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Dr. Kacir's ADHD Blog

ADHD in The New York Times

Perri Klass, M.D. wrote an article for The Times that summarizes the current science regarding ADHD.  It is entitled "Untangling the Myths about Attention Disorder."  She starts by contradicting the theories that today's world  breeds more problems with attention that are then diagnosed as ADHD and she rejects the use of ADHD as a metaphor for functioning in that world. She goes on to state that ADHD is a true disorder that goes beyond excessive multitasking.  In support of this premise, she references the first medical journal description of ADHD (although it wasn't called that) in 1905 and an 1845 poem entitled "Fidgety Philip" which described the disorder in rhyme.  She also refers to the imaging studies which have illustrated anatomic differences between children with ADHD and those without as well as the functional studies that show decreased brain activity in areas which control attention that can be corrected with stimulant medication.  What was most interesting to me was her discussion with Dr. Maximillian Muenke, the head of the medical genetics branch of the National Human Genome Research Institute.  His group has identified a specific gene associated with ADHD in some families that also seems to signal a good response to stimulant medication.  He predicted that in the future, genetic analysis might be able to indicate which patients with ADHD would respond to which medications or behavioral therapies.

ADHD on aol

I was quite surprised to see a headline on the aol home page entitled "What is the cause of ADHD?"  I read the blurb on the "front page," and it suggested pesticides, diet and "bad parenting," but went on to say that "experts separate fact from fiction."  I was pleased to read the main body of the article which used Dr. Wolraich as their primary expert.  He has been part of many academic studies on ADHD.  He denied that foods like refined sugar and food additives could cause ADHD, but did support regular mealtimes and a balanced diet, with a multivitamin for picky eaters.  There was no mention of increased Omega-3 fatty acids having a beneficial effect, although more than one study supports their use in ADHD.  He did acknowledge a recent study which found that there was a higher rate of ADHD in a group of children with higher levels of pesticide residue in their urine than there was in the group with the lowest levels studied.  His recommendation was either to buy organic fruits and vegetables or to wash non organic produce very well before eating it.  In summary, it was good to see that aol was providing reliable and responsible reporting on ADHD.
 

ADHD, Executive Function and Alcohol

 
ADHD is considered a disorder of "executive function."  I generally simplify it and describe this function as being a matter of prioritizing attention.  That is, does the brain keep paying attention to what it is doing, or does it shift its focus to a distraction?  The psychological literature, on the other hand, looks at the bigger picture and lists four components of executive function: verbal working memory, non-verbal working memory, self regulation and generativity.  Verbal working memory consists of the words with which we describe our present situation.  (Some psychologists call this "self-talk.")  Non-verbal working memory involves all the other "stuff" we have to remember about similar situations: how close to stand, how loud to talk, where to look, etc.  Self-regulation involves our "inner workings." How deeply do we need to breathe?  Should our heart beat fast or slow?  Do we need extra sugar in our blood?  How awake do we feel?  Generativity is a fancy word that summarizes what we do with all the other elements-- what plan will we follow in the situation we face?
 
 
What, you may ask, does this have to do with alcohol?  Well, I just read an article about scientists who did special EEG testing on 11-year-old children whose mothers admitted to binge drinking during their pregnancies.  The testing measured brain activity in different parts of the brain while these kids performed certain tasks and compared these measurements to those of other 11-year-olds whose mothers did not drink.  Both groups of kids were able to form memories well, but the children who had been exposed to alcohol in the womb had more difficulty retrieving those memories later (verbal and non-verbal working memory).  They also had more trouble stopping an automatic response to triggers when they were instructed not to respond (self regulation) and were slower at shifting their attention to one task from another as well as having difficulty describing the meaning of a given task (generativity).
 
I was intrigued by the parallels between the problems of ADHD and those demonstrated in this study.  A brain exposed to alcohol before birth might have changes that mimic those in the developing brain with ADHD.

ADHD in the United States

A national telephone survey of parents between April, 2007 and June, 2008 revealed that 9.5% of children aged 4-17 years had been diagnosed with ADHD.  According to the parents, 66% of these children were taking medication to treat their symptoms.  In 2003, a similar survey found that 7.8% of these children had ever been diagnosed with ADHD.
 
