Can you develop ADHD?

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Andrew was always a high achiever. He got straight A’s in high school, was valedictorian, and assistant captain of the basketball team. Andrew would often spend long evenings on the weekdays and even some of the weekends studying. His parents reassured him he was developing good habits.

When Andrew was 17, he graduated high school, and started university. As in high school, he spent much of his time studying. He put considerable effort into his academics. Unfortunately, a few weeks into his first semester, Andrew forgets to hand in a major project. A few weeks later, he doesn’t do well on a test. Andrew begins to panic and decides to see his doctor.

“Doc, there’s something happening to me.”

“What makes you say that, Andrew?”

“I think my brain is… failing or something. I’m struggling so much at university and I never had any trouble in high school at all…”

Attention-deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that affects attention. You can read more about ADHD here. What does neurodevelopmental disorder mean? In general, this term refers to any problem which may arise during brain development. While brain development occurs to some extent throughout our lives, the major development of the brain happens while we are still a fetus! This means that our understanding of ADHD is that it develops before we are born, as a result of numerous genetic, environmental, intrauterine factors.

Andrew might have ADHD. So how does that make sense, given what we know about ADHD? If ADHD exists from birth (probably), how is he only having problems now?

What Andrew is describing may be what is known as adult ADHD. What is adult ADHD? Well, it’s the same as ADHD! And it’s also present from birth. The only difference between adult ADHD and ADHD is that adult ADHD has been, until adulthood, undiagnosed, for a variety of factors.

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ADHD screening is usually initiated by primary grade school teachers. Sometimes I meet kids from lower serviced neighbourhoods and poorer schools that simply were not given the opportunity to be screened as a child. I meet kids who were recommended to be screened as a child by their teachers, who have parents which declined the screen for any number of reasons, including not believing in ADHD and religion. I often meet women (and some men) who have gone undiagnosed, despite having struggles with academics when they were younger, because they have the “less obvious” inattentive subtype (previously known as ADD). Other times, I meet children who have been able to compensate for their natural attention abilities in their brain, for example by excessive studying (4+ hours a day in some cases) and who have flown under the radar. These kids often run into problems as they move through the academic system and the demands of the program exceeds their ability to compensate.

Andrew is an example of one of these children. He was likely able to compensate for a naturally lower attention span/hyperactivity in high school, and these coping strategies were likely overwhelmed when moving to post-secondary. Features of ADHD in adults can include mood swings, impulsive anger, losing keys, forgetting appointments, trouble holding down a relationship, and trouble holding down a job. Fortunately for Andrew, medications for ADHD are 85% effective, among the most of any drug! Ever.

So did Andrew develop ADHD? No. ADHD is a neurodevelopmental disorder, and is (in all likelihood) present since birth.

Editor’s note: There are however other illnesses which can affect attention which can develop later in life. Depression and anxiety, for example. One thing that is not ADHD, which I often see college age kids asking about, is marijuana. Marijuana interferes profoundly with attention is my most likely suspect when a marijuana user presents with new symptoms of inattention.

Dr. Travis Barron is a resident physician in Toronto, Canada.

The small things

“Thirty five!”

My heart begins to pound. Could it be? That’s three out of six numbers so far, I had never done this well.

“Seventeen!”

I’m out of the seat. I grasp the lottery ticket in my right hand tightly and stare at the TV. Images of yachts, parties, European vacations flash before me. The woman on the TV bends over and pulls the last number from the bin.

“Eleven!”

I’m screaming. Everyone’s screaming. We’re hugging, jumping crying in joy, when –

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BEEEEEEEEEEEEEEEEEEEEEEEEP

I role over as I bring myself from a foggy haze back to the planet Earth. I look to my side, expecting to see the brightness of the TV and the infinitely smiling lottery woman. Instead I’m met with a dark bedroom and the slightest hint of sunlight beginning to break through the bedroom window.

It was all a dream.

