The opinions expressed herein are those of the guests alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Welcome to New Parenting on WebMD Live. Our guest today is Dr. Paul H. Wender. We will be discussing ADHD (attention deficit/hyperactivity disorder) in children.
Welcome to WebMD Live, Dr. Wender. It’s a pleasure having you here today. Before we begin, would you tell everyone a little bit about your background and area of expertise?

Dr. Wender: I got interested in what was called minimal brain dysfunction when I began my training 37 years ago. At the time, a group of children who were boisterous and disruptive and difficult to discipline. These children received treatment with amphetamines: this reversed their symptoms and allowed many to function as they had not before. I wrote my first book on this topic in 1971. After that, I did some political and biological research with these children. We now used the term ADHD to describe children with these symptoms.
Because I was interested in genetics, I began to question the parents of these kids as to whether or not they had the same problem. Many replied they still did. They described ongoing problems they had, and we decided to do research with them. We contacted their parents and interviewed them about how their now adult kids had behaved when in elementary school. In 1976, we did an experiment where we gave Ritalin (methylphenidate) and placebos to these adults. We found that 60 to 70 percent of them had very marked and favorable response, just about the same as the kids. We then started doing research with adults and have continued to do so for 25 years. We are studying many medications and doing biological tests which one cannot do with children, but can do with adults who give consent.
In 1995, I wrote “ADHD: Attention Deficit Hyperactivity Disorder in Children and Adults.” Most recently, we completed a one-year trial of Ritalin in over 100 ADHD adults and have been able to observe that they did not become tolerant of the medication. It continued to work. They made some gains, not only in symptoms, but also in many areas of life.
As I began to treat these children 30 years ago, I realized that an essential component was educating the parents about the causes, the symptoms, what kind of techniques we can use to help the child behaviorally, mainly, and to understand what the medication could and could not do.
As time has gone by, I’ve revised the book. Last year, the revision was released in its fourth edition. It contains expanded descriptions and a large section directed at ADHD adults themselves. In that section, I explain the symptoms and how they affect relationships, etc., and also provide some scientifically proven rating scales. Adults can screen themselves to determine if they may or may not have ADHD. This is not for self-diagnosis and self-treatment, but to enable one to determine whether it is likely or not that they have ADHD. This is very important, because in our research we have designed scientific ways of diagnosing adults and tests which allow us to determine whether an adult had ADHD symptoms as a child.
Many nonprofessionals (or inadequately trained ones) are overdiagnosed as ADHD, and it’s important for adults to determine if they may or may not have it, as there are many other psychiatric disorders which may share many of the same symptoms.

Moderator: Briefly, what are some of the characteristics of children with ADHD?

Dr. Wender: The three major groups of symptoms are: inattention, hyperactivity and impulsivity. In the standard psychiatric guide to diagnosis, the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Revision IV), the exact symptoms are given. For example, for impulsivity it might be: “blurts out answers.” For hyperactivity, it might be: “not being able to sit in a seat.” For inattention, it might be: “not able to follow instructions or doesn’t complete tasks.”
To have the diagnosis, a child must not only have the symptoms, but they must have started before he or she was 7 years old, and they must be causing problems in two areas: home, school or part-time work. There are other symptoms that go along with ADHD, although they are not necessary to diagnose the disorder. These include stubbornness, bossiness, hot temper, mood changing easily, easily excitable, easily depressed or discouraged, overreaction to ordinary stresses and frustration, if the child has a low frustration tolerance, and lastly, they may be more resistant to discipline.

Moderator: Member asks, “Is 3 years old too early to detect ADHD in a child?”

Dr. Wender: One can sometimes pick up ADHD when the mother is pregnant. If she has had one or more ADHD children before, she will comment that this one is kicking around a lot more than other pregnancies. However, one can’t really pick up such extreme instances at 2 or 3 years old because many kids are very overactive at that age. It is hard to determine if a child of that age is inattentive, for example. ADHD is more often picked up in preschool, because a child has to follow rules and ways, and the experienced teacher can compare him or her to other children the same age. The child must have the symptoms required before age 7, so it is certainly clear in kindergarten and first grade. Symptoms are often overlooked. Some ADHD children only have inattention, and unlike other ADHD children, they don’t cause many problems for the teacher. They may be overlooked and be perceived as “underachievers” or “not particularly bright,” which is unfortunate, because they often fail to get the treatment they need.

