ADHD, In Context: Give Me A Break

 

ADHD can look like PTSD, or in the new language,  a result of ACEs (adverse childhood events), in that the lack of focus could be a result of traumatic experiences interfering with the ability to concentrate. Understanding the child in context can help discern the various factors which contribute to difficult or disruptive behaviors. I am just not sure why this needs to be said, as it is inherently obvious. Yet, in lecture after lecture, that I go to, given by people with impressive degrees, I hear this as a take-away point, as if the audience does not know this. Without understanding the child’s environment, the speaker said, you can make the wrong diagnosis. Duh, was my private thought, while I was  stuck on whether the speaker thought she was being profound or if she thought that her audience was so clueless that she had to state the obvious. Every child, every patient needs to be seen in the broader context of their family, social and academic environments. In today’s day of assembly-line medicine, perhaps this does need to be said. I close with a common refrain of mine. Sad, sad, sad.

From Disruptive Behavior Disorder to Neurodevelopmental Disorder: DSM 5

 

The powers that be in psychiatry have moved ADHD from a “disruptive disorder” to a “neurodevelopmental disorder”. Let’s pause for a moment. Not all ADHD children or adults are disruptive. Girls, mostly, and some boys, suffer from the “inattentive subtype” which means they quietly sit there and count the tiles on the ceiling, not learning because they cannot focus, but they do not cause a disruption. So, indeed, the nomenclature needed to change. Welcome ‘neurodevelopmental disorder’ and new problems arise. To the extent we understand ADHD as an immature brain, a brain which has trouble with executive functioning, sustained attention, and impulse control, then it is certainly a “neuro” disorder. On the other hand, the role of development is not clear except to say that certain children will outgrow ADHD, implying they are slow to mature, or late bloomers, as I like to tell parents. Some, however, do not outgrow it, and they suffer a lifetime with  poor focus and poor executive functioning. For them it is not a developmental disorder, but a straight up disorder. If we think of brain functioning like circuits and some people lack critical circuits for functioning, then in the future, perhaps we will call ADHD a “circuit disorder”. As Russell Barkley explains, the problem with the circuit is a failure of inhibition, such that the ADHD patient is constantly vulnerable to whatever pops into his mind at that moment, leaving him or her unable to complete tasks, especially those which have little inherent interest. Further, he or she is also vulnerable to losing key items, not remembering details of a project, and failing to do daily chores, as the sudden thought, whatever that might be, overrides routine or “boring” activities. So, by my way of thinking ADHD is a brain problem, not always related to development. No one wants to think of themselves and worse yet, their children, as having a “brain problem” so I don’t think my idea would sell well, but I think it is the most efficient way to communicate our current level of understanding of this common disorder.

Adult ADHD-PriMed Returns

West Annual Conference

Anaheim, CA | April 27-30, 2016

Anaheim Convention Center

RegisterAgenda

Adult ADHD

• Friday, April 29
• 5:35 PM – 6:15 PM
• Ballroom A, Level 3

Description

This session will illustrate how ADHD manifests in adulthood. Assessment and management tools will be explored. The complicated interface between stimulant treatment and addiction will be discussed. Both old and new stimulants will be presented, along with behavioral interventions. Mindfulness as a tool for ADHD will also be discussed.

Learning Objectives

Discuss diagnosing ADHD in adulthood

Review treatment options for ADHD in adulthood

Discuss treating the adult ADHD patient who is also an addict

List non-pharmacological interventions for adult ADHD

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Syllabus

Download a PDF of the presented slides.

DOWNLOAD

Speakers

Shirah Vollmer, MD

Anaheim, here I come. I am going to talk to an audience of several hundred about adult ADHD. I will be on multiple screens and so this is as close to I get to rock star fame. Granted, I am not giving a plenary, a dream of mine, to be sure, but I will have my fifteen, actually thirty minutes of something. What are my main points? DSM 5 has given credibility to the diagnosis of adult ADHD. I might tell my story of my patient, a lawyer, severely impaired by ADHD, whose primary care physician said, by the patient’s report, “you can’t possibly have ADHD, you graduated law school.” Yes, yes, I like to make fun of anonymous physicians when I speak. Next point. Diagnosis does not mean pharmacological treatment. Understanding the trouble of a brain which has limited ability to inhibit impulses is in large measure therapeutic. Medications are another tool, but sometimes they are not essential. Third point. Productivity apps, the wonders of our new technology, can help ADHD folks considerably. The smart phone as an assistant brain is good for all of us, but for those with ADHD, it could be a significant game changer in their attention to detail and their focus on their schedule. Finally, I want primary care physicians to understand that brains come with different strengths and weaknesses, and helping patients understand that is a huge gift to their quality of life. And so my mission will be complete. Maybe, just maybe, they will ask me back and I will get another chance at this rock star business.

