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attention deficit disorder

Why is my ADHD bothering me now?

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ADHD (or ADD without the H) is a disorder whose symptoms start in childhood. Two of three of these children will continue to have symptoms to an impairing degree beyond age 18 . Of the adults with ADHD who are diagnosed in adulthood, only 25% were ever diagnosed as a child (Kessler et al 2007). One reason for the under-identification of children with ADHD is that only those children who are disruptive come to the attention of teachers and parents. Non-disruptive children with ADHD may not get diagnosed until later in life. So the question is, what would cause them to seek an evaluation later in life. “If you lived with it all this time, it can’t be that bad.” Right? Well, not exactly.

In our recent publication on ADHD throughout the Lifespan (Journal of Clinical Psychiatry February 2012), we discuss the developmental phases of life that prompt the question “Why is my ADHD bothering me now?” When reading this article, please note the authorship of internationally recognized experts in the field that include Drs. Atilla Turgay (Canada), Phillip Asherson (United Kingdom), myself and Russell Barkley (United States).

Each developmental phase of life takes on more responsibility. For example, moving from middle school to high school means the academic demands and workload increases. As you move from high school to college, you need to be able to organize yourself to get to classes, do assignments on time, schedule time for study, sleep, play, and classtime. If you go onto first job, you need to be punctual, respond appropriately to supervisors, and complete work on time. When you get married, you need to negotiate household responsibilties and complete tasks timely and consistently to be a team player in your marriage. And then you go on to have children which adds additional layers of tasks and responsibilities requiring increasing levels of organization and efficiency. How about a job promotion with more tasks and the oversight of others. So, each developmental phase of adult life has its set of tasks and responsibilities and your ability to adapt and compensate becomes more difficult. At some point, your daily performance suffers whether at work or home.  At this point, either you or someone close (employer, family, friend) to you will bring it to your attention. Sometime this is done kindly, sometimes it is the result of an argument because you haven’t followed through as expected by others.

Our publication was written for physicians and psychiatrists so that they would understand why an adult with ADHD who had never gotten treatment might come to their office for an evaluation. We hope that this publication will disuade physicians from discounting an adult’s compliant of daily function and look for ADHD when indicated.

If you are not a physician, I think the article is still quite readable for most people and may provoke some thoughts and discussions amongst those effected by ADHD.

Thank you for your time and interest in reading my postings.

David W. Goodman, M.D.

Medical Crossfire- 4 videos by experts on adult ADD

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Education about ADHD in adults is critical for everyone. In addition to my work in the public sector and assistance to public media (newspaper, magazines, and TV), I’m also involved in teaching physicians how to best identify their patients who have ADHD/ADD. My friend, Anthony Rostain, MD at the University of Pennsylvania and I did a 4 part video series (Medical Crossfire) explaining diagnosis, co-existing psychiatric conditions and treatments, both medication and therapies for adult ADD.

You are invited to view each of the segments here. You will need to register first. Don’t worry if you are not a physician. You will be able to understand the discussion. When you register: under “Profession” click on No Profession; under “Specialty” click on Non-clinical; under degree, well, you choose what’s appropriate.

These segments represent the opinions of internationally recognized experts speaking about the state of the art for this disorder. You will be very well informed after viewing each segment.

As I have said before, let science be the designated driver in the highway of opinions. Thank you again for your interest in my writings. I will be adding these video segments to my website in the near future.

“Why do you ask me the same questions?”

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Yesterday a patient, clearly annoyed, asked me  “Why do you ask me the same dumb questions each time I see you? How’s your mood been? How’s your sleep and appetite? Any side effects from the medicine? Did the side effects you mentioned last time go away? Is the medicine still serving its purpose?”

Yes, I plead guilty. I do ask these questions frequently. But the patient is annoyed. Shouldn’t I stop? Well…no, and here’s why.

