The Truth About ADD / ADHD Medications and Coaching
Updated: Sep 27, 2019
Today I'd like to share with you an interview I did with Dr. David Rosenthal, a psychiatrist here in Boulder, CO, who's an expert on ADHD. As someone with ADHD myself, I have found extremely effective ways of working with ADHD without medications. However, I understand that medications can be very helpful for many people, and as an ADD / ADHD coach, I sometimes refer my clients to Dr. Rosenthal as well. I love Dr. Rosenthal's approach because he's not "too fast on the trigger" when prescribing medications, and shares my view, that medications alone can't ever be the only solution. He's also always up to date with the most recent research, which I believe is an important responsibility of anyone who's in the medical and the mental health field.
By the way, if you suspect that you have ADD / ADHD you can take this 2-minutes online ADD test. Your life can truly be better!
Enjoy this conversation, and please leave a comment if you have any questions.
Sasha Raskin (ADD/ADHD Coach): Okay, so Dr. David Rosenthal, I think this interview would be possibly a good resource for people with ADHD and possibly also for mental health professionals who are not psychiatrist, to kind of get more idea about the different medications that are out there.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Certainly.
Sasha Raskin (ADD/ADHD Coach): And possibly even about current research. What has been working in the past, what seems to be working more recently based on current research, and also how do you decide to medicate or not medicated, are there other alternatives?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Sure.
Sasha Raskin (ADD/ADHD Coach): And also maybe kind of answer some concerns people usually have about side effects of medication.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, certainly I can do that, yes.
Sasha Raskin (ADD/ADHD Coach): So maybe we can start with why did you choose to focus on ADHD as a psychiatrist?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Okay, well, actually it comes from many years of working at Kaiser in California. I was there for about nine and a half years until I would say until I burned out with 6,000 patients calling me their psychiatrist, which is an unbelievable number of people. And oftentimes I think people end up choosing their specialty not necessarily because they chose it themselves, but because somebody else chose you as the expert.
Sasha Raskin (ADD/ADHD Coach): So you're only chosen.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): So, what happened, well, the way I got chosen, let me put it that way, is I'm a child psychiatrist, I was at Kaiser all of those years. And part of being a child psychiatrist is to get huge number of referrals for ADHD assessments in kids. And so what happened is I just happened to be seen so many of those and having some good outcomes that I got to be well-known among my let's say adult psychiatry colleagues and as the guy who sees the ADHD kids. So it started out very much in the child psychiatry area.
And that eventually led to a colleague asking me to co-author a book with them, which eventually led to co-authoring three books on ADHD and lots of articles and lecturing on ADHD. So that's how I fell into becoming an expert on ADHD. And just the sheer patient volume I got tremendous experience with finding out what works and what doesn't work.
And now since that time, that was many years ago, since that time I've come to Boulder, Colorado and now I'm in a private practice. And still the majority of people I see are for ADHD assessments, but obviously I have branched out now and have seen a huge number of adults with ADHD in mountains, just children with ADHD. So that's how I fell into it. That was the first part of your question.
Sasha Raskin (ADD/ADHD Coach): Yeah. Do you have any personal connection to the meadow if you want to show?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Sure, I think that, and this is also common with people under a particular field, it's probably because I have ADHD myself even though ... and I always comment that my wife would like to see me medicated for ADHD. But I've always managed I think quite well without medication, which does bring us to an important other question you've asked, which is how do you decide who needs medication and who doesn't need medication?
Sasha Raskin (ADD/ADHD Coach): Yes.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Given that, and some of this again is my own personal opinion, if you ask different psychiatrists you'll get different opinions about what percentage of people really need to be medicated for ADHD. So here's my personal algorithm for deciding about medication - There is great concern in the country these days about whether ADHD is being over diagnosed and overmedicated, over treated. And I do think that I'm of the belief that a lot of ADHD is on a spectrum of anything from the person has severe pathology and dysfunction to those who certainly meet the criteria for ADHD, but are really very highly functional.
So the criteria I personally use and my own internal criteria, so here they are - So when I'm doing an assessment I try to get some sense as to what do I believe this person's innate ability actually is, whether that's their actual IQ, for instance, a lot of people have actually been tested that I see and I'm told their IQ is 130 or whatever those numbers may be. And sometimes they've had extensive testing.
Sasha Raskin (ADD/ADHD Coach): So that was an example of the screen kind of turned off and you are able to come back to that.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Come back to the original. I get distracted quite easily, but since I know the topic fairly well hopefully I'm able to quickly get back on track. So that's a good illustration of the ADD distractibility as immediately noticing the phone.
