Attention Deficit Hyperactivity Disorder part 3

Before I talk about treatments for ADHD I want to talk a little bit about the causes of this disorder. Basically we do not know a lot. We do know that ADHD has a heritable component, that it does run in families. We know that those infants with low birth weight (which is a nonspecific marker for problems in fetal development) have a higher incidence of ADHD. However most children with low birth weights do not develop ADHD and most children with ADHD did not have low birth rates. One environmental cause is the use of alcohol in pregnancy. There may be but I do not know whether or not there is any association with use of tobacco. But overall we do not know enough about the causes of this disorder.

Well how about treatment? This is an area where there is controversy. There is no controversy within the medical field about the benefits of ADHD medications. Evidence demonstrates their effectiveness. But there is some controversy in our society as a whole about the whole idea of using medications that affect the brain in children and adolescents. One thing I think people need to keep in mind is that the brain is an organ of the human body. In fact it is our most complicated organ. We know that disease states can affect every other organ. It only stands to reason that there can be problems with the brain itself. Yet very few people would take the position that we should not treat other organs but for some reason people put the brain in a separate category as if there can be no disorder in this particular part of our body. There is no question that children with this disorder suffer greatly and that their families suffer as well. I think it is extremely arrogant for those who oppose medication treatment for ADHD to want to make these medications unavailable.

What about psychosocial interventions? Wouldn't there be effectiveness in this approach? It only makes sense that there would be behavioral interventions that make a difference. However numerous studies have shown the same thing. Behavioral and psychosocial interventions are very effective, but only in those who are on medication treatment. Psychosocial and behavioral interventions in the absence of medication treatment are no more effective than no intervention at all. This only make sense when one considers that ADHD is a brain disorder. This is no different than in other areas of medicine and in disorders of other body organs. Exercise and proper diet as well as the cessation of smoking are very helpful in the treatment of coronary artery disease but the vessels must be clear by medical interventions before these behavioral approaches will work. Behavioral interventions and lifestyle changes are very useful in treatment of diabetes but the blood glucose levels must be brought down to normal to have these interventions make a significant difference. So disorders of the brain like ADHD are no different in this respect from other body organ problems.

In my next post I will discuss specific treatments and we will review not only medications but also effective psychosocial and behavioral treatments.

Thought for the day

We need to be empathetic and not critical and judgmental with parents whose children have emotional or behavioral problems.

Attention Deficit Hyperactivity Disorder part 2

This is the second in a series on Attention Deficit Hyperactivity Disorder (ADHD). I said yesterday that I would describe the disorder and it's associated features. ADHD affects about
3% of the school age population. Some studies put the number at 6-7% but I believe that those figures include over diagnosis as the rates of the disorder before there were medications and while still called minimal brain dysfunction were about 3%. Males are affected at higher rates than females. ADHD symptoms change with maturation but the disorder does persist into adulthood. It is a very common co-occurring problem we see here at Cottonwood as one of the problems with ADHD is a much higher rate of substance abuse problems.

Attention Deficit Hyperactivity disorder begins in childhood. It represents a neurodevelopmental problem from birth and truly is a brain disorder. It cannot be diagnosed before age 5 as the symptoms overlap with normal childhood development. But in order to diagnose ADHD there must be symptoms present before age 7. ADHD is often not diagnosed until much later but the disorder begins early. Attentional and behavioral problems with onset after seven are very likely due to other causes. Two additional factors must be present for the diagnosis. The symptoms must occur in two or more settings such as home and school or at home and at work. There also must be significant social, academic, or occupational impairment as to adversely affect the ability to function as needed.

Attention Deficit Hyperactivity disorder is characterized by inattentive symptoms, hyperactivity and impulsivity or both as well as a number of associated features that are not part of the diagnostic criteria. The associated features are often the more disabling aspects of this illness. It can be diagnosed as ADHD - inattentive type or ADHD hyperactive type, or more commonly ADHD - combined type.

The symptoms of inattentiveness include failing to give close attention to details or making careless mistakes in schoolwork work or other activities, difficulty sustaining attention in tasks or play, difficulty listening when directly spoken to, inability to follow through on instructions and failure to finish tasks, difficulty organizing work or play activities, avoidance of tasks that require sustained mental effort, tendency to lose things, be easily distracted by extraneous stimuli, and forgetful in daily activities.

