Secrets of the ADHD Brain

ADDitude

Most people are neurologically equipped to determine what’s important and get motivated to do it, even when it doesn’t interest them. Then there are the rest of us, who have attention deficit.

by William Dodson, M.D.

 

ADHDers know that they are bright and clever, but they are never sure whether their abilities will show up when they need them.

ADHD is a confusing, contradictory, inconsistent, and frustrating condition. It is overwhelming to people who live with it every day. The diagnostic criteria that have been used for the last 40 years leave many people wondering whether they have the condition or not. Diagnosticians have long lists of symptoms to sort through and check off. The Diagnostic and Statistical Manual of Mental Disorders has 18 criteria, and other symptom lists cite as many as 100 traits.

Practitioners, including myself, have been trying to establish a simpler, clearer way to understand the impairments of ADHD. We have been looking for the “bright and shining line” that defines the condition, explains the source of impairments, and gives direction as to what to do about it.

My work for the last decade suggests that we have been missing something important about the fundamental nature of ADHD. I went back to the experts on the condition — the hundreds of people and their families I worked with who were diagnosed with it — to confirm my hypothesis. My goal was to look for the feature that everyone with ADHD has, and that neurotypical people don’t have.

I found it. It is the ADHD nervous system, a unique and special creation that regulates attention and emotions in different ways than the nervous system in those without the condition.

The ADHD Zone

Almost every one of my patients and their families want to drop the term Attention Deficit Hyperactivity Disorder, because it describes the opposite of what they experience every moment of their lives. It is hard to call something a disorder when it imparts many positives. ADHD is not a damaged or defective nervous system. It is a nervous system that works well using its own set of rules. Despite ADHD’s association with learning disabilities, most people with an ADHD nervous system have significantly higher-than-average IQs. They also use that higher IQ in different ways than neurotypical people. By the time most people with the condition reach high school, they are able to tackle problems that stump everyone else, and can jump to solutions that no one else saw.

The vast majority of adults with an ADHD nervous system are not overtly hyperactive. They are hyperactive internally.

Those with the condition don’t have a shortage of attention. They pay too much attention to everything. Most people with unmedicated ADHD have four or five things going on in their minds at once. The hallmark of the ADHD nervous system is not attention deficit, but inconsistent attention.

Everyone with ADHD knows that they can “get in the zone” at least four or five times a day. When they are in the zone, they have no impairments, and the executive function deficits they may have had before entering the zone disappear. ADHDers know that they are bright and clever, but they are never sure whether their abilities will show up when they need them. The fact that symptoms and impairments come and go throughout the day is the defining trait of ADHD. It makes the condition mystifying and frustrating.

People with ADHD primarily get in the zone by being interested in, or intrigued by, what they are doing. I call it an interest-based nervous system. Judgmental friends and family see this as being unreliable or self-serving. When friends say, “You can do the things you like,” they are describing the essence of the ADHD nervous system.

ADHD individuals also get in the zone when they are challenged or thrown into a competitive environment. Sometimes a new or novel task attracts their attention. Novelty is short-lived, though, and everything gets old after a while.

Most people with an ADHD nervous system can engage in tasks and access their abilities when the task is urgent — a do-or-die deadline, for instance. This is why procrastination is an almost universal impairment in people with ADHD. They want to get their work done, but they can’t get started until the task becomes interesting, challenging, or urgent.

How the Rest of the World Functions

The 90 percent of non-ADHD people in the world are referred to as “neurotypical.” It is not that they are “normal” or better. Their neurology is accepted and endorsed by the world. For people with a neurotypical nervous system, being interested in the task, or challenged, or finding the task novel or urgent is helpful, but it is not a prerequisite for doing it.

Neurotypical people use three different factors to decide what to do, how to get started on it, and to stick with it until it is completed:

1. the concept of importance (they think they should get it done).

2. the concept of secondary importance–they are motivated by the fact that their parents, teacher, boss, or someone they respect thinks the task is important to tackle and to complete.

3. the concept of rewards for doing a task and consequences/punishments for not doing it.

A person with an ADHD nervous system has never been able to use the idea of importance or rewards to start and do a task. They know what’s important, they like rewards, and they don’t like punishment. But for them, the things that motivate the rest of the world are merely nags.

The inability to use importance and rewards to get motivated has a lifelong impact on ADHDers’ lives:

How can those diagnosed with the condition choose between multiple options if they can’t use the concepts of importance and financial rewards to motivate them?

How can they make major decisions if the concepts of importance and rewards are neither helpful in making a decision nor a motivation to do what they choose? This understanding explains why none of the cognitive and behavioral therapies used to manage ADHD symptoms have a lasting benefit. Researchers view ADHD as stemming from a defective or deficit-based nervous system. I see ADHD stemming from a nervous system that works perfectly well by its own set of rules. Unfortunately, it does not work by any of the rules or techniques taught and encouraged in a neurotypical world. That’s why:

ADDers do not fit in the standard school system, which is built on repeating what someone else thinks is important and relevant.

ADDers do not flourish in the standard job that pays people to work on what someone else (namely, the boss) thinks is important.

ADDers are disorganized, because just about every organizational system out there is built on two things — prioritization and time management — that ADDers do not do well.

ADDers have a hard time choosing between alternatives, because everything has the same lack of importance. To them, all of the alternatives look the same.

People with an ADHD nervous system know that, if they get engaged with a task, they can do it. Far from being damaged goods, people with an ADHD nervous system are bright and clever. The main problem is that they were given a neurotypical owner’s manual at birth. It works for everyone else, not for them.

Don’t Turn ADHDers into Neurotypicals

The implications of this new understanding are vast. The first thing to do is for coaches, doctors, and professionals to stop trying to turn ADHD people into neurotypical people. The goal should be to intervene as early as possible, before the ADHD individual has beenfrustrated and demoralized by struggling in a neurotypical world, where the deck is stacked against him. A therapeutic approach that has a chance of working, when nothing else has, should have two pieces:

Level the neurologic playing field with medication, so that the ADHD individual has the attention span, impulse control, and ability to be calm on the inside. For most people, this requires two different medications. Stimulants improve an ADHDer’s day-to-day performance, helping him get things done. They are not effective at calming the internal hyperarousal that many with ADHD have. For those symptoms, the majority of people will benefit by adding one of the alpha agonist medications (clonidine/Kapvay or guanfacine/Intuniv) to the stimulant.

Medication, though, is not enough. A person can take the right medication at the right dose, but nothing will change if he still approaches tasks with neurotypical strategies.

The second piece of ADHD symptom management is to have an individual create his own ADHD owner’s manual. The generic owner’s manuals that have been written have been disappointing for people with the condition. Like everyone else, those with ADHD grow and mature over time. What interests and challenges someone at seven years old will not interest and challenge him at 27.

Write Your Own Rules

The ADHD owner’s manual has to be based on current successes. How do you get in the zone now? Under what circumstances do you succeed and thrive in your current life? Rather than focus on where you fall short, you need to identify how you get into the zoneand function at remarkable levels.

I usually suggest that my patients carry around a notepad or a tape recorder for a month to write down or explain how they get in the zone.

Is it because they are intrigued? If so, what, specifically, in the task or situation intrigues them? Is it because they feel competitive? If so, what in the “opponent” or situation brings up the competitive juices?