http://www.pri-med.com/medical-conferences/2016/annual-conference-west/agenda/sessions/QMONYA0E9ACU.aspx

Pri-Med West: Shameless Self Promotion

West Annual Conference

Anaheim, CA | April 27-30, 2016

Anaheim Convention Center

 

Adult ADHD: How To’s for Diagnosis, Management and Remission

Shirah Vollmer MD

• Friday, April 29

Description

This session will illustrate how ADHD manifests in adulthood. Assessment and management tools will be explored. The complicated interface between stimulant treatment and addiction will be discussed. Both old and new stimulants will be presented, along with behavioral interventions. Mindfulness as a tool for ADHD will also be discussed.

Learning Objectives

Discuss diagnosing ADHD in adulthood

Review treatment options for ADHD in adulthood

Discuss treating the adult ADHD patient who is also an addict

Learn non-pharmacological interventions for adult ADHD

ADHD: The Problem of Subjectivity

http://www.nytimes.com/2013/10/20/magazine/the-not-so-hidden-cause-behind-the-adhd-epidemic.html?_r=0

“Stephen Hinshaw, a professor of psychology at University of California, Berkeley, has found another telling correlation. Hinshaw was struck by the disorder’s uneven geographical distribution. In 2007, 15.6 percent of kids between the ages of 4 and 17 in North Carolina had at some point received an A.D.H.D. diagnosis. In California, that number was 6.2 percent. This disparity between the two states is representative of big differences, generally speaking, in the rates of diagnosis between the South and West. Even after Hinshaw’s team accounted for differences like race and income, they still found that kids in North Carolina were nearly twice as likely to be given diagnoses of A.D.H.D. as those in California.”

 

“Today many sociologists and neuroscientists believe that regardless of A.D.H.D.’s biological basis, the explosion in rates of diagnosis is caused by sociological factors — especially ones related to education and the changing expectations we have for kids. During the same 30 years when A.D.H.D. diagnoses increased, American childhood drastically changed. Even at the grade-school level, kids now have more homework, less recess and a lot less unstructured free time to relax and play. ”

 

This is the old saw. A “disorder” based on a history, with no objective findings, can be both over and under-diagnosed, in large measure, by cultural expectations and societal pressures. If a diagnosis is tied to services, to helping teachers explain test scores, or to an entry into a special pool, such as priority enrollment, then the incidence of the diagnosis is going to go up, resulting in an “epidemic” which really represents a change in the environmental pressures to make this diagnosis. This was our discussion in class yesterday, as we tried to open a conversation between medicating and over-medicating children. The lines are not clear, once again, taking us back to the importance of good history-taking and close monitoring. Even with that, we cannot ignore the societal pressures to make the diagnosis and we cannot pretend that these factors do not influence our decision-making. So, what if we, as professionals, are honest about our work? What if I confess that the reason I am giving your child a diagnosis is that, his symptoms put him on the border of a diagnosis, but given the upside of extended time on tests, for example, then the benefits of the diagnosis outweigh the harm. As my student said, “I like the transparency in that.” As psychiatrists, or old-fashioned psychiatrists, I should say, the most important tool to better mental health is intellectual honesty and authenticity. As such, we would be hypocrites to pretend that we have certainty where there is none. We would also be hypocrites to suggest that we are immune from external pressures. Being forthright about these issues is the first step to establishing credibility and thereby allowing us to move forward in the field. Otherwise, like in neurosis, we are stuck in a web of wishes and fantasies, far from the harsh reality of the uncertainty in everyday practice.

NEBA: FDA Approved…..Hmmm…..

