ADHD: Diagnosis, Symptoms & Treatment

Welcome to the Psychiatry and Psychotherapy Podcast. The podcast to help you in your journey towards becoming a wise, empathic, genuine and connected mental health professional. I'm your host, Dr. David Puder, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. I'm here with Dr. Michael Cummings for another episode on psychopharmacology and just general psychiatry and wisdom on ADHD. So today we are going to be going through the diagnosis of ADHD, the treatment, some of the biggest gaps that people have in their knowledge of ADHD. And yeah, Dr. Cummings, welcome to the podcast. Thank you. I'm pleased to be back. And indeed, I will attempt to pay attention. So let's start out by posing that question I did when I first came in. What are the biggest gaps that people have in your mind that they need to learn in terms of ADHD? I think probably the first gap or first need that people have is to be careful in making the diagnosis. ADHD has at times been a fad within psychiatry and has been over diagnosed. Children are inherently more active and less attentive than adults are. So people need to pay attention to the criteria in terms of failures of attention and overactivity. And impulsivity need to be of such magnitude that they truly cause distress and social dysfunction or academic dysfunction or in the case of adults work dysfunction in order to qualify for the diagnosis. You were telling me one third of people in Orange County at one point were diagnosed or treated or everything? At one point, the LA Times published an article that opined that one third of the children in Orange County suffered from ADHD. I suspect, frankly, that's not true. The better done, more rigorously diagnosed, studies suggest that prevalence in children is somewhere between 6 and 8 percent. In adolescence, about 2.8 percent and an adult is about 2.5 percent. There is an amelioration of ADHD as people mature as their cortex becomes adult in terms of configuration. That is not to say that it doesn't exist. And indeed, one of the myths that used to exist was that ADHD essentially went away with the onset of puberty. That's certainly not true. There is a decrease, particularly in the hyperactivity, but often attentional deficits remain into adulthood for people who have ADHD as children. Yeah, and I was looking at France and the difficulty of the diagnosis in France was that a child had to be admitted to an impatient hospital to get the diagnosis at one point, at least when I was reading this. Yeah, which is probably an overly conservative approach to diagnosis of the disorder. I think probably the better approach is that, which is suggested by a lot of child psychiatrists, that is that there be noted deficits in terms of function and problems socially and academically noted by both parents and by educators. I think in particular, this is an area where teachers input can be valuable in terms of most teachers get pretty good at recognizing the one or two children in their class who are more impulsive, more active, less attentive than everyone else. Often, the boys are easier to spot because they tend to be hyperactive, hyperkinetic. The girls are a little bit more difficult. They tend to more often fall into the inattentive subtype of the disorder. They may not be hyperactive or disruptive, but may not be doing well academically simply because they're not able to attend to information that's being given. In France, actually, there was a mother support group for kids with ADHD to the point that they were really upset with this need to be hospitalized before the diagnosis and treatment could begin. I find that in sort of contrast to people in America where it's like in some places it's likely highly overdiagnosed in other places where you don't have treatment providers that's probably underdiagnosed. Yeah, and one indeed, the problem is that unlike many disorders that have very clear markers, attention and the ability to modulate attention, of course, of varies in the population along a spectrum. And the difficulty often is withdrawing the line between what is simply somebody who is less attentive than the next person and somebody who's actually suffering from a disorder. I think that's where the key elements of the inattentiveness and the impulsivity and the hyperactivity are actually having a negative impact on the person's ability to perform academically or their ability to work if they're an adult becomes an important criterion with respect to the disorder. Yeah, and in regards to that, we have an article that we've reviewed before this and we'll share it with you guys on quality of life and how ADHD influences quality life and treatment of ADHD changes quality life. Would you like to say anything about that article? Yeah, that article is an excellent review of the disorder, both its criteria. And also, I think, underscores the point that the real reason the motivation for treating this is that ADHD does deteriorate or impairs the person's quality of life, their ability to function. I've had patients whose work life, I'm not a pediatric psychiatrist, so I don't didn't typically see people as children, but I've had adult patients who basically could not function at work unless they were treated. You know, they simply couldn't get anything done because they couldn't remain on task. Yeah, so I saw one group heavily because I used to work at a university locally and I would see a lot of these kids come in. Most often not treated in high school because they were high functioning enough to not need treatment. But once I got to college and the stress increased, they found it more difficult to procrastinate to the very end