At the end of the month, most people have compiled 50 or 60 different techniques that they know work for them. When called on to perform and become engaged, they now understand how their nervous system works and which techniques are helpful.

I have seen these strategies work for many ADDers, because they stepped back and figured out the triggers they need to pull. This approach does not try to change people with an ADHD nervous system into neurotypical people (as if that were possible), but gives lifelong help because it builds on their strengths.

Doctor: ADHD Does Not Exist

Time

Dr. Richard Saul

March 14, 2014

Getty Images

Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Raising a generation of children — and now adults — who can’t live without stimulants is no solution

This Wednesday, an article in the New York Timesreported that from 2008 to 2012 the number of adults taking medications for ADHD increased by 53% and that among young American adults, it nearly doubled. While this is a staggering statistic and points to younger generations becoming frequently reliant on stimulants, frankly, I’m not too surprised. Over my 50-year career in behavioral neurology and treating patients with ADHD, it has been in the past decade that I have seen these diagnoses truly skyrocket. Every day my colleagues and I see more and more people coming in claiming they have trouble paying attention at school or work and diagnosing themselves with ADHD.

If someone finds it difficult to pay attention or feels somewhat hyperactive, attention-deficit/hyperactivity disorder has those symptoms right there in its name. It’s an easy catchall phrase that saves time for doctors to boot. But can we really lump all these people together? What if there are other things causing people to feel distracted? I don’t deny that we, as a population, are more distracted today than we ever were before. And I don’t deny that some of these patients who are distracted and impulsive need help. What I do deny is the generally accepted definition of ADHD, which is long overdue for an update. In short, I’ve come to believe based on decades of treating patients that ADHD — as currently defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) and as understood in the public imagination — does not exist.

Allow me to explain what I mean.

Ever since 1937, when Dr. Charles Bradley discovered that children who displayed symptoms of attention deficit and hyperactivity responded well to Benzedrine, a stimulant, we have been thinking about this “disorder” in almost the same way. Soon after Bradley’s discovery, the medical community began labeling children with these symptoms as having minimal brain dysfunction, or MBD, and treating them with the stimulants Ritalin and Cylert. In the intervening years, the DSM changed the label numerous times, from hyperkinetic reaction of childhood (it wasn’t until 1980 that the DSM-III introduced a classification for adults with the condition) to the current label, ADHD. But regardless of the label, we have been giving patients different variants of stimulant medication to cover up the symptoms. You’d think that after decades of advancements in neuroscience, we would shift our thinking.

Today, the fifth edition of the DSM only requires one to exhibit five of 18 possible symptoms to qualify for an ADHD diagnosis. If you haven’t seen the list, look it up. It will probably bother you. How many of us can claim that we have difficulty with organization or a tendency to lose things; that we are frequently forgetful or distracted or fail to pay close attention to details? Under these subjective criteria, the entire U.S. population could potentially qualify. We’ve all had these moments, and in moderate amounts they’re a normal part of the human condition.

However, there are some instances in which attention symptoms are severe enough that patients truly need help. Over the course of my career, I have found more than 20 conditions that can lead to symptoms of ADHD, each of which requires its own approach to treatment. Among these are sleep disorders, undiagnosed vision and hearing problems, substance abuse (marijuana and alcohol in particular), iron deficiency, allergies (especially airborne and gluten intolerance), bipolar and major depressive disorder, obsessive-compulsive disorder and even learning disabilities like dyslexia, to name a few. Anyone with these issues will fit the ADHD criteria outlined by the DSM, but stimulants are not the way to treat them.

What’s so bad about stimulants? you might wonder. They seem to help a lot of people, don’t they? The article in theTimes mentions that the “drugs can temper hallmark symptoms like severe inattention and hyperactivity but also carry risks like sleep deprivation, appetite suppression and, more rarely, addiction and hallucinations.” But this is only part of the picture.

First, addiction to stimulant medication is not rare; it is common. The drugs’ addictive qualities are obvious. We only need to observe the many patients who are forced to periodically increase their dosage if they want to concentrate. This is because the body stops producing the appropriate levels of neurotransmitters that ADHD meds replace — a trademark of addictive substances. I worry that a generation of Americans won’t be able to concentrate without this medication; Big Pharma is understandably not as concerned.

Second, there are many side effects to ADHD medication that most people are not aware of: increased anxiety, irritable or depressed mood, severe weight loss due to appetite suppression, and even potential for suicide. But there are also consequences that are even less well known. For example, many patients on stimulants report having erectile dysfunction when they are on the medication.

Third, stimulants work for many people in the short term, but for those with an underlying condition causing them to feel distracted, the drugs serve as Band-Aids at best, masking and sometimes exacerbating the source of the problem.

In my view, there are two types of people who are diagnosed with ADHD: those who exhibit a normal level of distraction and impulsiveness, and those who have another condition or disorder that requires individual treatment.

For my patients who are in the first category, I recommend that they eat right, exercise more often, get eight hours of quality sleep a night, minimize caffeine intake in the afternoon, monitor their cell-phone use while they’re working and, most important, do something they’re passionate about. Like many children who act out because they are not challenged enough in the classroom, adults whose jobs or class work are not personally fulfilling or who don’t engage in a meaningful hobby will understandably become bored, depressed and distracted. In addition, today’s rising standards are pressuring children and adults to perform better and longer at school and at work. I too often see patients who hope to excel on four hours of sleep a night with help from stimulants, but this is a dangerous, unhealthy and unsustainable way of living over the long term.

For my second group of patients with severe attention issues, I require a full evaluation to find the source of the problem. Usually, once the original condition is found and treated, the ADHD symptoms go away.

It’s time to rethink our understanding of this condition, offer more thorough diagnostic work and help people get the right treatment for attention deficit and hyperactivity.

Dr. Richard Saul is a behavioral neurologist practicing in the Chicago area. His book, ADHD Does Not Exist, is p

ADHD – Diagnosing the Wrong Deficit

An opinion piece from The New York Times

Shannon Freshwater

IN the spring of 2010, a new patient came to see me to find out if he had attention-deficit hyperactivity disorder. He had all the classic symptoms: procrastination, forgetfulness, a propensity to lose things and, of course, the inability to pay attention consistently. But one thing was unusual. His symptoms had started only two years earlier, when he was 31.

Though I treat a lot of adults for attention-deficit hyperactivity disorder, the presentation of this case was a violation of an important diagnostic criterion: symptoms must date back to childhood. It turned out he first started having these problems the month he began his most recent job, one that required him to rise at 5 a.m., despite the fact that he was a night owl.

The patient didn’t have A.D.H.D., I realized, but a chronic sleep deficit. I suggested some techniques to help him fall asleep at night, like relaxing for 90 minutes before getting in bed at 10 p.m. If necessary, he could take a small amount of melatonin. When he returned to see me two weeks later, his symptoms were almost gone. I suggested he call if they recurred. I never heard from him again.

Many theories are thrown around to explain the rise in the diagnosis and treatment of A.D.H.D. in children and adults. According to the Centers for Disease Control and Prevention, 11 percent of school-age children have now received a diagnosis of the condition. I don’t doubt that many people do, in fact, have A.D.H.D.; I regularly diagnose and treat it in adults. But what if a substantial proportion of cases are really sleep disorders in disguise?

