Diagnosing ADHD: personality quirks or psychiatric disorder?

In a humorous article called “Pathology in the Hundred Acre Wood,” published in the Canadian Medical Association Journal in 2000, Sara Shea and colleagues sarcastically diagnosed and suggested medical treatment for the popular Winnie the Pooh characters. Piglet was diagnosed with generalized anxiety disorder, Eeyore with depression, and the lovable but dull-headed Pooh was diagnosed with attention deficit hyperactivity disorder, inattentive subtype.
Surprisingly, an unusually large number of responses to the article poured in from around the country—some missing the sarcasm and outraged that funding for research was being spent inappropriately, and some upset that the authors were poking fun at serious psychiatric disorders. The article, and the large mix of opinionated responses to it, highlights the rifts in opinion concerning diagnosing and prescribing medication for what some see as merely personality characteristics.
Among these psychiatric disorders, ADHD is probably the most entrenched in conflicting public, medical, and personal opinions about diagnosis and necessity of medical treatment. Some mothers become irrationally convinced that their child has ADHD, and others refuse to believe that having a high-octane, impulsive lifestyle should be classified as a psychiatric disorder. So how do you know if you or a close family member actually has ADHD, and whether or not you should treat it with serious psychoactive drugs? The answer, unfortunately, is iffy at best.
Attention Deficit Hyperactivity Disorder (ADHD) has, in the past decade, gripped the curiosity of our society for its social, political, and scientific complexity. About 3-9% of children around the world have ADHD, and as many as half of these kids will continue to exhibit symptoms into adulthood. The core cognitive deficits of the disorder include impulsivity, hyperactivity, and difficulty sustaining attention.
Despite the numerous and detailed genetic, anatomical, and behavioral data that have begun to characterize ADHD patients, it is still very difficult to confidently diagnose a child or adult with the disorder. This is partly due to the fact that the patient or patient’s parents provide most of the observational evidence for diagnosis, and partly because diagnosing it involves analyzing complex cognitive functions. Adding to the confusion is the fact that all ADHD symptoms occur normally in most individuals, but with much less severity and with no debilitating impact on daily living. In fact, in any given population there is a range of individuals exhibiting anywhere from no ADHD symptoms to severely displaying almost all of the symptoms. However, research in the fields of neuroscience, genetics, and neuroimaging could allow for more concrete diagnostic criteria as well as unique treatments in the future.
One approach in ADHD research is to use large-scale cognitive evaluations, such as observing patients or animal models doing tasks that require attention. This research is able to pinpoint specific cognitive deficits associated with the disorder, and can lead to new diagnostic criteria and test the effectiveness of new medications. Another approach is to attempt to discover underlying molecular mechanisms causing ADHD by looking at brain anatomy and physiology associated with the disorder’s symptoms. Both lines of research uncover valuable information about the disorder that can help doctors and patients diagnose and treat ADHD more accurately.
One of the most prominent biological characteristics of the disorder is a deficiency in the neurotransmitters dopamine and norepinephrine. Lower concentrations of these chemicals in the prefrontal cortex (involved in planning future actions) and basal ganglia (involved in coordinating complex motor activity), generally affect our ability to select, initiate, and complete complex tasks. Methylphenidate, commonly known as Ritalin, is a common stimulant used to treat ADHD symptoms that acts on dopamine transporters in the brain to counteract these chemical imbalances. Several genes have also been implicated in the disorder, and when they are present an individual has about a 75% chance of having the disorder.
Another interesting association with ADHD that has emerged is recurrent tonsillitis and snoring. It is believed that partially blocking a developing child’s airways during sleep, and thus desaturating the brain of oxygen, can lead to cell death in specific areas of the brain also involved in the development of ADHD. Cell death in these areas can actually lead to ADHD symptoms, and over half of children with ADHD also have disrupted breathing patterns during sleep.
On the more cognitive end of the spectrum, researchers are trying to understand the overall cognitive deficits in patients with ADHD. Although several theories have been brought up over the past decades, the most likely idea is that patients display two large psychological deficits: they are not able to inhibit impulses or random thoughts (inhibitions dysfunction), and they have trouble waiting for the completion of a task or event (delay aversion). As enticingly self-sufficient as these explanations seem, there has been no convincing research done that can link these psychological theories to the molecular data brought up by neuroscientists. Yet that hasn’t stopped some from finding a few practical, if bazaar, applications of our psychological understanding of ADHD.
UCLA Psychology professor Eran Zaidel and colleagues have discovered a unique way to treat ADHD symptoms. These researchers attached electrodes to individuals at rest, and when specific non-ADHD type brain activity occurred a computer simulated car would be propelled around a racetrack. By simply changing their thoughts haphazardly until the car began to move faster on the screen, individuals with ADHD were successfully able to at least partially alleviate their symptoms. Although this technique requires a lot of repetition to show results, it’s hard not to imagine an exciting at-home video game that interactively uses your brain activity in order to treat your ADHD symptoms.
Despite the quickly growing knowledge base for ADHD, there is still no concrete, underlying explanation connecting the psychological symptoms, brain anatomy, and physiology associated with it. Even without a clear-cut, self-explanatory model of ADHD, it is nonetheless obvious that the disorder exists and can seriously interfere with patients’ ability to perform daily life-tasks. Yet patients can show a vast range in severity of symptoms, and it is still very difficult to decide which, if any, medical treatments should be taken. At the end of the day, the lack of concrete evidence available to patients leaves them, or their parents, with the responsibility of deciding whether medical treatment is the right choice. On the whole ADHD is under-diagnosed, with only a fraction of people with the disorder seeking treatment. It is also reported that many people without ADHD are being prescribed stimulant medications. Clearly there is a significant problem facing our society as to who should and shouldn’t be taking serious psychoactive drugs.
As researchers continue to unearth stubborn details, it will become easier and easier to not only diagnose but effectively treat the often debilitating symptoms of ADHD. More people who aren’t getting treatment for their ADHD symptoms will get to, and fewer and fewer experimental but healthy college kids will be able to get their hands on stimulant drugs.

