ARTICLES TRANSLATED FROM SPANISH

My four decade relationship with Attention-Deficit/Hyperactivity Disorder (AD/HD), Armando Filomeno, M.D.

My first memories of a patient with what is known nowadays as AD/HD go back to my medical student’s days in Cayetano Heredia in the early sixties when I met a girl in the relation who was overly active  and whose behavior was out of control. My advice was to have her seen by a  neurologist; by her father’s choice she was seen by a neurosugeon with a busy neurological practice, whose diagnosis was dysrhythmia and prescribed an antivonvulsant which did not do any good to the girl, who continued having difficulties at school and home, and later had serious problems in her private life, which have become worse as time went by and continue up to now.

Through my readings I knew what was being called for the last couple of years Minimal Cerebral Dysfunction or Minimal Brain Dysfunction and I had read the first monograph that had been published on the subject (1); as  happens with many books, I lent it 38 years ago and it was never given back to me. I was also aware that  amphetamines were the most effective treatment, especially dextroamphetamine, but as I still was a medical student I couldn’t prescribe, so there was very little I could do for the girl, besides giving my relative the opinion of an beginner.

During my internship rotation through pediatrics in Lima, even though I was successful to have my boss subscribe to important foreign journals, I was not able to convince her about the existence of the syndrome and as far as I can remember, I never got to treat with amphetamines the patientes whom I made  this diagnosis in the outpatient clinic. I have to acknowledge, though, that we were very busy in our daily work with life and death problems like meningitis and encephalitis.

During my residency in adult and pediatric neurology at the University of Rochester, in the U.S.A., by the end of the sixties and beginning of the seventies, Minimal Brain Dysfunction (MBD) was a common diagnosis and the treatment used to be done with dextroamphetamine (Dexedrine) and also wityh methylphenidate (Ritalin).

Upon returning to Peru at the beginning of the seventies I met dysrhythmia again which ——besides being used as a euphemism for epilepsy—  was a diagnosis which used to be made for problems that ranged from misbehavior to mental retardation (MBD was in the middle of them). What gave some sort of unity to all this was the presence of EEG abnormalities, more imaginary than real. The diagnosis used to be made by neurologists, neurosurgeons and psychiatrists, and the treatment was done with  anticonvulsants and a few innocuous and useless drugs. I declared war to this diagnosis and treatment and I remember that at the 1974  Peruvian Congress of Psychiatry, Neurology and Neurosurgery I lectured on this subject in a humorous and ironic way —using slides with cartoons— which was considered funny by many people but did very little to change the concepts, diagnoses and treatments. I made some enemies with that lecture, though, because people who felt caught in fault said things like what is this young man up to?

I remember also how the diagnosis of Minimal Brain Dysfunction —beside which the diagnosis of Hyperkinetic Syndrome coexisted— in the eighties gradually turned into Attention Deficit Disorder  —with and without hyperactivity—, and in the last ten years it became Attention-Deficit/Hyperactivity Disorder (AD/HD), with its three types. However, this has been the least important  of all the events for patients, as terms have changed more than concepts.

It has been  more important that for several years it was impossible to buy methylphenidate in Peruvian drug stores and it was necessary to order it from Mexico —through a stewardess of Aeroperú who later died in an plane crash facing Lima’s seashore—  or from Ecuador, or that  for a while it was necessary to prescribe coffee  for AD/HD, which caused many a grandma to say how does this young doctor dare to prescribe coffee to my grandson!

In the last three years, the news was that methylpyenidate became —due to excessive bureaucratic zeal— a drug that needed a prescription form with two copies and an extensive information written on the patient, and that in the last year it must be prescribed in a special form that has to be bought at the Ministry of Health. This has made more difficult to buy Ritalin than cocaine in Lima. Another bad news is that the insurance companies frequently do not pay for the treatment expenses, saying that Ritalin is a stimulant…, therefore it is harmful for the brain…, and so forth.

At this point I must mention the negligence of the pharmaceutical laboratories that developed dextroamphetamine and methylphenidate; the first one has not sold its useful drug in this country for about four decades, and the second one has not introduced in Peru its eight-hour preparation (Ritalin LA) yet. Besides, the OROS twelve-hour methylphenidate (Concerta) is not sold in Peru yet; I have been told that it will happen in the next six months. It is a striking fact that such a high population of children, adolescents and adults is being neglected wheras several laboratories fight against each other for treating disorders that are several times less common, with a dozen drugs for them on the market.

