Dr Ioannis Delipalas on Medcast: The Real Talk on ADHD

Hello, Dr Wafaa. First of all, thank you so much for the invitation. It is an honor to be here and also give some insights about a very common neurodevelopmental condition that has been affecting people and people are constantly asking and inquiring about it. You asked about my journey. Yes, I always was fascinated by humanistic studies and medicine is the most humanistic of all. So I really studied very hard to enter a Democritus University of Thrace, which is the medical university in Alexandroupolis. That was a long time ago. I don't want to reveal my age.

And you asked me also when did the interest about psychiatry arrive. Well, I will share a story with you and with your audience. That came the very first time that the professor of psychiatry had his first lecture at Democritus University. And I need to give a tribute to Professor Dr [name], who was my professor in psychiatry. He inspired me to be a psychiatrist. The way that he was talking about mental health disorders, the way that he was revealing all the secrets of the human psyche, it was an encouragement for me and also an interesting journey about a medical specialty that has been a little bit underlooked from other specialties. I'm putting the blame to our colleagues, but it has so much to offer.

In a space where we meet a patient, he or she comes and reveals the most of the secrets that he or she carries. So this takes a lot of braveness of the individual. So it takes also a lot of tolerance and patience and understanding from the psychiatrist to do so. After I complete my medical studies, I moved to Sweden, where I had the blessing to have an excellent residency in very important hospitals, among others, the university hospital in Uppsala and, of course, Karolinska University in Stockholm, where I finally was granted the title of consultant psychiatrist in 2009. I have been working in out- and in-care patient units in Stockholm. And in 2019, I took the decision to come to the Gulf.

Thank you so much, Dr Wafaa. So I have been practicing since then. Currently, I am the consultant psychiatrist at the Valens Clinic here in Dubai.

First of all, attention deficit hyperactivity disorder, or commonly named as ADHD, is nothing more than a neurodevelopmental condition. In some textbooks or in conferences, you may hear the word disorder. I do not particularly like the word disorder when it comes to ADHD. Why? Because we are born with ADHD. It's a condition. It's a neurodevelopmental condition, meaning that the brain is somehow programmed in order to work in a different way compared to someone who doesn't have ADHD. So common symptoms of ADHD include the difficulties in concentration, what we call inattention deficit, problems with hyperactivity, and also problems with impulsivity.

As mentioned before, these are the three big types, meaning that ADHD can come across as ADHD-only inattentive type, so the individual has only problems with concentration, not anything else. Or the ADHD hyperactivity type, where the individual has restless problems or problems with being able to sit still. And finally, we have the combined type, where the individual has both inattention and hyperactivity. Now, the onset of ADHD can be as low as the three years of age, but the most common is in females and girls the age of 7 to 8, in boys between the age of 7 to 10.

And of course, we need to think that, oh, but all children can be a little bit of restless and cannot sit still, and they have a little bit of problem with focusing. This does not mean that these children will have ADHD. ADHD can be suspected when these symptoms are daily, they're persistent, and they're significantly more severe compared to the peers of the boy or the girl, and causing also extra frustration to the caregivers and also to the teachers. For example, children that they cannot sit still, children that they will disrupt the classroom, children that they will not do any activity in a very relaxed way, but they will be forced or take toys or throw toys and kids that they will explode often, what we call throw tantrums, which can be also very normal.

But when it comes too often, too persistent, too regular, then we can suspect ADHD. So the onset is around, but now we have data showing that the onset goes on an earlier and earlier age compared to the time that when I was a resident, I mean, I will not reveal my age again, about 15 years ago, the usual onset was between 5 to 7 for girls and 7 to 10 for boys, but now we can see as low as 3 to 5.

The youngest child that was diagnosed through my period as a consultant psychiatrist was the age of 4 in Sweden, but he was extremely, extremely stereotypical picture of ADHD.

ADHD symptoms can be a little bit different from age to age across the lifespan. For example, a boy at the age of 4 or 5 can be a little bit more disobedient, can be a little bit more aggressive. The parents may think that this is a normal attitude. But as the kid grows up and when the school may become more demanding, where certain responsibility lies there, for example, you are expected when you are in year one to sit still in your place, not to move.

