Mental Health and Medication with Dr. Alain Katic

Mental Health and Medication with Dr. Alain Katic

Dr. Alain Katic of Houston Clinical Trials joins us to answer parents' and professionals' questions about mental health and medication. He discusses how to tell if a medication is working, how long it takes to see changes, and provides information on side effects parents may see with certain medications. Many questions asked are related specifically to children who have speech, language and sensory processing difficulties. In addition, Dr. Katic provides background information on many common medications, including those used to treat ADHD, and gives a variety of parent resources for those seeking more information. This episode is recorded from a live virtual adult education session hosted by The Parish School in Houston, TX.

About Alain Katic, MD

Dr. Katic is a Clinical Assistant Professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. He has an extensive background in psychopharmacology, autism, major depressive disorder, schizophrenia, migraines in children and adolescents, adolescent and adult ADHD, and bipolar 1 depression. He has served as Medical Director for numerous hospitals and treatment facilities, including Houston Clinical Trials, where he currently serves as President and Medical Director. Dr. Katic and his research have been successfully published in reputable scientific journals and presented at scientific meetings.

For over 17 years, Dr. Katic has served as a principal and sub-investigator on over 200 Phase I-IV clinical trials in adult, adolescent and child psychiatry. As a principal investigator, he has conducted clinical trials for a comprehensive spectrum of indications, including ADHD, major depressive disorder, bipolar disorder, anxiety disorder, schizophrenia, sleep disorders and substance abuse.

Related Links:

Houston Clinical Trials website: Houston Clinical Trials

Stephanie Landis (00:06):

Hello, and welcome to Unbabbled. A podcast that navigates the world of special education, communication, delays, and learning differences. We are your hosts, Stephanie Landis and Meredith Krimmel, and we're certified speech-language pathologists who spend our days at The Parish School in Houston, helping children find their voices and connect with the world around them. This episode is a bit different from our normal format. Instead of an interview, we're bringing you a recording from a live virtual Q and A on mental health and medication with Dr. Alain Katic hosted by The Parish School. Dr. Katic is the president and medical director of Houston Clinical Trials, where he conducts clinical research and treats adults, adolescents, and children with psychiatric disorders. He has an extensive background in psychopharmacology and mental health disorders, including autism, major depressive disorder, schizophrenia, migraines, attention deficit hyperactivity disorder, and anxiety disorder. Dr. Katic and his research have been successfully published in reputable, scientific journals and presented at scientific meetings. Throughout the episode, Dr. Katic answers parent and professional questions, including how to tell if the medication is working, how long it takes to see changes and gives more information on side effects parents may see with medications. Many questions asked are related specifically to children with speech, language and sensory processing difficulties. In addition to answering questions, he also provides background information on many common medications, including those used to treat ADHD and gives a variety of resources for parents seeking more information.

Amy Lerman (01:39):

Good evening, everyone. Thank you so much for being here. My name is Amy Lerman and my role is community outreach on behalf of The Parish School. We are eager to begin the Q and A with our special guest, Dr. Katic and we are so honored to have you join us this evening. Once we get started, please feel free to wave us down and we'll go ahead and ask you to unmute yourself to directly ask your question to Dr. Katic. Of course, another option is to type your question into the chat and that way it can be read by either myself, Meredith Krimmel or Stephanie Landis. Okay, without further ado, I am so pleased to introduce Dr. Katic. Dr. Katic has an extensive background in psychopharmacology, autism, major depressive disorder, schizophrenia, migraines in children and adolescents, adolescent and adult attention deficit hyperactivity disorder and bipolar one depression. He served as medical director for numerous hospitals and treatment facilities, including Houston Clinical Trials, where he currently serves as president and medical director. Dr. Katic and his research had been successfully published in reputable, scientific journals and presented at scientific meetings. Thank you, Dr. Katic for being here this evening and I'll let you take it away.

Dr. Alain Katic (03:10):

Super. Well, thank you, thank you very much for inviting me. It's a little unusual to do this. In the past, I've always been able to see my audience. What I thought I would do, because I do tend to like to have these be free flowing open-ended conversation. This media may be a bit challenging, but what I'm going to do is start off just with a sort of quick little primer in essence of a child psychopharmacology, some of the main conditions that we treat, the medications that we use. And then really after that, we'd like to open it up to questions and try and can answer as many questions as I can. So I think a good place to start is with ADHD. And the reason I would start with ADHD is because it is the most common psychiatric disorder that we see in children.

