Archive for the ‘Research’ Category

Elected to the Board of Directors of American Professional Society of ADHD and Related Disorders

The American Professional Society of ADHD and Related Disorders is an organization of national and international researchers and clinicians. I was honored to be invited to present “Adult ADHD and Medication Treatment Options” at the annual conference held in Washington, DC in September 2013.  During the conference, I was nominated and elected to the Board of Directors consisting of 15 experts from around the world. This is an opportunity for me to directly participate with the international community of experts and assist in disseminating the state-of-the-art research and clinical treatments. In addition, I will provide assistance in the pre-publication peer review process for the Journal of Attention Disorders.

I look forward to making my contributions on behalf of all the people with ADHD and their families. Thank you for your interest.

David W. Goodman, M.D.

ADHD in People Age 50 and older

In the September issue 2013 of Attention Magazine, published by the national organization CHADD (Children and Adults with ADHD), my article was published on ADHD in people age 50 and older. There is remarkably little research looking at this population of patients. Clinical medication trials that seek the FDA approval for the treatment of ADHD include subjects up to 65 years old. However, the number of subjects over 50 in these studies is relatively small and often the mean age is 34.

Unfortunately, ADHD may not be a diagnostic consideration when older people complain of cognitive difficulties. A study looking at memory clinics in the U.S. found only 1 in 5 centers screen for ADHD. Therefore, it is possible that ADHD symptoms may be misdiagnosed as something else (Fischer BL 2012). Given that ADHD is a cognitive impairment, people wonder if ADHD is a risk factor for developing dementia. A recently published study looking at the question concluded that ADHD is not a risk factor for dementia (Ivanchak N, 2011). We’ll await further research.

Myths about ADHD over age 50:

Can’t diagnose ADHD in the presence of older age.

Can’t diagnose ADHD in the presence of medical disorders and medications.

Why bother treating it, they lived their whole life this way.

The ADHD medications aren’t safe in older adults.

Diagnosing ADHD in a person this age presents unique challenges because there are specific medical and psychiatric considerations in someone over age 50. If we just focus on the cognitive symptoms, the first issue is how much of the cognitive symptoms are age related. As we age we will notice some forgetfulness, difficulty in recalling information quickly, losing a train of thought, and getting distracted. What distinguishes this from ADHD is the fact that the symptoms started much later in life and not in childhood. Second possibility is a new diagnostic category in the DSM-5 called Mild Cognitive Impairment. This is a degree of cognitive change accompanied by impairment but not rising to the level of Alzheimer’s disease. Third are the effects of medication on cognition. As we age we will develop medical illnesses treated with medication that may have subtle effects on cognition (i.e. statins, antidepressants, chemotherapy).  The more medications we are on, the more likely they will affect our thinking ability. Fourth, medical illnesses themselves may affect our thinking ability (i.e. hypothyroidism, post cardiac surgery). Fifth, women in peri- or post-menopause often notice clear changes in memory and cognition. Sixth, a long history of alcohol and/or substance abuse may cause lasting cognitive symptoms. Seventh, head trauma/concussion/neurological disorders may leave persistent changes on memory and processing speed for information (i.e. multiple concussions from sports injury).  What distinguishes all of the above diagnostic consideration is the age of onset of these symptoms. Except for the possibility of head trauma in childhood, all the other diagnostic considerations occur later in life. The hallmark of ADHD is the presence of symptoms in childhood.

I will continue my blog on this subject in the future. Thank you for your interest. Hope it is helpful to you.

High Dose Stimulant Treatment for Adult ADHD

All ADHD medications that are FDA approved to treat adults have designated maximum daily doses. It is important to understand how these daily maximum doses are determined in order to consider higher doses beyond these thresholds.  The FDA receives the clinical registration trial research and it makes a determination of maximum daily dose based on the presented data. If, for example, a clinical trial had a maximum dose of 50 mg a day then the FDA will only approve the drug with a maximum daily dose of 50 mg.  An example of this is Vyvanse where the trial looked at 30 mg, 50 mg and 70 mg a day. Maximum daily dose approved is 70 mg.

In some cases where the clinical trial evaluated several doses, the FDA may only approve a maximum dose in the middle dose range from the trial because the higher dose didn’t demonstrate a statistically significant difference in effect. Case in point, Concerta maximum daily dose in the package information is 72 mg, although the U.S. adult trial went to 108 mg a day. However the trial protocols are not designed to answer the question “If you don’t respond to 72 mg a day, will you respond to 108 mg a day”.

Where am I going with this? I have several patients at what would be considered as very high doses of stimulant medication-methylphenidate 400 mg a day, Vyvanse 200 mg a day. Unsafe? Well neither patient complains of problematic side effects for which they would stop the medication. Also, blood pressure and pulse are in normal range. We got to these doses because lower doses didn’t have any effect until we went higher. In each of these cases, I have ordered stimulant blood levels to see if blood levels were too high. In fact, in each case the levels were lower that what was expected by mathematical extrapolation.

