ADHD

[Shikima]

yes this is wrong. the evidence is equivocal at best. patients with ADHD are more likely to have substance use problems, legal troubles, and die in accidents but there is no good evidence that treating ADHD makes any difference to these outcomes (data is mixed at best) though the ADHD moral entrepreneurs use the poorer outcomes to demand more access to treatment.

This then begs the question, is it really ADHD?

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[smalltownpsych]

This then begs the question, is it really ADHD?

Exactly. Since there are multiple etiologies for the symptoms associated with ADHD, there are likely multiple treatments that should be used. Unfortunately many of the causes are environmental so not much we can do about those. So we prescribe and tell ourselves it's better than doing nothing. I feel the same way about many of my outpatient adolescent work. I know it is not very effective and most cases require a much more significant intervention, but that is expensive as hell. So I tell myself that this one hour a week outside the patients environment is better than doing nothing. Hmmm.

 

[sloop]

yes this is wrong. the evidence is equivocal at best. patients with ADHD are more likely to have substance use problems, legal troubles, and die in accidents but there is no good evidence that treating ADHD makes any difference to these outcomes (data is mixed at best) though the ADHD moral entrepreneurs use the poorer outcomes to demand more access to treatment.

Thanks for your reply!

I did a little more research on this topic and I'm unsure why you flatly say this contention is wrong but I definitely see how, as you mention, the evidence is pretty mixed. So far what I've found on this issue includes:

Old NIDA notes detailing animal models (rats, mainly) conducted at MGH and a few other places that suggested that treatment of ADD might decrease the risk of SUD (assuming the people act like rats, of course).
A meta analysis of the landmark MTA study (original results c.1999) stating that treatment of any sort was neither protective nor a risk for later SUD. Admittedly this is probably the most extensive study with the most rigorous and well-detailed methodology of the articles I found.
A smaller clinical trial in Pediatrics around the same time (c.1999) claiming that treatment is protective for SUD.
A 2010 European consensus statement/group review article that said, essentially, that there is no good evidence to suggest that treating patients with ADD with mess increases their risk of addiction and that there is some evidence that it might decrease their rate of addiction.
A random 2003 Brazilian review article detailing evidence for the protective effects of ADD medication regarding substance use.
A 2007 Journal of Clinical Psychiatry article claiming a protective effect.

Is it incorrect or unfair to gather from this that there is virtually no such credible assertion that treating ADD with mess leads to substance abuse, but that there is conflictual evidence with regards to whether treating ADD is protective when it comes to substance abuse?

I just have a hard time not seeing the protective effect hypothesis as possibly or even likely true given the number of studies with different approaches documenting this finding. It also seems to make more intuitive and parsimonious sense than the null hypothesis in describing treated and untreated patients with respect to other social and economic outcomes. Still, it's hard for me to hold this as a strong position having now read the results of the MTA study analyses.

 

[splik]

yes the fact that the evidence is equivocal means that it is wrong for you to be taught that treating ADHD reduces substance use. If you think about this like a scientist then the totality of the evidence is importance for establishing a causal inference between treatment of ADHD and risk of SUDs. The equivocality suggests at best any effect is so small as to be barely discernible or at worst there is no effect because the association between ADHD and SUD is more complicated and we need to understand that. In this way I would consider it highly misleading to tell medical students that treating ADHD reduces outcomes like development of SUDs, criminality etc. Unfortunately many experts will overshoot the evidence and use the rather flimsy rationale "we we know x is associated with why, so we should assume that treatment of x with z will reduce y" is bad science.

To give some other examples - depression is associated with suicide, and SRIs treatment depression, but they do not decrease suicides. Similarly, depression following MI is a risk factor for increased mortality. sertraline has been shown to be an effective intervention for depression in patients following an MI but treatment does not reduce mortality. This suggests the association between depression and suicide or mortality in CAD is more complex than a simple linear relationship. It could be for example that the same factores that lead to depression lead to suicide, rather than depression per se leading to suicide..

Another example would be HIV dementia and viral load. Higher viral loads increase risk of HIV dementia, and it is clear that treatment with cART has reduced the people developing fulminant AIDS dementia complex. At the same time up 50% of people with HIV develop some sort of cognitive impairment, even if they are on cART and have undetectable viral loads. asymptomatic neurocognitive impairment is extremely common in this population and there is clearly more to it than just viral load and CD4 count...

there are many many more examples which is what keeps epidemiologists in a job

 

[sloop]

yes the fact that the evidence is equivocal means that it is wrong for you to be taught that treating ADHD reduces substance use. If you think about this like a scientist then the totality of the evidence is importance for establishing a causal inference between treatment of ADHD and risk of SUDs. The equivocality suggests at best any effect is so small as to be barely discernible or at worst there is no effect because the association between ADHD and SUD is more complicated and we need to understand that. In this way I would consider it highly misleading to tell medical students that treating ADHD reduces outcomes like development of SUDs, criminality etc.

Fair enough. I think I agree with you that my professor misleadingly exaggerated the evidence (knowingly or unknowingly, I'm not sure). In any case he shouldn't have done that.

Unfortunately many experts will overshoot the evidence and use the rather flimsy rationale "we we know x is associated with why, so we should assume that treatment of x with z will reduce y" is bad science.

I will certainly concede that this may be bad science (or, rather, unscientific), but is it really bad philosophy? It seems eminently rational to hold different standards of proof for things based on how well they fit a coherent framework of previously established knowledge. If someone told you that there exists a magical pink unicorn driving a Volkswagen bus in orbit around the sun, your reaction and standard of evidence would be entirely different than if they told you there existed a large bilobed asteroid in orbit around the sun.

