ATTENTION DEFICIT DISORDER
By Paul T. Elliott, M.D.
Terms often applied to persons with the ADD brain structure regardless of age.
No one with ADD will have them all, and some will seem contradictory, though only representing opposite ends of the spectrum for a given symptom. This simply illustrates the very wide range of manifestations this condition may exhibit.
Hyperactive, Hypoactive, Fidgety, Anxious or nervous, Lazy, Daydreamer, Procrastination, Chronic lateness, Learning disabled, Dyslexic, Poor visual motor coordination, Speech defects, Auditory processing difficulties, Early or late walking or talking, Unable to concentrate, Messy, Doesn’t perform up to capacity, Doesn’t finish tasks, Poorly organized, Violent sleeper, History of bed-wetting, sleep-walking, or sleep-talking, Poor interpersonal relationships, Oppositional behavior, Shy, Abrasive personality, Impulsive, Distractible, Restless, Impulsive, Acting without thinking, Poor memory, Abusive behavior, Substance abuse, Addictions to substances, gambling, or sex, Eating disorders =============================================
(First in a series)
Attention Deficit Disorder, or ADD, sometimes known as ADHD, for Attention Deficit Hyperactive Disorder, is one of the most misunderstood, most often overlooked normal conditions in our nation.
Unfortunately, as the condition gets more publicity, there is and will be a compounding of the confusion and incorrect information. Over my twenty-odd years’ experience, I have gained a new and often somewhat unorthodox insight into the condition and the problems encountered by patients and their families.
I know much of what follows is rather unorthodox, even contrary to conventional thinking on the subject. I also know much of the difficulty in coming to a proper understanding of the condition rests in the unyielding beliefs of us professionals who may be unwilling to re- examine our own thinking. In addition to physicians, I include psychologists and educators. Many of our long-held suppositions about ADD have turned out to be either partially or completely incorrect.
Having suggested that the professions need to re-examine their traditional ideas on the subject, as they may be incorrect, I realize this may stir a heated controversy. I do not shrink from this prospect and am prepared to engage that controversy to the extent possible in its proper priority: behind God, family, country, and the care of patients.
The first mistaken belief is that it is an abnormality. This consignment must have occurred primarily because the original research was done in the 1930s on persons with behavioral problems and an I.Q. that measured below average. Some of these patients had had brain trauma due to birth problems, head injuries, seizures, and infections. When this information was applied to the population in general, the concept of “damaged brains” was transferred with it.
Throughout the last 35 years, the concepts of the causes and the naming of the condition have changed rather significantly. The terms Minimal Brain Injury (MBI), Minimal Brain Damage (MBD), Minimal Brain Dysfunction or Disorder (MBD), and Hyperkinetic (or Hyperactivity) Syndrome have all been used and misused to describe the behavioral characteristics of the ADD brain structure. Though significant, these conceptual changes have been inadequate.
Because it has been thought of as an abnormality, we have philosophically handicapped our own thinking. This confining process has limited our ability to expand our concepts about ADD appropriately.
In fact, it is just a variation of normal brain structure, though in the minority in our society.
ADD is now felt to be a neurological difference in brain structure with many benefits NOT a PSYCHIATRIC DISORDER, as has been erroneously supposed in the past. It is an inheritable condition unrelated to childhood experiences, child rearing practices, or life experiences. Though males have been thought to be much more often affected than females, it seems now that they may simply be more evident, because of their greater likelihood of having the hyperactive form. Patients often have a pattern of under-achievement in school and life, puzzling to them and those around them. It has been felt by some professionals in the field to affect as much as one-third of the population to some degree. Persons with ADD should in no respect be thought of as diseased, mentally defective, brain damaged, or psychologically unbalanced. In fact, just the opposite is true.
Rather than a disorder, as it has been previously considered, I believe ADD should be renamed Thought Processing Difference (TPD) and considered a variation of normal brain structure whose differences sometimes do not fit well into the rigidly defined, highly integrated and controlled educational and societal structure in the U.S. In other words, it appears as an abnormality primarily because of the narrow and rigid structure of our society, including education, workplaces, job design, the way we structure businesses, and our societal form in general.
It is now recognized that it usually, if not always, persists throughout life, though in a modified form, with changing symptoms from one stage of life to the next. Therefore, need for treatment may vary throughout life.
The really good news is that neither the patients, nor their parents, teachers, spouses, children, friends, or the rest of society, needs to suffer the problems often associated with the ADD brain structure, regardless of age. Unfortunately, we have not offered treatment to most who would benefit and have inadequately, ineffectively, and under- treated many.
(Second in a series)
It was previously believed to be a condition rarely persisting into adulthood, but it is now recognized that it very frequently persists throughout life, though in a modified form with perhaps changing symptoms. Persons with ADD should in no respect be thought of as diseased, mentally defective, brain damaged, or psychologically unbalanced. In fact, just the opposite is true. Such individuals have higher than average Intelligence Quotients (I.Q.’s), have a superior ability to think creatively, are very sensorily aware of any small change in their environments, have the ability to react quickly to any threat or change in the environment, and can quickly alter course when the situation requires. Though depression may occasionally be found concomitantly with ADD, it is most often secondary to the ADD, rather being a separate issue. With appropriate medication therapy for the ADD, the depression frequently disappears.
The following symptoms are found frequently in ADD patients, though no patient must have all of them. Often, it may seem that a person may have symptoms exactly the opposite of those of another. Some patients will appear to have only a few, though they may be very vexing. This merely illustrates the broad diversity of the manifestations of the condition from one person to another.
In childhood, they often have a history of difficulty in school, in both the learning and behavioral areas. They may have been kept back or failed one or more years in the first twelve grades, or they may have been started a year later than their chronological peers because of being “slow to mature.” They may have difficulty with or be awkward in peer relationships. They may seem never to perform quite up to their apparent ability. They may seem “accident prone” or have difficulty with coordination in athletics. They interrupt conversations frequently. They frequently respond poorly to discipline, yet are very emotionally sensitive with either a high or low tolerance for pain. They may be hard to get organized and started in the morning and find it difficult to get to sleep at night. They are often “violent” sleepers and may have bed- wetting, sleep-walking, and sleep-talking in their history. They may seek high-intensity, highly stimulating environments, or they may seem very! inactive and passive.