~Nate Jacobs


References:

1. Sarah E. Shea, Kevin Gordon, Ann Hawkins, Janet Kawchuk, Donna Smith (2000)
“Pathology in the Hundred Acre Wood: a neurodevelopmental perspective on A.A. Milne." CMAJ. 163 (12): 1557
2. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. (2007) “The worldwide prevalence of ADHD: a systematic review and metaregression analysis.” American J of Psychiatry. 164(6): 942-8.
3. Greydanus, DE, Greydanus, HD, Pratt, and Dilip R. Patel. (2000) “Attention Deficit Hyperactivity Disorder Across the Lifespan: The Child, Adolescent, and Adult.”

4. DM. Golan N, Shahar E, Ravid S, Pillar G. (2004) “Sleep disorders and daytime sleepiness in children with attention-deficit/hyperactive disorder.” Sleep. 15;27(2):261-6.
5. Sonuga-Barke, Edmund J.S. (2002) “Psychological heterogeneity in AD/HD: A dual pathway model of behaviour and cognition.” Behavioural Brain Research. 130(1-2): 29-36
6. Hill, Zaidel, et al. Unpublished.

UCLA Research Insights: Sleep, Dreams, and the Siegel Lab

     We spend about one third of every single day of our lives unconscious. Without fail, the dopaminergic pleasure of cuddling with the warmth and comfort of a big puffy blanket, among other things, convinces us each night that we should just close our eyes and go to sleep for seven hours. Why do we do such a silly thing? What biological benefit do we get from sleeping? And, most importantly, how does our brain accomplish such a task? These are a few of the many questions being asked, and answered, by the Siegel Lab at the Center for Sleep Research here at UCLA.
     So what is actually going on upstairs while we blissfully neglect the stressful world around us every night?
     There are two main types of sleep that our brain cycles through during the night: slow wave sleep and rapid eye movement (REM) sleep. As we groggily climb into bed and close our eyes, we quickly drift past the semi-coherent sleep stages one and two and into the first major type of sleep: slow wave, or non-REM, sleep. During slow wave sleep, which is comprised of sleep stages three and four, our brains consume the least amount of energy, we often are the most deeply asleep, exhibit sleep-walking behaviors, and have little or no dreams. Enormous numbers of neurons across the brain fire together to produce relatively slow, synchronous waves of action potentials while we are in slow wave sleep.
     Guided by a small cluster of neurons in the brain stem, which is found at the base of the brain above the spinal cord, our brain cycles into the second major type of sleep called REM sleep.
     REM sleep is perhaps one of the most intriguing stages of sleep because it shows brain activity that is almost identical to that of someone who is fully awake. Our breathing and heart rate become irregular, as when we are awake. Energy consumption and brain activity rise, and smaller groups of neurons fire frequently and independently of each other.
     It is also during REM sleep that we have our most vivid and convoluted dreams, and when our motor cortex ceases to release its muscle-activating neurotransmitters so that we remain temporarily paralyzed. While we dream, bursts of activity arise from neurons associated with the people, places, and emotions we have experienced. The hippocampus, which helps us integrate our perceptions into a coherent plotline, is also highly active during REM sleep. According to the Activation-Synthesis hypothesis, the hippocampus tries to make sense of random bursts of sensory perception by quickly integrating them into the most realistic story it can create. What is not very active during this stage, however, is the frontal cortex which is responsible for correcting conceptual errors like “I am not capable of flying” or “There is no way that Hal Berry would actually go out with me.”
     So why do we sleep? Despite the extensive amount of research being done to uncover the mysteries of how we sleep and what the purpose of it is, the exact functions of sleep remain somewhat of a mystery.
     The UCLA Center for Sleep Research, headed by principle investigator Dr. Siegel, is doing its part to advance sleep research in a multifaceted, interdisciplinary way. Dr. Siegel and colleagues are answering many of the fundamental questions in the field by exploring the genetic, molecular, developmental, behavioral, and evolutionary aspects of sleep. The researchers there have published papers on a variety of sleep-related topics, including the neural mechanisms that make us sleep, the possible biological functions of REM and non-REM sleep, as well as the chemical and behavioral characteristics of narcoleptic patients, who fall asleep at random times of the day.
