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ADHD 1995 Review of attention deficit hyperactivity disorder in adults
New Ideas in Psychol. Vol. 14. No. 2, pp. 187-188, 1996 Published by Elsevier Science Ltd. Printed in Great Britain 0732-118X/96 $15.0(I + 0.00
Pergamon
S0732--118X (96)00007-4
ADHD 1995
Review of Attention Deficit Hyperactivity Disorder in Adults by Paul H. Wender. Oxford, U.K.: Oxford University Press, 1995. TOM LINNELL 112 South College Avenue, Fort Collins, CO 80524, U.S.A. Why should anyone write another book about Attention Deficit Disorder (ADHD) in children and adults? Literature on ADHD has risen from a trickle in the 1970s to a deluge in the 1990s. Weary clinicians might well mistrust the jacket testimonials to this book's originality and timeliness. The answer is that Paul Wender is not just anyone, and what he has to share stems from his lifelong dedication to the topic. The result is a book that will anchor a professional's shelf with an impeccable scientific foundation together with the wisdom of great clinical understanding. Readers familiar with ADHD will perhaps have given out countless copies of Wender's The Hyperactive Child, Adolescent and Adult. An Oxford paperback in its third revision, it is still one of the best 150 pages of user-friendly introduction to the syndrome. The same readers will remember how tentatively Wender began suggesting in the first edition that adults, too, could have ADHD and would respond to the same medications. Saying so was unpopular, even dangerous, and neither clinical nor research evidence was robust. Attacks by Scientology make it scarcely easier today, but Wender now comes forward fully prepared with painstakingly amassed research on adults. One suspects that his particular thoroughness in Chapters 3 and 4 on the prevalence and etiology of adult ADHD reflects his ongoing fear of the perennial critics. Where, then, does this book fit? Despite the flood of literature, the gap between the large reference volumes of Russell Barkley or Sam and Michael Goldstein and the essentially popularizing works of Edward Hallowell and John Ratey remained to be filled. Wender fits nicely right there. He speaks to researchers, clinicians, victims and their loved ones in a manner both authoritative and compassionate. The early chapters present the syndrome in black and white, while the human faces emerge in Chapters 6 and 8 through their own colorful stories. Perhaps the most striking contribution of the book, however, comes immediately to the reader in the Introduction. Here Wender graciously shares his own face--that of the clinician grappling with a most elusive syndrome, pursuing a firm diagnosis in a changeable discipline. Non-medical readers will appreciate his telling us not to worry, that similar difficulties exist throughout the medical world. When he says, "We are measuring amoeba with a rubber ruler," he has given us permission to laugh at our poor efforts, and we are assured that he knows what our days are like behind the office door. Beyond the introduction, Wender spills out a cornucopia of information for clinicians and scholars alike. Chapter 5 teaches the diagnosis of ADHD with adults through the protocols of the University of Utah Medical Center. Chapter 6 assesses the utility of the various medications he uses with ADHD, with unusual material on the MAOI class of drugs. These two chapters illustrate the difference between this book and the larger reference volumes on the shelf. Here Wender presents his own experience, rather than attempting an exhaustive review of the existing proto187
188
T. Linnell
cols or the pantheon of drugs. As such, the chapters will help in the training of clinicians in specific procedures, but may leave them lacking a broader perspective. Chapter 8, finally, offers a light sprinkling of research proposals that Wender finds interesting in the areas of genetics, spectrum disorders and biochemical constructs. Chapter 7 deserves special comment. It may be the most memorable chapter in the book. If other chapters seem lacking by comparison with the more exhaustive references, this chapter stands alone as far superior to its like among contemporary books on ADHD. It is in this chapter that Wender introduces his patients and lets them tell their stories of suffering and treatment. The disparate elements of etiology and prevalence, symptoms and diagnosis, come together in flashes of brilliant and personal prose. Here Wender made the exceptional choice to limit his own description of each person to a few words, trusting that they would tell their own stories in their own way. The results are indelible. Along the way, Wender touches--often too lightly--on a small host of old problems in this field: the observation that adoptive children display a higher rate of ADHD, the persistent comorbities of conduct and mood disorders with ADHD, the question of what percentage of children outgrow the syndrome, the recurring efforts to develop subtypes, and so on. Even in 1995, Wender delivers more description than