Adhd spotlight

Dr. Brian B. Doyle is a psychiatrist, a clinician and teacher who graduated from Harvard College and McGill University, Faculty of Medicine. He has written numerous articles and monographs, especially on the affective and anxiety disorders and attention deficit hyperactivity disorder. Coeditor of The Impaired Physician, his new book, Understanding and Treating Adults with Attention Deficit Hyperactivity Disorder, was published in June 2006. He is in his tenth year as the host of “Medical Answers,” a nationwide television program on the Public Broadcasting System. He has received awards for excellence in teaching from Georgetown University School of Medicine, the International Society of Business Communicators and the American Psychiatric Association. Military honors include the Meritorious Service Medal and the General Staff Insignia. Formerly on the faculty of Harvard and George Washington University medical schools, he is now Clinical Professor of Psychiatry and of Family and Community Medicine at Georgetown University School of Medicine. Dr. Doyle maintains an active private practice in Washington, DC, specializing in mood and anxiety disorders and attention deficit hyperactivity disorder. He currently serves as President of the National Association of Medical Communicators.

ADHD Spotlight is now a podcast!

A new video podcast, ADHD Spotlight, hosted by Dr. Doyle is now available here and will soon be listed at the iTunes Store. This first show is “Young Adults with ADHD,” and features college students talking about their experiences, and well-known experts in the field, including Dr. Carolyn B. Robinowitz, president of the American Psychiatric Association. Developmental Pediatrician Dr. Patricia O. Quinn, founder of the influential ADD/ADHD website, offers insights gleaned from her work with high school and college students and their families; Psychiatrist Paul Steinberg, whose provocative essay about ADHD in the New York Times challeges us to look at the condition from a more positive perspective, discusses the fine points of diagnosis and treatment. Dr. Doyle provides an overview of commonly prescribed medications, and explores the controversial topic of medication diversion and abuse on college campuses.

The show is about 20 minutes long, and is best viewed with a broadband connection. If you prefer to wait and download the file from iTunes, (which you can watch on a video iPod or your computer) keep an eye on Dr. Doyle’s blog. It should be up at the Apple iTunes store very soon, and we’ll post a link.

Upcoming program topics include:

• How is ADHD Diagnosed?
• Minorities and ADHD
• Depression and Adults with ADHD
• Heart Trouble and the CNS Stimulants
• CNS Stimulants: Finding the Right Dosage
• ADHD Medications – The Controversy
• Seven ADHD Life Strategies
• ADHD Success Stories
• Girls and Women with ADHD

You may want to check out my previous Video PodCast, Health Minute, at the Apple iTunes Store.

Insomnia, ADHD, and Bad Behavio

A new study on children with ADHD* sheds some light on the problems with insomnia — and then with behavior — that many adults with ADHD have. The surprising conclusion of the study? The use of stimulant medication in children and adolescents with ADHD does not seem to cause or worsen sleep problems.

This large, forward-looking study showed an odds ratio of 1.3 for insomnia among children with ADHD who had taken a stimulant or other form of ADHD medication in the previous year. That odds ratio is not statistically significant. Translation: the chances of insomnia are only slightly higher in children and teenagers who took meds for their ADHD.

In the study the 225 children and adolescents with ADHD averaged 14.9 years old; the 224 without ADHD had an average age of 16.1. Slightly fewer than half of the subjects were boys or young men (that’s unusual). In the year preceding the study, sixty-one percent of the youngsters with ADHD received a medication for the disorder. Only 6% of the controls received such medication. Other ( “comorbid” ) psychiatric disorders were also present in 51% of the ADHD subjects and only 10% of the controls.

Fully 42% of the youngsters with ADHD reported often having difficulty falling asleep in previous months, compared with 17% of the controls. That was a very significant difference ( the probability value, abbreviated as p, was less than 0.01 ).

