“I have been thinking all these years that he was not ADHD...I feel like I was the only one who believed it”
(The mother of a bipolar child)
Attention Deficit Hyperactivity Disorder (ADHD) has become a household word, or as Mark Gluckman said, the “flu” of psychiatric diagnosis.
It was in 1902 when Sir George Still, in article published by The Lancet, described people with a defect of attention but for 35 years nothing really happened until Dr. Charles Bradley reported a “spectacular change in behavior” in children who took the stimulant Benzedrine for one week1. Even though the results were quite striking, to confirm how slowly things move in psychiatry, it was in 1963 when the results of the first trial with methylphenidate (Ritalin) were published by Dr. Keith Conners and Leon Eisenberg.
Now ADHD is such a casual term that usually parents do not appear to be distressed by the realization that their child has this condition. For example, at a clinic in Arizona, 90% of the children were on Ritalin or some other type of stimulant medication when they were referred to me with the ADHD label. Half of them had been wrongly diagnosed but that is another story which I will present in detail throughout several chapters. I want to define ADHD and to look at its symptoms not only to contribute to the understanding of this condition but also to help you to figure out what ADHD is not. I actually look beyond mainstream’s conclusions and want to explain that hyperactivity can be more than just ADHD and to show several examples of “hyperactivity” as a symptom of a totally different problem.
In support of this idea, through the years I developed a list of multiple reasons that can explain hyperactivity in a child. This is how it looks on my office’s wall:
• Anxiety, as in Social Phobia or Generalized Anxiety
• A medical condition (problems with thyroid, malnutrition, etc.)
• Psychosis (hearing voices, paranoia, delusions)
• Flashbacks from traumas
• A racing mind, as in people with elevated mood
• Explosive aggression as in Intermittent Explosive Disorder
• Depression accompanied by anxiety
• Low IQ
• Learning disabilities
• Tics (as in Tourette’s Disorder)
• Absence seizures
Based on such possibility I keep repeating a very important fact: ADHD is a medical condition. This concept is accepted and disseminated even by the people who can benefit the most from the exaggerated (and false) prevalence of ADHD. One of them, the pharmaceutical company Alza Corporation, a subsidiary of McNeil Laboratories, maker of Concerta (a popular ADHD medication), distributed a pamphlet entitled “A Guide for Parents on Effective Management of ADHD.” It states:
“Establishing a diagnosis of ADHD is complex and requires information obtained from multiple sources, such as parents, physicians, and teachers. The diagnosis is dependent on the report of characteristic behaviors observed by parents and teachers and includes input from the child in addition to the physician’s examination of the child.”
As you can see, this is the same reasoning that we follow to bring a car to a mechanic instead of calling a plumber to fix it. In other words, psychiatrists, either on their own or following a provisional diagnosis formulated by a therapist, a pediatrician or Primary Care Physician (PCP), should do the final diagnosis of psychiatric conditions. Unfortunately, throughout the USA something very different is happening, as can be corroborated by the dramatic and sad examples presented here. They show the terrible consequences that prescribing stimulants for an aggressive or hyperactive child, misdiagnosed as ADHD can have.
This is not to say that a child afflicted with ADHD cannot be aggressive but it is the nature of his aggression that makes the difference. In the ADHD child the hostile behavior usually looks clearly impulsive and frustration-driven rather than deliberate, predatory aggression. Beyond this example of a practical fact, I want to share other basic concepts to help you to deal with a possible diagnostic confusion. For example, an important diagnostic criterion is the age of onset. If a child who did well in Pre-school or Kindergarten begins to have behavior and learning problems in first grade, chances are that ADHD is not the cause. This type of problem is present from the very beginning when caused by ADHD. The reason: ADHD is a genetic disorder of early childhood that becomes apparent when the child starts to perform tasks requiring attention and concentration. Unfortunately, it is common to see a child that was diagnosed ADHD, for the first time, while in third or 4th grade, despite a history of good school performance in first and second grade.
Supporting my view in this respect is the textbook of psychiatry by Kaplan & Sadock that describes some of the characteristics of the infant who’ll be identified later as ADHD. The authors say that these babies are very sensitive to stimuli and easily disturbed by noise and changes in the environment. They also affirm that these children are more active in the crib and require less sleep than the average baby. I find it interesting that parents of children and adolescents with bipolar disorder report similar experience.
Because it is usually the most important and most forgotten tip, I want to repeat it:
If the child did well in K and First Grade it is not ADHD.
Another hint: “ADHD is not an intermittent condition.” If, for example, a mother reports that her son “can be very good for one week and then out of control for 2-3 weeks,” we should take a meticulous look into the family history and search for conditions like a mood disorder, anxiety, explosive displays of rage, sexual abuse, psychosis, and etc.
To illustrate this idea here is comment from a foster mother:
“When she is by herself, you can’t ask for a better child.”
She was referring to a 6-year-old girl whose biological parents are both alcoholics and the father “extremely aggressive.”
