Tuesday, July 29, 2014

What's it Really Like to have ADD/ADHD?


What's it Really Like to have ADD/ADHD?
OK, now I've read just one-too-many media stories about ADD/ADHD that simplistically say it's inattentiveness, hyperactivity and impulsivity.  OMG people!  It is much more than that!  No wonder ADD/ADHD has an image-problem and about one-third of the world thinks we're just a bunch of wimps and whiners.  Let's get real.  Here's what it is REALLY like ……
*Often mentally and/or emotionally overwhelmed
*"Body Clock" is out of sync (different sleep pattern)
*Exceedingly difficult to wait in many circumstances
*Frequently feel "not OK" mentally; feel “different”/"odd"
*Frequent “I don’t want to” sensation, and can’t explain it!
*Others frequently react - angry, avoid, annoyed, frustrated
*Mind "wander off", "tune-out", frequently and involuntarily
*Poor emotional control in frustrating or exciting situations
*Distorted sense of time, passage of time, and of the future
*Frequently lose, misplace or forget many day-to-day things
*Real fatigue in response to frustrating/distasteful situations
*The harder we try, the worse it gets (brain activity decreases)
*Sloppy and disorganized, or struggle intensely to be organized
*Great difficulty paying attention to uninteresting/difficult tasks
*Intense difficulty facing the consequences (self-consciousness)
*Often say/do things impulsively, automatically, without thinking
*Involuntary physical and/or mental restlessness: ongoing or off/on
*Average or above-average IQ + inconsistent symptoms = severely challenges others efforts at understanding ADHD
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*Worst of all, many believe the ADHD person purposefully, willfully, and knowingly does the above things
*So, they believe the ADHD person makes a "choice" to do these things
*So, they treat the ADHD person accordingly!

(Note: Not All ADHD individuals have All these problems.  However, most ADHD people experience a majority of them.)

Saturday, May 03, 2014

No Evidence That Stimulant Medication for ADHD Influences Lifetime Risk of Substance Use or Dependence

Review: No Evidence That Stimulant Medication for ADHD Influences Lifetime Risk of Substance Use or Dependence

Alison Poulton

Evid Based Ment Health. 2014;17(1) 

Abstract

Humphreys KL, Eng T, Lee SS. Stimulant medication and substance use outcomes: a meta-analysis. JAMA Psychiatry 2013; 70:740–9.

Question

Does exposure to stimulant medication for attention deficit hyperactivity disorder (ADHD) have an effect on the lifetime risk of substance use or dependence?

Outcomes

Lifetime substance use or dependence (alcohol, cocaine, marijuana, nicotine and illicit non-specific drug). Method of assessing substance use/dependence is not reported for included studies.

Methods

Design

Systematic review and meta-analysis.

Data Sources

PubMed search for key words related to ADHD and substance use, supplemented by a hand search of reference lists of relevant articles, listservs of research organisations and contact with authors who have published longitudinal studies of children with and without ADHD; study inclusion dates January 1980 to February 2012.

Study Selection and Analysis

Longitudinal studies in children with ADHD where pharmacological treatment preceded the measurement of substance use. ORs were calculated for the risk of substance use/dependence among children with ADHD treated with stimulant medication compared with those not treated. Results were pooled using a random-effects model, and heterogeneity was assessed using the Cochran Q test. Publication bias was assessed using the Egger and Begg tests. Additional analyses examined whether the association between stimulant treatment and substance use/dependence was moderated by demographic and methodological factors of: age at follow-up, sex, race, age at initial ADHD assessment, percentage of participants in the medicated group, study population source, diagnostic and statistical manual of mental disorders version used to diagnose ADHD, and length of follow-up.