and sort of get everything done last minute because of just the weight of the material. And I see this also in medical students at times where they did, you know, they're very, very bright students and they were able to sort of put it off to last minute in college. And then, you know, when that sort of adrenaline picks up, people with ADHD can focus better. But when they get to medical school, just the pure amount of information that they have to learn is so vast that they can't do that anymore. And so they run into issues. How do you, I've seen that yourself. Yeah, that's very much true. I think that's the other thing that is somewhat confusing about the diagnosis at times when people are emotionally engaged when they are doing something that they are highly invested in, even if they have ADHD, they are able to focus. But if the demands are overly long or more mundane, that's when they run into the deficits imposed by the disorder in terms of ability to maintain a sustained focus and attention. You know, for people who don't know much about ADHD, you can replicate many of the signs and symptoms of ADHD and normal healthy people if they are adequately fatigued. If you are drowsy and you've been up too long, if you're a resident or a medical student, you've been on call. Everyone finds it more difficult to focus, more difficult to pay attention. There is a rustlessness in order to maintain alertness that begins. Those are many of the same. conditions that people with ADHD essentially live with at baseline. This disorder has been characterized as essentially a failure of the reticular activating system to adequately stimulate the portions of the brain above the brainstem. That is the cortex and basil ganglia, such that it's kind of like being a little on the drowsy side all the time. You know what's interesting about that is I find medical students who get through two rotations do a lot better once they're on the rotations that are interesting to them. For example, when they get to ER and they're doing their ER shifts, they don't even need to take medications because they're so activated, they're so, you know, the information is so novel coming at them and often they don't need medications at that point. Whereas to do the book work and to do, you know, study histology and pathology and all of these things, it's like really, really hard for that type of work. And it almost makes me think, you know, is there a type of person that has a survival advantage to have a higher threshold needed for activation, like so that they naturally are prone to, you know, do higher risk tasks, you know, things like, you know, that other people may have too much fear to do actually. It's almost like they need that higher threshold of activation to get them going. Well, from an evolutionary standpoint, certainly since ADHD has been conserved in the genome of humans, one would think that it must in some way serve a purpose to have people who are less attentive and less they are stimulated. And indeed, it may be that these are the people who are more likely to choose activities or professions that provide them with the stimulation they need to be alert and to pay attention, as opposed to those who are perfectly content to engage in more quiet activities and can remain focused for long periods of time without a great deal of external stimulation. So, let's get to a little bit of the treatment. So, what are the main categories of treatments for ADHD? The major category of pharmacological treatment are the dopaminergic stimulants. These drugs essentially serve to either increase the release of dopamine, the amphetamines, or to block its reuptake on drugs like methylphenidate. The amphetamines both increase release and block reuptake, whereas methylphenidate more purely is just a reuptake inhibitor for dopamine. The effective dopamine, of course, is to increase both motor activity and they basil ganglia. And most people, if you give it to a healthy person, you'll get more movement. Interestingly, if you give more dopamine to a person with ADHD, they'll actually become calmer and less motorically active. Essentially, you're returning them to what is more similar to the healthy populations state in terms of dopamine signaling. For those who don't tolerate or don't respond to dopamine increasing drugs, the other approach has typically been to increase norepinephrine with drugs like Adamoxetine or some of the noreadrinurgic anti-depressants or with the alpha-2 agonist like Guantfacine, thereby increasing the person's alertness. About 70% of people respond to dopamine urge agents. About 30% either don't respond or can't tolerate the increase in dopamine. Because of either insomnia, increased restlessness, anxiety or other side effects, such as anorexia. So let's start with anxiety. I think I've seen a lot of people with ADHD actually have comorbid anxiety and I had that explained by a professor, I don't remember who in a Grand Roundsly, I listen to saying that there's a survival advantage of both having ADHD and being willing to do high-fear tasks but also having the comorbid anxiety which keeps them from killing themselves from doing these high-risk things. So having these paired together is frequently what we see when patients come in. What is the first line for a person with that sort of anxiety? Would you treat the anxiety first or would you try something else to treat both the ADHD and the anxiety at once? Typically with people who have comorbid ADHD and anxiety, the most frequent approach to try to address the anxiety component is to increase the amount of serotonin that they have. And that often is done via giving them a selective serotonin reuptake