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm360811.htm

 

NEBA, the Neuropsychiatric EEG-Based ADHD Assessment Aid, has been FDA approved by the Center for Devices and Radiological Health, is a prescriptive device to aid in the diagnosis of ADHD. It uses the theta/beta ratio of the EEG for a patient 6-17 years of age, combined with a clinician’s evaluation to aid in the diagnosis of ADHD. The obvious question is how does this add to the clinical evaluation? A thorough history is the key to the diagnosis. Medication trials add new information. It might be interesting to see what the NEBA reports, but beyond interest, I am not clear how this is a useful clinical tool. The history would sway my thinking more than the brain waves, at this point in the science. The biomarkers are still not clear. We are moving towards understanding the brain, which will require less and less history, and more technology, but it seems to me, we are not there yet. Still, it is interesting that the FDA has approved this device, which, to my knowledge, has not been used in any other country. The device is from a start-up company in Augusta, Georgia, headed by Howard Merry. In the era of being able to quantify our bodily functions, it is exciting to think that our brain waves can be measured by a device that looks like a tablet. This excitement generates a wish that we could find objective measurements for diagnoses which, like ADHD, require painstaking history-taking. This wish will stimulate further research and development, so perhaps the NEBA is the important first step. On the other hand, it is important to know when something is more of a wish than a useful tool.

No Need To Attend to the Changes: ADHD and DSM 5

From WSJ June 16, 2013 “A Nation of Kids on Speed” by

By PIETER COHEN AND NICOLAS RASMUSSEN

 

“Last month, the American Psychiatric Association released the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders—the bible of mental health—and this latest version, known as DSM-5, outlines a new diagnostic paradigm for attention-deficit hyperactivity disorder. Symptoms of ADHD remain the same in the new edition: “overlooks details,” “has difficulty remaining focused during lengthy reading,” “often fidgets with or taps hands” and so on. The difference is that in the previous version of the manual, the first symptoms of ADHD needed to be evident by age 7 for a diagnosis to be made. In DSM-5, if the symptoms turn up anytime before age 12, the ADHD diagnosis can be made.

It’s also easier to diagnose adult ADHD. Before, adults needed to exhibit six symptoms. Now, five will do. These changes will undoubtedly fuel increased prescriptions of the drugs that doctors use to treat ADHD: stimulants such as Ritalin and Adderall.”

 

ADHD stabilizes in DSM 5, but the debate about it does not. This quote above, from  the opinion section of the Wall Street Journal, expresses deep concern about the over-diagnosis and hence the over-treatment of kids and adults with stimulant medication. The arguments are tired and true, but also exaggerated. This is a clinical diagnosis. There are no objective findings. Physicians make a lot of money making this diagnosis and drug companies, in kind, profit from the illness. Kids are given stimulants with the potential message that they are not responsible for their own behavior. “Boys will be boys” and so why are we trying to push square pegs into round holes. In the comments, one writer expressed the notion that savvy parents help their kids get an ADHD diagnosis so the child can qualify for extended time on tests, as if extended time will necessarily help the child have a higher score. The issue of whether any child should have a timed test is yet another question in education, but that puts us on a tangent. The issue here is first, DSM 5 is not moving us forward in the ADHD world. Without an objective test, diagnosis abuse will continue. Financial incentives are there, and so abuse will happen. At the same time, for some kids, going on stimulants is like getting a pair of eye glasses. The world is simply clearer to them, so that they, and their families appreciate the monumental change in their interface with the world.  My solution is simple. The better the history taking, the more likely the physician will hit the mark and the less likely there is financial incentive to over-prescribe. Quickies, or short appointments, lead to “ADHD mills” where over-diagnosis and over treatment is rampant. Physicians who take considerable time exploring the possibility of ADHD are much less likely to be vulnerable to the pressure to prescribe. A prescription can be a quick tool to rapidly get someone to leave your office. These hasty interactions is what has got to change: not the diagnosis or the treatment.

Dorsolateral Prefrontal Cortex (DLPFC): Heart Of Life’s Success

According to Wikipedia…..

“DL-PFC serves as the highest cortical area responsible for motor planning, organization, and regulation. It plays an important role in the integration of sensory and mnemonic information and the regulation of intellectual function and action. It is also involved in working memory. However, DL-PFC is not exclusively responsible for the executive functions. All complex mental activity requires the additional cortical and subcortical circuits with which the DL-PFC is connected.^[2][3]

Damage to the DL-PFC can result in the dysexecutive syndrome,^[4] which leads to problems with affect, social judgement, executive memory, abstract thinking and intentionality.^[5]“

