|F - Forgetful A – Achieving below potential S – Stuck in a rut T – Time challenged||M – Motivationally challenged I - Impulsive N – Novelty seeking D - Distractible S - Scattered|
|F - Forgetful A – Achieving below potential S – Stuck in a rut T – Time challenged||M – Motivationally challenged I - Impulsive N – Novelty seeking D - Distractible S - Scattered|
What’s in a label? When it comes to medical conditions, down through history various conditions have had labels which sometimes reflect our understanding of the underlying causes. A good example is the medical condition hyperthyroidism, which describes too much thyroid hormone in the system causing symptoms. Hypothyroidism, on the other hand, is a condition which reflects too little thyroid hormone in the body. Essential hypertension is another medical condition that we all recognize, but in this case the descriptive label does not reflect a clear understanding of what causes it. Diabetes mellitus (sugar diabetes) again is understood by most people to reflect an abnormality in glucose metabolism.
When we come to the area of psychiatric medicine, sometimes the descriptive label does describe the condition fairly clearly, and sometimes not. Major Depressive Disorder (MDD) would be understood by most people as reflecting depression. Panic Disorder again is a pretty good description of the actual condition in terms of anxiety symptoms and what a person would experience if they suffered an actual panic attack.
When we come to Attention Deficit Hyperactivity Disorder (ADHD) the labelling is interesting. The first good clinical description of ADHD was in 1917 by Dr. Gonzalo Rodriguez-Lafora, a physician in Spain who described the symptoms of ADHD in children:
"Children that cannot sustain their attention even to hear or to understand or to respond…get distracted even by a moving fly, pinch their classmates, make fun of everything and are in constant activity."- National Library, Madrid, Spain
In North America, this condition received a label in 1930 called Minimal Brain Damage, and this was changed later in 1960 to Minimal Brain Dysfunction.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a published summary by the American Psychiatric Association of all psychiatric conditions including ADHD. In Europe, there is a different classificatory system.
According to the DSM-II, ADHD was labelled Hyperkinetic Reaction of Childhood in 1968, and in 1980 this label was changed to Attention Deficit Disorder + or - Hyperactivity (DSM-III). In 1987, this again was changed to Attention Deficit Hyperactivity Disorder (DSM-III-R), and the current DSM-IV-TR version describes this condition as Attention Deficit Hyperactivity Disorder.
Why is this relevant? The latest version of the DSM, DSM-V, will be available in the next several weeks, and we are looking forward to some important changes. Previous renditions of ADHD in the DSM haven’t been based in validated diagnostic criteria, especially for adults. The age of onset of ADHD has been debated and the DSM-V may well raise the age of onset for this important condition from seven to 12.
Another important DSM change would be the clear description and recognition of Adult ADHD, validating its existence. Previous DSMs have only made fleeting references to it.
If we look more closely at the current label, ADHD (and this is not likely to change in the DSM-V), there still remain several issues specifically as it relates to how symptoms change across the timeline. Firstly, the label Attention Deficit Hyperactivity Disorder does not subsume one of the most important and core symptoms of ADHD, and that is impulsivity. Many people who would recognize hyperthyroidism or depressive disorder in others could be quite confused by what ADHD actually looks like in adults. A reason for this confusion is that much of the childhood hyperactivity (if it was present) does decline over time, but what can persist into later adolescence and early adulthood would be symptoms of distractibility (inattention) and impulsivity. Many people refer to Adult ADHD as “ADD” (minus the hyperactivity).
The point I am trying to make is that labelling any medical condition will always have its attendant challenges and fair share of criticism because of the very process of labelling. Against this, if we don’t have a clinical description and a label of what it is, then our cooperative efforts in terms of studying this condition will be less effective. We need some kind of common parlance so that people can communicate back and forth in terms our current understanding of ADHD.
In the original depiction by Dr. Gonzalo Rodriguez-Lafora, he published his description of these children in a book, Los Ninos Mentalmente Anormales, so even he resorted to a rough description of children with this condition.
Finally, the label ADHD presupposes that this condition is similar in females and males, and this is far from the truth. In fact, most of the research which has been done on ADHD has been done in studies focussing on Caucasian boys. The biggest study of children with ADHD, the MTA Study, focussed on males and only 20 per cent of the children in the study were female. In addition, most of the treatment studies have again focussed on little boys. And so as our scientific understanding of what ADHD looks like in females develops, certainly this will be included in later versions of the DSM.
All of this leads to lively debate and forces scientists and clinicians alike to better fine tune an evidence-based, clinically relevant description of Adult ADHD.
I recently had the great pleasure of being interviewed by Dr. Peter Zafirides for his podcast The Healthy Mind (http://www.thehealthymind.com).
During the interview, Dr. Zafirides was curious about the evolution of FAST MINDS, and how it came to be developed first as a nationally accredited medical educational program, and later became the basis for our new book FAST MINDS: How To Thrive If You Have ADHD (Or Think You Might).
I discussed this evolution during the interview (which you can check out by following this link: http://www.thehealthymind.com/2013/02/20/fast-minds-how-to-thrive-with-adhd-dr-tim-bilkey-interview/), and thought I would share the story with you here.