So, at the age of 7, probably the ADHD symptoms that they were there before, it's not like they started at the age of 7, they will be more noticeable. And now, I need to also make an important point about the difference in the outcome and the representation of ADHD symptoms between boys and girls. The stereotypical picture of a boy is the one who will throw tantrums, will talk back to the teacher, he will disturb the schooling process, he will curse, often to teachers, to peers, or to parents.

On the contrary, and this is very important, we're going to talk more about that as the podcast continues, is that in girls, the picture is totally different. Typically, a girl with ADHD will remain silent. She will be a daydreamer. She will not pay attention to what is happening around her. But, she will stay silent. Often, when I get the medical history of my patients, they always say, but, why do you suspect ADHD, doctor? I was the teacher's favorite. I said, why were you the teacher's favorite?

Because of your grades? No, because I didn't cause any problems. I was always silent. I was watching outside the window. I was thinking about Brad Pitt when I was like 10, 12. And this is also a sign of ADHD, of the inattentive type. So, we have different representations. Of course, what I'm saying here now, it's not the norm. ADHD is a spectrum. Everyone's clinical picture differs from person to person. But, in general, boys and men tend to be more on the hyperactive spectrum, more loud, if you like, more noisy, compared to women and girls that are more silent, more of a daydreamer.

And, of course, this does not mean that they don't have ADHD. This means that they mask the ADHD symptoms. That's why it takes longer for women to reach a diagnosis.

Yes.

Yes, definitely. Because they are more towards the inattentive type. So, apart from the daydreaming, the daydreaming will prevent them from staying focused or shift the focus to important things like what is happening in the classroom. And they were typically the girls that they will come back home and will not have a clue what was told in the classroom. And they will need to compensate a lot through very hard studies in order to maintain average grades. Yes. This is also another catch, if you like, that I get when I meet patients, that they don't really align at first with my clinical suspicion about ADHD.

And a common comment that I get is that, but I had average grades. And my next question is, did you need to work harder on these average grades compared to your best girlfriend? Yes, I need to study all day. She studied three, four hours and she would have [inaudible]. But I need to study all day long and sometimes nights to get the big grades. So, the girls, they put more effort, they go more silent, they mask the ADHD symptoms. That's why it's important for the parents to know and understand that something else may be going on.

In adolescence, adolescence is generally a quite difficult period across the lifespan. There is the time for identity exploration. So, in many ways, about personal identity or sexual identity or professional identity in the future. And also, there is the time to revolt, revolt against the parents, demolish them, as I like to say, and then rebuild the relationship again. Of course, adolescence means that there will be sometimes a lot of irritability or sometimes aggression in this part. This may somehow be presented as ADHD, but at the same time, we need to think that a teen who has been, who probably has an undiagnosed ADHD, these teen years will amplify the ADHD symptoms.

He or she may end up being more anxious than compared to a peer who doesn't have an undiagnosed ADHD or more depressed or lean towards substance use or experimentation with substances or even worse to a substance abuse in order to manage these ADHD symptoms. So, we have, like, two triggers going on. Adolescence, which is a difficult phase itself, and also the ADHD symptoms or the ADHD condition that has been undiagnosed. And we also need to think that year eight and nine are quite difficult years in school. They are the more difficult studies, more difficult exams, preparation for the final studies, meaning that it can be like an explosive mix.

Definitely. Definitely. And I cannot count the number of patients that they reached out to me being in the age of 15, 16, and having ADHD and having a proper assessment after screening being conducted by me, receiving a diagnosis, providing the medical report to school, being on stimulants, although we'll come to the medical treatment later on.

I feel I'm pushing a little bit on towards that.

And managing the final studies in an excellent way and also being able to attend the university of their choice. This is huge because there are some decisions made for life around that age that it shouldn't be compromised by an undiagnosed condition.

Adults.

We're coming to the juicy part.

