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Had AAD. On Adderall, Strattera And Ativan. Affecting Career. What To Do?
Question: Hello! I am a licensed clinical social worker who just discovered that I have had ADD all my life! Very disappointing since I spent hours with MD psychiatrists and psychoanalysts. My dad was a well -known cardiologist. My mother, looking back, has ADD "big time"! She was pre-med and couldn't function adequately. She smoke and drank while pregnant with me; I was born at 8 months, 4 lbs, 2oz. Nothing was every done! I spoke fast, interrupted people and so forth. Lots of questions, obviously, and a lot of grief in the inadequacy of the medical community to figure this out. I am dealing with my grief and anger. I am finally on Adderall (my current psychiatrist first had me on Strattera and Ativan; I was more upset and nervous). This disorder of course effected my professional career (didn't finish a doctoral program) and I didn't make much money for all the ADD reasons! I consider some of this "malpractice" on the part of the medical and psychiatry profession---can one XXXXXXX a psychiatrist for misdiagnosis, pain and suffering,and prevail?
I do not have an eating disorder! I am very healthy. I am married to an orthopedic surgeon (luckily) and now realize how much he has taken care of me. I feel bad that I did not contribute more financially and kept the home in better order. We have had couples' issues and tensions and we amazingly found a couples counselor who also has ADD; husband and other MDs have a hard time understanding this order or believing it exists! I want to know the best recent research and genetic information regarding this disorder. I fit almost all the "symptoms" of someone with ADD with an additional "small H" probably because my mom smoke and drank while pregnant with me. Her ADD is probably "hypo-active"! What's with the idea of "Epigenetics" and how it may relate or effect this disorder? I am leaving my private practice in clinical social work and more comfortable in a family service agency where I am made sure to do my charting and submit for billing (something I often did not do!) No wonder I never made any money!!
I do not have an eating disorder! I am very healthy. I am married to an orthopedic surgeon (luckily) and now realize how much he has taken care of me. I feel bad that I did not contribute more financially and kept the home in better order. We have had couples' issues and tensions and we amazingly found a couples counselor who also has ADD; husband and other MDs have a hard time understanding this order or believing it exists! I want to know the best recent research and genetic information regarding this disorder. I fit almost all the "symptoms" of someone with ADD with an additional "small H" probably because my mom smoke and drank while pregnant with me. Her ADD is probably "hypo-active"! What's with the idea of "Epigenetics" and how it may relate or effect this disorder? I am leaving my private practice in clinical social work and more comfortable in a family service agency where I am made sure to do my charting and submit for billing (something I often did not do!) No wonder I never made any money!!
Brief Answer:
Discussed below.
Detailed Answer:
Hi,
Welcome to Healthcare Magic!
I agree with you wholeheartedly that the diagnosis of ADD in adults is often missed, causing needless suffering and avoidable loss of productivity for many. But I am not sure if this is a "malpractice".
In my view, ADD is a disorder that has been in the spotlight only in the last decade or so. Prior to that, it was poorly understood and therefore often missed by doctors. Even now, there are people who strongly object when their children are diagnosed with ADD, accusing the doctors of "labeling" their children for monetary gains. They are organized and orchestrate protests complete with banners and slogans at psychiatry conferences all over the world. So when the diagnosis is controversial even in children, obviously it is not easy to make diagnosis for adults as well. Diagnosis of ADD in adults requires a history of ADD in childhood, and many times this history is difficult/impossible to obtain, making the diagnosis even more difficult. The prevalence of adult ADD is supposed to be 4% but I often ask my students if they are able to identify around 4 people with adult ADD in every 100 patients that they see, and the answer is always in the negative.
If you wish, you can XXXXXXX your doctors, but I really doubt if you will be able to find a good lawyer to represent your case and even if you do, I do not consider it likely that you will win the case. Though I guess that your comment about suing was in the lighter vein.
You are indeed lucky to have a supportive family and good counselors and doctors to help you. Still, it must rankle a lot to look back and see how life could have been different if this were identified and treated long back.