For some people — especially children — sleep deprivation does not necessarily cause lethargy; instead they become hyperactive and unfocused. Researchers and reporters are increasingly seeing connections between dysfunctional sleep and what looks like A.D.H.D., but those links are taking a long time to be understood by parents and doctors.

We all get less sleep than we used to. The number of adults who reported sleeping fewer than seven hours each night went from some 2 percent in 1960 to more than 35 percent in 2011. Sleep is even more crucial for children, who need delta sleep — the deep, rejuvenating, slow-wave kind — for proper growth and development. Yet today’s youngsters sleep more than an hour less than they did a hundred years ago. And for all ages, contemporary daytime activities — marked by nonstop 14-hour schedules and inescapable melatonin-inhibiting iDevices — often impair sleep. It might just be a coincidence, but this sleep-restricting lifestyle began getting more extreme in the 1990s, the decade with the explosion in A.D.H.D. diagnoses.

A number of studies have shown that a huge proportion of children with an A.D.H.D. diagnosis also have sleep-disordered breathing like apnea or snoring, restless leg syndrome or non-restorative sleep, in which delta sleep is frequently interrupted.

One study, published in 2004 in the journal Sleep, looked at 34 children with A.D.H.D. Every one of them showed a deficit of delta sleep, compared with only a handful of the 32 control subjects.

A 2006 study in the journal Pediatrics showed something similar, from the perspective of a surgery clinic. This study included 105 children between ages 5 and 12. Seventy-eight of them were scheduled to have their tonsils removed because they had problems breathing in their sleep, while 27 children scheduled for other operations served as a control group. Researchers measured the participants’ sleep patterns and tested for hyperactivity and inattentiveness, consistent with standard protocols for validating an A.D.H.D. diagnosis.

Of the 78 children getting the tonsillectomies, 28 percent were found to have A.D.H.D., compared with only 7 percent of the control group.

Even more stunning was what the study’s authors found a year after the surgeries, when they followed up with the children. A full half of the original A.D.H.D. group who received tonsillectomies — 11 of 22 children — no longer met the criteria for the condition. In other words, what had appeared to be A.D.H.D. had been resolved by treating a sleeping problem.

But it’s also possible that A.D.H.D.-like symptoms can persist even after a sleeping problem is resolved. Consider a long-term study of more than 11,000 children in Britain published last year, also in Pediatrics. Mothers were asked about symptoms of sleep-disordered breathing in their infants when they were 6 months old. Then, when the children were 4 and 7 years old, the mothers completed a behavioral questionnaire to gauge their children’s levels of inattention, hyperactivity, anxiety, depression and problems with peers, conduct and social skills.

The study found that children who suffered from sleep-disordered breathing in infancy were more likely to have behavioral difficulties later in life — they were 20 to 60 percent more likely to have behavioral problems at age 4, and 40 to 100 percent more likely to have such problems at age 7. Interestingly, these problems occurred even if the disordered breathing had abated, implying that an infant breathing problem might cause some kind of potentially irreversible neurological injury.

CLEARLY there is more going on in the nocturnal lives of our children than any of us have realized. Typically, we see and diagnose only their downstream, daytime symptoms.

There has been less research into sleep and A.D.H.D. outside of childhood. But a team from Massachusetts General Hospital found, in one of the only studies of its kind, that sleep dysfunction in adults with A.D.H.D. closely mimics the sleep dysfunction in children with A.D.H.D.

There is also some promising research being done on sleep in adults, relating to focus, memory and cognitive performance. A study published in February in the journal Nature Neuroscience found that the amount of delta sleep in seniors correlates with performance on memory tests. And a study published three years ago in Sleep found that while subjects who were deprived of sleep didn’t necessarily report feeling sleepier, their cognitive performance declined in proportion to their sleep deprivation and continued to worsen over five nights of sleep restriction.

As it happens, “moves about excessively during sleep” was once listed as a symptom of attention-deficit disorder in the Diagnostic and Statistical Manual of Mental Disorders. That version of the manual, published in 1980, was the first to name the disorder. When the term A.D.H.D., reflecting the addition of hyperactivity, appeared in 1987, the diagnostic criteria no longer included trouble sleeping. The authors said there was not enough evidence to support keeping it in.

But what if doctors, before diagnosing A.D.H.D. in their patients, did have to find evidence of a sleep disorder? Psychiatric researchers typically don’t have access to the equipment or expertise needed to evaluate sleep issues. It’s tricky to ask patients to keep sleep logs or to send them for expensive overnight sleep studies, which can involve complicated equipment like surface electrodes to measure brain and muscle activity; abdominal belts to record breathing; “pulse oximeters” to measure blood oxygen levels; even snore microphones. (And getting a sleep study approved by an insurance company is by no means guaranteed.) As it stands, A.D.H.D. can be diagnosed with only an office interview.

Sometimes my patients have resisted my referrals for sleep testing, since everything they have read (often through direct-to-consumer marketing by drug companies) identifies A.D.H.D. as the culprit. People don’t like to hear that they may have a different, stranger-sounding problem that can’t be fixed with a pill — though this often changes once patients see the results of their sleep studies.

Beyond my day job, I have a personal interest in A.D.H.D. and sleep disorders. Beginning in college and for nearly a decade, I struggled with profound cognitive lethargy and difficulty focusing, a daily nap habit and weekend sleep addiction. I got through my medical school exams only by the grace of good memorization skills and the fact that ephedra was still a legal supplement.

I was misdiagnosed with various maladies, including A.D.H.D. Then I underwent two sleep studies and, finally, was found to have an atypical form of narcolepsy. This was a shock to me, because I had never fallen asleep while eating or talking. But, it turned out, over 40 percent of my night was spent in REM sleep — or “dreaming sleep,” which normally occurs only intermittently throughout the night — while just 5 percent was spent in delta sleep, the rejuvenating kind. I was sleeping 8 to 10 hours a night, but I still had a profound delta sleep deficit.

It took some trial and error, but with the proper treatment, my cognitive problems came to an end. Today I eat well and respect my unique sleep needs instead of trying to suppress them. I also take two medications: a stimulant for narcolepsy and, at bedtime, an S.N.R.I. (or serotonin-norepinephrine reuptake inhibitor) antidepressant — an off-label treatment that curtails REM sleep and helps increase delta sleep. Now I wake up without an alarm, and my daytime focus is remarkably improved. My recovery has been amazing (though my wife would argue that weekend mornings are still tough — she picks up the slack with our two kids).

Attention-deficit problems are far from the only reasons to take our lack of quality sleep seriously. Laboratory animals die when they are deprived of delta sleep. Chronic delta sleep deficits in humans are implicated in many diseases, including depression, heart disease, hypertension, obesity, chronic pain, diabetes and cancer, not to mention thousands of fatigue-related car accidents each year.

Sleep disorders are so prevalent that every internist, pediatrician and psychiatrist should routinely screen for them. And we need far more research into this issue. Every year billions of dollars are poured into researching cancer, depression and heart disease, but how much money goes into sleep?

The National Institutes of Health will spend only $240 million on sleep research this year. One of the problems is that the research establishment exists as mini-fiefdoms — money given to one sector, like cardiology or psychiatry, rarely makes it into another, like sleep medicine, even if they are intimately connected.