Undiagnosed adults can also present quite differently compared to children and teens. We can easily understand that this has to do with the life circumstances. Being an adult means a lot of responsibilities. So someone needs to find a profession that he or she likes in order to make a living and then probably find the right partner and build up a family if he or she wishes for. And undiagnosed ADHD may stand in the way in order, for example, to regulate and organize tasks, manage the focus, and unaddressed ADHD may lead to productivity issues.

There are people with ADHD that they don't know they have ADHD, that they jump from work to work after six months, which is not very common. I had once a patient that had shifted 23 jobs in the period of 12 months, which is totally unusual unless something else has been happening. So people that they really don't fit in, they feel that there is something that is wrong with them, but they don't know what it is. And they have also even the daily tasks, like getting up in the morning or being prepared for work or making sure that he or she will not be late for work.

It's a struggle. For normal people with no ADHD, this is like a routine. I know what time to get up. I know that I need time for my breakfast to take a shower and I need to think about the traffic in Dubai. I will make it on time. People with ADHD, they struggle. It's not like a self-[inaudible] prophecy. They need to struggle and they need to be reminded. And of course, the higher the expectations, the higher the pressure, so much bigger the feeling of failure that can be constant in adults with undiagnosed ADHD, which can open the door for psychiatric outcomes like clinical depression or severe anxiety disorder, sleeping disturbance, and of course, substance abuse disorder.

Feeling like I cannot cope with work means that, okay, I will try to soothe it. And some people soothe it with their own coping mechanism like alcohol, which can lead to, of course, more problems than health.

Not at all. On the contrary, we have a lot of research showing that the way that these individuals have been compensating across their lifespan with the severe ADHD symptoms, it's their intelligence. So, they have found ways. I can bring a clinical example of a person saying that, okay, I will always top a student. So, my question was, how did you manage it with your so short attention span? Well, I found the formula. I was studying like two hours before the exams.

I would memorize the book. This is also a sign of high intelligence. And I would take the exams, excel in it, and then forget everything about it. So, actually, sometimes the intelligence is higher than the average. They are on the lower percentile of a high intelligence as a way to compensate. So, I need to make it clear. ADHD is not a disability, a learning disability, or intellectual disability. It has nothing to do with the intellectual intelligence. It has to do only with the way that we cope with organization skills, the way we cope with memory skills, the way we cope with controlling our impulses.

People with ADHD may encounter issues with their attention, managing, organizing tasks. They can be hyperactive. As you said, they can take wrong decisions very impulsively. And also, their hyperactivity. I would like also to mention that, of course, the hyperactivity component, it's not the same across the lifespan. So, in kids, it's typical someone who cannot sit, go around, like spinning around. But in adults, it may present as an anxiety disorder. So, I hear often the sentence like, doctor, I feel like I have an inner motor going on inside, 24-7.

It's like the way they feel the noise in the head out of this kind of hyperactivity. So, of course, in adults, just to put in the previous question, how is it manifested in adults? Also, the anxiety disorder, it is a by-product of the hyperactivity of the condition.

Because dopamine is a very important neurotransmitter in many, many, many ways. And not only in ADHD, but in conditions like abuse, like gambling, like binge eating, where dopamine secretes, we have a feeling of euphoria. And when dopamine goes away, that feeling of euphoria goes away. So, we need, what people say, the constant seek of dopamine. What is happening in ADHD is that it has to do with how it is being signaled in different parts of the brain. So, what we do on the medical aspect of the big treatment approach of ADHD is using re-uptake inhibitors of both norepinephrine and dopamine, which they work in the certain brain regions, where they're either overactive or underactivated in ADHD.

And these medications are stimulants, which is the most common prescribed. And I will start with methylphenidate, which has been the oldest one. It's Concerta, the long-acting agent. and Ritalin, which is the short-acting agent. Since 2009, we have also lisdexamfetamine, which is a synthetic amphetamine. I don't want your audience, Dr Wafaa, to be scared. This is not an addictive medication, although it sounds scary. lisdexamfetamine, which goes by the name Elvanse, or in the U.S., Vyvanse. And finally, we have Adderall, which is a blend of six synthetic amphetamines, which is very common in the U.S., less in Europe.

