(See "Five Myths About ADHD" below.)
Here's what else. I spend a lot of my time looking at healthcare through the lens of quality improvement - a perspective and a toolkit that treats variation in care as something to be eliminated, while standardization is reinforced. It relies on measurement of care delivery at scale, and sees health encounters as a set of inputs and outputs. By stark contrast, during 25 hours or so of lectures and discussion, the international thought leaders who were the faculty for this course spoke very little - if at all - about variation or standardization.
Instead, there was much discussion of individualized care -- and why there was no one-size-fits-all solution to mood disorders, or anxiety, and certainly not for ADHD or autism. The emphasis was on understanding the rapidly changing scientific landscape, the best approaches to assessment and how therapeutics must be modified to meet the individual circumstances of our patients. Ultimately, it seems to me, this contrast is essentially about the difference between the delivery of healthcare to populations, and the practice of Medicine, which remains, principally, about the care of individual patients with their own unique situations, needs, responses to treatment and preferences. This is not to say that one enterprise is inherently better or more valuable than the other.
It is to say, however, that they are distinctly different. Were healthcare like a forest, a few paved roads in that forest would be the things we can and should standardize, and then measure and improve. A vastly larger area would represent the forest itself, laced with trails cleared to varying degrees. We walk those trails with our patients, and sometimes we must walk where there is no trail at all. But in this is the challenge and the joy of medical practice.
FIVE MYTHS ABOUT ADHD
MYTH 1. It is always safer to avoid medications to treat ADHD
The outcomes associated with under-treated ADHD go far beyond the classroom. Individuals with this condition experience greater rates of tobacco and alcohol use during adolescence and beyond, each with their own known morbidity and mortality. Accident rates appear to be increased by 250% in affected individuals. In a placebo-controlled study of lisdexamfetamine on “surprise” driving events, Biederman and colleagues found that medication reduced the probability of motor vehicle collision by more than 60%. Finally, the effective treatment of ADHD appears to be important to reduce the effects of common co-morbid conditions, including low self-esteem, social isolation, depression and conduct disorders, with consequences that include encounters with law enforcement and suicidality. In a 10-year, prospective cohort study, compared with untreated patients, individuals treated for ADHD with stimulant medications experienced lower rates of anxiety, depression and ODD (Pediatrics 124(1):71, 2009).MYTH 2. If nothing else, avoiding medication for ADHD at least reduces the risk of illicit substance use in adolescents with this disorder
Despite concerns about psychostimulants as “gateway” drugs, in reality, untreated patients with ADHD experience significantly higher rates of substance use disorders (SUD) than individuals who receive effective therapy with stimulant medications.
MYTH 3. Children who can play video games for “hours at a time” can’t have ADHD
Symptoms of inattention and distractibility are context dependent. A better measure of these symptoms involves an assessment of the child’s performance when carrying out a task in which he is not naturally interested.
Myth 4. ADHD is a subjective diagnosis with no known biological markers
Multiple lines of evidence support the concept that ADHD is a distinct brain disorder, albeit one with multiple genetic and environmental risk factors. Functional MRI comparisons between ADHD patients and normal controls demonstrate differences in frontosubcortical networks involving the (ventromedial, dorsolateral and orbitofrontal) prefrontal cortex, parietal cortex and the basal ganglia - neural networks which appear to support attention, executive control, anticipation and reward. Additionally, studies have begun to elucidate the complex genetics of ADHD and other neuropsychiatric conditions.
MYTH 5. Children always “outgrow” ADHD
The typical trajectory of ADHD involves improvements in impulsivity and hyperactivity over time, while inattentiveness tends to persist. Studies have documented a worldwide prevalence of 5% among adults. This is a highly prevalent and highly morbid condition in the adult population, and one that is therefore worthy of significant attention by primary care physicians.