Regarding the recent research on causes and genetics of ADD/ADHD, it is still not clear what causes ADHD. Recent research including family studies as well as those centered on specific genes or genome-wide screening, have produced strong evidence that genes play a role in susceptibility to ADHD. It is believed that genetics account for 70 to 80 percent of the risk, with a mean estimate of 76 percent.
Gene studies, whether focusing on specific genes or scanning the whole genome, aim to link DNA variations with these observable symptoms. They also endeavor to locate the relevant chromosome regions. In recent years, a large number of studies on different candidate genes for ADHD have been published. Most have focused on genes involved in the dopaminergic neurotransmission system. However, a recent 2010 analysis of genome-wide studies found only one confirmed location on one chromosome (chromosome 16) that has been repeatedly linked to ADHD.
What I mean to say that though many genes have been implicated, we still do not know what exactly causes ADHD. Most probably, it is the interaction between multiple genes and the environment that is responsible. That is, an individual’s genetic make-up is neither sufficient nor necessary to cause it, but may increase their overall risk. Gene-environment interactions, which are as yet unclear, are likely to be of importance when understanding the role of genes in ADHD.
Here comes the role of epigenetics, which looks at the factors other than change in DNA sequence, that can alter the expression of genes. In simple words, the genome dynamically responds to the environment. Stress, diet, behavior, toxins and other factors activate chemical switches that regulate gene expression.
Epigenetics of ADHD is a recent focus of research. The potential epigenetic factors that confer a risk for ADHD are alcohol, tobacco, toxins, medications, and psychosocial stressors. Young maternal age, maternal smoking and preterm birth have been implicated. But our knowledge is still limited and much is yet to be understood.
I hope this answers your query. Please feel free to ask if you need any clarifications. I shall try to answer to the best of my ability.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Discussed below.
Detailed Answer:
Hi,
Welcome to Healthcare Magic!
I agree with you wholeheartedly that the diagnosis of ADD in adults is often missed, causing needless suffering and avoidable loss of productivity for many. But I am not sure if this is a "malpractice".
In my view, ADD is a disorder that has been in the spotlight only in the last decade or so. Prior to that, it was poorly understood and therefore often missed by doctors. Even now, there are people who strongly object when their children are diagnosed with ADD, accusing the doctors of "labeling" their children for monetary gains. They are organized and orchestrate protests complete with banners and slogans at psychiatry conferences all over the world. So when the diagnosis is controversial even in children, obviously it is not easy to make diagnosis for adults as well. Diagnosis of ADD in adults requires a history of ADD in childhood, and many times this history is difficult/impossible to obtain, making the diagnosis even more difficult. The prevalence of adult ADD is supposed to be 4% but I often ask my students if they are able to identify around 4 people with adult ADD in every 100 patients that they see, and the answer is always in the negative.
If you wish, you can XXXXXXX your doctors, but I really doubt if you will be able to find a good lawyer to represent your case and even if you do, I do not consider it likely that you will win the case. Though I guess that your comment about suing was in the lighter vein.
You are indeed lucky to have a supportive family and good counselors and doctors to help you. Still, it must rankle a lot to look back and see how life could have been different if this were identified and treated long back.
Regarding the recent research on causes and genetics of ADD/ADHD, it is still not clear what causes ADHD. Recent research including family studies as well as those centered on specific genes or genome-wide screening, have produced strong evidence that genes play a role in susceptibility to ADHD. It is believed that genetics account for 70 to 80 percent of the risk, with a mean estimate of 76 percent.
Gene studies, whether focusing on specific genes or scanning the whole genome, aim to link DNA variations with these observable symptoms. They also endeavor to locate the relevant chromosome regions. In recent years, a large number of studies on different candidate genes for ADHD have been published. Most have focused on genes involved in the dopaminergic neurotransmission system. However, a recent 2010 analysis of genome-wide studies found only one confirmed location on one chromosome (chromosome 16) that has been repeatedly linked to ADHD.
