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Dr. Kacir's ADHD Blog

psychological terminology and ADHD treatment

I am currently reading a book by Russell Barkley in which he proposes a new theory of ADHD and it is slow, heavy going.  I have reached the chapters where he reviews
 other psychologists' theories on executive function.  They are filled with terms like "cross-temporal behavioral structures" and "retrospective function utilizing provisional memory."  As I say to my patients, the concepts of executive function are useful for describing the symptoms of ADHD, but they aren't very practical in most cases, since complex psychological testing is required to evaluate them.
 
Given the above statements, I was intrigued to find the summary of an article where developmental specialists used these psychological tests to evaluate the effect of Concerta on executive function in children.  They performed a double blind, placebo controlled study on 30 children, 6 to 12 years old.  It appears to be a good study, since they first determined each child's best dose, then randomly assigned them either to that dose or placebo for a week.  At the end of the week, on therapy, the children underwent the complex testing of different aspects of executive function and were then switched to the other treatment (that is, placebo or Concerta) for the next week.  Again, after a week, the testing was repeated and only after the results had been recorded did anyone check to see which were medicated and which were not.
 
The results were not impressive.  The tests of working memory showed no improvement on medicine and the tests on specific aspects of generativity and self-regulation had variable results with improvement on one or two out of several measures of performance.  They did show a positive change in "response inhibition" on 2 out of 3 tests performed -- this can be an aspect of self-regulation if it stops the response to emotional content of a situation or quells a physical "fight or flight reaction.  (This is particularly interesting to me, since I regard the basic mechanism of ADHD symptoms to be the failure of the pre-frontal cortex to trigger inhibition of the natural response to a distraction when one needs to stay focused.)
 
All in all, this study reinforces the current practice of evaluating ADHD and its treatment by reviewing symptoms, rather than performing complex psychological tests.  Indeed, it would have been interesting to review symptom checklists at the same time the tests were performed to see how effective the Concerta was on a more practical level.

I agree with raising the minimum age for ADHD symptoms

Harvey A. Weinberg, Ph.D. commented on the plans for updating the diagnostic criteria of ADHD.  ADHD is currently defined by the American Psychiatric Association in the 4th edition of their "Diagnostic and Statistical Manual."  Proposed changes for the 5th edition are currently posted on the internet for discussion by interested professionals.  The particular change Dr. Weinberg objects to is the proposal that symptoms must occur before age 12 instead of earlier than age 7.  His first objection is that "it has been long established that ADHD is a neurobiological condition that takes hold during the early years of brain development and will likely show outward behavioral manifestations, in some shape or form, during early childhood."  He then states that "biological and developmental changes" and entering "the middle school environment" can cause many of the symptoms required for the ADHD diagnosis.  His last protest about raising the age of first inattentive or hyperactive-impulsive symptoms is that "many more youngsters could be diagnosed based on a later onset of symptoms and some could easily feign symptoms for the sake of acquiring performance enhancing drugs and abuse these medications."

As many of my adult patients may report, I do not insist that they report the presence of ADHD symptoms during childhood.  I have found that even adults who do not remember problems with focusing as children benefit from treatment of their ADHD symptoms.  One of my patients was told by her another doctor that she could not possibly have ADHD, because she had finished a graduate degree.  Yet when I evaluated her she had more than 6 symptoms of inattention and was impaired in two areas of adult function.    She thought she might have day-dreamed a lot in elementary school, but she didn't remember for sure.  I diagnosed her with ADHD and treated her accordingly.  After treatment she told me that she wouldn't dream of going back to her previous state.

Dr. Weinberg supports his views with statistics stating that over 60% of college students with prescribed ADHD medicines already give or sell them to others.  He also points out that more children are being diagnosed with ADHD every year even with the current minimum age of 7.  He then comments that some studies have shown biased diagnosis of ADHD based on date of birth and geographical location.  His concern is that there is already a "potential for misdiagnosis and overdiagnosis in the ADHD population" and that "raising the age threshold would contribute to this concern."

Dr. Weinberg and I have very different practices.  He is a psychologist and is the director of the ADHD department of a midwestern health care system.  Among other duties, he determines whether his patients qualify for services based on their functional deficits.  Most psychologists perform detailed psychological evaluations which look at IQ as well as the symptoms which define ADHD.  Once a psychologist makes the diagnosis of ADHD they can recommend interventions, but cannot prescribe the medications shown to be most helpful.  I, on the other hand, am a physician with a private practice in which I see individual patients.  I look specifically for ADHD, educate my patients about the diagnosis, and, if indicated, prescribe the most effective treatments known.  If the treatment doesn't work, the patient and I will try other interventions and may eventually consider other diagnoses.  I might even recommend that they see a psychologist or a psychiatrist!  Occasionally, evidence will arise that suggests a patient is misusing prescription medications; in that case we discuss the problem and I might have to stop prescribing them. 

