Dr. Joel Young Discusses Medication And Adult ADHD

Thu, 07/30/2009 - 3:41pm

When: May 7, 2013 at the Pittsfield Branch

Contrary to popular belief, most children who suffer from attention deficit hyperactivity disorder (ADHD) do not outgrow the disorders; they become adults who suffer from ADHD. Join us as Dr. Joel Young shares his expertise about ADHD in adults and discusses medications for the syndrome. Dr. Young is an acknowledged expert in the adult phase of ADHD and the author of the book "Contemporary Guide to Adult ADHD." He is the Medical Director at the Rochester Center for Behavioral Medicine in Rochester Hills, Clinical Assistant Professor of Psychiatry at the Wayne State University School of Medicine and a Staff Physician at William Beaumont Hospital.This event was cosponsored by the Adult ADHD Support Group of Ann Arbor.

Transcript

[00:00:00.00] [MUSIC PLAYING]
[00:00:18.11] MATTHEW CUNNINGHAM: Hi everyone. My name is Matthew Cunningham. And I am an organizer for the Ann Arbor Adult ADHD support group. And I just have to say, about three weeks ago I was a little worried that we may have the same issues we had last time was a little bit of snow. It snowed early in April. And I'm not from here, so I was like, please don't snow. Please don't snow.
[00:00:38.65] Just a round of the hands or put your hand up if you've ever seen snow in May in Michigan. Oh my gosh. And you folks still live here which is encouraging. So you can get used to it. OK.
[00:00:51.55] Well this is Suzanne Ostrowski-Dansel. And Suzanne is our co-organizer. And we both want to thank you and welcome you to be speaker presentation tonight. Dr. Joel Young will be speaking about adolescent and adult ADHD and more specifically, into diagnosis and medication.
[00:01:11.08] And I'm going to talk real briefly about our group, the ADHD support group. And then I'll roll right into talking about Dr. young. So Dr. Young's presentation's going to be about an hour long. And then we're going to have a little room for Q&A at the end, right around 8:00ish, 8:15. So please hold your questions until the end. And as Beth said, this will be filmed so if you're a known felon or have unpaid parking tickets here in Ann Arbor, then please stand at the back. They already know me. There's no hiding. OK.
[00:01:45.67] We;re associated with CHADD, which is Children and Adults with ADHD. It's an international nonprofit that basically provides resources, social support, and advocacy for families that are coping with ADHD. And we actually work very closely with the parent chat CHADD group here in Ann Arbor that's led by Tim Garver, Dr. John Milanovich, and Dr. Elizabeth Hammer.
[00:02:08.30] And what we do for our adult ADHD meetings, we typically meet on the fourth Tuesday of every month at the Washtenaw Intermediate School District, Teaching and Learning Center which is at 1819 South Wagner Road, so just right around here in Ann Arbor. And we typically meet from about 7-8:30 PM. And we're going to be skipping our May meeting since we're having this one. We're going to start our summer informal discussion groups in June. So everyone's very, very excited about that. We did that last year.
[00:02:38.56] And we are also on Meetup.com. So you can look up Arbor Area ADHD/ADD support group. And the great thing about Meetup is that you can go on, sign on for free, and register. And with limited information, you can put your first name. You can create a username. But what's great about it is you can, once you're registered, any time we make a change, we add an event, we talk about a discussion group, anything, and we announce that, it automatically sends an email to you letting you know about that.
[00:03:10.73] And what's also great is it will send a reminder the day before, which some of our members of the group have said is pretty helpful. If you're the kind of person that tends to forget things from time to time. So that's helpful as well.
[00:03:26.28] And that's on those little sheets outside. If you saw those little mini flyers. It'll have the direct link. And if you have any questions after the meeting about the group, please feel free to send me or Suzanne an email at AnnArborAddults@gmail.com. And it's adults with two Ds, not one D, which is why I'm saying it weird.
[00:03:42.82] So when we first started this group, I was really unsure of the level of interest that this would create, how many people would show up. Sari Solden, who is a local therapist who works with adults with ADHD, and actually lined up a lot of our speakers for us, was sure we were going to have a great turnout out. But just like Michigan weather, no clue.
[00:04:02.38] But after the first couple meetings, it was clear that there was an unmet need here in Washtenaw County. I mean, we have folks who were newly diagnosed, adults who were diagnosed with ADHD. We had adults who thought they might have it but weren't diagnosed. And then we just a lot of folks who were curious, partners who thought their partner may have ADHD. Professionals who just wanted to know about this as a resource. So we're happy to become that resource for a lot of folks.
[00:04:25.71] And to be honest with you, after the first couple of meetings, well before the first meeting, I was a little worried that we wouldn't have enough to talk about. As you might be able to imagine, you put a bunch of adults with ADHD in one room, there's never lack of conversation. OK? I mean, it was like it was the closest I had ever been to being in a room full of comedians from SNL. Very bright, funny people, had a lot of fun.
[00:04:53.70] I had two new worries after that meeting and that was getting out on time and angering the janitorial staff. So we've been working on that.
[00:05:01.26] And real quickly before I introduce Dr. Young, I just really want to thank the Ann Arbor District Library for putting on this event tonight. When we first started this group we just wanted as many people to know about it as possible. It's a free resource in the community. And the library's promotion of this event has just gone way above our expectations. It's in calendars or it has been calendars all over southeastern Michigan. And more specifically, I'd like to thank Beth Manuel who's here behind your-- Beth, if you could raise your hand-- and Tim Grimes who's not here, but was great in putting this together as well. So let's please thank them with a round of applause.
[00:05:37.90] [APPLAUSE]
[00:05:41.78] All right. Now for the guest of honor and the main event. Dr. Joel Young is the medical director and a founder of the Rochester Center for Behavioral Medicine which is in Rochester Hills, Michigan. He is an Assistant Clinical Professor of Psychiatry at Wayne State University. He is a staff position at William Beaumont Hospital. And he completed his psychiatric training at University of Michigan Hospitals.
[00:06:05.68] Dr. Young is certified by the American Board of Psychiatry and Neurology with qualifications in geriatric and forensic psychiatry. And he's also a diplomat of the American Board of Adolescent Psychiatry. And I Dr. Young and his clinic have been the primary investigators in a number of clinical trials involving antidepressant, ADHD, and bipolar medicine. Dr. Young has contributed chapters to textbooks and writings to over 50 publications. And he's actually written two books of his own, at least two. Right?
[00:06:38.71] DR. JOEL YOUNG: There's a third one coming out in December.
[00:06:41.74] MATTHEW CUNNINGHAM: OK. So check these two out. Pay attention to the one that comes out in December. The first one was published in 2007 and that was ADHD Grown Up, A Guide To Adolescent and Adult ADHD. And the second one that was published in 2009 was Contemporary Guide to Adult ADHD. And to date, I think that book has sold over 50,000 copies.
[00:07:06.77] DR. JOEL YOUNG: That's correct.
[00:07:08.82] MATTHEW CUNNINGHAM: Which is phenomenal. And when we were first looking for a psychiatrist to come and talk to our group about adolescent and adult ADHD and medication, I consulted with Dr. Arthur Robin who was actually a speaker in March for our group. He talked about ADHD in relationships and he's a psychologist at Wayne State University who is very well known in the adolescent and adult ADHD community. And he said that Dr. Young was an authority on ADHD and medication. One of the best there is, which is a very powerful endorsement coming from Dr. Robin.
[00:07:41.51] We're very fortunate, very excited to have them. Please join me in welcoming Dr. Joel Young.
[00:07:46.65] [APPLAUSE]
[00:07:55.91] DR. JOEL YOUNG: Well what a nice introduction. Thank you very much to Matt and for organizing it and to the Ann Arbor Public Library. What a beautiful site and room. So thank you. And if any of you were here in February when I couldn't be here because I could not get out of Oakland County, I apologize for the inconvenience. It's a much more beautiful day.
[00:08:18.33] So I will talk a little bit about adolescent and adult ADHD. I have to be a little bit louder. Maybe I'll pull my mic up a little bit. And I'll speak a little louder. And if there are problems, let me know. And I'll ask the back row to monitor that.
[00:08:40.05] And then I'll go through the slides to tell you a little bit about the way I conceptualized this thing called ADHD. And then I'm really eager to entertain your questions so that we can address all things ADHD.
[00:08:55.82] We do a lot of clinical trials. Most of the ADHD medicines that have been on the market in the past 15 years have come through our clinic. And so we take care of a lot of people. I spend about 70% of my time taking care of people and then about 30% of my time doing clinical research. So we get our hands on various psychiatric medications, sometimes years before they hit the market.
