So I'd like to introduce our next speaker, Dr. Pat Curick is a clinical professor at the UC Davis Department of Psychiatry. He's also a faculty member at the Mind Institute and is the director of UC Davis Child and Adolescent Psychiatry Division. Dr. Pat Curick is board certified in general psychiatry and in child and adolescent psychiatry. His clinical interests are ASD, ADHD and psychotic and mood disorders across the lifespan. Here's the medical director for the Mind Institute ADHD program and medical director for UC Davis Medical Center Behavioral Health Center Clinics. Please join me in welcoming Dr. Pat Curick. Hello everyone, can you hear me fine? Great, great. How about now? How about now? Right, thank you so much for inviting us, Calciano family. This is a great symposium and we really want to see a symposia like this one to increase awareness and grassroots support for ADHD families, children and adults. So thank you so much. These are two of my fellows at the program. One recently graduated but they are wonderful presenters. They're also responsible for some of the slides and participating in all the ADHD programs with me, Dr. Collins and Dr. Bedford. These are my financial disclosure items. We'll start with the overview. We'll talk about the history because I like history and I think it gives us a greater frame about what we are discussing. We'll talk about the basics. Dr. Schweitzer really talked about most of the basics. I will just review some of them from psychiatric point of view. We'll talk about the treatment including the medication treatment and some research update. I was up late last night trying to bring it up to date so I have some actually updated research information from yesterday for you guys. Shakespeare talked about ADHD as early as 1580 in John Faust's character in King Henry IV who described himself as having the disease of not listening, the malady of not marking. It's pretty amazing. And then it turns out 1775 was a great year for ADHD. First a German physician, Dr. Wieckhardt, talked about actually he wrote a textbook and he did talk about ADHD without calling it ADHD. And Scottish physician, Dr. Creighton, the same year talked about ADHD in a very elegant way. And toward the end he says what is very fortunate it is generally diminished with age. We'll talk about that in detail later. But it's really amazing that these individuals were insightful enough to observe and write about the condition. And 20th century. Some terminology starting from nomenclature starting from 1900s here. Defective moral control. You're laughing now but it was the real medical term then. It's hard to believe, right? Amazing. And this function doesn't sound much better to me. Hyperkinetic child syndrome and ADD, you're all familiar, attention deficit disorder in more recent 80s into 90s. I won't review this in detail but in red at the bottom you'll see symptoms are present prior to age 12. They have to be present for at least six months. Multiple settings, Dr. Schweitzer mentioned. And finally, decline in functioning is important for the diagnosis. If you do not experience any decline in functioning, it's difficult to use the term as a diagnosis. Very briefly what causes ADHD. Dr. Schweitzer mentioned there are some clinics that they will mandate parents to get treatment if they want their children. Or at least assess if they want their children to be treated in their clinics. There's a reason for that because we know the more structure, the better routine, the better the outcome in attention deficit type activity disorder. So if you work with parents, setting that structure will be much more feasible. I hear this all the time. Is it a real diagnosis? Is ADHD real? We have great genetic studies and heritability is very significant. In fact, it's immediately after your height. The level of heritability for ADHD is right after the parental height and predicting the child's height. Structural brain differences, Dr. Schweitzer spent quite a bit of time explaining some of those differences to us. Long and consistent, well-described clinical history with, of course, variation in the visual differences. Somebody asked this question earlier, but numbers may be from 3% to 11% or 12% worldwide. But 4.5 to 7 or 8 appear to be a good number for prevalence for ADHD. Diagnostic validity is important. We'll talk about psychiatric comorbidities. How are we doing so far? Slow down, good speed, good pace. Okay. So these are psychiatric comorbidities and I have another slide on this. I like this slide from Dr. Janssen because it's very simple and inclusive. If you look at that, you won't see some very important diagnoses though, right? Autism spectrum disorder is not there. I don't see substance issues there, right? And there are several others as well, including sleep problems. What is here is externalizing disorders or oppositional defined and conduct disorders, huge chunk. Anxiety disorder, more than one third of patients with ADHD will have comorbid anxiety. Unless you address the anxiety or depressive components with ADHD, the treatment won't be successful. And of course, tick disorders including Tourette's. This is the second slide on psychiatric comorbidities in ADHD. And I'll make some brief comments about the items here. One of the interesting ones is depression. I put here an interesting pattern because in adolescents and adults, the studies show us if you have ADHD or risk for depression, continue to increase until about 21, 22 years of age, then plateaus and slows down. So the adolescents and the early college years may be the peak, the highest risk for depression comorbid with ADHD. Now, that's different from the story with anxiety disorders because anxiety continues to increase across the life. So even if you are in your 50s and 60s, your anxiety symptoms may not plateau unless it's treated, addressed, and it may continue, the risk may continue to rise. Another interesting comorbidity is with bipolar disorder, bipolar disorder and ADHD. It appears that if you have bipolar disorder, your likelihood of developing ADHD symptoms or having ADHD symptoms will be significantly higher than general population. If you do have ADHD, however, to begin with, developing bipolar disorder in the future in late adolescence or early adulthood appears to be a lower risk than the other way around. We are trying to figure out why that is, but there are several other psychiatric comorbidities with similar dynamics. Now, when I started talking to our child fellows, child psychiatry trainees about increased risk for suicide a decade ago, they were very surprised. They did not think ADHD had any connection to increased risk of suicide. But think about what Dr. Schweizer was talking about, the increased impossibility. You're chronically demoralized because you're not reaching your potential in life. You have comorbid mood disorders and anxiety. It's really not a great combination, right? That's why it's very important for us to pay attention to comorbidities and address those effectively. Most of my adolescent and adult patients, when they present with the ADHD concerns for assessment for psychiatric treatment or evaluation, we really end up addressing their mood disorder or anxiety or other comorbidities first, it appears. And then see how much ADHD and how significant ADHD is underneath that. That's really important. And one wonders if their ADHD was treated timely, early, effectively, if that would play out the same way, perhaps not. If you have ADHD, there are wonderful qualities and traits come with ADHD, but one of the risks with ADHD associated with that is, unfortunately, earlier and possibly chronic use of alcohol, marijuana and nicotine. We can understand nicotine because it seems to help in the short term control some of the ADHD symptoms. It calms people down, hits similar areas that ADHD medications may be affecting. But it's never a long-term or effective solution, obviously. It makes things worse. Increase use of heart drugs if ADHD is associated with externalizing disorders. Do you remember