Similarly, depending on how well a concept fits our framework of established knowledge, it may be more likely that studies contradicting the concept are simply chance findings or bad studies than it is that the concept is false. If tomorrow there was a strong, well controlled study somehow indicating that evolution is false or that there are actually only 2 dimensions, people would probably rightly dismiss these findings in light of the tremendous evidence burden faced by anyone making a claim that dismantles an intuitive and parsimonious explanatory theory.

I guess I just think that there's a form of scientism in medicine that discounts the rational role of interpretation in the face of epistemic indeterminacy and believes that all hypotheses should be arbitrated as equals in the eyes of science. I disagree with this, though I certainly see the potential for abuse in people claiming things with more certainty than exists and hiding behind parsimony.

 

[keifernny2]

I do have a surprising number of ADHD patients who, upon transfer to me, when I politely order a UDS (all the while explaining that this is part of appropriate monitoring and recommended by the medical licensing board, and not at all an accusation of any type of substance use), reportedly develop immediate anuria. This form of anuria appears to go on for days (especially when I say, "it's ok, just drop by the office tomorrow, no worries!)". This link should be investigated further.

 

[birchswing]

Is ADHD in your experiences still highly correlated with the male sex? And do you notice a correlation with people born in the US vs outside the US?

I have my own pet theories on the prevalence of ADHD in the US, but don't want to bias your experiences by stating it.

 

[clausewitz2]

Fair enough. I think I agree with you that my professor misleadingly exaggerated the evidence (knowingly or unknowingly, I'm not sure). In any case he shouldn't have done that.



I will certainly concede that this may be bad science (or, rather, unscientific), but is it really bad philosophy? It seems eminently rational to hold different standards of proof for things based on how well they fit a coherent framework of previously established knowledge. If someone told you that there exists a magical pink unicorn driving a Volkswagen bus in orbit around the sun, your reaction and standard of evidence would be entirely different than if they told you there existed a large bilobed asteroid in orbit around the sun.

Similarly, depending on how well a concept fits our framework of established knowledge, it may be more likely that studies contradicting the concept are simply chance findings or bad studies than it is that the concept is false. If tomorrow there was a strong, well controlled study somehow indicating that evolution is false or that there are actually only 2 dimensions, people would probably rightly dismiss these findings in light of the tremendous evidence burden faced by anyone making a claim that dismantles an intuitive and parsimonious explanatory theory.

I guess I just think that there's a form of scientism in medicine that discounts the rational role of interpretation in the face of epistemic indeterminacy and believes that all hypotheses should be arbitrated as equals in the eyes of science. I disagree with this, though I certainly see the potential for abuse in people claiming things with more certainty than exists and hiding behind parsimony.

The danger is allowing your personal Bayesian updating function to overweight the priors based on how much a given hypothesis fits with your agenda. If you are an EBM zealot who radically discounts the relevance of theoretical frameworks at least you are serving a relatively pure cause.

However, I definitely am with you in saying Bayesian updating approaches allow you to avoid becoming the next Daryl Bem:
http://news.discovery.com/human/psychology/controversial-esp-study-fails-yet-again-120912.htm

 

[Shikima]

I proscribe to the school of thought from Dr. Peter Venkman in conducting ESP studies.....

 

[sloop]

The danger is allowing your personal Bayesian updating function to overweight the priors based on how much a given hypothesis fits with your agenda. If you are an EBM zealot who radically discounts the relevance of theoretical frameworks at least you are serving a relatively pure cause.

I definitely think this is a fair criticism. I just think that the consequence of the alternative view espoused by EBM purists is entirely useless, decontextualized information. The idea that the data/evidence alone is the only thing that is relevant towards the end of finding truth is really only defensible when reduced entirely to an abstract sense that "the data" are a reflection of real conditions in the experiment and of reality itself. There can be no room for application in the view that all the information to be had from an experiment exists in its data set. The entire idea of applied science (i.e. EBM) is that you are making your best inferences about how a data set can inform previous understanding and change actions.

What this all means is that anyone who really believes in applied science necessarily believes in the relevance of a Bayesian approach already. It's just that people have a choice to make about how they would like this pursuit to go: Entirely crippled but pure, highly dynamic but entirely ungrounded, or something in between.

However, I definitely am with you in saying Bayesian updating approaches allow you to avoid becoming the next Daryl Bem:
http://news.discovery.com/human/psychology/controversial-esp-study-fails-yet-again-120912.htm

That is pretty hilarious.

 

[DD214_DOC]

Interesting thread. I have never seen, "Bayesian" anywhere and I'm still not quite sure what it means, but I think I get it.

I had been accused by supervisors as being a bit, "loose" in my clinical approach. I familiarize myself with EBM but find it too restrictive, and I did not get into this field to be an algorithm monkey. The problem with EBM is that it assumes the information its based upon is factual and accurate. I care less about labels and more about what's actually going on, the symptoms experienced, and the impairment/problems they cause. It's all multifaceted. I tend to be pragmatic and know there is no such thing as, "truth" in psychiatry. By its very nature, the information we are obtaining to base our diagnosis and treatment plans on is inaccurate and always subjective. We receive information that has already been filtered by the patient: things are withheld, overemphasized, minimized, or outright falsified. Our own experiences with intraining psychotherapy taught us this. This filtered information is then filtered again through us and our own biases. The quest for diagnostic accuracy and truth is psychiatry is futile for the most part.

If we wanted to be honest with ourselves, we should be mostly using Unspecified Diagnoses to check the box and putting more effort into our formulation and assessment; an attempt to understand the patient in the context of their environment and relationships and how they all interact.

Funny thing, despite being accused as, "a bit loose", most of my patients improved. Maybe there's something to this thing about understanding our patients instead of merely describing them.

 

[smalltownpsych]

Interesting thread. I have never seen, "Bayesian" anywhere and I'm still not quite sure what it means, but I think I get it.