Academic Child Psychiatry, and Laura Tully PhD, in particular,  is trying to understand how social skills work on a neuroanatomical level, and in light of that, all roads point to the importance of a well-functioning dorsolateral prefrontal cortex (DLPFC). When this part of the brain works well, people can plan, anticipate, organize, empathize and thereby make good judgments, socially and otherwise. These findings deepen my appreciation for genetics, and how much of behavior, and positive outcomes, are based on DNA. Unempathic parents can disorganize a good brain, a good child, but empathic parents cannot replace a defective DLPFC. In other words, I think of the nature/nurture argument, as often supported by Steven Pinker PhD at Harvard, that growth is pre-determined, but malnutrition can change the outcome. A good diet cannot make someone taller, but a bad diet can make them shorter. So too with behavior. Good parenting does not always create “good” kids, but “bad” parenting can hurt “good” kids. The basic ingredient, a good DLPFC, is essential for life success. It is almost impossible to compensate for a defect in the DLPFC, as seen by people with head trauma resulting in damage to this area. Understanding the need for good brain functioning, helps parents of children with mental handicaps understand their limitations, as parents. Likewise, parents of children who do have good  brain functioning, need to understand that  their main job is “not to screw it up,” as I like to say. Nature and nurture go together, but understanding how this dynamic plays out, is essential to promoting the best development possible.

What Is With This Gender Disparity?

Teaching in Family Medicine, Psychoanalytic Institutes, Child Psychiatry, and Social Work students has shown me a gender disparity that floors me every time. My students are overwhelmingly female. We discussed this today, before I launched into my talk on ADHD. “We are more nurturing,” one student said, implying that women are better at taking care of other. “Yes, but in the 60s, psychoanalysis was predominantly male.” I reply, saying that when there is more status, men are more likely to be attracted to the field. “Teachers are very important to our society, but their female dominance makes it a lower paying field,” I speculate out loud. I am a weary of delving deeper into this subject, as one, this is not my job, and two, I am speaking to students who have picked a career, in which I am suggesting will decrease in respect as more women go into it. Nevertheless, I continue. “Is it women want to be home with their kids, or is there a glass ceiling which prevents women from obtaining more prestigious positions, or is it that women, as a group, are less genetically ambitious and so are more comfortable staying in lower paying positions?” We all agree that these are interesting questions, without clear answers. One thing, though, I feel certain about, is that a female-dominated profession will be thought of, by our society, as less important than male-dominated professions. Given that there are more women than men in the United States, I am inclined to think that many women share a typical man’s point of view about professional value. These are, of course, my musings. I do not claim to have expertise, only curiosity.

Low Self-Esteem or Disorganized: Hard To Tell

Elisa, thirty, misses appointments, forgets to pay her bills, does not return phone calls, and has trouble completing tasks. She suffers from ADHD, takes stimulants which she reports as “very helpful,” but she remains disorganized and thereby rude to her friends and family. As we explore her behavior, which occurs intermittently with our appointments as well, Elisa comes to the understanding that she runs her life in a “crisis mode.” By that she means that when they are just about to shut off her electricity, then she will pay her bill. Before that, “I just don’t see the need,” she says with a flat affect, seemingly uncaring that her two kids will have to suffer if the electricity gets shut off. “It seems like you need adrenaline to carry out a task?” I ask, noticing that the heat of a crisis bolts her into action. “Yes, absolutely, I have always been that way,” she responds rapidly. “Maybe that the adrenaline has to compensate for your general low sense of yourself and your general sense of unworthiness, such that you do not feel compelled to do the activities of daily living unless there is an immediate consequence which looms large.” I say, noticing that maybe layered over her ADHD is a sense that life is not much fun, that she is not much fun, if she has to be ordinary. “The sense that one has that it is OK to do ordinary things is often derived from a sense that one is OK. If you don’t have a sense that you are OK, maybe then you do not see the value in showing up and being a person of your word. Maybe you don’t think your word means much because you don’t feel that you mean much.” I say, again showcasing that perhaps if she had a larger view of her self-importance, maybe then she would comprehend why it is important to other people that she does what she says she will do. If she thinks low of herself, she may think that her word is not valued and therefore she is not obligated to follow through. I wonder. Elisa looks back at me mystified and unsure as to what I am talking about. “I don’t know what you are saying, but I will sure try to think about it,” she responds. “That is all I ask. Think about it.” I say, expressing hope that maybe through chewing on my idea,  Elisa can come up with her own ideas as to why she has trouble being responsible. She left confused, but also with a look of curiosity and reflection that made me think that we were involved in a deep journey.