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Articles by Dr. Billy Levin

Medical mistakes and relearning with regard to ADHD

© Dr. W.J. LEVIN MB ChB (Pta)

It is not surprising and very human to speculate, then evaluate, then research, and eventually prove a concept. Medical science is no exception. The problem arises when one is not familiar with the final and correct conclusion. In the field of ADHD there has been major confusion misinformation and incorrect interpretations, causing major problems for the doctors and the patients alike. I am equally sure the final word has not been reached and will one day be published. Some examples would explain why there is sadly, confusion and misinformation still amongst doctors.

An American professor recently estimated in a publication that in his opinion 70% of doctors treated ADHD incorrectly. I was asked to write and article published in "PED MED" entitled "ADHD-Confusion and misinformation".

When the American Psychiatric Association's Committee wanted to develop a protocol for ADHD assessments, they discovered nobody on their committee had any expertise. An ad hoc committee of experts was appointed, who developed a protocol. The original committee of non experts rejected the expert's protocol and published their own protocol. On the day it was published the American Pediatric Association rejected it and published their own protocol. Was this the blind leading the blind?

This so called DSM iv has been in existence for about 18 years. The new DSM V was published recently and is not much better than the previous one, it would appear.

In the UK, where the state pays for everything, their money saving policy is for the consultant to diagnose and prescribe the first prescription for ADHD. Thereafter the GP, who is not an expert, simply repeats the same prescription on a monthly basis without establishing if the treatment is effective or even examining the patient. A research project on in the UK suggested well over 80% of parents were dissatisfied with their children's treatment for ADHD. Is this surprising?

When the pamphlet in the Ritalin box suggested that Tofranil for enuresis was contraindicated if Ritalin was being used, despite this being incorrect. Enuresis is often part of ADHD. When Ciba was enlightened, the concept was changed to, it can used with caution.

Tourettes syndrome is often seen with ADHD and Ritalin was forbidden as it was suggested, it made Tourettes syndrome worse. It was even suggested that Ritalin caused the tics despite professor Tourette describing the condition about 50 years before Ritalin came onto the market. Later research suggested that Ritalin could be successfully used for the ADHD and possibly Serenace for the Tourettes syndrome with not risk to the patient.

When Concerta was introduced to South Africa the medical "rep" from Cilag, who market Concerta, informed me the maximal dose was 54mg. When I informed her that this was wrong and 72mg was acceptable her reply was that this is what is registered with the Medicines Control Council. A short while later a pamphlet to the doctors from Cialag Jansen announced the maximal dose is 72mg. Currently the recommended maximal dose is 108mg.

Novartis suggests that a maximum dose for the 10mg Ritalin tablet is 6 a day. If Jansen pharmaceuticals suggest 108mg Concerta, than 9 , 10mg Ritalin tablets is acceptable, obviously in divided doses. Who is correct?

The American Pediatric Association suggested that 6 years of age was the correct age to start assessing ADHD. About 18 months ago they changed their mind and announced that 4 years of age was acceptable. In the UK, 6 year olds are still the accepted age for assessment.

A professor's text book suggested treatment for ADHD was only acceptable till 12 years of age. When the professor was informed of his incorrect concept, when the book was eventually rewritten, the incorrect information was changed.

A medical aid refused to pay for an adult on treatment for ADHD as they insisted that there was no reason to treat adults as the patient would and should have outgrow their problem. They currently still refuse to accept that some ADHD adults still need medical treatment despite research suggesting adults should not be neglected. Many an adult only come for an assessment once one of their children have been successfully diagnosed and treated. In the UK they are only recently recognizing the need to treat adults. In 1982 I lectured at a National Medical Conference in Cape Town on the treatment of ADHD in adults.

A rating scale by an American professor for ADHD consisted of 10 questions which was not acceptable or effective, as it was too brief. When it was changed locally, to 12 questions and proved very successful, it took the world famous professor quite a few years, to admit the original rating scale was too brief.