     One interesting approach to looking at the functions of sleep taken by the Siegel lab is to compare the amounts and types of sleep that different species get. For example, you might assume that Homo sapiens have the most exhaustive mental activities, and therefore need the most sleep to recuperate. In fact, bats and opossums are the ones that spend more time asleep than any other mammal, getting as much as 20 hours of beauty sleep every day (God knows, they need it). Yet elephants, agreed to be one of the more intellectually inclined animals, spends a mere 3 hours a day sleeping.
     An article published in 2005 in the journal Nature by the Siegel lab showed that, more than any other factor, an animal’s size and metabolic activity are the best things to predict its amount of daily sleep. This may be due to the fact that smaller animals tend to have a higher metabolic activity (they consume and spend more energy each day), which may increase the amount of oxidative stress that is put on the brain. More stress on the brain would require more nightly rest to recuperate from the fast-paced activities of the day. This is just one idea among many others that is being pursued by researchers.
     According to Dr. Siegel, most of the data collected on sleep supports three general theories: 1) that sleep saves energy, 2) that it keeps animals from being active at inopportune times, and 3) that sleeping allows for the brain to recuperate from chemical changes occurring while awake.
     One specific interest of the Center for Sleep Research is to find out why we have REM sleep, and thus possibly the reason why we have dreams. The subject has attracted much research, and has led to pointed disagreement among scientists.
     Many articles both recently and historically have purported a strong correlation between REM sleep and memory consolidation, which is the process of solidifying important memories to make them more permanent. In fact, the belief that REM-sleep is necessary to retain information is fairly common. People say that you need to sleep for at least two hours before a test in order to ensure the onset of REM sleep, otherwise you wont remember anything you studied.
     Yet Dr. Siegel and his collaborators have carefully but vigorously attacked these claims, concluding in a 2001 publication that “the existing literature does not indicate a major role for REM sleep in memory consolidation.” What about needing REM sleep before taking a test? In fact, poor performance on tests after not getting any sleep is more likely to be due to the fact that you are drowsy and not that you can’t remember learned information. Not getting any REM-sleep (or any other kind of sleep) may not disrupt your ability to retain information, but being half-awake during a test will.
     A strong counterargument made by Dr. Siegel and colleagues to REM sleep-memory consolidation theories is that most antidepressants completely remove REM sleep from patients. Patients who regularly use anti-depressants, even those who have experienced an absence of REM sleep for over a year, do not show any significant memory or learning deficits. This, along with specific shortcomings of the studies that support the claim, show that perhaps REM-sleep does not act as a memory-forming catalyst.
     Another interesting hypothesis discussed in the same article from 2005 was that REM sleep might allow us to awake up in a more alert, responsive state of mind. People are more easily awoken from REM sleep, and when awoken tend to be more responsive than if they were woken up during non-REM sleep. As the night progresses, the amount of time we spend in REM sleep slowly increases until we are spending most of our time asleep in the REM stage. Thus, by the time it starts to get light out and the need to react to a possibly dangerous environment grows, the chances that you are in the easily-awoken REM stage is very high.
     REM sleep has also been suggested to play a role in the early development of our sensory systems. Before babies are born and their eyes, ears, and hands are not relaying sensory information to their brains, REM sleep may help the neuronal circuits fated to become our sensory systems develop by activating them sporadically.
     There are currently many competing theories about the function and nature of the brain activity associated with sleep. Each hypothesis, on its own not able to explain all aspects of sleep, nevertheless brings another piece of the puzzle to the table.
     Although the Siegel lab and the hundreds of other researchers working on sleep can not yet conclusively tell us why we sleep or dream, I’ll trust that the pleasure of letting my consciousness fall away from me each night is providing me with a significant biological advantage. Plus, do we really have the choice of turning down sleeping in until noon on a Saturday morning?

