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After reading and responding to the article, "Ritalin Gone Wrong" by L. Alan Sroufe, Dr. Sutton contacted his colleague, Dr. Steve Hinshaw, who was the University of California, Berkeley's principal investigator on the Multimodal Treatment of Attention Deficit/Hyperactivity Disorder (MTA) research study, which was referred to in Dr. Sroufe's article. Dr. Sutton took this opportunity to bring Dr. Hinshaw into a conversation with Rona Renner, who is a nurse, parent advocate for ADHD, and host of the Childhood Matters radio show, and Dr. Joshua Israel, a psychiatrist with the Bay Area Center for ADHD who also teaches at University of California, San Francisco.

The goal of the discussion was to bring together professionals with a wealth of knowledge to discuss the controversial issues around ADHD including the question of environment vs. genetics, over and under-diagnosis of ADHD, treatment of ADHD, the use of medication as treatment for ADHD, and the issues surrounding long-term effectiveness. Dr. Sutton also corresponded with Dr. Sroufe and brought some of his comments into the discussion that he had wished to be shared after the reactions to his NY Times article.

Click here to listen to the podcast of the discussion (you can also download the file by right clicking and selecting "save file as.. or "download linked file"; you can also click on this link on your online browser to listen to the podcast on your mobile phone)

There are many factors that lead to the success of a marriage. If you walk into any bookstore or online retailer, you will find a myriad of relationship help books aimed at married couples. In fact one of the largest reasons people seek psychotherapy is for help either starting, stopping, or keeping a relationship. Healthy relationships are a partnership that takes communication, sharing of duties, emotional presence, and mutual support among many other important factors. Now, suppose one of the individuals in this partnership is greatly limited in their ability to carry out any of for mentioned skills, because of ADHD (Attention Deficit Hyperactivity Disorder, often referred to as ADD). This type of scenario can very quickly lead struggles in the relationship.

Phil Boissiere, MFT says that "many if not most clients who have ADHD and are married have some level of dysfunction or dissatisfaction in their relationship.” Individuals with ADHD are often unable to execute tasks that others take for granted. The non-ADHD partner may often find themselves in a place of frustration and dissatisfaction with their partner’s lack of follow through, impulsiveness, and perceived lack of presence. All to often this frustration can lead to hurtful statements that ultimately compound the problems the couple is facing. Hurtful statements such as “Why can’t you just do_____!” can lead to increased self-doubt, diminished self-esteem and emotional reactivity in the ADHD partner.

The good news is that there is wealth of research on the treatment of couples where one member has ADHD. Sometimes the non-ADHD client is simply in the dark about their partner’s struggles and experience. Simply educating the couple in a supportive therapeutic environment can help facilitate positive change in the relationship. However, many couples need further intervention to work on communication skills and the cycles of frustration and negative emotions that often exist around ADHD. Therapeutic approaches that work to address distress and provide new strategies for the couple are extremely effective. One of the most effective treatment models for couples with ADHD is Emotionally Focused Therapy pioneered by Dr. Sue Johnson. The goals of EFT are to expand and re-organize key emotional responses, create a shift in the way couples interact, and foster secure healthy bonds between partners. There are a multitude of skills and techniques that can benefit couples that are facing adult ADHD. The first step is educating yourself on ADHD in order to understand your experience or the experience of your partner. This can often be most easily and efficiently accomplished in person with a clinician who has an in-depth understanding of ADHD and relationships, especially if a couple is emotionally charged and having trouble communicating.

Note: If you are reaching out for information online, make sure you are using a reputable source such as http://www.chadd.org/ or
http://www.aboutadultadhd.com/ or www.bayareaadhd.com

written by Phil Boissiere, MFT
Bay Area Center for ADHD/ADD Marriage and Family Therapist providing therapy and assessments for adolescents, adults, and families.

Living with ADD/ADHD means getting knocked down and caught off guard by ADD/ADHD. Medication, strategies, and therapy can help you get knocked down less, but what is most effective is learning to get back up. ADD/ADHD can trip adults and kids up in lots of ways like ruining a job interview due to being late, causing a teacher to give you a bad grade because you didn't read the directions of the assignment correctly, make your partner mad because you lost the keys again and they have to leave work to let you in the house, or cause your parents to yell at you to pick up your things for the 20th time that day. Many kids and adults with ADD/ADHD then beat themselves up and/or get angry and blame others and then sometimes do things that make matters worse (e.g., yell, drink, skip class, zone out on the internet for hours). Sometimes we call this a shame spiral that can be perpetuated by avoidance. The way to get out of this is by getting back up and getting back in the ring.

