Wednesday, June 25th, 2008
This is a great video of the importance of failing.
If you don’t ever fail, you can’t succeed…
I think this video is a great reminder for everyone, not just people with ADHD.
Please post your comments and reactions below,
Dr. Kenny
Sunday, June 22nd, 2008
The DSM is the Diagnostic and Statistical Manual of the American Psychiatric Association - and it the manual used to diagnose psychiatric disorders - including ADD and ADHD.
The DSM criteria used to diagnose ADHD were developed with children as the focus. The criteria have been criticized in how poorly they help in the assessment and diagnosis of adult ADHD (or ADD).
Here is an article from the American Journal of Psychiatry which documents this issue in depth.
This article begins by summarizing the history of the diagnosis of ADHD.
It then criticizes the limitations of the diagnostic criteria for adults with ADHD.
One of the examples cited is the age of onset criteria - i.e. having to have symptoms before the age of 7 is often limiting. It is problematic, because it is often hard to establish this early history in an older adult. New research is showing that the age of onset is also too restrictive (this paper cites two new research papers which challenge this criterion).
Another criticism is that the description of impairment is done from the perspective of childhood ADHD and is not appropriate for the impairment that adults with ADHD experience.
Furthermore, the diagnostic threshold (i.e. 6 out of 9 symptoms) doesn’t reflect several lines of research which document that adults with fewer symptoms are still quite impaired from their ADHD.
The DSM-V is due out in 2011. Many researchers are working to improve the DSM criteria for adult ADD/ADHD. This is particulary needed because many doctors are not comfortable with the diagnosis of adult ADHD, and they need to have diagnostic criteria which will help them to diagnose this condition more easily. Also, new research has shown that 4.4% of american adults have ADD/ADHD. So there is a lot of need out there, and ‘new and improved’ DSM criteria are needed.
Please share your thoughts and comments below.
Dr. Kenny
Technorati Tags: Adult ADD, Adult ADHD, DSM, Diagnosis
Wednesday, June 18th, 2008
A press release just came out today - publicizing a report which is available for purchase about the nature of the pharmaceutical market in ADHD. The press release documents that the ADHD market is worth $3.85 billion per year, and will have a compound annual growth rate of 1.2% over the next 10 years. They document that the adult ADHD ‘market’ is largely untapped, and they predict that it will likely be twice as big as the pediatric ADHD market.
I have to say that I always have a mixed response when I read statistics like this.
On the negative side - this type of data makes it seems that the pharmaceutical companies are just trying to make sure that more prescriptions are written, and they see people with ADHD as just consumers of their drug and ‘dollars and cents’. Additionally, these data help to fuel the ‘ADHD nay-sayers’ to talk about how ‘over treated’ and ‘over medicated’ ADHD is. (I can hear them saying - ‘almost $4 billion dollars of drugs sold per year???’).
On the other side - this type of just report documents facts…
It’s been documented that it costs over $1 billion USD to bring a new medicine to market. The fact that there is a profit in the ADHD market - and an opportunity for companies to expand sales in the future - means that there will be more research and thus more new treatments introduced in the coming years.
This is ultimately good for people with ADD or ADHD.
New treatment options coming out in the future is a good thing…
In summary - although this type of statistic can be shocking to some - I believe it is important to know that it means that the pharma companies will be willing to invest new monies into ADHD research and treatments.
The danger here is how this statistic can be sensationalized, and how people can get too fixed on the ‘medication only’ treatment of ADHD.
Please remember that the best approach to treatment of ADHD is multimodal - meaning including medication with non-medication approaches (including behavioral therapy, parenting supports, academic/occupational support, coaching, alternative approaches, etc.).
To read a special report that I wrote about ADHD Medication, please visit: Medication Mastery.
Please share your thoughts in the comments section below.
Dr. Kenny
Monday, June 16th, 2008
Thirty percent of children with AD/ADHD cannot tolerate taking stimulant medications.
For these individuals, the recent news that Shire is one step closer to gaining FDA approval for its time-released non-stimulant INTUNIV is welcome news.
Intuniv provides a 24-hour evenly released dose of the medication guanfacine. Specifically, guanfacine improves the symptom of the inability to concentrate in children with ADD/ADHD.
When given in conjunction with stimulants, it may also help reduce the aggression and the insomnia normally associated with the use of these drugs.
In fact, some physicians already prescribe it – in an immediate release version and under various brands – to their patients with ADD/ADHD along with other medications. The most common brand used is Tenex. This medication, however, appears not to be very effective at alleviating either the attention deficit or the distractibility seen in children with ADD/ADHD.