Moderator: Member asks, “How safe is long-term Ritalin use? My son has been on Ritalin for six years now. He is only 9 years old.”

Dr. Wender: We know and we do not know how safe long-term Ritalin use is. I say we know, because we treat children from elementary school through the adolescent years and find that one-third to two-thirds of ADHD children have problems that persist into adult life. They may diminish with age or may continue to be a problem. The doctor has to give a medication and then watch for side effects, as with any medicine. Most people don’t know that amphetamines are every bit as effective as Ritalin, and amphetamines were first used 30 years before Ritalin was devised. Doctors have 60 years of experience with amphetamines. Taken in therapeutic doses, it appears to cause no problem. One always wonders in medicine about safety because one never has scientific experiments that last 40 years to see if a medication is safe. Chronic amphetamine use for years, correctly or incorrectly, has specific side effects, but one important finding was there were apparently no serious side effects from such use on a daily basis. Ritalin or amphetamine is much safer than aspirin or penicillin and has many fewer unpleasant side effects than drugs such as Prozac (fluoxetine). The answer is we treat people as long as they appear to need the medication. As they get older, we may have some drug holidays when they don’t take the medicine, to see if the symptoms persist. In the case of adults, I have the patient and his partner describe what happens when medication is begun and what happens when there are drug holidays. Most adults with ADHD have had it their entire lives, so they don’t recognize its use or loss of benefits when stopped as accurately as do their partners. But to answer the question, so far as we know, it is extremely safe. So far, we have no evidence, over 30 years of use, that its long-term use is harmful.

sarahspindrift_webmd: Is treatment of ADD with Adderall effective?

Dr. Wender: Adderall (dextroamphetamine and amphetamine) is just a plain new formula of different amphetamine. The amphetamines before Adderall were shown to be just as effective as Ritalin. It is important that, although they are equally effective overall, a child or adult who doesn’t do as well as one would like on one drug may do better on another. Both Adderall and the amphetamine, which is also in Dexedrine (dextroamphetamine) lasts longer than Ritalin (four to five hours rather than two-and-a-half to three hours). The real question is whether or not Adderall is any more effective than Dexedrine, which has been around for 34 years. Doctors often like to use new drugs. They are also afraid to prescribe amphetamines because they have a bad reputation due to the “speed” epidemic. Adderall doesn’t have the same name as Dexedrine and physicians apparently feel more comfortable in prescribing it. But the answer is it is as effective as Dexedrine and Ritalin. It lasts longer than Ritalin. Ritalin and the amphetamines are equally effective, about 70 to 75 percent will do well on these medications. However, it is very frequently seen that, although they are equal overall, any one patient may do better on Ritalin than on the amphetamines, or on the amphetamines rather than Ritalin. Therefore, if a given child or adult doesn’t have as good a treatment response as one would like, one should switch from Ritalin to amphetamine or in the other case, amphetamines to Ritalin.

Moderator: Can you discuss the new medication, Concerta?

Dr. Wender: Concerta (methylphenidate — extended release) is a newly packaged form of Ritalin which is supposed to work for a period of 12 hours. Most physicians are finding that it does indeed last 12 hours. This is extremely useful, because children require at least three doses of Ritalin a day and it is difficult to arrange while they’re going to school. They either have to be depended on to take it themselves or they have to be called away by a school nurse (if there is one). Adults require Ritalin tablets five or six times a day, because it only appears to last two-and-a-half hours in them. Adults who get the medication two or three times a day complain that they feel like they’re on a roller-coaster. In the case of children, once a day dosing is terrific. The child can get it at 7 or 8 o’clock in the morning and it will wear off after school and may still be working for homework time. So, Concerta is not a different drug, but a different way of delivering the drug. Amphetamines last longer than Ritalin, so that adults need to take them only three or four times a day. There are already long-acting forms of Dexedrine which are currently marketed. One is Dexedrine Spansule (sustained-release capsules) and they last six to eight hours. Research is now underway to develop a long-acting form of amphetamines which will last 12 hours and be as useful as Concerta, for the same reasons. As with tablets, one will have to see whether a given child or adult does better on Concerta or this long-acting form of amphetamines.

magosse1_lycos: When a child has ADHD, can they outgrow it?