In adulthood, patients may seem to be impulsive, with a high energy level and a need for much environmental stimulation; or they may seem to be “lazy,” “messy,” “daydreamers,” poorly organized, and poorly motivated or directed, though still manifesting impulsive behavior. This impulsiveness is relieved somewhat by vigorous exercise, and they may become “exercise addicts” or “thrill seekers.” The impulsiveness may lead to alcohol or drug abuse in a pattern of self-medication, as well as other addictive behaviors. They may become spouse or child abusers, and are often themselves victims of abuse. The impulsiveness has the pattern of failure to consider the consequences of acts and may lead to a series of poor decisions in life, producing an erratic pattern in school, work, or personal life. >From middle life on, the symptoms may be primarily an increasing sense of confusion and/or memory impairment, with progressive difficulty in completing tasks and getting or remaining organized. Since there are numerous other things that can produce these patterns, careful evaluation of them by way of exclusion is absolutely essential.
Rather than a disorder as it has been previously considered, ADD should be renamed Thought Processing Difference (TPD) and considered a variation of normal brain structure whose differences sometimes do not fit well into the highly integrated and rigidly defined and controlled educational and societal structure in the U.S. In other words, it appears as an abnormality primarily because of the narrow and rigid design of education options, workplaces, jobs, and society.
The good news is that, regardless of age, medications can be used to give the patient full access to and control over all his or her inborn intellectual ability, perhaps for the first time in the patient’s life. This should be the only goal of any treatment program.
(Third in a series)
Psychotherapy as a method of treatment has been a failure, as one would expect with any purely neurological condition. A physically based problem cannot be “talked out.” The only globally effective treatment is with medications of the selectively stimulating type, such as Dexedrine, Desoxyn, Adderall, Ritalin, Cylert, Adipex-P, Pondimin, Ionamin, Tenuate, Zantryl, and others. Many of the antidepressants, such as Prozac, Paxil, Zoloft, Wellbutrin, Norpramine, Pamelor, Desyrel, and Tofranil, while usually failing to allow the patient full use and control of his or her inborn intellectual capacity, may be added to the selective stimulants to strengthen or broaden their effects.
It should be strongly emphasized that treatment with antidepressants is NOT to imply that the patient is depressed. In this instance, antidepressants are often used to enhance the control of the patient’s symptoms, rather than as treatment of primary depression.
Some other medications useful under certain circumstances include Inderal, Catapres, Klonopin, Buspar, and lithium.
However, proper medication alone may produce disappointing results in many patients. These persons require education and behavioral management training to learn how to use their new- found abilities and how to modify adverse behaviors developed because of the ADD. The form and duration of this training will vary from one person to the next.
Likewise, the ADD may have allowed the patient to make poor life- decisions, resulting in a tangled personal life. Counseling may be necessary to aid in straightening out these difficulties. The gratifying aspect of this is that, with proper medication control, the ADD patient can get far more value out of the counseling in a minimum of time, usually a new and gratifying experience for the patient.
Properly medicated with retraining when necessary, these individuals integrate very well into the societal and business structure of the nation in all respects, becoming very well focused, logical, directed, task-oriented persons able to direct, for the first time in their lives, their superior, inborn intellect to any task at hand in whatever environment they choose. On proper medication, they make better, more consistent, more reliable, more creative, less accident-prone employees; and more conversational, understanding, tolerant, forgiving, lovable, less impulsive friends and family members.
Broader awareness of the true scope of manifestations of the ADD/ADHD brain structure on the part of patients, families, friends, and our society, including its uniqueness, strengths, and benefits as well as its difficulties, is the cornerstone of treatment.
If we then persevere, with the belief and determination that all the difficulties we observe are controllable by the proper medication or medications, fully dosed in the most effective manner, it is often surprising how fully controllable all the manifestations of the condition are. These include not only attention span, focus, impulsivity and hyperactivity, but also organization, messiness, laziness, daydreaming, task completion, awkward interpersonal relationships, hand- eye coordination problems, auditory perception problems, learning disabilities and dyslexias, and poor memory.
Since ADD/ADHD patients often have an increased incidence of other diseases, such as allergies, asthma, migraine headaches, some eating disorders, digestive difficulties (e.g., colitis), Obsessive Compulsive Disorder, Bipolar Disorder (previously called Manic Depressive Disorder), tics and other movement disorders (such as Tourette’s Syndrome), phobias, and panic attacks, it is surprising how many of these conditions are more easily controlled, if the ADD/ADHD is properly treated.
Persons with ADD are considered to be covered under the provisions of the Americans with Disabilities Act (ADA), which went into effect in the summer of 1992.
(Fourth in a series)
I view this with mixed emotions, since I really consider that ADD/ADHD is a different type of brain structure with a different type of thought processing rather than a “disease” or an abnormality. I personally dislike further progression with the condition in the “disease” direction. I am glad that persons with the condition will have some formal recognition allowing for the appropriate treatment permitting patients full control of all of their inborn intellectual ability.
Unfortunately, many insurance companies selling life and health policies still do not understand the most current opinions about the condition, and deny or rate (charge more for) policies of individuals with this diagnosis. With respect to insurance, properly medicated, these patients constitute a better life and health insurance risk than without, and should neither be denied nor charged more for life or health insurance. Insurance companies, and now employers, often discriminate against people with ADD because of its long-held presumption as a psychiatric illness. This is now felt by many working in the field of ADD as completely inappropriate and is, instead, a neurological disorder.
For our patients, we have a special form letter for you to send to the company, should your insurance company or employer classify this as a psychiatric disease or attempt to limit benefits for office visits, laboratory expense, or medication on this basis. This is both for informational purposes, and to assist the patient in appealing any adverse action by an employer or an insurance company. Often, this alone is sufficient in obtaining a favorable response.
Some of the medications were used in the past for appetite control in a weight loss program and, therefore, insurance companies often inappropriately assume that this is their current use. The same applies to some of the antidepressants employed, not for the treatment of depression, but for the enhancement of benefits of the primary medication, or as a primary medication themselves. Again, this should be adequately covered in our special form letter.
As we consider whether to treat ADD with medications, we must keep in mind the goal of treatment: to deliver to the patient full access to and control over his or her inborn intellectual abilities. It should be pointed out that no medication, or any other treatment for that matter, will provide some brain capacity or ability that doesn’t already exist. We are unable to make a person more intelligent, though with full access and control of the brain’s full inborn abilities, it may seem as though the patient’s intelligence increases dramatically.