Sasha Raskin (ADD/ADHD Coach): And the ability to refocus.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And to refocus, which is again to the point about I'm not sure that I need medication, even though I have a whole range of ADHD symptoms. All right, so my own internal criteria, number one is so when I look at what I perceive as the person's innate ability level. And then I look at, all right, now compared to their ability level what is their current performance level, and is there a major discrepancy between their current performance and their innate ability level? And if that discrepancy between the two seems to be very small, then I'm not sure that they need to be treated with ADHD medication.
The other thing I'm certainly going to look at there is whether how much other ... well, I'll just go to the second criteria as it relates to what I was about to say. So the second criteria I use is that you there's a big discrepancy between their innate ability and their performance, what kinds of secondary complications is this person developing as a result of that discrepancy?
And I'll tell you what those are, so for an example, I mean, if you look at starting with childhood and it does differ ... the course differs whether you're talking about the average male or the average female. And these are just statistical differences. You can certainly see females who have a more of a male pattern and males who have more of a female pattern. But we know that statistically ...
Sasha Raskin (ADD/ADHD Coach): But just to clarify you're talking about biological sex assigned at birth, not necessarily about gender.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): And that's true. I'm not talking about gender. So we know that statistically biologically speaking more males tend to have hyperactive-impulsive ADHD and more females tend to have an inattentive subtype of ADHD with less hyperactivity and sometimes less impulsivity. We see plenty of females who have impulsivity problems. So obviously that's just a statistical thing.
So what I'm about to say when I talk about hyperactive-impulsive ADHD, if a girl is super hyperactive and impulsive then this is going to apply to them as well when I talk about the course for hyperactive-impulsive ADHD. It is just that statistically it tends to be more males biologically and statistically more females tend to get diagnosed with inattentive ADD.
But anyway the natural course of hyperactive-impulsive ADHD is that these typically are kids who are in trouble at early ages. And again, females happen to be hyperactive-impulsive, they're often in trouble at early ages as well. Now what I mean by being in trouble is meaning because they're hyperactive, because they're impulsive they're often being reprimanded, whether it's by their parents before they even reach school or now when they're in school they're not sitting still, they're not listening to directions, they're blurting out answers to questions before waiting their turn. So that's what I mean by being in trouble.
So I think innately I have belief that kids fundamentally want to please the adults in their lives, whether it's their teachers or their parents. And obviously there are many complications when there's dysfunction within the family. But most kids start off wanting to be well-behaved and to please, but what happens so often that I see time and time again in hyperactive-impulsive kids with ADHD is that at some point they get frustrated, they're always in trouble, it doesn't seem to matter how hard they try they can't seem to meet the expectations of the adults around them.
And then the next thing that we start to see, and I don't know if you wanted me to go into the whole comorbidity about ADHD which is where I'm headed.
Sasha Raskin (ADD/ADHD Coach): Yeah. I think before you go there, you're talking about also how the system affects ADHD as well, right? Kind of this circle of, "Well, if I can't sit still or if I interrupt people while they speak, my parents have the tendency to try and do their best to control that which makes me more frustrated," and then the comorbidity.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): More frustrated. And now the comorbidities or co-existing problems start to develop. Dramatically we use the word comorbidity but it's not a very pleasant term, so co-existing problems might be a better term than the term comorbidity.
So the first co-existing problem that we start to see with ADHD when the frustration level gets high enough is oppositional defiant disorder or oppositional defiant traits. So that's when the child starts to get defiant, you tell them to do A and they do B, they go out of their way to do B. They're angry, argumentative, defiant, frustrated, irritable.
We call that a diagnosis oppositional defiant disorder, but I have a lot of problems with that as a diagnosis because ...
Sasha Raskin (ADD/ADHD Coach): What is the main problem as you see?
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Well, because I think it's just a set of symptoms that reflect the level of frustration that the child is feeling. I don't like labeling it as a disorder. And in fact, what we typically see is that if you find a solution and you reduce the frustration that the child is experiencing, it tends to go away.
Sasha Raskin (ADD/ADHD Coach): And the solution can be behavioral, emotional.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Absolutely, behavioral, emotional.
Sasha Raskin (ADD/ADHD Coach): And parents coaching as well.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Parent coaching, absolutely. I mean, a big thing is that these kids lose their self-esteem if you don't do anything. And so intervening early and even aggressively is really important. Sometimes we say from a parenting standpoint these kids are so challenging that when I'm trying to teach parents about parenting skills I often use the expression that it's not good enough to just have good parenting skills, you have to be able to write the book on parenting, because these kids find loopholes. Everything you try to do works for a little while and then they find a way around your wonderful solution for a particular behavior problem.