The symptoms of hyperactivity and impulsivity include tendency to fidget or be restless, leaving seat or situation in which it is expected to stay, runs about or climbs excessively or in adults easy restlessness or boredom, difficulty with engaging in leisure activities, tendency to be often on the go or act as if driven by a motor, talking excessively, blurting out things, difficulty waiting or taking turns and a tendency to interrupt.

The associated features include low frustration tolerance, temper outbursts, bossiness, excessive expectation and insistence that needs be met, mood swings, depression, demoralization, peer rejection, poor self esteem, academic impairment and development of oppositional and defiant behavior. In addition there is an increased risk of developing a substance abuse problem.

So we can see that this disorder is all pervasive, is not restricted to attention alone, and clearly is not made up by the pharmaceutical companies. I will talk some about treatment tomorrow.

Thought for the day

" Those who don't follow the movements of their own soul will be unhappy".

Marcus Aurelius

Attention Deficit Hyperactivity Disorder

First of all I would like to thank those who have kindly inquired about my health following the bike accident. It was not my accident but unfortunatley happened to one of my colleauges here. It sounds like a harrowing experience and I am glad there were no serious injuries.

I have been asked by a reader to do another didactic series so I decided I would wade into the often controversial subject of Attention Deficit Hyperactivity Disorder (ADHD). It is controversial because it involves different ideas about the causes of behavioral problems as well as the use of psychotropic medication in children. This is further complicated by the reality that pharmaceutical companies make a lot of money from ADHD medications. I will say that I think this debate like many others is too polarized and often doesn't take into account that reality is often more complicated than our dogmatic assertions. In my opinion ADHD exists, and there is both under and overdiagnosis of the condition as well as both underutilization and over utilization of pyschotropic medication in children.

As I have discussed before most psychiatric diagnoses are phenomenologically based. That is they are based upon signs and symptoms. There are as yet no laboratory tests to confirm a diagnosis. This leads to the charge by some that psychiatric diagnoses are too subjective. However phenomenologic diagnoses have been helpful in the history of medicine and remain useful in some other conditions such as migraine and epilepsy. With this type of diagnosis the more severe the symptoms present the more likelihood that we are dealing with a common entity and the more mild the symptoms the more likely we are dealing with a behavior spectrum that ranges from moderate to normal behavior. This is further complicated in children in that the younger the child the more limited the repitiore of behavioral expression. An infant crying can mean many things and a six or seven year old child's behavioral problems can result from many causes all of which look very similar in this age grouop. As we grow to maturity we develop a wider range of ways in which to express internal distress. So in ADHD greater the severity of symptoms results in a greater likelihood that we are dealing with an actual entity and the milder the symptoms results in greater likelihood that we are seeing is behavior on a spectrum of problematic to normal varience.

Tomorrow I will define and describe Attention Deficit Hyperactivity Disorder. One thing is clear. This disorder is not one made up by the pharmaceutical companies. There are classic descriptions of this disorder dating back to the 19th century and early twentieth century long before there were any medication treatments available.

Thought for the day

"It is possible not only not to be angry with the insensitive and ungrateful but even to care for them".

Marcus Aurelius

Pfizer Assistance Program

I read the other day that the pharmaceutical company Pfizer has announced that it will provide continuation of medication for those on their drugs free of charge for one year to everyone who has lost their job due to the recession. Pfizer is the maker of the popular and big selling medications such as Lipitor, Viagra, Chantix, Geodon, and Lyrica. Although ultimately this is a self serving action it will provide genuine help for millions of people who otherwise could not afford to continue to take their medications and is another example of a win - win situation where both self serving interests and the public interests coincide..

The reason that this action is self serving is that Pfizer wants to maintain brand loyalty. People tend to stick with the medication that works for them and lack of access to the medications for a year would result in a number of people who would not restart their medication but either use cheaper generics or possibly obtain prescriptions for medications from a pharmaceutical rivalry. Lipitor will go generic very soon and there are alternatives to Geodon, Viagra, and Lyrica. It is an expensive but still very good idea for Pfizer and one in which other pharmaceutical companies may follow suit. I hope so as many people would not otherwise have access to continue their medications and if that is also good for the company that is OK by me.

Thought for the day

Make a difference one life at a time.

Technical Difficulties

I have a great staff member to introduce you to but I am having technical difficulties and can't get her picture up. Hopefully this is cleared up by tomorrow.