~Nate Jacobs


References:
-JM Siegel. (2005) “Clues to the Functions of Mammalian Sleep.” Nature. 437 (27): 1264-1271.
-JM Siegel. (2001) “The REM Sleep- Memory Consolidation Hypothesis.” Science. Nov. (294): 1058-1063.
-S Schwartz, P Maquet. (2002) “Sleep Imaging and the Neuropsychocological Assessment of Dreams.” Trends in Cog Sci. 6 (1): 23-30.
-JM Siegel. (2006) “The stuff dreams are made of: anatomical substrates of REM sleep.” Nature Neuroscience. 9 (6): 721-722.
-JM Siegel. (2003) “Why We Sleep.” Scientific American. Nov: 92-97.

A Majority of California Legislatures Have Chosen a Single Payer System to Solve Increasing Health Care Woes

       Almost one year ago, a state bill mandating universal health care for all Californians sat on Governor Arnold Schwarzenegger’s desk. The bill, SB 840, would require the funding of all health care costs to be turned over from private companies and create a single payer health care system controlled by the state. Written by our neighboring state senator Sheila Kuehl (D-Santa Monica), the bill was co-authored by 23 other state legislatures, supported by over 380 statewide and national organizations, and passed with majority support in both houses of state congress. Gov. Arnold Schwarzenegger vetoed SB 840 that September in 2006, saying that “socialized medicine is not the solution to our state's health care problems.” This fear of socialized medicine, along with his concerns about the financial risks involved with universal health care, is reflected in the opinions of most of SB 840’s opponents.
       Yet there is no question that Californians are becoming increasingly fed up with the current health care system. According to the nonpartisan Field Poll conducted this past August, 69% of Californians are dissatisfied with the current health care system with 42% of participants saying that they are very dissatisfied.
       Escalating public disapproval of the way private insurance companies are handling our health care system stems from a number of economic and social ills. There are an increasing number of Americans, with and without health insurance, facing either economic or health crises because of the cost of receiving health care. In fact, half of all the bankruptcies filed in the US are due to medical costs even though three fourths of those filing for bankruptcy have health insurance. Even for those who are paying for health insurance, many have to deal with overwhelming deductibles, co-pays, and denial of payment for essential care due to various loopholes in insurance contracts. In many instances, having a pre-existing condition (of which there are hundreds), can entirely exclude you from getting health insurance. As a result, 18,000 people die each year because they either couldn’t get or couldn’t afford health insurance, and it is now the 7th leading cause of death in the US.
       At least those that are receiving care in the US are getting some of the best medical attention in the world, right? In fact, this a common misconception about American health care. Although the US spends more than twice as much on health care than any other industrialized nation (both per capita and as a percent of gross national product), the quality of health care in the US is ranked by the World Health Organization below all other industrialized nations at 37th for quality, access, and efficiency of care.
       So, 69% of Californians are dissatisfied with our current system of distributing health care-  what serious health care reforms can we hope for in the future? Lawmakers and politicians across the nation have put forth a variety of proposals and legislature that generally fall into three categories: 1) retaining the current system with few alterations and allowing free-market competition to solve current problems, 2) reforming the current system by expanding publicly funded coverage, or 3) implementing a single payer system in which universal health care is offered to everyone and controlled by a government institution.
       Those in favor of relying solely on market-driven solutions to improve our health care system bring up several economic and personal freedom arguments. One argument is that if a bill like SB 840 is approved, then socialized medicine would lead to rationed care with longer wait times for standard procedures and limited treatment options for patients.  Opponents also argue that a market economy is generally accepted as the most effective way to reduce the cost of consumer goods and services in our country. One point commonly made by those in opposition is that many people in Canada often travel to America to receive medical services that are either not offered in their country or have too long of a waiting line. However, this highly referenced claim was significantly undermined by the findings of a large population study was conducted in 2002 by Katz and colleagues at the University of Michigan.
       California Gov. Schwarzenegger has taken a moderate approach in his recent outlines for health care reforms. His plans, which would work within the existing health system structure, would require all Californians to have health care insurance but would not directly pay for individuals’ plans. This type of health care reform, which tries to redistribute the financial burden of health care across business, government, and more wealthy individuals has recently been implemented in Massachusetts by presidential hopeful Mitt Romney. Although it doesn’t solve all of the problems with the current health care system, it addresses the fiscally conservative concerns by maintaining the private sector’s role in health care insurance.
