ADHD

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Study: A Simple, Cheap Way To Help Low-Income Kids With ADHD

Boston Medical Center (Wikimedia Commons)

Boston Medical Center (Wikimedia Commons)

Say you’re a pediatrician whose 8-year-old patient is showing symptoms of Attention Deficit Hyperactivity Disorder. That’s not unusual, up to 12 percent of American kids are diagnosed with it.

But you know that in general, ADHD treatment tends not to work as well in poor kids, like your patient, as it does in their better-off peers. And you also happen to know that the symptoms began two months after the patient’s father was incarcerated. It might be ADHD, or it might just be horrible stress. What do you do?

This is the kind of challenge that routinely faces pediatricians at Boston Medical Center, where most of their patients comes from the inner city, says Dr. Michael Silverstein, chief of the hospital’s division of General Academic Pediatrics.

In a study of 156 young patients just out in the journal Pediatrics, Silverstein and colleagues report some success with an experimental intervention they designed to address such challenging cases.

They found that with a relatively modest investment — about a week of training for a care manager that the patients’ families interact with anyway — they could “move the needle” on ADHD symptoms and social skills, he says.

I asked him to elaborate. First, the background:

General pediatricians tend to be fully equipped to treat straightforward cases of ADHD, Dr. Silverstein says, but for tougher cases like the one described above, and many among BMC’s population of vulnerable kids, they need specialists to address the more vexing issues. One proven model of providing that expertise is called “collaborative care.”

Providing care for low-income kids through mechanisms that address the health of both generations, parents and children.

The pediatrician is “driving the boat,” he says, but the specialists “essentially provide what we call ‘decision support.’ They say, ‘For someone like who you’re describing to me, I would try something like this.’ They give the rules of the road to the primary care doc, but the primary care doc drives.

And because it’s so hard to get busy people into the same room at the same time, the communication between the primary care doctor and the specialist is mediated through a ‘care manager’ intermediary.” (Ideally, a child psychiatrist would be right down the hallway, but that’s “pie in the sky” for under-resourced hospitals like the BMC, he notes.)

Research has shown that collaborative care works well, “but at BMC and places like it, this way of delivering care is probably necessary but not sufficient.” The reason? “A lot of kids with symptoms of ADHD don’t get better even when treated optimally. Why is that? You give them access to proper medication, the diagnosis is made properly, yet they don’t get better. And we homed in on three reasons that kids with ADHD symptoms may not get better that really were relevant to our population:

• The first is that we know that parents of children with ADHD have a disproportionate burden of mental illness themselves. You could imagine a child’s improvement trajectory might not be as good if his mother is depressed.

• Also, in general we see a guardedness about going to the doctor for behavioral problems — that’s not in everyone’s cultural frame of reference. So the idea of medication for inattention might not be where everyone is at. These are potentially stigmatizing conditions, so lots of times people recommend a course of action — medication or something else — but the families aren’t quite there.

• And the third reason is that we know that for certain children with ADHD, behavioral therapies work really well in addition to medication, but our families tend not to have access to those.

So we developed an intervention that was hung on the structure of collaborative care, where the care managers who serve as intermediaries between specialists and generalists are trained to address those three things. Continue reading

Son, Mom, Psychiatrists Reflect On Finding Your Own Way With ADHD

Peter and Ellen Braaten (courtesy)

Peter and Ellen Braaten (courtesy)

Peter Braaten, now 20, still retains an indelible third-grade memory of being unable — simply unable — to stay seated in a reading circle. “And I just started walking around, because that’s what made me feel okay at the time. And the teacher said, ‘No, sit down, sit down.’ And I basically just couldn’t sit there, because I felt unsettled at the time. And I just couldn’t read, I wasn’t getting into it, so I kept pacing, kept pacing…”

Ellen Braaten, PhD, Peter’s mother and the chief child neuropsychologist at Massachusetts General Hospital, is an expert on Attention Deficit Hyperactivity Disorder, but that doesn’t mean it was easy to cope with it in her son. She recalls the “humbling” experience of going to IEP — Individual Education Program — meetings with school staff as a parent rather than an expert: “Peter has seen me in IEP meetings where I’ve had to yell at them…”

They share their experiences in the podcast above with Dr. Gene Beresin, director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital, and the Center’s associate director, Dr. Steve Schlozman, who treated Peter. One central message from the podcast, Dr. Beresin says: “As with every psychological problem, we all have to find out what works for us. Because what works for one person is not necessarily what works for all. There are no magic bullets. No platitudes. No simplistic answers.” But Peter is now earning all A’s in community college, helped in part by academic coaching and regular exercise. The post below supplements the podcast above.