In spite of the fact I believe up to one third of the population has the ADD brain structure, I do not believe everyone with it must be on medication. With ADD more than any other condition, we must individualize the treatment to the patient. By this I mean, we must look at the person, assess the particular symptoms of ADD manifested in that person’s life at the current stage of that person’s life, and assess how those symptoms interfere with that person’s ability to perform in all aspects of his or her life.
For a time, we preached that everyone “outgrew” ADD. Of course, that was when we still considered it the result of “brain damage.” At that time, we even called it by several names suggesting damage: Minimal Brain Damage, Minimal Brain Dysfunction, and Minimal Brain Injury, to name a few. Currently, the prevailing opinion is that most people outgrow it. In my opinion, no one ever “outgrows” ADD. That would be like saying you “outgrew” your brain. Without question it changes, often dramatically, through the years. For example, the tendency for the hyperactivity, if present, to be minimal in adulthood, led to the belief ADD was outgrown. Later in life, memory loss can occur. Fortunately this type of memory loss is usually not severe, though if severe, it can be mistakenly confused with Alzheimer’s Disease.
(Fifth in a series) In the last issue, I mentioned the memory loss that can be a symptom of ADD in later life, though apparent memory loss may be seen in younger patients, also. This appears to be the result of distractibility, possibly increasing with age, rather than a true failure to store the information. However, to the patient or those around him, the result can be the same: the apparent failure ever to store the memory in the first place.
Any memory loss of significance should be evaluated, and the more severe ones deserve prompt and thorough consideration. Of course, the evaluation of a person for memory loss must be done cautiously and thoroughly, since memory loss may be the result of many other disease conditions, none of which should be overlooked. It should be strongly emphasized that true Alzheimer’s Disease will not respond to treatment for ADD.
Is ADD Really An Abnormality?
In my opinion, the ADD brain structure is not truly an abnormality. In fact, I believe a very good case can be made that it is not only normal, though in the minority, but may well be a superior brain structure. However, the talents of the person with the ADD brain structure are not those rewarded by our society at its current stage of development. In other words, the problems of the person with ADD are caused as much by the way we have our society, educational system, and business methods organized as by other factors more directly related to the ADD itself. I fully realize that these are not concepts generally shared by most other professionals. I have not always felt about ADD as I now do, but twenty years of experience treating ADD in all ages under a variety of conditions have lead me to my current beliefs.
A superior brain structure? A review of some of the things we know about the ADD brain structure and performance will demonstrate this possibility.
The average I.Q. of the person with ADD is higher than that of the average person in society. This is not to imply that all persons with ADD are more intelligent, but simply that the average I.Q. is greater.
The person with ADD has a greater ability to think creatively. This refers not only to creativity in the fine arts sense, though a person may have such a musical or painting talent, but to the ability to problem solve, create, or invent.
The person with the ADD brain structure has an increased sensory awareness. This stems not only from a heightened sensitivity of the senses, but also from the increased intrusion of those sensations into the conscious awareness of the person. In other words, the person sees, feels, hears, tastes, and smells more, and these sensations are more likely to distract the person.
Finally, the higher one goes on the I.Q. scale, the greater the percentage of ADD one finds. From an I.Q. of about 160 and above, virtually everyone has ADD. Now, if that is “brain damage,” as was previously felt, we should all be so damaged! Certainly it is not brain damage, and the sooner we acknowledge this, the sooner we will be able to take a more appropriate approach to ADD.
I encourage patients and their parents or families to view brain function in several unorthodox ways, not because that is the true way brains work, but because they effectively illustrate what we observe about brain function.
One is the Channel Method. There are two possible channels of function in the brain: Channel A and Channel B.
Everyone in the world is born with a Channel A in his or her brain. This is the average channel and the only one which the majority of people have, those with the average brain structure.
About one-third of the population also has a Channel B in the brain and we refer to these individuals as having ADD. The people with ADD use Channel B because it is the only channel they can get to work very well. They have the “wiring” for Channel A, but they cannot get it to work very well for themselves for very long.
Thought processing in the Channel A mode is very linear, or mono- dimensional, and driven by time, priorities, task, and a desire for completion. It is as though the person were on a rail going all the way to the end, finishing the task, turning around coming back down the rail, finishing the task, and so on, back and forth in an orderly fashion.
Thought processing in the Channel B mode is very three-dimensional. It is not only fore and aft, but up, down, side to side, and diagonally, broadly ranging from horizon to horizon, and the floor to the stratosphere.
(Sixth in a series)
As I mentioned in last month’s article, one of the models I suggest people use in thinking of ADD is the Channel Model with two possible channels of thought processing, Channel A and Channel B.
The Channel A mode of thought processing is very linear, or mono- dimensonal, orderly, sequential, time-based, and driven by time, priorities, task, and a desire for completion. The Channel A mode of thought processing is the one that every human being has.
The person with the ADD brain structure or function has, in addition to the Channel A, a Channel B type of thought processing, which is very three-dimensional and broadly ranging from horizon to horizon, and from the floor to the stratosphere, so to speak. Though the person with ADD has the “wiring” for the Channel A type of thought processing, he or she can’t use this channel effectively for very long at a time. Instead he or she uses the Channel B mode of thought processing, because that is the only one that the ADDer can get to work very well. The only way the ADDer can get the Channel A to work very well is to have a very high degree of external stimulation.
Though the actual mechanism by which this occurs in the brain remains unclear, it appears with exercise or other form of high intensity of external stimulation, that the body pours out adrenalin, the most potent stimulant in the body. This adrenalin, in turn, causes an increase in the circulating endorphins. Endorphins are sometimes referred to as the body’s own morphine. However, endorphins are far more complex than that and do many other beneficial things for us than help with pain control. Unfortunately, once formed, they are very short-lived compounds, lasting only sixty to ninety minutes in the body before breaking down. It is my belief that inadequate levels of the endorphins are responsible for many of the difficulties persons with ADD suffer. When the endorphins are stimulated, the ADD patient can function very well in the Channel A mode for a short period of time.
A way this may be illustrated in children would be with high physicial activity or an activity that is intensely stimulating, such as a movie of the Indiana Jones variety or a Nintendo game. In adults it might be manifested by thrill seeking behavior. or cramming the night before the exam.
For example, a person crams all night before the exam, because prior to that there isn’t enough stimulation for that person to get much out of the study, since he or she is very easily distracted when in the Channel B mode, finding it difficult, if not impossible to remain focused on the text long enough to absorb an appropriate amount of material. However, with the fear of failing the test, and possibly the semester, suddenly upon him, the person is flush with endorphins and finds concentrating, reading, and memorizing much easier than at any other time, in the semester. Since most of the population has only a Channel A in the brain, there is not a corresponding dual mode function in the average brain.