Of course, these medications, what do they do? They help better the signalization and the transport of these two neurotransmitters in the brain regions that they have been affected by ADHD. And we see an enormous improvement in the areas that they have been affected by ADHD, like memory, like organization skills, like the hyperactivity, like impulsivity, and like having that constant noise on the head. People who respond to stimulants, they feel more concentrated. I get often a saying like, oh, this is how a normal brain feels like to have.

And they can feel the change within days. It doesn't take long before they start working. They have a totally different mechanism compared to antidepressants. We don't need three or four weeks of the concentration levels to be built, so we have a therapeutic response. The therapeutic response can be noticed within days. So it is a quick, fast, and very safe approach to ADHD management. But of course, I have to say, medication is not for everyone. And there is no one-size-fit or a quick fix for everything.

Some people may respond to Concerta. Some people may need to move over to lisdexamfetamine. Or some people may need to try Adderall. There are also some non-stimulants available. Less in UAE. More, of course, worldwide. We have Strattera, which is atomoxetine. It has been approved for the ADHD management in children. Not particularly helpful for adults. But some adults may find it extremely effective. We have also medication that they're not actually pure psychiatric ones. They are anti-hypertensive, like guanfacine and clonidine, that have been tried and have been used for children's ADHD, especially for those who have extreme hyperactivity at nighttime.

So it can help enormously with sleep. Now, I believe that they have also received an indication for use in the adults. But I don't believe that it has been so beneficial.

As an adult psychiatrist, I tend to see individuals and patients from the age of 16 and above. And of course, the age of 16 is still considered to be minor legally in the UAE. So I have these questions a lot. I believe that you get these questions more often than me. Well, this also stems from the fact that there is a lot of stigma about mental health, psychiatry, psychiatric medication in the region. So the prejudice comes from the feeling that these medications are addictive.

No, they're not. We can stop ADHD medication anytime. They don't give any discontinuation symptoms. They don't induce any withdrawal. We don't experience any problems apart from having the ADHD symptoms flourishing once again back. So we have not a risk for addiction. Now there is also parents, and I came across in my career with a few of them that they have been extremely persistent that, no, I would like to have a more naturalistic approach for my child. Well, here we have the ethical dilemma as physicians, which one is to be treated with medication.

For example, when we have a severe case of ADHD, let's imagine a kid that he or she is 10 and cannot sit still for a second and causes a lot of problems, and the parents are exhausted by parenting, he cannot sleep, the kid should be on medication. This is de facto, because it will cause more problems, not only to the child, but to the surroundings. When we have a mild case of ADHD, where there is an overcompensation with extreme studies, maybe the medication will not be the first solution, it will be the last solution, and other approaches should be preferred.

For example, making sure that the school provides time for submitting the assignments, or extra time for the exams, or when the kid will be at home studying, that the mom or dad will make sure that the kid will have a break every two hours in between the studies, instead of being distracted. So, every case is unique, but when there is a decision about medication, what should be given would be a professional approach about the nature of the medication, the safety of the medication, and what to expect out of the medication.

And of course, there is also a number of parents that they want medication right away for the children, even if we have a mild case of ADHD, and then we have to fight towards persuading against that. This is not the first option, we will use it maybe later on.

If only Dr Wafaa, I got a penny every time I got this question, I would be a billionaire in Dubai. This is a very common question, and I get it a lot. In the sense that people, when they are being on medication and feeling good, on the next appointment, or after the next appointment, they come and ask me exactly the same. So, doctor, what do you think? Will I need to be on this medication forever? Well, here, there is not a solid answer.

There are individuals that they cannot function without stimulants. Their life turns upside down to the best with medication, so they are not willing to give that up during, especially their productive years. And the productive years is, let's say, from the age of 25 until 55, or later on. Of course, there are situations where the individual learns to cope with the ADHD symptoms, so the need for medication is a little less frequent. For example, someone may choose to use stimulants only Monday to Friday when at work, and making a stop during the weekends, or having the stimulants only on specific days when there is a lot of tasks or a heavy load.