inhibitor, along with whatever drug they are taking to ameliorate the attentional deficits that they have. Either dopamine, stimulant, or an adrenergic agent, or of course some patients simply take a mixed mechanism antidepressant to attempt to ameliorate both problems. Most children and adolescents with ADHD do best with a dopamine and an adrenergic agent, although those are also problematic in some people. Including things like the anorexia weight loss and inhibition of the release of growth hormone and children in particular. If somebody chronically takes a stimulant, they will be about an inch to an inch and a half shorter than they would have been had they not taken a stimulant during childhood and had lessons. Do you think that's enough of a decrease in height to actually be concerned about it? It depends very much on the individual and the inherent genetic makeup that they have. If you are talking about somebody who comes from a family of very tall people, you know, if you're 6'5" as opposed to 6'8", well that's not much of a difference. On the other hand, if you come from a very short family in terms of height, you might prefer to be 5'1" as opposed to 4'9". So there are those sort of social and cultural issues to consider. Yeah, that's interesting. And you said the other thing was anorexia. How often is that? It occurs to some extent in almost everyone treated with an opaminurgic drug. It is severe enough to be of clinical concern, fortunately, and only a very small minority, less than 10% of people treated with drugs like methylphenidate or with one of the amphetamine stimulants. There are approaches to that. There have been at times advocacy for drug holidays during periods when the person may not need to be as attentive. Of course, whether that's an advisable thing to do or not depends a lot on how disruptive the person's behavior tends to become if they're not on a stimulant. If there are people, if they're just inattentive, it may not be much of a problem during school vacations. On the other hand, if they're prone to a great deal of impulsivity and disruptive behavior that may cost them in terms of social consequences, there is a positive association between suffering from ADHD and the development of conduct disorder and the development later of anti-social personality disorder. Same more about that, the conduct disorder and anti-social personality disorder? One of the characteristics of people with ADHD, particularly during development and childhood, is they tend to be impulsive, often acting without thinking through the consequences of the behavior, which can lead them in some cases to do things that essentially get them in trouble either in school or in their social group. That can become a self-reinforcing phenomenon. If you're in trouble, and you're eventually viewed as the, quote, "bad kid" close quotes. Well, you may then begin to take on that role as something of an identity. One of the studies that comes to my mind is on car accidents, and how treatment of ADHD changes the amount of car accidents someone gets into. Can you speak to that study? Yes, that study was interesting. Well, obviously driving requires attention and responses, and if people are indeed prone to do impulsive things, if they're not prone to pay attention, that's an excellent setup to increase the rate of auto accident, and indeed accidents of other sorts. People with ADHD have overall a higher rate of injury than the general population because there are many circumstances in which not paying attention to your environment can be dangerous. And there's also studies showing decreased future smoking and drug use in people who are treated for ADHD? Yes, one of the interesting things, and something clinician struggle with is, of course, in particular, dopamine and urge agents, so I can't fit a means, and methylphenidate, do have diversion and abuse as a potential problem. But in people who are appropriately treated with stimulants who have ADHD, their later risk of drug addiction or drug abuse is actually lower than those people who don't receive appropriate treatment with those agents. And indeed, I think one of the things that occurs in people who don't receive appropriate treatment, including the psychosocial treatments and education about their disorder, for many people who have ADHD, the first time they run into a stimulant, perhaps experimenting in college, they, for many of them, they describe it as the first time they ever felt normal, which can be a powerful lure to revisit the experience of feeling more normal, and being able to pay attention, but without guidance, without education, that can become a pathway into drug abuse rather than an appropriate treatment. So what would you say to, like, a parent who says, "Well, aren't we just giving them methamphetamines?" Well, we're not giving them methamphetamine, which is, of course, a very highly psychoactive stimulant. The methyl group on the amphetamine increases its absorption and effect on the brain. The amphetamines that are, in use to treat ADHD, are essentially variants of dextro amphetamine. There are even versions now in terms of formulations available, which are very difficult to abuse, vivants, lide, dextro amphetamine, is essentially lysine, the amino acid, bound to the amphetamine molecule, until that lysine is removed, and the GI tract, you essentially have an inactive prodrug, so that if somebody attempts to abuse it by inhaling it or injecting it, nothing happens, because it won't enter the brain. It'll simply float around in their bloodstream. Similarly, some of the slow release versions of methylphenidate, methylphenidate, ER, concerta, are encapsulated in forms