Dr. Borgstedt started her presentation with an overview of the American Academy of Pediatrics (1991) criteria for ADD and then moved on to an overview of the "associated factors" which included: Learning Disabilities, difficulties with sequencing skills, cognitive processing, motor skills, memory, receptive-expressive language and modulation of emotional responses such as response to discipline, compliance with societal demands and other mood affects.
She then reviewed the principles of the diagnoses adding some statistical criteria such as:
She also added that there was no lab test which has met the criteria for a standalone diagnostic test for ADD and that it was her recommendation to have a team gather information. This information should come from parents, educators and medical professionals and that the diagnostic assessment should take a minimum of 5 hours.
She touched on the fields of pathophysiology which included use of PET scans where indications of decreased metabolism of glucose, decreased blood flow, and that Ritalin increases blood flow to the basal ganglia. There was much work under way involving brain activity potentials. Local researchers have been making measurements of neurochemicals and studying brain activity potentials and noted works including those by Klorman and Borgstedt (from 1979 - 1991) and Zametka and Rapaport in 1987. The studied populations included controls, ADD patients who were less than 10 years old, ADD adolescents both with and without noncompliant behavior and young adults.
Dr. Borgstedt noted that in addition to a physical medical examination, some of the tools that researchers used were sophisticated psychological tests for attention and information processing as well as tests for continuous performance (vigilance), Sternberg Memory Scanning Test and pair-associated learning tests. She also spoke of the long list of diagnostic tools used for subject selection including neuro-developmental evaluations by pediatric neurologists who conducted clinical psychological interviews.
Measurement tools included Diagnostic Instrument for Childhood & Adolescents, Home Activity Rating Scale, the Connors Scale and Parent/Teacher Aggression Scale. The findings she presented listed the beneficial effects of stimulant medication in patient response as measured by these tests. Dr. Borgstedt noted that the clinical findings supported the observations of parents and teachers - that when medication was involved, responses improved.
Dr. Borgstedt noted the need for multi-modal approach to treatment and that this approach was not only valid and recommended for making the diagnosis as it was necessary to rule out other medical conditions. She also noted that one cannot do medical treatment alone. Other strategies were essential such as educational programming, behavioral treatment and the like both at school and in the home environment. This treatment may include professional counselling which may be at the individual, group or family level.
She spoke of improvement in attention and information processing over the placebo with CNS stimulant therapy, with methylphenidate (Ritalin), Pemoline (Cylert which has lots of bad press and can have serious side effects), and Dexedrine (in use since the '30's) and noted Adderol was a newer version of Dexedrine. Dr. Borgstedt also spoke of the very cumbersome, bureaucratic procedure for prescription forms noting the expense of the forms themselves as just the beginning of the complex system established for maintaining control over these medications.
She commented that with both Ritalin and Dexedrine, these are short-acting. They get into the bloodstream quickly and are generally administered at 4 hour intervals including breakfast, lunch and sometimes at 4pm also. She mentioned TICS were only observed in 1 of every 1500 unselected cases (i.e. no prior history of TICS). She observed that meds so sometimes increase the episodes of TICS for patients who already have a history of or predisposition for TICS. There are some medications used to suppress TICS.
Before Ritalin, Dr. Borgstedt relayed, tricyclic antidepressants were used and still are as alternative to Ritalin, particularly when mood swings are present. She also mentioned combinations of meds and that Clonidine was used sometimes if there was anxiety or a Ritalin/TICS problem. She cautioned that the use of Clonidine has to be slow and cautious and that frequent blood tests be made and blood pressure monitored.
It was necessary to be alert for Oppositional Conduct Disorder, post-traumatic stress and other comorbid conditions. Meds such as Prozak or Zoloft were sometimes used at night since Ritalin is known to cause sleep difficulties if administered too late in the day. Monitor . . Monitor . . Monitor was Dr. Borgstedt's recommendation for ADD management.
The overall management of ADD included physical exams every 3 months, at least annual blood tests, frequent communications between parent, teachers, and physicians, the use of "drug holidays", close monitoring of psychoeducational programs to assure remediation of LD's and success experiences as well as counseling where appropriate.
She noted the advantages of treatment which included increased attention, improved information processing, improved perceptional motor coordination (writing), improvements in on-task behavior, decreased impulsivity and improved interaction of child and environment resulting in better self esteem and less frustration.
Summing up the advantages of treatment in a 3 year follow-up study by the California Child Study Foundation, Dr. Borgstedt reported (1) Educational improvement except in spelling, (2) Less antisocial behavior, (3) Increased attention in school and (4) Better adjustments at home.
Ed Note: Dr. Borgstedt's credentials included graduating from Medical School in Germany, then at the University of Rochester where she was a Clinical Professor of Neurology. She has had an avid interest in ADD since the "late 60's" and is currently a member of the Academy of Pediatricians.
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