Dr. Wender: People have attempted to answer this by selecting a group of kids (elementary school-age kids with ADHD) and then interviewing them at various intervals. One group has studied kids until age 25. Another group was studied until they were in their 30s. The overall conclusion is that, in one-third to two-thirds of children, the disorder persists to a degree which interferes with life into young adulthood and into pre-middle age. The form that ADHD takes, as a person becomes older, will change. The hyperactivity may sometimes diminish in adolescence and the form of the symptoms change as one gets older. Although blurting out answers may be a problem for the 7-year-old, it may not be a problem for the 19- or 35-year-old. As one becomes an adult, one can drive impulsively, which ADHD adolescents do, but a 7-year-old doesn’t. When they become adults, ADHD impulsivity expresses in such things as finishing other people’s sentences, spending money impulsively; and making decisions without thinking through the consequences carefully. ADHD adults may “max out” on their credit cards, make impulsive bad investments, and other similar changes. Adults can have other symptoms, which I will discuss later.

stayathomer_webmd: Please tell me how to get my 15-year-old son to take his medication. He complains he gets headaches from it.

Dr. Wender: The question here is about side effects, in this case, headaches in ADHD children. Some children (a few), do get stomach aches and/or headaches with Ritalin or amphetamines. The first thing the doctor should do is cut back the dose to see if he can eliminate the headaches or stomach aches without lessening a good effect on the ADHD. Sometimes, it’s possible to arrange a trade off, and sometimes it can’t be done. Other medications may be useful in the treatment of these headaches; however, they are definitely a known side effect of the drug, but fortunately, they occur in relatively few patients treated with the stimulant drugs such as Ritalin, etc.

sarahspindrift_webmd: My youngest was just diagnosed with ADD but not with hyperactivity. My oldest, 11 years old, was always inattentive, “out there somewhere, “and hyperactive since 3 years old and still has episodes of these symptoms. Was he overlooked? Is it more likely he could be ADD or ADHD as well? Should he be checked at his age? Why did it get overlooked?

Dr. Wender: With the older one, we see that some ADHD children are just hyperactive and impulsive, but not inattentive. That is uncommon. The best person to pick up inattentiveness is the school teacher, who sees if the child can follow instructions, or if the child is “off in space,” etc. The treatment for children who are just hyperactive and impulsive is the same for the child who is inattentive or who has all three major symptoms. So, if it looks as if this child is hyperactive or impulsive, a trial of medication may be very useful.

Moderator: Member asks, “I have three daughters and a 6-year-old son. His kindergarten teacher has evaluated him and sent home a note stating that my son is “overly hyperactive,” but I see my son as a normally behaved little boy. Do you have any suggestions?”

Dr. Wender: That is because different expectations are held at home and in school. In school, one is required to sit in one’s seat and not be disruptive. So on the other hand, if a child is up walking around at home it’s no problem for anyone, so therefore the teacher and the parent may disagree. The other advantage the teacher has if they are experienced, is, as I said before, that they can compare your child with many other children the same age. The problem is not whether or not the hyperactivity is present, but rather, are they disruptive or can they pay attention, which will cause problems as soon as he enters elementary school. However, the best way to make the diagnosis is to contact a child psychiatrist. Child psychiatrists receive a good deal of training in the diagnosis and treatment of ADHD children. Pediatricians can sometimes be helpful, but for the most part, their training is on the job. Furthermore, pediatricians aren’t given training in distinguishing ADHD from other problems of childhood that may cause inattentiveness or restlessness. Lastly, pediatricians practice methods that don’t allow enough time for evaluation of the ADHD child. As I say in my book, ADHD children or adults, a parent should have a good awareness of what a good diagnostician will do, and what the parents should expect from the evaluator, whether a pediatrician or a child psychiatrist.

Moderator: Member asks, “What role does diet play in ADHD, in particular, artificial colors and preservatives? Any recent research?”

Dr. Wender: To the best of our knowledge, food additives and food coloring does not produce ADHD, nor do food allergies. Allergies produced by these substances may make a child sniffle or irritable, but they do not produce ADHD. A number of studies done 20 years ago demonstrated this. It is not impossible that someone will find a dietary additive of some kind helpful, but so far we don’t know of any.