But we can’t wait any longer to pay attention to the connection between delta sleep and A.D.H.D. If you’re not already convinced, consider the drug clonidine. It started life as a hypertension treatment, but has been approved by the Food and Drug Administration to treat A.D.H.D. Studies show that when it is taken only at bedtime, symptoms improve during the day. For psychiatrists, it is one of these “oh-we-don’t-know-how-it-works” drugs. But here is a little-known fact about clonidine: it can be a potent delta sleep enhancer.

Vatsal G. Thakkar is a clinical assistant professor of psychiatry at the N.Y.U. School of Medicine.

A version of this op-ed appeared in print on April 28, 2013, on page SR1 of the New York edition with the headline: Diagnosing The Wrong Deficit.

Drowned in a Stream of Prescriptions – for ADHD

Drowned in a Stream of Prescriptions

The New York Times

Before his addiction, Richard Fee was a popular college class president and aspiring medical student. “You keep giving Adderall to my son, you’re going to kill him,” said Rick Fee, Richard’s father, to one of his son’s doctors.

By ALAN SCHWARZ

Published: February 2, 2013 500 Comments

VIRGINIA BEACH — Every morning on her way to work, Kathy Fee holds her breath as she drives past the squat brick building that houses Dominion Psychiatric Associates.

It was there that her son, Richard, visited a doctor and received prescriptions for Adderall, an amphetamine-based medication for attention deficit hyperactivity disorder. It was in the parking lot that she insisted to Richard that he did not have A.D.H.D., not as a child and not now as a 24-year-old college graduate, and that he was getting dangerously addicted to the medication. It was inside the building that her husband, Rick, implored Richard’s doctor to stop prescribing him Adderall, warning, “You’re going to kill him.”

It was where, after becoming violently delusional and spending a week in a psychiatric hospital in 2011, Richard met with his doctor and received prescriptions for 90 more days of Adderall. He hanged himself in his bedroom closet two weeks after they expired.

The story of Richard Fee, an athletic, personable college class president and aspiring medical student, highlights widespread failings in the system through which five million Americans take medication for A.D.H.D., doctors and other experts said.

Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.

Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.

Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”

Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors.

“Any step along the way, someone could have helped him — they were just handing out drugs,” said Richard’s father. Emphasizing that he had no intention of bringing legal action against any of the doctors involved, Mr. Fee said: “People have to know that kids are out there getting these drugs and getting addicted to them. And doctors are helping them do it.”

“…when he was in elementary school he fidgeted, daydreamed and got A’s. he has been an A-B student until mid college when he became scattered and he wandered while reading He never had to study. Presently without medication, his mind thinks most of the time, he procrastinated, he multitasks not finishing in a timely manner.”

Dr. Waldo M. Ellison

Richard Fee initial evaluation

Feb. 5, 2010

Richard began acting strangely soon after moving back home in late 2009, his parents said. He stayed up for days at a time, went from gregarious to grumpy and back, and scrawled compulsively in notebooks. His father, while trying to add Richard to his health insurance policy, learned that he was taking Vyvanse for A.D.H.D.

Richard explained to him that he had been having trouble concentrating while studying for medical school entrance exams the previous year and that he had seen a doctor and received a diagnosis. His father reacted with surprise. Richard had never shown any A.D.H.D. symptoms his entire life, from nursery school through high school, when he was awarded a full academic scholarship to Greensboro College in North Carolina. Mr. Fee also expressed concerns about the safety of his son’s taking daily amphetamines for a condition he might not have.

“The doctor wouldn’t give me anything that’s bad for me,” Mr. Fee recalled his son saying that day. “I’m not buying it on the street corner.”

Richard’s first experience with A.D.H.D. pills, like so many others’, had come in college. Friends said he was a typical undergraduate user — when he needed to finish a paper or cram for exams, one Adderall capsule would jolt him with focus and purpose for six to eight hours, repeat as necessary.

So many fellow students had prescriptions or stashes to share, friends of Richard recalled in interviews, that guessing where he got his was futile. He was popular enough on campus — he was sophomore class president and played first base on the baseball team — that they doubted he even had to pay the typical $5 or $10 per pill.

“He would just procrastinate, wait till the last minute and then take a pill to study for tests,” said Ryan Sykes, a friend. “It got to the point where he’d say he couldn’t get anything done if he didn’t have the Adderall.”

Various studies have estimated that 8 percent to 35 percent of college students take stimulant pills to enhance school performance. Few students realize that giving or accepting even one Adderall pill from a friend with a prescription is a federal crime. Adderall and its stimulant siblings are classified by the Drug Enforcement Administration as Schedule II drugs, in the same category as cocaine, because of their highly addictive properties.

“It’s incredibly nonchalant,” Chris Hewitt, a friend of Richard, said of students’ attitudes to the drug. “It’s: ‘Anyone have any Adderall? I want to study tonight,’ ” said Mr. Hewitt, now an elementary school teacher in Greensboro.

After graduating with honors in 2008 with a degree in biology, Richard planned to apply to medical schools and stayed in Greensboro to study for the entrance exams. He remembered how Adderall had helped him concentrate so well as an undergraduate, friends said, and he made an appointment at the nearby Triad Psychiatric and Counseling Center.

According to records obtained by Richard’s parents after his death, a nurse practitioner at Triad detailed his unremarkable medical and psychiatric history before recording his complaints about “organization, memory, attention to detail.” She characterized his speech as “clear,” his thought process “goal directed” and his concentration “attentive.”

Richard filled out an 18-question survey on which he rated various symptoms on a 0-to-3 scale. His total score of 29 led the nurse practitioner to make a diagnosis of “A.D.H.D., inattentive-type” — a type of A.D.H.D. without hyperactivity. She recommended Vyvanse, 30 milligrams a day, for three weeks.

Phone and fax requests to Triad officials for comment were not returned.

Some doctors worry that A.D.H.D. questionnaires, designed to assist and standardize the gathering of a patient’s symptoms, are being used as a shortcut to diagnosis. C. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice.”

Dr. Conners, an emeritus professor of psychiatry and behavioral sciences at Duke University Medical Center, emphasized that a detailed life history must be taken and other sources of information — such as a parent, teacher or friend — must be pursued to learn the nuances of a patient’s difficulties and to rule out other maladies before making a proper diagnosis of A.D.H.D. Other doctors interviewed said they would not prescribe medications on a patient’s first visit, specifically to deter the faking of symptoms.

According to his parents, Richard had no psychiatric history, or even suspicion of problems, through college. None of his dozen high school and college acquaintances interviewed for this article said he had ever shown or mentioned behaviors related to A.D.H.D. — certainly not the “losing things” and “difficulty awaiting turn” he reported on the Triad questionnaire — suggesting that he probably faked or at least exaggerated his symptoms to get his diagnosis.

That is neither uncommon nor difficult, said David Berry, a professor and researcher at the University of Kentucky. He is a co-author of a 2010 study that compared two groups of college students — those with diagnoses of A.D.H.D. and others who were asked to fake symptoms — to see whether standard symptom questionnaires could tell them apart. They were indistinguishable.

“With college students,” Dr. Berry said in an interview, “it’s clear that it doesn’t take much information for someone who wants to feign A.D.H.D. to do so.”

Richard Fee filled his prescription for Vyvanse within hours at a local Rite Aid. He returned to see the nurse three weeks later and reported excellent concentration: “reading books — read 10!” her notes indicate. She increased his dose to 50 milligrams a day. Three weeks later, after Richard left a message for her asking for the dose to go up to 60, which is on the high end of normal adult doses, she wrote on his chart, “Okay rewrite.”