I had been accused by supervisors as being a bit, "loose" in my clinical approach. I familiarize myself with EBM but find it too restrictive, and I did not get into this field to be an algorithm monkey. The problem with EBM is that it assumes the information its based upon is factual and accurate. I care less about labels and more about what's actually going on, the symptoms experienced, and the impairment/problems they cause. It's all multifaceted. I tend to be pragmatic and know there is no such thing as, "truth" in psychiatry. By its very nature, the information we are obtaining to base our diagnosis and treatment plans on is inaccurate and always subjective. We receive information that has already been filtered by the patient: things are withheld, overemphasized, minimized, or outright falsified. Our own experiences with intraining psychotherapy taught us this. This filtered information is then filtered again through us and our own biases. The quest for diagnostic accuracy and truth is psychiatry is futile for the most part.

If we wanted to be honest with ourselves, we should be mostly using Unspecified Diagnoses to check the box and putting more effort into our formulation and assessment; an attempt to understand the patient in the context of their environment and relationships and how they all interact.

Funny thing, despite being accused as, "a bit loose", most of my patients improved. Maybe there's something to this thing about understanding our patients instead of merely describing them.

Too bad I can't double-like this post.

 

[smalltownpsych]

Is ADHD in your experiences still highly correlated with the male sex? And do you notice a correlation with people born in the US vs outside the US?

I have my own pet theories on the prevalence of ADHD in the US, but don't want to bias your experiences by stating it.

What I recall off the top of my head is that the epidemiological research indicates that boys meet diagnostic criteria at about 2 to 3 times the rate of girls. Boys are more active than girls so this is not surprising. It has also been hypothesized that the increase in ADHD also corresponds with a decrease in male teachers. We also load more homework on kids and have less free play time than we did a few decades ago. Also, anxiety continues to increase in our society thanks to a 24 hour news cycle and this anxiety can mimic ADHD or lead to less free play time. We also have a societal dynamic of an increase in the medicalizing of behavioral issues. We also have a large group of people who state that they need medications to function and it seems like those meds tend to be benzos and stimulants and opiates. They are often too disabled by "my mental illness" to work either.

 

[DD214_DOC]

I would describe ADHD as a, "Syndrome", with a lot of potential etiologies and symptomatic overlap that we don't really understand. I think the push to conceptualize ADHD (and I mean actual ADHD, whatever that may be) as a neurodevelopmental problem is a push in the right direction, and the more recent research into neural networks and developmental changes in the in-network and inter-network connections is both very exciting and supportive of this. It's also one of the new conceptual models with objective information that is fairly consistent across different studies; ergo, its findings are very reproducible.

Other things that probably get misdiagnosed as ADHD are the usual anxiety/mood things, but also lesser known sleep problems like idiotpathic hypersomnolence and the like.

 

[Shikima]

ADHD is a diagnosis of exclusion.

 

[DD214_DOC]

ADHD is a diagnosis of exclusion.

Somewhat related, what's a good source to learn/understand more about pediatric sleep? Such as, what's normal for developmental age/phase, what's abnormal, and what to do about it. I have a very basic idea but this is a gap I would like to fill. Any good books, textbooks, articles, etc?

 

[Shikima]

Somewhat related, what's a good source to learn/understand more about pediatric sleep? Such as, what's normal for developmental age/phase, what's abnormal, and what to do about it. I have a very basic idea but this is a gap I would like to fill. Any good books, textbooks, articles, etc?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2898839/

Good article to begin with.

 

[Shikima]

Here's an interesting thought - Anxiety tx with psychostimulants. Understanding the nature in how amphetamines work both on the networks and the brain chemicals, it does make sense. Anecdotally I've seen this. Really goes to looking at what are the target symptoms and the expectations in treatment. Be more than just the candy man/woman.
http://online.liebertpub.com/doi/full/10.1089/cap.2015.0075

 

[FlowRate]

Joining the discussion late, I'm curious what the issue is, exactly. Don't want to do a bunch of ADHD evals? Dislike the patient population? Rather avoid giving meds to people who don't need them, but feel stuck doing so anyway? Then I feel like we've been circling around the discussion of whether it is more helpful but less ethical to assume a patient is lying. Anyone want to clarify for me what the sticking point is for them with this issue?

 

[st2205]

We also have a large group of people who state that they need medications to function and it seems like those meds tend to be benzos and stimulants and opiates. They are often too disabled by "my mental illness" to work either.

But they can't function without them. The problem is they can't function with them, either. But that's beside the point, in their view.

 

[DD214_DOC]

Here's an interesting thought - Anxiety tx with psychostimulants. Understanding the nature in how amphetamines work both on the networks and the brain chemicals, it does make sense. Anecdotally I've seen this. Really goes to looking at what are the target symptoms and the expectations in treatment. Be more than just the candy man/woman.
http://online.liebertpub.com/doi/full/10.1089/cap.2015.0075

I will take a look at both links when time permits later today (hopefully). To add on to this, anxiety/depressed mood can result as a direct consequence of the impairments associated with untreated ADHD symptoms, and treating ADHD which subsequently improves function can relieve the associated anxiety. Slightly confuses things more to a degree, but this is also a potential confounding factor. I try to tease this out, obviously, by characterizing the anxiety; if it surrounds school performance, tests, homework, uncertainty in tolerating frustration related to trying to get stuff done with untreated ADHD, or anxiety surrounding the hope that one does not impulsively do something stupid to embarass himself, I treat the ADHD and see what happens to the anxiety over time.

Actually, anytime I suspect ADHD and possibly something else, it's more, "cost productive" to treat the ADHD first and see what's left.

Do we sometimes get the diagnosis wrong and give people stimulants who may not need them? Probably. But if their function improves and quality of life is better, then who the hell cares.

Should we even broach the discussion about stimulants likely being better antidepressants than antidepressants?