[00:09:25.06] So today, I thought I would tell you a little bit about ADHD, the history of ADHD, talk a little bit about the prevalence and persistence, the economics of ADHD, which I think is pretty interesting as well, and why this is an issue of concern, not just to those of us in this room, those of us that treat people with ADHD or have ADHD or parent somebody with ADHD, but this has an impact on educators, the school systems, the penal systems, all aspects of society.
[00:09:58.88] It impacts, not only sociologically, but it impacts personally the impact on the quality of life is better understood now due to some research, which I'll share with you. Certainly functional process and impairments. How does this affect us on a day to day basis?
[00:10:15.92] We'll talk about how to make a good diagnosis because I think that that's key. There is so much publicity, it's hard to read the New York Times for a week without hearing some type of critical article about this diagnostic process of ADHD. It's actually quite amazing how much focus they have on this particular issue.
[00:10:37.81] And then we'll talk about comorbidities in adolescent and adult ADHD. What occurs with ADHD? And we'll talk about treatment. So we have a lot to talk about.
[00:10:49.45] The history of ADHD is actually pretty fascinating in and of itself. ADHD is not a new phenomenon. We certainly are talking about it more. One of the members of the audience, a member with whom I share a birth year, we talked about how things were less available when all of us were kids. Although, I remember in my elementary school years a few guys who were taking Ritalin and they were clearly hyperactive children. Some of them really had difficulties if I follow them through various reunions. So it was available.
[00:11:31.18] It is pretty interesting in my practice and in Oakland County sometimes seeing somebody in their 50s or 60s who was treated in the 1950s by faculty at Wayne State. The Department of Pediatrics was actually in the forefront. So there are people that were treated, but certainly far more understanding right now.
[00:11:52.39] But it has been covered in the literature. If you go back to the 100 years or so, there were discussions of what we now would consider ADHD to have been a morbid defect of moral character. Later became minimal brain dysfunction, which is rather pejorative, but at least they got the organ system right. This is a brain function.
[00:12:14.52] The hyperactive child syndrome is probably in the 1950s or so, as was the hyperkinetic reaction of childhood. In the psychoanalytic era, we talked about everything being a reaction to something else. And there was a reaction to childhood.
[00:12:32.88] It came into the modern era in DSM III where we started talking about ADD with or without hyperactivity, where a lot of people are now stuck because there is this big distinction between ADD and ADHD, which was clarified or maybe misclarified in DSM IV because we no longer have ADD, it's all ADHD. Right? That's the official diagnosis.
[00:13:01.02] But you have three different types of ADHD. You have ADHD predominantly hyperactive type, ADHD predominately inattentive type, and the most common is ADD combined type. So the nomenclature has changed over the years, but it really is the same young person, adolescent, and adult that we're talking about.
[00:13:22.61] So the prevalence is about 4-12% of children. And I'm more comfortable with about 8 or 9% if I look at some of the really good pinpoint prevalence studies. About 4.4% in adults. This will change. What's happening in May, actually this month, in San Francisco is the 2013 American Psychiatric Association meeting where DSM V will be announced.
[00:13:56.53] And the diagnostic criteria is changing for ADHD for adults to the extent that the belief is 4.4% of the population is actually a conservative estimate. And with the new criteria, the prevalence in adulthood will parallel roughly that of childhood, which is to say this is probably a persistent disorder. And if about 7 or 8 or 9% of children have this, probably that's the rate in adults. And the diagnostic criteria will be rewritten to be more inclusive at this point.
[00:14:36.35] So this is an old number, but they say 30-60% persistence. In my estimation, it's higher. I think it's probably 80%, which is sometimes disappointing news because families want to hear that this is something that they will outgrow or their child will outgrow. And I like to be optimistic, but also quite realistic.
[00:15:01.50] OK. So what we know is increasing. A lot of the work was done at Mass Gen and Dr. Biederman. and Willens, who was actually trained in Ann Arbor have their name on an awful lot of ADHD literature. They've been incredible contributors to the field.
[00:15:21.08] And among the things that they've identified is this is highly genetic disorder, more than 25% of first degree relatives have children with ADHD. So this is ADHD begets ADHD. Families can have the ADHD gene, although we haven't yet identified that. But it's rare for me as a psychiatrist to make the diagnosis of ADHD and not find somebody else in the family who has it.
[00:15:51.96] Now if they're not officially diagnosed, there certainly is a history, there's a remnant of this in previous generations. But this is a transmittable, considered one of the most inheritable of all psychiatric conditions. Of all physical traits, ADHD is right up there.
[00:16:12.61] This is what I mentioned before we break it down to the ADHD types. About 30% are people who just have ADHD inattentive type. They don't have hyperactivity. And this probably explains a lot of women with ADHD who don't have hyperactivity. They might have profound inattention and distractability.
[00:16:34.54] Part of the problem is we call it ADHD, predominantly inattentive type, and the H does stand for hyperactivity. So it's an absolute contradiction within the title. And this is a significant problem. I sometimes say it's Attention Deficit Hypoactivity Disorder because a lot of adults with ADHD feel lethargic and chronically fatigued. But it is officially ADHD Hyperactivity Disorder and I think that that's somewhat misleading.
[00:17:05.15] Interestingly enough, when we do a free association to what is ADHD, I would imagine most of us think of that eight-year-old boy who's bouncing off the walls and has a reserve seat in the principal's office. And yet, that's really only about 9% of people with ADHD, even though that's the image of what this disorder is. By and large, the combined type is what we see where people have symptoms of inattention and distractability and symptoms of hyperactivity. And they meet the criteria for ADHD combined type.
[00:17:42.98] This is a disorder that needs to be identified early on because it has an impact in the school setting and has an impact in the workplace. It just depends on your age. I was able to speak to a few people before tonight's talk. Some of you are in education and have been in special education. And so many children in a special education setting have learning problems and learning disabilities and ADHD is commonly seen.
[00:18:15.46] And as we know, this is one psychiatric condition which starts in childhood and then really develops [INAUDIBLE] to adulthood, but it starts, unlike many other psychiatric conditions which start much later in life. Depression, anxiety, typically.
[00:18:35.67] So this is an impact on counseling services, psychological services. Certainly, this to me should constitute a great deal of what education school should be, which is we have to teach teachers how kids learn and how they learn differently. And quite frankly, it surprises me sometimes that this is not really front and center in education curriculum.
[00:19:04.25] So I actually had a personal anecdote of this which is one of my children was in a classroom. She happens to be a good student and a diligent student. And she was in a classroom in third grade she was with three other children, two of whom had very severe ADHD. And she really turned very negative that year. It was a very difficult school year for her. We found out after the fact that the classroom was quite disruptive. The teacher, who was a veteran teacher, really had a very difficult time with these children.
[00:19:43.93] And subsequently, one of the children moved out of the district, two of them got treated. And the second part of the school year was really much more positive. The impact it had on me, I'm usually on the treatment end of it. But was to watch a non ADHD, in this case my daughter, how she was effected, the residual fact on not just the poor children who are suffering and their families, but actually the spillover effect it had on other people as well.
[00:20:13.15] So obviously, this appeals to those of us who are touched by this disorder or those of us who treat it. But it really has an impact certainly in the classroom. If you think of a prevalence rate of about 9%, it's going to affect all sorts of kids, not just the kids who are struggling with learning.
[00:20:34.99] Anyway, as we move later into the system, we see children with ADHD are more likely to have juvenile justice issues. They are more likely to have substance use. ADHD is a risk factor for the development of substance use disorder. There are statistics to show that young adults with ADHD are more likely to have really childbearing. And there's also more evidence that they're more likely to be careless and have higher rates of injury. So the orthopedic surgeons and the psychiatrists have a lot to talk about.
[00:21:11.01] And certainly, family costs. There are higher medical rates. There's actually data to show that families that have ADHD have higher medical bills. There's lost productivity because there's higher rates of accidents.
[00:21:25.35] We also know that folks with ADHD have higher absentee and this impacts productivity. I think they were hit in this most recent recession. I do take care of a lot of adults with ADHD. As you know, we had a very tough time in the last 10 years in this economy. I saw them to be the first laid off and sometimes the last, sometimes still not rehired.
[00:21:55.21] And this particularly hit many of the adults with ADHD in there 40s and 50s. They left the workplace during the recession. And they have had a hard time integrating and staying up and getting back into the system. So the impact is really widespread.
[00:22:17.85] So let's break this down a little bit and talk about inattentive symptoms and what it looks like in childhood and what it looks like in adulthood. So these are core ADHD symptoms of inattention. People within attention have difficulty sustaining their attention. They have a hard time with homework. They have a hard time with chores. And as they get older, they have a hard time with paperwork. So these are folks that report that they can never get their expense reports done. And they languish.