Richard filled that prescription later that afternoon. It was his third month’s worth of medication in 43 days.

“The patient is a 23-year-old Caucasian male who presents for refill of vyvanse — recently started on this while in NC b/c of lack of motivation/ loss of drive. Has moved here and wants refill”

Dr. Robert M. Woodard

Notes on Richard Fee

Nov. 11, 2009

Richard scored too low on the MCAT in 2009 to qualify for a top medical school. Although he had started taking Vyvanse for its jolts of focus and purpose, their side effects began to take hold. His sleep patterns increasingly scrambled and his mood darkening, he moved back in with his parents in Virginia Beach and sought a local physician to renew his prescriptions.

A friend recommended a family physician, Dr. Robert M. Woodard. Dr. Woodard heard Richard describe how well Vyvanse was working for his A.D.H.D., made a diagnosis of “other malaise and fatigue” and renewed his prescription for one month. He suggested that Richard thereafter see a trained psychiatrist at Dominion Psychiatric Associates — only a five-minute walk from the Fees’ house.

With eight psychiatrists and almost 20 therapists on staff, Dominion Psychiatric is one of the better-known practices in Virginia Beach, residents said. One of its better-known doctors is Dr. Waldo M. Ellison, a practicing psychiatrist since 1974.

In interviews, some patients and parents of patients of Dr. Ellison’s described him as very quick to identify A.D.H.D. and prescribe medication for it. Sandy Paxson of nearby Norfolk said she took her 15-year-old son to see Dr. Ellison for anxiety in 2008; within a few minutes, Mrs. Paxson recalled, Dr. Ellison said her son had A.D.H.D. and prescribed him Adderall.

“My son said: ‘I love the way this makes me feel. It helps me focus for school, but it’s not getting rid of my anxiety, and that’s what I need,’ ” Mrs. Paxson recalled. “So we went back to Dr. Ellison and told him that it wasn’t working properly, what else could he give us, and he basically told me that I was wrong. He basically told me that I was incorrect.”

Dr. Ellison met with Richard in his office for the first time on Feb. 5, 2010. He took a medical history, heard Richard’s complaints regarding concentration, noted how he was drumming his fingers and made a diagnosis of A.D.H.D. with “moderate symptoms or difficulty functioning.” Dominion Psychiatric records of that visit do not mention the use of any A.D.H.D. symptom questionnaire to identify particular areas of difficulty or strategies for treatment.

As the 47-minute session ended, Dr. Ellison prescribed a common starting dose of Adderall: 30 milligrams daily for 21 days. Eight days later, while Richard still had 13 pills remaining, his prescription was renewed for 30 more days at 50 milligrams.

Through the remainder of 2010, in appointments with Dr. Ellison that usually lasted under five minutes, Richard returned for refills of Adderall. Records indicate that he received only what was consistently coded as “pharmacologic management” — the official term for quick appraisals of medication effects — and none of the more conventional talk-based therapy that experts generally consider an important component of A.D.H.D. treatment.

His Adderall prescriptions were always for the fast-acting variety, rather than the extended-release formula that is less prone to abuse.

“PATIENT DOING WELL WITH THE MEDICATION, IS CALM, FOCUSED AND ON TASK, AND WILL RETURN TO OFFICE IN 3 MONTHS”

Dr. Waldo M. Ellison

Notes on Richard Fee

Dec. 11, 2010

Regardless of what he might have told his doctor, Richard Fee was anything but well or calm during his first year back home, his father said.

Blowing through a month’s worth of Adderall in a few weeks, Richard stayed up all night reading and scribbling in notebooks, occasionally climbing out of his bedroom window and on to the roof to converse with the moon and stars. When the pills ran out, he would sleep for 48 hours straight and not leave his room for 72. He got so hot during the day that he walked around the house with ice packs around his neck — and in frigid weather, he would cool off by jumping into the 52-degree backyard pool.

As Richard lost a series of jobs and tensions in the house ran higher — particularly when talk turned to his Adderall — Rick and Kathy Fee continued to research the side effects of A.D.H.D. medication. They learned that stimulants are exceptionally successful at mollifying the impulsivity and distractibility that characterize classic A.D.H.D., but that they can cause insomnia, increased blood pressure and elevated body temperature. Food and Drug Administration warnings on packaging also note “high potential for abuse,” as well as psychiatric side effects such as aggression, hallucinations and paranoia.

A 2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused A.D.H.D. stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.

When Mrs. Fee noticed Richard putting tape over his computer’s camera, he told her that people were spying on him. (He put tape on his fingers, too, to avoid leaving fingerprints.) He cut himself out of family pictures, talked to the television and became increasingly violent when agitated.

In late December, Mr. Fee drove to Dominion Psychiatric and asked to see Dr. Ellison, who explained that federal privacy laws forbade any discussion of an adult patient, even with the patient’s father. Mr. Fee said he had tried unsuccessfully to detail Richard’s bizarre behavior, assuming that Richard had not shared such details with his doctor.

“I can’t talk to you,” Mr. Fee recalled Dr. Ellison telling him. “I did this one time with another family, sat down and talked with them, and I ended up getting sued. I can’t talk with you unless your son comes with you.”

Mr. Fee said he had turned to leave but distinctly recalls warning Dr. Ellison, “You keep giving Adderall to my son, you’re going to kill him.”

Dr. Ellison declined repeated requests for comment on Richard Fee’s case. His office records, like those of other doctors involved, were obtained by Mr. Fee under Virginia and federal law, which allow the legal representative of a deceased patient to obtain medical records as if he were the patient himself.

As 2011 began, the Fees persuaded Richard to see a psychologist, Scott W. Sautter, whose records note Richard’s delusions, paranoia and “severe and pervasive mental disorder.” Dr. Sautter recommended that Adderall either be stopped or be paired with a sleep aid “if not medically contraindicated.”

Mr. Fee did not trust his son to share this report with Dr. Ellison, so he drove back to Dominion Psychiatric and, he recalled, was told by a receptionist that he could leave the information with her. Mr. Fee said he had demanded to put it in Dr. Ellison’s hands himself and threatened to break down his door in order to do so.

Mr. Fee said that Dr. Ellison had then come out, read the report and, appreciating the gravity of the situation, spoken with him about Richard for 45 minutes. They scheduled an appointment for the entire family.

“meeting with parents — concern with ‘metaphoric’ speaking that appears to be outside the realm of appropriated one to one conversation. Richard says he does it on purpose — to me some of it sounds like pre-psychotic thinking.”

Dr. Waldo M. Ellison

Notes on Richard Fee

Feb. 23, 2011

Dr. Ellison stopped Richard Fee’s prescription — he wrote “no Adderall for now” on his chart and the next day refused Richard’s phone request for more. Instead he prescribed Abilify and Seroquel, antipsychotics for schizophrenia that do not provide the bursts of focus and purpose that stimulants do. Richard became enraged, his parents recalled. He tried to back up over his father in the Dominion Psychiatric parking lot and threatened to burn the house down. At home, he took a baseball bat from the garage, smashed flower pots and screamed, “You’re taking my medicine!”

Richard disappeared for a few weeks. He returned to the house when he learned of his grandmother’s death, the Fees said.