 

[birchswing]

What I recall off the top of my head is that the epidemiological research indicates that boys meet diagnostic criteria at about 2 to 3 times the rate of girls. Boys are more active than girls so this is not surprising. It has also been hypothesized that the increase in ADHD also corresponds with a decrease in male teachers. We also load more homework on kids and have less free play time than we did a few decades ago. Also, anxiety continues to increase in our society thanks to a 24 hour news cycle and this anxiety can mimic ADHD or lead to less free play time. We also have a societal dynamic of an increase in the medicalizing of behavioral issues. We also have a large group of people who state that they need medications to function and it seems like those meds tend to be benzos and stimulants and opiates. They are often too disabled by "my mental illness" to work either.

Hmm . . . well my pet theory doesn't hold then, unless there are multiple etiologies or if there are distinct ADHD patterns in boys and girls that haven't been identified. Is there anything qualitatively different about ADHD in girls?

 

[DD214_DOC]

Hmm . . . well my pet theory doesn't hold then, unless there are multiple etiologies or if there are distinct ADHD patterns in boys and girls that haven't been identified. Is there anything qualitatively different about ADHD in girls?

Girls tend to be predominantly inattentive; more issues with attention/focus, executive function, emotional regulation type stuff.

I continue to maintain that the subtypes of ADHD actually represent separate and distinct "illnesses" likely with very different etiologies and prognosis. Responses to the stimulant and nonstimulant meds are also different, anecdotally. One problem with this assertion, of course, is that ADHD as a neurodevelopmental problem transforms over time; ADHD looks different across the developmental lifespan and, if you follow longitudinally, transforms over time and development. It can present variably as well.

I'm rambling. All of this is easily explained by the DMN interference hypothesis/model for ADHD, which is good but I was able to connect the dots from a few other studies that strengthens it as a model.

 

[smalltownpsych]

Joining the discussion late, I'm curious what the issue is, exactly. Don't want to do a bunch of ADHD evals? Dislike the patient population? Rather avoid giving meds to people who don't need them, but feel stuck doing so anyway? Then I feel like we've been circling around the discussion of whether it is more helpful but less ethical to assume a patient is lying. Anyone want to clarify for me what the sticking point is for them with this issue?

I think we have touched on all of the above. The initial point was OPs frustration with patients who are putting pressure on the doctor to potentially inappropriately prescribe stimulants. I am not sure what you mean by it being less ethical to assume a patient is lying. Recovering addicts are pretty open about how much they would lie and manipulate to get what they need. In the past, I have told substance abusers that I will trust them completely, even when you are lying to me. That's one of my own dialectical approaches to that particular dilemma.

 

[splik]

The danger is allowing your personal Bayesian updating function to overweight the priors based on how much a given hypothesis fits with your agenda. If you are an EBM zealot who radically discounts the relevance of theoretical frameworks at least you are serving a relatively pure cause.

However, I definitely am with you in saying Bayesian updating approaches allow you to avoid becoming the next Daryl Bem:
http://news.discovery.com/human/psychology/controversial-esp-study-fails-yet-again-120912.htm

I am an EBM zealot. No EBM purist would ever discount the relevance of theoretical frameworks. None of leading figures in EBM discount theoretical rationale, narrative, or individual experience. The term "n of 1" for example comes from EBM and highlights that we recognize sometimes we are experimenting on patients and what we do is trial and error. EMB says there are kinds of evidence and their are levels of evidence. Theory is one kind of evidence. If you don't have an RCT (or other data) to guide you then a theoretical framework is a kind of evidence. It is better than a blind stab in the dark because there is some rationale to suggest an approach or explanation is more likely than chance alone. But to cling on to theory in the face of a different kind of evidence (such as an RCT) is bad science.

 

[splik]

also evidence based approaches still rely on theory. The bradford hill criteria for causal inference include biological plausibility. If an association between exposure and outcome is not plausible then we need to reassess what that association means.

 

[clausewitz2]

I am an EBM zealot. No EBM purist would ever discount the relevance of theoretical frameworks. None of leading figures in EBM discount theoretical rationale, narrative, or individual experience. The term "n of 1" for example comes from EBM and highlights that we recognize sometimes we are experimenting on patients and what we do is trial and error. EMB says there are kinds of evidence and their are levels of evidence. Theory is one kind of evidence. If you don't have an RCT (or other data) to guide you then a theoretical framework is a kind of evidence. It is better than a blind stab in the dark because there is some rationale to suggest an approach or explanation is more likely than chance alone. But to cling on to theory in the face of a different kind of evidence (such as an RCT) is bad science.

Perhaps this is characteristic of EBM as it is practiced in the exalted empyrean of the Truly Enlightened Academies. Maybe this year's match will even give me the chance to experience that; certainly find that approach more appealing! EBM As She Is Practiced in the settings I have personal experience with is much more about refusing to generalize beyond datasets and their associated inclusion criteria and treating anyone suggesting interventions with less than RCT backing as a mental defective.

So what I am saying is that you are not describing a position that corresponds to what I was describing with the term "EBM zealot." That is a very positive thing.

I do disagree with your assertion that one must retreat from theory in the face of any hint of empirical evidence. This depends largely on how useful the theory is otherwise, i.e. the strength of your priors regarding the theory. It is not bad science, it is just science proceeding from a different set of philosophical assumptions.

 

[NontradCA]

That's what I tell patients -- Attention is a heterogeneous problem. It has many causes, including sleep deprivation, environment, emotional, workflow, anxiety (I think some distractibility is actually micro-anxiety moments with quick avoidance). I push for all my patients to do a round of therapy (CBT plus other interventions) prior to meds, if possible.

But from a practical standpoint, why should a patient want to do that when the stimulant will instafix?

 

[AcronymAllergy]

Girls tend to be predominantly inattentive; more issues with attention/focus, executive function, emotional regulation type stuff.