what those were? Oppositional defined disorder and conduct disorder. So if you have ADHD plus those externalizing disorders, you may have higher likelihood for these drug use behaviors. This is a simple slide, but I like it because it gives you the lifespan changing ADHD core symptoms as well as the comorbid psychiatric features. It even has the little etiology window in the corner. Now, medical comorbidities. This is very important. In fact, somebody brought up the sleep question. I would like to comment on that little later, but it turns out that individuals with ADHD are more likely to be overweight or clinically obese. We actually did not know this until recently. This is not a very old information, but both in early 21st century and more recent update seem to support this. Furthermore, if you remove all other factors, ADHD alone appears to be a factor for overweight status. It's really interesting and it appears to be some genetic connection there and in addition to lifestyle and everything else, but there are studies ongoing looking into those mechanisms. What other medical comorbidities? Definitely sleep difficulties. Asthma may be one of the medical comorbidities. Some research suggests that children with asthma may have higher likelihood or risk of having ADHD as well. I'm recently more interested hearing all these stories about concussion. We know individuals with ADHD are really likely to get into accidents in various ages. We also know that if they have a concussion, brains with ADHD appear to have larger damage than non-ADHD brains. One wonders though if ADHD itself is a clear risk for increased concussion. There are some small studies suggesting that, but we definitely need better studied comorbid research. This is summarizing what Dr. Schweitzer talked about earlier. One comment that we just started a pilot study, one of our fellows started a pilot study looking at metals, metal levels such as ferritin, you see that zinc and magnesium and see if there's a correlation with either severity or certain group of symptoms of ADHD. Personal medical history is not remarkable, no significant health issues. You don't really order labs at the initial assessment. Although if we do not see any labs, I like to order labs and include that in the initial blueprint for the child. Because even 10, 15 years sometimes people can go back and refer to those values. Now we have electronic medical records. It's going to be much easier doing that for future physicians with our records. So this is really key for ADHD treatment, multi-modal approach. And it doesn't matter if it's adults or children. And Alice was our patient was explaining to you earlier. It's so important to have that medication piece, therapy piece, family support, school or vocational support systems work together and longitudinally in the long term, not just for a brief period. This is one of the CDC data maps that I like. The next set will have to wait until 2021, I believe. Every 10 years or so they have these wonderful maps. But this one will address some of the questions that were previously explored. This is children ages 4 to 17 diagnosed with ADHD and receiving medication treatment. California is actually one of the lowest states in this percentage. You'll see under 65% the real number is 55.3. I'm not commenting it's a good or bad thing, but that's the fact. So the lightest one is under 65% and the darker color is higher percentage. So the last one is 76% or higher percentage receiving medication treatment with a diagnosis of ADHD. So the lightest, the lowest treatment percentage, which includes state of California. Now, this is a similar map. This is looking at all the children youth between ages 4 and 17, the general population, not just with ADHD, taking medication for ADHD. And if you look at the numbers, under 3%, between 3.7 and 5, the second color. And that's the category that California is. And then these numbers will change from decade to decade, obviously, every 3 to 5 years in a meaningful way. That's why it's really important to keep an eye on this sort of general data. It gives you a bird's eye view about the treatment. I'm switching gears here and talk about ADHD medication treatment. And this is from Dr. Barkley, Julie's mentor. I love this slide. We love this slide because it's very simple and very inclusive at the same time. Stimulants and non-stimulants can't get any simpler than that. Stimulants are metalphenidate, example Ritalin, or amphetamines, example Adderall. They are either short-acting or long-acting. Right? Pretty simple. The non-stimulants are, you have norepinephrine reuptake inhibitors. It's also called atomoxetine. The only example in this group is called atomoxetine, i.e. strotera. That's the commercial name. Alpha agonists, increasingly popular non-stimulant medications. And finally, very old class of medications, TCAs, or tricyclic antidepressants. Huge medical risks, but a very small group of ADHD, they may be an effective option still. I included both the generic and the commercial names in this slide to give you an idea about certain differences. You have short-acting and long-acting first area metalphenidate-based and the second area amphetamine-based options. Now, those in red, Methadate CD, Focalin XR, and Ritalin LA, are although they are long-acting, stimulant medications, metalphenidate-based, they are actually intermediate-acting.  They sort of dip in the middle of the day, and some parents feel that it may help children with their lunchtime appetite. It's a good thing, right? But it's not good that they stop working sort of around 2, 2.33 p.m. at times, because then you have the social interactions after school, as well as what else is after school? Homework. Homework, they know. There was feeling in that answer. Now, deitrana and concerta are pretty much the same medications, but deitrana is a patch form of concerta, very similar distribution system called OROS or OROS. And deitrana is well-liked by a subgroup of adolescent patients. They love having the patch and not the pill. Vivance in the second category is a very long-acting amphetamine-based medication. It has the longest half-life, it appears. And it's quite gentle and smooth, and some people will prefer that over something like Adrol-XR for the two, three additional hours, perhaps. I will try to summarize side effects here. I know you will have some questions about that. I did talk about the dual effect or dual pulse stimulants earlier. Younger children, starting the medication treatment with extended release is standard practice these days, but you will have younger children, you will have individuals with comorbid conditions, a short-acting, very small-dose trial phase may be the way to go. Long-acting medications can provide coverage all the way until bedtime in certain cases, but I have patients, their medication will stop working at 12.30. I know that because teachers make sure I know that. These are some of the common side effects. I know most of you are well-versed on that. The sleep problems can be, by modifying the medication or the half-life of the medication, the short-acting medication may be addressed. I do have patients, however, Dr. Schweitzer mentioned this, unless they take their medication, ADHD medication, 6 or 7 pm, they won't be able to fall asleep because they are so wired. They just, inner restlessness will not slow down and they won't be able to stop thinking and go to sleep. Now, this is our first non-stimulant, atomoxetine. It's a very long-acting medication, very gentle medication. It is a fluoxetine or prozac-like molecule. Therefore, there is a black box warning for increased suicidal ideation. What I like about strutero or atomoxetine, because it's such a long-acting medication, single daily dosing, may be sufficient. Children and adults with comorbid anxiety or tick disorders may benefit from this medication. One trick I learned from my patients is to initiate this medication at nighttime, at the beginning, and not in the morning, unlike the research studies, by the way, for