The morning after the funeral, Richard walked down Potters Road to what became a nine-minute visit with Dr. Ellison. He left with two prescriptions: one for Abilify, and another for 50 milligrams a day of Adderall.

According to Mr. Fee, Richard later told him that he had lied to Dr. Ellison — he told the doctor he was feeling great, life was back on track and he had found a job in Greensboro that he would lose without Adderall. Dr. Ellison’s notes do not say why he agreed to start Adderall again.

Richard’s delusions and mood swings only got worse, his parents said. They would lock their bedroom door when they went to sleep because of his unpredictable rages. “We were scared of our own son,” Mr. Fee said. Richard would blow through his monthly prescriptions in 10 to 15 days and then go through hideous withdrawals. A friend said that he would occasionally get Richard some extra pills during the worst of it, but that “it wasn’t enough because he would take four or five at a time.”

One night during an argument, after Richard became particularly threatening and pushed him over a chair, Mr. Fee called the police. They arrested Richard for domestic violence. The episode persuaded Richard to see another local psychiatrist, Dr. Charles Parker.

Mrs. Fee said she attended Richard’s initial consultation on June 3 with Dr. Parker’s clinician, Renee Strelitz, and emphasized his abuse of Adderall. Richard “kept giving me dirty looks,” Mrs. Fee recalled. She said she had later left a detailed message on Ms. Strelitz’s voice mail, urging her and Dr. Parker not to prescribe stimulants under any circumstances when Richard came in the next day.

Dr. Parker met with Richard alone. The doctor noted depression, anxiety and suicidal ideas. He wrote “no meds” with a box around it — an indication, he explained later, that he was aware of the parents’ concerns regarding A.D.H.D. stimulants.

Dr. Parker wrote three 30-day prescriptions: Clonidine (a sleep aid), Venlafaxine (an antidepressant) and Adderall, 60 milligrams a day.

In an interview last November, Dr. Parker said he did not recall the details of Richard’s case but reviewed his notes and tried to recreate his mind-set during that appointment. He said he must have trusted Richard’s assertions that medication was not an issue, and must have figured that his parents were just philosophically anti-medication. Dr. Parker recalled that he had been reassured by Richard’s intelligent discussions of the ins and outs of stimulants and his desire to pursue medicine himself.

“He was smart and he was quick and he had A’s and B’s and wanted to go to medical school — and he had all the deportment of a guy that had the potential to do that,” Dr. Parker said. “He didn’t seem like he was a drug person at all, but rather a person that was misunderstood, really desirous of becoming a physician. He was very slick and smooth. He convinced me there was a benefit.”

Mrs. Fee was outraged. Over the next several days, she recalled, she repeatedly spoke with Ms. Strelitz over the phone to detail Richard’s continued abuse of the medication (she found nine pills gone after 48 hours) and hand-delivered Dr. Sautter’s appraisal of his recent psychosis. Dr. Parker confirmed that he had received this information.

Richard next saw Dr. Parker on June 27. Mrs. Fee drove him to the clinic and waited in the parking lot. Soon afterward, Richard returned and asked to head to the pharmacy to fill a prescription. Dr. Parker had raised his Adderall to 80 milligrams a day.

Dr. Parker recalled that the appointment had been a 15-minute “med check” that left little time for careful assessment of any Adderall addiction. Once again, Dr. Parker said, he must have believed Richard’s assertions that he needed additional medicine more than the family’s pleas that it be stopped.

“He was pitching me very well — I was asking him very specific questions, and he was very good at telling me the answers in a very specific way,” Dr. Parker recalled. He added later, “I do feel partially responsible for what happened to this kid.”

“Paranoid and psychotic … thinking that the computer is spying on him. He has also been receiving messages from stars at night and he is unable to be talked to in a reasonable fashion … The patient denies any mental health problems … fairly high risk for suicide.”

Dr. John Riedler

Admission note for Richard Fee

Virginia Beach Psychiatric Center

July 8, 2011

The 911 operator answered the call and heard a young man screaming on the other end. His parents would not give him his pills. With the man’s language scattered and increasingly threatening, the police were sent to the home of Rick and Kathy Fee.

The Fees told officers that Richard was addicted to Adderall, and that after he had received his most recent prescription, they allowed him to fill it through his mother’s insurance plan on the condition that they hold it and dispense it appropriately. Richard was now demanding his next day’s pills early.

Richard denied his addiction and threats. So the police, noting that Richard was an adult, instructed the Fees to give him the bottle. They said they would comply only if he left the house for good. Officers escorted Richard off the property.

A few hours later Richard called his parents, threatening to stab himself in the head with a knife. The police found him and took him to the Virginia Beach Psychiatric Center.

Described as “paranoid and psychotic” by the admitting physician, Dr. John Riedler, Richard spent one week in the hospital denying that he had any psychiatric or addiction issues. He was placed on two medications: Seroquel and the antidepressant Wellbutrin, no stimulants. In his discharge report, Dr. Riedler noted that Richard had stabilized but remained severely depressed and dependent on both amphetamines and marijuana, which he would smoke in part to counter the buzz of Adderall and the depression from withdrawal.

(Marijuana is known to increase the risk for schizophrenia, psychosis and memory problems, but Richard had smoked pot in high school and college with no such effects, several friends recalled. If that was the case, “in all likelihood the stimulants were the primary issue here,” said Dr. Wesley Boyd, a psychiatrist at Children’s Hospital Boston and Cambridge Health Alliance who specializes in adolescent substance abuse.)

Unwelcome at home after his discharge from the psychiatric hospital, Richard stayed in cheap motels for a few weeks. His Adderall prescription from Dr. Parker expired on July 26, leaving him eligible for a renewal. He phoned the office of Dr. Ellison, who had not seen him in four months.

“moved out of the house — doesn’t feel paranoid or delusional. Hasn’t been on meds for a while — working with a friend wiring houses rto 3 months — doesn’t feel he needs the abilify or seroquel for sleep.”

Dr. Waldo M. Ellison

Notes on Richard Fee

July 25, 2011

The 2:15 p.m. appointment went better than Richard could have hoped. He told Dr. Ellison that the pre-psychotic and metaphoric thinking back in March had receded, and that all that remained was his A.D.H.D. He said nothing of his visits to Dr. Parker, his recent prescriptions or his week in the psychiatric hospital.

At 2:21 p.m., according to Dr. Ellison’s records, he prescribed Richard 30 days’ worth of Adderall at 50 milligrams a day. He also gave him prescriptions postdated for Aug. 23 and Sept. 21, presumably to allow him to get pills into late October without the need for follow-up appointments. (Virginia state law forbids the dispensation of 90 days of a controlled substance at one time, but does allow doctors to write two 30-day prescriptions in advance.)

Virginia is one of 43 states with a formal Prescription Drug Monitoring Program, an online database that lets doctors check a patient’s one-year prescription history, partly to see if he or she is getting medication elsewhere. Although pharmacies are required to enter all prescriptions for controlled substances into the system, Virginia law does not require doctors to consult it.

Dr. Ellison’s notes suggest that he did not check the program before issuing the three prescriptions to Richard, who filled the first within hours.

The next morning, during a scheduled appointment at Dr. Parker’s clinic, Ms. Strelitz wrote in her notes: “Richard is progressing. He reported staying off of the Adderall and on no meds currently. Focusing on staying healthy, eating well and exercising.”

