Dr Rod Bergh is a general pediatrician who has practiced medicine since the early 1960s.
I have practiced Pediatrics for most of the 59 years since I graduated from Medical School and I have seen tremendous changes in our knowledge. For the past 16 years, I have restricted my practice to children with ADHD and have experienced the great satisfaction of seeing in this period about 3000 children turn their lives around.
Change is based on knowledge gained by research. However, I would like to point out an area where I believe we have ignored evidence, which has resulted in some less-than-optimal therapy for ADHD.
ADHD, is a disorder that was first recognized, somewhat serendipitously, by pediatricians in the late 1940s. It was considered a disorder of children and it was primarily in the pediatric and psychological domains that research and treatment remained until the turn of the century. The initial understanding was that its impact was solely on academic performance. However, it was realized in the 1980s that many children with ADHD who were never treated developed Oppositional/ Defiance Disorder, and 50% were at risk for Conduct Disorders in their teen years. Further study showed that children with ADHD who were treated on school days only improved academically but continued to be subject to the same risk. The recognition of the continuing risk identified the importance of adequate and appropriate treatment (i.e. every day of the year) and was a huge step forward and was first included in DSM IV (Diagnostic and Statistical Manual of Mental Disorders) in 1994.
Over the years that ADHD was considered a pediatric disorder, it was realized that symptoms did persist into adulthood “in about 60% of cases”. As we became aware of the fact that adults with ADHD were also at significant risk for Conduct Disorders and social difficulties, members in the psychiatric field also became involved.
Long-acting medications for ADHD did not become available in Canada until the turn of the century, the stimulant medications having been available in only 4- and 8- hour formulations. For most medications used in treating children, dosage is calculated on a mgm/kg basis and a therapeutic range for treatment of ADHD was established, accepted and published for use in pediatric literature. Such dose standards were in use for several decades into the early years of this century with spectacular effect.
When the long-acting formulations were released, a more careful approach was recommended with a target of “Optimum” treatment. This target was to be reached by gradual increase of dose (“Start Low, Go Slow”) until this Optimum was reached, based on clinical assessments of benefit. There is no possible way to know when that “Optimum” dose has been reached because the patient has never experienced the ability to think “normally”. We can measure the output of thought but cannot yet measure the actual process of thought, and how would one explain “normal” thinking to someone who has never had that ability. Therefore a patient with ADHD cannot possibly identify the point in treatment at which his thought processing has become “normal”.
If one is born with a problem with vision, that individual cannot know what normal vision is until proper corrective lenses are prescribed. If lenses that give only partial correction are prescribed, better vision will result but the patient has no way of knowing that it could be even better because he has never experienced normal vision.
When a person is born with a problem with thought-processing (e.g. ADHD), they have no understanding of normal thought-processing until they are given an adequate dose of medication. If a less-than-adequate dose of medication is prescribed, that person may think better but will have no way of knowing that it could be even better because he has never experienced normal thought-processing.
Optimum treatment for ADHD requires adequate medication as the first step, followed by any other personal support that may be deemed necessary. Based on extrapolation from the doses that were recommended and used for the “Immediate Release” forms, the therapeutic dose of methylphenidate “Slow Release” is 1 – 2 mgm/kg/day and that for dextroamphetamine 0.5 – 1.0 mgm/kg /day. The mechanism of action of these stimulant medications is entirely different in a child with ADHD from the norm – these children do not become stimulated, for example – there is no significant change in BP or heart rate. (There are obviously other side effects, e.g. loss of appetite, which are manageable.) As self-esteem develops from social success, behaviour problems lessen. If an excessive dose is given, the child may become “zombied” but only until the dose is changed into the therapeutic range.
In recent years, many children have been referred for evaluation because a diagnosis of ADHD has been made and appropriate medication prescribed but the child “was not doing as well as expected”. While there may be other factors involved, an adjustment of the dose into the therapeutic range is often the only change required, invariably with much better result.
For at least 40 years, for children who had problems from ADHD, treatment with stimulants based on mgm/kg doses provided very effective control of symptoms with manageable side-effects. Within two weeks on an adequate dose, these children recognize and demonstrate positive changes in relationships and performance and improved self-esteem. They now have a bench-mark to use for the rest of their lives making them better able to recognize when they have “out grown” their dose, to improve compliance and to help determine, as they grow older, when and whether medication may be discontinued.
We have 40 years of the wonderful experience of treating ADHD with First-Line Medication prescribed on a mgm/kg basis with a defined target and which quickly gives the patient and family the understanding of what is actually possible.
The experience of passing from disorganized thought to a lifting of the fog must be awe-inspiring and something others cannot understand. An Evidence- Based treatment program gives patients the ability to be more successful in life – academically, professionally and socially – by reducing markedly the 50% risk of ODD/Conduct Disorder for patients who have not been treated adequately. The adult with ADHD comes to treatment because of difficulties which arise as a result of the disorder. As pediatricians, we are in the very satisfying position of being able to identify and start effective therapy to help prevent these outcomes. When the decision of whether or not to treat a child has to addressed, the immediate response by many parents (often Father), has been “I have experienced many of those problems as a child (including being in jail) and I do not want that for my child”.
I have learned from many years experience in treating ADHD that the gift of clear thinking, especially by controlling impulsivity, for a patient with the disorder requires a full therapeutic dose of a proven medication.