January 2022

I hope 2023 brings you some of that which you are seeking/ needing/ growing towards. I am optimistic it will be a year of growth and development of helpful knowledge, including from lived-experience, encouraging professional skill development and service development. 

As a mea culpa, I was interested in the Parkinson’s Secrets by Michael Okun in November 2022 outlining in detail, with the family’s consent, why Muhammad Ali actually had young onset idiopathic Parkinson’s Disease rather than chronic traumatic encephalopathy (time course, clinical features, medication response, FDG-PET imaging etc.) as many of us, from afar, will have assumed. There’s no substitute for careful clinical evaluation and being in possession of all the relevant facts. 

In this respect, the polarised argument discussed by Johann Hari in his book Stolen Focus about ADHD either as a “real” biological disorder or alternatively as trauma/ anxiety/ environmental-related concentration difficulties remains topical and is unlikely to be resolved soon. Some aspects are canvassed in the Science vs blog in December 2022 on the “evils” of Adderall, in the context of the recent shortage in the US. A recent book by Casey Schwartz, Attention: a Personal History of Finding Focus (or Trying To), is a case in point. Her story, to me, illustrates problems with poor quality diagnosis but also stimulant abuse, rather than the non-existence of ADHD; thus also “Addicted to Perfect” by Vitale Buford. And Johann Hari thinks we need an Attention Rebellion to overcome the environmental drivers of the collective fall off in attentional capabilities. Undoubtedly there are some people with attentional difficulties consequent on stress, depression and other issues who think they have ADHD when this is not the case, though also of course ADHD causes stress, depression etc. so reality is complicated, like the Muhammad Ali scenario. 

I am looking forward to Gloria Mark’s book Attention Span: Finding focus for a Fulfilling Life, due out in the next few days; she appears to have a different take on the environmental drivers of (non-ADHD) attentional complaints, including the importance of matching attentional demanding workflows to your chronotype. 

One area where ADHD has a substantial biological basis is in epilepsy; perhaps 30-40% of children with epilepsy having comorbid ADHD in some studies, and perhaps 20% of adults. This is clearly an under-served population, especially given the results of a 2019 Swedish study of 995 youth (Brickell et al. Epilepsia 2019 Feb; 60(2): 284–293) in which the use of stimulants reduced seizures by approximately 27%. The untreated ADHD may have a greater impact on functioning than the seizures. 

Some caution around atomoxetine in this context would be prudent as a 2020 Korean study (Park et al. Psychiatry Investig. 2020 May; 17(5): 412–416) suggested 8% may have had an increase in seizure frequency (though atomoxetine was only one discontinued in one case), but there is a reassuring 2018 ten year retrospective cohort study (Liu et al. J Child Adolesc Psychopharmacol. 2018 Mar 1; 28(2): 111–116) in which hospitalisations for seizures were not increased in children taking stimulants. 

It is hard to know why the prevalence is high—I fantasise it has something to do with interictal EEG spikes though common causal factors are often blamed and it is important to check attentional issues are not due to the anti-epileptic medication. Some authors consider stimulants may be less effective than in “normal” developmental ADHD, though my clinical experience is that they are beneficial in most cases. 

Obviously, Autism Spectrum Disorder is sometimes in the mix as well, either as part of an underlying syndrome (birth anoxia, severe paediatric TBI, velocardiofacial syndrome / 22q11.2 deletion….) or as a common neurodevelopmental comorbidity. 

Anyways, very best wishes for the year ahead.