About a week later, Richard called his father with more good news: a job he had found overseeing storm cleanup crews was going well. He was feeling much better.

But Mr. Fee noticed that the more calm and measured speech that Richard had regained during his hospital stay was gone. He jumped from one subject to the next, sounding anxious and rushed. When the call ended, Mr. Fee recalled, he went straight to his wife.

“Call your insurance company,” he said, “and find out if they’ve filled any prescriptions for Adderall.”

“spoke to father — richard was in VBPC [Virginia Beach Psychiatric Center] and OD on adderall — NO STIMULANTS — HE WAS ALSO SEEING DR. PARKER”

Dr. Waldo M. Ellison

Interoffice e-mail

Aug. 5, 2011

An insurance representative confirmed that Richard had filled a prescription for Adderall on July 25. Mr. Fee confronted Dr. Ellison in the Dominion Psychiatric parking lot.

Mr. Fee told him that Richard had been in the psychiatric hospital, had been suicidal and had been taking Adderall through June and July. Dr. Ellison confirmed that he had written not only another prescription but two others for later in August and September.

“He told me it was normal procedure and not 90 days at one time,” Mr. Fee recalled. “I flipped out on him: ‘You gave my son 90 days of Adderall? You’re going to kill him!’ ”

Mr. Fee said he and Dr. Ellison had discussed voiding the two outstanding scripts. Mr. Fee said he had been told that it was possible, but that should Richard need emergency medical attention, it could keep him from getting what would otherwise be proper care or medication. Mr. Fee confirmed that with a pharmacist and decided to drive to Richard’s apartment and try to persuade him to rip up the prescriptions.

“I know that you’ve got these other prescriptions to get pills,” Mr. Fee recalled telling Richard. “You’re doing so good. You’ve got a job. You’re working. Things with us are better. If you get them filled, I’m worried about what will happen.”

“You’re right,” Mr. Fee said Richard had replied. “I tore them up and threw them away.”

Mr. Fee spent two more hours with Richard making relative small talk — increasingly gnawed, he recalled later, by the sense that this was no ordinary conversation. As he looked at Richard he saw two images flickering on top of each other — the boy he had raised to love school and baseball, and the desperate addict he feared that boy had become.

Before he left, Mr. Fee made as loving a demand as he could muster.

“Please. Give them to me,” Mr. Fee said.

Richard looked his father dead in the eye.

“I destroyed them,” he said. “I don’t have them. Don’t worry.”

“Richard said that he has stopped Adderall and wants to work on continuing to progress.”

Renee Strelitz

Session notes

Sept. 13, 2011

Richard generally filled his prescriptions at a CVS on Laskin Road, less than three miles from his parents’ home. But on Aug. 23, he went to a different CVS about 11 miles away, closer to Norfolk and farther from the locations that his father might have called to alert them to the situation. For his Sept. 21 prescription he traveled even farther, into Norfolk, to get his pills.

On Oct. 3, Richard visited Dr. Ellison for an appointment lasting 17 minutes. The doctor prescribed two weeks of Strattera, a medication for A.D.H.D. that contains no amphetamines and, therefore, is neither a controlled substance nor particularly prone to abuse. His records make no mention of the Adderall prescription Richard filled on Sept. 21; they do note, however, “Father says that he is crazy and abusive of the Adderall — has made directives with regard to giving Richard anymore stimulants — bringing up charges — I explained this to Richard.”

Prescription records indicate that Richard did not fill the Strattera prescription before returning to Dr. Ellison’s office two weeks later to ask for more stimulants.

“Patient took only a few days of Strattera 40 mg — it calmed him but not focusing,” the doctor’s notes read. “I had told him not to look for much initially — He would like a list of MD who could rx adderall.”

Dr. Ellison never saw Richard again. Given his patterns of abuse, friends said, Richard probably took his last Adderall pill in early October. Because he abruptly stopped without the slow and delicate reduction of medication that is recommended to minimize major psychological risks, especially for instant-release stimulants, he crashed harder than ever.

Richard’s lifelong friend Ryan Sykes was one of the few people in contact with him during his final weeks. He said that despite Richard’s addiction to Adderall and the ease with which it could be obtained on college campuses nearby, he had never pursued it outside the doctors’ prescriptions.

“He had it in his mind that because it came from a doctor, it was O.K.,” Mr. Sykes recalled.

On Nov. 7, after arriving home from a weekend away, Mrs. Fee heard a message on the family answering machine from Richard, asking his parents to call him. She phoned back at 10 that night and left a message herself.

Not hearing back by the next afternoon, Mrs. Fee checked Richard’s cellphone records — he was on her plan — and saw no calls or texts. At 9 p.m. the Fees drove to Richard’s apartment in Norfolk to check on him. The lights were on; his car was in the driveway. He did not answer. Beginning to panic, Mr. Fee found the kitchen window ajar and climbed in through it.

He searched the apartment and found nothing amiss.

“He isn’t here,” Mr. Fee said he had told his wife.

“Oh, thank God,” she replied. “Maybe he’s walking on the beach or something.”

They got ready to leave before Mr. Fee stopped.

“Wait a minute,” he said. “I didn’t check the closet.”

“Spoke with Richard’s mother, Kathy Fee, today. She reported that Richard took his life last November. Family is devasted and having a difficult time. Offerred assistance for family.”

Renee Strelitz

Last page of Richard Fee file

June 21, 2012

Friends and former baseball teammates flocked to Richard Fee’s memorial service in Virginia Beach. Most remembered only the funny and gregarious guy they knew in high school and college; many knew absolutely nothing of his last two years. He left no note explaining his suicide.

At a gathering at the Fees’ house afterward, Mr. Fee told them about Richard’s addiction to Adderall. Many recalled how they, too, had blithely abused the drug in college — to cram, just as Richard had — and could not help but wonder if they had played the same game of Russian roulette.

“I guarantee you a good number of them had used it for studying — that shock was definitely there in that room,” said a Greensboro baseball teammate, Danny Michael, adding that he was among the few who had not. “It’s so prevalent and widely used. People had no idea it could be abused to the point of no return.”

Almost every one of more than 40 A.D.H.D. experts interviewed for this article said that worst-case scenarios like Richard Fee’s can occur with any medication — and that people who do have A.D.H.D., or parents of children with the disorder, should not be dissuaded from considering the proven benefits of stimulant medication when supervised by a responsible physician.

Other experts, however, cautioned that Richard Fee’s experience is instructive less in its ending than its evolution — that it underscores aspects of A.D.H.D. treatment that are mishandled every day with countless patients, many of them children.

“You don’t have everything that happened with this kid, but his experience is not that unusual,” said DeAnsin Parker, a clinical neuropsychologist in New York who specializes in young adults. “Diagnoses are made just this quickly, and medication is filled just this quickly. And the lack of therapy is really sad. Doctors are saying, ‘Just take the meds to see if they help,’ and if they help, ‘You must have A.D.H.D.’ ”

Dr. Parker added: “Stimulants will help anyone focus better. And a lot of young people like or value that feeling, especially those who are driven and have ambitions. We have to realize that these are potential addicts — drug addicts don’t look like they used to.”

Documentary screening and panel discussion on ADHD, “ADD and Loving It?!”