For a moment, I’m sad. I mourn my yacht. I mourn the Greek islands. I prepare to mourn for my would-have-been pet Tiger, when the hope begins to trickle into my mind.

It’s Saturday.

Oh, Saturday. The king of days, the glory of glory. We meet again. What have you brought me today? Is it a hike? An interesting play? The sweet nectar of shameless hedonism and laziness so that I may bathe myself in relaxation? Perhaps.

But first, there’s coffee.

Ah, coffee. I smell the sweet fumes, the pungency of the beans as they’re cracked over blade. I’m intoxicated with the idea. I climb out of bed and realize my mouth is watering. I sneak by my loved one and enter the kitchen, the regular opening scene to my Saturday-plays.

I grind the beans, turn on the machine, and wait patiently through the glug-glug. Soon, it’s ready. I sit on the step and drink from my chalice. I find myself wondering just how much of my blood is this very drink. For those moments, the world is still. As long as there’s blackness that sits in my cup, time is frozen, and it remains in good form until I take the final sip.

I find myself mourning the lottery once more. I look to my cup and smile to myself. What I really appreciate, are the small things.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Mental illness exists for a reason (part 3)

In part 1 of Mental illness exists for a reason, we discussed the evidence behind genetic control of temperament in two different primate species, Chimpanzees and Bonobos.

In part 2, we discussed how having a variation of behaviours within a species makes that species adaptable to a broad range of environments. Voles were a great case study on how polymorphic genes lead to a variety of behaviours within a species, allowing voles to thrive in a wide range of habitats on the planet.

In part 3, we will be discussing the role of the gene we have been examining, vasopressin 1a receptor, in human behaviour, and extrapolating from that why mental illness may exist.

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Humans are not voles. Before we get started, I want to reiterate that there are thousands of genes which interact to have an effect on human behaviour. No one gene is responsible for the beauty that is the human mind. When we examine human behaviours in studies, like the one I will be discussing today, we are observing trends in behaviour, and not absolute rules. Remember, personality is thought to be at most 50% genetic, and each one of those thousand genes are in direct interaction with each other, and our ever changing environment, at any given moment, to produce the “climate” of traits that becomes our personality.

So what’s the deal with vasopressin 1a receptor? What is it anyway?

In the human body, brain function is dependent on something called neurotransmission. In a nut shell, neurotransmission is when two different nerve cells, called neurons, communicate with each other. Neurons are constantly communicating with each other at any given time to produce consciousness, vision, hearing, touch, and just about any neurological function you can imagine.

41592_2018_268_Figa_HTML — Credit: Nature

How does neurotransmission occur? Through chemicals called neurotransmitters. In a neuron “discussion,” the first neuron sends a neurotransmitter to the second neuron. There is a receptor on the second/receiving neuron that picks up the message. Vasopressin 1a is this kind of receptor. Depending on the shape or form of the receptor, different things will happen to the second/receiving neuron. This is how variation in the receptor produces variation in effects!

Why is this important? Vasopressin 1a receptor has been implicated in pair bonding behaviours, across a wide range of species, including humans, chimpanzees, bonobos, and voles. Consistently, a “longer” form of the gene has been associated with increased pair bonding and less aggressive behaviours. Think the lazy, horny Bonobo and the monogamous Prarie Vole’s. And some humans.

A group at John Hopkins set out in the mid-2000’s to investigate the role of vasopressin 1a receptor in humans. You can read their study here. To summarize, the group found that a number of variations of the vasopressin 1a receptor exist in humans. That makes this a polymorpic gene. As expected, certain forms of the gene correlated with certain behaviours in humans. Longer forms of the gene were associated with increased pair bonding, as determined by a questionnaire. Amazingly, not only did carriers of the longer gene tend to report happier marriages, their partners did as well. Carriers of the shorter gene were unhappier in their marriages on average and were considerably more likely to have had a threatened divorce within the last year.

So why can’t we all be married, well fed, and happy?