What I mean to say that though many genes have been implicated, we still do not know what exactly causes ADHD. Most probably, it is the interaction between multiple genes and the environment that is responsible. That is, an individual’s genetic make-up is neither sufficient nor necessary to cause it, but may increase their overall risk. Gene-environment interactions, which are as yet unclear, are likely to be of importance when understanding the role of genes in ADHD.
Here comes the role of epigenetics, which looks at the factors other than change in DNA sequence, that can alter the expression of genes. In simple words, the genome dynamically responds to the environment. Stress, diet, behavior, toxins and other factors activate chemical switches that regulate gene expression.
Epigenetics of ADHD is a recent focus of research. The potential epigenetic factors that confer a risk for ADHD are alcohol, tobacco, toxins, medications, and psychosocial stressors. Young maternal age, maternal smoking and preterm birth have been implicated. But our knowledge is still limited and much is yet to be understood.
I hope this answers your query. Please feel free to ask if you need any clarifications. I shall try to answer to the best of my ability.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thank you Dr. Parakh for your sensitive and thorough response. You're right, I feel disappointed and somewhat let down by my own profession. I wanted to achieve higher goals. But at least the conversation has started. Is it known how much cognitive compensation can be gained with a psychostimulant like Adderall? Should I also be taking a norepinephrine reuptake inhibitor? Will I need to be on Adderall the rest of my life? Does it cause irreversible damage? Does one need an exit-strategy? I definitely feel more alert and less anxious on Adderall than on Strattera; I can think through to the end of problems much better. I can notice and act upon obstacles more quickly; I am more receptive to criticism and notice my contribution to a problem more quickly. Perhaps I will write a book which will help compensate for the financial loss that has accompanied this disorder. Who knows? If I can help someone else that would be satisfying. Thanks again for your intelligent responses. One more question: if psych stimulants effect growth in young children who have ADHD, would adding Human Growth Hormone help combat that side effect? Sincerely, XXXXXX
Brief Answer:
Discussed below.
Detailed Answer:
Hi XXXXXXX
Welcome back!
While it is not exactly known how much cognitive improvement can be gained with stimulants like Adderall, it is estimated that around 70% people get a significant improvement. If you are satisfied with the response Adderall has shown, then I do not think that you need to add any other medicine.
I may be wrong but it appears to me that you find the idea of being on a stimulant slightly disturbing. Please do not consider it as a "bad" thing or just as a drug that people abuse to get a high. It has given you a new life and you should consider it not much different from other medicines that you might be taking, say for example, antihypertensives. You do not "need" to be on Adderall the rest of your life. After all, you managed to do without it for so long! But if you wish, you can choose to take it as long as you wish. If a few years later, you feel that your day to day activities do not require sustained attention and alertness, you may decide to go off the drug or may consider reducing the dose. There is no need to worry about irreversible damage, but you do have to be cautious and watchful for any adverse effects, especially cardiovascular ones. No specific exit strategy is needed. Just be slow and cautious whenever any dose changes are made.
You may also benefit from the different nonpharmacological modalities popular in treatment of adult ADHD. These include cognitive-behavioral therapies, environmental modifications, attention process training, self-regulatory strategies etc. There are ADHD coaches who assist adult patients in making lifestyle modifications conducive to minimizing ADHD-related difficulties. Your counselor (who has ADD) might be able to suggest some such measures which are likely to suit you.
Regarding the use of growth hormone to prevent growth retardation in children on stimulants, it has been found that giving drug holidays, that is not giving stimulants on weekends or summer holidays ensures that there is a rebound increase in growth rate and overall there is no difference in growth rate between children on stimulants and other children. Since this is a much safer strategy than giving growth hormone supplementation, it is almost universally followed everywhere.
I hope someday you do write a book narrating your own experience of ADD and I get to read it.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Discussed below.
Detailed Answer:
Hi XXXXXXX
Welcome back!
While it is not exactly known how much cognitive improvement can be gained with stimulants like Adderall, it is estimated that around 70% people get a significant improvement. If you are satisfied with the response Adderall has shown, then I do not think that you need to add any other medicine.
