New Research Toward Personalized ADHD Medications
by Richard Rubin, MD
Clinical Associate Professor, University of Vermont
College of Medicine

Reviews of current knowledge and ongoing research were presented at this Symposium during the October 2007 American Academy of Child and Adolescent Psychiatry Annual Meeting. The conclusions support valuable concepts applicable to practice now, while data proof is still pending. One concept is recognition of the variety in Core Symptom responses to the three first line medicines, as defined by FDA approval (methylphenidate, amphetamines, and atomoxetine). Dr. Steven Pliszka reviewed current outcome studies, concluding there are no patient characteristics that predict the best medicine when a person has uncomplicated ADHD. Additionally, the efficacy and statistical effect sizes shown in clinical trials are influenced by several additional factors when we attempt application to community care choices. Dr. Mark Stein listed factors that change effectiveness in practice: acceptability versus stigma, safety, cost/availability, tolerability, duration, mode of administration, and perception of need.

While there are no current tests or technology methods to guide individual medicine choices, several lines of research may be useful eventually. Dr. Pliszka described how Functional Magnetic Resonance Imaging may be able to match areas of brain disorder with different medicine benefits. In addition, Drs. Stein and James McCracken described how testing of various genes associated with ADHD may be correlated with medicine response and side effect differences.

Another important concept is recognition that, besides ADHD Core Symptoms, people vary a great deal in their Impairments, meaning difficulties in life functioning. Just as the presence of Impairments is necessary to diagnose ADHD, they also influence treatment choices. Dr. Margaret Weiss described research with her Weiss Functional Impairment Rating Scale scale to measure impairment in family, school, life skill, self-concept, and social functions. Differences in medicine qualities and effects on impairments may inform treatment choices. Priority for several hours of school effort and behavior control with methylphenidate or amphetamine differs from continuous stabilizing of troubling emotion reactions with atomoxetine. In treatment, doctors need to evaluate separately: 1) a medicine's effects on ADHD Core Symptoms, 2) its effects on Impairments, and 3) how tolerability problems influence overall outcomes. In the discussion, I clarified with Dr Weiss that addition of other disorders definitely causes worsening of the Impairment burden. Specialists are recognizing that ADHD has three dimensions in each individual: behavioral, emotional, and cognitive, encompassing both each person's combinations of these features, plus the added function problems of co-existing disorders. At present, doctors can begin applying individualized concepts and considerations to provide personalized treatments.

Dr. Rubin practices Child and Adult Psychiatry, directs The Clinical Study Center in Burlington Vermont, and serves as Clinical Associate Professor at the University of Vermont College of Medicine.

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Budgeting Time, Budgeting Money
by Ari Tuckman, PsyD, MBA
Author of "Integrative Treatment for Adult ADHD" which was just published (see side bar)

We've all heard the expression "time is money." For those with ADHD, time is just like money when it comes to budgeting-slippery and problematic. Sure, they know all about how important it is and why they should do a better job of managing both. Yet somehow that general knowledge isn't enough to prevent too much being spent on some tasks or expenses, leaving too little left over to spend on others.

The problem is that managing time and managing money both require some of the same basic skills-skills that most ADHD adults can't count as strengths. Remembering one or two things is easy, but remembering a bunch of items (like tasks to complete or items that will need to be purchased) and mentally manipulating them, is much harder. For example, let's say you're tempted to go out to dinner rather than make something at home. How does that money figure into your overall budget? Sure, you've got twenty bucks in your wallet, but will you need that twenty bucks later this week for something else? How much gas is left in your car? How much food is in the fridge? Have you paid your big monthly bills yet? Etc., etc., etc. The same can be said for budgeting time-watching one more TV show is no big deal, unless you still have to shower, clean up the dinner dishes, and run a load of laundry before going to bed.

So how are ADHD folks supposed to avoid these kinds of predicaments? Here are a few thoughts:

• First, recognize that budgeting more than a few items is a difficult process, requiring a fair amount of mental calculation. So don't expect to be able to do it all in your head!· Writing things down, rather than trying to do it all in your head, takes a lot of strain off of your mental muscles. It also makes it more likely that you won't forget important bits and pieces. So find a schedule book or PDA that works for you and carry it around. For your finances, try to write down a general monthly and weekly budget. Don't get carried away, but try to create a general plan so you have something to compare against-for example, how much do you allotted for eating lunch out?
• Writing things down, rather than trying to do it all in your head, takes a lot of strain off of your mental muscles. It also makes it more likely that you won't forget important bits and pieces. So find a schedule book or PDA that works for you and carry it around. For your finances, try to write down a general monthly and weekly budget. Don't get carried away, but try to create a general plan so you have something to compare against-for example, how much do you allotted for eating lunch out?
• As fun as it can be to let an impulse carry you away, work really hard to not commit to a task or expense without first consulting your overall plan. Keep your schedule book with you whenever it may be necessary and keep your general budget in your purse or wallet. It can be really helpful to have these there to refer to, rather than relying on fuzzy memories.

myADHD.com and Addvisors.com offer a free ADHD related teleconference on the second Wednesday of each month.

Hear Alan Graham, Ph.D. and Bill Benninger, Ph.D. discuss "The Only Six Treatments for ADHD Worth Considering For Your Child." Th is your chance to have your questions answered by two psychologists who specialize in the treatment of ADHD.

Wednesday, November 14, 2007 from 8:30 - 9:30 pm
Call: (646) 519-5883 Pin: 2648 at 8:30 pm EST on May 9th to join the teleconference.