The appearance of the Peruvian Association for Attention Deficit (APDA)’s electronic newsletters more than two years ago meant —for an increasingly numerous and wide public— the possibility of obtainig information on many aspects of AD/HD, like the usefulness of drugs or the lack of evidence on the effect of some alternative treatments which have been introduced in the country; the newsletter enjoys an independence that makes some people feel uneasy. Since October 2004 APDA’s website has meant  —for the sake of parents, patients and professionals— having information permanently at hand.

I have had the privilege of attending meetings on AD/HD and Tourette’s Syndrome in Washington, Cancun, Nashville, Buenos Aires and Dallas in the last four years which have allowed me to get in touch with professionals of the highest level; in that context, it has been highly significant for me to meet in most of these places a lecturing physician who has studied or trained at the University of Rochester (2). I have been able to exchange with them memories of the Strong Memorial Hospital, the department of neurology and its illustrious founding chief (3), the school of medicine, the Eastman School of Music with its Sunday student recitals —with free admission of course—  Rochester’s arctic winters, etc.

I remember  very satisfactory periods in my medical activity, like when I was chief resident in neurology and then in pediatric neurology in Rochester, when I was a fellow at Johns Hopkins or when I did full-time teaching in neurology at Cayetano Heredia, and was the first pediatric neurologist at the teaching hospital. However, I can say that I wouldn’t give up my present professional work in a field I like to call Pediatric Neuropsychiatry —in which APDA’s electronic newsletters and web site are an important aspect.

____________________
This article’s topic was the basis for the lecture Attention deficit in pediatric patients. AD/HD in the last 40 years, given on March 31, 2005 at the international  scientific meeting for the 40th anniversary of the Hugo Pesce – Alberto Hurtado  medical school class of San Fernando (San Marcos University) and Cayetano Heredia University.

The original Spanish version of this article appeared in the newsletter nº 10 issued by the Asociación Peruana de Déficit de Atención (APDA), on December 15, 2005; it was slightly modified for the website.

Email:  armandofilomeno@telefonica.net.pe

References
(1) Bax, Martin and Ronald Mc.Keith. Minimal Cerebral Dysfunction. Little Club Clinics in Developmental Medicine nº 10. London: Spastics Society with Heinemann. 1963
(2) Washington 2002: Edward Kaplan, M.D. a streptococcologist (as he likes to be called) now at the U. of Minnesota; he graduated from college at the U. of R. Cancun 2003: Jeffrey Newcorn, M.D, a child and adolescent psychiatrist, at  Mount Sinai, New York; he went to college and medical school at the U. of R. Nashville 2004: Michael Finkel, M.D. who did his neurology residency in Rochester, now at the Cleveland Clinic in Naples, Florida; he is  in charge of international relations at CHADD.
(3) Robert J. Joynt, M.D., Ph.D., Distinguished University Professor of Neurology. Formerly, Dean of the School of Medicine and founding chairman of its Department of Neurology at the University of Rochester;  my mentor in neurology.

Hope, resiliency and success: AD/HD interventions for a lifetime, Armando Filomeno, M.D.

Review of CHADD’s 17th Annual International Conference on Attention-Deficit/Hyperactivity Disorder, October 27-29, 2005. Dallas, Texas, USA

The title of this year’s conference shows an emphasis on finding out what makes the prognosis of this disorder good and what can be done towards that goal.

More than one thousand persons attended this year’s conference, many of them from foreign countries —beeing as usual quite diverse—:mostly ADHD persons’ parents and professionals from the many areas that deal with this disorder. This review, by necessity, will be limited to the activities in which  Beatriz Duda —APDA’s president— and myself participated.

Among the Special Training for Professionals’ sessions on Wednesday  26,  there was a workshop on Skills for coaching adults with AD/HD, held by Jodi Sleeper-Triplett and Sandy Maynard, which dealt with how to motivate adults with this disorder, for coaching to be effective. There were also interesting half-day conferences  on Neuropsychological research and clinical best practices in the assessment of AD/HD and on  Advanced treatment of AD/HD —both of them across the lifespan—, given by CHADD President Anne Teeter Ellison, Margaret Semrud-Clikeman and Sam Goldstein.

In the half-day Pre-conference Institutes —in the morning of Thursday 27—, Arthur Robin gave an excellent lecture on Helping adults with AD/HD succeed  in marriage and parenting; he talked about the day-to-day problems in families with one or more AD/HD members, and what strategies are useful for success. Stephen Pliszka gave a well balanced view of AD/HD and comorbid disorders: diagnosis and treatment.

