April 5, 2012

Attention-Deficit / Hyperactivity Disorder

By far and away the most common concern that I see in my pediatric clinic pertains to the question of ADHD.   It usually stems from a concern about school performance, but the real underlying query has to do with whether the problem is or is not ADHD.  Unfortunately, psychiatrists in general have been pigeonholed into a predicament whereby medications are often the first line or only treatment. In some other countries, medications lie on the opposite end of the spectrum and are treated as a last resort, only after various therapeutic interventions have been undertaken.  The right path is likely somewhere in the middle between therapy and medications, as medications (whether over-the-counter or prescribed) do offer quick relief in many circumstances where therapy cannot gain a foothold for the severity of the symptoms, and medications do work to alleviate symptoms in ADHD, sometimes immediately so.  ADHD is indeed the bread and butter of most general child & adolescent psychiatric practices. It is the most studied of all of the childhood psychiatric problems, with well over 200 clinical trials investigating it and it’s treatment.  Though some might argue that ADHD is an illness manufactured by the pharmaceutical industry in order to push stimulant sales, there is no doubt in my mind that ADHD exists in some form or another.  The problem really, though, is “What is it?“.

According to the DSM-IV-TR, ADHD is defined by the following:

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A. Either 1 or 2:

1. 6 (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

  • often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
  • often has difficulty sustaining attention in tasks or play activities
  • often does not seem to listen when spoken to directly
  • often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the work-place (not due to oppositional behavior or failure to understand instructions)
  • often has difficulty organizing tasks and activities
  • often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
  • often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
  • is often easily distracted by extraneous stimuli
  • is often forgetful in daily activities

2. 6 (or more ) of the following symptoms of hyperactivity-imulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

  • often fidgets with hands or feet or squirms in seat
  • often leaves seat in classroom or in other situation in which remaining seated is expected
  • often runs about or climbs excessively in situations in which it is inappropriate in adolescents or adults, may be limited to subjective feelings of restlessness)
  • often has difficulty playing or engaging in leisure activities quietly
  • is often “on the go” or often acts as if “driven by a motor”
  • often talks excessively

Impulsivity

  • often blurts out answers before questions have been completed
  • often has difficulty waiting turn
  • often interrupts or intrudes on others (e.g. butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment form the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
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To oversimplify the disorder, it describes an inability to regulate attention appropriately.  There are things that can be focused on and things that are difficult to stay on task doing.  Generally, if a child is interested in something, she will engage and do well with it; if they are uninterested, they will struggle more to keep focused on it.  Parents often feel that the problems cannot be ADHD because their child can play video games with an attention that is unbreakable for twenty-four hours straight (what is described as hyperfocus); the problem therein is really in the inability to shift away from this interest.    We might be better in understanding ADHD if we moved away from the nomenclature and the stigma of this acronym. The way I like to think about it is as a deficit of self-regulation, which subsumes the attentional components without laying emphasis on inattention as the only problem, and also includes the idea that any dysregulation (emotional, behavioral, etc) can be part of the condition.  At its heart, ADHD describes difficulties in executive function, an executive dysfunction if you will.   Your executive functions are your ability to:  regulate attention, hold items in working memory, problem solve,  initiate and stop actions, monitor and change behaviors, plan ahead, sequence, shift tasks, and organize.  Your executive functions are housed in the area of your frontal lobes, sort of just above and behind your eyes.  It is perhaps the most evolved area of our brains and likely what makes us all-too human.  For a good review of executive functions in relation to ADHD, please see Dr. Ari Tuckman’s More Attention, Less Deficit, the first chapter of which focuses on the executive functions and is available to download through his website.