I continue to maintain that the subtypes of ADHD actually represent separate and distinct "illnesses" likely with very different etiologies and prognosis. Responses to the stimulant and nonstimulant meds are also different, anecdotally. One problem with this assertion, of course, is that ADHD as a neurodevelopmental problem transforms over time; ADHD looks different across the developmental lifespan and, if you follow longitudinally, transforms over time and development. It can present variably as well.

I'm rambling. All of this is easily explained by the DMN interference hypothesis/model for ADHD, which is good but I was able to connect the dots from a few other studies that strengthens it as a model.

There's research to support the bolded portion, at least to some degree, when looking at "typical" ADHD vs. ADHD without any history of hyperactivity (which is now sometimes termed Sluggish Cognitive Tempo, and often associated with characterological factors such as introversion and propensity for developing social/general anxiety). This is why many ADHD studies (e.g., those by Barkley et al.) will attempt to exclude such folks.

And yes, the theory/theories involving DMN regulation do seem promising.

 

[smalltownpsych]

There's research to support the bolded portion, at least to some degree, when looking at "typical" ADHD vs. ADHD without any history of hyperactivity (which is now sometimes termed Sluggish Cognitive Tempo, and often associated with characterological factors such as introversion and propensity for developing social/general anxiety). This is why many ADHD studies (e.g., those by Barkley et al.) will attempt to exclude such folks.

And yes, the theory/theories involving DMN regulation do seem promising.

One "type" that I have seen fairly commonly in a clinical setting are kids with various types of early childhood attachment disruptions. I have not been able to find much research in this area as most of it is geared toward the extreme end such as the kids from Romanian orphanages (one of the kids I worked with was from one of those). These kids definitely tend to be hyperactive and what I noticed is they are incredibly focused on people to the point where they disrupt any type of structured setting leading to an inevitable ADHD diagnosis. Also, I see emotionality inhibiting executive function as another type. I need to read up on DMN regulation as I'm not familiar with that.

 

[Ceke2002]

One "type" that I have seen fairly commonly in a clinical setting are kids with various types of early childhood attachment disruptions. I have not been able to find much research in this area as most of it is geared toward the extreme end such as the kids from Romanian orphanages (one of the kids I worked with was from one of those). These kids definitely tend to be hyperactive and what I noticed is they are incredibly focused on people to the point where they disrupt any type of structured setting leading to an inevitable ADHD diagnosis. Also, I see emotionality inhibiting executive function as another type. I need to read up on DMN regulation as I'm not familiar with that.

This is something I've wondered about myself, how much of ADD/ADHD is a separate phenomenon in its own right, and how much is due to attachment disruptions affecting neurobiological changes. If both are present then what came first? Did the ADHD et all pre-exist the trauma inducing attachment disruption, but the disruption in attachment just made it worse? Lots of questions, doesn't seem to be a lot of research though (at least none that I can access).

 

[smalltownpsych]

This is something I've wondered about myself, how much of ADD/ADHD is a separate phenomenon in its own right, and how much is due to attachment disruptions affecting neurobiological changes. If both are present then what came first? Did the ADHD et all pre-exist the trauma inducing attachment disruption, but the disruption in attachment just made it worse? Lots of questions, doesn't seem to be a lot of research though (at least none that I can access).

Not much research that I have seen either. Also, these are subjects who are likely to be screened out of the research. Which is actually true about a lot of the people that we are always working with in this field. The empirically guided research whether with medications or other forms of treatment is of limited usefulness when working with someone who doesn't match the test subjects. Even if they do match the characteristics, there is usually a surprisingly high percentage that respond to either placebo or don't respond to either condition. We don't account for that very well either and might be some of why we see the irrational pharmacology mentioned on other threads.

 

[Par4thecourse]

Currently and anecdotal, we're seeing an increase in requests, primarily from college age students who give the 'ole - "I took my friends Adderall and I can study better."

It's getting pretty bad with the PCPs, whom we partner with, have started saying no outright and are sending over to the clinic for further evaluation. Those who are currently on stimulants by the PCPs are being effectively cut off and sent to the clinic for further evaluation.

In a nutshell, is there a good collection of screening tools which has good validity in helping to screen those out for psycho-stimulants? Perhaps something of an easy decision making tree rather than citing the obvious which PCPs can use to help them through the process?

I'm hoping to ease the burden and requirements but also lessening demand through bogus claims.

Medical history is crucial. Hallowell's (Driven To Distraction) suggested criteria to meet ADHD in adults is excellent. Sub-test scatter on Wechsler IQ tests is a tell tale sign.

 

[Par4thecourse]

Interesting thread. I have never seen, "Bayesian" anywhere and I'm still not quite sure what it means, but I think I get it.

I had been accused by supervisors as being a bit, "loose" in my clinical approach. I familiarize myself with EBM but find it too restrictive, and I did not get into this field to be an algorithm monkey. The problem with EBM is that it assumes the information its based upon is factual and accurate. I care less about labels and more about what's actually going on, the symptoms experienced, and the impairment/problems they cause. It's all multifaceted. I tend to be pragmatic and know there is no such thing as, "truth" in psychiatry. By its very nature, the information we are obtaining to base our diagnosis and treatment plans on is inaccurate and always subjective. We receive information that has already been filtered by the patient: things are withheld, overemphasized, minimized, or outright falsified. Our own experiences with intraining psychotherapy taught us this. This filtered information is then filtered again through us and our own biases. The quest for diagnostic accuracy and truth is psychiatry is futile for the most part.

If we wanted to be honest with ourselves, we should be mostly using Unspecified Diagnoses to check the box and putting more effort into our formulation and assessment; an attempt to understand the patient in the context of their environment and relationships and how they all interact.

Funny thing, despite being accused as, "a bit loose", most of my patients improved. Maybe there's something to this thing about understanding our patients instead of merely describing them.

