Questioning ADHD red flags

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief

Dr. Manuel Mota-Castillo’s description of “Five red flags that rule out ADHD in children” (Pearls, April) is remarkably at variance with current research and clinical practice in the diagnosis and treatment of children with attention-deficit/hyperactivity disorder.

Mood disorders are well-known comorbidities of ADHD and, unfortunately, numerous young adults with a childhood history of ADHD do “get high on” and become addicted to cocaine and other street drugs. Further, impairing, problematic symptoms often are not noted until the second grade or later in the elementary school years, especially in children who have the inattentive type of ADHD. Absence of a history of symptoms in kindergarten certainly does not contradict a diagnosis of ADHD.

The Multimodal Treatment Study for ADHD, or MTA study, among others, found that about 40% of carefully diagnosed children with ADHD also had oppositional-defiant disorder (ODD), and that 10% to 20% had conduct disorder (CD). These are common ADHD comorbidities.

Finally, a child’s response to initial medication treatment never confirms nor refutes this diagnosis. This point has been emphasized in every major publication in our field for a decade.

Corydon G. Clark, MD
Medical Director,
ADD Clinic Inc Las Vegas, Nev.

I have several problems with Dr. Mota-Castillo’s comments:

First, moodiness can be a part of ADHD. Also, some unfortunate children have ADHD with comorbid bipolar or mood disorders.

Second, depending on the demands of the child, the environment, and the response to the child’s behavior (among other things), ADHD can appear to be intermittent.

Third, ADHD symptoms are present in kindergarten. Some kids do not get diagnosed that early, especially those with ADHD, inattentive type, but they still meet the criteria for ADHD.

Fourth, comorbidity is usually the rule with ADHD. Fifth, response to a stimulant does not make a diagnosis of ADHD. I do not have ADHD, but I would likely “think better” on a stimulant!

Finally, a follow-up appointment at 2 weeks does not confirm a diagnosis of ADHD. The diagnosis is made only after a thorough review of the child's history, a review of the pediatric record, a physical examination by the pediatrician, a clinical interview with the parents or primary caregiver, an interview and examination of the child, a review of school records, and input from current and previous teachers as well as all others who provide care for the child in structured and unstructured settings.

Lori W. Bekenstein, MD
Child and Adolescent Psychiatrist,
Richmond, Va

Dr. Mota-Castillo responds:

Dr. Clark’s letter is not surprising; his statements echo other ADHD experts and the ADHD clinics around the country. Let me clarify several misconceptions around this illness, however.

I don’t blame people who follow dictates from the MTA study, considering the high academic level of the researchers involved. Still, their findings are not immune to further investigation and clinical testing. In fact, other prominent investigators such as Charles Huffine, MD, and Andres Pumariega, MD, have requested the deletion of the CD diagnosis from DSM-IV. Several others have questioned ODD as a valid entity.

I am not a famous scholar from a prestigious school, but I can point to hundreds of children previously diagnosed with ODD who became “non-oppositional” after treatment for their real conditions—either a mood, anxiety, or psychotic disorder.

Other prominent researchers, including Kay Redfield-Jamison, have refuted the assumption that all children diagnosed historically with ADHD were correctly differentiated from other disorders that may display some similar symptoms. Jamison recently cited a tragic patient outcome: A young boy was misdiagnosed with ADHD, placed on stimulants, and ultimately hanged himself.

Most studies on ADHD, including the MTA, are statistically irrelevant because they are based on samples that include many wrongly diagnosed children. I can prove that the combination of ADHD, CD, and ODD really means that these diagnoses are erroneous. The same rationale also explains why statistics about the alleged lack of diagnostic relevance of medication trials are unreliable: Many patients who “failed” did not really have ADHD.

Major published papers do not carry an imprimatur. Remember that several decades ago, experts said that because of lack of ego development, children could not get depressed. Also remember the many papers that acknowledged that bipolar patients were being wrongly diagnosed with schizophrenia.

In regard to labeling with ADD people who abuse illegal stimulants such cocaine or “speed,” I want to emphasize that it is chemically absurd to believe that somebody can get “high” on cocaine and also respond focused and calm on Ritalin. Multiple psychopharmacological and addiction studies have demonstrated that these two substances are identical twins both chemically and in brain responses.

Finally, my clinical findings, described as “remarkably at variance with current research and practice” are based on my research of the files of hundreds of youths in the correctional system. These youths’ attitudes, behavior, and lives completely changed when stimulants were replaced with mood stabilizers or antipsychotics. Many of them stayed on stimulant medications despite overly elevated mood, hallucinations, and aggressive behavior. Aggravated assault charges landed them behind bars.

With regard to Dr. Bekenstein’s comments, I can only say that if she thoughtfully rereads my article, she will realize that I did not say some of the things she perceived.

In the end, I have hundreds of former “treatment failures” to corroborate my statements. I am not alone either in my perspectives on these ADHD issues if all research and practice are considered, or in the conviction that science and patient treatment is advanced by divergent research that tests current views.

Editor’s note:

Thanks to Drs. Clark, Bekenstein, and Mota-Castillo.

The concept of publishing clinical “Pearls” is to allow experienced clinicians to share what they have learned in practice. The somewhat sad truth is that a lot of what we do in practice every day is not “evidence-based.” As Dr. Mota-Castillo points out, much of what was generally accepted not long ago has turned out not to be true.

For the purpose of determining whether a clinician has met “the standard of care” in a professional liability case, the standard is not that what they did would be agreed to by all clinicians, or even by a majority of clinicians. The standard is whether a “reasonable minority” of clinicians would agree. In the case of “Pearls,” we are willing to print recommendations that are endorsed by a reasonable minority, even if they do not represent the majority opinion.

In our regular articles, we are careful to differentiate majority from minority opinion. We have not done that so far in the “Pearls” section. In the future, we will make sure to include an editorial comment in cases like this where most practitioners probably would not endorse the author’s opinion.

To be honest, I am pretty sure that I have seen patients who had ADHD who also became cocaine abusers.

J. Randolph Hillard, MD
Editor-in-chief