The goal of treatment is to provide the patient full access to and control over his or her inborn intellectual abilities.
Medications do not simply bump the patient out of the Channel B mode into the Channel A mode, shutting off the Channel B. Instead, medications open both channels simultaneously for the patient to use whichever of the combined features are best suited to the task at hand. Since the average brain has no Channel B to be opened, this appears to be another superior quality of the ADD brain structure and functional capacity.
Why The Medication Confusion?
Unfortunately, the use and benefits of medications are widely misunderstood by patients, parents, educators, psychologists, and physicians. Though these misunderstandings are rather pervasive, they never seem to inhibit the holders from expressing opinions. Of course, the same applies to the ADD condition itself: much mis-information prevails.
Medication does not “cure” anything, nor does it make any permanent changes or corrections. To get the benefits of medication for a lifetime, the medication must be taken for a lifetime. On the other hand, a person with ADD may not necessarily need the benefits of medication at all times throughout life. This is very different from one patient to the next and may change throughout life. We must look at the person, the particular symptoms ADD produces at this time of his or her life, and what that person needs to do.
(Seventh in a series)
If the person with ADD has bothersome symptoms that interfere with what that person must do, either in work, social, or personal life, then the use of medication should be considered. No longer must the person with the ADD brain structure struggle with the bothersome aspects of the condition.
However, the struggle can generally be abated only with medication of one sort or another. Many different types of medications have been tried over the years with variable success. Consistently, the amphetamines and their relatives have produced to best global control of ADD symptoms in the greatest number of people. By “global control,” I mean the greatest control of the largest number of the symptoms of ADD. This is certainly not to imply that other medications or treatment methods have not produced very beneficial results in certain patients. Anyone who would make such a claim is either inexperienced or does not understand the full spectrum of presentations of ADD and related disorders.
Effective medication remains the foundation of proper ADD symptom control for the large majority of patients. The term, “effective medication” is important, because we have most commonly under-medicated ADD patients in the past. By this, I mean we have paid primary attention to the very disruptive child in the classroom who is having trouble with academics, but who seems to be under-using his or her inborn intellectual ability. We medicate until the child is able to sit still ceasing the disruption and pay attention and contribute in class. We are also gratified that the child’s grades go from D’s and F’s to B’s and C’s. Everyone involved sighs a great sigh of relief. When the physician asks the teacher or parents how things are going, the response is, “Great!” Then everyone involved pats one another on the back, congratulating each other on a job well-done.
Aren’t excellent results enough?
Why should we not be satisfied with “excellent” results? We are asking the wrong question. Implicit in the way we are asking this question is the understanding that the results are “excellent” relative to the way things have been up to that point. Instead, we should be asking, “But are the results
excellent' compared to what that patient is capable of being?" If we cannot answer that affirmatively, we must consider that truly magnificent results may be possible. When I readjusted my own thinking on this issue, to my amazement, I did find that some patients were, indeed, capable of magnificent results. I truly believe we as physicians have failed to offer many of our patients their best. In order to offer each patient his or her best, though, we must have, not only the perspective of the patient, but that of all people around the patient, teachers, family members, especially parents, spouses, friends, and working associates, where appropriate. Getting the very best for the patient, however, often requires more visits to the physician and small medication changes, often with the addition of a second or third medication. Understandably, some patients or parents will not be interested in the difference between excellent and magnificent, feeling that the extra medication required may not be worth the expense. That is fine, in my opinion. However, the patient or parent deserves, at least the benefit of knowing what that difference is and what it takes to achieve it. Again, we must remind ourselves that the goal in treatment is to grant full access to and control over the patient's inborn intellectual ability. Treat normal conditions? In medicine, physicians are trained to treat only disease processes or injuries. We pride ourselves that that is exactly what we do. This is simply not the case. Take for example, all the cosmetic surgery that is done in our nation. While some may say they simply do not subscribe to the notion of having surgery done for purely cosmetic reasons, we can certainly find simpler examples. The prescription and wearing of glasses is a well-suited analogy. Most people wearing glasses have no true disease process in their eyes. Their eyes, simply by reason of genetics, do not precisely focus the visual image on the retina. Therefore, they must go through their entire lives without the most precise vision of which their brains are capable of interpreting. No matter how hard those patients try, they can never bring the image into best focus. They will never know what a properly focused image is. I choose to wear glasses to allow me to take advantage of all my inborn ability allows. Without them, I can never present my brain with the properly focused image which it is capable of interpreting. I choose to use this aid the remainder of my life, because I wish the benefit for the remainder of my life. This is a very similar situation to that of the person with the ADD brain structure. He or she has a brain capable of much more, but it requires medication to allow them to employ that capability. (Eighth in a series) Over the years, a great many treatment approaches have been tried, with some being substantially more effective than others. In my practice, I have striven to find the most effective ways of presenting the patient with complete access to and control over his or her full inborn intellectual ability. I have seen the effects of most of the things, both of pharmaceutical and non-pharmaceutical that have been reported to help. Besides medications, these include herbal remedies, dietary additions and eliminations, vitamin and mineral supplements, biofeedback, counseling, and acupuncture. Some are clearly ineffective. Others may help many people to a minor degree. Rarely do any of them produce very good or excellent results. By "excellent results," I refer to the treatment's effect on all the patient's manifestations of the ADD: globally effective. Unfortunately, we often focus on one symptom or set of manifestations of the ADD, such as hyperactivity, to the exclusion of the others. Therefore, we may be very gratified with the treatment's results on this single aspect, ignoring the areas of the patient's brain function which may not be benefited sufficiently. Who needs to be treated? My own belief is that a third of our population has the ADD brain structure. However, that does not mean I believe every patient with ADD should be on medication. It is very important to look at the person carefully assessing the particular manifestations of the ADD in that person at the current stage of life and how those manifestations or symptoms interfere with what he or she needs to do. If the ADD symptoms significantly interfere with his or her performance in professional, scholastic, social, or personal life making any or all of these areas a struggle, then the person deserves to have the option of the most effective treatment. If the person's situation changes, or the ADD manifestations change, the treatment can be altered or stopped. Patients often ask me if they will need to take medication all their lives. I reply that they need to take medication