The point? There are a group of ADHD adults who are very fast metabolizers who will only respond to very high stimulant doses. Since most of the metabolism of amphetamines and methylphenidate occurs outside the liver, I’m not sure obtaining a liver P450 enzyme profile to determine metabolism will be useful.

If you have ADHD and have not responded to appropriate stimulant doses, then consider seeing an ADHD adult psychiatrist who has experience and comfort with this dosing concept.  That’s what true expert clinicians are for.

Faculty speaker, annual American Professional Society for ADHD and Related Disorders conference

American Professional Society for ADHD and Related Disorders (APSARD) is an organization founded by a national and international group of experts in ADHD treatment and research. The annual meeting, “ADHD Advances: Challenges and Opportunities” being held September 27 – 28, 2013 at the Hyatt Regency Washington on Capitol Hill in Washington, DC  brings together these experts and other professionals interested in learning and advancing their skills. The presentations are the cutting edge research, treatment options, and technology developments to further our understanding of ADHD and the co-existing psychiatric and medical disorders.  Information and discussions extend beyond U.S. research to include Canadian, European and Middle East research and treatments.

I am honored to be invited to present a 60 minute workshop on the “Choice and Optimal Dosing of Medications for Adults with ADHD” with my co-presenter Dr. Janet Standard, a psychiatric Advanced Practice Nurse at the NYU Health Services. 

The conference is open to professionals in the health care field and registration is available now. . this link, you can browse the conference agenda, location, and hotel accommodations. This is a top-level, relatively small conference that allows all participants to engage and exchange thoughts and ideas. If you are in the field of ADHD, this is a conference not to miss. See you there.

David W. Goodman, M.D.

Brain test for ADHD-Expert does not endorse for diagnosis

As a follow-up to my blog on the new brain EEG “test” for diagnosing ADHD in children, a 2013 meta-analysis ( a review of all studies) research publication reviewed the individual studies on the use of EEG in children with ADHD. The NEBA study was included. The leader author of this study, Dr. M Arns at the University of The Netherlands concludes that EEG testing for ADHD is not a clinically useful test at this time. He explains his thoughts in a very recent piece for CHADD on their website.

Although the theta/beta wave ratio is different in ADHD children, there is too broad a range in this patient population to make the EEG test useful.

So, as I mentioned in my previous blog, be cautious if someone recommends this test “as a helpful way to make an accurate diagnosis.”  As I have said before, let science be the designated driver on the highway of opinions.

David W. Goodman, M.D.

Brain wave device for ADHD approved by the FDA

If you get ADHD alerts or listen to the media, you may have heard of the FDA approval for a brain wave test to aid in the diagnosis of ADHD. The study involved 275  children between ages 6-17. The test is an EEG and they say that the ratio of specific brain waves (theta and delta) increase the accuracy of making the ADHD diagnosis.

Here are my reservations:

1. The FDA has not released the study data so there is no way for researchers and clinicians to review the merits of the study.

2. Study methodology can strongly influence the data and subsequent interpretation.

3. We don’t know the threshold of benefit that was used by the FDA to merit the approval. The threshold was not indicated in their approval statement.

4. I’m unable to locate the study as a scientific publication at the NIH publication database (

5. What you may be reading in the media is simply a combination of the FDA’s statement of their approval and the press releases by the company who sought the approval.

6. Historically, attempts to find diagnostic tests like this for ADHD have been very elusive and ultimately of little added benefit in clinician practice.

7. Resist the “sales” pitch of practitioners to use and bill for this “test”. The prescribed treatment will still be the same, regardless of the “test” results.

Until the study or studies are publically available for scientific review, please be skeptical.  If it proves to useful, the studies will clearly indicate it.  Until then…..

David W. Goodman, M.D.

Nondrug ADHD treatments not very effective

I was recently invited to write an editorial for an international medical journal on a study by Sonuga-Barke and colleagues. This published study was an extensive review and analysis of published research looking at several different nondrug treatments for ADHD. My editorial will be published by the British Medical Journal in Evidence-based Mental Health June 2013. Dr. Sonuga-Barke’s analysis looked at 2904 studies of which 59 were selected because they satisfied high-quality data. I’m unable to provide my editorial text as the manuscript is embargoed until publication.

Dr. Peter Yellowless briefly reviews the study conclusion in a Medscape video.

The study divided treatments into several categories: restrictive elimination diet, artificial food color exclusion, free fatty acid supplementation, cognitive training, neurofeedback and behavior interventions. Only artificial food color exclusion and free fatty acid supplementation were statistically significantly effective, although the effect was relatively small.

Single clinical trials are often published showing some positive benefit. These studies then receive media coverage, especially if published in high impact journals. However, publication bias exists because negative studies often don’t get published, leaving readers with a false sense of benefit.

Publications like Dr. Sonuga-Barke’s help doctors and patients review multiple studies to see if replication of positive findings occurs. Evidence-based medicine in not based on single study reports but on the accumulation of studies over time.

As I like to say “On the highway of opinions, let science be the designated driver.” David W. Goodman, M.D.