I feel very strongly that some people develop the symptoms of ADHD at ages much later than 12 and that they ought to have access to effective treatments.  I am not sure about what can be done to prevent stimulant misuse or abuse of the disability laws, but I don't think that honest patients with true ADHD symptoms and impairments should be penalized.  Thus, unlike Dr. Weinberg, I support the increase in the age at which symptoms of ADHD must be evident to qualify for diagnosis.  Indeed, I will continue to diagnose adults with ADHD even if they cannot remember having symptoms during childhood at all.

Is more brain activity better?

I just read an article which reviewed functional MRI (fMRI) results in autistic individuals   fMRI illustrates brain activity while subjects perform a task.  The "investigators found that those with autism exhibited more activity in the temporal and occipital regions and less in the frontal cortex than those without autism." Temporal and occipital regions are involved in perception, while the frontal cortex is in charge of executive function and prioritizing attention to different stimuli. The studies were performed while the subjects performed tasks including face processing, object processing and reading. "This research helps explain autistics' exceptional visual abilities, where at least 1 out of 2 excel in visuospatial tasks," said principal investigator Laurent Mottron, MD, PhD.  Later, he suggests "instead of describing autism as a social deficit, "which may be true but isn't very specific," it could be described as "a condition characterized by a brain reorganization in favor of perceptual superiority."  When asked about the inference that more activity indicated "superiority" Dr. Mottron said: "Sometimes that corresponds to superior performance but that may not always be true,"
 
Indeed, in functional imaging of subjects with ADHD, they perform poorly on tests of executive function and exhibit more activity in their prefrontal cortex than do subjects without ADHD.  When they are treated with stimulants, they perform better and the amount of activity decreases to match that of someone without ADHD.  It seems that this activity corresponds to an increased number of electrical signals being sent without triggering the next action.  In other words, the increased activity may illustrate an ineffective "loop" where signals are sent and resent within one part of the brain and don't make it to the part which most efficiently performs the task in question.

Is ADHD "just" an extreme of active behavior?

I just read the summary of an article supporting the theory that ADHD is an extreme of the hyperactive behavior seen in "normal" children.  The support was based on 
images of the brains of ADHD patients compared to non-ADHD children without hyperactive behavior and then to non-ADHD children with some hyperactive behavior.  The authors stated that since the findings in the last group of children were in between those of the other two, ADHD was actually just one end of a "dimensional" spectrum.  I was not impressed with the summary of their study, but I do think that their premise is useful to consider.  (One of my major objections to the study was their focus only on hyperactive behavior.  What about inattention?)
 
Many parents have questioned the validity of using ADHD symptoms to "qualify" for the diagnosis of ADHD by saying "everybody does that sometimes!"  Some have even asked if it is possible to have "just a little bit of ADHD."  Agreeing with these two statements would imply that ADHD is merely an excess of "normal" behaviors.
 
In most cases of ADHD the difference between "normal" and "ADHD" is very clear: there are definitely more than 6 symptoms of either inattention or hyperactivity/impulsivity.  However, what should be done for someone who has only 5 symptoms and yet is not doing as well as he or she would like in school and has to work twice as long as siblings do to accomplish chores?  Purists would claim that such a person does not have a "disorder" because he or she did not fulfill the definition by which the diagnosis is made.  Given that determination, a physician would not be able to prescribe medication since the patient did not have a disease.  Indeed, some would say that allowing such a patient to take stimulants would be equivalent to prescribing "performance enhancing drugs" to an athlete. 
 
I am not such a purist.  I think that it is possible to have "just a little bit of ADHD."  If a person has some symptoms and is experiencing problems in two areas of life, I think that a trial of ADHD medicine is useful.  Of course, a medicine should not be used if it causes side effects nor should it be used just for testing or for big projects.  (The latter use is typical of how stimulants are abused by college students for whom it is not prescribed.)  As with any medical intervention, the benefits must outweigh the risks both to the patient and to society.

ADHD and diet

A researcher in The Netherlands did a study to determine whether diet affected ADHD symptoms in children between the ages of 4 and 8.  Fifty children ate regular meals with their families after gettting advice about healthy eating.  The other fifty went on a strict elimination diet.  All they could eat were meat, vegetables, pears and water, sometimes getting potatoes, fruits and wheat.  All the kids were evaluated for ADHD symptoms after 2 weeks.  About half of the children on the limited diet did not respond, so the potatoes, fruit and wheat were taken away.  After 9 weeks, 64% of the children on restricted diets had improved their ADHD symptoms, while none of the children on regular diets showed any improvement.  Then, in a second part of the study, foods were added back one at a time and this caused the ADHD symptoms to come back in 19 out of 30 children who had improved.  Interestingly, the types of food that caused relapse had nothing to do with immunologic testing for sensitivity to the food.
 