that don't release the drug easily, except very slowly in the GI tract, again, making it very difficult to divert or abuse those formulations. What would you say are other differences between abusing amphetamines and using it therapeutically? It is very much similar to abuse or appropriate use of any molecule. The person who is using a stimulant appropriately is using it essentially to improve their functionality, that is to be able to pay attention, to be able to sit still, to be able to function better. The person who is abusing a stimulant is taking it for the purpose of getting high, that is altering their mental state and taking essentially the euphoric effects of the stimulants. In many ways, that could be set of all substance abuses versus treatment with substances that can be abused. What about the order of magnitude? If someone smokes methamphetamines and they get their high, how is that dose different compared to the use of, let's say, Adderall XR, 20 milligrams? The typical person who is abusing methamphetamine on the street, the common term used on the street is going for a speed run, and we will consume about half a gram to a gram of methamphetamine during their speed run. That is much different than somebody who is taking 10, 20, 50 milligrams of methylphenidate or amphetamine a day in order to maintain their alertness and their ability to concentrate. It is about an order of magnitude difference between the people who abuse and the people who are using the stimulants appropriately to treat their ADHD. I once had a patient in the emergency room who would just put a little bit of methamphetamine in her coffee every morning. I almost wondered as I listened to her story because she wasn't necessarily getting high off it if she just had ADHD or not, and if she was self-treating. Do you think that methamphetamines is the drug of choice for people who maybe have ADHD and just haven't had the diagnosis and treatment? There are people who probably do self-medicate with amphetamines or with cocaine, you know, in most of the world. Cocotee is a legal product and indeed people in the Andes have been chewing coca leaves for likely millennia in order to improve their alertness and their ability to work at high altitudes. In those forms where they are taking small amounts on a regular basis, there is not much evidence that that constitutes the characteristics that would be typical of addiction or abuse. I think one of the important things in thinking about addictive disorders is that the addictive disorders have as a core characteristic the use of a substance in ways that leads to a deterioration and the person's ability to function. And indeed one of the principles I learned in residency was to judge people's use of any substance or medication based on is it improving their functionality or is it deteriorating their functionality as to whether this constitutes abuse or addiction? Interesting. Okay, so we've talked a little bit about some of the side effects, but are there other side effects that you think are maybe misunderstood by people or new research has come out to sort of maybe contrast that it's not as big of an issue as we thought it was? I think when they're appropriately used, these stimulants are by and large, fairly well tolerated and generally safe class of medications. When they're misused, they can be very dangerous and indeed the dopamine stimulants in particular can be dangerous in children in terms of things like cardiac arrhythmia, a rare outcome, but it is a risk with the mixed-and-fedamine salts in particular. This is why I think it's important that people be plugged into an overall treatment program that involves a person with expertise, a usually a pediatric psychiatrist, administering and monitoring their medication use, engagement in psychosocial programs to help teach the person about their ADHD and to help them with techniques to improve attentiveness and their ability to work with others to be less impulsive. All of those are important elements of their treatment. Like many psychiatric illnesses. people with ADHD should not be treated with medication only. It should be part of a broader psychosocial treatment. Yeah, and I was looking at like, if a child is under the age of six, it should be pretty much behavioral treatment as first line. You know, psych. like, basically techniques for sort of overcoming through therapy, some of the deficits that are showing up. Yeah, indeed, the initial approach, as we alluded to, to begin with diagnosis should be made carefully. If the person does have ADHD, the first treatment should be behavioral and nature, and certainly psychodecational for both the patient and the family. And then medications should be reserved for those who don't adequately respond to those initial psychosocial interventions. I also think exercise is one of those pieces that I would definitely recommend for patients. I've seen a lot of patients who stop exercising at some point in their ADHD worsens, which leads to them coming in to see me as a professional. And, you know, like, let's say they were an athlete in high school, and they were, you know, doing three sports and working out all the time, and then they arrived to college, and they stopped everything. And all of a sudden, they have a much worse difficulty concentrating and focusing. And I don't know if you can speak to this at all. Yeah, I mean, basically, aerobic exercise in particular enhances synthesis and release of a number of neurotransmitters, including neuropinephyrene and dopamine. So the person's level of alertness will be enhanced by routine aerobic physical activity, as opposed to becoming more indolent and less active. That