By Peter Braaten, Ellen Braaten and Gene Beresin
Guest contributors

Peter:

One of the most difficult things for me about being diagnosed with ADHD (especially at such an early age) was understanding this as a helpful push in the right direction. It was very hard for me to appreciate what a “diagnosis” means. Does it just mean a guide for treatment? Well, that might be fine for a doctor, but in my experience it is not good guide for others. In some ways, it significantly influences the ways others view you. Some understand what it means, while others don’t — some adults around me did not even believe it exists or just seemed to disregard it.

‘I have gotten in trouble more times than days I’ve lived on this planet.’

Context is what I find difficult with this diagnosis. It is really something that affects every aspect of your life, which is why it is so hard for other people (teachers, parents, etc.) to understand what it means for an individual to have ADHD. A diagnosis in itself does not inform others around you what tasks are easy or difficult. It does not differentiate effort levels. So for me, some activities have been pretty easy to accomplish, while others are very hard, if not impossible, without some kind of coaching. And the amount of energy that it takes me to do different projects is highly variable. But only I know this, and a teacher, parent, friend might not know what I am going through — they are not living my life.

We live in a world where results are everything. Too often I have been told to just ‘try harder.’ Well, ‘trying hard’ just doesn’t cut it anymore – it is not so simple if you have ADHD, and especially if you have problems with organization in some tasks. I have gotten in trouble more times than days I’ve lived on this planet because I complete 85% of an assignment, task, or any kind of job. And then when I just cannot do the rest, others around get angry, frustrated, or don’t understand. And worse, I get really down on myself! Continue reading

Ritalin Nation: ADHD Drugs Not Studied Enough For Rare Or Late Risks

The ADHD drug Ritalin (Wikimedia Commons)

The ADHD drug Ritalin (Wikimedia Commons)

If we’re going to keep putting millions of American children on ADHD drugs, we really need to study the meds longer and better to pick up rare and late-onset side effects.

That’s my takeaway from a study just out from Boston Children’s Hospital. It found that in many cases, ADHD drugs had not been studied for long enough — really, can a clinical trial of a few weeks be long enough for a drug that’s typically taken for many years? — or in enough people. And drug company promises to keep studying the drugs’ effects even after the FDA approves them have often fallen by the wayside.

From the press release:

Over the last 60 years, the U.S. Food and Drug Administration (FDA) approved 20 medications for attention deficit/hyperactivity disorder (ADHD) based on clinical trials that were not designed to study their long-term efficacy and safety or to detect rare adverse events, researchers at Boston Children’s Hospital report today in PLOS ONE. The study highlights gaps in how the long-term safety of drugs intended for chronic use in children is assessed as part of the FDA approval process.

“This study doesn’t address whether ADHD drugs are safe, though their safety has since been established through years of clinical experience,” says study senior author Kenneth Mandl, MD, MPH, Boston Children’s chair in biomedical informatics and population health and director of the Intelligent Health Laboratory in Boston Children’s Informatics Program. “Instead, we point to the need for an agenda emphasizing improved assessment of rare adverse events and long-term safety through post-marketing trials, comparative effectiveness trials and more active FDA enforcement.”

The numbers: Continue reading

Breastfeeding May Lower Risk Of ADHD, Study Finds

To the long list of health woes breastfeeding might protect your child against, add this one: attention deficit hyperactivity disorder.

vintagebreastfeedingResearchers from Israel report that breastfed children may have a lower risk of developing ADHD, one of the most common neuro-behavioral disorders of childhood.

UPI covered the study, published online earlier this year and just out in the journal Breastfeeding Medicine:

Dr. Aviva Mimouni-Bloch of Tel Aviv University’s Sackler Faculty of Medicine and Loewenstein Hospital and colleagues completed a retrospective study on the breastfeeding habits of parents of three groups of children: a group that had been diagnosed with ADHD; siblings of those diagnosed with ADHD; and a control group of children without ADHD and lacking any genetic ties.

The study…found a clear link between rates of breastfeeding and the likelihood of developing ADHD, even when typical risk factors were taken into consideration.

Children who were bottle-fed at 3 months were found to be three times more likely to have ADHD than those who were breastfed during the same period, the study said. Continue reading

It’s The Carbs: ADHD In Childhood Linked To Adult Obesity, Study Finds

(Tobyotter/flickr)

(Tobyotter/flickr)

Ned Hallowell is a Sudbury, Mass. psychiatrist and expert on ADHD who suffers from the condition himself. Today, he spoke with NPR about a new study in the journal Pediatrics that found boys with ADHD are more likely to become obese men compared to children without the condition. Hallowell is quoted saying the results seem reasonable:

“It makes sense, because they’re self-medicating with carbohydrates. Carbs do the same thing that stimulant medications do — promote dopamine,” says Hallowell, who wasn’t involved in the latest study. “So you get the gallon of ice cream at midnight.”