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Like the Prarie Vole, humans live in a wide variety of environments. This is different than Chimpanzee’s and Bonobo’s, who are really good at living in the kinds of places they live, but not great at living elsewhere. Humans live in mountains, on swamps, the plains, the coasts. There’s hardly a terrestrial environment on this planet that we haven’t conquered. The point? Humans have had to be extremely adaptable to achieve this level of success across the wide range of environments we inhabit. This doesn’t only apply to geography. The massive differences between an urban metropolis and a rural village cannot be understated. The variation in cultures across the West and East is difficult to appreciate. These differences in the societies in which we lives requires a broad range of behaviours to be within our species to succeed. We need people who thrive in a big city, among thousands of their peers, in cramped, noisy, stimulating environments. Without them, the economic engines of our nations would collapse. We need people that can’t stand the city, who need wide, open expanses, and tranquility to survive. Without them we wouldn’t be able to feed the masses. The point is that variation in our personalities allows some of us to succeed, and to excel, so that society and the species may go on.

But that doesn’t mean we are all meant to succeed. Or rather, that we are all meant to succeed in every environment.

Variation means exactly that – variety. For every person that thrives in a city there’s another who suffers. Sometimes, there is a fundamental mismatch between our personality, and our environment. Try as you may, a monogamous Vole ain’t gonna do well at a polygamous Vole frat party. A Bonobo chimp would be dead meat caught in a Chimpanzee civil war.

These mismatches occur in humans as well; sometimes, we may call that mismatch, a mental illness.

Join me in part 4 for a discussion of how we can use our understanding of why mental illnesses may exist to help guide treatment and recovery!

Editor’s note: I do not want to diminish the role of, “nurture,” in the nature vs nurture argument. By no means in personality 100% genetic (most studies show it’s around 50%)! This blog simply looks at the genetic side of things.

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Three weeks in!

Hello internet! Travis here, on day nineteen of the blog! Blogging is something new to me, so thanks for bearing with me as we go through growing pains together. I now know what a widget is!

Why did I start blogging? Well, I find education empowering. As different as every single patient who takes a step into my office is, it amazes me how many similarities there are between their questions and misconceptions on the field of mental health. Hopefully by sharing my understanding, I can help someone out there find some clarity.

To that effect, do any of you have a topic you’re wondering about? Have any questions? Send them my way and I’ll do my best to answer them next week!

Stay tuned for Mental illness exists for a reason (part 3) this weekend! You can read part 1 here and part 2 here!

Chest pain is in your head

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It’s a beautiful winter’s day in suburban Ontario and you’re shoveling snow. It’s the first snowfall of the year so you don’t absolutely hate the task at hand. Yet. You stop to breath in the beauti—-

BLAARRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR.

The snow plow is on you in seconds and quickly packs your hard-shoveled driveway back in. As you swear to yourself, you continue to shovel.

Suddenly, there’s chest pain. Your vision goes black in the corners and you grab for something. You stabilize yourself on the side of your home and take deep, laboured breaths. You manage to pull your cell phone from your pocket, and dial 911.

“Hello you’ve reached 911 what’s your emergency?”

“I think I’m having a heart attack.”

***

“I don’t get what you’re saying.”

“Let me start from the beginning. Everything checked out fine with your heart. Your rhythm is normal and there are no signs of a heart attack. I think the most likely explanation is a panic attack.”

black and white blood pressure kit — Photo by Pixabay on Pexels.com

“So you’re saying it’s in my head? That’s ridiculous. How could you possibly know it’s not a heart attack?”

“Besides the fact that your blood tests and EKG were normal, sir, you are 28. You have no previous cardiac history, you don’t smoke, and your family history is insignificant. Taking all of this together, there is no likelihood that this is a heart attack.”

“So I’m going crazy?”