[00:22:47.82] As children, they lose things. As adults, they lose things. They procrastinate. They have trouble budgeting their time. And this is really very problematic to them. They say, I don't know. I'm working but I'm just not getting anything done. And in our society that so values productivity and now can measure it, there is really very little wiggle room.
[00:23:13.32] As children, the parents will bring their child in with an audiology report. They say, I thought my child could not hear. And I'll look at the audiology report and it's perfect. They can hear. That's a cranial nerve. They have no problem hearing. There's a difference between hearing and listening. And children with ADHD who have listening problems become adults. They sometimes are inefficient. They sometimes have a hard time processing multiple steps.
[00:23:46.90] Children with ADHD have trouble with follow through. Adults with ADHD begin things and don't finish it. So the classic report is there's no toilet in our bathroom. My husband took out the toilet to repair it and it's not back. The house is unpainted. Three rooms are unpainted or just enough so we can't inhabit it. And just can't get it done. But he started with such a flourish over Memorial Day weekend. And now it's Memorial Day weekend 2013. And problems with organization are key issues that are problematic.
[00:24:23.69] Let's move on to hyperactivity. So DSM is actually pretty economical when it comes to hyperactivity. I think they don't give enough definition to it. So DSM says children with ADHD have troubles in their seats, sitting quietly in their seats. Adults say, oh, at board meetings or any large meaning, I just can't tolerate it. It's just very, very difficult.
[00:24:52.33] And one thing about folks with ADHD, I realize is many of them hate boredom. None of us really like boredom, but people with ADHD are allergic to it. They don't want anything to do with it. They will avoid situations where they get bored. So they have to keep busy. And if they can't, then it's repellent to them.
[00:25:18.30] And consequently, this is part of maybe helping a child learn, is sometimes they should be allowed to doodle while they listen. Maybe some kids do better learning while standing up. It's such that not everyone needs to be sitting behind a desk to learn. There are all sorts of ways that people learn. And if you go to the library here where lots of Ann Arbor spends their time, some kids are studying in solitude and some like to study in the middle of the party. So there's not one way that people need to concentrate. And there's not one way of learning.
[00:25:57.71] Some of the other hyperactivity symptoms are interrupting others. And frequently, patients will tell me I was raised better than to interrupt, but if I don't interrupt right then and there, I forget what I'm going to say. So I have to interrupt or else it's gone forever.
[00:26:16.29] At the same time, you can also get people who are quite obsessive compulsive of what they tell you because they don't want to forget any detail. So they're overly inclusive at the same time. Again, just wanting to spill it so that they don't feel that they've missed anything.
[00:26:37.82] So what persists in this whole spectrum of ADHD as you move from childhood to adulthood. It's not hyperactivity. We see hyperactivity in children. And we see it in some adults. But what really persists are inattention, inattentive symptoms. Inattention and distractability persist into adulthood. Whereas the hyperactivity might get somewhat better, we see that this is a very problematic for folks. And there's nice data showing that.
[00:27:14.61] Again, this slide constitutes what is the progression of symptoms from childhood to adulthood. And this is seen in adolescence. Sometimes the hyperactivity can be picking your fingers or skin picking or twirling your hair, but it's some type of physical activity that somehow is calming to the ADHD soul.
[00:27:41.23] And one sees it so frequently that it is quite clear that what people want to do is they want to kind of soothe their own sense of anxiety or agitation. And they find various ways, sometimes hyperactivity, sometimes skin picking, picking their nails, other ways which seem on one level problematic, on the other level, there are somewhat calming to folks with ADHD.
[00:28:17.19] So we'll talk about ADHD. And I think one issue that we're having difficulty with is years later still getting clinicians to make the diagnosis of this. And what I hear frequently are people frustrated with access to care and major universities and departments of psychiatry are not paying attention to this disorder. There's a lot of emphasis on mood disorders and a lot of emphasis on anxiety disorders. And a lot of emphasis on psychotic disorders. But right now, we're not addressing these issues of ADHD.
[00:29:00.94] One way that clinicians can pick up ADHD is using rating scales. And this is maybe a technical slide. For those of you that are clinicians, you might find this interesting. My point in including it here is there are a number of different rating scales. What I encourage mental health professionals to do whenever somebody presents in distress, which basically is everyone in your waiting room because who else would want to wait for you, they're in some type of distress.
[00:29:32.82] And what I think happens to people in distress-- doctor I'm anxious, doctor I'm depressed-- is they do often get a default diagnosis of a mood disorder or depression. And I argue that if you screen for ADHD, lo and behold, you will find it. The rates of ADHD are similar to the rates of depression and anxiety. And it's the responsibility of a mental health professional not to make this a default diagnosis. Oh, well everything else failed so let's think but ADHD. This should be considered at the first breath of the first evaluation.
[00:30:08.22] And there are a number of rating scales. I won't get into each one of them. They do different things. And at a meeting of ADHD diagnosticians, people argue which scale they think is the best. What we do at our clinic is we actually give all three of them. The Brown scale, the Conner scale, and the self report. And we find that they're all valuable in some ways.
[00:30:34.45] But they need to be given to people who are complaining of frustration or high levels of anxiety because they're highly prevalent disorders. And these rating scales are out there. Some of them are in the public domain. Some of them are proprietary.
[00:30:52.42] This one is in the public domain. This was put up by the World Health Organization. And it's actually online. You can get it at the World Health Organization. And their website is here. It's also at NewYorkUniversity.edu.
[00:31:12.43] But actually, if you go to the World Health Organization and type in ADHD, you'll get this. And it's brief. It's a screening. It's not a diagnostic scale. But very helpful in making the diagnosis. And very helpful for clinicians to give their patients.
[00:31:32.02] So when we talk about assessing this. We really ask what's bring you in today and why now. One of the interesting questions about people with ADHD is if they present when they're 20, and they have ADHD. They've had a for 20 years. If they present when they're 45, they've had it their entire life. I'm actually a geriatric psychiatrist. And we regularly see this in people in their sixth and seventh decade of life. The prevalence doesn't change.
[00:32:03.59] There's a long tradition in psychiatry of using Ritalin for treatment of depression, but probably in retrospect, we're treating adult ADHD. But the folklore is that it's a treatment for geriatric depression. So everyone is under suspicion who can have this. It's not just kids under 15. It can be really anyone. And it's really important to ask why you're here.
[00:32:38.00] Many people will struggle with ADHD their entire life. Many of them have been in the system. Many of them, as I said, have been diagnosed with other disorders. But very frequently, this disorder more than anything when I ask people why they're here, it's because my child was diagnosed with ADHD. Or very commonly, I saw this on Doctor Oz. I saw this on a website. This is one example of the democratization of illness and access.
[00:33:09.32] What's not happening is the people are not necessarily hearing it from their doctors. They're approaching their doctor and saying, do I have this? Which is very different than a lot of other conditions. Because you can't walk out of your doctor's office without him telling you about your weight or your blood pressure, right? They're approaching you. We need to be in the situation, this is such a high prevalence disorder that it really shouldn't be consumers chasing doctors. It should be to some extent, the other way around.
[00:33:36.16] And so it's really important to ask why you're here. And very few people say I can't focus. I can't concentrate. I can't get motivated. I can't sustain my motivation.
[00:33:47.69] And it's important to ask when did these symptoms first appear. And it's very important to get this collateral input from spouses or parents because sometimes folks with ADHD, believe or not, may not be the first people in the room to know that these symptoms are there. Really important to get this input from other people.
[00:34:13.42] One characteristic feature of ADHD is that it's chronic, right? It doesn't let up. A lot of other psychiatric conditions have episodes-- major depressive episode. We have a beginning, middle, and an end. ADHD is persistent unless it's treated. It does not relent.
[00:34:32.27] There are times that it might be more problematic, right? It's more problematic in October when the semester is heating up than it might be in July when there's not as much going on. But the symptoms are there.
[00:34:45.73] And one of the key things for a clinician to understand is, are the symptoms that you're complaining about longstanding and persistent? Or do you have episodes-- a beginning, middle, and end? ADHD is a more chronic condition.
[00:34:58.76] We always think about medically what you can rule out because we want to make this diagnosis very carefully. And that's why I suggest for clinicians using all sorts of different rating scales. But also to think about this-- could this be something else? We look at thyroid conditions. Theoretically, could present, although I have to say I rarely find thyroid abnormalities to explain a chronic history of inattention and distractability.
[00:35:30.14] Theoretically, you could also concern yourself with iron deficiency anemia. Could also help explain some of these conditions.