And this can also be the case. And there are some people that they feel so confident in their medication. They feel that the ADHD has been stopping them from reaching their full potential, that they have improved on many levels, family-wise, career-wise, personal-wise, and relationship-wise, that they don't want to give up on the medication. Of course, as a treating psychiatrist to many, many patients in Dubai with ADHD, I always encourage an open discussion with my patients. I mean, what is the goal here?

What are we aiming for? And, of course, there are cases where during holidays, for example, I encourage individuals to stop the medication. You're not at your work. You're not going to give a report to your boss. You don't need to meet deadlines. You're going to be in the Maldives and seeing the sunset. So stop the medication. We'll see a little bit how things will go. Now, to answer the initial question, some individuals may need to be on medication lifelong, but I think this will be a minority, a small amount of patients.

Usually, there is need during the hard period in life, let's say, university, let's say, the last years in school, let's say, when there is an extra demand on a very high-end level job, but after a while, the individual under the closed monitoring and the advice of the psychiatrist may make an attempt to end or discontinue and see how it goes.

Correct.

Well, we're moving a little bit to other approaches when it comes to ADHD management, apart from medication. Yes, apart from medication. And, of course, I need to point out the fact that an individual with ADHD, what is the most common in this group of people is the lack of routines. So diet is one of a routine that needs to be there. When I talk about diet, we have a lot of research showing that individuals with ADHD, they tend to junk food and more to processed food compared to a healthier lifestyle.

This is like firing a big box with explosives. Why? Because processed food and especially junk food, like pizzas and burgers, they can cause inflammatory process in the gut, which can worsen the ADHD symptoms. You mentioned sugar. Sugar is the enemy number two. Why? Because sugar makes us jittery. It makes us hyperactive. It worsens definitely the ADHD symptoms. Imagine a child being eight or nine and having like an already hyperactive type of ADHD and eating one kilo of candies. That person will not sleep for two days.

So what I advise, and also we need to mention that we tend to see a lot of sugar cravings and binge eating disorder in individuals with ADHD. And once the medication, let's say that these individuals are on medication, they respond to medication, then the cravings for sugar, they go down, they almost subside, and also they need for the junk food. having said that, it is also a constant struggle to be aware that a balanced diet not only will help with the ADHD syndrome, but with the general well-being.

For example, here in Dubai, we have a plethora of vegetables and fruits, but people tend, for example, to order and tend to take out and don't indulge fast food, of course. A diet based on good carbs, like quinoa, or like amaranth, instead of like bread or processed food. And diet rich in fish, like salmon, and here it comes, the omega-3.

Because these fish, like salmon, sardines, they contain a lot of omega-3, which have the good fatty acids that they provide the brain with extra armor and resilience. It's not like they will cure the ADHD symptoms, but it will make the concentration better, it will help with the resilience, and it will also help with the management of coping with the challenges better. And this does not apply only to individuals with ADHD, also to normal people with no ADHD.

Yes, we'll come to that. Another important...

And the mood, definitely. Another important aspect that we tend to neglect is the sleep regulation. People with ADHD, they do not sleep.

And the sleep...

Which is very important, and we have the challenges of regulating the sleep. Of course, this does not start in the adulthood. Kids with ADHD, they have a hard time sleeping. Parents get exhausted. They cannot be persuaded to sleep. And this is where melatonin can also be helpful, which is our own body-sleeping hormone, which can be extremely helpful in many cases. Another important aspect in management ADHD is the regular exercise. Because imagine an individual that grounds and bottles up a lot of energy and a lot of hyperactivity.

Lashing out on the gym is a great way to manage the hyperactivity, boost the concentration, and also improve and generate and general well-being for the general mood.