atomoxetine, because I started using it in the morning and I was called by parents and teachers alike telling me that the kid, by the second period, they were all falling asleep. The sedation is relatively temporary, but it's really problematic in first few weeks of the medication treatment. Start with the nighttime. If necessary, you can switch to morning. Children who cannot tolerate stimulant medications, atomoxetine, may be a really good choice. Now, guanfacine and clonidine are interesting medications. It's almost rebirth. They are blood pressure medications, so they will lower blood pressure of individuals, and if you stop taking them suddenly, your blood pressure may go up. It's a rebound phenomenon. I had a patient, a wonderful family, they forgot their short-acting clonidine and took a trip to Hawaii, and the young adolescent did not take his medication, and he ended up at the medical center emergency department because of significant increase with the blood pressure. However, the extended release form of the same medications, both guanfacine and clonidine, number one, they are less sedating. Blood pressure fluctuations appear to be less problematic, and they really address all core features of attention deficit hyperactivity disorder. Ones or twice daily dosing seem to be quite effective, and they seem to address anxiety comorbid anxiety symptoms as well as sleep initiation in certain cases as well. Dizziness may be a common side effect, especially if you use these medications in older individuals, because their vessels, blood vessels may not be as flexible as the younger ones, so they may experience blood pressure changes more dramatically. I included some names for you to be familiar with these medications as well. Now, this is a scorecard for ADHD medications, stimulants, and others. Now, the first one is metathenidate and amphetamine, so Ritalin and Adderall are pretty much the same score, about eight, one to ten. The atomoxetine, our long-acting non-stimulant, scores a 6.5, pretty much. Clanidine and guanfacine close to six on that scorecard, not the most brilliant students. And omega-3 fatty acids, if you look at the studies, it seems to do better than placebo. It may be a good additional strategy for the parents to consider. This is fish oil, right? Scores a 3, one to ten, but we'll take 6 plus 3, right? That may be a reason. This is a really cool map. I like this map a lot, because it gives you two very important pieces of information. Are they receiving medication treatment the previous week? And did they receive any behavioral therapy, dinosaur, PCIP, CBT, supportive therapy, DVT, within the past year? And they merged them into one map. It turns out that California did quite well in terms of receiving behavior therapy. The light blue color, you see that the California, a set of California has above 70%. And the medication-wise, under 70% for medication, I apologize, and the behavioral therapy, the largest yellow, dark yellow dot is on the California, that means that more than 51% did receive some sort of behavior therapy. So they looked at the medication treatment within the past week and behavioral therapy of some sort within the past year. Preschool 8 children. Now we have more study for preschool 8 children. It's really a very important group to consider treatment, multimodal treatment, again medication and all other support. Behavioral therapy needs to be considered as a first-line treatment. And when I say behavioral therapy here, really working with parents is crucial, right? We were talking about that earlier. We have a really good study called PATS, that's preschool ADHD treatment study. And if there is significant comorbidity, the medication treatment response will suffer. It's actually not all that different from adults or young adults with comorbid conditions in ADHD. Medications definitely have a place for these young children, however. The dosage needs to be very gentle, very small dose, if it's needed. If the child, when is it needed, the function is so severe that a recent admission, they got kicked out of three or four preschool programs within less than three months. That's pretty big warning sign for you to look into. Or they are so impulsive that you will hear these stories. They run into traffic constantly. The impulsivity is so life-threatening that the parents will certainly discuss medication treatment as one of the options here. Now, this is a... In psychiatry, we study adult conditions first, for some reason. Schizophrenia, bipolar disorder, depression, anxiety. We have lots of adult studies and really just new beginnings of good studies for children, young children and adolescents, right? ADHD, it's reverse. We have better children, adolescents studies, but because of the attention not being paid to adult ADHD, the studies are really just beginning and being funded better than before in this population. Late adolescents, college age, and young adults in general. Dr. Schweitzer mentioned, look for academic records. We had a patient in his early 70s, brilliant individual, and we have more than one, showing up with his elementary school reports from his teachers. That is so helpful to us to establish that long-standing pattern for reliable diagnosis. Figure out if there are any comorbid conditions and try to address them effectively and use checklists to both screen and perhaps to monitor treatment response. Vocational support is crucial. They are usually demoralized just like some of our students in high school. They are demoralized. They feel that they are not getting enough opportunities to reach their potential, giving them a five-minute break every 20 or 30 minutes at workplace. Having a desk that they can stand and walk around every so often may make a huge difference. Simple but effective solutions, I won't review that in detail because Dr. Schweitzer addressed that, can be very significant for these adults. Adults did very well with metalphenidate or Ritalin. In fact, according to this study from Spencer, their response was 76% versus 19% with placebo. It's a very significant statistically treatment response. Tim Willens looked at the atomicity in the struttera in adults with comorbid chronic alcohol use disorder. Their ADHD symptoms improved. However, the response in their alcohol use remained rather inconsistent. Medication plus cognitive behavior therapy in adults appears to be more effective than in children, especially younger ages. And in addition to anxiety, it seems to help with some of the ADHD related difficulties as well. This is head-to-head metalphenidate versus atomoxetine study, so one stimulant, one non-stimulant. And both groups did very well, and they did not have significant differences in terms of their side effects or adverse effects with these medications. I'm slowing down so our brains can be set. How is the pace? Still okay? Great. All right, so this is a really interesting treatment. Cognitive behavior therapy and dialectical behavior therapy. It's very fresh, but we want to share this with you. 14-week program, what they did is they took individuals with ADHD. They put them in a 3-plus 14-week long group therapy, one-weekly group that used some sort of mixed CBT-DBT style. They did assess them for their ADHD symptoms one month during the trial before and also one month and six months after they completed this group therapy. So this is the only treatment modality they are using, I remind you. And they did fantastic. All their ADHD symptoms had improved and they maintained the improvement after six months. That's really very hopeful, at least for this population, for us to add other additional therapy modalities to the mix. Furthermore, according to Nasri, their anxiety symptoms were better managed as well, as well as depression. So sort of overall global improvement with their symptoms, both with ADHD and comorbid experiences. Dr. Schweitzer talked about yoga. I just would like to share some information about exercise. Some professional athletes have been talking about how exercise did benefit them from ADHD point