there are a raft of side effects: Weight gain, lethargy, sleep disturbance, acathisia, hormone imbalances particularly in girls, and gynecomastia in boys given Risperdal, Geodon and several other meds. The common denominator in most of these cases is ADHD.

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What?! ADHD?! How can that be? They were doing so well before. Maybe they weren't straight A students but they were passing their classes and causing no major problems. Therefore, being under the radar, they couldn't have had a problem. The idea that, perhaps, had an early diagnosis been made and treatment begun these kids could be on a fast track to success is lost on many. This is the usual reasoning as proclaimed by the usual suspects.

Unfortunately too many parents, teachers, therapists, pediatricians, family doctors, and psychiatrists are too ready to make the diagnoses du jour, proffer the chemical cocktail of the week and miss all the important points. Why are so many responsible adults so ready to accept these major diagnoses and these major medications but resistant to the notion that ADHD may be the key factor. Oh dear, the stigma! No one is going to label my child with ADHD and put him or her on Ritalin or amphetamines! Much better to make them numb, dumb and fat with Seroquel, Depakote, and Celexa. Simultaneously a staggering number of parents and clinician's ignore or minimize the use of marijuana which is an entry level drug for people with ADHD and does lead to bigger and badder things.

People with ADHD have different brains and cerebral function than those with regular brains. [Please see previous posts and comments for that discussion]. Many of the brightest, most clever, creative and talented get by for a variable period of time on their brain power alone. They never bother to learn study skills, they don't take notes, they tune out that which does not interest them and at some point they overload and short circuit. Indeed many of them do become anxious and depressed at that time. Many begin to self treat.

Almost everyone with ADHD has hit the wall at some point. It is usually at a transition. People with ADHD handle transitions poorly to begin with but this is a specific phenomenon as they become overwhelmed and crash. For some poor kids it happens in first grade. And it happens to some each year. However it is the major transitions-primary to middle school, middle school to high school, high school to college, college to medical school or a job-when they a flame out in droves. Know that puberty unmasks and exacerbates ADHD dramatically.

I have written before and do not have the space right now to get into a detailed discussion of comorbidities with ADHD but in the preponderance of the cases to which I refer correction of the ADHD and concomitant sleep disorder-periodic limb movement disorder-is all that is necessary, assuming a sober state. Sometimes a noradrenergic antidepressant is necessary, but never an SSRI. Rarely, very rarely a mood stabilizer and just about never an antipsychotic drug.

In my private practice I un-diagnose bipolar disorder and a variety of other incorrect diagnoses and correct the diagnoses to ADHD/PLMD more often than I make it in any treatment naive patient. At the clinic wherein I consult upon the cases of innumerable children and adolescents under court supervision and in the custody of children's services 99% come in with a diagnosis of bipolar disorder or schizoaffective disorder and with chemical cocktails that could bring down a rhino. True, a few have been diagnosed at some point with ADHD but they are not being treated for it or the putative treatment is incorrect and at best useless.

Teaching at that clinic I use a simple analogy. I ask the following question: If you are called to consult upon the case of a young black child or adolescent who presents with low-grade fever, abdominal pain and joint pain what is the first thing you think of? No, it is not systemic lupus erythematosus or juvenile rheumatoid arthritis or Lyme disease. You think of sickle cell disease.

Similarly when you see children or adolescents with the sudden onset of behavioral disturbances, deterioration in academic performance, outbursts, sleep problems and a host of other symptoms it's rarely just growing pains. It's rarely just puberty. But most importantly it is not commonly but rarely bipolar disorder and usually not just depression. No, it is not always ADHD either but it often and in my experience usually is.

If one does not contemplate a diagnosis one does not look for the diagnosis nor make the diagnosis. And from a purely medical, clinical perspective it matters not whether you like the diagnosis of ADHD, it is very real and very problematic. So in your practice, clinic, classroom, office, home, consider it. Then have your child or adolescent evaluated by a specialist in ADHD.

Yes this has been a broad overview of a serious problem. I cannot go into depth about every one of the issues but hope to provoke thought and awareness. Keep in mind at all times at 70-80% of psychotropic drugs are prescribed by non-psychiatrists.

Jory F. Goodman, M.D., is a practicing psychiatrist in Beverly Hills, with more than thirty years of clinical experience.

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