So parents have to really know good parenting skills, behavioral management skills, to be able to stay on topic. Totally, because they're extremely challenging, as opposed let's say to the inattentive ADD kids who are often very compliant and not causing behavioral problems. That is a different person.
Sasha Raskin (ADD/ADHD Coach): And then it can be undiagnosed, right? Because I have read some books that actually talk about the fact ... well, the researchers think that it's actually might be undiagnosed, and specifically with inattentive ADHD that seems to be no behavioral problems and they experience it internal.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Internal, right. And so I'm starting to say they have very different courses, so the hyper ... I agree, the hyperactive-impulsive kids come to somebody's attention very early, and the inattentive kids, statistically more females, often don't show up until high school or junior high or high school or even college. Because they've been quietly falling behind and not working up to their potential.
Sasha Raskin (ADD/ADHD Coach): And there are more requirements as they're progressing greater.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right. So maybe I'll just briefly summarize the comorbidity problem or co-existing disorders, and then we'll move on to the stimulants in the interest of time. So briefly the hyperactive kids, impulsive kids, start off with oppositional defiant behaviors. If it continues and gets worse and there's still no intervention, they often end up with conduct disorders, meaning more serious behavioral problems, stealing, lying, dishonest behaviors, and delinquent behaviors when they hit the teenage years, they're very high risk for substance abuse and on and on. And it can get progressively worse. The females, and sometimes depression and anxiety but less commonly more the conduct, we call them as externalizing behaviors instead of internalizing, which I'm going to turn to the inattentive type.
So the inattentive type as we just said is more commonly diagnosed at a much later age. It gets missed very often. But when we start to really manifest itself as you were saying, when the academic challenges get greater and greater, particularly in highly intelligent kids - They manage to perform at a very high level because if you actually look at their ability to focus they have terrible inability to focus on things they're bored with, but ...
Sasha Raskin (ADD/ADHD Coach): As segue way that was my experience in high school, I became very good in memorizing to compensate the fact that I could not focus. I did not remember what the teacher was talking about and I have ADHD as well.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): So that's a great example. So they managed to skate by on their intelligence for years, until the academic load gets so extreme that they can no longer get by just on being smart.
Sasha Raskin (ADD/ADHD Coach): Yes.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Because at some point you actually have to study, most people have to start at some place.
Sasha Raskin (ADD/ADHD Coach): And independently the parents are not required as ... well, at least as society views it to help their kids with homework and so on.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Right. Well, in our society particularly because we're very ... we stress the need, well, we do have a need for kids to learn to be independent and so we call it separation individuation. So, because they're struggling with that as teenagers as a normal developmental phase in our society, then they get very upset and angry when parents hover and try to help them with their homework and want to help them succeed, they get more defiant because they want to do it on their own.
Now there are societies in the world where there is no separation individuation phase, you grow up, you live with your parents until you die or until they die. And there's no need for separating. Well, then it's not ... we don't have that same developmental phase, it doesn't create the same degree of problem. If we have time I can certainly talk about those societies. I did a research study in Bali, Indonesia.
Sasha Raskin (ADD/ADHD Coach): Yeah, that's the concho annamund is very important.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah.
Sasha Raskin (ADD/ADHD Coach): Maybe we can another ...
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah, we can do another one, we can do another. So here we have a strong need for separation individuation which creates a lot of conflict with parents. Well, anyway, so quickly the female, it is not always female, but the inattentive course then is it's often discovered much later and it's often by the time it's discovered they're often ... it's often at that point there's often tremendous anxiety or depression, comorbidly or co-existing with the ADD by that time, because the frustration level rises and rises and manifests itself in those forms, in depression and anxiety much more commonly.
Okay, so going back to my original criteria for using medications. So one is, is there a big discrepancy between innate ability and low performance? And secondarily is that discrepancy causing these secondary problems? And if those secondary problems are great and there's a big discrepancy, then absolutely we should intervene with medication.
Sasha Raskin (ADD/ADHD Coach): And do you see the same criteria for children and adults? It just manifests.
Dr. David Rosenthal (ADD/ADHD Psychiatrist): Yeah, I use the same. Yes, I use the same criteria for children and adults in terms of when to intervene with medication. And then you ask the question about, well, when do you use stimulants versus non-stimulants? If you want me to go ahead and answer that.