NYC Child, Adolescent and Adult Psychiatrist Diary: ADHD, the Parent, and the School

In a previous article, we discussed the fact that kids with ADHD are increasingly prescribed not only Ritalin and Adderall (which are FDA approved for ADHD), but also antipsychotic medications (which are not).


Why?  Here’s the typical story:

A parent comes to see me saying, “The school is really concerned about Johnnie’s behavior. The teachers and school psychologist are calling me every day about how aggressive and disruptive he is. They want me to speak to you about his medications. They feel that being on Ritalin is not enough and that he may need something like Risperdal. The school staff told me that this is a safe and effective treatment for ADHD and that other kids in his class are taking it.”

They said WHAT? No,  no, no!  Risperdal is NOT a treatment for ADHD. It is an antipsychotic medication FDA approved to treat Bipolar disorder, Schizophrenia, and irritability in children with Autism.

Risperdal is by no means a benign medication. It is in the category of major tranquilizers and carries with it the risk of weight gain, as well as elevated blood sugar and cholesterol.

I don’t want to sound like I am placing blame on our parents, teachers and schools. Many of our schools are  inundated with too many students and have too few resources. I have the utmost respect and admiration for them, and I’m truly inspired by the work they do.

But we need to educate our parents, teachers and schools about psychotropic medications,  their indications for use, and their side effects.  Many parents and  educators have unrealistic expectations about these medications and misunderstand their role in treatment.   Too many  in the mental health field are either quick to start or to  advocate for the use of these powerful medications before more beneficial alternatives are utilized.

I often have to explain to parents that psychotropic medications are only a piece of the overall treatment. Behavioral interventions, programs, and other school activities are in my opinion a much larger and effective piece of the puzzle.

Applied Behavioral Analysis (also known as ABA) is  a scientifically validated approach to modify problem behaviors. ABA is nationally recognized as safe and effective and is endorsed by many state and federal agencies including the U.S Surgeon General and the New York State Department of Health.

ABA therapy has demonstrated improvements in learning, reasoning, communication and adaptability in children with Autism. Many of these same principles are also being applied to help treat kids with other behavioral disorders including ADHD.

I would love to receive phone calls from teachers and parents asking me about ABA therapy rather than pushing for the use of powerful medications like Risperdal.

As I  discussed in a previous article commenting on Dr. Richard Friedman’s New York Times article, often all that  is needed is a reassessment of the child’s individual education plan, classroom setting and size.

Let’s not forget the power of talk therapy. Kids need to have someone to talk and share their feelings with.  They may be depressed or anxious over conflicts in the house, parents separating and divorcing,  or perhaps even domestic violence.

Sometimes aggression in school is due to a child’s feelings of inadequacy about having learning difficulties and not being able to comprehend the material like the other children.

So please let’s not be so trigger-happy with psychotropic medication. Save the Big Guns for when there are no other alternatives.

And let’s not forget  the various scientifically validated behavioral therapies that we have at our disposal.  As far as I know, ABA therapy has yet to be associated with weight gain or diabetes.

©Roey Pasternak, MD
New York City

Adderall vs Risperdal.

Why it’s important to optimize stimulant treatment for ADHD before adding other medications

As a child, adolescent, and adult psychiatrist seeing people with ADHD, I’m stunned by how many of them arrive in my office already taking medications that no one (including the FDA) ever intended to  be used for this condition.


Stimulants such as Ritalin (methylphenidate) have been used in children to treat symptoms of ADHD since the 1960’s. We have decades of experience as well as substantial research evidence  supporting their effectiveness.  Although stimulants are by no means free of side effects, today we have more sophisticated formulations of these medications that are quite well tolerated by most people.

But it’s surprising how many people bring their ADHD kids to see me, and I find out that someone has prescribed Risperdal or Abilify.  These are not stimulants.  They’re atypical antipsychotics.  They’re not approved for ADHD.  So why are practitioners in the community prescribing them for ADHD kids?

Risperdal and Abilify have been available since the 1990’s, and have been marketed as an alternative to older generation antipsychotics for treating schizophrenia and bipolar illness.  We think that they are less likely to cause  EPS (Parkinson-like symptoms). However they do have some potential serious side effects such increased risk for high blood sugar levels, excess body fat around the waist and increased cholesterol levels.

In 2006 the FDA approved the use of the Risperdal to treat irritability in children and adolescents age  5-17 with Autism.  In 2009 Abilify followed suit and also obtained FDA approval for the same indication in children with Autism.

Since the FDA approved Risperdal and Abilify for use in children with Autism, there has been a substantial increase in the use of these medication to treat aggression and disruptive behaviors in non-Autism kids. Sometimes these medications are prescribed rather quickly before exhausting non-drug treatments or other medications with fewer side effects.

The impulsiveness and hyperactivity of Kids with ADHD can look superficially like irritability. It can take a trained psychiatrist to tell the difference.

It really irks me when new patients come to see me on inadequate doses of  stimulants plus  an antipsychotic. When I ask why the antipsychotic was prescribed, parents often say the following: “I thought that the Risperdal was also for the ADHD.”