Our present understanding is that it is a lifelong neurobehavioral/neurodevelopmental disorder that affects roughly 3-7% of the population.  Although it is the most heritable condition in psychiatry, the symptoms can also be acquired through trauma and toxic exposure (like in utero cocaine).  In fact, recent research suggested that a Western “unhealthy” diet is also implicated in ADHD, with food additives and preservatives playing a role in dysregulated behaviors.  The presentation tends to change over the life-course.  In general, the hyperactivity subsides with puberty, leading people to believe that they’ve outgrown the illness. However, the underlying impulsivity and distraction generally persist, obviously so in 40-60% of adults diagnosed with ADHD as children.  In fact, the average age of diagnosis ADHD in America is now 39.   In adults, because school is generally no longer the problematic area, one sees symptoms emerging with finding and keep jobs, poor relationships, poor job performance, poor concentration, poor organization, poor self-discipline, low self-esteem, and mood instability.  The last on this list is often the main presenting issue if the ADHD has gone untreated, with those adults never really achieving a state of stability on traditional mood stabilizers until the ADHD is addressed directly.  The mood instability is often what begets the equally common and controversial bipolar diagnosis.

Although it is thought of as is a life-long problem, the brain is highly plastic and changes in response to the environment. The brain continues to actively grow until about 25 years of age, and after that, continues to change dramatically in response to stimuli- both internal and external. So it is not unreasonable to think that the brain, including areas of executive function, can change with training and that the problematic symptoms can be disciplined away, so to speak.  In fact, therapy for ADHD often focuses on skill sets and tasks to help discipline the often problematic issues, like having a place to put your keys every time you come in the door so that excessive time is not spent searching for them each monring. Mindfulness and meditation can also help improve concentration. Dr. Lidia Zylowska  from UCLA has published research on mindfulness in ADHD with promising results and has authored a forthcoming book an treating adult ADHD through mindfulness based practices.  It might be that symptoms can diminish to the point of non-interference.  Another interesting approach for children is through simplicity parenting.  Dr. Kim John Payne  noted that children moved from being highly symptomatic on behavior checklists to functioning within the normal range when parents dramatically simplified their children’s environments (more on this to come at a later posting…).

ADHD as a disorder describes basically a set of symptoms deleteriously effecting executive function. When you actually look at the diagnostic criteria for ADHD, everyone has these symptoms to some degree.  Where it becomes a condition necessary to treat is when it interferes significantly in your life.    The difficulty then becomes ascertaining to what degree these symptoms are interfering, and whether there is anything else that might be causing the executive difficulties, as executive dysfunction is not limited to ADHD.   If you have depression, anxiety, trauma, hunger, insomnia, hallucinations, learning disabilities, attachment problems, sedation, a head injury, nutritional deficits, etc. you may not be able to pay attention well and may present as if you had ADHD.  One of the often-overlooked problems in our society is an almost universal sleep deficit.  If you’ve ever sat through a boring class and tried to keep yourself awake, you’ve no doubt fidgeted. The same applies to sleepy kids, only to a greater degree of hyperactivity.  When kids are tired, their body kicks in cortisol, their stress hormone, which keeps them moving, sometimes excessively so, and keeps the teachers questioning ADHD.    As a neurology mentor taught, it is impossible to make an accurate diagnosis for any psychiatric ailment in the face of an ongoing sleep problem.  The rub though is that parasomnias (sleepwalking, sleep-talking, latency problems, etc) which can interrupt sleep quality occur more often with ADHD.  From a nutritional standpoint, we know that single mineral deficiencies in zinc, iron, magnesium, or boron can lead to attention problems and that, as a whole, we as a nation are undernourished in spite of our obesity epidemic, and rarely with just a single nutrient depletion.  So nutrition is an essential component in any assessment and a potentially safe inroad in beginning treatments.  So one of the primary tasks in evaluating ADHD is to evaluate whether the constellation of symptoms could in fact be related to another deficit.  Unfortunately, there are no set “tests” to rule-in or rule-out ADHD. It is a clinical diagnosis. Clinicians generally rely on checklist of diagnostic questions supplied by family members, teachers, babysitters, etc, to determine the extent of the problems.  There are some computer programs like the Continuous Performance Test which can test for errors of commission and omission (impulsivity and distraction respectively) and are often used in the context of psychological testing.  There is also a growing body of literature about using the qEEG (quantitative electroencephalogram) to measure for patterns of brain wave activity that might correlate with ADHD.  At this time, there is no current evidence that structural imaging, such as with an MRI, can rule-in a diagnosis of ADHD.   Most of these tests help to build the case for ADHD, but are not diagnostic in their own right.