insight or breakthrough for most of these issues. It becomes clear that his hopes fly toward "molecular genetics" as the likely source of understanding in the next wave of research. As helpful as this book is, it nevertheless falls short in a number of areas of more than passing importance. Wender unfortunately refers to the DSM-III-R more often than 1995 will tolerate. Was there no way to edit in favor of the DSM-IV criteria and conceptualization of adult ADHD? Elsewhere, Wender leaves the reader with a clear message that late afternoon doses of psychostimulants are always contraindicated because of their effects on sleep patterns. Not only is it well understood in the field by now that this is not the case, but Wender himself presents a case report in Chapter 7 in which bedtime doses of Ritalin actually improved sleep. Sleep disturbances are a frequent complication in ADHD, and the subject called for a more consistent treatment in a book of this depth. A third shortfall concerns the discussion of stimulants as Schedule II controlled substances. Here Wender simply repeats the rationale for the status quo, without reference to current proposals before the FDA to give them less restrictive classifications. These proposals arise from consumer groups and clinicians who recognize the need for easier access to these medications. The objections arise from those who fear their potential for abuse. Wender's own research states that patients do not develop tolerance or become addicted to the stimulants. Whether or not he believes they should be reclassified, should we not have expected to hear his thoughts on this question? This was an opportunity for leadership. In perspective, this is a field where enormous public pressure has forced clinical practice to move ahead faster than its scientific base. Wender's discussion in Chapter 3 about the limits of our knowledge and his frank recognition that rigorous scientific criteria "are probably honored in the breach (and) experienced clinicians.., may diagnose ADHD in the presence of a smallerthan-necessary number of solid signs" confirm his understanding. In 1995, the underground information flow has surfaced as a flood on the Internet, revealing what we had suspected before, that victims and their loved ones are continuing to push back the edge of the unknown in their search for solutions. No clinician/scientist, even one as dedicated as Paul Wender, could reasonably bring to focus all of the hot topics in ADHD. The help he offers through this book is genuine and well founded. Readers will open the book again and again to review what is reliably known, and to draw from the strength of a master.
Pergamon
S0732--118X (96)00007-4
ADHD 1995
Review of Attention Deficit Hyperactivity Disorder in Adults by Paul H. Wender. Oxford, U.K.: Oxford University Press, 1995. TOM LINNELL 112 South College Avenue, Fort Collins, CO 80524, U.S.A. Why should anyone write another book about Attention Deficit Disorder (ADHD) in children and adults? Literature on ADHD has risen from a trickle in the 1970s to a deluge in the 1990s. Weary clinicians might well mistrust the jacket testimonials to this book's originality and timeliness. The answer is that Paul Wender is not just anyone, and what he has to share stems from his lifelong dedication to the topic. The result is a book that will anchor a professional's shelf with an impeccable scientific foundation together with the wisdom of great clinical understanding. Readers familiar with ADHD will perhaps have given out countless copies of Wender's The Hyperactive Child, Adolescent and Adult. An Oxford paperback in its third revision, it is still one of the best 150 pages of user-friendly introduction to the syndrome. The same readers will remember how tentatively Wender began suggesting in the first edition that adults, too, could have ADHD and would respond to the same medications. Saying so was unpopular, even dangerous, and neither clinical nor research evidence was robust. Attacks by Scientology make it scarcely easier today, but Wender now comes forward fully prepared with painstakingly amassed research on adults. One suspects that his particular thoroughness in Chapters 3 and 4 on the prevalence and etiology of adult ADHD reflects his ongoing fear of the perennial critics. Where, then, does this book fit? Despite the flood of literature, the gap between the large reference volumes of Russell Barkley or Sam and Michael Goldstein and the essentially popularizing works of Edward Hallowell and John Ratey remained to be filled. Wender fits nicely right there. He speaks to researchers, clinicians, victims and their loved ones in a manner both authoritative and compassionate. The early chapters present the syndrome in black and white, while the human faces emerge in Chapters 6 and 8 through their own colorful stories. Perhaps the most striking contribution of the book, however, comes immediately to the reader in the Introduction. Here Wender graciously shares his own face--that of the clinician grappling with a most elusive syndrome, pursuing