Medical histories are the backbone, IMO, as well as extensive scholastic and social history including grades, reviews by several teachers, coaches, parents, friends. Does the individual have an unnamed and persistent, painful ache deep within that doesn't go away, no matter what?

 

[smalltownpsych]

Medical histories are the backbone, IMO, as well as extensive scholastic and social history including grades, reviews by several teachers, coaches, parents, friends. Does the individual have an unnamed and persistent, painful ache deep within that doesn't go away, no matter what?

Who has time to find out all this info? Also, I think the neuropsychologists would contest the point about the WAIS scatter being diagnostic. It is much easier to just write a script and call it good. That is how it works in the real world. I cringe every time I get an ADHD referral because I have no reliable assessment measure and it doesn't really matter what I recommend as much as what the parents, patient, or teachers wants.

 

[Shikima]

Who has time to find out all this info? Also, I think the neuropsychologists would contest the point about the WAIS scatter being diagnostic. It is much easier to just write a script and call it good. That is how it works in the real world. I cringe every time I get an ADHD referral because I have no reliable assessment measure and it doesn't really matter what I recommend as much as what the parents, patient, or teachers wants.

I cringe every time I hear someone saying they have all the symptoms because they read it on the innerwebz or took their child's medication "accidentally" and a sudden epiphany opened up where they felt better, so they must have that medication!

 

[sunlioness]

I took a buzzfeed quiz. I have it too.


Sent from my iPad using Tapatalk

 

[Information Underload]

Call their parents, and do it with them in the room. Seriously. The DSM criteria insist that symptoms need to be present before the age of 12, so you call up the family and ask how Junior did in school and with his chores. Was everything half-done? Ask him to do 3 things, and you found him out rolling his Hot Wheels around with no recollection of having to set the table? Was he the kid who constantly had his homework floating in some alternative universe or never seemed to have any at all until they found out he was failing everything because he never turned it in or did it? The kid who almost went into orbit from leaping from the couch?

I guess you can wait months on equivocal neuropsychological testing, but really what we are looking for is clinical impairment more than results on a test. I think ADHD is vastly under-treated and see so many individuals really turn their lives around when you address the symptoms. I also don't see the abuse of stimulants that you see with benzos and the like. Why waste time with Adderall when there is meth out there? It does happen, sure. But I think you have to weigh that against the potential benefits.

 

[smalltownpsych]

Call their parents, and do it with them in the room. Seriously. The DSM criteria insist that symptoms need to be present before the age of 12, so you call up the family and ask how Junior did in school and with his chores. Was everything half-done? Ask him to do 3 things, and you found him out rolling his Hot Wheels around with no recollection of having to set the table? Was he the kid who constantly had his homework floating in some alternative universe or never seemed to have any at all until they found out he was failing everything because he never turned it in or did it? The kid who almost went into orbit from leaping from the couch?

I guess you can wait months on equivocal neuropsychological testing, but really what we are looking for is clinical impairment more than results on a test. I think ADHD is vastly under-treated and see so many individuals really turn their lives around when you address the symptoms. I also don't see the abuse of stimulants that you see with benzos and the like. Why waste time with Adderall when there is meth out there? It does happen, sure. But I think you have to weigh that against the potential benefits.

Because meth is illegal and you get into big trouble when you have addiction problems, but if you can get adderall and some benzos and maybe a few opiates as well from the doctor then everything is okay. These patients are the ones clamoring for these substances and it is harmful for them. I have had plenty of patients who take stimulants and benzos that don't have substance abuse problems, I don't think anyone has a problem treating them. The patients who struggle with addiction are the challenging ones.

I have a current patient who is several months clean and their emotions are all out of whack as is typical, they also have a history of some trauma amplifying this. SSRI's aren't helping and have some unwanted side effects, patient desperately wants something to help them feel better. They even tried their friend's vyvanse to see of that would help because maybe the racing thoughts are ADHD, but they are thinking Xanax would work better because it is anxiety, I tend to agree, but I also worry that going down that path could lead to my patient's demise. It is a tough place to be because it is hard to see the patient struggle and suffer when I know something that would alleviate that, but it could also harm. So far they are committing to psychotherapy and deriving some benefit from it so am cautiously optimistic.

As an aside, the friend who is prescribed vyvanse has active meth and alcohol abuse.

 

[sunlioness]

I just saw a former meth/cocaine addict here because he knows he has ADHD. He now realizes that he was self medicating. He's prescribed benzos by another doc.

Fortunately, he accepted the referral for testing with very good grace. And I hope that by the time the report comes back that I won't be here anymore.


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[thoffen]

I am not going to dissent with everyone in this thread. It is clear that there are quite a growing number of patients with murky at best stories for ADHD and a clear cultural phenomenon of seeking treatment, particularly in college-aged students. I agree that neuropsych testing is often very unhelpful in that it just isn't very good at diagnosis ADHD and thus relies on the same assessment that a psychiatrist can do. Nonetheless, there is utility for testing for confounding or potentially comorbid diagnoses, especially specific learning disabilities.

Nonetheless, it's rough to discount the high effect sizes of stimulant treatment for ADHD, especially when we compare them to our other pharmacologic interventions. Longer term data is somewhat sketchier, but there does appear to be benefit as well.

The biggest challenge is the adults with either malingered symptoms or significant diagnostic complexity independent of ADHD. If someone wants this diagnosis, it is easy for them to frame routine life difficulties as diagnostic criteria for ADHD. On the flipside, that real ADHD (especially inattentive in a high-pressure household) is a setup for significant depressive and anxiety comorbidities. In many cases, the anxiety is even functional at first in order to prevent tasks from slipping away. When you have the complete picture, what do you do? Prioritize depression/anxiety? Sometimes these might not improve unless you treat the ADHD. Or sometimes you'll find that there is no ADHD or that the symptoms are not impairing within a patient's functional context after treating those conditions.

