Physicians Can Compound “ADHD Denial”

Speaking of ADHD and denial (as we were, with the previous post), Dr. Charles Parker wrote to say that treating physicians often compound the problem. I’ve personally witnessed this more times than I can count: An adult with ADHD is perfectly willing, even eager, to seek medical treatment, only to become so beset with side effects that medication is foresworn forever. This is a preventable tragedy. Dr. Parker explains:

Denial and misrepresentation of ADHD difficulties remains pervasive in spite of remarkable new science. One of the most important reasons, other than some simply not wanting to have a problem or take medications, is the fact that the basic new science is often overlooked. Most importantly, the psychiatric labels have not kept up with functional brain science. The current labels are too superficial, too descriptive, and lack functional biological significance.

The unhappy result of these circumstances: medical targets are imprecise, miss significant symptom objectives, and often are simply used capriciously. If docs don’t have a precise target, it’s almost impossible to hit the mark. Missing the mark directly correlates with encouraging denial.

These seven brief observations underlie some of the most challenging public perceptions regarding the use of medications used to treat ADHD.

First three basic points: Result from medical confusion and inexact use of medications without specific measurements – the key background word is iatrogenic – from my first posting two years ago at CorePsych Blog:

1. Right Diagnosis: If the ADHD diagnosis is made with shallow observations, descriptively, not functionally, the treatment targets appear vague, unconvincing, and somewhat imaginary – as indeed they are with description alone. Regrettably, medical practitioners struggle daily with these vagaries.

2. Right Medication: While many understand the pharmacology of stimulant medications, many simply do not take the time. If the doc does not know the differences he/she will not address them, and if not addressed with the patient, inevitable adverse effects will be blamed on the diagnosis and the specific medication – and the client simply does not want to do that again.

3. Right Dosage: All ADHD medications require titration strategies to dial them in specifically. If titration strategies are not used, and many do not practice specific titration, the course of treatment is confounded by ups, downs and inside outs. The treatment regimen itself becomes a disincentive for the long term medical relationship necessary to adjust medications. The Therapeutic Window, discussed extensively in other articles here, is often simply overlooked as significant.

4. Belief Systems: Some docs simply do not believe in ADHD, and they challenge the care given by other more informed docs. Science does not count; to many, ADHD is a character or personality disorder, based on will. This maladaptive belief is encouraged by the cloudy diagnostic process – led by those who are correctly challenging the vagaries of the diagnostic process.

5. Antidepressant Thinking Applied to Stimulants: Some docs who are interested in treating ADHD apply 24 hour half-life thinking, such as is seen with antidepressants, to these shorter half-life stimulant medications ( which often last less 12-14 hours). Stimulants must be adjusted quite specifically.

6. Noncompliance: Patients take the stimulant care into their own hands, using medications irresponsibly, have side effects, then blame the doc, the diagnosis, or the medications. Capricious dosing results in capricious outcomes, and ultimate dissatisfaction. The new longer acting medications offer significant improvements on this process.

7. Previous Bad Experience: Older medications just did not work as well, proved too cumbersome and subject to abuse, thus turning the public against all ADHD intervention possibilities. Some of the most profound denials come from those identified with ADHD as children, and were then improperly dosed with what are now antique medications. Managed care companies regularly favor outdated drugs that provide less predictable outcomes.

Precise dosing, careful selection of medications, knowledge of drug interactions, and appreciation of multiple possible comorbid conditions will significantly improve outcomes.