of view. I strongly agree with that. It should be part of their everyone's routine with or without ADHD, by the way. Although with ADHD, we are really talking about vigorous, significant, serious exercise. According to Michael Phelps, nine hours of swimming a day. Go for it! But there is definitely, if you are, you know, lots of parents tell me how they like to keep them in sports that they enjoy, martial arts, certain sports that they may be into. Some kids will do great with golf, make them walk on the golf course if possible, if it's not raining, or a sport that they are interested, an activity that they are interested. I think that will be one way to get the process started, and then keeping exercise logs will be very helpful. There are some schools actually, in addition to their PE class, they will ask parents to keep an exercise log and to share with the school teacher to keep reinforcing that positive behavior. It makes perfect sense to me. Remember, we also talked about, in an earlier slide, the relationship between ADHD and increased risk for obesity, overweight status. So it turns out that brain drive, neurotrophic factor, BDNF, you'll hear about this more and more, increased significantly with exercise. And it's really a revitalizing chemical for certain parts of the brain, both for synaptic formation and cells. There are some other explanations as well. Another complementary additional treatment strategy may be fish oil, omega-3 fatty acids. And initially, we really did not take the smaller results, we are not very impressive, but they did this larger overview of the smaller studies. And then they found that, although not very dramatic, it appears to be clinically significant improvement in ADHD symptoms. So now, and usually the risk of taking a reasonable amount of fish oil is rather controlled. It may be considered for at least certain patients. Who is familiar with TMS? I see lots of hands, that's great. So I don't have to explain this to the group. I'm just kidding, of course. This is from Mayo Clinic Foundation. It's a very simple visual. Basically, there is the brain, there is the electromagnetic coil, and then there is little field being generated. It is approved for certain forms of depression, treatment-resistant depression, as a treatment modality. A recent study, though, used this very same treatment, repetitive TMS, transcranial magnetic stimulation, for a group of ADHD individuals with ADHD. This is one of the studies that I was telling you about really days old. So the understandings that there may be reduced excitability on the right prefrontal cortex as well, and what they did is they, very simply, they have a group of subjects with ADHD and typical individuals with no ADHD, and they administer three types of treatment. Deep TMS, that's usually the more effective clinically-utilized one. Standard TMS and sham coil. Nothing really is going on. And then they did really good testing, including Connors. They did some task assessment for these individuals before, during, and after, after, and this was a three-week study, and in TMS, usually the treatment is daily. So in a week, Monday through Friday, is the treatment.  Both their reduced excitability that I mentioned at the beginning and ADHD symptoms showed significant improvement according to this study. This is really promising because further studies will follow this, and even if this doesn't appear to be as powerful a treatment option for us moving forward, it will probably give us much new information and considerations. And it's only three weeks now. Do you remember one of the significant side effects or adverse effects with the TMS treatment? One of the, really, the more severe one is it may cause or it may activate seizures, right? In this particular study, 53 plus 41, they had only one individual having seizure activity leaving the trial. I'm not minimizing it. One is a lot. However, it was a good start for the hopeful early results. Ticks and stimulant medications, I know some of you are very well informed about this with your clients, with your patients, you worry about ticks with or without medication treatment. The understanding was all because of 1970s case stories. I put the child on stimulant, there was a significant increase or start of tick or tick disorders. Treatment of ADHD in children with ticks or tacks, you will hear about, they're just like pads in preschoolers we talk about, you'll hear about tacks and MTA all the time, right, in ADHD. But it's a large tick disorder study. It's a very well designed study. And the results were really eye-opening. One of the medications that we used to help with ticks, Clanidine, ended up activating ticks more than stimulant methylphenidate in this study. And 22% for placebo versus 20% with methylphenidate also called Ritalin, right, one of the medications that you're very familiar with. So, our approach is work with the individual if there's a worsening of the tick symptoms. You may want to try another stimulant medication unless you started the medication, those are perhaps a little too high or perhaps there are some comorbidities that need to be assessed. Comorbidities you hear repeatedly from Dr. Schweitzer and myself, so it's a really very important theme in ADHD. And furthermore a larger overview of many studies looked into the association between ticks and medication treatment and did not support any worsening not start even worsening with the stimulant use. There was no difference between methylphenidate and amphetamines so Ritalin and Adderall numbers were not clinically different in terms of ticks. This is the recent ACAP American Academy of Child and Adolescent Psychiatry Guidelines and as we discussed their suggestion change to a different stimulant or consider one of those non-stimulant options. Now, I include this because we talk about children into adulthood there are actually very few studies looking into their academic achievement in the long term. They did this study and they looked into these are the research studies child patients as young adults they did wonderful achievement testing they had their background testing they continued to monitor them and they did further achievement testing and they saw that reading and math skills were significantly behind and this is important because as mentioned earlier not being able to realize their potential in life can be quite demoralizing but also need for professional vocational or college for college students educational support are crucial to make a difference. Some people earlier discussed with me how important to work it takes a village really applies just like many other conditions we have to work together and use all the helpful strategies perhaps for the best results now an earlier question sleep regulation I remember a four year old boy my first inpatient when I was in training in New York this boy was so bright so funny but he used to get so violent during his rage episodes very low frustration tolerance he ended up one of our very experienced unit nurses one of these rage episodes this little guy ended up breaking her arm that's how serious it was so I really could not I went through several weeks of not sleeping thinking about this case we keep adding medications things are not improving what are we doing wrong so I started going early this kid wakes up literally dark gray and then you could just hear he's not sleeping right now we realize that his enlarged chronically enlarged tonsils which was never brought up to our attention up to that point might have been causing significant sleep difficulties or obstructive sleep apnea right or sleep disordered breathing so we had a consultation had those tonsils removed with the parental support and then he went from I think three or four medications to single medication at a very low dose and he was so much more redirectable he still has the ADHD but the severity was very different from the previous state so about the sleep question that is one example why little extra time and effort to get a good sleep consultation should be perhaps for