I actually had an epiphany moment for me with a therapy pt on screening for ADHD. He was talking about his childhood and how he was getting in trouble a lot, but he never really knew what he was doing wrong. That seems to me the classic experience, and a bit more useful than subjective inattention/lack of organization/impulsivity.

 

[smalltownpsych]

We are caught in the middle of a lot of societal dynamics with ADHD and stimulant medication.

• Patients who can benefit not wanting to take it because of stigma.
• Doctors who have seen first hand the effects on people addicted to dangerous substances and are reluctant to prescribe controlled substances.
• Doctors who are tired of arguing with patients and take the path of least resistance.
• Healthcare and reimbursement systems that incentivize brief and only positive patient interactions.
• A culture that believes in a medicine to fix illnesses.
• Pharmaceutical companies that promote medications to give you a better life.
• Doctors who make a significant amount of money off these phenomena (Amen, Barkley, and this Hallowell guy who I just heard about today)
• War on drugs.

No wonder I don't want referrals for rule/out ADHD.

 

[Shikima]

We are caught in the middle of a lot of societal dynamics with ADHD and stimulant medication.

• Patients who can benefit not wanting to take it because of stigma.
• Doctors who have seen first hand the effects on people addicted to dangerous substances and are reluctant to prescribe controlled substances.
• Doctors who are tired of arguing with patients and take the path of least resistance.
• Healthcare and reimbursement systems that incentivize brief and only positive patient interactions.
• A culture that believes in a medicine to fix illnesses.
• Pharmaceutical companies that promote medications to give you a better life.
• Doctors who make a significant amount of money off these phenomena (Amen, Barkley, and this Hallowell guy who I just heard about today)
• War on drugs.

No wonder I don't want referrals for rule/out ADHD.

I don't either. Give me narcolepsy or IHS any day of the week.

 

[swisschard]

I grilled all my attendings on ADHD diagnosis during 4 years of residency and no one could give me a clear answer. One of them essentially encouraged me to ask leading questions about how dirty their rooms are, or how often they get distracted. This is pretty spot on:

I am not going to dissent with everyone in this thread. It is clear that there are quite a growing number of patients with murky at best stories for ADHD and a clear cultural phenomenon of seeking treatment, particularly in college-aged students. I agree that neuropsych testing is often very unhelpful in that it just isn't very good at diagnosis ADHD and thus relies on the same assessment that a psychiatrist can do.

 

[DD214_DOC]

There's research to support the bolded portion, at least to some degree, when looking at "typical" ADHD vs. ADHD without any history of hyperactivity (which is now sometimes termed Sluggish Cognitive Tempo, and often associated with characterological factors such as introversion and propensity for developing social/general anxiety). This is why many ADHD studies (e.g., those by Barkley et al.) will attempt to exclude such folks.

And yes, the theory/theories involving DMN regulation do seem promising.

Any good references I can read? I'd be interested in learning more about this. I actually have inattentive ADHD and it basically is like I have a constant low dose benzo circulating in my blood. It's way more than just inattention.

 

[AcronymAllergy]

Any good references I can read? I'd be interested in learning more about this. I actually have inattentive ADHD and it basically is like I have a constant low dose benzo circulating in my blood. It's way more than just inattention.

Sure. I have a few saved to my computer here at the office; I don't recall which might be the best amongst them, but if nothing else, they can all serve as good springboards for additional references.

----------
Carlson, C. & Mann, M. (2002). Sluggish Cognitive Tempo predicts a different pattern of impairment in the Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type. Journal of Clinical Child & Adolescent Psychiatry, 31(1), 123-129.

Barkley, R. (2012). Distinguishing sluggish cognitive tempo from attention deficit hyperactivity disorder in adults. Journal of Abnormal Psychology, 121, 978-990.

Barkley, R. (2013). Distinguishing sluggish cognitive tempo from attention deficit hyperactivity disorder in children and adolescents: Executive functioning, impairment, and comorbidity. Journal of Clinical Child & Adolescent Psychiatry, 42(2), 161-173.

Becker et al. (2016). The internal, external, and diagnostic validity of sluggish cognitive tempo: A meta-analysis and critical review. Journal of the American Academy of Child & Adolescent Psychiatry (was early access when I got it; don't have volume, issue, or page#).

Lee., S. Y., Burns, G. L., Beauchaine, T. P., & Becker, S. P. (2015). Bifactor latent structure of attention-deficit/hyperactivity disorder (ADHD)/oppositional defiant disorder (ODD) symptoms and first-order latent structure of sluggish cognitive tempo symptoms. Psychological Assessment (again, don't have volume, issue, or page# for this one).

Leopold, D. R. et al. (2016). Attention-deficit/hyperactivity disorder and sluggish cognitive tempo throughout childhood: Temporal invariance and stability from preschool through ninth grade. Journal of Child Psychology and Psychiatry (yet again, no volume/issue/page # info).
------------

I'm sure I have more stored at home, but that should hopefully be an adequate starting point. Hope it's helpful.

 

[AcronymAllergy]

I am not going to dissent with everyone in this thread. It is clear that there are quite a growing number of patients with murky at best stories for ADHD and a clear cultural phenomenon of seeking treatment, particularly in college-aged students. I agree that neuropsych testing is often very unhelpful in that it just isn't very good at diagnosis ADHD and thus relies on the same assessment that a psychiatrist can do. Nonetheless, there is utility for testing for confounding or potentially comorbid diagnoses, especially specific learning disabilities.

Nonetheless, it's rough to discount the high effect sizes of stimulant treatment for ADHD, especially when we compare them to our other pharmacologic interventions. Longer term data is somewhat sketchier, but there does appear to be benefit as well.