The genetic link between that little girl and her father was neglected by her first evaluator who forgot that “maybe, the apple did not fall too far from the tree” and gave her an ADHD diagnosis which was treated without success.
Another relevant fact is that when Ritalin (or one of the amphetamines, i.e. Adderall) is given to an authentic ADHD patient, the usual response could sound like this:
“I have a new child… this is a miracle, a complete change.”
In the presence of a minimal response, we should suspect that it’s because stimulants improve attention even in people who do not have a deficit or that the initial dose was insufficient. On the other hand, if a child is treated with a stimulant and his symptoms get worse, there is not a scientific reason to increase the dose. My experience with more than 2,000 children evaluated in the past nine years has demonstrated the validity of this equation:
Worsening of symptoms after a treatment= Wrong diagnosis
A mild improvement or no response could be a valid indication that an increase in the amount of medication is needed.
The above-mentioned textbook (Kaplan & Sadock) clearly states that, when used for ADHD, amphetamines do not induce tolerance (dependence or addiction to the drug).
By the way, a very popular myth is that amphetamine medications cause a predisposition for substance abuse to people with ADHD. Psychologists and psychiatrists from prestigious universities have written several papers stating that such risk does not exist.
The truth can actually be the opposite. Children with ADHD will never become addicted to stimulants for this simple reason: they don’t get a “high” with cocaine or amphetamines. On the other hand, many of those misdiagnosed, as ADHD will search for a “home remedy” (i.e. marijuana) in the street to appease their mind, especially after being bombarded with Ritalin or one of its partners. I use the word bombarded because I have seen the suffering of youths who are desperately needing something that could slow down their racing thoughts and, instead, they are prescribed with a substance that accelerate their fast-running mind even more.
At risk of sounding like somebody who tries to justify addictive behavior, it is fair to say that, when doctors fail or the individual refuses to ask for help his pervasive anxiety will find shelter in alcohol or marijuana. Depressed individuals can become addicted to the short lived happiness that cocaine or “crystal meth” can give to them. By the way, eating disorder patients know that they will lose appetite with these substances. Psychotic individuals can “normalize” their thoughts with heroin, and so forth.
Going back to the strategy of increasing the Ritalin dose when the symptoms get worse after the first trial, I remember the case of a 7-year-old boy who has ADHD in addition to being the victim of sexual abuse and neglect. When he was 5, one psychiatrist kept increasing the dose of Ritalin up to 45 mg (more than twice the maximum dose for his weight) until he finally realized that Ritalin was not helping this boy.
The reason for the “medication failure” was a simple one: besides his ADHD condition he also has severe anxiety and attachment problems. Since amphetamines are not a treatment for anxiety (in fact they worsen it) it is hard to understand what kind of expectations the treating physician had.
As you can see from stories like the one of that 7-year-old boy, I feel comfortable enough to say that a significant part of the research data on ADHD and other childhood disorders is questionable at best. However, that particular issue will be discussed in a separate chapter. At this point let’s continue to talk in a common language about ADHD.
Simple and practical observations help to avoid misdiagnosis; i.e., the child with ADHD cannot be quiet, but the one with Bipolar Disorder does not want to be quiet… his hyperactivity only disturb those around him. One manic individual told me once:
“I don’t suffer from mental illness…I enjoy every minute of it!"
And never forget this fact: any person, including a child, can have more than one illness at a time. I have found several cases of children who have ADHD plus another psychiatric diagnosis. If you only treat one of them, the outcome is not going to be good.
As diagnostically challenging as the 7 year-old boy mentioned before were two siblings with the same parents but with different diagnoses: One has ADHD and the other a mood disorder, a situation that seems to be supported by several investigators who have postulated that the same set of genes accounts for several psychiatric illnesses. But it gets more complicated. One of them, after three years on Adderall (and doing well) began to show aggression, drastic mood changes insomnia and a decline in school performance. At 12 year-old she is now on mood stabilizers, like her brother and her parents.
Another aspect of the ADHD diagnostic confusion is the frequently attributed aggressive behavior. Many clinicians connect aggression with this illness even though the official classification (DSM-IV) does not include aggression as a diagnostic criterion for ADHD. Additionally, the “DSM-IV Handbook of Differential Diagnosis” (page 17) under “Decision Tree for Aggressive Behavior” does not even mention ADHD.
Nevertheless, frequently parents are led to believe that aggression is a component or a symptom of ADHD. “He strikes out when frustrated,” some clinicians will say. Though that makes sense, it also makes sense to realize that such “aggression” is not predatory or out of proportion as seen in other conditions.
With a very high frequency I see that other type of aggression and defiance (which it is typical of youth with mood problems) linked to an alleged ADHD diagnosis and then called Oppositional-Defiant Disorder (ODD) or, in the worse scenario, Conduct Disorder. In all the instances that I have observed a child with the ODD label, he was actually showing an elevated mood or was afflicted by anxiety or had been sexually or emotionally abused.
It seems clear to me that behaviors were a reaction to other identifiable explanations, that were missed by evaluators, but never a deliberate act of defiance.
