Joe Smith had been a successful high school student with a GPA of 3.6. He had performed well on the varsity wrestling team and participated eagerly in student government. Lastly, he scored well on the SAT's and was accepted into a well known eastern university. He had accomplished all this even though he had ADHD. How was he able to carry this out? Joe had been on Ritalin since the fourth grade. His response to the medication had been instantaneous and complete. He had no associated learning disability and was blessed with a superior IQ. This had been an ideal therapeutic situation. He was in the fortunate 30% of ADHD patients who have no concomitant educational handicap.
Upon leaving for college our evaluation substantiated the fact that although he was 19-years-old stimulant medication was still needed to control his symptoms. He was sent off with medication and the admonition that Ritalin therapy needed to be continued. A physician in the area of the school was referred to him in order to continue the care of his ADHD.
Two years later Joe's mother frantically phoned me at the office. Would I be willing to see her son again? He had dropped out of school and had just arrived home after spending the last year and a half "bumming around the country".
A few days later Joe appeared at my office. He was dejected, embarrassed and wasted. We exchanged a short welcoming conversation when he plunged into a sad tale of intellectual decay, despair and confusion.
After arriving to the university he quickly adapted to the work load and did his usual competent scholastic productivity. When the Ritalin supply ran low, instead of seeking care from my referral, he opted for the student health service. It was more convenient and the price was right. Here the caregiver convinced him that "adults don't need Ritalin. In fact, it doesn't work on adult patients".
Joe listened, and agreed that her experience must be right. He didn't want to take the medication anymore and her advice with his desire to stop led him to cease the therapy.
Very quickly Joe's scholastic performance diminished and the impulse control disappeared. Within only a few months he had dropped out of school. Joe resorted to self medicating himself with street drugs. According to his own history the next 1 1/2 years were a blur. He wandered along the eastern seaboard, homeless, disillusioned, and filled with despair. By his own admission he would not or could not correlate the cessation of medication with the collapse of his academic career. Worse of all was the thought of facing his family, having failed in college. It took time, but finally the realization of embarrassment upon returning home a failure was better than this miserable existence. He trekked across the country to present himself to the family.
Relating this story Joe was a depressed and defeated young man. He asked if it would be possible to try the medication again. Ritalin therapy was immediately resumed. Following some counseling and a short course of anti-depressants to augment the Ritalin, Joe enrolled in a local university. Four years later he graduated from college with honors, and today is doing well, on stimulant medication.
This story underlines the following facts and misconceptions about ADHD and stimulant therapy:
With today's plethora of road rage, immature behaviors and unprovoked violence could some of these acts not be the expression of adult ADHD patients who are undiagnosed and untreated.
Joe's history is a perfect example of the tendency for this type of patient to unknowingly self treat with street drugs. Frequently pseudo experts have been heard to state that the treatment of ADHD patients with stimulants leads to street drug usage. However, a patient who uses appropriate therapy would have no need to explore the dangerous world of self medication. It always follows in the wake of discontinuance of a carefully monitored prescription medication program.
Joe was fortunate. He pulled himself out of a downward spiral that could have led to self destruction. Most adults with ADHD do not get into this type of situation. The majority exhibit some of the five key symptoms listed above.
Due to lack of insight on the part of the patient or lack of experience on the part of the therapist adults with these hallmark symptoms are not offered pharmacological help. Instead they are subject to prolonged counseling which alone, without medication, cannot be successful in true ADHD of primary or central origin. It is true that medication alone, without directive counseling, in many adults does not yield maximum results.
Adult ADHD is a real neuro medical entity, as is Tourettes Syndrome or epilepsy. Surely there is no reader out there who would agree that counseling would be the primary source of therapy for seizure disorders. The problem rests in an accurate diagnosis. The symptoms of adult ADHD can appear as psychiatric conditions or behavioral disorders that would not be helped by stimulant medication therapy. One must be sure that the prescribing physician has carefully and completely evaluated the patient before long term Ritalin or amphetamine therapy is started. This frequently necessitates the consultation of a psychologist experienced in managing adult ADHD patients if the physician is not a psychiatrist.
If you have a successful adolescent ADHD patient on medication remember, when he or she leaves home at least 50% of these patients may need the therapy into adult life. Warn them about the myth exemplified with their case. Alert your offspring to the misinformation one is subjected to by the internet and news media. Advise them to follow the direction of an experienced physician or psychologist before ceasing the use of medication. Joe was lucky. Not all patients with untreated adult ADHD are so fortunate.