Merry Christmas you filthy animals

TCPR: How did adult ADHD enter the picture?

Dr. Gualtieri: Researchers, including Paul Wender and I, started writing about adult

ADD in the 1970s and 1980s (Gualtieri CT et al, Clin Neuropharmacol 1985;8(4):343–

356). Treatment of adult ADD took off after 1996 with Ned Hallowell’s book Driven

to Distraction, and further in the early 2000s with the first FDA approvals for adult

ADHD. Today, the number of children and adults who are diagnosed with ADHD and

given stimulant prescriptions is astonishing—and a bit troubling.

TCPR: Do they all have ADHD?

Dr. Gualtieri: I don’t think so. Inattention and mental fatigue are extremely com-

mon among people who are completely “normal.” A drug that gives you energy and

helps you focus is always going to be popular. They are taking “energy” and “confi-

dence” pills like they did in the 1930s.

TCPR: It sounds like today’s “ADHD” includes a few patients with MBD, and a lot more who are hyperkinetic, inattentive,

or have nonspecific cognitive complaints.

Dr. Gualtieri: Yes. We have to understand that different kinds of patients may meet DSM criteria for ADHD. Children with MBD

are only a small proportion of those kids. In some children, what we call ADHD is a personality trait. They have high energy and

are impatient with desk work. They are good, hard-working kids, often busy with sports and jobs on the weekends. They regard

schoolwork as dull and boring. We give them stimulants so they will pass their grade and stay in school. But we’re not treating a

neurodevelopmental disorder.

TCPR: But they are inattentive and restless, so how is it any different from ADHD?

Dr. Gualtieri: They might check all the boxes on an ADD rating scale. But the criteria say the symptoms have to occur in multi-

ple settings. Real ADHD (that is, MBD) is a neurodevelopmental disorder, which is why the problems occur in most settings. The

criteria also say the symptoms have to cause significant distress or impairment. Those are wise words. Significant distress is not a

patient complaining of problems concentrating. Sitting still and concentrating is hard work for everybody, and especially children.

Significant distress is not the everyday problems of living.

TCPR: Can ADHD symptoms be temporary in some children?

Dr. Gualtieri: Yes. Some kids have a very mild, transient neurodevelopmental disorder. Their frontal lobes are slow to mature.

They are smart but haven’t developed attentional control mechanisms at the expected rate. Stimulants give them better attentional

control and may even stimulate brain maturation. These two groups—those with

ADHD-like personality traits and those with delayed maturation—probably repre-

sent the largest number of so-called ADHD kids. It’s why most children who take

stimulants for ADHD only take the drugs for two or three years.

TCPR: What are the pros and cons of stimulants in patients without classic ADHD?

Dr. Gualtieri: With children, there aren’t many cons. We prescribe the drugs to help

with transient problems, and they do. Stimulants are safe in low doses (eg, 15–20 mg

of long-acting methylphenidate in an 8-year-old child), and no one has established

significant long-term harms with over 50 years of use in children. The side effects

that children have are painfully obvious—gastrointestinal distress, weight loss, head-

ache, personality suppression. Kids with these side effects are “zombified.” Parents

don’t carry on treatment in the face of those effects. Small children (< 66 lbs) are

more likely to have stimulant side effects, and they tolerate methylphenidate better

than amphetamines. Young children also do well on alpha-2 agonists like clonidine

and guanfacine.

TCPR: What about risks in adults?

Dr. Gualtieri: Adults are different. Some adults take stimulants occasionally, when they are fatigued or have to concentrate on tedious

work. That is usually safe, unless they have a blood pressure spike and an unstable cerebral aneurysm. What concerns me is people

who take amphetamines day in, day out for years. Children usually take stimulants on school days, over an average of just two or three

years. That’s not what adults do. Really, they’re just giving themselves one more cardiovascular risk factor. Who needs that? Also, adults

are prone to take higher doses. One patient recently said to me, “I’m taking 30 mg of Adderall 3 times a day, but this ADD is killing

me.” His family doctor sent him to me because he was uncomfortable with the high dose.

TCPR: What dose ranges are OK?

Dr. Gualtieri: I’m more comfortable in the lower dose range, which for adults would be 10–20 mg of Adderall XR or 10–30 mg

of long-acting methylphenidate (Farhat LC et al, JAMA Psychiatry 2024;81(2):157–166). Low doses of stimulants have positive cog-

nitive effects. Higher doses impair cognition (Sprague RL and Sleator EL, Science 1977;198(4323):1274–1276).