Main Results

Fifteen longitudinal studies (n=2565) were included. Pharmacological treatment for ADHD, typically methylphenidate, did not influence the risk of later substance use or dependence. Pharmacological treatment did not influence the risk of alcohol use (OR 0.99, 95% CI 0.61 to 1.62, 4 studies), alcohol abuse/dependence (OR 0.80, 95% CI 0.46 to 1.38, 11 studies), cocaine use (OR 2.21, 95% CI 0.87 to 5.65, 3 studies), cocaine abuse/dependence (OR 1.10, 95% CI 0.51 to 2.38, 7 studies), marijuana use (OR 1.01, 95% CI 0.68 to 1.50, 4 studies), marijuana abuse/dependence (OR 0.97, 95% CI 0.59 to 1.59, 9 studies), nicotine use (OR 1.55, 95% CI 0.73 to 3.30, 4 studies), nicotine abuse/dependence (OR 1.34, 95% CI 0.90 to 1.99, 6 studies), non-specific drug use (OR 1.27, 9% CI 0.88 to 1.82, 3 studies) and non-specific drug abuse/dependence (OR 0.85, 95% CI 0.51 to 1.40, 7 studies). No significant publication bias was detected. Moderator analyses found that a higher proportion of children with ADHD receiving pharmacological treatment reduced the risk of alcohol dependence/abuse, whereas longer follow-up was associated with increased risk of alcohol abuse/dependence. A higher proportion of males in the study population increased the risk of non-specific drug abuse/dependence.

Conclusions

Treatment of ADHD with stimulant medication does not predispose towards or protect against later substance use or abuse.

Notes (If Necessary)

One of the included studies had a population of children with a reading disorder rather than ADHD.

Commentary

ADHD has long been recognised as a risk factor for substance abuse and dependence, particularly in association with conduct disorder. Increasing rates of diagnosis and treatment have been paralleled by increasing levels of community concern about whether stimulant medication could increase individual susceptibility to substance use. An earlier meta-analysis by Wilens et al [1] suggested that stimulant medication had a protective effect for subsequent substance use disorder. Although the larger meta-analysis by Humphrey and colleagues did not replicate this result, it still suggests that, on average, stimulant medication appears not to increase the risk of substance use and addiction across a range of substances.

Meta-analyses are useful because they can derive an overall risk based on large cohorts derived from a series of studies. The main drawback is that much detail is lost. This means that significant confounders may not be evaluated and findings can be difficult to interpret. The individual studies were carried out in a range of settings and it was noted that as the size of the treated group declined relative to the untreated group, the proportion of treated individuals meeting the diagnostic criteria for alcohol abuse and dependence increased. Although this could be indicative of subgroups of individuals with ADHD for whom stimulant medication might increase the risk of alcohol abuse, it could also reflect different prescribing practises.

A meta-analysis is limited by the quality of the data reported in the included studies, and importantly, Humphrey and colleagues were unable to control for baseline symptom severity. They could not therefore determine whether those who were treated were more severely affected and should actually have had a higher risk of substance use.

Although reassuring, this study is unlikely to change clinical practise. The need remains for longitudinal studies that extend well into adulthood and report symptom severity as well as the presence of associated diagnoses and important individual and social factors. Once all of these have been controlled for, it is likely that any residual contribution of stimulant medication, whether protective or otherwise, will be small.

References

1.     1. Wilens TE, Faraone SV, Biederman J, et al. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics 2003;111:179–85.

 

Competing interests

None.

Sources of funding

National Institutes of Health.

Evid Based Ment Health. 2014;17(1) © 2014  BMJ Publishing Group Ltd, the British Psychological Society and the Royal College of Psychiatrists

Thursday, April 17, 2014

Misconceptions About ADHD



Misconceptions--

    






*It’s over diagnosed

*It’s only hyperactivity

*It’s the current fad disease

*It’s not that serious a problem!

*It's just an excuse for bad behavior

*It’s an emotional or family problem

*I observed them ... no signs of ADHD

*They're too bright … can’t have ADHD

*It’s just a matter of will-power and motivation

*I think they’re just lazy; unmotivated; irresponsible

*Other people act the same, and they’re not ADHD (?)

*This is how I parent/teach.  They’ll just have to adapt

Wednesday, March 05, 2014

Developmental Stages of ADHD

There are definite phases and changes we ADHD'ers go through in life.  Briefly, here are the main ones:
*Hyperactivity tends to decreases with age
*Often labeled as “immaturity” in kindergarten
*ADHD not always noticeable in early childhood
*ADHD people developmentally 30% behind peers
*70% grow to adulthood with significant symptoms
*Comorbidities show-up mostly between ages 5-10
*Mood, oppositional symptoms worsen in adolescence
*Treatment and intelligence most influence life success
*Behavior and/or learning problems worsen 3rd-4th grades
Mike G.