most of these individuals part of the initial work up when needed now this is a different type of sleep problem though it's called EDS and this is excessive daytime sleepiness you saw the video of the patient earlier Alice and she talked about how sleep was one of her difficulties she said I'm either very active she's so active her ADHD can be so severe by the way very rare this level of severity but then she will go to these very sedated phases and I remember just as this is being just as difficult challenge for her as the core ADHD symptoms unfortunately in her case she did not have narcolepsy a sleep disorder that may cause this but her medication treatment for severe ADHD stimulants help address her excessive daytime sleepiness as well so we got lucky that really stimulating in certain parts of her brain address both issues that was really interesting to see and that helped functioning as much as addressing the core ADHD she's a successful researcher administrator wonderful advocate and I have to mention she's one of our advocates and she loves actually coming and talking to groups like this but she's a great artist writes beautiful poems and creates sculptures as well very talented woman now this is another talk about understudied groups and this is really important two-fold number one people did not study expecting woman with ADHD so this was a first and really large larger study but when they look at the numbers they looked at depression anxiety even mood disorder other mood disorders such as bipolar disorder but when they looked into ADHD they realized that it was just as functionally limiting for these expecting mothers I'll just go here and actually the problems with their attention if I can find that the inattentive symptoms were significant predictors of professional life or vocational impairment daily life impairment overall day-to-day tasks which can be very frustrating as well as relationship including spousal relationship really correlated very closely and fully with all these functional impairments now the next question I think I'll put here as discussion this is a very recent study but very promising that we're beginning to look these less explored populations when it comes to ADHD but the discussion here should be perhaps what are the treatment options the initial should be recognizing the problem and getting them the support that they need right so that they can keep with their doctor's appointments their perhaps care of their existing children their relationships etc but the other part is if their condition is so severe and if there were certain periods during their or trimesters during their pregnancy if the medication treatment should be considered for some of them if so this is for them for the baby and if they are breastfeeding what are the risks for the baby there are some studies but we need really much more work in this particular area these are very important questions I have some answers for some of them but these are from smaller studies understandably so we need to look into these difficulties and explore them a little bit better I think this is we are almost there we are concluding EEG is an interesting tool or it can be a helpful diagnostic tool yes but what is but so ADHD is neurodevelopmental disorder but we are really lacking biomarkers I cannot get your blood level and guess at this point the condition but EEG turns out may be a helpful integrated strategy not a diagnostic tool but an integrated diagnostic support how so Snyder looked into this in brain and behavior article and then they looked at a certain ratio in the brain electric activity that can be measured by EEG theta-beta ratio and they looked at the clinical assessment and then there was a large group of clinicians who did much more detail than the initial screening they looked at checklists if necessary testing they had a consensus a large group of came to a consensus diagnosis and they found out that the 6 to 17 year old so we are talking about middle childhood lessons in this relatively large study high ratio of these two waves correlated with reference standard large group consensus diagnosis very closely and using EEG as an integrated biomarker is supportive to may be meaningful and what happened to those clinicians who either under or over diagnose the condition their specificity their validity of their diagnosis went from 60 to 87 percent that is a very significant improvement and that has been confirmed by the consensus diagnosis so if somebody comes and tells you that they have EEG that it will diagnose the ADHD in N1 that's probably not very reliable just like at the current state which was talking about the imaging studies and their validity but in case of EEG perhaps there is hope to incorporate that to more challenging cases at least as an integrated tool assistance thank you so much here is my email address and please if you have if you want to discuss any cases if you want to talk to us about our clinical services at the mine institute feel free to shoot an email I'm usually pretty good at responding depending on how busy things can be that particular day but what I can tell you is I remember having a conversation with Dr. Schweitzer when we were starting our clinical services at the ADHD program about eight years ago and we decided to include adult patients both young and adult patients at the clinic to us it just made sense but most of these adult studies at the time did not exist the ADHD was really still perceived as very much a childhood condition but nobody talked about what happens in college age or in young adulthood didn't make sense to us now you see someone like Alice who's been with us for eight plus years and many other and we are evaluating some adult medications and diagnosing them for the first time after really living with this condition for decades for the first time so I think looking back that was a very good decision reaching out some of these individuals families and sort of working our way together to get the support needed for these families thank you I'll take some questions I have a question about side effects you were talking about the stimulant medication and one of them was cardiac and I was wondering if it can create a cardiac problem or does it just exacerbate it? Stimulant medications can increase blood pressure and pulse but it seems to be in healthy individuals a not significant issue one of the screening questions or assessment questions we have for these families and children if there's a significant cardiac history in the family such as sudden death for cardiac reasons if there is one of the things that you can do you can either get an EKG to get a better understanding of the child's cardiac status better yet we are a little bit spoiled at the academic center what we do is we request a a consultation from a cardiologist so we request a full consultation, clearance and that usually seems to be the guiding light however you do not need to get EKG in healthy children with no cardiac family history I have a question about medication vacations for adolescents sometimes people talk about during school breaks or on summer vacations to have students go off medication I'm just wondering about what happens with the brain with that is that recommended or not what is your advice you know people may have different answers to this question but I have been working with these individuals 3-2 our youngest patient right now active at the clinic is 3 all the patient is 74 I can tell you what I learned longitudinal that's why the title of my presentation longitudinal work is make them as long as they need their medication it's important to take their medication every single day the reason is we are not treating school work if you talk to these families after 4 o'clock after 5 o'clock men the medication stops working their relationships with other family members will decline significantly low frustration tolerance vulnerability fighting rage episodes social learning immaturity so just because the school is out should not mean that their all level of learning