[00:35:38.81] Family history is key in making the diagnosis. Again, as I mentioned earlier, this tends to run in families. And it's unusual to find somebody where there is no other history whatsoever. And when I hear that, I look at people, nobody else has struggled? Nobody else has these symptoms? It makes me, as I'm always doing, redouble back and think about my diagnosis because it tends to run in families.
[00:36:11.06] These are some of the observations. Does the patient have a hard time sitting still sometimes? Your patient is very impatient. Tapping their feet. Really having a hard time even sitting through a discussion. You know when people have extreme inattention is when they're in your office and the focus of conversation is them. And they're still distracted. Because nothing is more interesting than ourselves, right? But if even that gets boring or is distracting, then that's an observation of inattention distractability.
[00:36:53.47] On the other end of the spectrum, people that talk excessively. We know this is part of the diagnostic criteria, just having a hard time editing yourself. Losing your train of thought. Starting one place and ending up in another place. And these conversations are such that you focus and you think you're going to follow through to the end of the conversation. Then you find yourself lost. They you start again and then you find yourself lost again. And then you know that this can be a problem with distractability or starting one place and not really finding its logical conclusion.
[00:37:27.24] And people are often disorganized and late because they have a hard time staying focusing. I think Matt alluded to this in his comments.
[00:37:37.95] To get the diagnosis of ADHD, and again, I think we have to be most accurate in this diagnosis, but we look for problems in more than one domain of life. Right? If you're only having problems at home but you're doing well in school and the workplace, there might be something going on at home. There might be some discrete problem.
[00:38:00.98] Truly the diagnosis of ADHD is across various domains. And these are individuals who are having trouble in the workplace but they're also having trouble at home. Their family is unhappy because they're not following through or they're having a hard time with consistency. Or they might have some problem with anger or impulse dis-control. They're also having the same problems at work or in the school setting.
[00:38:25.63] So this is a disorder which in its ideal sense crosses the various domains that we all have. We all wear different roles, different hats in our personal, academic, and our professional life.
[00:38:42.43] To people that don't have ADHD or who write for the New York Times, I think this sounds like a trite disorder. It is anything but trite. And I think about this. And I've had to because I don't have ADHD, but I think about these children that do. So you have a hard time focusing. You have a hard time concentrating. And one of the principles of being a student is somebody's evaluating you every moment of the day every day of your academic life. You're getting report cards. You're getting feedback, which is great if you're doing well. Terrible if you're not.
[00:39:30.06] And it's happening to children at the most vulnerable times. They don't really even have the psychological defenses to be philosophical about it. They're just not matching up. And I think about the impact this has on a child's life. It's quite clear that a school will look feudal. There's going to be a subgroup of kids who are going to resent their teachers or the principals for continually giving them bad news.
[00:39:59.20] And humans don't like doing things that they're not good at, maybe with the exceptional of like golf where people keep going back. But by and large, people don't do things where they know what the outcome if the outcome's going to be negative. No doubt that school will be a negative experience for many of these kids. And again, unlike adults, they really often don't have the coping skills to say, well I'm good at other things.
[00:40:25.98] So we see that by fourth or fifth grade they get disenchanted. High rates of dropouts in kids who don't have intervention. So it's not trite. And early intervention and identification is necessary. And school systems should be doing this. We got fluoride treatment when we were kids. We got hearing tests. There's no reason why kids should not be screened for something that has such a high prevalence rate.
[00:40:52.49] And I see kids in my practice who come out of public schools and out of the elite private schools. And the private schools are no better at picking this up than the public schools. And it lends itself to public health intervention because you use screening tests, they're not diagnostic tests. You just screen and then you bring it to somebody who's more of an expert. No reason why this shouldn't be really done regularly in the public school setting.
[00:41:24.52] What frequently happens to kids is they start in the public school setting. They don't do well. People don't identify why they don't do well. And they migrate to private or parochial schools. So these kids are actually congregated at private schools because they usually started in the public schools and they end up there because parents are just dismayed. What's wrong? Well it must be that it's a bad teacher student ratio. That's not it at all. It's your child can't focus and concentrate. And it's incumbent on educational professionals to identify this.
[00:42:05.28] Impulse dis-control. Remember the three tenets of ADHD are hyperactivity, inattention, and impulsivity. If you can't control your impulses, you're in difficulties. So we teach our kids to keep their hands to themselves, but that takes a little bit of impulse control. We tell people not everything you think about somebody should be said. Right? That takes a little bit of filtering and impulse control. If you don't have that, you get into trouble. You alienate your friends quite quickly.
[00:42:35.85] And there's an impact on self esteem if you alienate others. People will distance themselves. And people can get pretty lonely.
[00:42:47.34] We see kids with ADHD are often parented by adults with ADHD because we've already established the genetics of this, although we just touched the surface of it. So kids with ADHD are more likely to be brought up in homes where there's divorce. So they're having difficulty often wherever they turn.
[00:43:09.57] So let's talk about this functional impairment. There are a number of studies that have looked at it. And these are just common events that are more likely to affect ADHD populations. They are more likely to be in households with divorce, more likely to be in households where there is separation compared to folks without ADHD.
[00:43:34.87] They're less likely to report a good relationship with their parent. They're more likely to have been addicted to tobacco. More likely to have used excess alcohol. Much more likely to use recreational drugs. Much more likely to have been arrested. So you can see the trend.
[00:43:55.90] Higher rates. I mentioned this earlier higher rates of underemployment and unemployment folks with ADHD. And in my experience running this clinic where we see a lot of folks with ADHD as I mentioned, once they are out of the workplace, they have more difficulty getting back into the workplace. So they end up with high rates of disability. We've seen this in our folks.
[00:44:24.26] And other functional impairments. These are predictable from some of the things I said before, but we actually have studies which follow people out. This was Dr. Barkley's study who did a longitudinal study of kids with ADHD grown up. And he followed these kids every two years for nearly two decades. And he looked at their rates and compared them to control populations. Higher rates of being jailed. Higher rates of being involved in assaults, shoplifting. Shoplifting and ADHD are often synonymous because shoplifting so commonly is an impulse dis-control.
[00:45:06.10] And I have people in my practice that have shoplifted dozens of times. They can't control their impulses. Judge doesn't know what to do with a 65-year-old woman who's been arrested 20 times. What do you do? How do you punish somebody like that? So shoplifting is a very nice example of how folks with ADHD can get into trouble. Chronic shoplifting. I'm not talking about criminal.
[00:45:39.82] Poor credit ratings. Exceeded the card limit, et cetera, all sorts of economic issues associated with having ADHD.
[00:45:49.27] So as we move to the treatment, I know there's going to be a lot of interest in treatment. But this question is of intrigue to me. Why now? Why do you come see me now?
[00:46:03.30] So we know a couple things. We know that hyperactive males are more likely to get diagnosed earlier, probably because they're noisy and people pay attention to it. They do incur the wrath of their teachers and their principals and the referral is often made. So in our practice that takes care of children, one of the presentations is an ultimatum. The school says that unless you treat my child, my child has no future in that school. So that's diagnosis by ultimatum.
[00:46:39.99] Later on, when people present, they don't present because someone says you have to get this child identified and treated. Later presentation is associated with female, women, and higher IQ, which might be the same thing. And they are more likely to compensate until later on in life.
[00:47:04.49] I always say that somebody with ADHD hits the wall at some point. It could be when you're six and it really could be when you're 36 or later. There's usually something that's going on. And oftentimes, if it's just the ADHD alone, people compensate. But if they have a second issue, they become depressed. They become anxious. Their parents go through a divorce. They enter middle school. They enter their freshman year. They leave home and leave their routines. They enter the army.
[00:47:34.00] Sometimes, it's two things that occur, it's this perfect storm that creates the presentation. So that's often my question. Why now? Why are you seeing us now? And oftentimes, they've seen other people before. So it's been a chronic problem.
[00:48:01.89] The impact is profound. So at one point, we ask people how ADHD impacted them? And these were patients of ours that had time to think about this. This were not newly diagnosed people, but this is the luxury of knowing people over years. And then at some point, we just asked a few of them to write down how your life would have been different. These are people with contacts. These are people who've been diagnosed for years. They've had time to think about it. Some of them might have been in some type of therapy.
[00:48:33.50] And somebody says, well I would have made a better choice of spouse. And probably would not have gone through a divorce. Other people say more mundane things. Friends wouldn't have to repeat themselves. I wouldn't seem like I was aloof or I wasn't listening. I probably would have stayed away from self-medicating with drugs. I probably would have avoided that period of my life of promiscuity. So I thought these were real words from real patients.
[00:49:05.07] On their professional life, I would not have as much job hopping. I would have benefited from knowing my limitations and seeking resources instead of feeling so incompetent.
