An Interview with Dr. Keith McBurnett

By Rheba Estante

 

Keith McBurnett, PhD is a professor at the University of California, San Francisco (UCSF) in the Department of Psychiatry. Dr. McBurnett studies ADHD treatment and conducts research on hormonal factors in disruptive behavior disorders, developmental psychopathology, classification and treatment outcome. Dr. McBurnett has a Ph.D. in Clinical Psychology from the University of Georgia and completed postgraduate training at NYU Medical Center where he did an internship in Rehabilitation Psychology.

 

What led you to a career as an ADHD researcher?

I first became interested in ADHD in my first job at a pediatric clinic that focused on ADHD. There were wide variations in how ADHD impacted the kids’ quality of life. Some kids were being kicked out of school and later had relationship problems that negatively impaired their personal and professional lives.

 

What is the primary cause of ADHD?

ADHD is caused by genetics. A person’s eventual adult height tends to be an average of their parents, and ADHD is almost as genetically determined as height. If you apply the diagnostic criteria to both ADHD and non-ADHD people, you will see different genetics, brain functions, test performances and brain structures between the two groups. Neuroscience research has produced valid data that provides extremely good evidence of the genetic basis for ADHD. ADHD doesn’t arise from bad parenting, though providing families with extra skills in handling their child can reduce the severity of symptoms.

 

Are there other things that can induce ADHD?

There are cases of acquired attention problems caused by exposure to environmental toxins, head trauma, maternal smoking or alcohol use, and physical and emotional trauma, so ADHD symptoms can start in adults at the same time they experience trauma. Post-Traumatic Stress Disorder (PTSD) can continue to affect the brain and it could manifest ADHD symptoms. There is some literature on Army combat participants who developed ADHD symptoms as a result of severe combat traumas. We have not studied milder situations that may create the same outcomes in adults, and there have been no studies on trauma inducing ADHD in children.

 

Portions of the general public still doubt the validity of ADHD as an actual neurological condition. Why can’t we use PET scans in diagnosing and treating ADHD?

The jury is still out on these brain scans since there needs to be more peer reviewed research on findings. PET scans are in the category of neither proven nor unproven science. The problem with relying on any single test is that, while on average, kids with ADHD may show differences, but these differences emerge from group averages and don’t always show up in every individual case.

 

After school, what can people with ADHD do to improve their chances for success? For example, should people with ADHD look for specific types of jobs where their condition won’t impair them as much?

Jobs with a lot of structure and interest are good for ADHD patients because your duties are very clear compared to jobs where you rely on your own self-discipline to read and summarize things. People with ADHD naturally do better in highly structured or highly stimulating employment. We see a lot of students and young adults not attaining their full potential. Some very bright young people with ADHD enter a doctoral program but never finish their PhD, or take entry level work as a taxi driver or retail salesperson. These people get stuck in dead-end positions instead of being able to climb the ladder in a career. It’s important to try to find a job that you really enjoy and turns you on. People with ADHD find it extremely difficult to concentrate on something that is not interesting, and they will never excel in a situation where they are required to do that. Finding jobs that excite and motivate them is essential.

 

Do you think certain industries, like entertainment, attract and retain a higher percentage of ADHD patients than the general population?

ADHD-types run into trouble learning lines unless they are really excited and dive into it, hone their skills and pour their energy into it. They have to be turned on to perform well. To cope with the difficulties of being motivated, people with ADHD find ways to cope such as using medication for certain activities. For example, some attorneys with ADHD take a short-acting stimulant when they have to do a lot of reading and writing of legal documents. But when they are in court or interviewing people, they may not need the medication as much and they may prefer not to take it.

 

In the movie “Limitless,” a man’s life improves considerably thanks to a super ADD drug. He first becomes dependent on it until he learns to adjust the dose to alter his brain chemistry naturally. By the end, it seems he no longer needs the drug because his brain structure has altered. Do you think a time like that will come for ADHD patients?

We are light years away from that sort of drug treatment. There is very preliminary evidence that some of the new non-drug treatments such as neurofeedback and working memory training may lead to permanent cognitive improvement. Neurofeedback uses behavior modification to change brain electrical activity, and there are reports that it has led to lasting changes. However, the scientific literature is mixed. No one has done large scale, definitive studies, and a lot of smaller studies have shown varying degrees of validity. Some patients found positive effects and others have not. The process works by identifying abnormal electrical activity in the brain and training individuals how to consciously control it. The method is very expensive and criticisms include that it is unproven and lucrative for practitioners seeking a profit. I don’t have a position on that, as long as a patient is informed of the evidence for neurofeedback, medication, and behavioral treatments.

 

Drug treatment is very complicated and it is not the only treatment available. For some patients it takes a combination of doses from different drugs. Patients have to try different medications and see what works really well and is worth taking. The first step requires trying one dose of one drug and working to adjust it to the right dosage or finding another drug that works better for you. Some people have a chemistry that is biased towards methylphenidate (like Ritalin), and others respond better to an amphetamine product (like Adderall). Others do better with non-stimulants. In some cases, medication has huge benefits, while in others it doesn’t help or even makes things worse.

 

In 2005, Slate Magazine published an article* about the literary pedigree of amphetamines. Kerouac reported that he wrote “On The Road” in a marathon writing session after taking benzodiazepine. He was not the only writer who claimed high productivity from daily injections of amphetamines. I have never heard of Ritalin helping an author produce a book. Can Adderall be a secret weapon for those with literary aspirations or other ambitious projects?

It’s quite common for performance to improve from taking a stimulant. College students often borrow stimulants to do an all-nighter or to get a paper finished. Stimulants can help with being able to work faster for longer hours. The controversy is that we as a society must decide on how much of a problem that is. Some people advocate for greater access to cognitive enhancers for the general public. They argue there is a risk in not making it more available in a fast paced and competitive world. These drugs are relatively safe if used properly as prescribed, and people can use stimulants for years with little ill effects. We can’t deny that they can enhance cognitive performance. But there are many risks to unsupervised use. (www.slate.com: The Adderall Me by Joshua Foer)

 

What are the prospects for new drug development? Many ADHD patients report that any medication will eventually stop working after their system becomes accustomed to a drug.

It doesn’t happen all the time, but frequently we hear the need to increase the dose or to change medications after a few months because the medication doesn’t seem to be as effective. We don’t fully understand what is going on in such instances, because one, some of these patients are growing and adding significant size in a few months, and two, environmental demands are constantly changing. We worry about tolerance, but this kind of tolerance is not the same as what happens when people smoke or inject stimulants to get high, and it isn’t associated with addiction. ADHD researchers continue to work on the development of new drug products with pharmaceutical companies, and here at UCSF we have conducted many clinical trials for new ADHD medications, some of which have made it to the market. Also here at UCSF, my colleague, Linda Pfiffner and I, are working on how to address ADHD symptoms in schools through psychosocial behavior therapy.

 

Rheba Estante is a San Francisco writer working in higher education and pursuing her Master’s degree in Counseling Psychology at Golden Gate University. Known for her compelling articles featuring women’s lifestyle and health issues, she interviews industry leaders ADDA’s E-News, the Potrero View newspaper, and for the SF Women’s Health Examiner for Examiner.com. Learn more about her work on LinkedIn.