Prenatal treatment of ADD on the horizon

With anticipated widespread acceptance of revised diagnostic criteria in DSM-5, the bible of psychiatric diagnoses, researchers are now keen to examine the efficacy of treatment for prenatal attention deficit disorder (ADD-PN).

“We’ve already got the drugs. This will allow us to study the incidence and treatment of ADD in the womb (ADD-PN) using only the highest ethical standards in medical research,” said Dr. Erma Kidd, a psychopharmacologist on staff at Slamdunk Medical College and Hospital, one of the few remaining medical institutions in the country not underwritten by the pharmaceutical industry.

Researchers have known for decades that ADD (or ADHD, as it is sometimes called) carries a genetic predisposition. “We’ve been able to track this malady through generations of families. The trouble was that we had no good clinical criteria for prenatal diagnosis of the disease,” Dr. Kidd explained in a recent e-mail. “Publication of DSM-5 changes all of that. Now we can diagnose ADD-PN in the womb. And if we can diagnose it, treatment options are just around the corner.”

This late-breaking news comes on the heels of recent announcements that child psychiatrists, general practitioners, pediatricians and maintenance personnel working in their offices have been given the green light to treat preschoolers with powerful stimulant medications in an effort to improve quality of life—for them and for their parents.

Off the record, preliminary studies examining the efficacy of prenatal pharmacologic treatment for ADD-PN have been underway since last year. “It’s been exciting, but extremely tough on our research team,” Dr. Kidd wrote. “After devising modalities to administer methylphenidate-like drugs to a cohort of fetuses, we were forced to wait until the babies were born before we could adequately study their behavior and development.”

Nevertheless, preliminary data is promising. “Mothers who had methylphenidate infused into their amniotic fluid reported considerably less fetal movement during the third trimester of gestation,” Dr. Kidd said. “Indirectly, we infer that the drug was helping these fetuses to calm down, to become less impulsive and more focused in the womb.”

Subsequently, some of the subjects have been born; and the data so far is impressive. Developmentalists report that when compared with their peers, many infants in the research cohort seem to be able to rest comfortably in feeding chairs in front of daytime television game shows for longer periods of time. They also exhibit less interrupted sleep, and coo and babble only when prompted.

“Imagine, babies genetically destined to suffer from ADD throughout their lifetimes, who now at only 2 months of age show less impulsivity when vocalizing with their parents. They wait to be recognized before speaking; and even then, their remarks seem to be much more age appropriate.”

The future looks bright for these children. “No more food fights at the dinner table, no more negative behavior at bedtime,” Dr. Kidd added. “We’re working hard to make it a better world for parents, for all of us.”

Still, some clinicians exercise a word of caution. “When it comes to the grey matter of the human brain, nothing is black and white,” one researcher commented. “In these clinical trials, nothing is a slam-dunk.”

Apart from stock options which she has yet to exercise, Dr. Kidd has disclosed no contractual relationships with any of the major pharmaceutical companies who market methylphenidate in their product lines.

Flaubert and Hemingway: Stylists at heart

It took Gustav Flaubert almost four years to complete Madame Bovary. As a writer, he worked tirelessly at his craft, composing numerous drafts of each passage, paring each revision down to its basic elements. In the end he wrote over 4,500 pages.

“A good sentence in prose should be like a good line in poetry,” Flaubert said, “unchangeable, as rhythmic, as sonorous.”

His original drafts are available online at Édition des manuscrits de Madame Bovary de Flaubert. Flaubert believed that the success of the book was entirely dependent upon the style of composition.

“What a bitch of a thing prose is! It’s never finished; there’s always something to redo. Yet I think one can give it the consistency of verse,” Flaubert wrote in a letter to his mistress Louise Colet. He strove to hone a narrative style that was direct, precise and polished “as smooth as marble.”

Flaubert also worked hard to develop his characters through dialogue. In another letter he describes an “episode of six or seven pages without a single reflection or explanation coming from the author (all in direct dialogue).”

