The Adam Jeffrey Katz Memorial Conversation: Braving the Gauntlet of Adolescence and ADHD

The focus was on ADHD—and especially the risks it poses for adolescents—at the ninth annual The Adam Jeffrey Katz Memorial Conversation yesterday at The Kaye Playhouse at Hunter College. A panel of ADHD experts was introduced by Dr. Harold S. Koplewicz, president of the Child Mind Institute, which sponsored the event.

Dr. Rachel Klein, Fascitelli Family Professor of Child and Adolescent Psychiatry at NYU School of Medicine, previewed the latest results from a longitudinal study of children with ADHD begun when they were 8; those children are now 41. The study found that adolescents with ADHD have substantially increased risk for depression, anxiety, serious substance abuse and severe rule-breaking, or anti-social behavior. But the latest results show that once children emerge into adulthood, the heightened risk goes away. “If we can prevent the development of these complications in adolescence, they are essentially out of the woods,” Dr. Klein said.

In adulthood, the risk of developing depression, anxiety, new substance abuse, and anti-social behavior is no greater than that of children who don’t have ADHD, she added.

The focus on preventing complications was underscored by Dr. Ned Hallowell, psychiatrist and author of the influential Driven to Distraction,who talked about his strategy of helping kids understand ADHD as a set of gifts that can work well for them if they can learn to harness them: “I tell kids, you’ve got a Ferrari engine for a brain. But you’ve got bicycle brakes. You can’t stop when you need to. You’re going to get into trouble.

“But I’m a brake specialist,” he tells kids, “and I’m going to help you learn to control this amazing engine, so you can win races, and be a champion. And they leave my office motivated to do the tremendous work it takes to build those breaks, so that they can become champions.”

Each of the key symptoms of ADHD can become an asset if it’s harnessed effectively, Dr. Hallowell said: Inattention becomes curiosity, impulsivity becomes creativity—”creativity depends upon disinhibition,depends upon spontaneity!”—and hyperactivity is called energy.

Dr. Hallowell recalled talking to David Neeleman, the founder of JetBlue Airways, about his feelings the day JetBlue went public, when he was suddenly hundreds of million of dollars richer.  Driving home that night, Neeleman, who has ADHD, told Dr. Hallowell, “Was I driving home to celebrate? No. I felt like the same loser who couldn’t hack it in high school.”

“That is what we’ve got to stop,” Dr. Hallowell said, “the punishing negative energy that surrounds these kids. We’ve got to tell them, ‘You’ve got amazing abilities that may not be measured in the classroom, but boy are they measured in life—as long as you don’t acquire the real disabilities, which are shame and fear and loss of hope, giving up yourself.’”

Dr. Hallowell noted that Neeleman also invented the electronic airline ticket. “Huge innovation,” he said. “Typical ADD. Think outside the box. And I think it’s fitting that the man who has ADD thinks of a way for us to go to the airport without having to remember to bring the ticket.”

Avoiding irreversible mistakes in adolescence

Dr. F. Xavier Castellanos, the Brooke and Daniel Neidich Professor of Child and Adolescent Psychiatry at the NYU School of Medicine, underscored the theme that adolescence is a time of great risk. “We need to have guard rails during adolescence, ” he said. “The goal is to make it through that gauntlet of potential irreversible mistakes—addictions, motor vehicle accidents, sexually transmitted diseases, arrest records. It’s a short list, but they’re really to be avoided—everything else is a learning opportunity.”

Dr. Castellanos also said parents should be alert to a crisis children often reach when they’re 12 to 14 years old. “Virtually every child with ADHD is going to decide one day that they’re no longer going to be ‘drugged’ by their parents.” It’s part of the process of developing autonomy, he said, and is the point where the child needs to be brought into the conversation. A good strategy is to suggest a test, in which the child goes off the medication for 2 weeks, and then takes a look at how it went. If everything went fine, perhaps the medication really isn’t needed anymore.

“But 95% of the time,” he said, “kids very quietly resume taking the medication, because now it was their own decision.”

Dr. Gail Saltz, psychiatrist, professor of psychiatry at Weill Cornell Medical College, commentator on the Today show, and the event’s moderator, asked the panelists to discuss parents’ concern about giving kids medication for ADHD.

“Not to give medication once a diagnosis is made is like saying after you’ve had an eye exam, ‘why don’t you try squinting for a year before we give you glasses,’ ” said Dr. Hallowell.  Medications make all the other things kids with ADHD need to do to “become their own managers” work better, he said. “It’s safer than aspirin, and it’s as effective as eyeglasses.”

By the time kids are 16 to 18 their symptoms may be minimized, Dr. Klein said, and they may not need to continue medication. But it’s important to understand that giving teenagers medication doesn’t heighten their risk for drug abuse, she added. In fact, studies clearly show that kids who use medication to manage ADHD have a lower risk of substance abuse than kids who don’t use medication.

Behavior therapy helps both parents and children

Dr. Klein also noted that medication is only one of the tools that helps children with ADHD; behavior therapy that involves children and their parents is also very valuable, she said.

“Children are designed to provoke parents—they’re hard-wired to do it,” she said. “In kids with ADHD, the provocation can go beyond what’s comfortable. It can be very difficult for parents not to respond with exasperation and negativity. We talk about kids becoming demoralized. Parents become demoralized too, about their own parenting abilities.”

Parent-child interaction therapy can be especially useful in resetting the way parents and kids interact, and boosting children’s ability to rein in behavior that’s disrupting their families and making things difficult for them at school.

Dr. Castellanos tackled the common complaint that American kids are being overmedicated, and that the abuse of stimulant medications by kids who don’t have ADHD is becoming a serious problem.

“In every field of medicine there is overtreatment and undertreatment,” he said. “When to do surgery and when to hold off is always a balancing act.”

Yes, there are kids who are getting meds without sufficient, clear diagnosis, but there are also many kids not getting meds who should be getting them.

Abuse of stimulants is far outweighed by benefits

Dr. Castellanos stressed that the use of stimulants prescribed for ADHD by kids who don’t have the disorder is not particularly dangerous if it’s ingested by mouth, though those who take it for the mood effects—not just for test-taking and all-night study sessions—can develop a dependency or addiction. “While it’s regrettable to see kids buying Adderall in college libraries, the probable reality is that many of those individuals, if they were appropriately diagnosed, would merit their own legal and above-board prescription,” he noted. “It’s not for nothing that they’re finding themselves in the situation where they feel they need it.”

Dr. Klein concurred, saying students looking for an “anti-fatigue drug” find them terrifically effective. Used in moderation, they’re not a public health issue. Abuse comes in when they’re used for other things; injecting or snorting can lead to psychosis or serious harm.

Dr. Hallowell noted that misuse of these stimulants is minimal, compared to their benefits. (“It’s not a great high, by the way,” he said, ” ‘I scored some Ritalin and read three books!’”) And none of the side-effects are irreversible.

In closing he, he said, reporters who write about side-effects of medication aren’t putting them in perspective with the side-effects ofnot taking medication: “A life of underachieving frustration and misery.”

“The headline ought to be that stimulant medication can save lives, schooling, college, marriages, careers,” Dr. Hallowell said. “Stimulant medication can really put someone back on track. It has powerfully, positive effects in the context of a comprehensive treatment plan.”