should stop the other part is Dr. Schweitzer talk about very nicely about impulsivity and the lifespan risks including earlier experimenting with sex alcohol driving risks I don't want my child if my child has ADHD to get close to that car Alice explained it very well without his treatment or her treatment that is so important but I would suggest that to maintain the gains to keep adding because your goal is really to reach the potential my suggestion would be and there is some that seems to support that is to continue with the medication treatment I did see also cases that they took a break during Christmas in addition to getting all kind of troubles if they are teenagers right or summer break they went back on the same stimulant medication same dosage first of all they responded as if they are taking the medication for the first time in terms of the side effect profile but also in some cases we are not sure what happens to receptor sensitivity but it changes and they become non-responders to the same medication or the same dosage that happens by the way with several other psychotropic medications as well so that's another consideration that one needs to think about just one more comment having said that some of these individuals will stay on their medications they will improve they will learn coping skills their brain will change and then they will stop their medication treatment they will do beautifully they will be student in berkeley other good colleges they will have healthy non-impossible meaningful relationships it's wonderful to see that and that happens on a daily basis but they just need that initial support what are the medication considerations for people who presents with ADHD but there's a parent history or family history of bipolar and more specifically have you seen stimulant medications induce a manic episode that's an excellent question it's been talked about for decades now and we finally have really good research support on this if you have bipolar disorder plus ADHD we talk about comorbidity being very high for bipolar disorder having ADHD the treatment strategy we would recommend is addressing the bipolar disorder first address the mood disorder stabilize the patient and then if the ADHD is still problematic address the ADHD but once the bipolar state is stable that's really the key sometimes it's not what you do in psychiatry but the sequence and also it's important to be consistent with these treatments sometimes I will see families that they tell me oh no medications ever work for our son he's now 17 what are the medications oh everything from Y-Vans to Adrol oh really 20 plus medications how long did he stay on these medications oh about 2-3 days each these are real stories in order to see unless they have significant side effects of course it's really important to have a 3 month trial with the medication before making any decisions because you really the medication starts working right away but finding the right dosage may take a while and also sometimes the changes in behavior pattern will take some extra time but in bipolar disorder that is the helpful approach that we use as a follow up to that what if the patient hasn't been diagnosed with bipolar disorder but there's a family history is there a concern about stimulant medication initiating a manic episode or something with a child with ADHD great question that's why I want to refer back to writer's comment about using rather than just a checklist like Vanderbilt or ADHD specific if you can use a like Bask if you use or CVCL a checklist that will give you some screening idea about different diagnoses as well that's really the first step that's very important so that are we suspecting some psychosis, bipolar disorder etc that will really address that at the beginning that will be a good starting point and then get a good work up both stimulants and antidepressant medications can certainly activate bipolar disorder symptoms in individuals but sometimes they will cause short term irritability that may be perceived as bipolar disorder which has nothing to do with that so it's really very case by case basis very careful monitoring frequent careful monitoring and initial assessment I have a couple of questions please do you have any experience with whether a person who has had weight loss surgery needs to go on either long acting or short acting that's the first question and the second question is if you have an adolescent who you think may have ADHD is it diagnostic if you give them a medication like concerta and the next day for that day they're like totally different and improved as much as coffee test is diagnostic probably not very reliable approach individuals their concentration may improve if you look at some of the learning scores it may improve but it's not diagnostically the observation is significant but it may or may not be diagnostic so I would stay away from that approach and it may have some additional risks in terms of the weight loss surgery this is really very important question if you have been following to not just in academic centers by the way there has been a significant increase in demand for these surgeries, bariatric surgeries in older adolescents now younger adolescents even children probably in our population the approach should be just like the sleep disorder we were talking about start with the basics and improve the sleep hygiene start with the activity level lifestyle exercise healthy eating behaviors before even considering a much more drastic step now let's say that we are dealing with an adult very appropriate diagnosis receive a surgery if they are not having any absorption problems ADHD treatment may be considered it's more about their really absorption state and it's not necessarily just specific to stimulants however gut enzymes are definitely very important for ADHD and these medications to be metabolized so it will be a careful thoughtful treatment process excellent question and unfortunately it applies not just for ADHD medications if you look at the same sort of maps in both lower socioeconomic status and minority areas you will see that we as treatment providers are quick to and this may be at the primary care provider level too quick to address the issues with medication alone if you look at the if you look at the psychosis treatments or use of antipsychotics for any one diagnosis you will see the same pattern that you very nicely summarize from that map that is a very large problem and it will only I think improve number one with symposia like this one increasing awareness of multimodal treatment improving our education system there are so many layers to it and it will have to be discussed in setting like this and the other observation if you look at that map some of these areas with heavy in the minority groups you had really high medication but very low behavior therapy along with that we see that even in our area by the way depending on the socioeconomic group that we are working with as well as the minority factors it's an ongoing problem but it's not specific to ADHD treatment great question thank you I think that's about all we have time for please give a warm round of applause for Dr. Pacurek thank you so much I know there are many more questions so please take this opportunity to write your questions down and put them in the boxes at the front here that we will have a lot of opportunity this afternoon at the question and answer session to talk to all of the speakers