As a young writer, Hemingway educated himself in the art of writing by reading the masters: Turgenev, Tolstoy — and Flaubert. He developed his powers of observation in his work as a journalist, gathering facts necessary to flesh out the story. Like his mentor Flaubert, Hemingway’s writing — particularly his early prose — is clear and direct. He uses lengthy stretches of dialogue to develop characters. Hemingway became a meticulous stylist, writing and rewriting passages until the cadence was perfect to his eye and ear.

“I rewrote the ending to Farewell to Arms, the last page of it, thirty-nine times before I was satisfied,” he told George Plimpton in a 1954 interview that appeared in the Paris Review.

And in a letter to Gertrude Stein, Hemingway wrote: “But isn’t writing a hard job, though?”

In his seminal biography of Hemingway, Carlos Baker describes the writer’s self-laudatory remarks upon finishing The Green Hills of Africa:

A narrative that combined true reporting, the excitements of action, and the quality of real literature was, Ernest thought, a pretty rare thing. First it all had to happen, and second the man to whom it happened had to be equipped to “make it all come true.” This was as hard as “painting a Cezanne,” and Ernest felt that he was “the only bastard right now” who was capable of such an achievement.

Referring to his early experiences as a newspaper reporter, Hemingway said: “On the Star you were forced to learn to write a simple declarative sentence. This is useful to anyone. Newspaper work will not harm a young writer and could help him if he gets out of it in time.”

Writing is difficult, and good writing is even harder to achieve. Even the masters are apt to fall short.

Flaubert alluded to the writer’s attempts to perfect the craft in these lines from the pages of Madame Bovary:

As if the fullness of the soul did not sometimes overflow in the emptiest of metaphors, since none of us can ever express the exact measure of our needs, or our ideas, or our sorrows, and human speech is like a cracked kettle on which we beat our tunes for bears to dance to, when we long to move the stars to pity.

Crafting a lens

“Once when I was down in Florida I attended a presentation on bird photography. The fellow who spoke was a professional. His photographs of hawks were exquisite: sharp, clear detail; up close. I asked him what sort of lens he used for those shots. ‘A 600 mm,’ he said matter-of-factly, without batting an eye. Do you know how much that 600 mm lens sells for? $10,000.”

A long-time friend who I don’t get to see that often had stopped off for the evening on the last leg of a week-long trek through New England. We were discussing digital photography over dinner at a local tavern. He took out his Droid to show me some of his bird photographs he had posted on Facebook. Every year he visits the Ding Darling bird sanctuary on Sanibel Island where he sets up his portable blind and waits, sometimes for hours, to capture a particular type of bird in a once in a lifetime shot. “Wish I could get you down there sometime,” he said.

“One of my buddies has a time-share on Sanibel. He and his wife go down every February,” I told him.

“I’ve gone in March,” he said, “but January and February are better months for birding. The great blue herons mate in January. By the time I arrive, their young have already hatched out and stand this high.” He indicated a span of perhaps 12 inches with his two hands.

He told me that many of his photographs were shot from a blind he’d erected by the driveway of his Pennsylvania home. “I put up a few feeders and wait for the birds to show up.” He tapped the screen of the Droid. “Here’s a hummingbird hovering in mid-air. I’m particularly pleased with the way the tail came out in this photo.”

"Hummer" 2011 © Arthur Drescher

I admired the sharply focused head, frozen in time; the tiny body; the lotus-cupped tail.

“My problem these days is that with my glasses off, I can’t see well enough to focus through my SLR camera,” I told him. “I’ve taken what I thought were great shots, only to find that they’re blurred when I get the prints back.” He studied my face with a slightly puzzled look. “Yes,” I admitted, “I’m still shooting 35 mm film.”

“You’ve got to go digital,” he told me. “The camera beeps twice when the lens is in focus. Very handy for those of us with aging eyes.”

“I can see how digital technology has revolutionized the art of photography,” I said.