will tend to make the person more vulnerable to both their attentional deficits and to that urge to become hyperactive and impulsive. So let's say someone comes in your office for the first time. They've never been diagnosed with ADHD. You start with a careful history, mental status, and in the history, you're looking at, you know, how things are at home, how things are at work, if they do work, or if they go to school, you know, how things are in their social life. And do they have symptoms across all sort of areas of their life? They typically do have effects of their inattentiveness or hyperactivity or impulsivity in several areas of their life. Those areas that are less demanding of attention won't be as obvious, you know, if they're in a job, for example, that requires periods of attention, completing projects, organizing projects. Those will inherently be more difficult for somebody with ADHD. And, you know, activities that are more recreational are that don't put as much demand on them. But you will see evidence of their inattentiveness and hyperactivity and impulsivity in a variety of settings. One of the things that's important in terms of diagnosing ADHD, particularly in younger people, children adolescents, is collateral history. Often people around the person with ADHD are maybe much more aware of their deficits than the person themselves, at least until they reach adulthood where the demands of society may make them much more aware of their problems. So one of the things in sort of the diagnosis of ADHD is the role of psychological testing. You know, there's a series of batteries of tests that PhD level psychologists can do in order to sort of clarify the level of inattention and also the level of their sort of IQ and how those sort of are relating to how they're doing in life and functioning in school and such. Would you like to speak to that or talk about when that would be necessary to get or helpful to get as a psychiatrist or treating professional? Yeah, psychological testing can be very useful in a couple of ways. One, to help confirm the diagnosis because these tests are normed on large population groups and essentially what you're doing is comparing your individual patient to the average performance of population on a given test and most of those functions are normally distributed in the classic Gaussian curve. So you can tell how far away your patient is from the mean in terms of their ability to attend and maintain focus to perform cognitively. The other element that's very useful for a psychiatrist is to get a benchmark of their performance before beginning treatment and then once treatment is in place, both psychosocial and medication, to follow that up with later testing to essentially see how effective your treatment has been. Frankly, that can be useful in a couple of ways. One, clinically certainly to know whether your treatment is optimal, but also for very pragmatic things like documenting for the person's insurance carrier that yes, this treatment is effective and here's the proof in numeric form. Yeah, luckily insurance hasn't been so nitpicky in my patients that they're asking for such details at this point, but well, I have to clarify. Sometimes they don't want me to start more expensive ADHD medications first. They want to several trials of the other sort of more generic ADHD medications. Indeed, one of the problems with the things I can mediate release to methylphenidate is the short-acting drugs are more prone to diversion and abuse. Even in those people who are not vulnerable to diversion and abuse, they're of course by definition short-acting. The person will be on something of a rollercoaster ride in terms of being attentive and functional and not being attentive or functional. Having to take another dose, that's particularly important for children and adolescents in a school setting where they may have to go to the school nurse to get their mid-morning dose of stimulant, which can be somewhat embarrassing. The longer-acting controlled release medications are often much more effective and much less prone to side effects than the short-acting and medial release drugs. The problem there is the cost, right? Because the short-acting, you know, you go to Costco, you can get these sometimes for $20, $30 for cash pay. Whereas the long-acting, you know, I've had patients who lose their insurance and they're like, "Dr. Peter, what do I do?" And it's like they go to Costco, which is, or someplace, you know, where they sell bulk and cheap usually. And it's like $300, $400 for their long-acting stimulant. And they're like, "I just can't do this." And so it's like, "Okay, we're going to have to do a short-acting. We're going to have to take it three or four times a day." But that's what we need to do. Yeah, you are, you know, you and the patient are sometimes stuck in that situation. The long-acting drugs are from ecologically preferable, but they are more expensive because most of the long-acting drugs are also proprietary, which means expensive. Cost of medication is something in the US that we still have not dealt with effectively as a society. Drugs are higher priced in the US than essentially anywhere else on the planet. And more drugs are invented in the US than anywhere else on the planet. Yes. And indeed, the pharmaceutical companies depend on the US market to recoup their R&D costs because in many other countries the prices they can charge are limited by the governments of those countries. Whereas in the US, that's not true. And indeed, even for large social programs, there are prohibitions in law against, for example, government agencies negotiating drug prices, which is