TCPR: What’s another way patients are misclassified with ADHD?

Dr. Gualtieri: Another common one is people with active minds. As children, they are creative and intelligent. They have quick

minds and are impatient with traditional forms of education. They are raised on video games where things go really fast, and

those skills don’t translate into schoolwork. They are delightful to talk to. They are funny, creative, and complex. They are a bit

undisciplined, but not to the point of behavioral problems. But if you give the teacher a Vanderbilt questionnaire, the child will

generate an ADD profile. They often get stimulants, but what they need is a more tailored form of education and training.

TCPR: Do they grow up to be adults with active minds?

Dr. Gualtieri: Yes, and they are often quite accomplished. They are intelligent kids, and quite resilient. Taking low doses of a

stimulant for a couple of years doesn’t stunt their creativity.

TCPR: Should they test into a gifted program or go to a charter school?

Dr. Gualtieri: Yes, but to get into those programs they’ll probably have to pass math and score well, and they won’t get in if they

can’t buckle down. Stimulants help them do that. We shouldn’t tell them they have a “disorder” that needs long-term stimulants.

The drugs are at best a temporary fix until they get into a school (or a job) that’s better suited to their talents.

TCPR: In our first interview, you said stimulants are helpful for nontraditional ADHD, but I imagine the benefits are limited.

Dr. Gualtieri: Time-limited, yes. They can be quite helpful for a while, but stimulants don’t have reliable, long-term benefits

on memory, attention, executive function, creativity, or test scores (Advokat C, Neurosci Biobehav Rev 2010;34(8):1256–1266).

Some artists will tell you that stimulants enhance their creativity, but I don’t believe that. Artists and poets have said that

about cannabis, cocaine, opium, and alcohol. Stimulants don’t improve cognitive flexibility; rather, they confine one’s perspec-

tive. They can make people hyperfocused, stubborn, and robotic—like a zombie. These effects tend to be dose-dependent, but

there’s one group who is especially vulnerable.

TCPR: What group is that?

Dr. Gualtieri: Anxious and compulsive patients. These are patients who are constantly doubting themselves, to the point that

they start to think they have ADD. They’ll tell you, “My high school GPA was 5.5, but I always had to work so hard.” What

they’re saying is true, but it’s not the ADD that’s making them work hard; it’s obsessive anxiety. Perfectionism. People with this

trait do well on cognitive tests, but it takes them longer because they have to use

a lot of mental energy to overcome the internal negative biases that distract them.

TCPR: Do the stimulants make them more anxious?

Dr. Gualtieri: You would think so, but anxious patients often respond favor-

ably. Anxious patients have slower mental processing speed, and stimulants

increase processing speed. Maybe stimulants give them a boost of mental

energy to control anxiety. The problem is that stimulants are “on-off” drugs.

You experience their effects when they are working, and you can feel when

they wear off. Patients who are anxious or compulsive already have problems

with self-absorption. They are obsessive about their mental state. When we give

them stimulants, we are conditioning them to monitor their mental state, which

is not necessarily a good thing. When the stimulant wears off at the end of the

day, their mental state changes, and their anxiety ramps up: “Wait, I’m fatigued,

I’m distracted.” They obsess about being on just the right dose and how long

that dose lasts. It never lasts long enough or works well enough. To be clear,

I’m talking here about people with anxiety and obsessive-compulsive personal-

ity traits, not OCD. About a third of people have such traits—as does virtually

everyone who gets into medical school.

TCPR: A few years ago, there was a trial that randomized professional chess

players to methylphenidate or placebo. The ones who got the stimulant per-

formed worse because they kept second-guessing their moves (Franke AG et

al, Eur Neuropsychopharmacol 2017;27(3):248–260).

Dr. Gualtieri: Yes. And it’s why a dose of amphetamine won’t help you on the SATs. Stimulants are cognitive enhancers in

patients with ADD and many brain injury patients, but not in people who are cognitively normal. Stimulants just give them a

bit more energy and confidence. Even in ADD, the cognitive effects of stimulants are mixed. When we give patients a dose of

a stimulant in the clinic and test them an hour later, they usually improve on tests of attention and mental processing speed,

but they get worse on the Stroop test, a measure of cognitive flexibility.

TCPR: What about people who just have too much on their plate?