With impulse control often a problem for people suffering from the disorder, Hallowell also says that nutrition should be part of an ADHD treatment plan. Continue reading

10 Facts You May Not Know About ADHD

By Karen Weintraub
Guest Contributor

When you think about ADHD, what do you imagine? If you’re like most people, it’s probably a stereotypical image of a young boy bouncing off the walls, buzzing with pent-up, unfocused energy.

But many people with ADHD aren’t hyperactive at all, and by the time they reach adulthood, most hyperactive people have calmed down — at least on the outside. This helps explain why Attention Deficit Hyperactivity Disorder, which used to be considered a childhood condition, is now being diagnosed in adults as well.
adhd

There are some who dismiss the condition as massively over-diagnosed, perhaps as a ploy by drug companies to boost business. And maybe there’s some truth to that on the margins. Not everyone who’s got ideas racing through their head should be medicated. (Just ask most of the faculty at MIT.)

But there are large numbers of people — studies suggest it’s as many as 4 percent of adults – who are profoundly affected by the symptoms of ADHD. Many can’t hold a job or stick with a relationship. They’re chronically late or forgetful. They jump into jobs and purchases and relationships without thinking them through, only to regret their impulsive actions later. They get stuck in self-destructive patterns, fall prey to addiction and depression. And they can’t figure out why they struggle so much more than everyone else.

For this population, a diagnosis can be a huge relief, explaining why they’ve always felt out of step with the world.

Here are a few other things you might not have known about ADHD, drawn from a new book I co-write, Fast Minds, How to Thrive if You Have ADHD (Or Think You Might) published by Berkley Books:

Medication Can’t Fix ADHD
Treating ADHD in adults with medication can be helpful – and it’s often the first suggestion a diagnosing doctor will make. But it’s not enough. Adults with ADHD often need help getting and staying organized, even with their own priorities in life. They may need help at critical moments, making a constructive choice, rather than a destructive one. And they need emotional support to counteract all the negative messages they’ve received all their lives when their actions didn’t meet other people’s expectations.

Not Everyone Who’s High Energy Has ADHD
Our images of ADHD come from celebrities who talk about having it, like singer Adam Levine or actor and game show host Howie Mandel. But many people with the condition struggle to get up off the couch. They were the quiet ones in class who always seemed like they were in their own world. As adults, they may be unsure of what to do, or want to do so many things that they paralyze themselves. On the other hand, there are plenty of people who have some of the traits of ADHD without being impaired by the condition. Some of the same organizational and self-control strategies may help.

People With ADHD Don’t Have Trouble Paying Attention Continue reading

How Doctors Think About ADHD Medication Abuse

By Karen Weintraub
Guest Contributor

Like any other medication, drugs used to treat Attention Deficit Hyperactivity Disorder can be abused.

A story in last Sunday’s New York Times showed the potentially tragic consequences of such abuse, and revealed some of the systemic factors that enabled it.

There is no blood test to diagnose ADHD – no biological marker that says “yes” you have the condition or “no” you don’t. Accurate diagnosis relies on the sophistication and experience of the doctor and the honesty of the patient.

(Adam Crowe/flickr)

(Adam Crowe/flickr)

The New York Times piece suggested that one or both of these factors broke down in the case of Richard Fee, a college graduate who committed suicide at age 24, two weeks after his last prescription for the stimulant Adderall expired.

Drugs like Adderall are far more available now than they used to be, because awareness of ADHD and prescriptions have increased markedly over the last decade, particularly among adults.

Most people tend to see ADHD as a condition of childhood. Research suggests that 5-10 percent of children meet the criteria for ADHD and are impaired by it, while roughly 4 percent of adults do.

Although there has long been discussion about whether ADHD medications are overused in children, this story raised concerns about the drugs in early adulthood, when drug abuse is most common. “We’ve got a lot more drugs out there in that age population,” said Dr. Glen Elliott, chief psychiatrist and medical director at the Children’s Health Council in Palo Alto. “The need to be more alert to possible diversion and misuse and abuse in this population has certainly increased.” Continue reading

ADHD: Girls Get It, Too

Although ADHD is generally associated with males, females have the condition, too. Celebrity Paris Hilton said in a 2007 interview that she has struggled with ADHD since she was 12. (Chesi-Fotos CC/flickr)

By Karen Weintraub
Guest contributor

The stereotypical boy with Attention Deficit Hyperactivity Disorder bounces off the wall of his classroom, unable to sit still or pay attention to lessons. Boys are three times more likely to be diagnosed with ADHD than girls, but a new study suggests that when girls do have the condition, they are likely to have serious challenges.