Attention-Deficit Hyperactivity Disorder (ADHD) affects 1 out of 25 adults globally.
While it is such a common condition in general primary and psychiatric medical practice, it often goes unrecognized. The DSM-IV did not address variability in the presentations of ADHD across the lifespan. This leads to under-recognition.
The symptoms of ADHD over time change, so that much of initial hyperactivity wanes. Distractibility and impulsivity continue to play a role in an adult’s life with ADHD. These traits, however, are extremely subtle and often are unrecognized as symptoms of ADHD.
Because of this, I felt committed to helping other doctors recognize the subtleties of Adult ADHD. Physicians love acronyms in terms of their own learning, and I decided to develop an acronym for Adult ADHD. FAST MINDS™ came out of this process as a quick tool for primary care doctors to better recognize the symptoms of Adult ADHD.
Knowing the symptoms only gives the bare bones of what this condition really is, so in addition I developed pictures of how adults would present with ADHD. Tying the acronym together with how people actually present and the stories they tell gives a 360 degree perspective for better recognition of Adult ADHD.
FAST MINDS™ meets this goal.
The original acronym was developed to summarize the symptoms of Adult ADHD. The acronym is FAST MINDS™:
F - Forgetful
A – Aptitudinal underachievement
S – Symptoms frequency
T – Time challenged
M – Motivationally challenged
I – Irritable
N – No tolerance for boredom
D – Distractible
S – Symptom severity
This is an easy to use, easily remembered acronym for primary care physicians.
From a clinical interviewing perspective, and based in a literature review, 10 typical profiles of how patients would present to a primary care practice with Adult ADHD were developed. These presentations were demonstrated on video through mock patient interviews. These clinical vignettes are snapshot pictures of what doctors need to think about with underlying ADHD. We consider these vignettes as different versions of Adult ADHD.
You can see many of the mock patient interviews demonstrating these clinical presentations on this Tumblr site or over at Youtube: www.youtube.com/user/DrBilkey.
The pilot project FAST MINDS™ was presented to a family practice medical unit and based on feedback, changes were implemented.
National accreditation was received from the College of Family Physicians in 2009.
National accreditation required College of Family Physicians of Canada (CFPC) members from five regions from across Canada to review the program. Physicians from Ontario, Quebec, British Columbia, Nova Scotia and Manitoba were requested to complete a learning needs assessment and responses to this assessment strongly supported the need for family physician education in the area of Adult ADHD.
The physicians reviewed the FAST MINDS™ program and confirmed that is was relevant to family medicine.
Ongoing peer evaluation continues to validate this program as relevant to family medicine, free of commercial bias and meeting stated learning objectives.
National accreditation for up to 2.0 Mainpro points was granted, and the first nationally accredited presentation of FAST MINDS™ took place on October 28, 2009.
FAST MINDS™ has been presented across the world in English and Spanish.
An interest in ADHD in females resulted in the development of a peer-reviewed film on this topic: Her FASTMIND – An In Depth Look At ADHD as it Affects Women.
So, there is the story of the origin of FAST MINDS™, which grew from an idea to an educational program. Finally, the book FAST MINDS: How To Thrive If You Have ADHD (Or Think You Might) resulted from a collaboration with my co-author at Massachusetts General Hospital Dr. Craig Surman and our wonderful writer Karen Weintraub.
Here is some more positive feedback on the book FAST MINDS (in stores February 5) to get a cold week off to a warm start:
"A great resource for adults with ADHD and their loved ones. This book offers clear, effective solution-focused strategies for dealing with the challenges of ADHD. I highly recommend it."
This review was provided by Kathleen Nadeau, Ph.D., co-author of ADD-Friendly Ways to Organize Your Life.
Thanks for the kind words.
With our book FAST MINDS set to arrive in a book store near you in just 18 days, I wanted to share another excellent review.
This one comes from Patricia Quinn, MD, Director of the Center for Girls and Women with ADHD in Washington, DC. Dr. Quinn wrote:
"Finally, somebody gets ADHD! FAST MINDS offers readers a path from the despair of self-criticism to the sunlight of success. Practical, moving, with many real-life examples, this book helps adults with ADHD build the life they want! I really appreciated that each chapter had a section with practical suggestions for significant others to help those they care about who have FAST MINDS. This book can make a difference and I wholeheartedly recommend it to all."
As always, thanks to all of our reviewers for taking the time to read FAST MINDS and provide us with feedback.
Here is another great review for the book FAST MINDS, which will be in book stores in Canada and the U.S. on February 5, and is available for pre-order through a number of retailers, including Amazon, Indigo and Barnes & Noble. This review was provided by Edward Hallowell, co-author of Driven To Distraction.
“FAST MINDS delivers! A concise, practical, easy-to-read, yet sophisticated guide to what will help you most if you have ADHD. This book has the virtues of brevity and simplicity without losing the authority and power its roots in evidence and research provide. A superb book.”
Thanks again to all our reviewers for their very kind words.
The Adult ADHD self-help book I co-authored with Dr. Craig Surman, “FAST MINDS: How To Thrive if You Have ADHD (or Think You Might)” will be available in book stores on February 5 - and is now available for pre-order through such booksellers as Amazon, Indigo and Barnes & Noble.