Dr. Gualtieri: Overload can make one inattentive. So can fatigue, sleep deprivation, stress, and a physically deconditioned

state. But overwork is something that often brings patients to our clinic. Some people take on too much work because they

are compulsive. For others, it’s out of necessity. They are working two jobs, or managing kids while working virtually from

home. They are sleep deprived. Often they’ll take a friend’s stimulant, or one of their children’s, and experience a pleasing

burst of energy. So, they decide they must have ADD. They visit a doctor, check the right boxes on a short questionnaire, and

presto! They have ADD. Stimulants may help in such circumstances. They do help with mental energy, and there is evidence

that they stimulate mitochondrial activity. But they don’t help multitasking as such. They just give patients a bit more energy

TCPR: What are the risks of giving stimulants to normal, overworked people?

Dr. Gualtieri: If you’re dealing with a responsible individual, it’s not a major risk to prescribe them a low dose of a stimu-

lant to take occasionally, by which I mean like once a week or once a month. Where we can run into trouble is when a

patient has a psychotic illness, bipolar disorder, a substance use disorder, or cardiovascular risk factors. Some people get a

transient blood pressure spike when they take stimulants intermittently, and this can pose a problem, particularly in elderly

patients.

TCPR: How do you handle stimulants in patients with major psychiatric disorders?

Dr. Gualtieri: Practically all major psychiatric disorders compromise attention and executive function. But the risk of psycho-

sis is high when people with bipolar disorder or schizophrenia take a stimulant. I will use them occasionally in bipolar disor-

der if the patient is conscientious about treatment and has had a stable mood for a long time. But otherwise, it’s not a good

idea (Moran LV et al, Am J Psychiatry 2024;181(10):901–909).

TCPR: Some people don’t have a lot on their plate, but they complain of mental fatigue. They may be older, have long

COVID or other medical problems, or are burned out on their job.

Dr. Gualtieri: Or they have “brain fog” from cancer chemotherapy or menopause, chronic fatigue syndrome, or fibromyalgia.

Sometimes stimulants are effective there, sometimes not. There are, of course, nonstimulant alternatives, but they don’t always

work. These people are experiencing real suffering, and it’s frustrating when no drug helps.

TCPR: Do stimulants help age-related cognitive decline? Dr. Gualtieri: Low doses of methylphenidate, like 5–20 mg a day in long-acting form, help cognition, mood, and energy in older adults with various medical problems (Sassi KLM et al, Curr Neuropharmacol 2020;18(2):126–135). It’s not unreasonable to try a stimulant for conscientious older patients who won’t overuse it and don’t have cardiovascular disease. However, cholinesterase inhibitors (eg, donepezil, galantamine, rivastigmine) and some antidepressants (eg, bupropion, vortioxetine) are better cognitive enhancers for older people (Lenze EJ et al, Am J Psychiatry 2020;177(6):548–555). TCPR: How do you counsel patients who aren’t so conscientious and don’t have classic ADHD? Dr. Gualtieri: The problem is that some people misuse stimulants. During past amphetamine epidemics in countries like Japan and Sweden, up to 10% of the adult population was using these drugs. In the US, we’re approaching similar numbers—though now it’s largely through prescriptions under what’s considered medical supervision. But how careful is that supervision, especially with the rise of telemedicine? It’s important to remember a patient doesn’t have ADHD just because they say they do. While attention problems are real, they don’t automatically mean ADHD. Instead, they should prompt a careful differential diagnosis to determine the actual cause (see the table on page 6, “Ten Causes of ADHD Misdiagnosis”).

TCPR: What about people who overuse stimulants? Dr. Gualtieri: Some of them have stimulant use disorder. Others don’t meet the criteria for that, but stimulants have become part of their way of life, as coffee is for other people. They may smoke cannabis to go to sleep and take stimulants to wake up. It’s not a great idea, to say the least, but is it substance use disorder? In some colleges, 25% of students seem to be doing just that (McCabe SE et al, JAMA Netw Open 2023;6(4):e238707). TCPR: And sometimes their clinician will oblige them and raise the dose. Dr. Gualtieri: You and I are not that kind of clinician, nor the majority of our colleagues. When encountering such patients, I explain that stimulants have an inverted U-shaped curve in their cognitive effects: Low doses improve cognition, but higher doses impair cognition. Those high doses can also cause a cardiac arrhythmia. They listen politely and go find another prescriber. If I can get them to stay, I lower the dose by about 10 mg a month. They complain that they can’t function without more, but on testing their cognition usually improves. TCPR: Thank you for your time, Dr. Gualtieri