“I didn’t say that…”

Panic attacks are real, intense manifestations of anxiety. Features of panic attacks include chest pain, shortness of breath, tunnel vision, dizziness, sweating, anxiety, and a fear you are dying, just to name a few. Best of all, panic attacks can have a clear trigger (snakes, for example!), or culminate out of apparent nothingness. Panic attacks can be unpredictable and debilitating, and are definitely uncomfortable. To put the icing on the cake, panic attacks can often present like a heart attack. Your fear of dying just got a lot better, didn’t it?

One of the most common consultations I have seen in my office are individuals who have presented to hospital numerous times with non-cardiac chest pain. The consulting physicians are usually suspicious of panic attacks. These consultations often unfold in a similar fashion – the discussion around the patients understanding of what’s going on, a discussion of their mental health and personal lives, and inevitably, feedback.

To all of my doctor friends out there in the internet, here’s what not to say when you suspect someone is experiencing panic attacks:

“It’s all in your head.”

Medicine and psychiatry are a lot of things, the least of which is not, being a source of reassurance. By dismissing an individual’s symptoms as “in their head,” you have immediately invalidated that person and there’s little chance they will listen to anything else you have to say.

But panic attacks are in your head, and so is the chest pain. But this is also the case with true cardiac chest pain. What am I saying? Everything, including true heart attacks, are to some extent, in your head!

What the hell am I talking about?

In your body, there are a specialized type of nerve cell called neurons. Neurons are like wires that connect different parts of the body and allow parts of the body to communicate with each other. There are neurons that go from your brain to your muscles, for example, which send messages on how to move. There are neurons that go from our skin to out brain which tell our brain what we are feeling.

This is equally true in heart attacks.

When you are having a heart attack, blood is suddenly cut off from a part of the heart and damages the heart muscle. This causes chest pain. The neuron that goes from your heart to your brain sends a message to your brain that you are having chest pain. This is how you become aware of it. As is appropriate when you’re having a heart attack and experiencing chest pain, you then begin to feel anxious. This anxiety protects us and drives us to call an ambulance and seek help.

So what’s going on in a panic attack?

paha If you recall, neurons are like wires. Like wires, messages can pass down nerve bundles in both directions. Messages can be sent from the heart to the brain (as in a heart attack), or from the brain to the heart. In panic attacks, our brain “hijacks” our natural nerve circuitry and sends the message in the opposite direction (brain to heart). This causes the cycle (chest pain -> brain aware -> anxiety) to reverse (anxiety -> brain aware -> chest pain)!

The take home message? The chest pain in panic attacks is as real as the chest pain in a heart attack. The difference is that the pain in each scenario is driven by a different cause (heart damage vs anxiety).

Why do I find this is important to understand? In my experience, when people seek help for panic attacks, often times a patient and physician can get too caught up on whether the chest pain is “really” happening. It definitely is. But to understand and accept that your chest pain is real and is highly unlikely to be caused by heart damage, for all of the reasons listed in the opening dialogue of this post, is empowering and indespensible.

Editor’s note: This article is not a substitute for medical consultation! If you think you are having a heart attack, particularly if you carry risks factors, you should seek medical attention.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Mental illness exists for a reason (part 2)

In part 1 we discussed the differences in behaviour between Bonobo chimp’s and their closest relatives, the Chimpanzee. Bonobo’s and Chimpanzee’s each have distinct temperaments between their two species and minimal variation in the these temperaments within their own species. What does this mean? Most Chimpanzee’s are territorial, aggressive, and violent, and most Bonobo’s are chill, horny, and non-violent.

And now, to the promised star of part 2, the Vole.

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Voles are a group of small rodents that reside in North America. Unlike the Chimpanzee and Bonobo, Vole’s occupy an extremely wide variety of habitats. If you recall, Bonobo’s live in one small part of Africa, in a very specific habitat, while Chimpanzee’s have a large range of similar habitats (to their own, not Bonobo’s) all across Africa. You can find Vole’s in prairies, meadows, mountains, and your basement. So what is it that make voles extremely adaptable?