Moderator: Member asks, “How can I be a more effective parent for my 8-year-old son with combined ADD/ADHD when I also have ADHD and have trouble remembering what I have just asked him to do and cannot remember what consequences he was given? Please respond and refer me to a book or reading material, since I have a memory problem.”

Dr. Wender: ADHD children usually come with one or more ADHD parents. This is unfortunate, because if the ADHD parent’s symptoms are still serious, they interfere with raising the ADHD child. The best parent for an ADHD child is one who is consistent, orderly, cool-tempered, who follows through and sets a model for a child in doing things in an organized way. The ADHD parent cannot help their symptoms, but treatment may be just as important for themselves as for the child. These parents need to learn the best and worst ways of handling the child. I recommend the parent be diagnosed to see if they have ADHD and be treated. Treatment would probably involve medication. The person should see a child psychiatrist, as they have training in adult psychiatry, or an adult psychiatrist.

edmundsk_webmd: What do you say to people like John Rosemond who deny the existence of ADD/ADHD, and how do you address the fear of medication which some parents have?

Dr. Wender: There is no difference. There is no reason not to give Ritalin to a child with ADHD unless he has other psychiatric disorders, in which case, it may not be the best treatment. This is why a consultation with a child psychiatrist can be so useful to determine if the child in question has ADHD and more important, whether he has any other condition suggesting not to use Ritalin. We have every reason to believe ADHD is a disease. This follows studies from different parts of the brain, from the study of genes in ADHD children, and the chemistry of the brain in ADHD children. We know that, in many instances, it is genetic. This can be shown by assessing a number of studies. For example, the way adopted children of ADHD parents still have the problem, even if reared in a very organized, structured home.

Moderator: What are the symptoms of ADHD in adults?

Dr. Wender: The symptoms of ADHD in adults differ from those in childhood. That is not surprising. In children, we discuss only their behaviors, but in adults, we discuss behavior and symptoms. Further, even when they have similar problems, say, inattention, they are different from those in children. Inattentive adults don’t listen to other conversations, so spouses are upset they’re not listened to. They can’t concentrate on reading without reading something two or three times. They misplace or lose things. Adults may also be hyperactive, but they tell you they like outdoor jobs or they tap their foot or can’t sit still through a movie, etc. They complain of mood problems. They shift to sad or glad quickly. They get discouraged or excited easily. They are often so disorganized they produce real-life problems, which make them upset. They can have a hot temper or a short fuse. They can be angry, impulsive drivers. They tend to be stress-sensitive. They’re easily stressed-out by comparatively minor things going on and get angry, confused, etc. They are disorganized: they cannot plan ahead. They start another project before completing one. They can’t organize their kitchen, workspace, etc. It is important for the audience to know that when stimulant drugs work, it diminishes their concentration problems, restlessness, moodiness and they are much more resilient and can tolerate stress. Organization improves eventually. They’re less impulsive. Those go away in 45 minutes, if the medication works. They get substantial changes in their lives. They do better vocationally, in marriage and in relationships. They go from being moderately impaired to functioning well. Treatment, when effective, produces life-changing effects. My book shows histories of adults and children treated, and shows life changes. These are not written by me, but are autobiographies by patients and comments by their partners. These stories will illustrate a substantial benefit when a person is properly diagnosed and treated.

Moderator: We are just about out of time. Dr. Wender, before we say goodbye, do you have any closing comments?

Dr. Wender: Yes. If people have children with the disorder, they should learn about it from books such as mine or others. For the best evaluation, one should see a child psychiatrist, even if HMOs demand referral from a pediatrician. Adults should determine if they have the disorder. Their proper evaluation and treatment can have a huge impact, not only on their children’s lives, but on their own lives.

Moderator: Unfortunately, we are out of time. Thank you very much for joining us, Dr. Wender. It’s been a pleasure having you on WebMD Live. Thank you for sharing your knowledge and expertise with us.

Dr. Paul H. Wender is a pioneer in identifying and treating attention deficit hyperactivity disorder. A researcher and clinician who has treated patients with ADHD for many years, he has now thoroughly revised and updated his classic handbook on the subject, “ADHD: AttentionDeficit Hyperactivity Disorder in Children and Adults.” Wender was formerly distinguished professor of psychiatry and director of psychiatric research at the University of Utah School of Medicine.

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