Two advantages of INTUNIV
Manufactured and marketed as INTUNIV, though, this form of the medication would hold two distinct advantages over what is currently being used. First, it would be approved specifically for the treatment of ADD/ADHD. And secondly – and most importantly to those whose concentration is low – it would relieve the unevenness produced by the immediate-release version of guanfacine.
Guanfacine works well in improving concentration, but it only lasts several hours, and once the medication wears off attentiveness wanes again.
Recent clinical trials conducted as part of the FDA approval process show that INTUNIV is extremely effective at boosting concentration levels consistently for a 24-hour period
The data the FDA scrutinized included the pooled analysis of results from two double-blind trials. Both of these studies used the teacher based ADHD Rating scale as the criteria for improvement.
One group of children received INTUNIV for the other group received a placebo which contained no medication.
All groups which received the medication scored significantly better in the rating scale than those who received the placebo.
The studies also examined the length of time the medication was effective for these children. Assessments were made at 12, 14 and 24 hour periods following the administration of this drug. Again the data showed significant improvement in the concentration of the children at each of these points in time.
Mild and moderate side effects of INTUNIV
Between 75 and 80 percent of the children, did display mild adverse side effects while taking INTUNIV, most of which appeared within the first two weeks and eventually tapered off. These seemed to be dose-related and included: upper abdominal pain, constipation, dizziness, hypotension, sedation, dry mouth, and drowsiness.
The most common of these side effects were related to sedation.
The medical community has been examining guanfacine for its effectiveness since 2001. That year a study appeared in the American Journal of Psychiatry showing that guanfacine to be a safe and effective treatment for children with ADHD and those who suffer with tic disorders.
The medication, according to the journal article, produced a mean improvement of 37 percent in the total score on teacher-rated ADHD Rating Scale following eight weeks of treatment. This was compared to the eight percent improved for those who received the placebo.
INTUNIV is not a controlled substance — as stimulants are — and does not appear at this time to carry any risk for either potential for abuse or dependence.
The FDA has issued an “approval letter” for INTUNIV, which means that it is prepared to approve the new drug application as soon as certain conditions are met, such as any requests for additional information.
How guanfacine works
Guanfacine works, according to Shire, by acting indirectly on the prefrontal cortex of the brain. Located directly at the very front of the brain and directly below the forehead, the prefrontal cortex controls what are known as the executive functions. This includes the resolution of conflicting thoughts, the choices involved in “right or wrong” and “good and bad” decisions, as well as the prediction of future events.
This section of the brain also governs social control that is it is the area used when we suppress or emotional urges.
Guanfacine is a selective alpha-2A-agonist medication.
Admittedly, the treatment of ADD/ADHD is a highly individualized challenge. Discovering the most effective combination the proper medications and other forms of therapy may mean attempting to use several medications in various combinations as well as varying doses. What is appropriate for one child or adult, may not be either appropriate or effective for another.
Nearly 8 percent of all school-aged children have been diagnosed with ADD/ADHD, according to the U.S. Centers for Disease Control and Prevention. While not normally thought of as a disorder affecting adults, some 4.4 percent of all adults, ages 18 to 44 are affected.
The major characteristic of ADD/ADHD is an inattention or hyperactivity-impulsivity that exceeds those normally observed in most individuals. Official diagnosis of this disorder can not be made until the symptoms have been observed for at least six months.
References:
Pro-drug gets attention,
http://www.sciam.com/article.cfm?id=pro-drug-gets-attention, accessed 11 Jun08
Guanfacine, http://www.depression-guide.com/guanfacine.htm, accessed, 7 Jun 08
Intuniv reduces ADHD symptoms, http://www.realmentalhealth.com/adhd/adhd_toc.asp, accessed 6 Jun 08
Shire Investigational Nonstimulant INTUNIV Showed Significant Efficacy In Reducing ADHD Symptoms, http://www.medicalnewstoday.com/articles/106801.php, accessed 10 Jun 08.
