My NEW ADHD Research Summary: Out of Pure Frustration With Lack of Current Knowledge!

[MedStudent82]

Hey all,

So, as most adults with ADHD find, and especially those newly diagnosed like me, the process of "trial and error" when personalizing/matching ADHD medication(s) to oneself in addition to titrating them seems grossly unscientific and frustrating. As with other psychiatric conditions, there is no blood, genetic test, or brain scan that can diagnose ADHD. A big source of my frustration has to do with how little knowledge we have about the neuropathological basis of ADHD in addition to any genetic regulatory/epistatic and proteomic level biomarkers to test for, which could help a) diagnose a very "real", indisputable disorder in the brains of ADHD patients, and b) guide psychiatrists down a protocol for better targeted medication therapies (AMP vs. MPH vs. non-stims according to what ADHD subgroup people are: Inattentive, Hyper, or Combined).

The past 5 weeks I've had to throw myself to the cognitive/behavioral mercy of 3 different stimulant medications in all their side-effect glories: from Adderall to Focalin to curretnly Ritalin, and I've had to indepthly research them all upon every switch in order to assess expectations (just "taking them and seeing what happens" and constantly evaluating them day-to-day for 2-3 weeks each is an agonizing process). Adderall seemed perfect in the behavioral department, but I couldn't do cognitive tasks/follow lectures or lab presentations, text, email, etc. fast at all. I was cognatively slow on Adderall to a pronounced degree (moreso than others I've come to find out). The MPH side of meds let me think clearly, but they don't give me the concentration/motivation Adderall gave me. Instead I'm just quiet, still, and stuck on whatever task it is at hand (whether it be productive or procrastinatory). And while I'm grateful that I'm moving in the right direction, I can't help but think that it is a monumental loss of energy and time considering how biomedically advanced we're supposed to be.

We are in freaking 2011, ADHD medications are a $4+ Billion dollar industry, and they're just NOW getting around to doing global-genomic studies, fMRI clinical trials with ADHD medication efficacies, cross-medication and dosage effecacies on cognitive vs. behavioral performance? They didn't really even know that ADHD persists in adults until relatively recently, when they've had Ritalin since the freakin '50s?!?

Here is a compilation of new studies I've researched that show that there is indeed breakthroughs about to happen in the basic biomedical research area of ADHD. I hope this helps you, because I've been obsessed with it all for the past month. Various levels of results I've found:

1) Newest Neuro/Genetic Research: (Poelmans et al paper):
They've started making breakthroughs in neurodevelopmental protein maps/networks specific to ADHD helping with understanding the disorder (using the new "Ingenuity" and "BINGO" pathway bioinformatic analysis software that my lab has also started using with immunological studies -- essentially does a battery of tests on many genes (microarray analysis) and computes very complex down & upregulatory effects of genes on one another -- very cool! but still in its infancy with kinks to work out, but still offers an unprecedented complex computational analysis that would take us an eternity to do by hand), specifically 45 out of 85 ADHD gene candidates that are directly related to neurite outgrowth and pathway formation that they can now rigorously investigate. They also have brand new ADHD candidate genes that will hopefully guide research into psychopharmacological ADHD treatments in the near future.

They're beginning to also find genetic microdeletions, gene copy number variants, and significant (though subtle) epistatic interactions among neurochemical pathway genes all over the place, and also specific gene deletions in genes related to melatonin signaling pathways which lead to melatonin deficiencies (hence another reason many ADHDers find it harder to fall asleep, amongst a ton of other multifactorial reasons).

2) Newest Opinions on General Treatments for ADHD (Medications in combination with behavioral therapy):
Stimulant medication still provides the most dramatic/effective treatment for adult ADHD symptoms even over cognitive behavioral therapy alone, and a recent finding that meta-cognitive therapy (MCT) is found to have the best success as a supplementary treatment for ADHD over simple cognitive-behavioral therapy (support group sessions with a psychologist moderator). Dr. Mary Solanto, a world-wide leading ADHD PhD psychologist of the Mt. Sinai School of Medicine and AD/ HD Disorder Center who published this 2010 paper developed a 12-week program at Mt. Sinai School of Medicine AD/HD Disorder Center to help people with ADHD learn to manage time, break down daunting tasks into manageable steps and keep themselves organized.

"One mantra of the program is: "If it's not in the planner, it doesn't exist," says Dr. Solanto. In a study of 88 patients published last month in the American Journal of Psychiatry, they found that those who participated in the program improved significantly more than those who received more standard supportive therapy."