Welcome back to my channel and welcome if you're new here. My name is Jen I'm a certified weight loss and nutrition coach and I'm on the WWW blue plan It is Saturday, so it's grocery haul day. If you missed last week's grocery haul. I had a massive massive $600 haul where I literally stocked up on all the things from Costco for about the next month month and a half Thanksgiving lots of staple groceries So this week's haul is not as large as normal just because I'm just filling in the gaps of what I'm out of or Items that I need for upcoming recipes, but I still have a really good haul for you with some new food finds and some exciting things So before we jump in if you are excited about another grocery haul Give this video a big thumbs up and of course if you're not yet subscribed help me reach my goal of 30,000 subscribers by the end of 2020 and hit the little subscribe button and the bell next to it So you're notified when new videos are uploaded. Thank you in advance for helping me reach my goal I'm so close about 400 subscribers away Also, make sure that you're checking out that description box down below for my nutrition coaching website I offer one-on-one coaching macro and calorie calculation There's a little bit of something for everyone so take advantage of those services as well You'll also find the links and discount codes to all of my favorite things and the link to head over and join Us on my Facebook group. We'd love to have you so let's jump into this week's grocery haul So here's this week's grocery haul and medium-sized haul this week just because we had that massive haul last week So I had to pick up a few things for Thanksgiving and then also for some recipes this next week Due to Thanksgiving. I just did Walmart grocery pickup. I didn't go anywhere else So everything I have is from Walmart. So let's jump in of course. I restocked my kombucha I picked up a guava goddess watermelon wonder two of the Gingerberry and two of the golden pineapple this one is so good Walmart actually had quite a good selection of flavor So I stocked up on a few different ones turkey pepperoni. I actually need this for a dinner recipe this next week This big pack of ham because for meal prep I'm making egg cups that require a slice of ham and I wasn't sure if there was 12 slices in the smaller pack So I just grabbed this double one.  That's okay. We'll just have turkey cups instead of ham cups mozzarella cheese This is a for a recipe as well And then I was so excited that they actually had their chicken apple sausage in stock So I picked up three packs because we already went through the other three packs and this seems to be really Really hit or miss at my Walmart So let me know down in the comments if it's hit and miss at your Walmart as well and then some 99% ground turkey I just added this kind of at the last minute to throw in the freezer Green beans for the dogs. Of course, I just buy the no salt added I do rinse them even though they're no salt added and they get these instead of table scraps And it works really well. They look forward to their beans. So I picked up three cans of those Vinegar because we were completely out and I actually use this a lot to clean my shower heads because it helps get off the really hard water Marinara sauce for a dinner recipe I just have not had time to make the skinny-ish dish and this one is really good ingredients really really low calorie This is the organic great value And then a can of diced green chilies. This is also for a dinner recipe. This was a substitution I ordered the walmart brand and they gave me the ortega brand two cans of Campbell's healthy request cream of Mushroom soup for a recipe. I actually needed two cans Pesto I ordered the classical brand and they didn't have it so they substituted with the sam's choice Which is actually less calories. So I was excited about that. I love pesto. This is for a dinner recipe A can of corn also for a recipe Two cans of chunk-like tuna in water tories having tuna fish sandwiches This next week for his lunch. So I picked up two of the big cans And then this was also a substitution. I ordered the 12 count Of the colby in Monterey jack cheese sticks and they substituted with a 36 pack for three dollars Which is a great great deal. They must have had a shortage of cheese sticks So we scored big time getting this big box for the price of a 12 pack And then everything else I have is produce. So I have some green onions for a dinner recipe and salads Lemons for my water since I didn't go to trader joes again I just picked everything up at walmart Troy asks for cucumbers. He likes to kind of have those sliced up in his lunch Two bell peppers for a recipe. I'll actually have an extra. I'll use it for salads or toss it in another recipe Tomatoes for Troy's lunch this next week bananas for meal prep frozen peas for a recipe and last but not least some lime juice for a recipe And I do sometimes like to put lime or lemon juice in my water So that's everything guys for this week's grocery haul Let's take a look at what we're doing for my meal plan and my meal prep So here is this week's meal plan. This is the week of november 28th through december 4th December you guys how crazy is that? So of course saturday isn't out to dinner Higher calorie use my weeklies day. I don't know what we're doing But i'm definitely not cooking on saturday sunday I'm making chicken fried rice and you will actually see this recipe in wednesday's what I eat today So stay tuned for that monday. I'm going to do a slow cooker hamburger hash with our bathroom remodel I just need an easy meal the first part of the week when things start picking back up remodeling wise So i'm just going to throw this in my slow cooker It's going to be delish and then tuesday's always leftovers. I've been doing the 5 30 p.m In my garage jazzer sized glass so that way we just have a quick meal once i'm done Wednesday i'm doing pepperoni chicken bake with basil and pesto So this sounds incredible. It's basically the best of all the world's pepperoni pesto chicken So i'm excited for that Thursday is going to be barbacoa beef, which is a copycat chipotle recipe So i'm pretty excited for that too and then friday is a leftover night just to finish up Whatever's left over from the meals earlier in the week and on monday in meal prep for breakfast this week I'm making ham and cheese egg cups, but walmart did not give me the right meat So i'm actually going to do turkey and egg cheese cups So you guys will see that in monday's what i eat in a day lunch is queso baked chicken I love queso so i'm pretty stoked for that And then i don't know why i put dinner that should say snack or dessert But i'm going to make banana bread and this is a healthy delicious low point low calorie banana bread And the recipe is incredible. So definitely stay tuned for monday's meal prep video Thank you for joining me on another weekly grocery haul I hope you enjoyed coming along with me today for all of the groceries that i picked up for the week as well as my Meal plan and meal prep you're not going to want to miss meal prep on monday So stay tuned for that of course all of those recipes will be on my recipe website So you definitely want to keep an eye out for monday's video again If you enjoyed this grocery haul, please give this video a thumbs up And please don't forget to help me reach my goal and subscribe to my channel and better yet Turn the bell on next to it. So you're notified when i upload Don't forget about that description box down below with my nutrition coaching website Links and discount codes to all of my favorite things and my facebook group And with that being said i want to wish you a happy happy saturday And i'll see you in tomorrow's video and get ready for vlog miss starting on december 1st Love you guys and have a great weekend. Bye


Hello, I'm Sergeant Major of the Army, Dan Daley. By now, most of you have heard about blended retirement. It's another important step that we've taken to modernize our force. All soldiers, regardless of length of service, will now earn retirement benefits. Beginning January 1st, 2018, new soldiers will automatically be enrolled in blended retirement. All current soldiers are grandfathered into the current system. But those of you with less than 12 years of service as of 31 December 2017 will have the option to choose. Additionally, all soldiers eligible to opt into the new system are required to complete the blended retirement opt-in course. This can be found on the Joint Knowledge Online homepage. For more information, visit the Military One Source website or contact a financial counselor at your installation.