probably, well, it's to the benefit of pharmaceutical firms because it's expensive to bring a new drug to market. But it's not very good for consumers who If they're having to pay for the drug out of pocket, drugs can be prohibitively expensive and, indeed, there are a lot of people who don't receive adequate treatment in our society simply because they can't afford it. So Dr. Cummings, let's talk a little bit about the alternative to the dopamine stimulants. What are some of them and what are their mechanism action and are they as good as the dopamine stimulants? Okay. The classic stimulants are those that increase the available dopamine in the brain. The other class that can be useful for those people who don't tolerate increases in dopamine or who can't, for other reasons, be treated with dopamine orgic agents are a norepinephrine agent, so either drugs that decrease the reuptake of norepinephrine, this would be drugs like stratira, atomoxetine, which blocks the reuptake transporter for norepinephrine or any of the noreadrenergic antidepressants, drugs like bupropryon or leave them on the massopran or among the older drugs things like desepramine can increase norepinephrine as a way to increase alertness and attention. Essentially increasing norepinephrine decreases the refractory time after a neuron fire so it can fire more frequently because it repolarizes more quickly. The alpha-2 agonists, clonidine and guanfacine also can increase norepinephrine essentially by fooling the locustorulius into releasing more norepinephrine in the brain. In general, the noreadrenergic drugs are not as effective as the dopamine and ergic drugs, but maybe easier for some people to tolerate. What are some of the common side effects of these medications? For the noreadrenergic drugs, probably the single most common side effects, particularly early entreatment, would be increased anxiety, a feeling of jitteryness and some people insomnia, be sweating if they have difficulty with hypertension, increases in heart rate and blood pressure. Those are, in many cases, things that can be overcome by titrating the drug more gradually or being very attentive to the overall dosing of the drug. Are there any patients that you think that this should be started on first before the amphetamines? Likely, the amphetamines are, for most people who treat ADHD, they are the first line treatment. If the person, however, has things like difficulty with anorexia, concerns about statuary if they're still growing, if they have very strong family histories of vulnerability to addiction or abuse, then choosing a noreadrenergic agent first may be a prudent choice. And are there, for clonidine and guanfazine, are there any side effects of those medications of particular concern? Yeah, the clonidine can make people drowsy. It is a short half-life drug, so you have to take it several times a day in order to be effective. It also, and some people can cause them to become hypotensive, so they may be dizzy when they stand up. Guanfazine is usually somewhat better tolerated, it has a longer half-life and is not as prone to sharp peaks and troughs as clonidine. So most pediatric psychiatrists, if they're going to reach for an alpha-2 agonist, they'll tend to reach for the guanfazine first. And clonidine only, if the guanfazine, for some reason, isn't available. What about people who may have issues with aggression or irritability at baseline? Would that change how you would start, which medication you would start, or how you would dose the medication? Certainly, if they have uncontrolled impulsivity, that deserves a great deal of attention, because indeed dopaminergic agents can, and some people, increase impulsivity, depending on whether you're getting a larger effect in ventral-tegmental strital areas or a bigger effect in terms of cortical functioning. Interestingly, dopaminergic agents can both improve impulsivity, which is the most common outcome in ADHD, but you will find a subset of patients in whom dopaminergic agents worsen impulsivity. And those also tend to be the people who are going to be more prone to diversion or abuse of stimulants. As in all medicine, a good part of this and the choices have a lot to do with getting to know the patient well and being very careful about doing a really good benefit risk analysis in terms of what that person is vulnerable to versus what benefits may be available to them. Yeah, with regards to the irritability and impulsivity, I'm wondering about the come down portion for some of the amphetamines. It seems that like late at night when they're coming down off the medications, they can be more irritable or impulsive. Yeah, that's one of the major features that makes the long-acting drugs more desirable. The offset of the dopamine stimulation is much more gentle than with the immediate release short half-life drugs. Our formulation is often the same drug, just the formulation is different. The short-acting drugs are very prone to missing the mark in both directions. They can be peak plasma concentrations over stimulating. And then as they fall very rapidly to a trough, you get the irritability and the hyperactivity and essentially the person has a hard time being close to that sort of happy medium because the drugs are too high or too low a lot of the time. What about, like let's say they had impulsive sexual sort of behavior in the past that could be even of a forensic quality, how would that change your treatment? That would tend to make me pursue a noradrenergic agent sooner rather than later indeed dopamine stimulation as illustrated in Parkinsonian patients is very vulnerable to inducing things like compulsive sexual behavior, compulsive