I became aware of the article describing the survey through a physician discussion forum, where one of the more vocal doctors (an orthopedic surgeon) derided the findings.  He argued that the diagnosis was vague since it didn't rely on objective findings like laboratory tests.  Then he said that ADHD was being diagnosed more often because drug companies were interested in selling more drugs to parents who weren't properly disciplining their children.  I obviously disagree with these arguments, but I thought it would be interesting to post them here for reactions.
 

Nature Deficiency Disorder

This topic is not directly related to ADHD, but I have read several articles recently which referred to the problems which arise when children are not exposed to nature.  There was one study which I read a couple of years ago that treated kids with ADHD by taking them to a park for 30 minutes every day as part of their school program.  Their teachers reported fewer ADHD symptoms in the children who participated.  The articles I have read more recently compare children with varying exposures to natural outdoor environments and find that those with the most time spent outdoors have better general health, including emotional states.  I have not seen any research about outdoor exposure in adults with ADHD.

Neurofeedback and ADHD

I was listening to National Public Radio this morning and heard a piece describing the use of Neurofeedback as treatment for ADHD.  The presenter was a mom who was treated with it first and then decided to treat her 12-year-old son.  The presentation summed up the positive and negative aspects of the treatment very well.  On the positive side, it has been shown to work, although it is not clear how long the effects last when the active treatment stops.  On the negative side, it is complex, expensive and time consuming.  Furthermore, it is difficult to evaluate practitioners who provide the service.
 
What is Neurofeedback?  Essentially it involves a limited EEG or electo-encephalogram, during which electrodes are attached to the patient's scalp so that the patient's brainwaves can be displayed to him or her.  The patient then concentrates on increasing certain brain waves that are associated with better concentration and decreasing those that are produced with distraction.  It is "biofeedback for the brain" and is provided by a subset of biofeedback centers that have the right equipment and personnel trained to use it.

ADHD medications in The Netherlands

I just read a summary of a study that looked at the records of prescriptions filled for ADHD medicines in The Netherlands.  The first conclusion was that 75.5% of children from age 6-17 who were prescribed ADHD medicine reached a stable dose of such medicine during the 3 years reviewed.  (2003-2006)  The second conclusion was that the medicine for which a stable dose was reached most quickly was long-acting methylphenidate.  (They do not specify whether this is Concerta, Ritalin LA, Metadate CD or FocalinXR.  It may be a combination of all or some of them.)  Unfortunately, I don't think that this information is particularly useful.  It does, however, support the observation that 80% of people with ADHD respond well to the first stimulant they try.
 

ADHD and Headache: both common but not related

In a study of Brazilian children, the authors of an article on Pediatric Migraine noted that ADHD was not more common in those with headache.  In addition, headache did not occur frequently in children with a diagnosis of ADHD.  They did find, however, that children with hyperactive and impulsive behaviors (but not enough to be called ADHD) were more likely to complain about headache symptoms than were children with average activity and impulse control.  However, even among the hyperactive/impulsive kids, headaches occurred in fewer than 1 out of 10.
 

New evidence of ADHD genetics

I just read a report on an article in The Lancet, a British medical journal.  It documents a study comparing the genes of about 400 children with ADHD to those of more than a thousand kids without symptoms of ADHD.  They found that genes from those with ADHD were twice as likely to have extra copies or fewer copies of certain genes associated with brain function.  This is the first direct genetic evidence for ADHD and defines it as a neurodevelopmental condition and NOT a behavior disorder!

Dr. Kacir enters the blogosphere

So many people have recommended that I add a blog to my website that I have finally taken the plunge.  I hope to be able to monitor it at least once a week and will respond to comments about ADHD in general, but will not provide medical advice about individual patients.  I hope to communicate about ADHD resources as I review them and to relate interesting tidbits relevant to ADHD and its treatment. 
 
Today, I finished reading Taking Charge of Adult ADHD by Russell Barkley, PhD.  Dr. Barkley is a psychologist who has been in the forefront of research involving ADHD evaluation and treatment since 1993.  He wrote an excellent guide for parents of children with ADHD entitled Taking Charge of ADHD before adult ADHD was commonly diagnosed.
 
The new book describes Adult ADHD well, utilizing vignettes of adult patients.  He acknowledges the major role of medication in the treatment of ADHD and summarizes basic facts about it in 3 chapters.  (I am biased, but I think that I do a better job in person!)  The real strength in his writing lies in his descriptions of additional measures by which to combat specific problems and symptoms that go along with ADHD.  He is able to suggest practical strategies for dealing with the challenges faced by those who struggle with inattention and impulsivity.
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