This is why I encourage parents to do whatever it takes to get the ODD diagnosis deleted from their children’s record because such label implies a malicious intention to misbehave. Just think of how unfair that label is for a child who is refusing to attend school because he has Social Anxiety Disorder (also called Social Phobia).
But it can be even worse. I have seen cases of Mild Mental Retardation diagnosed as ODD because they “refused” to do the school work, however nobody considered the cognitive deficit. For more details you should read the chapter “There is not such thing as ODD.”
Another important concept to keep in mind is this: the ADHD diagnosis is a clinical one. What this means is that no test has been officially accepted as valid to corroborate or rule out the presence of ADHD. We determine that a child has this condition by using clinical skills and experience. Several investigators (James McCraken, MD at UCLA among them) are looking for that genetic test that can say, “beyond reasonable doubt, this is ADHD.” At the anatomic level, in 1995 Dr. Judith Rapoport reported that her group at the National Institute of Mental Health found a decreased volume in the brain structures known as the Caudate Nucleus and the Globus Pallidus. She compared 57 boys diagnosed as ADHD with 55 healthy control subjects.
At a more sophisticated level, in terms of neurotransmitter (chemicals involved in the regulation of moods and feelings) evidence points in the direction of the Dopamine and Nor-epinephrine receptors (a specialized chemical structure that receive the messages communicated by the neurotransmitters) but nothing is definitive yet. But, even if a test like this is available, it is so expensive that we still must rely on the clinical interview and observations reported by relatives and teachers. In most case we have do “detective work” and to pay attention to every word the child says or gestures displayed during the evaluation.
This is an illustrating example: During the interview of an 8-year-old girl, while talking about the speed of her mind, I asked if her mind was slow or fast upon awakening. This is what she said:
“My mind is slow in the morning…after I take my pill (Adderall) it goes fast.”
At this point I asked if with the increased speed of her thoughts if it was easier or more difficult to think and she responded:
“It is kind of hard to think.”
And then she proceeded to talk about the “good” side of her brain and the “bad” side and how each side tell her nice and nasty things, respectively. To my surprise, her brother, who was almost 10 years old and only 59 pounds, was not experiencing hallucinations despite being on 120 mg of Concerta (another brand name of Ritalin) which is the highest amount of this medication that I have seen prescribed to a child who weighed less than 60 pounds. That boy also was taking 60 mg of Strattera (a non-amphetamine drug for ADHD) and clonidine, a blood pressure-lowering drug that helps aid sleep.
In my experience, asking if the medication for ADHD “helps you to think better or not” can be helpful but only when the answer is understood in the context of the whole picture, which includes the symptoms that prompted the evaluation, family history, demeanor during interview, the presence or the absence of anxiety, psychotic symptoms, rapid mood changes, etc. All of this, complemented with the answers to clinical questionnaires such as the bipolar spectrum scale, the Incomplete Sentence List or the Conners Behavioral Scale.
When asking younger children about the speed of their thoughts, I usually move my hand at 3 different speeds and ask them to pick up the one that resembles how fast the brain is thinking. Other times I use a piece of paper to draw circles while applying increasing speeds to my hand, starting with the “slow mind” (numbered one) and continue with a “number two” that is going medium speed. “Number three” “goes” really fast.
It should be said that normality usually goes unnoticed and that the opposite applies to abnormal situations. For example, if we are asked “how fast is your heart going?” we will have a hard time figuring that out. But if we have been jogging we become aware of the heart rhythm. Something similar happens with the speed of our thoughts. If they are going at normal pace we are not even aware of the thinking process; but if it is too slow, i.e. alcohol-intoxication with slurred speech, or too fast, as in the case of one person with elevated mood who declared:
“I am trying to fall sleep and my brain keeps going... I wish I could shut it off and fall sleep,”
That awareness immediately becomes a painful reality.
I became a believer of children’s ability to accurately report racing thoughts because I had the fortune of witnessing the following: A five-and-a-half-year-old Caucasian boy was admitted to an inpatient psychiatric hospital due to out-of control behavior at home and at his Day Care Center. He had been on 20 mgs of Adderall (a medication that combines four types of amphetamines) until a few weeks before his hospitalization. He was hitting children and adults, masturbating constantly, speaking about “a man that was talking to him in his head” and addressing authority figures with an adult-like demeanor.
I asked him this simple question: “How fast is your mind going” and he gave me this amazing answer:
“Fast, really fast, so fast that I don’t even know what I’m thinking”.
At the same time, he jumped from one chair to the other and said:
“I’m half monkey”.
This happened in Arizona where his father was raising this child by himself. The boy’s mother left the family, during an episode of mania, when they were living in a southern state and she never came back. A psychiatrist in his native state started him on Ritalin before the father moved to Phoenix where a pediatrician switched him to Adderal. He ended up admitted to Charter Hospital in Glendale, AZ as a “bad case of ADHD.” In less than a week he was able to sit quietly after Valproic Acid and Risperdal (mood stabilizers) completely controlled his misdiagnosed “ADHD.” His mind was no longer going fast.