Health Care Reform House Version

This will be my last in a series of discussion of health care reform for now. I will probably come back to this subject as the House and Senate pass their own versions of reform.

I am glad that many on the House Energy and Commerce Committee are considering some public-private joint ventures that would not dismantle those aspects of the health care system that do work. The House plan proposes that all Americans be required to carry health care insurance with government subsidies to help families making less than $88,000/year pay for the costs. The requirements would make employers, individuals, and the government all have responsibilities. The proposal would include greater consumer protections so that there will not be denials based upon pre existing conditions nor could insurers charge extraordinary rates. The House proposals are designed to minimize disruption by allowing people to keep their own existing health plans. The government would also create purchasing pools called "exchanges" to make private insurance coverage more affordable for individuals and small businesses.

One problem with the House proposals so far is the inclusion of a government plan that would compete with the private insurers. Like Senator Schumer's proposal this plan would have to be paid for by premiums rather than tax dollars. Reimbursement rates however could be low enough to drive the private insurers out of business and establish a government monopoly. As I indicated before a psychiatrist in private practice cannot maintain a business with current government rates through either the Medicare or Medicaid programs.

I appreciate any further comments on the various health care reform proposals.

Thought for the day

"Encourage the fainthearted, help the weak, be patient with everyone".

St. Paul

Health Care Reform

I want to continue talking about health care reform proposals. I again want to emphasize that the views expressed here are my own and not those of Cottonwood.

I am disappointed that the Obama administration is rushing health care reform without adequate input from doctors, hospitals, private insurers, and consumer groups. The plan is to get legislation signed by mid summer and I think this is way too fast. The Senate Finance Committee is meeting behind closed doors to consider four different plans none of which includes any possibility of public-private ventures. All the plans are a one size fits all which I think is unwise and may threaten those aspects of our current health care system that do work.

One proposal is the Medicare like plan that I previously talked about in which the government directly competes with private insurers which will after a time drive the private insurers out of business and leave us with a single payer system. Another proposal being considered is no public plan at all which I don't think is being seriously considered by anyone. Another plan would be to allow states to set up their own public plans. This at least gives some flexibility to allow changes and course corrections if things don't work well. The Arizona Medicaid AHCCCS program partially works, though doctors and hospitals can't survive if that is the only plan available. The Tennessee TennCare plan turned out to be a disaster and had to be drastically altered to keep the state from going bankrupt. But at least there was the opportunity for more local self correction.

The fourth plan being considered is a proposal by Senator Charles Schumer of New York. His idea is a Medicare like plan that would have to be paid for by premiums, not tax dollars. The public plan would have to follow the same rules as private insurers, maintaining a reserve fund to cover liabilities as well as having the same consumer protection rules with doctors and hospitals free to participate or not. This is as close to a private-public plan that is being considered and has some merit although it is very unlikely that in practice doctors or hospitals really would be able to not participate.

Overall I am disappointed that these are the only ideas being considered and do not think it is wise to rush to a decision with no real outside input.

Thought for the day

" If anything matters then everything matters".

W.M. Paul Young

Falling off my bike at age fifty-seven

Falling Off My Bike at Age Fifty-Seven

It was a great idea. I had a meeting at 7:15 am and it was only three miles each way. I was going to get in a meeting and my exercise in one fell swoop. At the meeting everyone was adequately impressed with my aging attempt at cardio exercise even though I never broke a sweat. The meeting was over in an hour and I was feeling good, so I decided(in my perfectionism)that three miles back home was way too easy. I would make a detour to Alvernon and put in another two miles. Yeah, I was doing it all right; after all...what could go wrong?

Alvernon is a wide, steady moving example of inter-city congestion. I knew it had a bike lane and felt like it was a safe road to travel. I biked from Country Club to Alvernon with no mishaps. It was great. As I started riding on Alvernon, I noticed that that the road had gaps of about three inches wide every so often. I never noticed that before and preferred to have a smoother ride if possible. So I decide to move onto the sidewalk; less bumpy and I've always felt that it is a safer place to ride. As I made my move, I saw the lip of concrete that separates the street from the driveway entrance. Did you know that a one-inch high piece of concrete could literally mangle you? As I expertly (NOT!) guide my bike onto the driveway towards the sidewalk...BAM! I didn't have time to react or scream. My transportation once my friend had suddenly turned on me or should I say slipped on me. One second I was happily riding along, the next second I was on the ground. The bike slid out from under me as easy as butter melting in a hot pan.