On Thursday afternoon the Iberoamerican Forum was held. Orlando Villegas lectured on Opositional defiant disorder and Conduct disorder. I presented the results of a study on AD/HD teaching in medical school in Peru (www.deficitdeatencionperu.org/estudioperu.htm). María Teresa Hill —the reelected president of the Forum— and Gabriela Delgado Paulsen presented the project of a suvey on how much teachers in Iberoamerica know about AD/HD; the study will produce a guide for teachers.

The opening keynote address —with massive attendance— was on Thurday evening on The bully, the bullied and the bystander, given by Barbara Coloroso, a well-known lecturer and author of books on education.

In the morning of Friday 28 —in the main conference room— James Swanson lectured on the molecular aspects of AD/HD; among other aspects, he talked about a seven repeat mutation of the D4 dopamine receptor, which is present in many people with AD/HD and seems to confer an evolutionary advantge. Among other lecturers, he made fun of Tom Cruise, who is well known for his ridiculous comments on Ritalin, AD/HD and related issues.

On Friday afternoon, Glen Elliott handled in a very neat way the drug treatment for the core symptoms of AD/HD.  Sam Goldstein —despite not having technical equipment for this lecture— presented a good review on what can be done to encourage resiliency, the master key for success for those who have AD/HD (resilience, a concept borrowed from Physics, is the ability to overcome adversity).

In the evening, the Networking sessions by track (Interest group) were held; we attended the Spanish language and culture/International, facilitated by José Bauermeister, which had a remarkable attendance —mostly by iberoamericans— where common interest subjets for our countries were discussed. Concern was expressed about the declarations by fake experts who question the scientific facts on the diagnosis and treatmento of AD/HD and hereby uselessly confuse and alarm people who are not well informed.

In the morning of Saturday 29 —in the main conference room— Sam Goldstein, a remarkable lecturer, presented testimonies of people who have succeeded through resilience; he also mentioned that beside them, many failed to do so. In the Research symposium, Marshalyn Yeargin-Allsopp announced the National Children’s Study —in which AD/HD will also be studied— with the participation of 100,000 pregnat women and children, which will be followed-up  until age 21 years,  whose preliminary results will be known in the years 2010-2011; the cost of the study will be 2.7 billion dollars of federal funds. The morinig research session concluded with Regina Bussing’s study which showed that women and ethnic minorities have fewer chances of having a correct diagnosis and treatment for their AD/HD.

On Saturday afternoon, Thomas Brown lectured —with his well-known ability— on the Dilemmas in the treatment of complicated cases of AD/HD, and Chris Zeigler Dendy handled, with great efficiency, Developing an educational plan to address executive function deficits.

CHADD’s 18th Annual International Conference on AD/HD State of the Art: Science and Research in Practice was annouced, which will be held on October 25-28, 2006, in Chicago. U.S.A.

CHADD’s conferences, besides offering up-to-date knowledge, make possible to meet people from all over the world  —especially from Iberoamerica in our case—, with affinity and comon interests. We were pleased to meet Isabel Rubió, president of ADANA,  and to see again Ernestina Pergolini, president of Fundación TDAH from Argentina, Doris Ryffel, and Norma Echavarría; we are thankful to the latter for the article of AD/HD in women, which she has sent us for our December newsletter. We were sorry that Michael Finkel and Rubén Scandar could not attend the conference.

Link to a review of CHADD’s 2004 conference (in Spanish).

____________________
Dr. Filomeno is founding advisor neurologilst to the Peruvian Association for Attention Deficit (APDA).
The original Spanish text ot this review may be read in this link.

Are present day worldwide controls on the sale of methylphenidate justified?, Armando Filomeno, M.D.

¿What proof exists that methylphenidate is a drug that can cause addiction or that it has a high abuse potential that justifies the present day control on its sale?

None; many medical articles endorse this statement. The present day standpoint, widely accepted by physicians who have knowledge and experience in the subject, is that far from producing or favoring addiction, methylphenidate protects ADHD patients from that risk. The studies have been done on stimulant drugs; as methylphenidate has been the most widely used stimulant drug in the last 30 years, the results apply especially to it.