As you can see the key to a good diagnosis is still based on good history and a complete mental status examination. Unfortunately, many professionals chose to “shoot from the hip” and rush into fast diagnosis. Others do not even bother to make a diagnostic evaluation and take as valid what a non-physician allied professional suggested, “after testing for ADHD,” which as I already said, is not possible because there is not a valid written test for this illness.
Considering the scenario presented in the preceding lines we can understand the surprise of a mother who stated:
“I am amazed that you are actually taking notes and expending time talking about my son…These other doctors scare me…They handled me a Ritalin prescription without asking half of the questions that you have today.”
Her twin boys were on Ritalin during 4 painful years and another 6 months on Adderall. She stopped the second medication after a very smart case manager suggested having the boys free of medication until the appointment already scheduled with me. They showed clear improvement in aggressive behavior and decreased clowning just by being without the stimulant. As in many other cases, that mother was in treatment for bipolar disorder and she described the children’s biological father as “the most hyperactive person I have seen in my whole life” and said that he also was a class clown.
In the following pages I am going to present several real-life stories that illustrate how pervasive these diagnostic confusions are. They also provide living proof of the actual age when mood disorders can begin.
The Half Milligram Miracle
“Ashley” was a beautiful 27- month- old girl referred to a child psychiatrist by a Glendale, AZ, psychologist. Her mother is very assertive lady, who divorced the girl’s father soon after her daughter was born, due to his persistent spousal abuse and refusal to get treatment for his well-established diagnosis of Bipolar Disorder. The psychologist’s diagnosis was confirmed by my assessment and I started the little toddler on Depakene (a mood stabilizer a seizure medication) that made the girl less aggressive toward other children but she still would not go to sleep until midnight, even without taking naps. During follow up visits she exhibited destructive/aggressive play in my office and the aggression toward other children re-emerged.
After being on therapeutic levels of Depakene for several weeks and having tried Vistaril (an anti-allergic drug), without good results, I prescribed 0.25 mg of Risperdal, another mood stabilizer. There were no side effects but no improvement was observed. After 4 weeks the dose was raised to 0.5 mgs with only a minimal decrease in her aggression.
She was the blond and smaller version of Melissa, another girl mentioned in several chapters; because when she came to office’s reception area she would shout “Dr. Mota!!” and run toward me like a tornado.
In April 2000 during a regular follow up appointment something extraordinary happened. That day, the first voice I heard came from the mother:
“Doctor, what a miracle half a milligram can make!”
Not understanding the meaning of her statement, I asked for her daughter and she responded:
“This is the miracle I am talking about. She is behind me”
In an act of desperation, the mother had increased the Risperdal to one milligram the week before (something that parents shouldn’t do without consulting the doctor) and, fortunately in this case, there was no harm. In fact, the little girl was a “completely different child,” as her mother would describe her later in the conversation. For the first time since starting medication treatment, she sat quietly to play with the Legos and there was no disruption in the office or aggressive destruction of toys.
Five years after that experience the public opinion is more open to the idea of medicating children but not a two-year old. I do not share the fear but, as a father of six children, I understand how it feels to give medication to a little girl. Nevertheless, from a more objective point of view, when it comes to preserving the brain of that precious child, and I am 100% certain of the diagnosis, I don’t hesitate to offer medication to a toddler in need of treatment. Besides, pediatricians use Depakote for children the same age with seizures and nobody even blinks. I have to continue discussing ADHD but I will take a few more lines to disperse the fears around medications in children. To start, given the wrong medication for a wrong diagnosis is bad for anybody but given a necessary medication should never be denied on the sole base of age. We should keep in mind that, Risperdal (the medication I prescribed to the little girl mentioned above) decreases the amount of dopamine in the brain, which is exactly the opposite of what Ritalin, Concerta and Adderall do. When psychiatrists modify the levels of that substance with psychotropic drugs many eyebrows are raised but when a pediatrician actually administer pure dopamine to a three pound baby who is fighting for his life everybody welcomes that treatment. In the Neonatal Intensive Care Unit it is common practice to give intravenous dopamine to babies in septicemic shock (a severe generalized infection that overcomes the body’s natural defenses) without concern for the safety of the“developing brain” the anti-psychiatry groups love to present as threatened by our treatments.
One last question: have the objectors ever asked a parent like the mother of “A” how she feels about the opposition against the professionals that returned happiness to her home?
I would love to hear the answers.
A Whole Family with Social Phobia
Can you imagine a safari guide mistaking an elephant for a zebra? Hard to believe but something like that happened in a town in the outskirts of Phoenix, Arizona. A 10-year old boy was diagnosed with ADHD and ODD because he was refusing to attend school. The child was being very nervous in the classroom (“hyperactive” was the description of his behavior) but he ended up completely unable to stay in the school for more than one hour. When he came to the clinic for a psychiatric evaluation, his mother had to drag him into the office. He was avoiding eye contact and kept asking “when are we going to be done with this?” A few minutes later his mother explained that I should take no offense for his behavior because he always felt uneasy around any stranger.
