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