This study is interesting, but does not provide a lot of evidence about diet causing ADHD symptoms.  For one thing, the researchers, patients and families knew which group each child was in and this can influence results.  The study did reveal that IgG testing does not tell which foods are likely to cause ADHD symptoms.  For families that are willing to do the hard work of severely restricting their diets, it may be a helpful thing to do.  However, this study does not show that the results are necessarily worth the effort.

brain cartoon with dopamine

My stepson sent me this cartoon:
He said that the dopamine made him think of me!  Although the cartoon is not about ADHD, it does illustrate a potential result of over-focus on the internet.  It also shows what happens when executive function isn't doing its job.  The patient is not following the rules of normal speech in words and in action; her self-regulation is not appropriate and the end behavior in this situation is not effective.  It may be that ADHD is a contributing factor to the trochee fixation after all! 
 
Remember that ADHD is a disruption of executive function and that executive functions consist of verbal working memory, non-verbal working memory, self regulation and generativity.  Longer term effects of these deficits result in difficulties with working toward future goals and an inability to stop behaviors that provide immediate gratification in order to attain delayed rewards. 

Methylphenidate in Adults

Eighteen studies of methylphenidate, the active ingredient in Ritalin, Concerta and Metadate, were reviewed to explore its role in treating adults with ADHD.  From these studies, methylphenidate had a "moderate" effect on ADHD symptoms that increased with increasing doses.  The average dose in adults was about 60 mg per day.  The reviewers were unable to determine if there was a difference in effect for different forms of the medicine.  (For example, long acting vs short-acting.)  Those patients who had problems with substance use did not respond as well as those without substance use disorders.  My experience in using methylphenidate in adults with ADHD is consistent with these findings -- I find that Concerta and generic methylphenidate are both effective and that the main differences are in the side effects and the length of action rather than in how effective they are.
 

ADHD and the National Survey on Children's Health

The "Morbidity and Mortality Weekly Report" is an excellent resource for statistics about the health of U.S. Citizens.  It recently reviewed the results of the 2007 National Survey on Children's Health (NSCH) and compared them to those from a similar survey performed in 2003.  According to their parents, 22% more children had been diagnosed with ADHD!  The rise in diagnoses was highest for teenagers from 15 to 17 years old.  It is not clear why the rate has increased so significantly.  Some people think that there is less stigma attached to the diagnosis now while others feel that clinicians got better at recognizing and treating ADHD.  It will be interesting to see whether the rise continues in the next NSCH and to continue to study the results of this one.
 

More genetics and ADHD

I have just read more evidence about the complexity of ADHD genetics.  Twin and family studies make it very clear that ADHD is an inherited disorder, but no specific causative genes have been identified.  Current thinking is that many genes are responsible for ADHD and that outside factors like toxins and disciplinary styles can change how it appears.  As part of the human genome project, scientists looked at over 3000 genome samples including 896 ADHD individuals and could not find a significant ADHD gene.  They did find a few sequences which were promising for future research especially for gene-gene interactions.
 
The authors also theorized that there may be interactions between genes and the environment.  Another study looked at one of the genetic sequences which has been associated with some cases of childhood ADHD.  548 families with an ADHD child contributed DNA to a study and answered questions about discipline, ADHD symptoms and attitudes in the home.  It was found that if the child had the sequence being studied and received "inconsistent parenting" that child exhibited significantly more inattentive and oppositional symptoms.  If the child took responsibility for problems between the parents, he or she was also more inattentive if the studied sequence was in his or her genes.
 
A lot more information needs to be gathered to make conclusions about this aspect of ADHD, but it is certainly a promising beginning!  Thinking about some of the other associations with ADHD symptoms brings up possibilities for future research.  For instance, it was shown that high levels of a pesticide in the urine of children were associated with ADHD diagnoses.  Wouldn't it be interesting to look at their status with respect to some of the associated gene sequences?
 

Exercise and brain function

Researchers have shown that better physical fitness leads to better brian function!  They tested 9 and 10-year-old children on a treadmill to see how fit they were, then they did MRI scans of their brains and measured different parts.  The hippocampus, which is key to learning and memory was bigger in the children who were in the best physical condition.  In animal and adult studies, a bigger hippocampus meant better performance on tests of brain function.  So they tested all the children and found that those who were most physically fit were better able to remember and use information they were given.
 
This information isn't specific for ADHD, but it implies that regular exercise is good for everybody's brain.  Memory and learning are part of the executive functions that are affected by ADHD, so get out there and exercise!
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