Dr. Alain Katic (04:01):

Um, most studies tend to show about a 10% prevalence in the population as a whole. Some are a little higher, some are a little lower, but 10% in general of children who have ADHD or meet criteria for an ADHD diagnosis. And that also actually progresses into adulthood though about 50% of folks grow out of their ADHD. And so by the time you get to adulthood, the prevalence rates tend to drop into the 4 to 5% range. But ADHD again is the most common psychiatric disorder in children and diving into the medications that are used to treat ADHD. There are basically two main categories. What I consider and I take that most professionals have considered the gold standard are the stimulant medications. And they're the gold standard because they are frankly the most effective medications. They are actually some of the most effective medications in medicine as a whole. They're very, very effective.

Dr. Alain Katic (04:57):

Second category would be the non-stimulant medications. Um, I'll actually start with those first because there's fewer of them. The non-stimulants that are currently approved by the FDA are three medications. One is a drug called Strattera, and the other two are similar to each other and that they're old high blood pressure medications. Um, one called Intuniv, or the generic is guanfacine, and the other Clonidine or sorry, Kapvay and the generic being Clonidine. Uh, the reason the stimulants are the gold standard is frankly, the non-stimulants are less effective than the stimulants as a whole. They do have a different side effect profile than the stimulants so sometimes for some patients that can be preferred. But besides being less effective, they also take time to work. So these are medications that you have to take for at least several weeks before they really begin to kick in. With Straterra, taking sometimes upwards of three to six weeks to reach full effect.

Dr. Alain Katic (06:05):

So, if, you know, your child or yourself is going to be taking a non-stimulant, you definitely gotta give it a chance and don't expect an immediate response or improvement in your symptoms. Um, now moving to the stimulant category there are, I believe at this point 30 different formulations of stimulants that have been approved. But basically what you're looking at within the stimulant category are two main categories. One being Ritalin-based medications and the other being amphetamine-based medications. And so some of the Ritalin-based medications that you might have heard of are things like Concerta, Focalin. There are some of the newer ones, Adhansia. There's actually the first ever approved stimulant given at night time, a drug by the name of Jornay PM that is dosed at eight or nine o'clock in the evening, but does not begin to release medication until about 10 hours later. So about 6:00 AM the next morning.

Dr. Alain Katic (07:17):

And all of these and then on the, sorry, on the amphetamine side, you have Adderall, which people are very familiar with at least the name and then Vyvanse. There are a few other, those are the two long-acting amphetamine-based medications. There are some short acting ones that you may have heard of like Evekeo. But again, those are your two major categories. Studies have shown and it's frankly been my clinical experience that all stimulants are equally effective. The amphetamines are not better than Ritalin. There isn't a particular drug that is better for inattentive ADHD, or hyperactive. They are all equally effective. They all do also share the same side effects, the most common ones being decreased appetite and insomnia. Insomnia tends to improve, but unfortunately in children, decreased appetite tends to be a persistent and problematic side effect.

Dr. Alain Katic (08:18):

All stimulants basically last three to four hours and thus, they are packaged into these long-acting forms, such as Vyvanse, a long acting version of dextroamphetamine to try and create a single dose medication that can last anywhere from eight hours being the shortest of the long actings that would be Ritalin LA, Vyvanse, the dextroamphetamine-based medication I mentioned can lasts 12 to 13 hours. Some of the newer ones claim to last, even longer than that. There's a drug, Mydayis, which is a long acting version of Adderall XR that may last up to 14, maybe even up to 16 hours. But really trying to again, create a single dose medication so that you know, children aren't having to line up at the nurse's office or for adults, that they're not in the middle of a meeting and their short acting has worn off, and now they're without medication.

Dr. Alain Katic (09:14):

So again, ease of administration and maintaining efficacy throughout the day. That's the ADHD category. There are some off-label medications that physicians will use that can include an antidepressant, Wellbutrin. There are also some pro wakefulness drugs that you may have heard of like Provigil or Nuvigil, that have some data indicating against some efficacy in ADHD, but again, less effective than the stimulants. I will throw out one other category in terms of some of the natural treatments, if you want to call them that for ADHD. Um, and there is data showing that Omega-3 fatty acids have some effect in improving ADHD symptoms. Unfortunately, the problem really becomes, as you're moving down from stimulants to non-stimulants, you're losing, and as you move down to Omega-3 fatty acids, you're really getting down to not very powerful effects at all.

Dr. Alain Katic (10:20):

So that's ADHD treatment in a nutshell. Then I thought what I'd like to do is move on to another large category that we see in children and most definitely in adults, depression and anxiety. And the reason I'm going to clump those two together is because the treatments are very similar. Focusing on children because I'm a child and adolescent psychiatrist, there are currently two approved medications for the treatment of depression in kids and that is Prozac and Lexapro. Those two belong to a class of drugs known as SSRIs or Selective Serotonin Reuptake Inhibitors that is believed to be one of their primary mechanisms of action in childhood anxiety disorders. There are three drugs that are approved by the FDA, and that's specifically for OCD and those three drugs are Prozac again, Zoloft and Luvox. Again, all three being SSRIs.