Listing, The Virginian-Pilot

Oct. 10, 2012

The Fees decided to go. The event was sponsored by the local chapter of Children and Adults with Attention Deficit Disorder (Chadd), the nation’s primary advocacy group for A.D.H.D. patients. They wanted to attend the question-and-answer session afterward with local doctors and community college officials.

The evening opened with the local Chadd coordinator thanking the drug company Shire — the manufacturer of several A.D.H.D. drugs, including Vyvanse and extended-release Adderall — for partly underwriting the event. An hourlong film directed and narrated by two men with A.D.H.D. closed by examining some “myths” about stimulant medications, with several doctors praising their efficacy and safety. One said they were “safer than aspirin,” while another added, “It’s O.K. — there’s nothing that’s going to happen.”

Sitting in the fourth row, Mr. Fee raised his hand to pose a question to the panel, which was moderated by Jeffrey Katz, a local clinical psychologist and a national board member of Chadd. “What are some of the drawbacks or some of the dangers of a misdiagnosis in somebody,” Mr. Fee asked, “and then the subsequent medication that goes along with that?”

Dr. Katz looked straight at the Fees as he answered, “Not much.”

Adding that “the medication itself is pretty innocuous,” Dr. Katz continued that someone without A.D.H.D. might feel more awake with stimulants but would not consider it “something that they need.”

“If you misdiagnose it and you give somebody medication, it’s not going to do anything for them,” Dr. Katz concluded. “Why would they continue to take it?”

Mr. Fee slowly sat down, trembling. Mrs. Fee placed her hand on his knee as the panel continued.

Prescription Pills Abused for Better Grades

Lisa Wiltse for The New York Times

“Now I have to worry about this, too? Really? This shouldn’t be what they need to do to get where they want to,” said Dodi Sklar, after listening to her ninth-grade son, Jonathan, describe how some classmates abuse stimulants.

By ALAN SCHWARZ

 

He steered into the high school parking lot, clicked off the ignition and scanned the scraps of his recent weeks. Crinkled chip bags on the dashboard. Soda cups at his feet. And on the passenger seat, a rumpled SAT practice book whose owner had been told since fourth grade he was headed to the Ivy League. Pencils up in 20 minutes.

The boy exhaled. Before opening the car door, he recalled recently, he twisted open a capsule of orange powder and arranged it in a neat line on the armrest. He leaned over, closed one nostril and snorted it.

Throughout the parking lot, he said, eight of his friends did the same thing.

The drug was not cocaine or heroin, but Adderall, an amphetamine prescribed for attention deficit hyperactivity disorder that the boy said he and his friends routinely shared to study late into the night, focus during tests and ultimately get the grades worthy of their prestigious high school in an affluent suburb of New York City. The drug did more than just jolt them awake for the 8 a.m. SAT; it gave them a tunnel focus tailor-made for the marathon of tests long known to make or break college applications.

“Everyone in school either has a prescription or has a friend who does,” the boy said.

At high schools across the United States, pressure over grades and competition for college admissions are encouraging students to abuse prescription stimulants, according to interviews with students, parents and doctors. Pills that have been a staple in some college and graduate school circles are going from rare to routine in many academically competitive high schools, where teenagers say they get them from friends, buy them from student dealers or fake symptoms to their parents and doctors to get prescriptions.

Of the more than 200 students, school officials, parents and others contacted for this article, about 40 agreed to share their experiences. Most students spoke on the condition that they be identified by only a first or middle name, or not at all, out of concern for their college prospects or their school systems’ reputations — and their own.

“It’s throughout all the private schools here,” said DeAnsin Parker, a New York psychologist who treats many adolescents from affluent neighborhoods like the Upper East Side. “It’s not as if there is one school where this is the culture. This is the culture.”

Observed Gary Boggs, a special agent for the Drug Enforcement Administration, “We’re seeing it all across the United States.”

The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use. (By comparison, the long-abused anti-anxiety drug Valium is in the lower Class 4.) So they carry high legal risks, too, as few teenagers appreciate that merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony.

While these medicines tend to calm people with A.D.H.D., those without the disorder find that just one pill can jolt them with the energy and focus to push through all-night homework binges and stay awake during exams afterward. “It’s like it does your work for you,” said William, a recent graduate of the Birch Wathen Lenox School on the Upper East Side of Manhattan.

But abuse of prescription stimulants can lead to depression and mood swings (from sleep deprivation), heart irregularities and acute exhaustion or psychosis during withdrawal, doctors say. Little is known about the long-term effects of abuse of stimulants among the young. Drug counselors say that for some teenagers, the pills eventually become an entry to the abuse of painkillers and sleep aids.

“Once you break the seal on using pills, or any of that stuff, it’s not scary anymore — especially when you’re getting A’s,” said the boy who snorted Adderall in the parking lot. He spoke from the couch of his drug counselor, detailing how he later became addicted to the painkiller Percocet and eventually heroin.

Paul L. Hokemeyer, a family therapist at Caron Treatment Centers in Manhattan, said: “Children have prefrontal cortexes that are not fully developed, and we’re changing the chemistry of the brain. That’s what these drugs do. It’s one thing if you have a real deficiency — the medicine is really important to those people — but not if your deficiency is not getting into Brown.”

The number of prescriptions for A.D.H.D. medications dispensed for young people ages 10 to 19 has risen 26 percent since 2007, to almost 21 million yearly, according to IMS Health, a health care information company — a number that experts estimate corresponds to more than two million individuals. But there is no reliable research on how many high school students take stimulants as a study aid. Doctors and teenagers from more than 15 schools across the nation with high academic standards estimated that the portion of students who do so ranges from 15 percent to 40 percent.

“They’re the A students, sometimes the B students, who are trying to get good grades,” said one senior at Lower Merion High School in Ardmore, a Philadelphia suburb, who said he makes hundreds of dollars a week selling prescription drugs, usually priced at $5 to $20 per pill, to classmates as young as freshmen. “They’re the quote-unquote good kids, basically.”

Read more

“Attention Problems May Be Sleep-Related”

 A New York Times Article

By KATE MURPHY

April 16, 2012

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Diagnoses of attention hyperactivity disorder among children have increased dramatically in recent years, rising 22 percent from 2003 to 2007, according to the Centers for Disease Control and Prevention. But many experts believe that this may not be the epidemic it appears to be.

Many children are given a diagnosis of A.D.H.D., researchers say, when in fact they have another problem: a sleep disorder, like sleep apnea. The confusion may account for a significant number of A.D.H.D. cases in children, and the drugs used to treat them may only be exacerbating the problem.

“No one is saying A.D.H.D. does not exist, but there’s a strong feeling now that we need to rule out sleep issues first,” said Dr. Merrill Wise, a pediatric neurologist and sleep medicine specialist at the Methodist Healthcare Sleep Disorders Center in Memphis.

The symptoms of sleep deprivation in children resemble those of A.D.H.D. While adults experience sleep deprivation as drowsiness and sluggishness, sleepless children often become wired, moody and obstinate; they may have trouble focusing, sitting still and getting along with peers.

The latest study suggesting a link between inadequate sleep and A.D.H.D. symptoms appeared last month in the journal Pediatrics. Researchers followed 11,000 British children for six years, starting when they were 6 months old. The children whose sleep was affected by breathing problems like snoring, mouth breathing or apnea were 40 percent to 100 percent more likely than normal breathers to develop behavioral problems resembling A.D.H.D.

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