Behaviour, for one.Voles, unlike Chimpanzee’s and Bonobo’s, have a wide variety of behaviours within their species. Some voles are monogamous, and some are not. Some are territorial, and some are not. By having a wide range of available behaviours within their population, the Vole species always ensures that there’s somebody (somevole?) around who are able to handle the demands of the environment. Prairie Vole’s, for example, are monogamous, while Meadow Vole’s are not. Maybe this means that a gentle, monogamous Vole may not survive in the meadow, but it ensures, on a population level, the survival of the species across a wide range of environments.

What’s responsible for the variations in behaviour seen across the Vole’s? If you recall, in part 1 we discussed the role of a gene, vasopression 1a receptor, in the different behaviours observed in Chimpanzee’s and Bonobo’s. Well, as it turns out, the vasopression 1a receptor gene is also responsible for the different behaviours among the Vole’s.

As you can read in this study, genetic testing has shown a variety of vasopression 1a receptor mutations within the Vole genome. We would call this a polymorphic gene, meaning that many different forms of the gene exist within the same species. Humans have polymorphic genes for hair, eye, and skin colour, for example. Monogamous Vole’s appear to have a higher density of vasopressin 1a receptor and, similar to Bonobo’s, a “longer” version of the gene.

The take away? It’s not that vasopressin 1a receptor is the God-gene controlling our every instinct. The reality is there are thousands of genes that play a role in behaviour, and each one is more nuanced than the next. This should however stand as an example of how variation of a gene within the same species produces a variety of behaviours!

In part 3, we examine the role of vasopressin 1a receptor in human behaviour in an effort to extrapolate why mental illness exists!

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Narratives and Post-traumatic stress

“I was walking down the road… I don’t know why the light didn’t go off… there it was, the screeching… and Amanda, she didn’t know what was happening…”

“That sounds upsetting. Let’s take a step back, and go back to the beginning. Which road were you walking down?”

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Trauma affects us in many ways. But what is trauma? There is no simple answer to that question. The reality is what may be traumatic to one person may not be traumatic to the next. Trauma cares about context. About who we are. About our past experiences. And importantly, trauma cares about how we react to it, and what we have the opportunity to do after a traumatic event.

The dialogue above might seem a little disjointed and confusing. Don’t worry, that was intentional! This is an example of poor narrative cohesion, a feature commonly seen in post-traumatic stress.

During a traumatic event, our senses are often overwhelmed and over-stimulated. Everything seems to happen so fast and take forever at the same time. In many ways, a traumatic event “shocks” the brain. Our memories of a traumatic event may seem sped-up, disjointed, or contain blanks. They can seem chaotic. As we think and reflect on a traumatic event, we piece together a cohesive narrative that makes sense to us, almost like a story.

This isn’t always as easy as it sounds. Traumatic memories are exactly that – traumatic! They’re not pleasant and can even be painful to think about. People may actively avoid thinking about a traumatic memory, or may avoid talking about it with friends, even if it’s all they can think about. This can contribute to the development of poor narrative cohesion, as seen in the dialogue above. Without the chance to think, talk, and reflect with our peers, we don’t fully get the chance to piece the story together for ourselves. It isn’t unusual that the first time someone has spoke about a trauma has been with me in my office, and it isn’t uncommon for their story to be disjointed at first.

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Discussing traumatic events with someone isn’t only important to string together your story. Speaking to someone about trauma plays an important role in the prevention and treatment of post-traumatic stress disorder.

Whenever we recall a memory, that memory is overwritten and re-coded by our memory of the memory – wait, what? To simplify it, if we have a memory of an apple, and we remember the apple as being a little more red than it actually was, our memory would now be re-written as a little more red (and distorted!) than previous.

This phenomenon is why over time you might take a new perspective on a vacation you thought was bad, or change your thoughts on a movie. In post-traumatic stress, it allows us to continually expose ourselves to the traumatic memory, and re-code it into something more pragmatic and tolerable. This is why narrative therapy, a form of therapy which gives individuals an opportunity to explore their own experiences, and form them into a story that they can use to better understand themselves and their own story, is a key feature of any trauma-focused therapy.

