Interview: Dr. David Velkoff discusses attention deficit and substance use disorders in adults
David Velkoff, M.D., is the medical director and co-founder of the Drake Institute of Behavioral Medicine in Northridge and Irvine, California. Dr. Velkoff earned his master’s degree in psychology from the California State University at Los Angeles in 1975, and his doctor of medicine degree from Emory University School of Medicine in Atlanta in 1976. Dr. Velkoff completed his internship in obstetrics and gynecology, with an elective in neurology, at the University of California Medical Center at Irvine. He then shifted his specialty to behavioral medicine and went through his initial biofeedback training at the renowned Menninger Clinic in Topeka, Kansas, in 1980, where clinical biofeedback was pioneered. Dr. Velkoff has served as the clinical director of an international research study on psychoneuroimmunology with the UCLA School of Medicine, department of immunology, and the Pasteur Institute in Paris. In 1980, he co-founded the Drake Institute of Behavioral Medicine in California.
On Jan. 8, Dr. Velkoff participated in a roundtable discussion on the “In Your Right Mind” radio show entitled “ADHD and Addiction.” We sat down to speak with Dr. Velkoff to expand on his thoughts on the subject of attention deficit disorder/attention deficit hyperactivity disorder.
Question: Dr. Velkoff, thank you so much for sharing your time and expertise with us. We hope this article highlighting your work in behavioral medicine will help those with attention deficit hyperactivity disorder (ADHD) and their families. Could you please begin by explaining what ADHD is and who is affected?
Answer: ADD/ADHD is a neurodevelopmental disorder due to dysregulation in certain areas of the brain. It causes inattention, distractibility and difficulty concentrating on nonpreferred tasks. Highly intelligent people can suffer with ADHD. The frontal part of the brain is not activated or being fully utilized, so people with ADD/ADHD get bored very easily and have to put out extra effort to stay focused to complete nonpreferred tasks such as homework. Typically, no difficulty focusing on preferred tasks. Only about half of patients are fidgety or hyperactive. Many have other comorbid disorders such as learning disorders, auditory/language processing disorders, sensorimotor processing disorders, anxiety and/or depression. Children (over 5 years of age) and adults are affected.
Q: A 2015 report revealed a 43 percent increase in the incidence of ADHD in schoolchildren since 2003. Some people say this is due to overdiagnosis – do you agree?
A: I think that there is overdiagnosis or inaccurate diagnosis taking place, mainly due to superficial evaluations. Often, people go to the doctor and they fill out a checklist, see the doctor for 15 minutes and get started on stimulant medication. People want a quick fix, so they take the medication, even though their symptoms may be caused by problems other than ADD/ADHD, such as an anxiety disorder, depression or a learning disorder. Everyone has trouble concentrating at times, or gets bored and may feel occasionally fidgety. The diagnosis should only be considered when symptoms are not age-appropriate and are more severe and persistent for the patient’s age, disrupting the person’s life and ability to function effectively.
Q: When these children grow up, do they grow out of their symptoms?
A: Even though some children/adolescents may outgrow the disorder, we know today that many children and adolescents with ADHD will have persistent, disruptive symptoms in their adult life, particularly with inattention and executive functioning. They are less likely to have problems as adults if they are diagnosed and treated successfully during childhood. If they are simply medicated, the symptoms return once the medication wears off. Stimulant medication, like Ritalin, may stimulate the frontal lobe and temporarily improve focus, but that is like treating an infection with aspirin – you lower the fever but the infection is still there.
Q: Are stimulant medications safe taken long-term?
A: The fact is we don’t know what the long-term effects of these drugs are. We do know that tolerance can develop over time, requiring higher doses to achieve the same effect, increasing the risk of side effects and adverse events. So 40 or 50 years down the road, have we compromised these patients’ brains and hearts with these drugs? We simply don’t know. It is common sense that taking amphetamine class drugs (“speed”) chronically is not likely to be healthy for the heart and brain, even more so in children when their organs are still developing. Furthermore, we don’t have any evidence showing that long-term use resolves the disorder – meaning that when the drugs wear off, the underlying problem is still there.
Q: Are stimulant drugs habit-forming? Does taking stimulant medication during childhood predispose people to drug addiction as an adult?
A: Stimulant drugs require a Schedule II prescription because of the potential for abuse and dependency. I have read opposing studies on these drugs increasing and decreasing the risks for drug addictions in adulthood.
Q: If it is a neurodevelopmental disorder, how is it possible for some people to reach adulthood before they are diagnosed?
A: Many develop compensatory mechanisms that allow them to get by in childhood, particularly if one is very bright, though they are likely to underachieve to their ability because of ADHD. But those compensatory mechanisms often are not sufficient any longer in adulthood, because they become overwhelmed by so many more complex demands and responsibilities.
Q: How do you use quantitative electroencephalograph (qEEG) to identify and map out the areas of the brain that are not functioning normally, link those areas to symptoms and then develop neurofeedback protocols for each patient?
A: The areas of the brain that are dysregulated could be underactive, overactive (as seen in anxiety and alcoholism), or have poor connectivity with other areas, causing the inattentive symptoms or behavioral problems. By identifying the dysregulated areas and poor connections, we can use neurofeedback to improve these functional connections in creating and strengthening neuropathways. Neurofeedback uses an interface between brain waves and a computer software program so that the user can learn to self-regulate more normally how the brain operates. This leads to long-term improvement toward optimal brain function, so the majority of patients no longer require medication.
Q: Do you treat ADD/ADHD in adults differently than in children?
A: Yes. Adults with ADD/ADHD typically also have stress and anxiety that need to be addressed. First, we use stress biofeedback to help anxiety, panic disorder or depression. Neuropathways can then be more readily improved with brain map-guided neurofeedback for adult ADHD. Once the ADD/ADHD is treated, patients are in a better position to respond to psychotherapy for healing psychological issues that may have developed over their lifetime. The ones who are highly motivated to change will do the best. Those who are less motivated or self-medicating obviously are not going to do as well.
Q: What other factors do you think contribute to addiction in adults with ADHD?
A: Certainly genetic factors. Adults with ADHD can be more vulnerable to stress because of the mismatch between life’s demands and an adult ADHD patient’s neurophysiological limitations for being able to utilize their full potential. Also, the American diet is very high in sugar. From an early age, children are doused with it and it may have adverse effects on their neurodevelopment. Many parents of the children I treat with ADD/ADHD tell me that their children are addicted to sugar. Like chronic drug and alcohol use, sugar dysregulates neurotransmitters and may even decrease the total number of dopamine transmitters in the reward center of the brain. Whether or not there is a direct relationship between sugar addiction and the development of substance use disorders remains to be seen, but some researchers are exploring that possibility. Good nutrition is essential for neurogenesis. Avoiding sugar and processed foods is important, as well as artificial sweeteners and food coloring.
Q: Is there anything else you would like adults with ADD/ADHD and addiction to understand?
A: Because of neuroplasticity with proper brain map-guided neurofeedback and neuromodulation treatment, the brain can reorganize and develop more optimal regulation and functioning, enabling one to develop a healthier, successful life. I see it every day in my clinical practice.
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