Sometimes all that’s needed is for the stimulant to be adequately dosed.

In children with Autism, Risperdal and Abilify can be wonder drugs for  aggression, irritability, and tantrums.  But in kids with ADHD, there are usually better solutions that are safer for the child.

Let’s pay attention to diagnosis. And let’s make sure we use the right medicines at the right doses.

NYC Child Psychiatrist Responds to “A Natural Fix For ADHD” by Dr. Richard Friedman in the New York Times

The New York Times and ADHD — Deja Vu All Over Again

For reasons known only to its editors, The New York Times has for years championed non-medication approaches to ADHD.  For the most recent example of this, see Dr. Richard Friedman’s article “A Natural Fix For ADHD.”  The title alone gives you a pretty good of idea of The Times’ slant on the matter.


Dr Friedman, a distinguished psychiatrist and psychopharmacologist at Weill Cornell School of Medicine, describes a patient with ADHD who struggles at a routine desk job. When this individual quits his job and joins a start-up company, he thrives in the more active stimulating environment and his ADHD symptoms no longer cause much of a problem.

There’s certainly some science behind this. It is thought that a specific genetic variant of the dopamine receptor DRD4 is associated with yearning for novelty and with being less able to tolerate routine.  In addition, research conducted at the National Institute on Drug Abuse (NIDA) shows that people suffering from ADHD have fewer dopamine receptors in the reward circuits of their brains compared to non-ADHD controls.

The fewer the dopamine receptors, the greater the symptoms of inattention reported.  The upshot? People with ADHD may be walking around with less sensitive reward centers. Less sensitive reward centers don’t make interesting activities boring. They simply make boring activities horribly boring— or even intolerable.

But let’s get back to Dr Friedman’s main idea:

What’s the best way to treat ADHD?

I think Dr. Friedman and The New York Times does people with ADHD a disservice by suggesting that the “natural fix” of switching to a less routine job “cures” ADHD.

The truth is that all jobs involve some tasks that are more interesting than others. As a child, adolescent, and adult psychiatrist who treats many people with this condition, I’ve heard too many stories of creative individuals who falter in their careers due to not being able to get their billing or other paperwork done.

In fact, one wonderful thing about medications for ADHD is that unlike many other psychotropics, they can be taken as-needed. The analogy might be made to reading glasses. Most immediate-release preparations of methylphenidate (Ritalin), for example, give about 2-3 hours of effective help.

What if we just medicate ADHD in some situations, but not in others? I’ve had patients report that they only needed a short burst of Ritalin to get started in the library, and after that their natural interest in whatever they were working on kicks in.

One patient,  a surgeon,  has no need for ADHD medications when he’s operating. It’s exciting, and there’s enough risk to keep his brain awash in dopamine. But during office hours, it’s a different matter. A little Adderall helps both him and his patients.

I’m not going to tell that many of my ADHD clients that they should consider a career in party planning or professional hockey. There’s creativity and boredom in almost every job. To paraphrase Ecclesiastes, there’s a time for medical treatment and a time for career counseling.

A good psychiatrist should be able to do both.

©Roey Pasternak, MD
New York City

See related articles:

Is Stimulant Medication for ADHD Addictive?   We all hear stories about people abusing ADHD medications.  Yes, this does happen. But stimulant medication for ADHD is far and away still the best treatment for this very common and often debilitating condition.  The best solution is to make sure stimulants for ADHD are being prescribed by a careful and experienced child, adolescent, and adult psychiatrist who does a thorough evaluation and spends enough time with patients to make sure they’re on the right track.

Does Medication for ADHD Lead to Drug Abuse? An ADHD Specialist Child Psychiatrist Speaks Out.   The link between ADHD and chemical dependency is an association with the ADHD itself, not with the medications we use to treat the condition. There is a common misperception that stimulant medications make people into addicts.  In fact, research shows the opposite:  Adolescents with ADHD treated with medication show less incidence of problematic substance use.

NYC Child Psychiatrist Speaks Out on the “Myth of ADHD.”   Psychotherapy helped Rebecca in many ways, but it did nothing for her ability to concentrate.  Finally when she became the mother of two young children, she was overwhelmed with the stress caused by forgetting and losing things she and her children needed.   Finding out she had ADHD was by itself helpful.  Just knowing that there was an explanation for why she had such a hard time getting organized (you mean I’m not just lazy?) helped her immensely.  She chose to try a stimulant medication, and it took a few tries before we found the right one for her.  In the end, the combination of psychotherapy and medication was particularly helpful.  Her daily life has markedly improved.  So has her marriage.

Is stimulant medication for ADHD addictive?

NYC ADHD specialist child psychiatrist, Roey Pasternak, MD responds to the New York Times.

A New York Times Article, “Drowned in a Stream of Prescriptions” shares a very sad and chilling story about a college graduate whose abuse of stimulant medication eventually cost him his life. His doctors were aware that he was going through his prescriptions in half the time allotted, but they continued to prescribe it.




You can easily read this article and come away thinking stimulants are extremely dangerous and something to steer clear of.