The Mesopotamian division relied on multiplying by the reciprocal, and the Mesopotamian scribes had tables of reciprocals at their disposal. But how were these reciprocals found? There were two common methods. We can describe these as either using the reciprocal relationship or by using the trailing heart algorithm. So let's start off with the reciprocal relationship. If A times B is equal to 1, then A and B are reciprocals. And this means that if we can find two numbers that multiply to 1, they are reciprocals. But in base 60, 1 is also equal to 60 sixtieth, and we can move the sex decimal point around. So how does this help us? Well, let's find two numbers that multiply to 60 and then use our values to find the reciprocals in base 60. So let's pick two numbers that multiply to 60, about 5 and 12. Now, remember that 60 is equal to 1, 0 in base 60, and we want the product to be 1, so we need to move the sex decimal place in 1 or both of the factors. And there are two ways of doing this. We can move the sex decimal place 1 space over in the 5, or we can move the sex decimal place 1 place over in the 12. And so the reciprocal of 12 is 5 sixtieth, while the reciprocal of 5 is 12 sixtieth. And it's worth remembering that in mesopotamian numeration, the sex decimal point is never indicated. And what this means is that if you were a mesopotamian scribe, the reciprocal was just 5 or 12. We can extend this a little bit further. Suppose the product of two numbers is 60. Then if we multiply a by n and divide b by n, the product will still be 60. And since we can shift the sex decimal point, we can focus on the actual digits of the numbers. So we might begin with the fact that 4 times 15 is equal to 60, and then we can find other reciprocal pairs. So 4 times 15 equals 60. Now this is going to require us to divide by something. And so what can we divide by without having a reciprocal table? Well, we could probably divide by 2. So if we divide the first factor by 2, then multiply the second factor by 2, the product is still 60. And so from the fact that 4 and 15 are reciprocals, we also find that 2 and 30 are also reciprocals. We can use this approach to find specific reciprocals. So let's say we want to find the reciprocal of 8. Since we'll either be having or doubling a number, we want to find two reciprocals where we can have or double one of the factors to get 8. Well, let's start with 4 times 15. So if we double our first factor, we get 8. Now we have to take half of 15. And so to find half of 15, we could think about 15 as 14 and 60, 60ths. If you want to think about this as time, 15 minutes is 14 minutes and 60 seconds. So that means half of 15 will be half of 14, 60, which is just going to be 7, 30. And if we are worried about where the sex decimal place is located, we can shift the sex decimal place around. The product is 60, which is the same as 1, 0. If we want that to be 1, we have to shift the sex decimal place 1 space. And since we are trying to find the reciprocal of 8, we can't shift the sex decimal place on 8. We have to shift it on 7, 30. And so that gets us the reciprocal of 8. Another method of finding reciprocals is known as the trailing part algorithm, and it works as follows. To find the reciprocal of a number n, find a sequence of multipliers that make the last digits 0 a multiple of 60. If the product of all of these factors is 1, or 1, 0, 0, and so on, the reciprocal is the product of the multipliers. So, for example, let's try to find the reciprocal of 50. We'll begin by choosing any multiple of 50 that gives a multiple of 60. So we'll find 50 times 2, 50 times 3, and so on. And we find that 50 times 6 gives us 300, which is a multiple of 60. So let's multiply 50 by 6, and we'll trade and convert this into a number in base 60, 50. Now, note that the last non-zero digit is 5, so we want to find a multiple of 5 that gives a multiple of 60. And we note 5 times 12 is 60, and so multiplying by 12 gives us, and since our product is 1, 0, 0, that means the reciprocal of 50 is going to be 6 times 12, 72, or as a number in base 60, 1, 12. And there's a sexy decimal place located somewhere in here, but remember in Mesopotamia Numeration, the sexy decimal point is never indicated. Or let's try to find the reciprocal of 9, so we want to find a multiple of 9 that gives us a multiple of 60, and so we find 9 times 20 gives us 180, which we convert into 30. Now, our last non-zero digit is 3, so we want to find a multiple of 3 that's a multiple of 60. 20 works, and so we multiply and trade. And since the product is 1, 0, 0, our reciprocal is the product of our two multipliers, 20 times 20, 400, which we can convert into 640.