[00:49:23.56] So we will give folks all sorts of ways of compensating for these conditions. I think at the core of helping people compensate is treating them. And in this particular condition, treatment, I think, the focal point are medications. But there are also some psychosocial things you can do. You can help them with organization.
[00:49:52.12] Also help them with education and knowing what their rights are. There is some provision under the Americans for Disability Act. Schools have to accommodate. The workplace, theoretically, should accommodate. Although this is more difficult to do.
[00:50:07.57] And so treatment is comprehensive, but it involves helping them with medications, helping them with psychotherapeutic techniques, also helping them look back at their life and see really how their life has been impacted. And practical tips like teaching them how to use organizers and encouraging them to do that and encouraging them to stay consistent. That's one of the things that a therapist or a coach can do is keep somebody consistent as much as possible.
[00:50:42.06] OK. So again, these are our symptoms of ADHD. And this slide speaks to why I think ADHD is so commonly misdiagnosed. And one of the most common misdiagnosis of ADHD in adults is people say I've been called bipolar or even bipolar type II disorder. And you can see the overlap between hyperactivity and particularly mania. And folks will say well I was called manic because I talked too much or I'm on the go. And on the left hand side of the slide shows the hyperactive and impulsive symptoms. And explains how it could be misinterpreted as part of a mania in bipolar disorder.
[00:51:32.43] So again, when I hear the diagnosis of bipolar disorder or previous diagnosis of bipolar disorder, I think ADHD. When I think of ADHD, I want to make sure that it's not bipolar disorder.
[00:51:44.80] And this slide helps explain some of the differences. And I mentioned them before. ADHD are chronic mood symptoms and manic symptoms are episodic. That's the most important thing. ADHD's not associated with psychosis, where is people with bipolar disorder can become psychotic and end up having auditory hallucinations or delusions.
[00:52:08.45] And people with bipolar disorder have long episodes of depression or normal or mania. These can last days or weeks. People with ADHD have rapid mood swings up and down within the course of an hour, certainly within the course of a day. So when you hear somebody up and down or you can even witness how quickly their mood swings, that's really not bipolar disorder. And that will not respond to bipolar medications. That responds really nicely to ADHD medications. Now one of the under-appreciated benefits of ADHD medications is that they stabilize mood.
[00:52:49.32] We find that as I mentioned ADHD really is a risk factor for other psychiatric conditions. We see higher rates of conduct disorder in adolescents with ADHD. So they often get in trouble because they often don't have a lot of empathy and they can treat other people harshly and they're more likely to get into difficulty because of it. So conduct disorder is one of the common disorders comorbidities that we see with ADHD in adolescence.
[00:53:30.11] But we also see high rates of depression with ADHD. And that might be one most common things that we see in our clinic are folks that have both ADHD and major depression. If you have both those conditions, you can't just treat the depression or can't just treat the ADHD. One needs to treat both if you're going to get a good outcome.
[00:53:51.84] This is some work that was done by [? Brookette ?] and published in 2005 which is showing that ADHD is perhaps a risk factor for the development of personality disorders. So people are more likely to have histrionic and even borderline personality disorders. And this is of particular interest to clinicians and therapists that treat folks.
[00:54:14.84] So again in our clinical, whenever somebody presents with a history of a personality disorder we wonder why-- let's talk about histrionic personality disorder. People with histrionic personality disorder more theatrical. They don't exactly react necessarily well or appropriately. They might overreact to situations. It's great on the stage. It might be difficult if you're married to somebody with histrionic. It might be difficult if the person next to you at work has histrionic personality disorder.
[00:54:49.69] And it might be a situation where folks with ADHD because of their inattention and their distractability they're not reading other people well. And they're not really reading well how they're transmitting their own behavior. And so consequently, they're more likely to stand out. And a really good treatment is to see if there's an underlying ADHD.
[00:55:10.98] When people can focus and concentrate and slow down and read other people's faces and nuances, then it actually affects their interpersonal relationships quite dramatically.
[00:55:25.75] Again, high rates of substance use disorder, high rates of anxiety disorder. I made the point earlier that one needs to distinguish ADHD from bipolar disorder, except in a situation where both ADHD and bipolar disorder run together. And that's a difficult thing to identify and to treat, but it's actually very compelling to treat because it often addresses some of the most refractory of all patients who are struggling with both conditions. High rates.
[00:56:03.59] OK. So I know people are interested in treatment and I want to focus on that for the next few slides as I go into the home stretch. When people have, patients have ADHD, when they present, we want to identify and treat in rank order if there;s substance use disorder. So if patients are actively drinking or alcoholic or using, we have to identify that and stabilize that.
[00:56:34.96] If they're very depressed, suicidally depressing and have ADHD, we certainly want to stabilize them, stabilize their mood, and their anxiety. And then we identify ADHD. This is not to say that we shouldn't think about ADHD early on. We should. But this sometimes for clinicians they want to know where do you start. And typically, we start by looking at substance use, then looking a mood anxiety disorders, and then focusing in on ADHD. This is debatable. And certainly, I'd be interested in taking part in that debate.
[00:57:14.07] Treatments have gotten better. And I left the University of Michigan, Department of Psychiatry in 1993. And at that point when I started my practice, I was interested early on in ADHD, we had to Ritalin. We had Ritalin and Dexedrine. We had short acting Ritalin. And then we had this explosion in the 1990s and the early 2000s of long acting medications. And so the first drug that captured our imagination was Concerta. It was long acting Ritalin. It came out about 50 years after methylphenidate or Ritalin came out.
[00:57:53.43] And finally, in year 2000, we were able to deliver this over the long term, over a 10, 11 hour period. And that's really very important. So prior to that, we were asking people who were disorganized and inattentive to take medications every three or four hours. Very hard to do.
[00:58:14.12] So this was a great example of a clear need. I remember early on in my career I said, I wish I could give you something that lasts the whole day. And then two, three years later, I was able to say we have something that lasts the whole day. It's actually been very nice. And the movement has been and should be towards long acting medications. It's more convenient. It's greater for confidentiality.
[00:58:37.66] If you put your child on the bus in the morning with his medication, he doesn't have to go to the school principal, the school nurses, which really don't exist in Michigan, but in the East, they still have school nurses where kids go down. But there's been much less need for that now that you can treat people with long acting medications. This was a clear victory for the delivery of medications that are long acting medications.
[00:59:03.88] And the other victory in the last couple of decades has been the identification of treatment for adult ADHD. We actually have specific medications approved by the FDA for long acting for adults as well. The first one that was Strattera, which was a non-stimulant medication, but several others were approved. Focalin XR, Adderall XR, Concerta, Vyvanse, Intuniv is not yet indicated for adults. We actually have a trial going on for adults, but the six on top were medications that have specifically been approved for adult ADHD.
[00:59:53.94] We certainly have the short acting medications that are available. One medication that is of interest to some folks is Daytrana because it's the only skin patch that's available. So you put the patch, a very thin film, we put on the child's hip and it's approved for up to nine hours, but can be used longer. There's more recently a long acting liquid suspension called Quillivant which just hit the market in the past few months.
[01:00:32.61] So things are changing. Some of these drugs are now generically available, and so that's impacted cost and availability. And some are still brand name and exclusive.
[01:00:50.04] These are some of the side effects associated with stimulant medications which are really the mainstay of treatment. They include insomnia, GI upset, dry mouth. Patients tend to accommodate very quickly to these side effects.
[01:01:10.06] One of the most common side effects that's not really a side effect but it's part of the phenomenon is rebound effect. So patients will come to me or parents come to me and say, I can't quite figure this out. My child's doing much better in school. I see it. The grades are better, but at home, things aren't any better. I just can't figure this out. Well it really doesn't take long to figure out that what happens are some of these medications, even long acting medications, last eight, nine, ten hours. So do the math. You take it at 8:00 in the morning and by the time they get home from work or school, there's no medicine available.
[01:01:50.70] So one of the most common side effects is a huge discrepancy between what happens when you're on the medication and when the medication wears off. And if you're sleuth-like, which I try and be as people will say, well these were going well, but then I had this terrible explosion with my family and it was just terrible. My anger just got the best of me. And, again, you do the math and you realize, oh, it probably happened at the end of the day.
[01:02:19.86] And sometimes, people with ADHD say, it's terrible in the morning. I can't get out of bed. I just can't. And the way we start the family is an argument. I want my son to get out of bed. He won't get out of bed. It's destructive, terrible to everybody. And, again, realize in the morning, if you're on stimulant medication, you last had your dose the following morning. There is no medication on board. And for some folks they actually have to take their medication while in bed, snooze,-- this is a great trick-- take your medicine, have a bottle of water, snooze for half hour, then you'll get up much more easily. So this is a pragmatic technique.