a firm diagnosis in a changeable discipline. Non-medical readers will appreciate his telling us not to worry, that similar difficulties exist throughout the medical world. When he says, "We are measuring amoeba with a rubber ruler," he has given us permission to laugh at our poor efforts, and we are assured that he knows what our days are like behind the office door. Beyond the introduction, Wender spills out a cornucopia of information for clinicians and scholars alike. Chapter 5 teaches the diagnosis of ADHD with adults through the protocols of the University of Utah Medical Center. Chapter 6 assesses the utility of the various medications he uses with ADHD, with unusual material on the MAOI class of drugs. These two chapters illustrate the difference between this book and the larger reference volumes on the shelf. Here Wender presents his own experience, rather than attempting an exhaustive review of the existing proto187
188
T. Linnell
cols or the pantheon of drugs. As such, the chapters will help in the training of clinicians in specific procedures, but may leave them lacking a broader perspective. Chapter 8, finally, offers a light sprinkling of research proposals that Wender finds interesting in the areas of genetics, spectrum disorders and biochemical constructs. Chapter 7 deserves special comment. It may be the most memorable chapter in the book. If other chapters seem lacking by comparison with the more exhaustive references, this chapter stands alone as far superior to its like among contemporary books on ADHD. It is in this chapter that Wender introduces his patients and lets them tell their stories of suffering and treatment. The disparate elements of etiology and prevalence, symptoms and diagnosis, come together in flashes of brilliant and personal prose. Here Wender made the exceptional choice to limit his own description of each person to a few words, trusting that they would tell their own stories in their own way. The results are indelible. Along the way, Wender touches--often too lightly--on a small host of old problems in this field: the observation that adoptive children display a higher rate of ADHD, the persistent comorbities of conduct and mood disorders with ADHD, the question of what percentage of children outgrow the syndrome, the recurring efforts to develop subtypes, and so on. Even in 1995, Wender delivers more description than insight or breakthrough for most of these issues. It becomes clear that his hopes fly toward "molecular genetics" as the likely source of understanding in the next wave of research. As helpful as this book is, it nevertheless falls short in a number of areas of more than passing importance. Wender unfortunately refers to the DSM-III-R more often than 1995 will tolerate. Was there no way to edit in favor of the DSM-IV criteria and conceptualization of adult ADHD? Elsewhere, Wender leaves the reader with a clear message that late afternoon doses of psychostimulants are always contraindicated because of their effects on sleep patterns. Not only is it well understood in the field by now that this is not the case, but Wender himself presents a case report in Chapter 7 in which bedtime doses of Ritalin actually improved sleep. Sleep disturbances are a frequent complication in ADHD, and the subject called for a more consistent treatment in a book of this depth. A third shortfall concerns the discussion of stimulants as Schedule II controlled substances. Here Wender simply repeats the rationale for the status quo, without reference to current proposals before the FDA to give them less restrictive classifications. These proposals arise from consumer groups and clinicians who recognize the need for easier access to these medications. The objections arise from those who fear their potential for abuse. Wender's own research states that patients do not develop tolerance or become addicted to the stimulants. Whether or not he believes they should be reclassified, should we not have expected to hear his thoughts on this question? This was an opportunity for leadership. In perspective, this is a field where enormous public pressure has forced clinical practice to move ahead faster than its scientific base. Wender's discussion in Chapter 3 about the limits of our knowledge and his frank recognition that rigorous scientific criteria "are probably honored in the breach (and) experienced clinicians.., may diagnose ADHD in the presence of a smallerthan-necessary number of solid signs" confirm his understanding. In 1995, the underground information flow has surfaced as a flood on the Internet, revealing what we had suspected before, that victims and their loved ones are continuing to push back the edge of the unknown in their search for solutions. No clinician/scientist, even one as dedicated as Paul Wender, could reasonably bring to focus all of the hot topics in ADHD. The help he offers through this book is genuine and well founded. Readers will open the book again and again to review what is reliably known, and to draw from the strength of a master.