only as long as they need the benefits of the medication. If that is a lifelong need, then they should consider using the medications without stopping. Of course, treating or not treating is strictly optional. Certainly, most of the persons with ADD throughout history have had no treatment whatsoever. However, that does not mean those people did not have difficult, perhaps severe, struggles throughout life with some of the manifestations of their ADD. The most effective medications The most globally effective treatment for the vast majority of patients with ADD are the medications referred to as the psychostimulants, often simply referred to as stimulants. The primary medications in this group are Dexedrine, Adderall, Desoxyn, Ritalin, and Cylert. Other very effective medications that are less often used are Adipex-P, Zantryl, Pondimin, Ionamin, Tenuate, Didrex, and others. While many of the antidepressants are beneficial in the overall treatment of ADD, they are usually mediocre as the primary medication. They usually function better when added to one of the stimulants. Medicating in the treatment of ADD is, at the same time, one of the most simple and one of the most difficult tasks we face. The concept is very simple: to grant the patient complete access to and control over his or her full intellectual ability. However, each patient is very different, sometimes extremely so, in response to medications. A given patient may respond rather dramatically differently to one drug than to another, which is a chemical close cousin of the first. In medicating patients with ADD it seems that we experience a greater incidence of paradoxical response to medications. This means that a drug has a rather different, or perhaps opposite, effect than that which is usually found. Physicians treating ADD, and patients being treated for it, need to keep this ever in mind. I encourage patients to realize that, with diligence and determination, the chances of achieving a very beneficial result are very great. However, with some patients this is a laborious, time-consuming process of trying various medications, dealing with side-effects, and using combinations of medications. Unfortunately, there is no way of predicting a given patient's response in advance. The important thing the patient or parent can do in this process is make careful observations of the effects of the medications throughout each day, both during and after the medication's effective period. (Ninth in a series) How I Medicate ADD (Part 1) My initial drug of choice is Dexedrine. This is manufactured in capsule form in 5, 10, and 15 mg. strengths. The manufacturer, Smith Kline Beecham, has trademarked the name "Dexedrine Spansule" for its 12-hour timed-release capsule. It is also manufactured as Dexedrine Tablets, a 5 mg. tablet, lasting four hours. The generic name of the drug is dextro- amphetamine sulfate; and other manufacturers, such as Richwood Pharmaceutical Company, Inc., produce 5 and 10 mg. tablet forms, but there are no other manufacturers of a sustained-release form. Dexedrine Spansules are my first medication of choice for most ADD patients for several reasons: First, it is among the most successful medications in producing what I refer to as "global control." By this, I mean it is one of the most effective drugs for relieving all of the bothersome symptoms of ADD. Second, it is the least expensive of the most effective medications on the market. When contemplating taking a medication for several years, a difference of several hundred dollars a year may make a sizable difference in the expense of treatment. Third, it produces a rapid effect, and so its benefits can be fairly quickly assessed. The advantage of the rather predictable 12-hour release mechanism is to avoid extra doses throughout the day, either at school or at work. In a busy day it is often difficult to get in additional doses of medications, such as Ritalin, which require dosing every 3-4 hours for maximum effectiveness. About 15-20% of patients will not need a second dose of Dexedrine at the end of the 12-hour period. They simply notice that the benefit of the medication fades away, with a gradual return of the ADD symptoms. The remaining 85% of patients, however, will notice a rather abrupt drop-off in the effect of medication, with a rapid return of the ADD symptoms. In fact, patients often experience a rebound of the ADD symptoms, which are actually amplified above the pre-medication level. I refer to this as "filtered rebound." By this, I mean that even though the medication's effectiveness has subsided, there is still a small amount of the medication remaining in the blood stream which can modify the symptoms of ADD as they return. Therefore, the symptoms in this rebound period may be somewhat different from the symptoms in the pre-medication state, and are frequently amplified over the pre-medication state. This "filtered rebound" lasts anywhere from 2-8 hours, but is more likely to be! toward the 8-hour end of this range. Because of the rebound effect, adults and children may have difficulty going to sleep. There are several ways this can be managed, but it frequently does not indicate too much medication, as is often assumed. What it actually represents is too little medication at the wrong time. Most often, by adding some of the 4-hour tablet form of Dexedrine at approximately 11-11 1/2 hours after the morning dose of the spansule or capsule form is given, the patient can go to sleep quite readily at the end of this period. I refer to this as the "sleep window." The "sleep window" lasts from 30 minutes prior to expected wear-off of the medication to about 60 minutes after the expected wear-off. If the person is able to get to sleep during this period of time, the rebound still occurs, but usually does not waken the patient, nor does it usually prevent a person from getting back to sleep, even if that person must get up during the night. On the other hand, failure to get to sleep within the 90-minute sleep window places the patient into the rebound period. Once this rebound has begun, it frequently keeps the patient awake for several hours. There are several ways this can be managed. One of the best on a short term basis is to use a minidose of the tablet form of Dexedrine (2.5-7.5 mgs.), which is just enough to muffle the rebound effect, but not enough to keep the person awake. If this is needed very often, other medication approaches are usually better. I normally begin with up to one-tenth of a milligram per pound of bodyweight in the Spansule form, with a maximum starting dose of 10 mgs. That is to say that a person who weighs 50 pounds would be started on 5 mgs. Someone who weighs 100 pounds would be started on 10 mgs. Someone who weighs 200 pounds would still be started on 10 mgs. I suggest the patient increase the dose by the starting amount at 4-7 days, in case side effects, such as headache, nausea, jitteriness, perspiration, or diarrhea, are not too bothersome. I check them again at two weeks to consider an increase. (Tenth in a series) How I Medicate ADD (Part 2) We must keep in mind that the goal of any treatment of ADD should be to deliver to the patient complete access to and control over all his or her inborn intellectual ability. It is important for the patient to take the medication every day, rather than just taking it on days when the patient feels the need. The reason for this is that a certain amount of physical adjustment to the medication is necessary. If the patient takes it daily for several days, that adaptation begins. If this is followed by a period of several days where no medication or a lower dose of medication is taken, that adaptation ceases and a de-adaptation begins. Therefore, the patient is riding a medication roller coaster, so to speak, never achieving the best result possible with the medication: never achieving "complete access to" nor full "control over" all the "inborn intellectual ability." As I previously mentioned, I customarily begin with Dexedrine in doses of 5-10 mgs. in the Spansule form. I expect that this will be a smaller dose than that to which the patient will respond most beneficially. If the patient is not having any bothersome side effects, I ask him or her to increase by 5-10 mgs. every 4-7 days. This allows the patients to adapt to any unpleasant physical effects, so that the medication can be increased to the levels where the brain functions at its best. The