It's no doubt that ADD/ADHD will trip you up, but there is no use beating yourself up or avoiding the pain of the fall. Hopefully, you can sit with the bad feelings long enough to learn what needs to be done to fix and/or prevent the situation from happening again, but not sitting with the pain so long that you become paralyzed. We also don't want to avoid the pain so that we don't learn what to do next time. So when you get tripped up and knocked down by ADD/ADHD, remember, everyone gets knocked down and messes up from time to time, but its getting up that matters most.

W. Keith Sutton, Psy.D.
Center for ADHD/ADD Psychologist providing adolescent, adult, couple, and family therapy and neuropsychological assessment.

Dr. Sutton's response to the controversy around the NY Times Op-Ed Article, "Ritalin Gone Wrong":

In a conversation I had with Steve Hinshaw when he was at my home for a discussion group I host with providers treating ADHD, he explained to me that the difference in effect with the MTA study kids (the longitudinal study that is referred to in the article), was that after the study, the medication group went into a "treatment as usual" context (rather than having the dosage and medication adherence being closely monitored). He is one of the principal investigators on the MTA study and explained that all of the children randomly assigned to intensive medication, behavioral, or combination treatments for the 14 months of the "clinical trial" portion of the study went back to being treated by pediatricians for their medication with inconsistent dosing, after the clinical trial ended (I asked if they looked at psychiatrists vs. pediatricians and he thinks it was 100% pediatricians, but is going to go back and check the data for me).

Part of the issue with ADHD is that it is highly heritable (.81 heritability coefficient in monozygotic twins, which is more hereditable than diabetes or schizophrenia, this was a study where I was a work study student with Bruce Pennington in my undergraduate training, this is compared to 29% of monzygotic twins, so that addresses the environmental issues). Also, there is a 57% chance (some studies place it more around 30-40%) that a child of an adult with ADHD may have ADHD and a 64% that a child with ADHD will have a parent with ADHD (32% chance for each parent). Thus, implementing a treatment plan, remembering to administer medication, make follow up appointments, etc can be inconsistent when a parent has ADHD too. Also, 80% of psychotropic medication is prescribed by general practitioners with no specialized training in mental health treatment. Thus, many of the children may be treated incorrectly.

There is the issue that of the people with ADHD that take medication, 80% find it effective. I talked with our adult psychiatrist in our Bay Area Center for ADHD, Joshua Israel, who works exclusively with adults with ADHD and reviews all the literature on ADHD. He explained that about 25-33% of the time, the medications do lose their effect over time. There is not much research on this that he is familiar with and this phenomenon is not clearly understood (there is some tolerance building as the medication is titrated, but usually finding the person the dosage is reaches a consistent effective level).

Also, I think the article touches on another controversial issue, which is diagnosis. Due to the difficulty of diagnosing ADHD (executive functioning is one of the first things to go when a child or adult has anxiety, not enough sleep, not eating well, depression, trauma, is spread too thin at work, is abusing substance, is going through a difficult period, has a learning disability, head injury, or a number of other issues), many children and adults can be misdiagnosed if not given a proper assessment. There was recent research done where phone calls were made at random and asked parents if their kids had ADHD. Some states had rates as high as 16% and other 5% prevalence rates, although there is the question of who is doing the diagnosing.

The best way to diagnose ADHD is through a thorough clinical interview, taking into account the history (a neuropsych can give a profile of strengths and weaknesses, help rule out learning disabilities of which 50% of those diagnosed with ADHD also have, but a neuropsych is not necessary for a diagnosis of ADHD) . Current DSM standards look at symptoms existing prior to age 7, but DSM-V will most likely change that to prior to age 12 (or particularly Barkley's recommendations are prior to the onset of puberty).

There is also discussion about what are the "real" prevalence rates? The current DSM symptoms are based on children 4-16 years old, with a cut off of 6 symptoms out of 9, which placed children at the 93rd percentile (1.5 standard deviations above the norm, remember, to be inattentive and impulsive at times is a normal human trait, but when it becomes significantly abnormal and significantly affects functioning, it is considered a disorder, that's how most of us can identify with ADHD symptoms from time to time). Unfortunately, this same criteria for young children creates over diagnoses (for example, all 18 month olds meet 6 symptoms due to the frontal lobe of the brain not being developed enough) and under diagnosing adults (adults are no longer seeming as if they're driven by a motor or climbing on furniture). Actually, Barkley explains that 4 out of 9 symptoms place adults at the 93rd percentile, which is another controversy in the changes in DSM-V.

The most important part of a clinical assessment for ADHD is obtaining information about the early years, even when diagnosing an adult, which means talking to a parent (I've talked with parents in their 70s with adult clients in their 50s). One of the hardest differential diagnoses is when there are additional issues in childhood, such as trauma, family conflict, poverty, etc. Often, the behavioral, cognitive, and family treatments are the same (organizational skills, skills for distraction management, regulate sleep, healthy eating, exercise, school accommodations, therapy for the anxiety, family, depression, trauma), but the biggest difference is whether medication is prescribed.