He nodded. “You remember that 600 mm lens I told you about, the one that costs $10,000? Someone told me it takes seven months to assemble one, there are so many intricate parts.”

I reflected on that fact in silence. Momentarily, he said: “But no matter how intricately constructed the lens or the body, the camera will never be able to duplicate what the human eye sees.”

He tapped the touch screen of the pocket Droid again and showed me another digital photograph. “I shot this with my Nikon 300s and a Nikkor 105 mm macro lens at an f/stop of 7.1, shutter speed 1/400 of a second directly into the early afternoon sun. Can you guess what it is?”

"Strand Spectrum" 2011 © Arthur Drescher

I studied the three strands of colored ribbon stretched across the dark backdrop and drew a blank. “A feather?” I guessed, knowing it was the wrong answer.

“The strands of a spider web,” he said.

Modern technology has given us a lens capable of bringing the silken strand of a spider web into focus, simultaneously dissecting it into a spectral ribbon of diffracted light. Yet even this level of technology does not approach the intricate construction of the human eye.

How much longer, how much more difficult, for the writer to craft a description of the same entity, capable of capturing the same spectrum of emotional responses as the digital photograph.

"Spider Web Rainbow" 2011 © Arthur Drescher

Humane Medicine — Just passing through

I watch them go — a new family I will most likely never see again. They’ve played by the rules, but got burned by the system. Lose your job, lose your health insurance, lose your doctor. more»

Interested readers can now access my latest Humane Medicine columnTransitional Medicine: Patients who are just passing through — recently published in the Journal of the American Academy of Physician Assistants.

Impressionistic Medicine

The Danish impressionistic artist Camille Pissarro lived most of his adult life in France. During his long tenure as a painter, Pissarro gleaned much from Corot, Courbet and Jean-François Millet, forerunners of the Impressionist school. Many other artists worked under his tutelage, Gauguin, Cezanne, and Seurat among them. Eventually, Pissarro came to be regarded as the father of French Impressionism, the only artist to exhibit his work in all seven Impressionistic salons over the last quarter of the 19th century.

More than a mere painter, Pissarro was an anarchist, whose radically egalitarian views found their way into his work. For his subjects Pissarro chose rural peasants, depicting them at work in the fields, as domestic servants, as buyers and sellers in the market place.

In the 1880s, Pissarro assembled a portfolio of 30 pen and ink sketches rendering the horrors of urban capitalism entitled “Turpitudes Sociales” (“Social Disgraces”). He used his art to draw public attention to the injustices inherent in what he saw as an unethical and immoral social order of his day.

Throughout his life Pissarro envisioned a kinder, gentler society, one where people have what they need in order to live a good life — and no more. He put his ethics into practice, opening his home to all visitors, including young hungry artists.

One could not wander through the recent Clark Institute’s Pissarro’s People exhibit without admiring the canvases depicting bucolic scenes peopled with peasants engaged in work and talk. Pissarro’s vision becomes contagious to a visitor immersed in such beauty and grace.

While standing in front of one of his portraits, I — as a practitioner of another form of art, the art of medicine — could not help but think that we clinicians are called to view those patients entrusted to our care as equals in the sense of their humanity, their needs and wants.

Osler summed it up when he wrote: “Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures.”

I have learned much from looking at the world through Pissarro’s eyes. Collectively, his canvasses could be considered windows through which one glimpses the art of impressionistic medicine.

“Notes from a Healer” — Frustrated

These are the days of pediatric practice that try clinicians’ souls.  more»

My latest installment of Notes from a Healer — Frustrated — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online journal fostering discussion about the culture of medicine, medical care, and experiences of illness. Interested readers can access a list of editorial board members and regular contributors here.

Semper Paratus

In the United States we are faced with a shortage of primary care physicians, but fewer medical school graduates elect a career in primary care. Have the members of any Washington think tank seriously considered the role of generically trained physician assistants in this equation?  more»

Interested readers can examine my thoughts on this issue in my latest Musings blog post newly published in the Journal of the American Academy of Physician Assistants.