Wednesday, February 26, 2014

Recent Responses to Web stories on ADHD


"Expert insight on ADHD", by Deborah Smith.   Feb. 7, 2014

Assuming all the comments made by the writer are entirely accurate representations of the noted sources, I have the following comments.

The title of the ABC-TV program, "Kids on Speed", clearly implies a very negative stance toward stimulant medications.  One cannot interpret this in any other way, since those who try to vilify stimulants typically use the word "speed" to heighten the alarm of the public.  This story says the TV program is "neither for nor against medications", but this hardly seems true given the inflammatory title.

A statement is made that the biological explanation for ADHD remain a mystery.  This is only partly true.  A large volume of professional literature exists documenting several biological factors that appear to be involved.  The "mystery" is the lack of conclusive proof as to how these factors are involved.

Another statement is made that the existence of other problems (like ODD or anxiety) lead to misdiagnosis.  This is a very misleading statement.  The most common cause of misdiagnosis (in the USA) is clinicians who do not follow accepted diagnostic guidelines.  The existence of other or co-occurring conditions [does] create diagnostic difficulty.  However, if accepted diagnostic guidelines are followed differential-diagnosis is achievable and accurate. It also should be noted that the vast majority of ADHD has co-occurring condition(s).  This is also true for most mental health conditions.

It is also stated that this TV series attempts to clear-up myths and confusion.  Again, the title alone does not appear to support that goal.  Furthermore, several statements made in this story actually help to perpetuate existing myths about ADHD.

Although I have not viewed the TV series, I have grave doubts about its true intent and impact. 

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"ADHD Does Not Exist" - New Republic  2/14/2014  by  Richard Saul, MD

This was my first read of any of Dr. Saul's publications.  I had hoped he had something really new or even revolutionary to say.  But, alas, he starts with a faulty premise and it mostly goes downhill from there.

He says the core concept of ADHD has remained unchanged since 1937.  This statement is so inaccurate it defies sensibility.  All one need do is study the history of ADHD research and visit websites such as those by Russell Barkley, PhD and Thomas Brown, PhD to get a good sense of how the clinical view of ADHD had changed over time and what the most recent thinking is.

He says we are still approaching ADHD the same way.  This, also, is so dramatically inaccurate that it is astonishing.  The currently accepted diagnostic guidelines for ADHD, if followed, lead to quite accurate outcomes.  There are many treatments that have been developed in the past 10-15 years, both medical and behavioral, that work very well (evidence-based).

Dr. Saul's implication that only surface symptoms are treated and not the root cause is another wholly inaccurate statement.  First, symptomatic-treatment is done with many diseases and disorders, both physiological and neurological.  Second, many current ADHD treatments were developed with an root-cause in mind.

His alarming descriptions of stimulant side-effects (SE's) give the impression of wild scare tactics in light of the fact that all of those SE's are typically the result of treatment mis-management by the prescriber.

His patient case, William, is very revealing.  Dr. Saul is very thorough in his assessment (and consistent with current guidelines), but then he offers another diagnosis, Bipolar Disorder, that has also been attacked as vague, ill-defined and over-used.  He then goes on to try another medication as a first approach.  Sure enough there are SE's (true with nearly any medication).  He makes no comment on the well established fact the Lithium, especially in youth, is generally viewed as highly risky due to hepatic complications.

His final comment, that our definition of ADHD is "outdated and invalid" belies a serious lack of up-to-date-ness on his part.

The most pressing problem today in the realm of ADHD diagnosis and treatment is:  Over 90% of physicians who first see potential ADHD patients do NOT use currently accepted guidelines in diagnosing and treating those patients (AAP sponsored study 2013).

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"The Drugs Don't Work - How Adderall could actually hurt your kids grades"   2/14/2014

Ms. Guilford:

Your story does a great disservice to the general public but especially to families with ADHD students.

You fail to mention that the preponderance of studies over the past 40+ years indicates the opposite:  That properly prescribed and monitored medication improves both the performance as well as the manageability of ADHD students.  Yes, studies to the contrary can be found. 

Two major problems have existed:  (1) Over 90% of physicians who first see most potential ADHD patients do NOT follow accepted guidelines for the diagnosis or treatment of ADHD (AAP sponsored study in 2013), and , (2) Medications do not correct underlying learning difficulties.  Regarding the second point, effective medication does help give the student a more positive, self-affirming educational experience, plus it can give them increased capability to learn and practice better learning and social skills. 