But what articles like this leave out is that stimulants do not prescribe themselves. It takes a physician to write the prescription and allow this terrible spiral of events to occur.

Many prescribers don’t spend enough time with their patients to find out what’s really going on. As an child, adolescent, and adult ADHD specialist, I feel it’s essential to spend at least 30 minutes with a patient even for a “routine” medication follow up. Get to know your patients well, and you won’t get fooled as often.

Patients in New York State who are worried about addiction can also take some comfort in that fact that New York State has now put in place the I-STOP program, requiring that every time a physician writes a prescription for Ritalin, Adderall, or any other controlled substance, he or she must perform a search on the New York State Department of Health website to make sure no other prescriber has been refilling that medication.

With the advent of this new mandatory monitoring program, it’s become a lot more difficult for patients to abuse medications.

Yes, it’s true that stimulants can themselves be addictive. But as I wrote in aprevious article, young people with ADHD are more likely to become drug-dependent when they’re NOT treated with stimulant medication.

Let’s remember that stimulant medications don’t prescribe themselves. If you have ADHD (remember to get a good assessment to find out), and are seeing a well-trained ADHD specialist, go ahead and ask your doctor about the relative risks of taking vs not-taking stimulant medications.

The answer may surprise you.

© Copyright Roey Pasternak, MD 2014

Does medication for ADHD lead to drug abuse? An ADHD specialist child psychiatrist speaks out.


“Is there an association between ADHD and drug abuse?”  
Yes.  But the association is with the ADHD itself — NOT the medications we use to treat it.  Untreated ADHD clearly leads to higher rates of substance use.   Kids with ADHD are also more likely to also have conduct problems such as lying, stealing, and skipping school, and all these are are known to contribute to substance abuse.

But not one study has ever shown that treatment with stimulant medication leads to substance abuse.In fact, research shows the opposite. In large, prospective studies conducted at SUNY Upstate Medical University, adolescents with ADHD who were NOT treated with stimulant medications had a 2 fold increased risk of developing a substance abuse disorder compared to adolescents treated with stimulants.

Another recent study published in the New England Journal of Medicine showed that people with severe ADHD symptoms were less likely to commit crimes when they were taking medications. People with ADHD in this study who took their medication had lower rates of criminal activity and were more likely to stay out of prison.

Cutting the crime rate . . keeping adults out of jail. Now that’s effective pharmacotherapy! And for all my patients who just need some help studying for exams or organizing their lives — it’s not quite as dramatic, but it’s often life-changing.

Let’s make sure the media conveys this important information — that ADHD treatment reduces substance use and crime.  And let’s put to rest the wrongful idea that ADHD medication causes drug abuse.

It’s just not so.

NYC Child Psychiatrist Speaks Out on the “Myth of ADHD”


A response to Time Magazine Article, “ADHD Does Not Exist” by Richard Saul, MD

These days there’s always someone proclaiming against the diagnosis of ADHD.  For instance Dr Richard Saul, a neurologist writing recently in a Time Magazine article with the rather authoritative sounding title, “ADHD Does Not Exist.”  

My response?  Not so fast . . .

Yes, as Dr Saul points out, there are many disorders that can look like ADHD.  So does this mean that ADHD doesn’t exist? Absolutely not.  Let’s not paint with so wide a brush.  The real world is more subtle than that.

As an NYC child, adolescent, and adult psychiatrist, it’s particularly jarring to hear that ADHD doesn’t exist, since so many of the patients I see every day are dramatically helped by having their ADHD recognized and treated.

For instance, Rebecca (not her real name) struggled every day in school from not being able to concentrate.  A decade of psychotherapy did nothing for this.  Finally when she became the mother of two young children, she was overwhelmed with the stress caused by forgetting and losing things she and her children needed.  

At her first visit with me, we discussed her current symptoms, and I also asked her in detail about other common symptoms of ADHD.  We reviewed her childhood experiences including her school history, and I took a thorough medical history as well.   I spoke with her primary care physician to make sure her laboratory studies were up to date and that there were no current medical problems. And after all this was done and I was convinced she had ADHD, we sat together and discussed treatment options.

Just knowing that there was an explanation for why she had such a hard time getting organized (you mean I’m not just lazy?) helped her immensely.  She chose to try a stimulant medication (they’re the most effective for most ADHD patients), and it took a few tries before we found the right one (Vyvanse) for her.

Her daily life has markedly improved.  So has her marriage.

I’d hate to have to tell her that her ADHD isn’t real.  And I don’t think she’d believe me.

I agree with Dr Saul that many doctors just throw stimulant medications at patients, without carefully checking to see whether it’s ADHD or something else (such as a sleep disorder or anxiety, or trauma).  But to me this just means that a patient should be careful to seek out a trained psychiatrist who is able to spend enough time finding out.  

I advocate for everyone to have a thorough evaluation with a psychiatrist — even better, a child psychiatrist, who is likely to be the most highly trained in diagnosing and treating ADHD.  These are the docs who through a proper evaluation can  tease apart what’s truly ADHD,  and what might be something else.