The answers to the questions are important and may have changed since I last saw the person. The stability of the answers or any changes is necessary to consider when changing treatment. Maybe I’ll increase or decrease the dose. Maybe I’ll add or subtract a medication.  Maybe there are life circumstances that need to be addressed and no change in medication is needed. You are probably nodding your head saying, “Ok, I understand that.”

So why is my patient annoyed? Perhaps he or she would like to spend the time more productively discussing a recent situation at work or home. I understand that.

I also see their annoyance as a good thing. What? You see, the person is annoyed because they are so accustomed to the questions that they can ask and answer them themselves. “So why waste time in the session with what I can do at home.” That’s what I want, assess yourself. My repetitive questions have been incorporated by the person into their own mind and they have learned to assess themselves the way I do. That’s a good outcome. I want my patients to be able to assess their symptoms on a day-to-day basis. I want them to note the side effects that I might have to address if they don’t subside. I want them to ask themselves “Is the medication helping me with what I want help with?”

Ultimately, we take medication not so much for health (long-term issue) but for quality of life (daily issue). Does the medication allow me to function to my satisfaction? Does the medication provide me with a comfortable state of mind?

Every time you swallow a pill, you consciously or unconsciously ask yourself “Do I really need this?” Well, if you ask yourself my “annoying questions”, you get the answer.

I want my patients to learn the symptoms of their illness, identify when symptoms are stable or not, judge the level of distress and/or impairment, and make treatment decisions accordingly. This ability gives them a sense of control over the illness rather than being a victim of it.  And they want to same.

Adult ADHD in Europe

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Sitting on a plane back from Berlin, Germany, I thought I’d convey information about adult ADHD you may not readily find. I had the opportunity to be invited to a small meeting of international experts on adult ADHD from several countries (2 from North America, 3 from Europe). The purpose of the gathering was to exchange the current state of the art for adult ADHD in the respective countries. It was fascinating discussion because all the experts agree on what adult ADHD is. This agreement occurs despite varying levels of research in the individual countries. It appears that the experts are relying on the internationally published medical literature for guidance. The opponents to the validity of adult ADHD claim that the disorder is largely a U.S. phenomenon and doesn’t exist elsewhere in the world. These folks have apparently not left the U.S. to discuss it with other psychiatrists. Nor are they aware of the ongoing international research funded and conducted by the World Health Organization.

In some European countries (Germany, United Kingdom and Netherlands) there are centers with experts conducting research on adult ADHD and providing care. However, there are also countries (France, Italy, and Spain) that remain opposed to the diagnosis. Unfortunately, not believing in the disorder doesn’t mean the disorder doesn’t exist in the population. Because you close your eyes doesn’t mean the world goes away.

To advance care, there have been three publications recommending preliminary diagnosis and treatment guidelines internationally- CADDRA (Canada), NICE (United Kingdom) and European Consensus (several European countries). I was the pre-publication peer reviewer for the European consensus paper. To date, the United States experts have not yet issued such guidelines. It may be that we’ll wait until DSM-V (to be published in May 2013) better refines the diagnostic criteria for adults with ADHD. Canada and the European experts have not felt the need to wait because clinical guidance is necessary now in order to provide evidence-based treatment to adults with ADHD.

To compound the international difficulty in receiving care for adult ADHD, the medications available are severely limited and determined by country. Immediate release methylphenidate is the most commonly available but immediate release dextroamphetamine is less available. Atomoxetine, Concerta, Vyvanse, and Adderall are also variably available country to country. There are some countries where you may not enter with a stimulant medication (Italy and Japan). My patients traveling abroad need to be aware of this before leaving the U.S. For those countries that permit stimulants, I provide a note on my letterhead that states this person is under my medical care and should be allowed to carry medication. Medicines alway need to be in the prescription bottle appropriately labeled by the pharmacist.

I am very fortunate to be able to participate in international research on this disorder and cultivate a world-wide network of ADHD experts. This allows me to bring state of the art care and treatment back home to my patients, in addition to contributing to the world’s published research literature.