What is prefrontal cortex?, http://www.wisegeek.com/what-is-the-prefrontal-cortex.htm, accessed, 11 June 08
Larry Scahill, M.S.N., Ph.D., Phillip B. Chappell, M.D., Young S. Kim, M.D., Robert T. Schultz, Ph.D., Lily Katsovich, M.S., Elizabeth Shepherd, M.A., Amy F.T. Arnsten, Ph.D., Donald J. Cohen, M.D., and James F. Leckman, M.D. A Placebo-Controlled Study of Guanfacine in the Treatment of Children With Tic Disorders and Attention Deficit Hyperactivity Disorder, http://ajp.psychiatryonline.org/cgi/content/abstract/158/7/1067, accessed 11Jun08
Technorati Tags: Intuniv, Shire, ADHD, ADD, ADHD Medication, ADD Medication
Friday, June 13th, 2008
This past week, a study was released in the prestigious Journal of the American Medical Association, which documented that St. John’s Wort has no benefit in ADHD or ADD.
You can access the original article here.
While I’m glad to see a natural treatment receive such rigorous research, and publication in such a leading journal, the question is: who cares?
The main concern that I have with this study is: Who even thought that St. John’s Wort worked for ADHD?
In the introduction of the research paper, the authors assert that St. John’s Wort is one of the top 3 botanical/herbal remedies used for ADHD. This statistic is referenced from a survey published in 2003 (you can read the abstract of this study here). There is a problem with taking this as a conclusion from this survey. This study surveyed pediatric patients treated for depression and ADHD, and reported on the most common herbal treatments used in the past year. The top 3 herbal preparations used included: gingko biloba, echinacea, and St. John’s Wort. However, the authors did not correlate the herbal medicine’s use with the condition - in other words, if an ADHD patient had taken echinacea, this study does not tell us that he/she took it for ADHD or for the common cold. In other words, the St. John’s Wort could have been taken for the depression (which was also tracked in the study) and not for the ADHD. Furthermore, there were very few patients who had taken herbal preparations in the past year (i.e. 18), bringing into question if this study was representative of the wider use of herbal preparations in ADHD.
As a physician in the field of ADHD - talking to my patients who try alternatives, and reading about it as well - I have never heard of using St. John’s Wort for ADHD. Referencing the book:ADHD Alternatives: A Natural Approach To Treating ADHD, By: Aviva Romm and Tracy Romm - they document that St. John’s Wort is effective for depression, but they do not even consider it a treatment for ADHD.
The American Herbal Products Association (AHPA) responded to the study, documenting two main concerns:
Click here to read the AHPA’s response to this study.
In summary, I like seeing a major clinical trial on an alternative treatment for ADHD. I believe that we need a lot more of those. In future, my hope is that the researchers will choose compounds which are both widely used and considered to be effective before running the whole trial.
Please share your comments below - and if you do have any experience with St. John’s Wort - or more importantly - an herbal treatment which actually worked for ADHD - please share it below (in the comments).
All the best,
Dr. Kenny
p.s. to read more on St. John’s Wort - here is the wikipedia article.
Technorati Tags: St. John’s Wort, ADHD, Herbal Medicine, ADD
Friday, June 6th, 2008
We know that medications for ADD or ADHD help to improve concentration in those who have ADD and ADHD.
Some people - even if they don’t have the condition, take these medications to help to improve their focus and productivity (so called: ‘brain steroids’).
Each year, the press comes out with one or two stories (usually during exam time) talking about college students taking adderall to get through exams.
I must admit that the reason that I watched an episode of ‘Desperate Housewives’, was because a patient told me that one of the mothers on the show took her kid’s ritalin (I think that was in the first season).
Wired magazine did a story on using ‘brain enhancing medications’ for people who don’t even have ADD or ADHD.
It is surprising to hear of how many people use these medications to help with focusing and being productive. (Many of these people are scientists and researchers!)
In the first part of the article, the authors discuss the issue.
In the second part, they share some of the medication ‘regimens’ that people are using. They are generally a combination of ADHD medications like: Concerta, Ritalin, Focalin, Adderall, as well as Modafinil (provigil).
This is a concerning development - and one which can be quite dangerous.
In the past two years, the FDA has issued several warnings about ADHD medications including risks of cardiovascular concerns, psychiatric side effects- including hallucinations, agitation and suicidal ideas.
Most of the people taking these medications as performance enhancers - are taking these medications without proper medical supervision.
My suggestion: if you need a pick me up - have a large Starbucks (or even a Red Bull), but stay away from ADHD medications unless you’ve been properly diagnosed with ADHD and you are being medically monitored.
Please share your thoughts on this topic.
Since I know that the vast majority of my blog readers have ADD/ADHD or support a loved one with ADD/ADHD, please share your experiences with this topic - maybe it’s friends trying to get some of your pills!
All the best,
Dr. Kenny
Technorati Tags: ADHD Medication, Adderall, Vyvanse, Concerta