Dr. Alain Katic (11:28):

So sharing the same basic mechanism of action in inhibiting the reuptake of serotonin in the central nervous system. Now, when you look at, adult depression and adult anxiety disorders, there's a much larger group of these SSRI medications. So for instance, things like Paxil that you may have heard of, newer ones like Trintellix, Viibryd. So again, but mostly all of those have, again, this common mechanism of action. One group of medications with a slightly different mechanism, which are known as SNRI, Serotonin Norepinephrine Reuptake Inhibitors, again, approved for either the treatment of depression or various and or various anxiety disorders. And those drugs would include medications such as Cymbalta, Effexor, Pristiq. Now, none of those have ever been approved in children.

Dr. Alain Katic (12:35):

Some of them have done studies. I was involved in a number of those studies. So for instance, using Cymbalta as an example, Cymbalta was unfortunately not able to separate from placebo in an adolescent depression trial. But what was interesting about that trial was that there was a comparator drug. So basically you had Cymbalta, Prozac and placebo. And Prozac, which I mentioned previously as having been FDA approved, actually failed to separate from placebo in the Cymbalta, Prozac, placebo study. So it can be difficult to demonstrate efficacy for these medications in children and people argue and scratch their heads over why that is, and, and there's all sorts of theories. But again, so there's a very limited number of medications that are approved by the FDA. It doesn't mean that physicians don't use other off-label medications in children and that's not unreasonable, particularly if one has exhausted the currently approved therapies.

Dr. Alain Katic (13:52):

So that's depression and anxiety disorders again in a nutshell. And then, the last major group. I was not going to focus on psychotic disorders or schizophrenia this evening. But more, looking at it again, conditions that one might encounter in children. So the last major sort of grouping, and it's not so much that these disorders, have similarities to each other, but the similarity being the medications that are used to treat them. And that would be bipolar disorder and then autism spectrum or autism disorders. And basically, the common medications that are used to treat those two conditions are what are commonly referred to as atypical anti-psychotics or sometimes known as mood-stabilizing medications. And so in bipolar disorder in children. Excuse me. There's a number of different medications, such as Zyprexa, Risperdal, Seroquel, Abilify and others that have been approved. And several of those medications, again, such as Risperdol, Zyprexa and Abilify, had been approved for the treatment of symptoms associated with autism. All of those medications, again, share a similar mechanism of action, namely, blocking dopamine receptors in the central nervous system. So that is their commonly shared mechanism of action. And, you know, with that, I thought I'd go ahead and start to take some questions and trying to drill down to more specifics as people ask questions.

Amy Lerman (15:46):

Thank you so much, Dr. Katic. Yes, we do have one question that was sent in ahead of time. Thank you very much. And the question is, are stimulants a safe way to treat six-year-olds for ADHD? What if their behavior becomes outrageous? Do you quit taking the stimulant or do their bodies need time to adjust to the medication?

Dr. Alain Katic (16:11):

So, was that the question? Yeah. So stimulants are a reasonable approach in treating six-year-olds and most, well, actually all of the stimulants are approved for six and above. And so there is data from studies indicating efficacy in children that young and just so you know, the FDA actually has requested in a number of studies being done by various pharma companies in children, four and five years of age and that data will be coming out over the next few years. So stimulants, again, are approved. As I mentioned earlier, they are the gold standard in terms of altering a child's behavior in a negative manner that can occur. You can see children become more moody, irritable, weepy, and that can occur sometimes on the medication and by on the medication. I mean the duration of the drug. So let's just say a child is on an eight hour long acting stimulant. You could see potentially during those eight hours more commonly, what one tends to see is that that kind of moodiness or irritability will occur as the medication is wearing off sometimes known as a rebound or where the child actually is, again, more moody, irritable, possibly more hyper and that typically wanes after 30, 60, maybe 90 minutes. Is it reasonable to hang in there? It is, because clinically what one sees and what studies show is you'll tend to get the most side effects in the first week. And they will tend to peak, and they do tend to abate over time. Except for the one that I mentioned at the start, appetite suppression. Unfortunately, appetite suppression tends to simply be a persistent side effect in children.

Dr. Alain Katic (18:09):

Um, I can't remember all the details of the question, but one of the things I'll say also one of the nice things about stimulants is that they do give you quick answers. And so literally you will be able to tell within a day or two, depending on the dose that's chosen, to maybe a week as one is possibly increasing the dose, if it is an effective medication. But the other nice thing about it is, if it's not effective, where it's causing problematic side effects. If you don't give a stimulant the next day, it's gone. So you can literally be in and out of a trial of a medication within a day, two or three. And so unlike some other medications where, you know, if you've taken it for a week and you stop it, it's gonna take a week or so to get out of your system.