“He never goes to shopping malls or restaurants. That’s why we live in the desert; his father is just like him, or maybe worse. I am here because somebody had to get out but I am uncomfortable too.”
A diagnosis of Social Anxiety Disorder was made and he was started on 5 mgs of Paxil. In the second visit, 2 weeks later, he still had pretty much the same nervousness. The medication was increased to just 10 mgs to avoid possible side effects that could sabotage the tenuous alliance being started. That day I also had the chance to evaluate his 12-year-old sister who presented with similar symptoms. In the 6th week of treatment this boy walked into the office without arguing or pestering his mother in the reception area. He made normal eye contact and exchanged a brief conversation about his experiences of being back in school for half/day, which was a drastic change from his “Yes” or “No” answers on his first two visits. At this point I began to plant the idea in his mother of getting treatment for herself because she was very pleased with the changes she was observing in her son and I increased his medication to 15 mgs.
To make the story short, after three months of combining medication (20 mgs now) and cognitive-behavioral therapy for him, plus “in home” Family Therapy provided by a skillful and dedicated therapist, the boy was ready to start his full time school attendance. His sister was also doing better and his mother had gone on Paxil too, prescribed by her PCP. Just a few months after the beginning of treatment, both brother and sister were attending school like any regular child their age. Their mother was doing better with her symptoms. It was a success story but how scary it is to think that this child was diagnosed ADHD and prescribed Ritalin, a medication that, as should be expected, worsened his anxiety.
To conclude this story, and as this is not a soap opera but real life, I should clarify there was not a completely “happy ending.” The father refused to go into treatment because he does not believe in medications. He is also the one with the most severe symptoms in the family. His wife explained how they met when she was told about the idea of including her story in a book and in a Case Report, she smiled and explained:
“We met through mutual friends… He can stay inside the house for 3-4 days. I don’t care for going out… In the supermarket I feel uncomfortable with so many people.”
With a big and sincere smile she stated:
“I still get nervous when I talk to people.”
They live on a 10-acre farm and the closest house has been vacant for many years. Until they got into treatment, their way of life was interpreted by the family as “just the way we are.” They did not suspect that “enjoying” isolation was their way of coping with a mental disorder.
Even though many people know about Social Phobia because Paxil and Zoloft have been advertised on TV and magazines, I should explain why an antidepressant medication works for this condition and that not only Paroxetine (Paxil’s generic name) but also all of the “SSRIs” can improve the symptoms of anxiety, OCD, Social Phobia, Panic Disorder or Generalized Anxiety Disorder. “SSRI” stands for “Selective Serotonin Re-uptake Inhibitor.”
The following drawing is the graphic expression of a 10 year old girl who was diagnosed ADHD because she was “restless and inattentive” in class. In fact, she was only nervous about leaving home.
The word selective was included in the name of this category because other antidepressants, like imipramine, also work on the serotonin receptors, but not exclusively. The first SSRI was Prozac (Flouxetine) released in 1988. Paxil was the second, soon followed by Zoloft (Sertraline) and Luvox (fluvoxamine). More recently, Celexa (citalopram) was added to the list and 2 years later its manufacturer developed an improved form of citalopram and named it Lexapro (estacilopram). It should be said that several organs, including the brain naturally produce serotonin. A deficit, or an excess, of serotonin in the brain affects mood and aggressive behavior but in other parts of the body it can be responsible for skin reactions and diarrhea, to mention just a few of its other actions. The various SSRIs have almost similar effects but the side effect profile (unintended reactions) can be different. They differ in terms of their “half life,” which is the number of hours the active substance and its derivatives remain in the blood after ingesting one dose of it.
Until three or four years ago investigators thoughts that Paxil could be the least likely to induce mania in a person with a family history of bipolar disorder or actually having the condition but the pasges of time has proved all antidepressant are equally guilty of aggravating and/or triggering mania. Once again, this is not a book aimed to educate psychiatrists and clinicians, but parents, patients and the teachers that have to deal with emotionally disturbed children. By including this type of information I intend to provide you with the technical jargon commonly use by doctors.
The Youngest Case of Mania
C K was 25 months old when he was referred to me by Dr. Alicia Torruellas, a clinical psychologist practicing in Phoenix, AZ. Dr. Torruellas’s skillful clinical knowledge made her realize that the little boy had more than ADHD, as the day care center suggested.
C K’s parents noticed that something was wrong, when he began to display unprovoked aggression at home and at several day care centers. Within months he’d been expelled from five of those centers, and a baby sitter quit the job and his mother was covered with bite marks and bruises. Both mother and father are non-aggressive people and very loving parents, but the father has Bipolar Disorder and the mother suffers from depression. When he entered the office he was elated, hardly re-directedable, very restless and hyperactive, but with a clearly elevated mood. After gathering all the history, parents were presented with the possibility of using a mood stabilizer. It was easy for them to make the decision, not only because the father was taking lithium but also because I told the parents that children younger than her son take valproic acid for seizures, without any major problem. She was also reassured that I would monitor his liver function and white blood cell count as recommended by the drug manufacturer.