There are at least twelve studies in the academic medical literature that endorse this, against one single study —which has been widely criticized due to its defective methodology— which states otherwise. This is thoroughly discussed by Dr. Russel Barkley — a pychologist who is an authority in the field of ADHD— in an article published in Pediatrics in January 2003:

Russell A. Barkley, Mariellen Fischer, Lori Smallish and Kenneth Fletcher. Does the Treatment of Attention-Deficit/Hyperactivity Disorder with Stimulants Contribute to Drug Use/Abuse? A 13-year Prospective Study. Pediatrics, Vol. 111 n.º 1. January 2003 (pages 98 and 99 are especially pertinent).
Link to the full text article:
http://pediatrics.aappublications.org/cgi/content/full/111/1/97
Link to an abstract of the article:
http://pediatrics.aappublications.org/cgi/content/abstract/111/1/97

Dr. Joseph Biederman from Harvard Medical School and the Massachusetts General Hospital —a recognized medical authority in the field of ADHD— demonstrated, in two excellent articles published in 1999 and 2003, that stimulant drugs protect ADHD patients from addiction.

Joseph Biederman, Timothy Wilens, Eric Mick, Thomas Spencer and Stephen V. Faraone. Phamacotherapy of Attention-deficit/Hyperactivity Disorder Reduces Risk for Substance Use Disorder. Pediatrics, Vol. 104, n.º 2, August 1999.
Link to the full text article:
http://pediatrics.aappublications.org/cgi/content/full/104/2/e20
Link to an abstract of the article:
http://pediatrics.aappublications.org/cgi/content/abstract/104/2/e20

Joseph Biederman. Pharmacotherapy for Attention-Deficit/Hyperactivity Disorder (ADHD) Decreases the Risk for Substance Abuse: Findings from a Longitudinal Follow-Up of Youths With and Without ADHD. Journal of Clinical Psychiatry. 2003. Vol. 64 (suppl 11).
Link to the full text article:
http://www.psychiatrist.com/supplenet/v64s11/v64s1101.pdf
Link to an abstract of the article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14529323&query_hl=10&itool=pubmed_docsum

Dr. Nora Volkow, Director of the National Institute on Drug Abuse, NIH, and the distinguished neuroscientist Dr. James Swanson, have shown that, after oral administration,  methylphenidate’s slow entrance to the brain and its even slower exit set it apart from drugs which produce addiction.

Volkow, N.D. and James M. Swanson. Variables That Affect the Clinical Use and Abuse of Methylphenidate in the Treatment of ADHD. American J. Psychiatary. 160:1909-1918. 2003.
Link to the full text article:
http://ajp.psychiatryonline.org/cgi/content/full/160/11/1909
Link to an abstract of the article
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14594733

There is evidence that the abuse potential of methylphenidate is lower in ADHD people, probably due to the increased number of dopamine transporters they have.

Kollins, Scott H. Comparing the Abuse Potential of Methylphenidate Versus Other Stimulants: A Review of Available Evidence and Relevance to the ADHD Patient. J Clin Psychiatry. 2003;64(suppl 11):14-18.
Link to the full text article (especially page 17):
http://www.psychiatrist.com/supplenet/v64s11/v64s1103.pdf
Link to an abstract of the article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=14529325&query_hl=12&itool=pubmed_docsum

The abuse potential of methylphenidate would be limited to the abnormal routes of administration, like intravenous injection and inhalation.

James M. Swanson and Nora D. Volkow. Serum and brain concentrations of  methylphenidate: implications for use and abuse. Neurosci Biobehav Rev. 2003 Nov,27(7):615-21.
Link to an abstract of the article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14624806

The phenomenon known as sensitization in experimental animals has never been shown to happen in humans. There is no evidence that children treated with methylphenidate have a higer risk of addiction in adult life. Researchers from NYU Child Study Center have studied this aspect thoroughly:

Klein R. and Mannuzza S. Is there stimulant sensitivity in children? J Atten Disord. 2002;6 Suppl 1:S61-3
Link to an abstract of the article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12685520

Klein R. and Mannuzza S. Does stimulant treatment place children at risk for adult substance abuse? A controlled, prospective follow-up study. J Child Adolesc Psychopharmacol 2003 Fall; 13(3):273-82.
Link to an abstract of the article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14642015

Finally, besides all the evidence that has been shown, it is reasonable to think that if methylphenidate helps people with ADHD normalize their lives —a fact demonstrated beyond any doubt— the risk of drug addiction, due to repeated frustrations and decreased likelyhood of success, must necessarily be lower in those who are being or who have been treated with this drug.

____________________
This translated text has been extracted from:” Reunión con la Ministra de Salud sobre la venta del Ritalin”, published in APDA’s newletter nº 5.
Modified in September2006.
Dr. Filomeno’s e-mail is: armandofilomeno@telefonica.net.pe