       Yet more frequently people are citing the health insurance companies themselves as the source of most of our system’s problems. Even if the costs of premiums, deductibles, and co-pays are brought under control by moderate legislative reforms, the major problems concerning denial of care and exclusion from insurance plans based on pre-existing conditions remain. In a meeting with state legislatures to screen his new health care documentary “SiCKO,” director Michael Moore likened an insurance company denying emergency care to individuals to a fire truck denying its services to a burning house. Referring to a hospital’s need to ask health insurance companies’ permission before providing certain care, Mr. Moore noted “that when someone is wheeled into a hospital that question should never be asked… That is an immoral question to ask amongst a humane society.”
       The most radical legislative reform proposed in California is instituting a single payer system under SB 840. This type of reform has been proposed by many of the Democratic presidential candidates and is currently supported by a majority of California state lawmakers.
       Supporters of universal health care draw from a long list of examples of successful publicly funded national health care systems. Most notably Canada, Australia, Japan, Russia, and all of Europe have successful single payer health care system in place. All of these countries spend less for their health care systems, and most have better quality medical care than the US provides. When Steve Lindsay of the California Association of Health Underwriters (a vocal opponent of SB 840) was asked by the Assembly Health Committee Chair “Of the top 8 countries, can you name the ones that don’t have a comprehensive health system?” Lindsay was forced to respond that “America does not have one.” In fact, the United States remains the only industrialized nation that does not have a publicly funded, universal system.
       In California, a single payer system would completely remove the $136 billion private health insurance industry and replace it with a pooled government run system that would cover all medical costs for all California citizens. People would be able to choose their own doctors, and the medical care provided would include (beyond basic medical care) emergency transportation, dental, vision, and hearing care, prescription drugs, substance abuse treatment and health education, to name a few.
       According to the Lewin Group, an established third party organization that analyzes the impact of health reform initiatives, if SB 840 was passed the state of California would save $8 billion in health care costs in the first year alone.  Of that amount, $5 billion would be saved in family health care costs. Instead of paying for premiums, co-pays and uncovered treatments as medical conditions arise, people would have a constant 3.8% income tax that would effectively “smooth out” health care costs to avoid any individual medical expenses that could be financially devastating. Under the bill incomes under $7,000 and any income beyond $200,000 would not be subject to the 3% tax, removing financial burden from the poor and not over-taxing the wealthy. An 8% tax would also be implemented on business revenues, but would replace any current health care costs paid by employers.
       After Gov. Schwarzenegger vetoed SB 840 last fall, state senator Sheila Kuehl re-introduced the bill on February 27th, 2007 in a crowded Sacramento hearing room standing beside hundreds of the bill’s supporters. The bill currently has 43 co-authors and is supported by a gamut of organizations including Physicians for a National Health Program, California Nurses Association, the California Federation of Teachers, California School Employees Association, Health Access California, League of Women Voters, Service Employees International Union, as well as several religious and elderly groups, among hundreds of others. In July the single payer bill passed both the state Senate and House of Representatives with majority support, and Senator Kuehl is currently deciding whether or not to send the bill to Gov. Schwarzenegger this year or next year.
       Outspoken doctors, politicians, and political activists are calling for a grass-roots effort by communities and local governments to help get single payer legislation passed. City governments, state- and nation-wide organizations, and individual outspoken citizens are preparing to combat the inevitable billions of dollars that will be spent by insurance companies in advertising and lobbying to keep health care coverage in their control. After over four years of steadily growing support for Kuehl’s single payer bill, impassioned citizens and politicians have created majority support for their legislature.
       With universal health care hanging in the balance, Californians await the upcoming decision by their Governor.

~Nate Jacobs



References:
1. S. Katz, K. Cardiff, M. Pascali, M. Barer,and R. Evans. (2002) “Phantoms in the snow: Canadians’ use of health care services in the United States.” Health Affairs. 21(3).
2. Aug 2007 Field Poll, available at: http://www.bayareanewsgroup.com/multimedia/mn/news/fieldpoll_082207.pdf
3. SB 840 Lewin Group Report (2004), available at: http://www.healthcareforall.org/lewin.pdf
4. Additional information can be found at these websites:
www.firstresearch.com/IndustryAnalysis/California.asp
www.californiahealthline.org
www.photius.com/rankings/healthranks.html
http://en.wikipedia.org/wiki/Single-payer_health_care