There are still doctors prescribing schedule 6 medications like Concerta and Ritalin with repeat prescriptions, despite this being illegal. Only one months supply is permitted, to do monthly reevaluations. Some time ago, a doctor who issued repeat prescriptions was fined by the Medical Council and warned, he would be struck off the medical register if did it again.

Many years ago the "Feingold diet" was recommended. Dr Feingold suggested diet played a role in the treatment of ADHD. This was disproved and is no longer recommended. Sugar and colorants were also blamed only to be rejected as unimportant. If ADHD is right brain dominance and left brain immaturity, how can food, colorants and sugar, promote right brain functions and hamper left brain functions. How can the external so called mesomorphic features often seen on the skin of ADHD patients be caused by food. They are visible at birth. I refer to high palate, tiny ear lobes, curved little finger, single simian fold in the palm, a web between second and third toe and a big space between first and second toe.

Research has clearly showed that the dose of Concerta and Ritalin needs to be titrated to an optimal does to be effective, yet doctors are prescribing an estimated dose that does not work. The Modified Conners rating scale done before and after starting medication will show very accurately if the doses are effective. An effective dose has nothing to do with age or weight but how they respond to medication.

Occupational therapy is still recommended for young ADHD patients despite the fact that research suggests, it has no value. It boosts the right brain while medication tries to boost the left brain. OT does have a value but not for ADHD. I have over 400 parents who tried OT prior to coming to see me for their child's ADHD. Not one found any benefit from OT. Can they all be wrong?

Many patients are referred to psychologists initially for a neurological conditions like ADHD, despite a previous Minister of Education suggesting a medical diagnosis is needed in an official notice to schools from the Department of Education and Culture , from the House of Assembly. Psychologists have no training in neurology. Moreover they sometimes advise on medical treatment despite having no training in pharmacology. An article in the SAMJ some time ago warned of the dangers of this situation. However, psychology certainly has a value for psychological problems.

Doctors may suggest that "drug holidays" are advisable despite this having a negative effect on the chances for success. Every day treatment is essential. In the very hyperactive child, the bad behavior during the week end off medication can be a major problem.

Many doctors are prescribing the short acting 10mg Ritalin as a "once a day" treatment, despite it only been effective for 4 hours. The "rebound phenomena" when Ritalin fades is being ignored. As Ritalin is a stimulant it must not be given too late in the day so as not to cause insomnia. I have seen a prescription from a paediatrician for Ritalin to be given at night only. The pharmacist could not believe this and phoned the doctor. The doctor insisted. That's why the parents can to see me as the evening dose was causing major problems with insomnia.

An article in a South African news paper suggests that homeopathic medication is effective for ADHD. Yet research in the UK, America and Australia suggests homeopathic medication does not work. I have a small series of children with ADHD who were given homeopathic treatment prior to coming to see me. Not one was successful.

There is confusion regarding the danger of addiction for stimulants used to treat ADHD. In other countries Dexamphetamine is still prescribed but it may cause addiction if abused. In South Africa it is banned. In South Africa, Ritalin and Concerta are both Methylphenidates which is not addictive but may be abused.

The above is just a brief summary of the confusion and misinformation regarding ADHD treatment. There is as much confusion about the causes of ADHD. It is a proven neurological inherited dysfunction, where the right brain develops too much or the left brain is immature. Either, one or the other or both in varying degrees from mild to severe. ADHD and ADD are not the same. The former includes behavior problems. ADD is a learning problem.

Some time ago I was informed that athletes participating in some national events are forbidden from using their Ritalin despite it having been prescribed by a doctor. Did they know of the dangers of not taking this medication. They reasoned that taking a stimulant was not acceptable and unfair. What they did not know is that when used for ADHD is normalizes, not boosts athletes ability. When used illegally in non ADHD people it may boost ability.

Keith Conners a famous American and the developer of the very effective Conners rating scale, suggested in a book he has published,that there is no confusion among experts, only minor variations. However there is major confusion among non experts.

There is more than enough correct, scientific information currently available, for anyone who is interested enough to make the effort. to study available information. However, this does not mean the final word has been published. Time will tell.

Dr Billy Levin - 30/8/15

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