expected and ideal pattern for the Dexedrine Spansule is that the dose be taken early in the day. The blood level of the medication rises to the therapeutic level and remains uniform until the end of the 12- hour release period, when the medication is cleared out of the system and the blood level drops back to zero. Initially, on the smaller doses in the transition period, the dose of Dexedrine in the Spansule form may seem to "wear off" before the end of 12 hours. While there is some medication in the blood stream for the full 12 hours, the initial, most beneficial level may not hold. As the blood level drops off, in a pattern which may be noted beginning as early as 5-6 hours after the dose is taken, the person may have a return of the ADD symptoms in the "filtered rebound" pattern previously mentioned. As the dose is gradually increased in getting closer to the most suitable level for a particular patient, the duration of medication effect more closely approaches the designed 12-hour period. In some patients, regardless of the fact that the most suitable dose has been achieved, there is still a drop-off in the benefit toward the end of the medication period. This may be overcome by adding a small dose of the tablet (4-hour) form about 30-45 minutes before the return of the noticed ADD symptoms. This raises the blood level of the medication back up to the most beneficial level seen earlier in the dosage period. As I mentioned, the majority of patients will feel the drop-off of the medication effect at about 12 hours after the dose. If the return of the ADD symptoms, either in standard or "rebound" form, produces a problem for the patient or his or her family, an additional dose of Dexedrine may be added. This should be in the tablet form, and will extend the effective period of medication from 12 to 16 hours. Consideration of the "sleep window" should be kept in mind as this process is pursued. In fact, this is often a reason to add another tablet dose at the end of the Spansule dose. If a patient on the Spansules in the morning is having difficulty getting to sleep at night, this is most often due to the ADD rebound, meaning the patient has missed the sleep window. Adding the tablet dose at the end of the Spansule dose moves the sleep window more closely to the anticipated bedtime of the patient. Some would argue that beginning with the tablet form is the best way to determine the patient's actual needs and that transition to the Spansules could be done later. That is a very reasonable approach, except that, while the tablet form is readily absorbed and metabolized in a predictable fashion, the medication release and the blood level of the drug in the spansule form vary from patient to patient and the effect on a milligram for milligram basis may be significantly less. If this is the case, a new process of determining the patient's best dose must be undertaken, producing two such exercises instead of one. I prefer balancing patients on the form they will ultimately use, shortening the process and reducing patient frustration. (Eleventh in a series) How I Medicate ADD (Part 3) While the amount of amphetamine to properly and completely medicate ADD can be extremely variable from one patient to the next, there are no hard upper limits to the amount necessary, nor the number of milligrams per pound of body weight. Essentially, we start at a low dose and gradually move up, permitting the physical side-effects to subside, while we search for the dose necessary for the brain to function at its best. For the majority of patients, once the best dose has been determined, it will remain stable for months or years. However, for a few patients an adjustment, either up or down at 6-20 weeks, may be necessary, depending on the patient's response. ADD symptoms also fluctuate on a long-wave cycle of months to one or more years and may require adjustment up or down during these periods, as well. Another phenomenon occasionally noticed is what might be described as the spontaneous resetting of the brain's receptors. The receptors are areas on the brain cell where the drug attaches to exert its effect. If the receptors are very sensitive, not much medication is required. If the receptors are less sensitive, the dosage may be higher. For reasons not understood, the receptors can spontaneously change, necessitating a change in the dosing of the medication. Illustrating the variability of dosage from one person to the next, I currently have a man, weighing 250 lbs., well-controlled on a single 15mg spansule of Dexedrine each morning. By contrast, I have a woman, weighing approximately 145 lbs., who requires 90-105mg each morning. Each of these patients takes approximately 1/3 of that dose in the tablet (4-hour) form, to provide a full 16 hours of medication coverage. Each has found this to be an ideal dose. The most effective dose is that dose which controls the ADD symptoms, either completely or sufficiently to relieve the struggle the patient had in that particular area of life. A patient will usually ask, "How will I know when I have reached my best dose?" I reply that frequently we do not know what the best dose is until we find out what too much is. With that determined, the dose is reduced by 10-15 mgs., which usually places the patient at the best dose of that particular medication. Occasionally, when we reach the best dose, the patient will notice a sudden resolution of all of his or her struggles. This is usually very evident to the patient, and those around him. More commonly, we have to search for the best dose by actually pushing the amount until we get unpleasant side-effects that do not subside with continued use. When this occurs, we reduce the medication by 10-15mg and usually find that this is the best dose of Dexedrine for that particular patient. The patient's next question usually is, "How will I know whattoo much’ is?” I reassure the patient that I am not sure what the symptom of too much medication will be for him or her, but when that dose is reached, the patient will know it.
The effects of a little too much medication can be very different from one patient to the next. The most common effect is over-stimulation, producing a jittery, nervous, somewhat anxious feeling. Another effect of too much medication is a sense of internal pressure or stimulation that produces an edgy, impatient feeling and demeanor in the patient that is usually evident to him, as well as those around him.
Other symptoms may include insomnia (different from the insomnia of the ADD rebound discussed earlier); progressively more attention to smaller, more insignificant details not contributing to the overall goal of the project; picking at various things on the body, such as skin, hair, or nails, being unable to stop for any significant time; biting the lips or cheeks; clinching or grinding the teeth; or focusing on a particular task or activity with the inability to stop or to see that the activity is inappropriate. Sometimes the patient can recognize that it is inappropriate, but still cannot stop without feeling a progressive sense of internal discomfort until returning to the task.
Physiological manifestations may include a rapid heart beat persisting at more than 90 beats per minute, and blood pressure persisting at greater than a 30 point rise from the premedicated state, in both the systolic (upper number) and the diastolic (lower number). This elevation of pulse and blood pressure may increase with exercise and can limit both a patient’s exercise and heat tolerances. For this reason, we check patients at frequent intervals as we are exploring for the best dose. We urge patients to reduce their exercise and remain well hydrated during the adjustment period, especially during exercise. As a rule, the exercise and heat tolerance return to normal after a patient has had a stable pattern of medication for 6-8 weeks.
Occasionally, the best dose of a medication does not produce complete resolution of the patient’s ADD symptoms and requires a switch to another medication, or the addition of a second medication. My guiding consideration is that the patient has a chemical problem with a chemical solution. If we keep this goal clearly in mind, we can produce much better results for all patients. On the other hand, if we simply try a standard, cookbook approach, we will produce benefit for many, but many others will find it an extremely frustrating process with little reward.