[01:03:04.25] Far more common than any of the side effects that I've listed here. These are the official side effects. But in real life and real clinical life, it's making the distinction between when you're on the medication and not.
[01:03:24.42] What seems to make the news about ADHD is that some kids are using it to do better in school and enhancement of their grades. And this is of concern. And we tell anyone who we prescribe this medication to that it doesn't belong to anyone else. This is not currency. And it really is a federal law to misdirect or misappropriate this medication. And we tell kids this.
[01:03:58.85] But it still is used, I don't think it's public health problem number one, but I don't think it should be diminished as well. But this is not the ADHD story. This is not. But one really good way of avoiding any diversion is by using long acting medications because if there is a market, it's for short acting medications. And they really should not be used unless under special circumstances.
[01:04:27.76] One special circumstance will be what I said before. Somebody's on Adderall XR, long acting, which does not have a huge ability to be diverted. But the medicine lasts eight or nine hours and the child needs a little bit of a boost at the end. And sometimes you'll use some short acting Adderall. But really by and large, it should be the long acting medications. And this study by Dr Bright shows that if there is diversion, it's with short acting medications.
[01:05:01.48] I treat all sorts of psychiatric disorders. When I think of ADHD, I do think that medications do play a core role, more so than a lot of other conditions. But there are other treatments that we emphasize as well. Cognitive behavioral therapy has been shown to be very helpful. I think. However. It's a false discussion to say it's medications versus therapy. It's both.
[01:05:28.54] And that's not a fruitful discussion because they do different things and they complement each other. But we really believe that once a diagnosis is made, part of treatment is educating, a little bit of reflection, and also some organization and some really practical tools to help. And sometimes this is what cognitive behavioral therapy can accomplish.
[01:05:49.97] So I have probably spoken too long. And I guess I had a lot to cover. And I'm going to turn it over and see if there any questions. And I think I'll repeat the question because I imagine maybe we'll circulate a microphone.
[01:06:10.30] Come to the mic.
[01:06:13.90] AUDIENCE: Yeah, name's Hal. And I wanted to ask about crashing on the medication.
[01:06:17.82] DR. JOEL YOUNG: Yes.
[01:06:18.58] AUDIENCE: I've been taking Vyvanse and started taking it a couple of years ago, mainly because Adderall there was a shortage and all that. And loved it, but the window of when it worked seems to get shorter. And now it seems like I get like four or five hours of it, then I drop.
[01:06:35.84] DR. JOEL YOUNG: Yeah.
[01:06:36.20] AUDIENCE: --or whatever. And I may, next month, she may add a short acting Adderall to what I'm doing. But is that pretty common with that medication?
[01:06:45.41] DR. JOEL YOUNG: Yes. So the issue, again, is even for the longest acting stimulant medication which you're on, some people get a brief period of coverage. And you're talking four or five hours. That's not unusual. That would put you in the shorter duration of effect range, but it's a large group of people.
[01:07:09.12] So your doctor, I think I heard you say, is considering adding a second medication. And I think that that's perfectly appropriate. And sometimes you actually need to use something like Vyvanse twice a day, even though it's counter intuitive to use a stimulant at night, sometimes that is the recommended approach.
[01:07:30.28] AUDIENCE: Yeah, except it's an expensive medication too. If you take it twice a day, it can factor in as well. And also, what about treating the crash? It's a real lethargic-- some days, it's not that bad, some days, it's just like blah.
[01:07:46.50] DR. JOEL YOUNG: Right.
[01:07:46.81] AUDIENCE: You know? And it's like a big drop in altitude or something.
[01:07:52.52] DR. JOEL YOUNG: Yes. Yes. And it's very disconcerting and sometimes it's unpredictable because it can affect some nights and maybe less dramatic other nights. So there are various strategies. One of them is to use a long acting medication with a short acting medication to follow up. Sometimes we use the long acting medication twice daily. And I think with enough persuasion, an insurance company should cover that. If you're lucky enough to have medication insurance. But I've certainly persuaded insurance companies to cover that twice a day. It's a very legitimate use of the medication.
[01:08:34.22] Sometimes using a stimulant medication and a non-stimulant medication in tandem is appropriate to the extent that sometimes the non-stimulant medications-- we have three of them, Strattera, Intuitive, and Cafe, only Strattera is approved for adults on label, but sometimes that gives a low level effect at all times. And then when the stimulant medication is on board, you get an enhanced response. But once the stimulant medication wears off, you still have an non-stimulant working. And that sometimes helps mitigate the collapse, the crash. So there are various strategies that can be used. Please.
[01:09:23.04] AUDIENCE: I work with a lot of adult and adolescent ADHD young people. And I noticed a trend with the adolescents of being particularly defiant to the parent who seems to be carrying the bulk of the load.
[01:09:42.27] DR. JOEL YOUNG: Yes.
[01:09:43.61] AUDIENCE: Do you have particular suggestions for the parents?
[01:09:48.26] DR. JOEL YOUNG: Yes. Well what a difficult circumstance. And that parent is often mom, it's often the mother, not always, but very frequently. And there is this intense relationship because the mother or that parent is so often attentive to the child's needs. And the child, of course, is defiant and it makes for such a tense relationship. And it is quite distressing for mom.
[01:10:26.12] What do I do? I encourage mom. If mom has her own needs, we try and address those, either in psychotherapy or if she becomes depressed or is she has ADHD herself. It's really important that parents be treated so that they can be more effective parents in that regard. So they do need our support and we have to avoid blaming parents.
[01:10:54.93] And this is actually what my book coming out in December is about. It's called When Your Adult Child Breaks Your Heart. And it's specifically talking about the role of parents who have difficult adult children and what a heartbreak that is. And of course, there's this long tradition of blaming parents for their children's difficulties. When very frequently, if not for them, the situation would be much worse.
[01:11:24.19] So today, there was redemption. I had this young man who's 23 years old. And he came in with his mom. I could just envision them 10 years earlier when he would have been a defiant 13 or 14 year old. He said, you know, mom. you were right. I realize now that my friends are pulling away. I wish I had gotten my ADHD treated. I wish I wasn't so defiant to you and the doctor at the time. And now I can see it. I could not see it then.
[01:11:53.28] And so I think that there is some redemption that if she just stood there long enough those words that parents give their children do pay dividends. And this was really a nice example. Please.
[00:00:00.00]
[01:12:09.17] AUDIENCE: I'm sorry. To address what you just spoke about, I'm a mom with ADHD. And I had two kids out of three kids with ADHD myself. And once I was diagnosed at 42, it seemed very helpful for me to be pretty honest about what it meant for me as a mom. And in doing so, we became more like a team instead of me being in a position to instruct him about how to run his life.
[01:12:38.41] And unfortunately, for my 14 year old, he's the neural typical one in the household, we do a lot of educating each other about how we learn, how we process, how we manage in our days, who has strengths and what area so we can look at our household as a collective instead of an individual. And just teach each other as much as you possibly can about how to advocate for themselves. In academic settings, tell the teacher this is how I learn best.
[01:13:12.45] And just spend a lot of time talking about differences among each other. And not that one is right or one is wrong. We're a collective. And as a family, we can get the job done . And that kind of helps. I was often able to talk to my kids about my own struggles. And instead of putting myself in a superior prideful position of being the punitive authoritative parent, I just talk to them about it and it seemed to really help a lot.
[01:13:44.72] I have another question. Can I ask--
[01:13:46.00] DR. JOEL YOUNG: Please.
[01:13:46.26] AUDIENCE: --while I have the mic?
[01:13:46.51] DR. JOEL YOUNG: Of course. Yeah.
[01:13:47.80] AUDIENCE: It's dangerous giving a speech there when there's a microphone. I am a mom and I'm in my middle ages. Diagnosed at 42. And this is a whole other issue for women to consider and it's one that hasn't been considered I don't think very much.
[01:14:03.28] The effects of menopause and perimenopause on women is significant. And I think neural typical people as they age feel like they can almost empathize with ADHDers because they're losing their memory. And they think, oh now I know what it's like to be like that. When you go through menopause, and you're diagnosed or undiagnosed with ADHD, you're already compromised neurologically speaking. And same is true when you're pregnant. The hormonal effects on your cognitive ability are more severe and significant than anything I could have ever imagined.
[01:14:46.76] I work in a very challenging job with small babies and toddlers. And I work with a huge number of kids with a lot of details involved in every single case. And my job got more impactful. I'm a single mom. And I found myself barely able to put together an agenda for a team meeting of therapists. To be able to think in a linear fashion, remember the issues, put them down, and communicate them was excruciating.