I lay there, my 57-year-old overweight form lying halfway in the bike lane and halfway in the driveway, my bike resting partially on my body. All I could do was be still. Okay I tell myself, don't panic, take nice deep breathes. Breathe, breathe. I breathe and I pray. Three minutes seems like eternity when concrete and flesh meet. The morning rush hour traffic is moving by my horizontal body at a predictable speed. One woman bless her soul, shouts out her car window, asking if I want her to call 911. She is halfway down the block before I could stoically say no don't bother. I lie there looking at the sky wondering what all these people must be thinking of me. Do they think I'm dead? Do they think I am drunk? On the other hand, do they just think I'm stupid? They are probably not thinking of me at all.

I take stock of my situation. Nothing seems to be broken, although my ego is bruised. I sit up slowly, unable to make any sudden moves. I start taking inventory of my body...ams, legs, hips, shoulders, everything seems to be in order. Could it be I fell and didn't hurt myself? A few bruises and scrapes but that was all. A woman walks over and asks me if she could call someone for me. That was nice. I told her I was all right and that I have a phone. Whom would I call? Why would I call? I'm not hurt, my bike seems okay. I get back on my bike and finish the ride. I finally arrive home to safety. I am afraid of how this fall will affect me later.

All of a sudden I realize how frail and vulnerable I feel. Of course, I do all the right stuff; ice, ibuprofen, relax, breathe, pray, call work. I could have done without this one adventure. As I lay on the couch nursing my wounds, I wonder if I should give up bike riding. Am I too old? Should they have remedial classes for bike riding specifically for the age-challenged? This accident makes me feel old. I have never felt old before. This is not a good feeling. Thank God feelings are not facts. Well, I have felt worse things, like cement forcefully interacting with my body. I think I am taking myself too seriously. However, I do know this, I will get back on that bike. I will get back on that freaking bike if it kills me! What is the definition of insanity...doing the same thing over and over again expecting different results? That's me.

Fifty-seven and holding

Health Care Reform Proposals

As I indicated before I will spend some time over the next few days to review some of the proposals for health care reform that are being considered by the US Senate and the Obama administration. Again the opinions expressed here are my own and do not represent the opinions of Cottonwood.

One proposal being considered is that of eliminating the tax exempt status of health care benefits and discontinuing flexible spending accounts. Currently this tax exempt status is a tax break available only to those that have health insurance through employers and unavailable to those without health insurance. There is an anticipated savings of over 200 billion dollars per year on what essentially is a tax hike. But it also is essentially a "salary reduction" on those who have employer sponsored health insurance. These salary reductions do not affect the employers' bottom line as the changes really directly affect the worker. I don't really know what to make of this proposal. On the one hand the "haves" get more through health insurance tax breaks but this is also true for the tax break on home owner's interest payments and I don't think anyone would seriously considering eliminating that.

I am just not sure that a tax increase and effective salary reduction is a good idea in a time of recession. I would love to hear what other people think on this issue and really would like comments. Thanks.

Thought for the day

There are no easy answers.

Health Care Reform

I am back after having been gone to Dekalb, Illinois to see my oldest daughter graduate with her Master's degree in philosophy. It was a very fun trip and I enjoy spending time with her.

I want to talk a little bit about health care reform as that is currently being considered by the US Senate and the Obama administration. I will outline the various options that are being considered but today I just want to look at one of them, the idea of making a Medicare like program to all Americans. My views are my own and do not reflect the views of Cottonwood. This is my personal opinion.

Medicare has been a program that provides insurance coverage by the Federal government for all adults 65 or older. In many ways it as been a successful program but it is in financial difficulty now and there are proposed payment rate reductions to both health care providers and hospitals.

One problem I have had with the program all along is the lack of choice available to seniors. A person age 65 or older does not have to use Medicare. However if a patient wishes to go to a physician and pay out of pocket he or she is prevented from doing so as the doctor is not permitted to charge the patient outside the Medicare program if he or she sees any Medicare patients at all. So while I had my office practice no patient for confidentiality purposes could pay out of pocket or I would have run afoul of federal regulations with severe penalties. I had to bill Medicare. That is just not right. For psychiatric patients the reimbursement was only 50 % of the Medicare charge. I did see a number of geriatric patients but each one was a financial loss. If a Medicare like program was available to all Americans I do not see how a psychiatrist could maintain a private practice. Hospitals cannot survive on Medicare payments as well.