For an occasional patient, the best medication, the best dose, or the best combination of medications, may take many months, possibly as long as a year. While this can be very frustrating for the patient, the payoff is a much better result that is more likely to remain throughout the ensuing years.
A common pattern of response as we increment up with each addition to the Dexedrine dose, is that there is an improvement for one to several days, followed by a drop in the benefit to a plateau, persisting as long as that dose is used. This usually indicates an inadequate dose. As we approach the patient’s optimum dose, the benefit with each upward increment is more likely to persist as long as that dose is continued, without a drop in the effect to a lower plateau.
The loss of appetite, which occurs in most patients initially, will return to near normal after a patient has been on a stable dose for 6-8 weeks. At that point, if a patient wishes to lose additional weight or increase weight, he can do so carrying out his resolve with sufficient consistency to produce the desired effect. This consistent and persistent behavior is not something the ADD person in the unmedicated state has good control over.
The over-focus on a particular task, mentioned earlier, may take two forms. One is that the patient may simply be dealing with greater and greater detail that is not helping to accomplish the overall task at hand. While the detail may be appropriate to be dealt with in other circumstances, it has to be looked at in the context of the primary goal. A second form is that more closely resembling true obsessive/compulsive disorder, where the patient understands that it is not producing benefit toward the overall goal, but simply cannot stop doing the particular activity without becoming progressively more uncomfortable, until he gives in and returns to it. Either of these things will be reduced or eliminated by simply decreasing the dose.
Any of the stimulant medications, as well as some others used for ADD, can unmask a tendency toward Tourette’s Syndrome (TS) or Bipolar disorder (BPD), previously known as Manic-Depressive Disorder. Since both TS and BPD occur more often in patients with ADD, we frequently must treat these comorbid conditions along with the ADD. The picking nails or skin, or lip-biting may represent the tics of TS. Manic symptoms may be precipitated by the medications, but if recognized early, can usually be managed simultaneously.
=============================================This is not intended as specific medical advice and is for general informational purposes only. It is not intended to serve as a replacement for consultation or evaluation by an appropriate physician.
Dr. Elliott is a family physician in the Dallas, Texas, area with over twenty years’ experience treating ADD in all ages.
(c) 1995, Paul T. Elliott, M.D., 600 University Village Center, Richardson, TX 75081, 214-234-0352; CompuServe: 71016,676; AOL: PTElliott; Internet: firstname.lastname@example.org. All rights reserved. Permission granted for reproduction unchanged and in its entirety for personal use only. All other uses require written permission. Uploaded by author. Ver. 950907
WHETHER TO USE ABUSABLE MEDICATIONS TO TREAT PATIENTS WITH A HISTORY OF ALCOHOL OR SUBSTANCE ABUSE
There is a very high incidence of ADD among patients with a history of alcohol or substance abuse. However, as you might imagine, there is a great reluctance by people on 12-step programs, and in other recovery programs to avoid any possibility of taking a medication that might produce an additional dependency, substituting one dependency for another. These concerns should not be taken lightly, since this was a common therapeutic misadventure in the past.
The substance abuser is often faced with a genuinely thorny dilemma. When he or she suspects that ADD may be an underlying contributor to the substance abuse or the difficulties of life previously experienced, the patient strongly desires to see those struggles relieved. Occasionally, they will even go through the diagnostic process and have the firm medical diagnosis of attention deficit disorder, though still be very reluctant to take any medication, much less one with a reputation of being “addictive.”
This is certainly understandable, particularly in light of the fact that 12-step and other programs emphasize “no foreign substances.”
Please do not misunderstand, I will not begin anyone on treatment for ADD with any of the abusable medications until they have been in successful recovery for at least 6 months. If they have a history of repeated recidivism, I often explain that their credibility is very low. If they are willing to begin a program of no-notice, random drug screens, where I call them and they report to my office, or an independent drug-screening facility, for a drug screen within 48 hours, I will consider treating them. Furthermore, I advise the patient that their credibility in my eyes is very fragile and easily destroyed, and that I will not continue treating someone who fails to remain clean and sober; anyone who fails to keep appointments; and anyone who gives me any reason to believe he or she is misusing the medication in any way.
I freely admit that this may not be “fair” to the patient, but I simply state that these are the only terms under which I will continue treating them. In my opinion, they must be capable of making a commitment and following through with reasonable consistency, when on appropriate medication. I understand all the arguments: too much expense, too much time, too much hassle, too judgmental, etc. Having “been the route,” I am not impressed. It is my obligation, as a physician, to avoid contributing to any further abusive behavior on the part of the patient. I have a legal responsibility to avoid this, as well.
If a patient is currently unwilling to maintain these contractual terms, I encourage them to give the idea of medication further consideration, returning, if and when, they find within themselves a willingness to make such a commitment.
I encourage people with a history of substance abuse to understand several things.
First, the medications such as Dexedrine, Adderall, Desoxyn, Ritalin, Cylert, Phentermine, etc., are abusable but are not “addictive,” that is to say habituating. Drugs, such as alcohol, nicotine, narcotics, the benzodiazepines, and the barbituates, are habituating (“addictive”), as well as being abusable.
Being habituating means that sudden cessation of the drug produces an extremely unpleasant, and often life-threatening, withdrawal syndrome. This results in patients seeking the drug to avoid the pain of withdrawal from the drug.
While many of the medications useful for ADD are abusable and may have a “street value,” meaning they can be purchased illegally, can be irresponsibly used to avoid dealing appropriately with the realities of living, and can be massively overdosed for a mind-altering, dysfunctional brain experience, there is no longer any such need for those things in the life of the properly diagnosed and medicated ADD patient. After all, most ADD patients have had sufficient struggles with what they perceive to be brain dysfunction that they only want to have full access to and control over their brain resources.
Second, properly medicated, the rate of recidivism for (return to) any substance abuse is markedly lower. Much of the substance abuse we see today is actually undiagnosed ADD patients who are self-medicating. Many, if not most, of the abusable drugs do help some ADD patients, occasionally very remarkably with their ADD symptoms. The hallucinogens are the only major exception. However, for a number of reasons, these illegitimate sources are poor choices. The results can be devastating, as we see on a daily basis in our society.