[01:15:24.35] And I seriously for one entire year thought that I might not be able to continue to work. I was that impaired by it. And I had taken a screening test that said I was non-menopausal, but it was a screen. So a different time of the month or whatever, it would be completely different. I went an entire year thinking that hormones had no place in how I was feeling. And I almost lost my mind.
[01:15:54.99] And I reflect back in those moments. I went in after a year to my doctor, and she said, go right back in and get another test. I did. I was menopausal. She put me on hormones. And my sanity came back. It was that significant. It was that significant. I felt completely cognitively impaired. I'm a special Ed teacher and a diagnostician. It's what I do every day.
[01:16:23.28] DR. JOEL YOUNG: Right.
[01:16:23.82] AUDIENCE: And I could see myself slipping away so severely that it scared me.
[01:16:30.15] AUDIENCE: From menopause?
[01:16:30.67] AUDIENCE: Yes. And I think about my grandmother who I know was untreated with ADHD. And I'm a global thinker, big picture thinker. I think a lot of women, former generations, were hospitalized in mental institutions that may have been ADHD at their core.
[01:16:53.69] DR. JOEL YOUNG: Yeah.
[01:16:54.35] AUDIENCE: And life with all the hormonal fluctuations put them right over the top. And I don't know what the medications were back then, but I can see very much where that impacts women with ADHD.
[01:17:06.98] DR. JOEL YOUNG: Yeah.
[01:17:07.96] AUDIENCE: In pregnancy times, menopause, whatever. So I encourage everyone to pay attention to that.
[01:17:13.94] DR. JOEL YOUNG: Yeah, I don't know if I can add much to that. I think phenomenon is if you have ADHD and some other physiological event-- menopause, pregnancy, the onset of another illness-- it's that combination of factors that unhinges people. Where is they, to some degree, might have been able to compensate with two physiological challenges, it's too much. And that's when they decompensate. So I think that's a very nice example.
[01:17:47.44] AUDIENCE: [INAUDIBLE] doctors that address those issues together.
[01:17:50.63] DR. JOEL YOUNG: Right, exactly.
[01:17:52.41] SUZANNE OSTROWSKI-DANSEL: OK. Another question.
[01:17:53.95] DR. JOEL YOUNG: Please.
[01:17:55.42] AUDIENCE: What are your recommendations for finding a doctor to prescribe medication, to find the right combinations that work best for someone with ADHD that's already been diagnosed but is trying to find a physician for the medication portion?
[01:18:10.38] DR. JOEL YOUNG: Yeah, yeah. So this is problematic, unfortunately. I think we need more specialists in this regard. And I think there are stretches of America where there are not people really focused on these issues. And I think it's difficult.
[01:18:34.30] The primary care docs often will take the ball. Once they're kind of given their marching orders, they often will prescribe. And these are stimulant medications so they're controlled. So you really do need this ongoing, sometimes decades long, relationship with your doctor. But they often want to work with a specialist to fulfill your needs.
[01:19:05.22] Michigan actually has more than much of the rest of the country. So there's actually people in this area. There are people in Traver City. The best way of networking, I think, is through CHADD. And then talking to people who had good success.
[01:19:25.37] But I'll tell you the demand is much greater than the supply of people. And I think I expressed frustration that we're not farther ahead in that regard. Please.
[01:19:42.76] AUDIENCE: Yeah, the doctor makes a big difference. And my experience has been that finding a support group and connecting with other people in CHADD has made all the difference for networking. And the information is the biggest thing that's made a change, is understanding what's going on. It's a tremendous relief.
[01:20:03.41] I love the book title, You Mean I'm Not Lazy, Stupid, or Crazy?
[01:20:06.53] DR. JOEL YOUNG: Yes.
[01:20:08.21] AUDIENCE: That says a lot. Questions. I was taking Concerta for awhile and it was very effective but very expensive.
[01:20:15.77] DR. JOEL YOUNG: Yeah.
[01:20:16.61] AUDIENCE: And is there a chance that it's going to go generic? And how long? Concerta has? Concerta or Ritalin?
[01:20:25.83] SUZANNE OSTROWSKI-DANSEL: Yeah, they come in both.
[01:20:27.42] AUDIENCE: Concerta? Really?
[01:20:29.30] SUZANNE OSTROWSKI-DANSEL: Yeah.
[01:20:30.69] AUDIENCE: Fantastic. OK.
[01:20:32.02] DR. JOEL YOUNG: It did come up there. It was an interesting story, but there was lawsuits, but a generic manufacturers ultimately prevailed. And the cost has come down. It's interesting when generic medicines do come out, it takes usually six to nine months for the market to respond. But when it responds, it generally responds favorably for the consumer.
[01:20:59.54] AUDIENCE: That's great news. I'm a real fan of Costco because boy, it makes a huge difference. Another question, is there any correlation you've seen between nail biting and this?
[01:21:13.31] DR. JOEL YOUNG: Yes. Yes. So I believe it is a subcategory of hyperactivity. And there are people that from early on until their last day will pick their nails and have no nailbeds. It's very problematic. It's a very hard habit to break.
[01:21:38.79] And my theory about hyperactivity, lot of the hyperactivity is it's soothing--
[01:21:44.85] AUDIENCE: Yes, yes.
[01:21:45.63] DR. JOEL YOUNG: --to this person. And so is twirling your hair. And it is somehow probably a brain function. If you remember biology 101, when you looked at how birds mate and they put their wings out and they show their colors. They have a basal ganglia, which we do as well. And some of this kind of primitive grooming and over grooming behavior is probably highly brain based.
[01:22:15.56] The paradox is that it's evident in untreated ADHD and the paradox is that treatment could make a better or it could make it worse. Sometimes lot of these medications enhanced dopamine and that actually increases some of these self grooming behaviors or actually ticks.
[01:22:35.48] On the other hand, and more interesting, sometimes what we find with people who are supremely inattentive is they're in a different world. They actually lose time. And they're actually disassociating in their own world.
[01:22:49.47] AUDIENCE: Spaced.
[01:22:50.49] DR. JOEL YOUNG: They're spaced. And they can sometimes skin pick during these periods of time, waste a lot of time with grooming behavior and not even realize how much time. So the paradox is that sometimes treatments can make these self grooming, over grooming behaviors worse as often they can make it better.
[01:23:08.52] AUDIENCE: I've been a nail biter all my life. And I just recently broke the habit, but it feels like a major accomplishment. And it took a technique. It's still an ongoing challenge. And there's definitely a neural physiological feeling that comes over me when I need to bite that's clearly something going on in a neurological level.
[01:23:32.54] DR. JOEL YOUNG: Yeah.
[01:23:33.03] AUDIENCE: Thanks.
[01:23:33.83] DR. JOEL YOUNG: Thank you. We'll circulate some questions. Thank you for that.
[01:23:38.76] AUDIENCE: I'm disappointed with your response about how to find a good doctor in town, because apparently you need to open up a satellite office here in Ann Arbor because even in Ann Arbor, I think people think that there's so many doctors here, and there are, but they're not necessarily enough psychiatrists to go around to meet the demand.
[01:23:58.90] On the issue of one of the side effects you listed as far as GI upset--
[01:24:03.19] DR. JOEL YOUNG: Yes.
[01:24:03.51] AUDIENCE: --from the medications, would that be something that would present itself similar to somebody who had irritable bowel?
[01:24:13.62] DR. JOEL YOUNG: OK. So yes.
[01:24:22.06] AUDIENCE: And then how do you know that it's not irritable bowel and that maybe it's being caused by medication for somebody who may be dealing with it.
[01:24:29.67] DR. JOEL YOUNG: There's a whole group of nebulous medical disorders that primary care doctors fear are going to hit their door. One of them is irritable bowel syndrome. Another might be fibromyalgia. Some people have temporal mandibular joint disorder, TMJ, lower back pain, tinnitus, ear ringing. These are ongoing conditions that the doctors do not like to treat because doctors, like everyone else, like success. And they really can't find really good treatments to issues like irritable bowel and chronic fatigue syndrome.
[01:25:16.44] So we actually having seen a lot of these people over the years, we actually just wrote a paper that was published looking at high rates of chronic fatigue and some of these nebulous medical problems of which IBS, irritable bowel syndrome, is one. We think by treating the underlying ADHD it has a calming effect. And it actually decreases some of these kind of lingering nebulous physical symptoms.
[01:25:49.46] And so I've had people with IBS, which is a nonspecific GI distress, essentially an upset stomach, a lower upset stomach associated with diarrhea and cramping. And we've had some success. Now it's not a controlled study. A lot of this is anecdotal. But I believe there is a relationship between some these medical conditions and adult ADHD.