'Generally, ADHD can make life very difficult. It's thought to be an imbalance in neurotransmitters, the chemical messengers that relay signals in the brain, particularly in the frontal cortex that governs planning and impulse control. Adults typically have trouble with paying attention, focusing and prioritizing. Managing time and money are particularly difficult.
"What it really is is a disturbance of the executive functions of the brain -- it's the inability to plan things, to initiate them at the appropriate time, not to skip any of the steps and to terminate them at the appropriate time." -
http://online.wsj.com/article_email/SB10001424052702304620304575165902933059076-lMyQjAxMTAwMDAwNjEwNDYyWj.html

This paper is now currently changing the landscape of how psychiatrists/psychologists/APA may advise future protocols for ADHD behavioral therapy. (Quick summary article on this paper from Medscape.com: http://www.medscape.com/viewarticle/718932).

Yet Dr. Solanto admits that meta-cognitive therapy is still relatively new, and isn't offered in most local communities. Also, there's debate over whether her method in the study was really metacognitive therapy (MCT), but instead just rather a combination of cognitive-behavioral therapy (CBT) with time management and organizational skills training (challenge OP/ED article here: http://ajp.psychiatryonline.org/cgi/content/full/168/3/327-a). I just bought her book Dr. Solanto just recently published (March 2011) for physicians to use, interestingly titled "Cognitive-Behavioral Therapy for Adult ADHD: Targeting Executive Dysfunction" (ISBN-10# 160918131X). It nonetheless goes into graphic detail about new CBT methods for ADHDers that she used in the 12-week sessions that include even all the new smartphone syncing note/organizational apps like Evernote, iCalendar, ToodleDo, Outlook, etc.

In addition to medication and self-help books (I don't have much time before med school starts in the Fall! lol) I'm also thinking of hiring an ADD behavioral therapist or counselor, and have found http://www.coachfederation.org/ to be helpful in finding an ADD coach, though I may just choose a local one. Having someone there who can whip your *** into shape and hold you accountable once or more times a week to get a good organizational system down seems like a pretty good idea, as I don't want to take any chances on another undergrad-style ADHD coping disaster.


3) Newest Evidence for Stimulant Medicinal Effects on Cognitive and Behavioral Outcomes:
Basically, I wasn't crazy when I thought the Adderall was making me think excrutiatingly sluggishly (Ha!). There have only been spotty studies in the past on stimulants and how they affect academic performance. Basically there has been no recent substantive adult ADHD research, and the focus was always on kids. In the 90's researchers only focused on improvement of behavioral symptoms of ADHD in children and an "overall improvement" in school. They did not delve into the variables of different stimulants used (MPH vs AMP), high or low dosage and each of their affects individually on behavioral remission vs. cognitive increase/decrease. They've finally had brand new (2011) studies come out which focus only on MPH that show that MPH does improve academic performance, but that lower doses actually assist academic cognitive processing more than higher doses. Even though higher doses of MPH produce more desired behavioral symptom relief for parents, the kids can't think as straight on the higher doses and do better on lower doses on tests/math problems, verbal reasoning, etc. Kind of makes sense, but they LITERALLY have not done any of these studies before (ludacris, right?). They've also found in another 2011 study that long-acting MPH (Concerta, LA, Methadote, etc) improve overall academic and memory function and decrease impulsivity in kids overall. This is because they comply with medication more if it's once a day (DUH) and don't have to go to the school nurse every lunch and get teased by kids. The goal for most people once they're set/titrated on a med or combo of meds is to have a long-lasting dose exposure. They've also found (2011) that MPH improves cognitive performance a little, but not by being a cognitive processing or organizational/executive function enhancer, but by simply helping the brain be aroused at a higher/normal state to allow for better focus/attention and less impulsivity and anxiety. They also found out (Chinese study) that IQ isn't significantly affected, but that overall cognitive performance is helped, again through better focus/concentration/less impulsivity.

What this new info does for me is establish a set of expectations (not just placebo effect or empty expectations that I'll get magically better at organization through a pill, but rather have to keep working on organization myself with better applications and methods). Knowledge is half the battle

So, I hope this is helpful to you all! (Sorry this is so long, I've stayed up all night b/c I was "hyperfocused" like no one's business this weekend literally glued to my computer trying to get to the effing bottom of what's going on with me). But at least I'm self-aware about "hyperfocusing" -- 5 weeks ago, I thought I was always just weird like that.