gambling because you're indeed stimulating those reward pathways whenever you give a dopamine agent. It's a case of having to modulate it so that you're getting optimal activity in those circuits between the nucleus accumbens and the forebrain versus overstimulating those circuits. And that can be a difficult target in some patients. So you would consider more of the noradrenergic medications. Would there be any, like with one particular patient I'm thinking of, like I'm very hesitant because I do not want the impulsivity because if this person becomes more impulsive, you know the consequences can be very severe to their life. So would there be, in this case, like out of moxetines, strutera would that be a good option? Yes. But here it does have several advantages. One, it's a long, inherently a long half-life drug. Dosing is typically once per day in the morning. So in those people, in whom it provides adequate improvement in their attention and their ability to focus, it's often an optimal drug because it has a very slow onset of action. They're not, you know, feeling jittery and nervous an hour after they take it. It lasts. long enough that they don't need to take multiple doses. The trough level is low enough usually by the evening that they don't typically have difficulty sleeping at least not after they accommodate to the increased norapen effort. They may have difficulty sleeping the first week or two, but that their insomnia will get better over time. And it does not tend to produce the sort of compulsive sexual or gambling behaviors that you see in some people with dopamine, dopaminergic drugs. Very good. Are there any other pieces of information that are important that you want to get out there before we finish this podcast? I think the one piece I would come back to is something that I think has been a problem with ADHD is that it should be carefully diagnosed. It has at times been an over diagnosed disorder. Children are not as quiescent as adults and that doesn't mean the child has an illness. So we shouldn't be too quick to apply the label of ADHD to people. It needs to be a careful, thoughtful diagnosis. And coming back to that psychological testing, one thing that I've seen is that people who it's not straightforward, I get the psychological testing for. And also if the people are planning on going into professional schools like dentistry or medicine because having that psychological testing can be helpful to get them denoted extra time on the MCAT or the professional test they need to take. Having that psychological testing can really be helpful as well because it can tell you like, okay, this is how you would expect them to perform. Like I've had several patients that IQ is off the charts on the psychological testing, but their ability to focus and concentrate that frontal lobe function is in the second or third percentile. And it's like, okay, this is the person who when they have treatment will respond very well. And so I think the psychological testing can be helpful, but it isn't in and of itself enough to make the diagnosis. No, you need the psychological testing should be considered almost like laboratory testing that is as a confirmatory measure for what you're entertained as a diagnosis based on the person's complaints, their history, information from collateral sources about the difficulties they've had with attention with hyperactivity. Those things should be the basis of the diagnosis. The psychological testing then becomes very useful for confirming your clinical impression and for benchmarking how severe their deficits are. And for, as we suggested earlier, measuring their response to treatment. Another thing I think you mentioned, which I think could be re-emphasized, is other than medications, the types of treatments that you would recommend. And I would be curious specifically for adults, are there anything that they can do without seeing maybe a professional that they could pursue on their own that would be helpful that you know about? Yeah, there are cognitive behavioral therapies that have been developed that are essentially self-administered either via computer in many cases. There are also therapies that are based on mindfulness theory that helps the person do a better job of self-monitoring so that they are able to better modulate their social interactions, their work interactions. And all of those things are important. As in any disorder, the more the patient knows about their disorder and how to deal with it, the better off they will be. Yeah, that's helpful. Let's see, any future developments that you see coming out that are going to be targeting this disorder? Yeah, there are several lines of research looking at different ways to stimulate structures in the frontal lobe such as the anterior singular gyrus. Things like rapid trans cranio-magnetic stimulation, direct current stimulation of specific areas of the brain, targeted at improving frontal lobe functioning that may lend themselves in the future to being alternative treatment approaches to things such as ADHD. Dr. Cummings, thank you so much for coming on and really appreciate it. I think the people out there appreciate it as well. Okay, thank you. It's been a pleasure. And we'll put some notes on the website regarding this episode and thank you Dr. Cummings for coming on. Okay, thanks. As we end, if you find this podcast helpful and need continued medical education and want to support the podcast growth, please sign up for the podcast continued medical education yearly membership. For each episode, you can take a short quiz to get category one CME and self-assessment CME. 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