At present there is no established cure for ADHD, only symptom relief and management.  When it comes down to treating ADHD, medications do have a profound impact and have been proven efficacious in multiple studies.   The medications that appear most effective increase catecholamine function, typically either dopamine or norepinephrine.  In the standard-of-care setting, the first line of medication treatment is often a stimulant.  Stimulants essentially stimulate dopamine, a catecholamine neurotransmitter, which then stimulates your executive functions and helps you focus, settle, and think; think of it like stimulating your brain’s breaks so that you can stop, look, and listen.  Stimulants come in two large categories, either methylphenidates or dextroamphetamines.  The methylphenidates include Ritalin, concerta, metadata, daytrana, focalin, and methyline; the dextroamphetamines include dexedrein, adderall, and vyvanse.  44% of people respond  to one group better than another.  Regardless of diagnosis though, almost anyone who takes a stimulant will focus better, ergo the rampant Adderall abuse among college students and professors, and companies push to have coffee in the work-place since the 50′s.  With ADHD, stimulants (even coffee) can cause more of an outwardly paradoxical effect, a calming and slowing.  In addition to stimulants, there are a number of prescribable non-stimulant medications like strattera, intuniv, tenex, clonidine and wellbutrin.  Unfortunately, there are not tests at present to determine which medication will be effective beyond trial and error.

So do alternative remedies work?  Alternative therapies are a slippery slope.  Research within mainstream medicine hardly focuses on herbal remedies, likely because they tend to yield less economically.  Herbal remedies are not classified technically as drugs and thus do not fall under the supervision of the FDA, which mandates that drugs demonstrate both safety and efficacy, an arduous and expensive process.  Rather, herbal remedies are classified as dietary supplements under the Dietary Supplement Health and Education Act.  Without FDA oversight, anyone can package and market a product and make wide claims as to its efficacy without data to back it up.  Only after it has been proven to be a health risk or safety hazard can the FDA file a complaint and potentially remove it from the market.   The onus, thus, is on the FDA, not the product.  The herbal remedy also cannot claim to “treat, mitigate, or cure a disease,” but only to offer symptom relief.  So, buyer beware. To paraphrase Dr Scott Shannon, a holistic child psychiatrist in Fort Collins, CO, if a product is presented as a cure-all with wide marketing distribution and poor clinical documentation, be suspicious.  There are, however, a lot of herbal remedies offered that might prove efficacious. I’ve already talked about Truehope  and EMPower in previous blogs.  Evidence about EMPower’s effectiveness in ADHD over the course of months is impressive, as documented in Dr. Julia Rucklidge’s research in New Zealand.  Since we (mostly) know the action of the stimulants, which typically work well with ADHD, anything that functions in a similar way to boost catecholamine function might also prove to be helpful in ADHD, like the amino acid tyrosine, the precursor to dopamine and norepinephrine.  Another interesting product is Learn from nourishLife, which uses essential fatty acids and several key vitamins to help improve brain function. The main issue when it comes to assessing whether an herbal remedy is worth trying hinges on the risks : benefit ratio; if the risks of the product outweigh the risks of the untreated illness, don’t take it.  For most herbals and vitamins, the risks are rather benign… not nothing, but they certainly are less of a safety concern than most prescribed products.   Dr.  Shannon has an excellent review on alternative therapies for ADHD (and other childhood mental health concerns) which can be accessed from the Wholeness Center.   His regimen often includes the addition of Omega 3 fatty-acids and vitamins to improve brain functioning and focuses strongly on treating the subtle comorbidities, like anxiety.  Since you are essentially what you eat, your diet has a profound impact on your focus and attention.

I will delve much further into alternative ADHD treatments in future postings.