Another problem with this approach to health care reform is that because of lower government set rates the private insurers will be gradually driven out of business and the Medicare like program would then be the only insurer, restricting both patient choice and and resulting in restriction of services.

I hope that this approach to health care reform is not adopted.

Thought for the day

One size does not fit all.

Graduation

Friday is an exciting day for me! My oldest daughter is graduating from her Master's degree program at Northern Illinois University. She will be entering a doctoral program in philosophy at Notre Dame this fall which she has been working toward a long time. I am very proud of her and it will be nice to see her again. Our younger daughter is going with us. She and her sister are very close. My guess is that they will want to catch the first midnight showing of the new Star Trek movie when it is released this weekend.

It will be a short trip for me. I will be off blog for several days but will be back on Monday. Until then,

Thought for the day

It is a blessing to be a father.

NIDA Alcohol Smoking and Substance Involvement Screening NIDAMED

The National Institute on Drug Abuse (NIDA) has released a new program designed to help physicians be more proactive and more proficient at asking patients about and screening for alcohol and other substance abuse problems. Overall, we as physicians have not been very good about screening for these disorders despite taking care of the many medical and surgical/trauma complications from substance abuse that we see everyday. It has never really been clear to me why this is the case as we know that those with substance abuse use an inordinate share of medical resources. It has been somewhat of a mystery to me why we have been so poor at this. There are signs of changes. For instance the American College of Obstetrics and Gynecology has recommended substance abuse screening for all patients. Trauma centers must screen for substance abuse in order to maintain accreditation.

One problem maybe is that physicians as a group don't really know how to ask about alcohol and drug abuse problems. The National Institute on Drug Abuse has now provided a way to make that task easier. Through their NIDAMED resource center there is now an interactive web based program, the NIDA Alcohol Smoking and Substance Involvement Screening (NIDA-Modified ASSIST) which guides the physician through initial screening questions and then with follow-up questions. If the initial screening questions are negative the program ends but if there is an initial yes answer the program moves forward. Not only are the follow-up questions computer program driven but it also provides recommendations for what interventions may be appropriate. The questions and recommendations also can be used in a printed form. I have looked at these and they look pretty good. Another feature is that this program can be integrated into the electronic medical record (EMR) which is becoming increasingly necessary today.

So I recommend that physicians take a look at the NIDA Alcohol Smoking and Substance Involvement Screening which can be found through NIDAMED at www.drugabuse.gov

Thought for the day

The web is amazing.

Telaprevir Chronic Hepatitis C Infection

I read a news report the other day about a potential advance in the treatment of hepatitis C. Telaprevir is a new experimental drug that may decrease the number of people who develop severe complications from chronic hepatitis C infection.

Hepatitis C (HCV) is a viral induced liver disease that affects approximately 3 million Americans and over 170 million people worldwide. It is the most common blood borne infection in the United States. It is transmitted from person to person by contact with the infected individual's blood such as sharing dirty needles, blood transfusions before hepatitis C was recognized, needle sticks, and any blood to blod contact with sexual activity. It is a slowly developing disease and most people who have it do not know they are affected as it might be years before symptoms develop. It is a chronic infection in that the virus continues to live and cause liver damage. It is a potentially fatal disease as those with chronic hepatitic C infection are highly likely to develop liver cancer or liver scarring leading to cirrhosis. There is no vaccine for hepatitis C. The only treatment available has been peginteferon and ribavarin administered for 24 - 48 weeks. Peginteferon and ribivarin helps the immune system fight off the virus which in about half the cases leads to eradication of the virus as measured by loss of serum HCV virus RNA. But less than half of all patients respond and continued treatment in those in whom it is not eradicated initially does not affect the outcome. So better treatments are needed.

Vertex Pharmaceuticals is in process of testing the new drug telaprevir which is suppossed to directly attack the virus. Initial studies show that telaprevir is effective in about 65% of patients who take it along with standard treatment for one year. This is a considerable advance but like many treatments is associated with some significant side effects and many patients quit taking the drug primarily because of rashes and gastrointestinal complaints. So at least there is a new option for treatment, telaprivir, which may be available soon and help save the lives of a number of people with chronic hepatitis C infection who are not helped by current treatment but as in most areas of medicine more research and other possibilites are needed.

Thought for the day

"Which one of you by worrying can add even one hour to his life?"

Jesus of Nazareth