I may be wrong but it appears to me that you find the idea of being on a stimulant slightly disturbing. Please do not consider it as a "bad" thing or just as a drug that people abuse to get a high. It has given you a new life and you should consider it not much different from other medicines that you might be taking, say for example, antihypertensives. You do not "need" to be on Adderall the rest of your life. After all, you managed to do without it for so long! But if you wish, you can choose to take it as long as you wish. If a few years later, you feel that your day to day activities do not require sustained attention and alertness, you may decide to go off the drug or may consider reducing the dose. There is no need to worry about irreversible damage, but you do have to be cautious and watchful for any adverse effects, especially cardiovascular ones. No specific exit strategy is needed. Just be slow and cautious whenever any dose changes are made.
You may also benefit from the different nonpharmacological modalities popular in treatment of adult ADHD. These include cognitive-behavioral therapies, environmental modifications, attention process training, self-regulatory strategies etc. There are ADHD coaches who assist adult patients in making lifestyle modifications conducive to minimizing ADHD-related difficulties. Your counselor (who has ADD) might be able to suggest some such measures which are likely to suit you.
Regarding the use of growth hormone to prevent growth retardation in children on stimulants, it has been found that giving drug holidays, that is not giving stimulants on weekends or summer holidays ensures that there is a rebound increase in growth rate and overall there is no difference in growth rate between children on stimulants and other children. Since this is a much safer strategy than giving growth hormone supplementation, it is almost universally followed everywhere.
I hope someday you do write a book narrating your own experience of ADD and I get to read it.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Dr. Parakh---I am very impressed at how well you have synthesized my concerns and managed to cover "all the bases"! I feel less upset and worried. I do have a concern that my 21 month old grandson manifests some early signs of ADD (i.e. he spaces out, seems to seek out some risky behavior for his age, etc.). My son is a licensed psychologist and works with kids; he also shares this concern, but your answer about stimulants effecting growth in children and whether or not to give human growth hormone, alleviates much of this worry; apparently, this is a known concern and is being watched carefully. We are trying not to be overly concerned and are being very cautious; we don't want to "make a mountain out of a molehill" but not voicing our concerns isn't healthy either. I can't thank you enough----you are doing a great job! Sincerely, XXXXXX
Brief Answer:
No need to be concerned at present.
Detailed Answer:
Hi XXXXXXX
You absolutely do not need to worry about your grandson at this point of time. Many children appear to be hyperactive when they are very young but grow out of it. Your grandson is not even two years old. Wait for him to be at least five or six years old before thinking whether he needs treatment or not. In fact, studies have shown that only 50 percent of hyperactive preschool children followed prospectively since age 3 had a diagnosis of ADHD at age 9.
Even if he turns out to have ADHD, it is not mandatory that he be treated with stimulants. Other agents like atomoxetine (Strattera) and clonidine (Catapres) work very well in children. These can be used for the growing years and stimulants may be started later if required.
Since your son is a psychologist, he may read up on strategies that can be used to build up the attention-concentration capacity in children and apply them on your grandson when he grows up a little. For example, give him games which require concentrating for some time and reward him if he is able to complete it in one sitting. A jigsaw puzzle would be a good option.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
No need to be concerned at present.
Detailed Answer:
Hi XXXXXXX
You absolutely do not need to worry about your grandson at this point of time. Many children appear to be hyperactive when they are very young but grow out of it. Your grandson is not even two years old. Wait for him to be at least five or six years old before thinking whether he needs treatment or not. In fact, studies have shown that only 50 percent of hyperactive preschool children followed prospectively since age 3 had a diagnosis of ADHD at age 9.
Even if he turns out to have ADHD, it is not mandatory that he be treated with stimulants. Other agents like atomoxetine (Strattera) and clonidine (Catapres) work very well in children. These can be used for the growing years and stimulants may be started later if required.
Since your son is a psychologist, he may read up on strategies that can be used to build up the attention-concentration capacity in children and apply them on your grandson when he grows up a little. For example, give him games which require concentrating for some time and reward him if he is able to complete it in one sitting. A jigsaw puzzle would be a good option.
Best wishes.
Dr Preeti Parakh
MD Psychiatry
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Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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