I recently came across this article from HuffPost Canada that talks about a particular legal barrier some therapists may face in Canada if they wish to provide treatment to a Canadian juror. Apparently in Canada, section 649 of the Criminal Code prohibits jurors from discussing elements of their cases with anyone, including therapists, despite them being committed to confidentiality with their patients. As a physician, I wouldn’t have even thought about this legal scenario and I can promise you it wasn’t taught in medical school. That’s probably because it’s absolutely absurd.

Do you think it’s fair to vulnerable jurors at risk for PTSD that they cannot seek counselling?

Editor’s note: Narrative therapy is an important element of trauma-focused therapy but not the first element. Most trauma therapies first focus on building skills to manage distress before delving into traumatic memories. This can be important to prevent psychological distress from accessing memories that may be at first very difficult to recollect.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Mental illness exists for a reason (part 1)

Damn you, Mother Nature!

It’s complicated.

Deep in the Democratic Republic of the Congo, near the South Congo River, lives the rarest species of great ape in the world – Bonobo chimpanzees. Why are the great apes important? They are the animals most closely related to humans on the planet! And they’re also the next most intelligent animals on the planet. These animals exhibit complex social behaviours and relationships, and members include chimpanzees, bonobos, orangutans, and gorillas.

Apeldoorn_Apenheul_zoo_Bonobo — Bonobo – Credit: Wikipedia

Bonobos are particularly interesting because they only live in one place in all of the world – the South Congo River. This is in contrast to traditional Chimpanzees, who have ranges all across the African continent. This has resulted in Bonobos being the last discovered great ape and have therefore been the least studied! Until recently, that is.

Chimpanzees are notoriously aggressive. Jane Goodall infamously documented a brutal chimpanzee civil war when she lived among the apes in 1974-1978. Chimpanzees have a complex social structure, with rank and sexual capital determined by violence. Bonobos, on the other hand, are like your cool uncle. They do not appear to compete for rank, males are often subordinate to the females, sex is often homosexual and not for the purposes of procreation, they are considerably more sexually active than Chimpanzees, and importantly, are non-violent!

Scientists have been trying to understand the basis for the differences in behaviour for some time, in hopes that this can lead to a better understanding of the operation of the human mind. Genetic studies have begun to uncover key differences in the genomes of both apes. It turns out Bonobos are the second most related ape to us, after the chimpanzee, and Bonobos appeared to diverge genetically from Chimpanzees between 2 and 2.5 million years ago.

So what happened?

Geological studies show that 2.5 million years ago, in the Zaire river, there was a large drought, which pushed the previous chimpanzee-bonobo ancestor out of that area. The group diverged, with the river being a dividing line. Those apes that went South of the river, found food plentiful. They were able to continue the fibre, plant-based diet the apes always had eaten. These apes are what we now call Bonobos. This was not the case for the apes which moved North. These apes had to compete with African Gorillas for scarce food resources, and due to competition and food scarcity, had to shift their diet to an omnivorous one, and include meat. These apes have evolved into Chimpanzees. You can read more about that here!

So what explains the stark difference in their behaviour? If you recall, I mentioned earlier that Bonobos and Chimps are our two closest relatives; both Bonobos and Chimpanzees are more related to each other than we are related to them. That provides a pretty interesting opportunity. Because Bonobos and Chimps are so closely related, it should be relatively easy to find differences in their genome, which provides an opportunity to find the gene, if there is one, responsible for this change in behaviour.

I won’t get into the technical stuff here, but it turns out that is the case. This study identified a key mutation in a gene (vasopressin 1a receptor gene) which occurred in Chimpazees and has been associated with lower sociability and increased anxiety. It makes sense why these traits are helpful when you are forced into competition with one another, and Gorillas, and have to hunt meat. Bonobos on the other hand carry the non-deleted form of the gene, which has been associated with increased openness to each other. You can read more in the previous link (it’s technically heavy) but the researchers argue pretty convincingly that this is the genetic basis for the differences in personality!