As a therapist, who does not prescribe medication, I work with adolescents and adults who are both on and not taking medication. Behavioral therapy helps and medication helps. The standard of care is using both in combination, and making sure the medication is being monitored by a specialist in ADHD. At our Bay Area Center for ADHD, we provide individual, family, couples, and educational therapy as well as medication management. We've got great psychiatrists who work closely with the therapists to monitor and titrate medication and David May, our child psychiatrist, works very closely with families, emailing with parents daily during the beginning of medication treatment to ensure a proper dosage. He also works very well with parents wary of medication and often will not prescribe.

I think that it's very important to not throw the baby out with the bathwater regarding medication and ADHD. ADHD is a real, debilitating problem that if not properly diagnosed (or even when properly diagnosed), can lead to difficulties throughout the life time. The majority of adults that I work with experience a great deal of shame for not being able function at the level of others. One of the best interventions for a child with ADHD is the child and family understanding what ADHD is, how it impacts them, and working to help prevent the shaming that can happen from the difficulties ADHD brings and also to give them hope, since there are so many successful people with ADHD (e.g., Charles Schwab, Michael Jordan, Richard Branson, just google famous people with ADHD).

As with all other mental health problems, a mutlimodal approach is the best approach. Medication, in combination with healthy eating, exercise, adequate sleep, family/partner intervention, educational accommodations, and skills. When the diagnosis is not clear (history of ADHD but also history of trauma, family conflict, depression), then I collaborate with clients to determine if they would like a medication evaluation from a psychiatrist and treat the symptoms just as I would ADHD (even if its trauma, you help the person build coping skills to be more functional, then treat the trauma, just as you would if they had both ADHD and trauma). Often times, once we've treated the depression, sleep problems, anxiety, etc. and still find there are problems associated with ADHD, then the client might go for a medication evaluation. I tend to be conservative in my diagnoses of ADHD as it is such a difficult diagnosis.

Another interesting point is that there is much criticism of over medication of ADHD, but Barkley reports that studies have found 2% of the population on medication for ADHD. With a prevalence rate of 5-7%, that would mean only 28-40% of those with ADHD are on medication. In Hallowell's response to the NY Times article, he points out that 19 out of 20 parents that he sees are wary of medication (and many opposed), not eager to put a child on stimulants for a "quick fix".
I've seen adults in tears in my office, when they finally have learned that they had ADHD and took medication. They realize all the years they were being told they were lazy, the years they were yelled at by teachers, and the years their parents struggled with them could have been different if they knew what was going on and that there was something to treat it. I've also seen parents and families transform when they understand that their child has ADHD and is not being defiant with their schoolwork. Through medication, family therapy, cognitive skills, and educational skills, the family is able to heal some of the pain that occurred during the struggle to help the child function.

But just as any medication, its not the sole answer. Just as a child who needs glasses will be able to read better, a child with ADHD with medication can focus, be less hyperactive, and initiate more in classwork. If they don't have the remediation in school, the structure at home to get homework done, or the skills to keep organized and do their work, the medication alone will not equal success. Again, just as a child who is behind on reading because no one realized they needed glasses, they will still need remediation to catch up on their skills, the doctor will have to keep checking the glasses to make sure they are the correct prescription as the child ages, the child and parents will have to remember to send the child to school with the glasses, and they'll still have to provide the proper structures at home to get all the homework done and checked, while wearing glasses.

To read the NY Times Article, click here:

To read some responses to the articles, click the links below:



written by
W. Keith Sutton, Psy.D.
Bay Area Center for ADHD/ADD Psychologist providing therapy for adolescents, adults, couples, and families and providing neuropsychological assessments.

I highly recommend the app, Reqall, which is a handy little smart phone app to remember those thoughts that pop into your head when you're on the go. With one click on your phone, the application opens up, you touch the screen and it starts recording, you speak into the phone (e.g., remember to send the rent check, don't forget to call Jane, get oil changed next week), and then press the screen again and the app transcribes what you've said and emails it to you (I recommend setting it "add by voice" and "tap to record another" rather than opening up an options page to set priorities, dates, etc.). It's great for those thoughts that pop into your head while you're on the go and then when you sit down to your computer with your to do list, you can add all those fleeting thoughts that you usually forget. It's not great with the transcription, but it also attaches the audio. You can also use if you don't have an app by calling a phone number. Best of all, its free. You can here for more info: http://www.reqall.com/

written by
W. Keith Sutton, Psy.D.
Bay Area Center for ADHD/ADD Psychologist providing therapy for adolescents, adults, couples, and families and providing neuropsychological assessments.

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