Happy Monday

Selected References (not full format, but enough):

1) Poelmans et al, Integrated Genome-Wide Association Study Finding: Identification of a Neurodevelopmental Network for Attention Deficit Hyperactivity Disorder (Am J Psychiatry 2011)

2)Segurado et al, Epistasis between neurochemical gene polymorphisms and risk for ADHD (European Journal of Human Genetics 2011)

3)Lesch et al, Genome-wide copy number variation analysis in attention-deficit/hyperactivity disorder: association with neuropeptide Y gene dosage in an extended pedigree (Molecular Psychiatry 2011)

4) Chaste P et al, Genetic variations of the melatonin pathway in patients with attention-deficit and hyperactivity disorders (J Pineal Res. 2011 Apr 27. doi: 10.1111/j.1600-079X.2011.00902.x. [Epub ahead of
print])

5) Solanto, et al, Efficacy of Meta-Cognitive Therapy for Adult ADHD (Am J Psychiatry 2010)

6) Knouse et al, Current Status of Cognitive Behavioral Therapy for Adult Attention-Deficit Hyperactivity Disorder (Psychiatr Clin N Am 33 (2010))

7) Hale James et al, Executive Impairment Determines ADHD Medication Response: Implication for Academic Achievement (J Learn Disabil 2011)

8) Wigal et al, Academic Behavioral, and Cognitive Effects of OROS Methylphenidate on Older Children with Attention-Deficit/Hyperactivity Disorder (Journal of child and adolescent psychopharmacology 2011)

9) Zhang et al, Effect of Methylphenidate on Intelligence Quotient Scores in Chinese Children With Attention-Deficit/Hyperactivity Disorder 2011)

10)Claire Advokat, What are the cognitive effects of stimulant medications? Emphasis on adults with attention-deficit/hyperactivity disorder (ADHD) (Neuroscience and Biobehavioral Reviews 2010)

[Dizfriz]

MedStudent

Very good recap.

One of the betterr ways of keeping up at this level is Russell Barkley's ADHD Report. This is aimed at clinicians and educated parents and is written with that audience in mind.

You can access many of the back issues at no charge with a subscription. There is also a subscription discount for those who are either are ADHD or are parents of an ADHD child.

I do not normally recommend things that require buying but this is one of the best sources on ongoing information and research on ADHD available.

One of the recent issues had a good article on the progress in developing a CBT protocol for ADHD adults.

I am not going to recommend you subscribing but it might be worth your while looking into it.

In an attempt to say within the guidelines, I am not going to post a link but you can look up "Barkley ADHD Report" on a search engine if you are interested.


Good luck this semester,



Mods: if this steps over the line, please remove it and let me know. I posted it because The ADHD Report is somewhat special in the area of educating about ADHD and is a major project of Barkley's since 1993.

As I understand it, this publication is a point of pride with him and he puts in a lot of work on this. A good bit of original research is presented as well as recaps of ongoing research.


Dizfriz

[Retromancer]

Thanks Med Student. I quickly cut and pasted your post to Google Docs. (Setting the spacing at 1.5) Available as a PDF at:

https://docs.google.com/viewer?a=v&p...thkey=CIqowOkF

I'm going to print this out later and pull out the highlighter etc.

Originally Posted by War Lord

wall of text/10

[Anna B]

We Know the problem,
the causes are multiple,
body/brain development are proven,
treatments vary as stimulating the brain is only partial response,
what I would like to know is how many mothers were malnourished while expecting-
what medications did they take during first,second and third trimesters.
How many were on birth control within 1-7 years before conceiving, And whats the first academic activity you remember learning- please relate entire setting. Thanks Querymom, Anna B

[Dizfriz]

Anna, this was a thread from 6-11. I doubt the op is still around.

This is very easy to do and I have posted a number of times without catching the data.

Dizfriz

[Anna B]

Have you posted specific questions to gather consensus on things like maternal health and prescription use somewhere? Reading older posts like crazy but can't find info. is there a way to pose a checklist type questionnaire without the id of indaviduals posting being visual? I would really like list type format, of things like profession, education, meds, brief med history,to compare...?

[Dizfriz]

Originally Posted by Anna B

Have you posted specific questions to gather consensus on things like maternal health and prescription use somewhere? Reading older posts like crazy but can't find info. is there a way to pose a checklist type questionnaire without the id of indaviduals posting being visual? I would really like list type format, of things like profession, education, meds, brief med history,to compare...?

You are really over my head here. I simply post on the forum and have very little expertise on how it works. You might contact one of the moderators as there is a way to do a poll but I haven't a clue of how it works.

Dizfriz