It turns out humans, and… prarie voles? also contain the gene for vasopressin 1a receptor. In part 2, we can use our understanding of this gene in humans to extrapolate why mental illness may exist!

I would like to credit Dr. Albert Wong at the Centre for Addiction and Mental Health for inspiring most of the content of this blog post.

Dr. Travis Barron is a resident physician in Toronto, Canada.

Does ADHD exist?

“Based on all of the information you have provided, the collateral information, and the report cards, I think the most likely explanation is Attention-Deficit/Hyperactivity Disorder, also known as ADHD.”

“The doctors tried to diagnose me with that when I was a kid, and now you want to medicate my kid? I don’t believe in ADHD, we’re getting out of here.”

boy runs at the street while people looking at him — Photo by RUN 4 FFWPU on Pexels.com

It’s not an uncommon scenario. A parent brings their struggling child into my office for an assessment. The child promptly runs into my office, and immediately begins playing with the toys laid in a bin by my desk. Mom continually redirects the kid, who for some reason, just can’t seem to sit still. “He’s run by a motor,” she says, “he’s always been this way, full of life! But he’s really struggling at school.”

Attention-Deficit/Hyperactivity Disorder is a real disorder, that in broad strokes, can present in two different ways. There is the hyperactive sub-type, which is probably what most of you picture when you think of ADHD. Less recognized is the inattentive subtype of the illness, previously known as ADD. These are people and kids who can zone-out and have trouble maintaining attention, but are not running around the classroom (as a clinical pearl, women tend to present with the inattentive sub-type, and males with the hyperactive).

So what is ADHD, other than a hyper kid? To understand that, we must first understand what are psychiatric diagnoses. You can read more about that here. The punchline is that a feature of personality, behaviour, or mood, only becomes an illness when it begins to interfere with functioning. If you’re an anxious person, that can be a source of strength. It makes us on time for work, helps us meet deadlines, and not forget our wedding anniversary. If your anxiety gets to the degree it begins to cause avoidance and problems functioning (for example, anxiety causing you to miss work), then you would meet criteria for an anxiety disorder.

There is a similar phenomenon with ADHD (which *disclaimer* remains poorly understood!)

pdfnormal

Our attention span lives in our frontal lobe, the front part of the brain. If we took one hundred people and tested their attention span, it’s likely we would find a range of different attention spans among the population sample. If we plotted this on a graph, it would likely look something like the picture to the left. Attention span would be on the x-axis (bottom), and the number of people with that attention span on the y-axis (side). Note that the numbers contained on the graph in this post are meaningless and are just for understanding!

A quick interpretation of the graph allows us to arrive at some conclusions. Most people have an average attention span, represented by the peak in the graph. Some people have a superior attention span, the plateau on the right side of the graph. The plateau on the left would be those with poor attention spans. So in summary, there exists a spectrum of attention spans, with most people falling near the middle, with some people (outliers) on the edges.

diagram-of-frontal-lobe-of-the-brain — Credit: Medicalnewstoday

The prevalence of ADHD is between 5-10%, meaning 5-10% of the population have ADHD. These individuals would be represented on the graph by the lower attention span outliers, about from the “-2” on the x-axis above to the left limit of the graph. But does having a low attention span mean you have ADHD?

No!

Remember, context is always important in psychiatry! If something does not interfere with your functioning, it’s not a disease, it’s just who you are. Our society has, over time, placed increasing emphasis on an education model focused primarily on sitting in a seat. A math test is in many ways as much a test of your ability to sit still for an hour straight as it is about your skills in math. The modern day office is in many ways a person with ADHD’s nightmare. If you take the same child and place them in a playground, a gym, or a more active form of education, you may find they excel. Many of the people diagnosed with ADHD today may find they did not qualify for the diagnosis one hundred years ago, when time spent at a desk was minimal. All of that to say, ADHD exists, and is a result of the direct interaction between our individual attention spans and societal expectations!