[01:26:14.61] AUDIENCE: Oh, because I was thinking that the medications were what was causing the GI upset. So then it--
[01:26:22.07] DR. JOEL YOUNG: Usually not. Usually the medications don't cause lower GI. It might cause some dyspepsia. It's trangent. It's up there, but it's rarely a non starter. It usually is something that's not caused by the medication.
[01:26:41.88] AUDIENCE: OK. Thank you.
[01:26:44.17] DR. JOEL YOUNG: Please. Thank you for your question.
[01:26:45.74] SUZANNE OSTROWSKI-DANSEL: I know. Matthew and then--
[01:26:49.35] MATTHEW CUNNINGHAM: And I just wanted to touch real briefly on some of the questions that we just had. And these really are some of the benefits of being an attendee to this support group, is that as a leader of the support I have access to what's called the Michigan Adolescent and Adult ADHD Professional Network with professionals in many different fields associated with ADHD or just work with ADHD population, that we're able to send folks in the right direction. There are many different specialists. And they say regionally where they are. And that's kind of a good start. A lot of folks will have those questions. And I like to be able to offer some resources.
[01:27:33.95] And then also, I think you sort of talked about the book You Mean I'm Not Lazy, Stupid, or Crazy?, the co-authors of that book were Kay Kelly and I think it's Peggy Ramundo, I believe. And Peggy is actually doing a webinar tomorrow at 2:00 with Additude Magazine, which I believe is a magazine associated with CHADD.
[01:27:58.14] DR. JOEL YOUNG: Yes.
[01:27:58.45] MATTHEW CUNNINGHAM: And so you can talk to me after about that, but I believe it's Additude Magazine or whatever it is slash webinars. And you can find that if you have time tomorrow. I know a lot of people work during 2:00, but that may be something you may be interested in. So if anyone has any questions about local resources, I'd be happy to shed light on some of those or what I have at my disposal.
[01:28:22.32] DR. JOEL YOUNG: Thank you, Matt.
[01:28:24.54] SUZANNE OSTROWSKI-DANSEL: OK. We just have two more hands up. And then we're going to have end the evening. One moment.
[01:28:30.95] AUDIENCE: Hi there.
[01:28:31.40] DR. JOEL YOUNG: Hi.
[01:28:32.86] AUDIENCE: I was wondering if you could talk a little bit about the differences between Adderall and the methylphenidate groups because I was told recently that the Adderall type can like help with task initiation. And I got really excited because I've been on Concerta a long time. And then I don't feel like it does anything different. But I can tell there's difference. Can you talk about the differences between the two I guess?
[01:28:57.13] DR. JOEL YOUNG: So we have three central classes of ADHD meds. And I'm hoping we'll have more. But right now we have three. And this is why we need to actively develop new drugs because our needs are there.
[01:29:15.69] And one of our philosophies is that, just like I can't look at you and say which ice cream you like, I do think you have the right as somebody with ADHD to see which one fits best. And tailoring medication regimes is something that an ADHD specialist would try and do.
[01:29:37.99] So there are three major classes. They're the stimulants and the non-stimulants. And within the stimulants, there are a methylphenidate or Ritalin class and then there's the amphetamine or Adderall class. And nobody has come up with clear definitions as to who should be on which one. Every once in while somebody thinks oh I have this figured out, but it's not often the case.
[01:30:07.42] So the general rule is if you're on a medication every day of your life foreseeably for a while, you should be on what's best for you. And that means like trials of various different medications. It seems that methylphenidate, Concerta, Focalin, may be more effective in younger folks and maybe people without a mood component. Amphetamine, Adderall, Vyvanse seems to work nicely in maybe a slightly older population and maybe people who have problems with motivation, lack of motivation. And that might be a general rule.
[01:30:53.70] The non-stimulant medications seem like they work very nicely in tandem with the stimulant medications. That's--
[01:31:00.86] AUDIENCE: At the same time? Or just after [INAUDIBLE]?
[01:31:04.21] DR. JOEL YOUNG: Well, they're long acting. They're 24 hour medications. So when the stimulant medication wears off inevitably whether it's four hours or eight hours or 10 hours, then there's always that non-stimulant medication in the background. So that's how we're using it in combination. For those of you who treat diabetes, sometimes you use various agents in tandem.
[01:31:27.26] But I can't say that there's one secret formula. It's kind of a way of doing it methodically and trying to work with your provider to do that in a methodical way. Please.
[01:31:42.55] AUDIENCE: Hi. My name is Bjorn. And what I'd like to talk about is I'm in recovery. I had a problem with drugs and alcohol for a long time. I started taking stimulant medications about three years ago. So I pretty much have been on the three major medications for periods. And I'm married. I have two boys ages one and six.
[01:32:12.39] And I genuinely believe that I'm adult ADD patient. And what I wanted to talk about was that the medications Adderall, in particular, are a very touchy subject in my marriage. I first started taking Ritalin. And I was on that for about a year and I finished school. I feel like it kept me focused.
[01:32:44.06] And then later, I moved on to Vyvanse and I feel like I did well with that. I stayed close to the principles of recovery. And last winter, I switched to Adderall because, personally, my doctor's a psychiatrist. I see him about every two weeks. And I just kind of wanted to beat the high out of pocket costs of Vyvanse. I felt like Adderall was a good deal cheaper.
[01:33:14.19] And I really went into sort of an extreme addiction pattern. And [INAUDIBLE] caused a lot of strife in my marriage. And fortunately, I've been back on Vyvanse and it seems like it does not have the same craving to do more. So I just wanted to ask whether-- I know that there's a huge world of people who are abusing Adderall.
[01:33:46.00] DR. JOEL YOUNG: Yeah.
[01:33:47.01] AUDIENCE: And if you could comment about the differences between Vyvanse and Adderall.
[01:33:50.95] DR. JOEL YOUNG: Yeah. First of all, I'll say congratulations on your recovery. It's a fight every day.
[01:33:55.87] AUDIENCE: Thank you.
[01:33:56.69] DR. JOEL YOUNG: And trying to raise a family. It's a struggle. So congratulations on your progress. I think if I ever wrote a book on 10 things I've learned about being a psychiatrist, one of the things would be that most people are not self defeating. Most people do things to help themselves even though in the long run it might be problematic. So nicotine is a good example. In the short run, it helps you focus and concentrate. In the long run, we all know what it does in the long run.
[01:34:31.94] People often use substances because they feel badly. They feel anxious. They feel uncomfortable. They feel depressed. And they don't have a pharmacy or a psychiatrist next door, so they use what's available. And so I think that's often the relationship between substance use disorders and psychiatric conditions, particular ADHD. I think people turn to substances that are available and what's ubiquitous in our society is marijuana and alcohol.
[01:35:00.00] They're very bad in the long run, but seductive in the short term. That's the essence of an addiction, right? It's appealing in the short run and terrible for you in the long run. Opiates are a good example.
[01:35:13.85] But we have this inherent paradox that people with ADHD and substance use, if you treat their ADHD using a stimulant controlled substance, trying to keep them away from a street drug. And this is highly controversial among providers and among the public at large.
[01:35:37.75] What we try and do, in this regard, we do it imperfectly, but we try really hard, is we try and identify people's ADHD, only use long acting agents, probably not going to Adderall because it's less expensive, but staying with a long acting medication because it's smooth and there's not as much of a reinforcement that you see a physiological reinforcement that you see with short acting medications.
[01:36:01.11] And then you bring the family involved and you say, look, you're going to get 30 pills this month. You can have someone else dispense it to you. That's your social contract within your family. And it's yours to use. It's yours to misuse. But if you misuse it more than once or twice, the doctor is not going to be complicit.
[01:36:24.35] And so it's a family system's approach. And it works. You have to do it. It requires a great deal of orchestration with the doctor, the therapist, and the family. It's doable. They're not mutually exclusive. They have substance use and they have ADHD. You have to use long acting medications, non-stimulant medications, and work within the family. And it's a daily struggle.
[01:36:52.05] SUZANNE OSTROWSKI-DANSEL: We don't have any more time for questions. But we have just one more announcement. Thank you.
[01:36:56.95] MATTHEW CUNNINGHAM: And folks, if you have any questions, please feel free to write them down and either send them to me or give them to me after the program. And I'd be happy to either sent it to Dr. Young or some other psychiatrists that are associated with the group and point you in the right direction. So with that, let's thank Dr. Joel Young for coming and speaking to us.
[01:37:17.54] [APPLAUSE]
[01:37:22.23] [MUSIC PLAYING]
[00:00:00.00]

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May 7, 2013 at the Pittsfield Branch

Length: 1:42:00

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