Girls diagnosed with ADHD in childhood were more likely to attempt suicide, cutting and other self-harming behaviors as teenagers than those without the condition, according to the study, by Stephen P. Hinshaw, of the University of California, Berkeley, among others.

It is well established that people diagnosed with ADHD are also more likely than others to have other conditions, like depression, bipolar and eating disorders. It’s as if their brains are more vulnerable to all sorts of hits, not just ADHD. But Hinshaw said he’s particularly worried about girls.

It’s not clear whether the girls who are diagnosed with ADHD have more problems than boys with the condition, or whether girls with milder forms of ADHD are just missed by clinicians, because they don’t fit the stereotype. Or, perhaps, the trauma of growing up as a girl with ADHD scars these girls so much that they resort to self-harm, Hinshaw said.

The old assumption that children will grow out of ADHD is wrong, with roughly 60 percent continuing to have symptoms into adulthood, research shows. Continue reading

Deep Murk On Cause Of ADHD Drug Shortage

When I wrote about the rising shortage of ADHD drugs earlier this month, I felt like a failure for my inability to offer a clear explanation for what lies behind it. I ran into a sort of hall of mirrors, with conflicting accounts from federal officials and drug companies, some of it frustratingly off the record — and I threw up my hands, hoping some more investigative type with more time would ferret out the truth.

So I’m a little comforted that in his excellent report today for NPR on the national ADHD drug shortage, Dick Knox, a veteran health and science reporter whom I respect maximally, seems to have run into the same thing. He says that the ADHD drug Adderall has become hard to get in recent months “for reasons that are unclear.”

And in the Web version of his story, he writes, near the end, “For one version of what really may be going on behind the scenes to cause (or exacerbate) the shortages – or market distortions, as the DEA would have it – read this.”

“This” is a long and fascinating piece on “the fix,” a Website on addiction and recovery. It has “The Great American Adderall Drought” in the headline, and in the sub-head, “Naturally, it’s all about Big Pharma profits.”

Please forgive my prudishness, but I’m going to delete a profane gerund in this quote: Continue reading

Voices: The Hunt For Elusive ADHD Drugs

Some attention deficit disorder drugs are running short around the country, and Massachusetts is no exception. In our report on the shortage and its possible causes, a leading ADHD expert, Dr. Edward Hallowell, says that the recent deficit of the drug Adderall “seems crazy.” He can prescribe substitutes, but otherwise, he doesn’t know what to tell his patients other than, “I guess, ‘Go shopping.’

Around the state, people are indeed going shopping — or perhaps “hunting” is a better word for the quest that many must undertake for the stimulants prescribed to offset Attention Deficit Hyperactivity Disorder.

Some need the medications for themselves, some for their children. Our initial post describes the oddly patchy shortages that one shopper encountered when calling around to various pharmacies in Brookline and Newton. In search of the bigger picture, I turned to Lisa Lambert, executive director of the Parent/Professional Advocacy League, which advocates for children with mental illness. She could teach Facebook a thing or two about social networking, and she kindly sent out our query to listservs run by Mass Family Voices and MassPAC. Nearly a dozen responses immediately rolled in from people struggling to find ADHD medications. Here’s a sampling:

From a Mansfield father of two daughters with attention deficit disorders:
“Just recently, I was getting the prescription filled for one of my daughters, and the doctor had written the usual prescription plus one that was faster-acting, and CVS didn’t have that one in stock — they’ve been backlogged for quite a while.
I pulled up to the drive-through window and the lady told me that for that particular Adderall, they were on back-order; they didn’t have any and they’re finding it’s universal, I probably wouldn’t find it at another drugstore either. I drove away thinking, ‘My God, why would it be a universal drop in that availability?’ There
is an incredible demand for this stuff. How, or in what way, or if at all that plays a role in the lack of its availability I don’t know.”

[Note: His experience jibes with the FDA list of drug shortages, which shows the current crunch largely in immediate-release stimulants rather than longer-acting ones.]

From a mother in Bridgewater, whose daughter takes a 40-milligram dose of long-acting Ritalin — no supply problems with that one — and then in the afternoon, a 20-milligram dose of immediate-release Ritalin. Continue reading