His case and several others were reported in the Journal of Affective Disorders, March 2002 issue. The following is a compendium of what was reported in the scientific journal: I started him on 125 mg of the liquid valproic acid (brand name Depakene) and there was an immediate improvement in his behavior but the amount was later raised to 250 mgs. He never had a side effect during the one and a half years that I treated him. But he is not the only one. In less than a year I evaluated several two and three-year-old children with a variety of symptoms which, I suspect should bring this question to your mind: Why do these cases come to Dr. Mota and not the other professionals? The answer is a simple one: The referring insurance company could not find another psychiatrist that would accept a child younger than 4 years old. That was true in 1999 in Arizona and, six years later, the same was happening in Orlando, Florida. Maybe I should explain what seems to be a “never talked about” big misconception about mental illness. Apparently there is a “secret agreement” (or a huge denial?) to believe that early childhood is a shield or immunization against mental illnesses. Very few people will entertain the idea that a two-year-old can have OCD or anxiety, not to say a Mood Disorder. Paradoxically, the majority of professionals do not have any problem in giving a serious diagnosis, like autism or leukemia, to a child of the same age.
Here are several enlightening stories about small children:
The Gatorade Boy
Francisco was a three-and-a-half-year-old Hispanic boy referred by the counselor that was working with him. His pediatrician had diagnosed him with autism, a year before because he was not talking, and the only food that he would eat was Gatorade and soda crackers. He was even hospitalized to search for a physical condition but nothing was found.
When I met him he was engaging, had normal eye contact: he would not speak but indicated what he wanted using his hands. He did not have a history of ritualistic behavior and willing to participate in normal playing with siblings and other children, although he didn’t talk.
I explained to his mother that Francisco was missing the basic element in autism, lack of relatedness to other people. My diagnostic impression was something in the realm of OCD and I started him on the smallest amount of liquid Prozac that can be measured to gradually increase it to 2.5 mgs/day in a four weeks interval.
At the 2.5 mg dose, two months later, he grasped a piece of hamburger from his older sister. He ate the whole portion, and after that he added another element to his diet. Twelve months after his first visit he was saying several words, eating tortillas and drinking milk.
I do not know what happened after that because the family moved to another state and I lost contact with them but I have no doubts he was not autistic.
The Batman Boy
“Tommy” was a 3-year-old when he was referred by his day care center because he was refusing to take off his Batman costume and would throw a fit if somebody called him by his real name. He demanded to be called Batman at home, he would not let his cape be removed to take a bath, and his parent also had to call him Batman.
His mother was a smart and sophisticated Caucasian lady who was familiar with the diagnosis of OCD because of personal experience with several relatives and her own readings. She agreed to start him on liquid Prozac and continue it, even after the day care staff asked her to report me to the Board of Medicine for giving such a strong drug to a little child.
In less than a month, Tommy was allowing people to call him by his name and by the 3rd month he completely forgot about the Batman costume. At that time, 1997, I was not aware of any study of Prozac in small children, but I knew that several studies did not find any harm to fetuses when pregnant women took the medication.
The rationale was that at the fetal stage the brain is undergoing more significant development than at age three, and if it did not do harm to a fetus, it should be safe for a three-year-old. At the last follow up, three years later Tommy was just fine.
One more time grandmother’s knowledge would explain the establishment’s apathy:
“The blindest man is that one that refuses to see.”
There is perhaps nothing we can do to change the willing blind but we can refuse to be restricted by their wrong beliefs.
The Runaway Boy
“He is very smart and will do well in class, if he wants to... He can be loving and caring but it will be hell if he does not get his way...He always thinks that he is the man of the house.”
With these words an African-American grandfather in Central Florida described his 13-year-old grandson. The boy came into his care after his drug addicted mother lost custody due to neglect. Even though she abused cocaine and alcohol when pregnant with him, his intellect appears to be above average.
At the time of evaluation he appeared to be a happy boy but also very defiant to authority figures to the point of leaving home to spend the night with friends if he was frustrated with household rules.
Not surprisingly, he was on a high dose of Adderall (amphetamines) in combination with two mood stabilizers (Depakote and Risperdal) because he was diagnosed, not only with the “evil triad” of Oppositional-Defiant, Conduct Disorder and ADHD, but also with Bipolar Disorder. A psychiatrist who gathered a family history of mood disorders and substance abuse added that last diagnosis, instead of deleting the wrong one. I felt compelled to fix the diagnostic confusion and to discontinue the Adderall because, even if the boy actually had ADHD, it is nonsense to prescribe together two drugs that antagonize each other as is the case with Adderall and Risperdal: One increases dopamine and the other reduces the level of this substance in the brain.