The biggest challenge is the adults with either malingered symptoms or significant diagnostic complexity independent of ADHD. If someone wants this diagnosis, it is easy for them to frame routine life difficulties as diagnostic criteria for ADHD. On the flipside, that real ADHD (especially inattentive in a high-pressure household) is a setup for significant depressive and anxiety comorbidities. In many cases, the anxiety is even functional at first in order to prevent tasks from slipping away. When you have the complete picture, what do you do? Prioritize depression/anxiety? Sometimes these might not improve unless you treat the ADHD. Or sometimes you'll find that there is no ADHD or that the symptoms are not impairing within a patient's functional context after treating those conditions.

I actually had an epiphany moment for me with a therapy pt on screening for ADHD. He was talking about his childhood and how he was getting in trouble a lot, but he never really knew what he was doing wrong. That seems to me the classic experience, and a bit more useful than subjective inattention/lack of organization/impulsivity.

I've heard similar report from patients at times and generally feel the same way, although would of course caution that particularly depending on the type of ADHD (and other factors present during childhood/schooling), children with ADHD may nonetheless not get into trouble very often. If they're more inattentive in their presentation and there's a more rambunctious child in the class, for example, or if they've consistently attended resource-strapped schools, the problems may go unnoticed.

I will generally always try to get some type of collateral report; ideally from a parent, but even from a spouse or other friend/family member to verify current symptoms and impairment. Unfortunately, I'm not often able to do so, and am generally "flying blind" much of the time in that respect. In the few situations when I've been able to contact parents, it's been universally helpful.

And in situations where there's been a childhood diagnosis, I'll try to get more information about the circumstances surrounding the diagnosis. Was the child evaluated at the request of a teacher due to recurrent problems or concerns? Who conducted the evaluation and what type of interview/testing was involved? Et cetera.

 

[thoffen]

I've heard similar report from patients at times and generally feel the same way, although would of course caution that particularly depending on the type of ADHD (and other factors present during childhood/schooling), children with ADHD may nonetheless not get into trouble very often. If they're more inattentive in their presentation and there's a more rambunctious child in the class, for example, or if they've consistently attended resource-strapped schools, the problems may go unnoticed.

I will generally always try to get some type of collateral report; ideally from a parent, but even from a spouse or other friend/family member to verify current symptoms and impairment. Unfortunately, I'm not often able to do so, and am generally "flying blind" much of the time in that respect. In the few situations when I've been able to contact parents, it's been universally helpful.

And in situations where there's been a childhood diagnosis, I'll try to get more information about the circumstances surrounding the diagnosis. Was the child evaluated at the request of a teacher due to recurrent problems or concerns? Who conducted the evaluation and what type of interview/testing was involved? Et cetera.

Very good points. I think the inattentive child does get in trouble a lot too, though, but you are right if the school and home environment has a more hyperactive/impulsive person getting all the attention, the inattentive child will get left out.

The thing I wanted to highlight instead of getting in trouble often is the part of not knowing why. This doesn't necessarily mean discipline, but just finding yourself yelled at or not meeting an expectation down the road, and not even realizing it until someone is giving you grief about it.

 

[DD214_DOC]

Sure. I have a few saved to my computer here at the office; I don't recall which might be the best amongst them, but if nothing else, they can all serve as good springboards for additional references.

----------
Carlson, C. & Mann, M. (2002). Sluggish Cognitive Tempo predicts a different pattern of impairment in the Attention Deficit Hyperactivity Disorder, Predominantly Inattentive Type. Journal of Clinical Child & Adolescent Psychiatry, 31(1), 123-129.

Barkley, R. (2012). Distinguishing sluggish cognitive tempo from attention deficit hyperactivity disorder in adults. Journal of Abnormal Psychology, 121, 978-990.

Barkley, R. (2013). Distinguishing sluggish cognitive tempo from attention deficit hyperactivity disorder in children and adolescents: Executive functioning, impairment, and comorbidity. Journal of Clinical Child & Adolescent Psychiatry, 42(2), 161-173.

Becker et al. (2016). The internal, external, and diagnostic validity of sluggish cognitive tempo: A meta-analysis and critical review. Journal of the American Academy of Child & Adolescent Psychiatry (was early access when I got it; don't have volume, issue, or page#).

Lee., S. Y., Burns, G. L., Beauchaine, T. P., & Becker, S. P. (2015). Bifactor latent structure of attention-deficit/hyperactivity disorder (ADHD)/oppositional defiant disorder (ODD) symptoms and first-order latent structure of sluggish cognitive tempo symptoms. Psychological Assessment (again, don't have volume, issue, or page# for this one).

Leopold, D. R. et al. (2016). Attention-deficit/hyperactivity disorder and sluggish cognitive tempo throughout childhood: Temporal invariance and stability from preschool through ninth grade. Journal of Child Psychology and Psychiatry (yet again, no volume/issue/page # info).
------------

I'm sure I have more stored at home, but that should hopefully be an adequate starting point. Hope it's helpful.

Interesting. I also ran across a forum with many patients discussing their experience with SCT-like symptoms and in comparison, the studies seemed to neglect the larger, "tiredness/sleepiness" factor. I really wonder if the SCT concept is really just idiopathic hypersomnia but being approached by two completely-different disciplines.

 

[cookymonster]

I do have a surprising number of ADHD patients who, upon transfer to me, when I politely order a UDS (all the while explaining that this is part of appropriate monitoring and recommended by the medical licensing board, and not at all an accusation of any type of substance use), reportedly develop immediate anuria. This form of anuria appears to go on for days (especially when I say, "it's ok, just drop by the office tomorrow, no worries!)". This link should be investigated further.

How often do you C&A docs suspect that stimulants for a kid are getting diverted? And if so, what can you do?

It would be really easy to manipulate a UDS by having the kid take it the day before, and that wouldn't identify the cases where a parent is cutting the dose and keeping the rest for themselves.

I guess you could insist that they keep and dispense the med at school, but those still must be very difficult conversations to have.