Early reviews for FAST MINDS have been excellent, and with the book launch less than a month away, I thought I would share one with you today. Russell A. Barkley, Ph.D., Clinical Professor of Psychiatry and Pediatrics at the Medical University of South Carolina, who is the author of a number of excellent books on ADHD, including “Taking Charge of Adult ADHD”, had this to say about FAST MINDS:
"FAST MINDS offers a fascinating and refreshing perspective on ADHD in adults that clearly explains the deficits in executive functioning, attention, and self-regulation that permeate this disorder and the serious impairments in numerous major life activities to which they can lead if left untreated. While few disorders seen in outpatient mental health centers are as or more impairing than ADHD in adults, few if any disorders are as treatable as this one. The authors provide an excellent set of recommendations for how people with adult ADHD can manage their difficulties and lead more successful and fulfilling lives. The information and recommendations for management provided here are well-grounded in the current science on the disorder and offer numerous ways in which adults with ADHD can better improve their personal, family, educational, work, and recreational activities with sound approaches to treatment."
Thanks to Dr. Barkley and all the reviewers for their comments on FAST MINDS.
In a very early draft of the book FAST MINDS (the final version will be launched in February 2013), I included a chapter titled “ADHD Goes to Jail”. I recognized at the time that this was not a very encouraging title for a chapter in a book I expected to be full of hope for the future, however, the reality is that under-diagnosed or insufficiently treated ADHD can definitely lead a person to the justice system.
Thankfully, a new study has revealed that medical treatment of ADHD can reduce criminality and recidivism.
But let’s start from the beginning. We know that children with ADHD underachieve academically. And it is this lack of bonding between young ADHD minds and educators and the educational systems which is a later predictor of addictions, according to a report from the Canadian Centre on Substance Abuse. Addictions can lead to dropping out of school, and eventually, if a person is caught possessing drugs or driving while under the influence, into the hands of the police.
ADHD and addictions overlap in up to 50% of cases.
Impulsivity is a core symptom of ADHD, and outcomes of this symptom can clearly contribute to criminal charges: Using drugs impulsively and then in an intoxicated state driving a car, getting into a fight, dangerous driving, hit and run accidents, impulsive stealing (shoplifting) – these all are problematic.
A study published in the International Journal of Offender Therapy and Comparative Criminology, published in 2009, looked at Attention-Deficit Disorder in men and women newly committed to prison. Out of 319 offenders, 68 (21.3%) met criteria for ADHD. This study also looked at the symptoms of ADHD which were over-represented in this population and they very much resemble theFASTMINDS acronym. Figures revealed that 89.7% were distractible, 91.2% were impulsive, 89.7% were fidgety and 70.6% were irritable; 86.8% were not achieving and 67.6% were not organized; 92.6% had problems with impulsive money spending.
While those figures showed that 21.3% of those incarcerated had ADHD, numbers cited elsewhere vary. In an excellent blog by Pete Quily titled Adult ADHD Strengths (you can find it at http://adultaddstrengths.com/2011/01/12/adhd-and-crime-ignore-now-jail-later-15-clinical-studies/) prison figures range from 25% of prisoners from theU.S.having ADHD, up to 50% of male prisoners inIceland.
And these figures do not only pertain to males, as it is noted in Pete Quily’s blog: “46% of female prisoners in Rhode Islandmet criteria for childhood ADHD.” When researching the original FASTMINDS book, I also dug up some information on females and the penal system. In a study by Rosler et al., published in 2009 in the European Archives of Psychiatry and Clinical Neurosciences, it was noted that females with ADHD were likely to have an earlier age of incarceration and to be incarcerated for longer periods of time.
Now to the hopeful part of this blog.
On November 22, 2012, the New England Journal of Medicine published an article by Lichenstein et al. titled: “Review of Medication for Attention-Deficit Hyperactivity Disorder and Criminality” Despite the “criminality” in the title, this is a good news story.
This article derived data from 16,087 men and 9,569 women in Sweden who had at least one diagnosis of ADHD. Among the men with ADHD, 36.6% had been convicted of at least one crime, compared to 8.9% of the general population control group. For women, the figures were 15.4% and 2.2% respectively.
While many in the study had, at one time, taken ADHD medication (53.6% of men and 62.7% of women), very few had continuous treatment for their condition. It was noted: “At total of 689 men (4.3%) and 368 women (3.8%) were receiving ADHD medication during the entire period.”
However, the very good news is that for those who were being treated for their ADHD, there was a huge reduction in criminality. The authors noted that among those receiving ADHD medication, “There was a significant reduction of 32% in the criminality rate for men and 41% for women.”
The authors also reported, “These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD.”
With this new information, shared by my Swedish colleagues, it looks like we are making good headway now.
Y - You aim for success with flexible, mindful steps
O - Organize your world around what is important to you
U - Use your natural skills set to help drive your life
C - Capitalize on being motivated by your passions
A - Activate engagement in life’s work by increasing interest level and dialing down distractions
N - Nourish your spirit (self) with people who get your deal