A year after our first meeting, the grandfather reported that his grandson’s behavior had improved and there were no more episodes of running away or defiance. In school he was getting excellent grades which confirms he was never ADHD but bipolar from the very beginning.
The Child Who Reads Charles Dickens
“A giant stream of air is trying to lift up my head.”
This was B.D.’s description of his racing thoughts at the time of his evaluation. He presented as a very healthy and handsome 13-year-old boy, described by his father as having a superior intelligence, even though he was born, in 1989, weighing only 4 lb., and needed a medication to help his lungs mature enough for normal breathing.
He was referred to me by a hospital in Florida after he received a few days of involuntary inpatient treatment prompted by a comment he made to his teacher. B.D. said: “I am going to blow my head off.”
The interesting part of this story is that this happy and very articulate boy was not depressed or suicidal but very distressed by the discomfort of a fast-firing brain and auditory hallucinations. Reading was like torture for him because his thinking could not state focused on the book’s subject and his mind wandered while his eyes were looking at the lines of words. He also admitted to losing his temper easily and described “trance-like episodes” when he gets angry.
“I want to get everything right on the first try or I will explode… I hear my name being called.”
“He believes he is an adult,” father said. And B.D. admitted to feeling that he knew better than his teachers do.
After two weeks on 300 mgs twice/day of lithium and 0.25 mgs of Risperdal he reported a mild decrease in his racing thoughts but stated:
“I still can’t really catch up with anything I am thinking.”
He had no more auditory hallucinations but sleep was still difficult due to his racing mind. The lithium level was 0.5 (effective levels should be around 0.8 to 1.1) and all his blood tests were within normal range, which supported an increase of Lithium dose to 900 mgs/day and Risperdal to half milligram/day.
A month after that, a very relaxed B.D. walked into the office with the Charles Dickens book “A Tale of Two Cities” which prompted this comment from his mother:
“He eats books.”
Then he gave the most impressive description of going back to normal brain function a child his age could ever state:
“My mind has been going on so fast for years that now it is catching up with its breath.”
No wonder this boy scored 600 just in the math component of the SAT, even thought he was only in the 7th grade. He does not have racing thoughts anymore and his attitude toward his teachers now is very different:
“I just sit down and learn whatever they have to teach me ...No, I don’t think I know more than them.”
His weight, after two months on medications was two pounds less than his starting 102 lb. (a surprising finding because his medications are known to increase appetite) while the only reported or detected side effect was a mild tiredness that it is not interfering with school performance.
There is Not Such Thing as “Terrible Twos”
Another popular myth that interferes with proper diagnosis of small children with behavior problems is the misconception about alleged “normal” aggressive behavior around 24 months of age. Prominent pediatricians, such as Alan Greene (not to confuse with the outstanding Harvard professor of psychiatry Alan Green) has written books and comments about it in his popular website. Again, it is another by-product of the same problem that we address throughout this book: The best pediatrician in the world still is not a psychiatrist and the best psychiatrist is not a pediatrician, unless your last name is Rubin, Dana in Boston and Mark in Phoenix, and you trained in both pediatrics and psychiatry.
If you talk to the parents of children with a psychiatric diagnosis and ask about the beginning of first symptoms, in many cases they will tell you that it was around the age of two or even before.
I believe that it is important to burst this mythical bubble because it deprives children of prompt diagnosis and treatment, which in many cases can hurt the self-esteem of those children that are disliked because of unruly behavior. Of course, it is less painful to take the ostrich’s strategy and hide away from the problems, pretending it is just a faze, but we need to remember that it is not a solution to the problem.
If you take that route, the Internet can become your house of dreams because an abundance of dreamers maintain shelters where they can escape from reality. They are not excellent pediatricians, like Dr. Greene, but individuals without a real knowledge of what constitute normal development in children. For example, one of them claims that it is part of the normal development of a child to kick, bite and hit.
That would be a bad news for me because then I have 6 very abnormal children.
From “The Worst” to the “Most Improved”
A 10-year-old Florida boy and his very determined mother did everything possible to prove the psychiatric/educational establishment wrong. His pediatrician prescribed him Ritalin in 1st grade, even though the child’s father has been diagnosed with bipolar disorder, and was described as a violent person.
When I first met him, his mother was extremely frustrated because she was convinced her son was afflicted with the same condition his father had but his previous doctor stated repeatedly that he was too young to be bipolar. Describing his behavior, the mother said: "there is no reasoning with my son.” In school he had been suspended several times while taking 30 mgs/day of Dextrostat (a brand of amphetamine) that was making him angrier, according to mother.
I discontinued the stimulant medication and started him on 2.5 mgs of Zyprexa, a mood stabilizer that yielded a remarkable improvement. In a matter of days his whole demeanor started to become “the child he used to be,” his mother said, but he was sedated in the morning when the dose was increased to 5 mgs. Then he was switched to Risperdal with continued positive results, without the sleepiness.
After 4 months of corrected treatment and diagnosis, he came to proudly show me his ROTC award as “the most improved”, wearing a smile, full of pride. He was oppositional-defiant no more.