Vilifying medications helps no one. 

More due diligence, please?

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2/21/2014  -  Mind & Matter     by Alison Gopnik

Are Schools Asking to Drug Kids for Better Test Scores?

Alison, unfortunately your story is loaded with half-truths and total inaccuracies.  You do a disservice to the public.

You start with the implication that ADHD is over-diagnosed and primarily treated by "drugging" children.  It's not that these don't happen.  It's that neither are the biggest or root problems.

You appear to confuse the lines between causation and links.  Toxins are a relatively minor "cause" of ADHD-like symptoms.  But the diagnosis in those cases is not ADHD; it's traumatic brain injury (TBI).  Worse parenting does not "cause" ADHD, but does worsen it.  That's a "linked" problem.  Better detection, now that really is linked to the increased diagnosis of ADHD.

Regarding schools - They have used Special Education laws for [many years] to pressure parents to put kids on medications and to re-classify kids so they are excluded from overall academic score calculations.  This is far from "news".  Rates of this have increased simply because several States have now formally sanctioned it.

You also have given misinformation regarding the definition of "disease", and regarding the categories of "disease" vs. "social problem".  The definition that you give for "disease" is overly simplistic, narrow and grossly inaccurate.  ADHD has been solidly established as a neuro-biological disorder based on 40+ years of research.  The more recent research you refer to actually says the neuro-biological roots of ADHD are more complex than previously thought; not that there are "social" "causes".

You appear to vilify ADHD medications.  This helps no one. 

Only near the end of your story do you get at some "real" issues, but then only very briefly.  Behavioral treatments [should] be used first.  Schools [should] attempt to accommodate a wider range of brains (but many have been saying that for years, to little avail).

Here's the biggest and most real problem of all:  Over 90% of physicians who are the first to see most potential ADHD patients do NOT follow accepted guidelines for diagnosis and treatment (AAP sponsored study 2013).

Your story only helps the spread of misinformation.  I had somehow expected more from the WSJ.

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Melissa Healy -  LA Times - Science     Feb. 25, 2014

"The ADHD explosion: A new book explores factors that have fueled it"


Great story, Melissa!  Finally someone has taken a serious look at this phenomenon.  Just a few observations.  

Distinguishing between over-diagnosis vs. mis-diagnosis is extremely important.  Over-diagnosis may imply that some kids with no real problem get the diagnosis.  The more accurate description is "mis- diagnosis", because the vast majority of those kids do have some problem, maybe just not ADHD.

In my experience (40+ years in MH field, 20 specializing in ADHD), most public schools are so chronically under-funded that they are always looking for ways to get more Federal dollars.  NCLB has brought even more pressure to bear on this problem.  So, they simply do what most people do in similar situations, they follow the money.

The link between the timing of NCLB and the CDC surveys, on the one hand, and the increase in ADHD diagnosis on the other is very interesting; and accurate.

ADHD diagnosis is really not quite as "fuzzy" a most people think; even some academicians.  If current guidelines are followed the diagnosis is rather accurate and differential diagnosis no more "fuzzy" than with any other disorder.

I'm glad to see the myth that stimulants improve performance for everyone busted.  Also, glad to see it noted that if monitored properly stimulants have almost no addiction potential for ADHD people; whereas, there is some addiction potential for non-ADHD people.

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The Salem News -  David Selden   Feb. 25, 2014


"Column: Guard against misuse of ADHD medications"


Nice story, David. Following accepted guidelines for diagnosis and treatment of ADHD is essential. Taking medications only according to directions is imperative.

Just a few issues. Adderall [is] in the same class as other amphetamines. However, "speed" is methamphetamine. Not the same as Adderall. They are chemically different. Methamphetamine is almost never used to treat ADHD and when it is this is usually only in research.

Recent research has shown that amphetamines used by Non-ADHD people do NOT enhance their cognitive performance. They create a false sense of enhanced performance. Excessive use/abuse of amphetamines will produce hyperactivity and reduced impulse-control.


Your statement that, "when young people learn to control their thinking and emotions via chemicals..." is misleading.  When people with ADHD take prescribed stimulants that help improve their thinking and emotional control, they have much better life experiences and, thus, have an opportunity to develop and learn their own strategies.