We assume that people who sleep poorly don’t function or behave as well as those who are well-rested. We assume that children with ADHD don’t function or behave as well as others do. We might assume as well, then, that children who have both problems are at special risk for bad behavior.

The investigators used the Child Behavior Checklist to check out these assumptions in the study subjects. They found that kids with ADHD and insomnia had significantly more behavior problems than their non-ADHD counterparts who had insomnia.

Eric Mick, ScD, assistant professor of Psychiatry at Harvard Medical School, led the study. He asserts that the most intriguing result he and his colleagues found is the connection between insomnia and behavior problems.

I like studies that support my assumptions, the way this one does. For adults with ADHD, it bolsters the evidence that sleep problems are a basic part of the disorder of ADHD. Here’s the take-home message: treating ADHD, even with stimulants, may not worsen sleep problems.

When we’ve slept badly we do not function at our best ( that’s an understatement, eh? ). The study results prod me to watch for sleep problems among my adult ADHD patients. The study also means that if you have sleep problems, report them to your doctor. They are definitely worth working on. You’ll feel better. Even more important, you may well function better.

Listening-ADHD Spotlight

When I’m treating persons who have ADHD, I need to remember that there is more to effective treatment than prescribing the right amount of the right medication.

I’m all for medications. I’m aware of their effectiveness but also of their limitations, dangers and side effects. Sometimes I have to re-learn that the central curative factor in treating any patient is listening and responding to the person. Whether or not they have ADHD.

This hit me forcefully recently when I was reading The Last of the Just ,* by Andre Schwartz-Bart. The theme of this astonishing book is that in each generation of Jews a just man takes on the sins and sufferings of the world.

Chaim Levy, one of Schwartz-Bart’s just men, was a cripple who claimed no special powers other than, “perhaps,” the power of tears. “Even when he could do nothing for a sufferer, he always conversed with him, not on higher matters, as one might have hoped, but on entirely anodyne affairs lacking in interest, such as the married life of the sick man, his work, his children, his cows, his chicken. A strange thing — people went away happy, saying that he knew how to listen, that by following your little tale he uncovered the grieving thread of your soul.”

“One day, to a poor old lady who was thanking him: ‘My dear old friend, don’t thank me. My soul goes out to you, for I have nothing else to give you.’ ”

There in a few sentences is the essence of psychotherapy. Whatever I offer to my ADHD patients, I hope that listening is central. The kind of listening that “uncovers the grieving thread of your soul.”

Genes and Meds

Someday we will be able to tell which patients will do well by which medications by looking at their genes. This will happen for ADHD patients as well as for many other kind of patients. When that information is available, instead of the current system of, “first we’ll try this, and if it doesn’t work then we will try that,” we will have a scientific and highly accurate plan. We will link up our illnesses with medications that we can count on to be helpful.

Sound like science fiction? It may — but we are closing in on being able to do it. Some Brazilian researchers have recently studied treating children and adolescents with ADHD with methylphenidate (Ritalin). They found that youngsters with ADHD who had a specific genetic alteration (the so-called ADRA2A-1291 C>G polymorphism) responded better with treatment using methylphenidate (Ritalin). (The full reference to this research is: Polanczyk G, Zeni C, Genro JP , et al: Association of the adrenergic alpha 2A receptor gene with methylphenidate improvement of inattentive symptoms in ADHD. Arch Gen Psychiatry 64:218-224, 2007.)

We know that this gene is important in determining how well the brain uses norepinephrine, or adrenaline. When there is an abnormality there, it may contribute to ADHD symptoms. The ADHD symptoms of patients who had this abnormality steadily improved with increasing doses of methylphenidate.

This clinical study just used one medication. Certainly other research needs to be done to see if other medications work as well if not better for patients with this genetic makeup.

What counts is the principle of the thing: linking specific genetic findings with specific effective medications. There will be increasing numbers of such studies as clinical researchers work to make treatment for ADHD and other disorders more specific and more effective.