So do we medicate these kids, if a change in environment can sometimes optimize functioning? That’s a complicated question. The answer is (usually) yes. The impairments in functioning caused by ADHD can be life changing. Academic and vocational success may depend on it. Happiness in relationships, impulsive anger, and substance use, are all impacted by treated/untreated ADHD. The reality is our ability to change the environment in our regulated world is extraordinarily limited. The fact is we are all expected to graduate high school, and that’s that. While some parents find success for their children in alternative school systems with different education models, in my experience this has a limited benefit.

It’s not all doom and gloom. Treatment for ADHD is 85% effective, among the highest response rates for any medication for any illness. Ever.

I recently met a middle aged man presenting with problems losing things. He was worried he had dementia. This man worked as a camera man for an international news agency, and his work brought him all over the globe. He has worked in countless battlegrounds, war torn countries, and environments on earth that I cannot begin to imagine. And he excelled at his job. On further history, outside of occasionally losing his keys, the remote, or his cell phone, he wasn’t really having any issues. He had many of the features of ADHD and may very well have met criteria for the illness, particularly when he was school-aged, based on his old report cards which he brought in at my request. This man, however, had found a partner and an occupation which were not only tolerant of this mans attention span and resultant behaviours, but embraced it.

“So doc, do you think I have ADHD?”

“Nope!”

Editor’s note: Often times I meet people who later in life, after high school and college, find a niche job that works for them and they can reduce or even eliminate the need for medications. If your child is struggling in school due to ADHD, I highly recommend treatment, because it can have life changing consequences!

Dr. Travis Barron is a resident physician in Toronto, Canada.

Pride for the fallen

I waited hungry-eyed in the line at McDonald’s. The ambient beeping of God-knows-what machine and the occasional interruption of a screaming child. Above the fray, I hear a call.

“Order 421?”

“That’s me!”

Finally. My chicken nuggets had arrived. I settled down to eat them and thought, today is a good day.

It’s pride week in Toronto and many of the patrons of the establishment were garbed in a variety of rainbow outfits. Beside me sat a small boy and his parents.

“Mom, why does that guys shirt say remember?” he asked, as he pointed towards a large-bearded gentleman with a tye-die rainbow shirt with #remember printed on the chest.

“What do you think?” asked mom.

“They’re remembering people I think!”

“Good job, what people?”

“Maybe the war? Like world war 2?”

“Close! They’re celebrating gay pride and they’re remembering the people who came before them. It’s not that long ago you could be beaten to death for being gay.”

The boy looked appropriately surprised as his mother continued; “you know, there’s parts of America where you can’t get married if you’re gay.”

The boy responded,”what?! That doesn’t make any sense!”

I had to stop myself from getting up and hugging this mother, for thanking her on raising such a gentle, open-minded child. He was surprised to hear being gay was something people considered bad. It didn’t make sense to him that there are jurisdictions where gay marriage remains illegal. It was a breath of fresh air among increasingly suffocating calls for “straight pride.” They aren’t discriminated against any more and if we are about equal rights, we should have a parade too! being among the most common complaints solicited on the average Facebook newsfeed.

I got up and left the table, thinking about the family as I left. The moment I had just witnessed, I thought to myself, was the perfect example of why gay pride is important.

Homosexuality has been various degrees of criminal in the modern memory of the Western world. LGBTQ2+ members of our society have been jailed, beaten, tortured, and forced into hiding, because of our collective intolerance of their own sexuality.

If you ever find yourself wishing for a straight pride parade, think for a minute if you want what came before it. And while you waste your time contemplating such a frivolous question, I’ll be celebrating gay pride.

Dr. Travis Barron is a resident physician in Toronto, Canada.