For those patients habituated to narcotics, alcohol, benzodiazepines (Valium and relatives), or barbiturates, I would urge an aggressive approach with a treatment program for that substance, a good support structure, and an on-going accountability system to stop the substance and develop the skills to avoid abusing again. With this success in place, the ADD, if present can and should be treated aggressively. This dual approach will produce the best longterm results, in my opinion, and will become the standard procedure for all substance abuse programs in the future.
=============================================This is not intended as specific medical advice and is for general informational purposes only. It is not intended to serve as a replacement for consultation or evaluation by an appropriate physician.
Dr. Elliott is a family physician in the Dallas, Texas, area with over twenty years’ experience treating ADD in all ages.
(c) 1995, Paul T. Elliott, M.D., 600 University Village Center, Richardson, TX 75081, 214-234-0352; CompuServe: 71016,676; AOL: PTElliott; Internet: email@example.com. All rights reserved. Permission granted for reproduction unchanged and in its entirety for personal use only. All other uses require written permission. Uploaded by author.
TO MEDICATE OR NOT TO MEDICATE?… THAT IS THE QUESTION
Once a person is diagnosed with ADD, the question arises whether medication is necessary. The dilemma of using or not using medications most often occurs the patient is a child. This is an understandable concern of parents and patients, as it is of physicians.
Many of the original concerns we had about using psychostimulants, the best category of medication for most patients, was the worry of possible growth retardation, as well as the possible increased incidences of cardiovascular disease and hypertension, perhaps years after the medications had been discontinued. As time has gone on, through experience and research, these have been set aside as serious considerations. We now recognize that the long term use of the medications appears to have no effect in any of these regards.
Several years ago a well-done research project was reported demonstrating that Ritalin, if it did cause a temporary slowing in growth rate of a child, could be continued and the child’s growth rate would accelerate to “catch up.” The ultimate stature of those children, on reaching adulthood, was what had been predicted from studies of their families.
Parents also express concern about the possibility of other, unsuspected effects that may show up later in life, after we have medicated and studied many more patients. Every physician shares this concern with parents and is cognizant of these possible risks. However, as previously mentioned, the concerns of a theoretical nature have not been borne out, nor has any other unanticipated serious reaction shown up.
A parent will sometimes ask, “But is there any possibility of something as yet undetermined?” The proper response, in a scientific sense, to any question that contains the word “possibility” must always be “Yes.” What the parent really wishes to know is, “What is the likelihood of this occurring?” As pointed out previously, the likelihood is extremely small.
However, there is a far more important consideration: The effects of NOT treating ADD. It is absolutely vital that we address the possible long- term effects on the patient of NOT using medications to treat the ADD. With children this is particular concern. Inadequate education, poor socialization, social ostracism, poor self-esteem, the 33% likelihood of alcohol or drug abuse, and substantially increased likelihood of slipping into the “counter culture” movement are all very substantial, very significant, very well-known, potentially devastating, and very long-term, potentially lifelong!
When compared side by side, these two sets of risks leave us with essentially no question as to which is the wiser choice. When parents express a grave concern and fail to accept medication for their children, I urge them to consider carefully the risks of the failure to medicate. Unfortunately, most of the time the parent has never thought in these terms and finds it refreshing to see that there is a very medically justifiable, compelling reason for the use of psychostimulants to treat ADD.
As with any other treatment, we do not have to make a final decision as to whether to keep on the medication long-term, nor whether to take it every day vs. leaving it off during week-ends, holidays, and summer vacations. While I personally strongly favor not leaving the medications off, a decision does not need to be made in that respect initially. I urge parents to consider simply trying the medication, making a reasonable attempt to find the best dose of the best medication for the patient, deciding at a later time whether to stop it intermittently, or to continue it on a daily basis.
There is some other good news: It seems that some patients, when medicated early (beginning at 5-7 years of age) and continued for as long as appears necessary, seem to have better control of their ADD symptoms for the remainder of their lives. The cause is uncertain. Some professionals believe that medication, used early during the formative years, allows the patient to develop the skills and habits which carry forward throughout life. Others believe that medication, used on the growing brain, actually allows the brain to develop in a less “ADD” manner. It remains to be seen whether this observation is “real,” and if so, what is the cause.
What about Adults?
Adults, of course, face a different dilemma. They must make the decision about the use of medication for themselves. On first glimpse, this may seem to be an easy decision to make. ADD is, what I call, a “24/7/forever” condition. By this I mean that one does not “outgorw” ADD. It is with the patient for a lifetime, though it does change throughout life. Furthermore, it is present, affecting one’s life 24 hours a day, 7 days a week.
Each person’s situation must be individualized. Even though I feel about one-third of our population has ADD, I do not feel that each person must take medication. We must look at the patient, evaluate the particular symptoms of ADD he or she has at this particular time of life, and consider what he or she needs to be doing. If the patient is having a struggle in academic/professional life, social life, or personal life, that patient deserves the option of medication.
At different stages in life, the patient may feel that his or her combination of ADD symptoms does not conflict or interfere with what he or she needs to do. However, that patient’s employer or family may not agree. Therefore, not infrequently, that patient must seek the opinion of those important people in life, before deciding whether to take medication. Occasionally, those around the patient may feel more strongly that medication is necessary than the patient. Where the difference of opinion persists, the patient may need to take a trial of medication, to settle the issue.
On the other hand, when an adult with ADD has had great struggles in various aspects of life, the decision to take medication may be much easier. Will the patient need to take medications for a lifetime? Only if the patient needs the benefits of medication for a lifetime. Since ADD and the patient’s circumstances each change throughout life, a patient may need medication for a time, followed by a period without it. When the patient is taking medication, though, I do recommend this be done everyday at a consistent dose to get the best results. There are no hard and fast rules.
I usually tell adult ADD patients that life is enough of a struggle by itself. You certainly don’t have to add the struggles of ADD to that, since we can control the ADD symptoms.
============================================= This is not intended as specific medical advice and is for general informational purposes only. It is not intended to serve as a replacement for consultation or evaluation by an appropriate physician.
Dr. Elliott is a family physician in the Dallas, Texas, area with over twenty years’ experience treating ADD in all ages.
(c) 1995, Paul T. Elliott, M.D., 600 University Village Center, Richardson, TX 75081, 214-234-0352; CompuServe: 71016,676; AOL: PTElliott; Internet: firstname.lastname@example.org. All rights reserved. Permission granted for reproduction unchanged and in its entirety for personal use only. All other uses require written permission. Uploaded by author.Vers. 950809fc=============================================