Question: What exactly is ADHD? Why does it exist in the world? Why has it become the “diagnosis du jour”?
Answer: In most cases ADHD can be thought of as a part of personality. Personality is made up of temperament which is mainly genetic, and character which is mainly learned. Temperament includes:

Question:  What causes ADHD?

Answer:  Personality is thought to be 1/2 temperament which is primarily genetic.  But personality disorders are thought to be primarily learned, maladaptive, and mostly deficits in character development. ADHD on the other hand has been found to be 75% genetically determined.  Studies include comparing ADHD identical vs. fraternal twins and studying individuals who have been adopted at birth.  The likelihood that they will turn out to be ADHD primarily correlates with the presence or absence of these traits in their biologic parents not their adoptive parents.  This is much less true for personality disorders or character. 

So whether we are ADHD is mainly (75%) determined by how we choose our parents and the luck of the draw.  What about the other 25%?  Several things have been found to increase the chances that ADHD traits in childhood will continue into adult life.  This includes early childhood trauma and neglect which increase risk/severity of ADHD symptoms.  Early exposure to television correlates with increased severity of ADHD symptoms also.  Undoubtedly being exposed to high stimulation such as computer games, or maybe even computers themselves will result in brain adaptations that might make it harder to focus in low stimulation settings.  Modern lifestyle with the demands for multi-tasking will be more difficult for “all or none” ADHD personalities. 

Question: Once we have a diagnosis of ADHD what is next?
Answer: The role of medication in treating ADHD is as strong as the role of antihypertensive medications for high blood pressure. The MTA study showed that medication is by far the most effective type of treatment. Just as it is in managing high blood pressure, patient education and cognitive behavioral changes are an essential component.

Question:  Can any physician diagnose and treat ADHD in kids, or does it have to be a specialist?

Answer:  Most pediatricians are comfortable at least screening for ADHD in kids and in many cases will try at least a couple of medications before referring to a specialist.  One problem with being treated by a non-specialist is that studies have shown a lower success rate.

In the largest most comprehensive study MTA Study , patients that were treated in the community did not fare as well as those treated by specialists using a set protocol.  The kids treated in the community on average ended up on lower doses of medication per dose and fewer doses per day (of short-acting medication).  Most striking was that after medication was initially stabilized the patients in the community were seen on average 15 minutes every 6 months.  Those treated by specialists were seen every 3 months for 30 minutes.

Question: Can my physician diagnose and treat ADHD in adults or is a specialist required?

Answer: In a recent survey the majority of primary care doctors felt comfortable diagnosing and treating anxiety disorders (85%) and depression (95%) in adults.  Only 15% were comfortable diagnosing and treating ADHD.  The main reason the majority of primary care doctors have not become comfortable with ADHD is that the best medications are stimulants that in many states require a special prescription and are more likely to cause problems with regulatory agencies or diversion of medication for non-medical purposes.  Unfortunately some doctors will prescribe non-controlled medications such as Strattera, Wellbutrin XL or other medications as the first line treatment.  Multiple studies have shown that stimulants are about twice as effective as other medications for ADHD.  Some people may wrongly assume that their suboptimal response to non-stimulants means they’re not really ADHD or that treatments are not particularly useful.

Question:  What exactly is an ADHD specialist?

Answer: Unfortunately there is no formal training or certification to reflect a certain minimal level of competence in the diagnosis and treatment of ADHD.  The most important factor in determining a clinician’s expertise in treating ADHD is experience.  What percentage of their current practice is ADHD?  How long have they been treating it?  Experience is especially important for doctors who realize that every patient is a teacher as well as a student. 

There are frequent seminars and short courses available.  Several good books are also available.  Any book written by Dr. Edward Hallowell is based on good scientific studies and his years of clinical experience.  His most recent book is Delivered from Distraction.  There is a lot of material available online through CHADD.org and ADD.org. 

Chances of getting an accurate diagnosis are better when seeing a specialist.  One particular problem is the need to identify any other medical and/or mental health problems before beginning treatment for ADHD.  Studies show up to 85% of ADHD adults have at least one other significant problem like anxiety, mood disorder, impulse control disorder, or substance abuse.  Specialists are generally more comfortable and experienced with the full range of medication options as well as the cognitive behavioral component of treatment.  They are usually more comfortable with higher doses required by some patients and combinations of 2 or more medications.

Question:  Are there different types of ADHD?

Answer:  Yes.  Recent research shows that there are two genetically distinct subtypes of ADHD symptoms.  One involves the need for higher levels of stimulation for the brain to work well.  There is lower level of functioning than normal when reward is delayed.  There are problems with being bored in settings that are not particularly stimulating like school classrooms, doing homework, or adult’s typical work setting.  Frequently there are problems listening to conversations if the ADHD person is not acutely interested in the topic being discussed (not great for marriages).

The other subtype of ADHD involves deficits in executive functioning.  One of the main functions of our highest brain centers is to inhibit our instinctual or emotional reactions.  What response or course of action is compatible with our values and long term plans?  I have a Dennis the Menace cartoon where he says, “by the time I realize the consequences of my action I’ve already done it!”  That’s the problem with impulsivity - act first, think second.  The problem with hyperactivity is excessive arousal and “noise” in background brain activity.  It is hard to focus on the important things when the brain is being constantly bombarded with the unimportant.  This subtype of ADHD results in being easily stressed or having too much on the mind at once.

http://www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

Question:  Why do most ADHD individuals have symptoms of different subtypes?  

Answer:  Models have been developed to show how a person can inherit one subtype of ADHD and develop symptoms of the other over time.  This helps us to understand the fact that the majority of ADHD patients have some symptoms of both.  Problems with focus, attention, and concentration can be associated with both types.  In one the brain won’t turn on - “not interested”.  In the other there’s too much noise and the individual can’t focus on the important because of too many unimportant distractions.

Question:  What is genopharmacology?

Answer:  It is the interaction of gene variations with specific medication treatments.  Although some people inherit both the subtypes of ADHD the majority of the time this is probably not the case.  There are already over a dozen gene variations (polymorphisms) that have been found to be more common in ADHD.  Last week a new study was reported in which one gene variation was found to respond very favorably to one type of stimulant (in 60% of these patients) but another gene variation was found to not respond at all to the same medication.  The use of genotypes in predicting treatment response is coming soon.