Michael Finkel M.D.

Dr. Armando Filomeno met Dr. Michael Finkel (who also did his neurology residency at the Strong Memorial Hospital of the University of Rochester) at the Nashville CHADD Conference in October 2004. At his request, Dr. Finkel —who does an important job in the field of international relations in the above mentioned institution— sent this article, written as a letter, about a subject in which he is an expert.

February 21, 2005

Dear Armando,

I am grateful for the opportunity to discuss the issue of AD/HD in adults with you, with our colleagues, and with our patients and families in Peru. As a means of introduction, let me say that I am a parent and spouse of individuals with AD/HD, as well as a neurologist who has worked with children and adults with this disorder for 15 years.

DEFINING THE CONDITION. It is now widely recognized that AD/HD is a disorder that often extends beyond childhood, and rarely occurs by itself. comorbid conditions are medical syndromes which occur at a frequency greater than what would be expected by chance alone. These comorbid conditions can be subcategorized as follows. Neurological comorbities include migraine headaches, restless leg syndrome and periodic limb movement disorder of sleep, epilepsy, tic disorders, Tourette syndrome, stutter, and enuresis. Psychiatric comorbities include depression, bipolar disorder, anxiety disorders, obsessive compulsive disorder, oppositional defiant disorder, conduct disorder, antisocial behavior, and substance abuse/chemical dependency.

Migraine headaches can occur before puberty in males, with the peak occurrence during the second decade of life.  For females, the migraines can begin with menarche and continue through the reproductive years, to diminish with menopause. Restless legs and periodic limb movement disorder of sleep usually do not become a problem until the third decade, although parents will frequently note that the child has excessive limb movements during sleep. Epilepsy tends to be in the teen age years, and is not a common comorbidity.  It is usually absence seizures, consisting of staring spells and eye blinking. Tic disorders can begin around 9-10 years of age, more often in males, and consist of two types. Motor tics involve simple and/or complex movements of the head, eyes, face, and limbs. Verbal tics involve simple noises or throat clearing, or complicated ones whereby the person blurts out things that are offensive to those who are around them.  Fortunately, both types tend to peak around age 15.  However, if both types occur in the same person who has AD/HD, often with obsessive compulsive disorder, the diagnosis broadens to be called Tourette syndrome. Stutter can be a lifelong problem. Enuresis ends by age 15.

Depression can occur before puberty, and is not necessarily caused because the child is having difficulties in school.  Puberty will exacerbate it in both sexes, and menstrual irregularities can provoke or intensify episodes of this condition.  For many adults in their fourth and fifth decades, the mood disorder is more disabling than the AD/HD. Bipolar disorder has different types, with variable presentations and ages of onset.  A manic or hypomanic episode can be mistaken for the first onset of AD/HD or an exacerbation, and a psychiatrist has to separate the two conditions to treat them. Anxiety disorder can manifest as separation anxiety in children, and generalized anxiety, with or without panic disorders, from the second decade onward. Obsessive compulsive disorder is part of Tourette syndrome, although it can occur as an independent comorbidity.  It may begin in the first or second decades, and becomes more problematic with age. Oppositional defiant disorder involves disrespect for adult authority.  When property damage, criminal behavior and physical threats occur before age 18, it is called conduct disorder.  After 18, the name changes to antisocial behavior, as the individual has reached the arbitrary and statutory definition of adulthood. Substance abuse/chemical dependency involves use of tobacco by minors, tobacco as adults, and drug/alcohol abuse as a minor and/or an adult.

Frequently, the AD/HD is the presenting problem during the first decade of life. However, the comorbid conditions can occur later, in a sequence and at an age that can be predicted.   By being aware of the different types of AD/HD, one can be prepared to recognize when a patient might develop a comorbid condition later in life, plan a strategy, and prevent or lessen the impact of the condition, and even cause remission. The patients, families, and doctors need to visualize AD/HD as if it is the tip of the clinical iceberg, warning us of future danger below the surface.

TREATMENT STRATEGIES. First, we establish that the patient has AD/HD, and decide how to treat it.  Many adults have learned to cope with the problem at work by taking jobs that are not sedentary and boring, or which allow the individual to learn a repetitious sequence of events from which there is little deviation, or by becoming self employed, with no one else to make the rules.  However, requirements at home may require behavioral modifications as well a medications.  The medical treatments are primarily stimulants (dextroamphetamine or methylphenidate based medications), atomoxetine, tricyclic antidepressants, and new antidepressants like venlefaxine and buproprion. However, one has to use stimulants cautiously in hypertensive individuals, and men in the fifth decade and above may experience erectile dysfunction, loss of libido, and problems emptying the bladder with atomoxetine. Therefore, one needs to be thorough in evaluation before starting them.

Second, we establish which comorbidities are present, and how to treat them. The neurological and psychiatric conditions have several additional medications that can treat them, as well as behavioral strategies. Sometimes the comorbid condition is more serious at the moment than the AD/HD, so we treat the most significant problem first.

We try to use the fewest number of medications, but we often need more than one type of medication.  Therefore, many patients need two or more medications, depending on the type and severity of the problems, and whether or not a medicine can treat more than one condition.  For example, some anticonvulsants and antidepressants will reduce the frequency of migraines.

Third, we have to modify the plan as conditions change. Sometimes migraines and depressions may need only 6-12 months of intensive treatment, while AD/HD medications might be needed for long periods of time.

I hope that this clinical discussion will help our colleagues, patients, and families understand how we physicians approach treatment plans in adults.

Yours sincerely,

Michael F. Finkel MD, FAAN
Cleveland Clinic Florida in Naples

A Spanish translation of this article appeared in the newsletter nº 7 issued by the Asociación Peruana de Déficit de Atención (APDA), on March 14, 2005.