And of course, we cannot also forget that it's very important for some individuals to complete the medical treatment with therapy, in that case cognitive behavioral therapy in order to develop their own techniques and skills in order to improve their time management, their organization in tasks and also the forgetfulness. So, CBT focused on the ADHD symptoms can also prove extremely efficient. Of course, there is also a prejudice here and people think either or. Either I do medication or I do therapy. Or there are people that they have had their assessment without consulting with a psychiatrist first.

And of course, the psychologist who did the assessment may a little bit point out the importance of therapy compared to medication. I need also to draw the line here that there is no antagonism between medication and therapy. It should be a synergy. So, we have research showing that the people that they enjoy the longer lasting effects on managing ADHD and other conditions is combining medical treatment with psychotherapy. Psychotherapy in ADHD can be extremely helpful where there is a good response on medication but still the individual may find it hard to organize his time.

So, CBT can be helpful in order to create a pattern like reminders like a specific type of approaching in order to improve the medical the time management which is important for sustaining his work for example or his interpersonal relationship and all of that.

Excellent. This is a very nice question, because I think that the lack in focus can affect all of us at any point in our life, more or less, without necessarily having or meeting the clinical criteria for a condition. So it can happen out of a bad night sleep that we cannot be focused the next day. It can happen to all of us. It can happen that after a very heavy alcohol consumption we may not be focused the next day. It may happen, if we eat a particular type of food which is not necessarily healthy, that we notice that day after day our focus is going down.

So the tips that I would give, the advice to individuals in order to boost, and the most important, not only boost, maintain their concentration, leading to better results, and also the creativity that you mentioned, Dr Wafaa, is the absolutely need for routines. And we are in a very fast paced city. Dubai is the land of promises and fast paced and a lot of opportunities, but we need to forget that we are programmed as human beings to have certain routines. For example, the 7 to 8 hours of sleep is extremely important.

I get that question a lot. I get the question like, what are you talking about, doctor? I sleep like 4 hours per day, I'm so busy. I mean, if you continue sleeping, having only 4 hours of sleep, you will end up being depressed and [inaudible] in 2 or 3 months from now. So I don't mean to be scared with my patients, but I need somehow to promote the idea that things that we have learned 30, 40, 50 years ago, they do not necessarily apply for people in Dubai.

We don't have superpowers in Dubai because the city is fast paced. We still need our 7-8 hours of sleep. We need to have a proper qualitative sleep, with the right temperature, the right mattress, and also making sure that we don't have a heavy meal like one hour before going to bed. So sleep is important, that we need to track. Maybe there are some underlying conditions: we may have sleeping apnea problem, which also results in sleep deprivation, resulting to our focus, and we need to check on that.

Apart from that, we need to take care of our diet. There we have, we know for sure, that there is food that can boost our concentration: flavonoids that we can find in berries, like blueberries or raspberries, or omega-3, as you mentioned, and supplements like zinc can help also with the concentration, magnesium if there is a deficiency to that, of course vitamin D, which can also lead to exhaustion if we have vitamin D deficiency. So all of these small tips, and maybe exercise, and also avoidance as much as possible of processed food.

Maybe I sound pedantic, but I'm not. Everyone will have the cheat day during the week, but it's important not to replace a healthy lifestyle, when it comes to diet, with processed food or with only takeout and all of that, because we need to be in control of what we're eating, and only us can do that.

First of all, thank you, Dr Wafaa, once again for having me here and also giving me the opportunity to bring some insight about ADHD, which is as common as affecting 5 to 10% of the general population. We need to understand that ADHD is not a choice. So the children that they are suffering with being distracted, when they have hard time sharing or taking turns or listening or picking up on social cues when they are with their peers, it's not their choice.

They're often labeled as the troublemakers. They're often labeled as the lazy ones. They're often labeled as, what is typical in school reports, oh, you can do so much better if you can focus a little bit more. But what parents should understand is that these children do not choose to be like that. It is the ADHD problem, not their own problem. So once they notice that there is maybe something that their child struggles with, that they need to refer the child to a mental health professional for what I call a mental check-up, like we go to our GP to have our blood test done.

And also during this process, what is important for the parents are to show support, understanding and a great deal of patience. Thank you so much, Dr Wafaa, for having me here.