The only sad part of this outcome is that the establishment may choose to ignore stories like this, which make me wonder what could be a different explanation for such a transformation? …why should this boy labeled oppositional-defiant if the bipolar diagnosis (inherited from his father) could explain his behavior?
Two plus Two= Five?
The story of Pablito is another one that you will find hard to believe. He was born in the same psychiatric hospital where his mother met his father and at the age of 18 months a nice and caring Puerto Rican lady adopted him.
Hyperactive from the beginning, he would jump from his cradle to the floor; his mother told me 11 years later. By the time he was four-years-old, it was necessary to have him evaluated by a psychiatrist at a major teaching hospital in New York City.
Despite the adoptive mother’s report about Pablito’s biological parents (both schizophrenic) he was diagnosed ADHD and prescribed Ritalin. That was the beginning of a painful ordeal that ended when I diagnosed him with a psychotic disorder and switched his medications from Adderall and Clonidine to Zyprexa and Depakote. That was in August of 2003 and he did so well that his follow up appointments were scheduled every 3-4 months. Unfortunately, after two years he stopped taking medications and deceived his mother about his compliance with treatment.
When I hospitalizing him my thoughts were that the possibilities of schizophrenic parents having an ADHD child are similar to Japanese parents having a Navajo or Apache boy… or 2 + 2 being equal to five
An Adult Conspiracy?
In 1994 Frankie was 3 year old when he began to show sexualized behavior and severe temper tantrums. His aunt (and foster mother) took him to a pediatrician who told her that nothing was wrong with the boy. A year later his behavior escalated to the point that he was “terrorizing” the classroom in Pre-K.
His teacher, in Phoenix, AZ, told Frankie’s mother:
“Either you put him on Ritalin or we are not going to take him in Kindergarten.”
He was taken to his pediatrician with a behavioral questionnaire and a note from the school with the boy’s diagnosis, as determined by the educator. The doctor wrote a prescription for the drug and he was accepted in school.
A few weeks later he began to exhibit more aggression and was staying up late during the night. His mother took him back to his doctor and he was given clonidine to help him to sleep and Ritalin was replaced with Dexedrine which is another amphetamine. As could be expected (because he was still on the same type of medication) nothing changed except for an improvement in his sleep.
Multiple medication adjustments and combinations characterized two years of serious behavior problems at home and school. Because he was not getting any better, his pediatrician requested a psychiatric evaluation for “this severe case of ADHD and ODD.” The poor boy was “upgraded” to oppositional-defiant because, according with the teacher and the doctor “he didn’t want to change his behavior even with appropriate treatment for ADHD.”
When I was faced with this “defiant” boy (in fact showing an elevated mood) and I heard the family history of mood problems, violent behavior and substance abuse, Frankie left the office with a prescription for Depakote and the advice to stop the Adderall (combination of 4 amphetamines) he was taking.
There was an immediate improvement in his behavior, but still his mother only heard a negative comment from the pediatrician:
“This medication is only going to make him gain weight.”
“Good” said the mother, referring to the fact that he was underweight. But the big surprise came from the school Principal. In a clear disregard for the psychiatrist’s expertise, he said:
“There is no way that an eight year old can be bipolar.”
Despite all the negativism around him, and with the help of that wonderful aunt and foster mother that stood with him, even when he was being labeled as a “bad boy,”
Frankie was able to survive that “adult conspiracy.” He is another example of a child who became “non oppositional-defiant” with the right treatment for a correct diagnosis. To conclude I want to share with you this letter that was published by the dynamic and informative journal “Current Psychiatry”:
Vol. 4, No. 7 / July 2005
ADHD or Bipolar, but not Both
“What’s the best treatment for comorbid ADHD/bipolar mania?”by Drs. Nick C. Patel and Floyd R. Sallee (Current Psychiatry, April 2005) was well-written and offers excellent treatment guidelines. However, the idea that patients can have comorbid bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) is a fallacy.
I challenge any colleague, from the leading expert to the most recent graduate, to present a bona fide case of “comorbid” ADHD/bipolar disorder. I can prove that only one diagnosis is correct because:
Bipolar disorder is more heritable than other psychiatric illnesses. Many patients labeled as having “comorbid” bipolar disorder and ADHD have parents with bipolar disorder or schizophrenia or are in foster care and their biological parents’ histories are unknown.
I’ve seen hundreds of patients enter full-blown psychosis after another clinician put them on amphetamines or antidepressants while being treated for ADHD.
Bipolar disorder can explain any so-called ADHD symptom.
ADHD does not include moodiness or predatory aggression.
Over 10 years, I have diagnosed three or four patients as having comorbid bipolar disorder and ADHD. After a few years and inpatient treatments, these patients proved the second diagnosis wrong. We can decrease costs and avoid patients’ suffering by refining diagnostic criteria.
Manuel Mota-Castillo, MD,
Medical director The Grove Academy, Sanford, FL and Lake Mary Psychiatric Services