Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Disorder (ADD)
Overview of Attention Deficit Hyperactivity Disorder (ADHD)
What exactly is ADHD?
ADHD is defined as "a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development." In my clinical opinion, it is a disease of being under-stimulated. Our bodies evolved to be in constant motion during waking hours, similar to the rest of our primate cousins. Humans have been evolving over the past 300,000 years and only in the last century have people been expected to sit 8-14 hours a day. I'm surprised most people haven't been diagnosed with ADHD!
Causes and Types
ADHD is caused by a deficiency of dopamine and norepinephrine in the frontal lobe of the brain. It can be diagnosed as inattentive type, hyperactive type, or combined type. The hyperactivity sub-type is more common in children, and the inattentive sub-type is more common in adults. Combined is fairly self-explanatory, and is a combination of both the hyperactivity and inattentive sub-types.
The hyperactive sub-type has more physical symptoms such as being fidgety, unable to sit still, and needing to be in constant motion. Sometimes this can be confused with anxiety because it often causes similar behavioral symptoms. I've treated many children who were experiencing unpleasant side effects and few benefits from ADHD medications, only to later identify anxiety as the real condition. Unfortunately, this is a common result of our current healthcare system, which pushes physicians to hurry through appointments with patients, leading to misdiagnoses and incorrect treatment plans.
The inattentive sub-type of ADHD is more psychologically based and symptoms include impulsiveness, interrupting others, inability to focus in the classroom. Both the inattentive and hyperactive types can lead to behavioral issues in the classroom.
There are both non-pharmacological and pharmacological treatments for ADHD. Exercise is one of the best natural treatments for ADHD and other mental illnesses. There are three classes of medications proven to treat ADHD effectively: stimulants, alpha-agonists, and norepinephrine reuptake inhibitors.
Stimulants by far are the most effective and powerful medication for ADHD. Stimulants are fully effective within 1-2 hours. The two main classes of stimulants are methylphenidate and amphetamine. The methylphenidate class only stops the reuptake of norepinephrine and dopamine, whereas the amphetamine class not only prevents the reuptake of norepinephrine and dopamine, but also causes additional dopamine and norepinephrine to be secreted. The most common side effects of stimulant use are trouble sleeping and decreased appetite. Because of this, I recommend patients take stimulants after breakfast.
Not all stimulants are created equal. The half-life of a medicine indicates how long the average person takes to metabolize (get rid of) ½ the dose. If a medication has a ½ life of 8 hours then in 8 hours, 50% of the drug will be cleared from the body. In another 8 hours, only 25% of the original dose is still in the body. In other words, medications with a short half-life will be in the body for less time. There are short-acting medications with a half-life of 2-4 hrs (Focalin, Adderall, Ritalin), medium-acting medications with a half-life of 6-12 hours (Adderall XR, Focalin XR, Ritalin LA), and long-acting medications with half-lives of 12-16 hours (Vyyanse and Concerta).
The short-acting stimulants need to be taken 2-3 times a day and have the most potential to be abused, because they immediately start working. Unfortunately this means they also abruptly stop working, which can lead to feeling tired, hungry, and unfocused between medication doses. Because of this, patients tend to feel better when taking one long-acting tablet per day, such as the medium-acting stimulants.These medications allow patients to complete the school or workday without having to take another pill or experience side-effects between doses.
Many people have difficulty sleeping when taking long-acting medications, and if they can sleep, frequently find themselves being woken by hunger in the middle of the night. The advantage of Vyvanse and Concerta is that these stimulants have the lowest abuse potential. Vyvanse has the amphetamine molecule attached to a lysine group (amino acid) that can only be broken down in the stomach or intestines and thus can't be snorted or injected. Concerta has a hard shell and is slowly pushed out by a sponge.
Frequently Asked Questions
Amphetamine? That sounds like methamphetamine. Will this treatment make my daughter a drug addict?
The last thing I want to do is harm patients with medication. Methamphetamine is indeed an amphetamine-based drug, but methamphetamine has an additional methyl group. In chemistry, additions of elements and compounds can drastically change a compound’s properties.
For example, H20, is two hydrogen atoms and one oxygen. But when altered, hydrogen or oxygen by itself is essentially rocket fuel. A methyl group is one carbon and three hydrogen atoms, which is what the medications I prescribe do not have.
In fact, studies have shown that children treated for ADHD with medications are 85% less likely to abuse drugs than children with ADHD who are untreated. Additionally, patients treated for ADHD as children are less likely to use illicit drugs as adults, when compared with children with ADHD who are not medically treated.
Is there an organic, non-medication way to treat ADHD?
ADHD can be somewhat modified through lifestyle changes. Exercise is one of the best natural treatments for ADHD and many other mental illnesses. Exercise causes both dopamine and norepinephrine to be released in the brain. Many children with ADHD benefit from playing on a sports team where they get exercise on a near daily basis, lowering their excessive "energy" levels. This may allow them to focus better in school the next day.
Adults with ADHD can benefit from exercising while studying or working. I've had patients who say they can focus more on what they read, if on a treadmill. Alternatively, others may be able to listen to audiobooks while doing other activities. Taking consistent breaks in the office to walk the stairs or even better, walk outside can also be helpful.
I see ADHD symptoms falling along a spectrum with mild, moderate, and severe cases. If a child has mild ADHD, does well in school, and is socially well-adjusted then I would argue no medication is required. However, in most cases, the benefit of treatment outweighs the risk. Studies have shown that adolescents with ADHD are more likely (38% for males and 42% for females) to get into a car accident if untreated. I would also consider starting treatment before your child begins taking high stakes examinations such as college entrance exams. However, this last part is controversial. If the adolescent is getting good grades then some people might argue that prescribing stimulants gives an unfair cognitive advantage.
How can my child have ADHD when they sit still and plays video games for 5 hours a day?
Video games and other digital entertainment are designed to be continually moving from frame to frame. For many people with ADHD, the complexity, constant action, and decision-making can be relaxing and soothing in a world they feel moves too slowly for them to be comfortable. The entertainment industry has responded to this interest with an increased change in frame rate over the past several years.
Below are links to websites with information regarding diagnosis, treatment and classification of ADHD:
An excellent website regarding treatment and understanding of ADHD
Produced by the American Academy of Child and Adolescent Psychiatry