Dr. Alain Katic (19:02):

That is simply not true with stimulants. So that's one of their advantages, possibly. But it's also one of their disadvantages because if you don't take it the next day, that doesn't work obviously. But, so sometimes I'll describe them to families as, you know, giving us a quick answer. Yay or nay. And if it's yay, we hang on to it. If it's nay, you can stop it and move on. And one of the things I'll just go back to sort of my summary on ADHD that I do want to mention. I said that all of the stimulants are equally effective. They do all share the same side effects. It's not uncommon also for patients to try multiple stimulants. And so if your child did not do well on say Focalin, and it had some problematic side effects, it's not unreasonable to try another stimulant. Because though they share the same side effects, you may not get the same side effects and you may find and actually my experience is that many patients will choose their final stimulant based on not efficacy. Not that that was better, work better than this one, but on side effects. I was in a better mood on that one. I slept better on this one. I had a better appetite. Those are often the factors that drive which medication a person ends up taking over the long term.

Amy Lerman (20:16):

And that's a really helpful answer because what you ended up doing was answering quite a bit of the second part of this person's question, which was, is there a way to know which medication will work best for your child besides trial and error, and you really just spoke to that a lot.

Dr. Alain Katic (20:34):

Yeah. And unfortunately it really is trial and error, and it's a matter of picking a starting point. As I said again, there isn't a one drug that's better for inattention or hyperactivity. Different doctors have different, frankly, practice habits and they're all reasonable. I tend to start younger children on Ritalin-based medications. Ritalin is a slightly less potent stimulant than the amphetamines. And no, so I'm rationalizing that maybe they'll tolerate it better. But I do have many kids, young kids on amphetamine-based medications. So it's really a matter of picking your starting point and, you know, starting and seeing how it goes. The good news is, again, barring side effects, these are very effective medications and many kids will respond well to whichever medication they're placed on first and rapidly so.

Amy Lerman (21:31):

Wonderful. Next question. Would you ever prescribe a mood stabilizer with a stimulant or non-stimulant?

Dr. Alain Katic (21:39):

So, um, yeah, what you're touching on there is you know, what sometimes is referred to as polypharmacy. And polypharmacy really occurs generally because these conditions run together. So they are comorbid. So for instance, using ADHD, ADHD commonly runs with anxiety disorders. It can commonly run with depression. It can commonly run with bipolar disorder. And so it's not uncommon to have to use two different medications to, in essence, treat two different conditions. So a stimulant or a non-stimulant for the ADHD, and then a mood stabilizing medication possibly for bipolar disorder or for a child who's on the autism spectrum to manage some other mood symptoms or behavioral issues that the stimulant simply can't address, because its main target, frankly, is ADHD symptomatology. It may be worth going back and re-exploring medications. I've seen many times where patients respond to something, maybe lose their response and you go back to it again at some later date.

Dr. Alain Katic (22:53):

Well, again, and then the other thing that I would just say, you know, you mentioned at the end that he hadn't been on stimulants in a long time. It may be worth reconsidering that. I've seen many times where young children, you know, five, six years of age, don't tolerate the stimulants as well. Three or four years later, they respond much, much better. You know, your brain is developing. Things are coming online. If you want to think that way. And again, a child may do well on a medication at a later date that they did not do well. And as I said earlier, one of the nice things about stimulants, they give you a quick answer. You will know pretty quickly, you know, is this a good move or not

Amy Lerman (23:40):

Another question that we've got here is how often do you recommend taking your child off medication for a trial period? This to determine if they can achieve success off medication.

Dr. Alain Katic (23:53):

Yeah. it's a good, great question. Let's break it down in terms of some of the diagnoses that I've gone over. So, ADHD, as I said earlier, it does get better as you get older and 50% of children who meet criteria in childhood do not by the time they get to adulthood. It's not unreasonable, in my opinion, to do trials off of medications for ADHD potentially. And what one is looking for is, you know, as you come off of the medication, do the symptoms manifest themselves again, whether it be behaviorally, academically, a combination of both. And if they do, well, then, okay, it's not the time to stop the medications. One goes back on them. Now it gets a little more tricky if you start to look at things like depression and anxiety. Anxiety disorders unfortunately do tend to be chronic.

Dr. Alain Katic (24:50):

They do wax and they wane, but they don't generally go away. And so many patients once they respond to, let's just use Prozac as an example, they may take it for many years. Again, not unreasonable as that child is aging to consider possibly coming off of the medication. What I tend to do with my patients is I let the child know that they're in the driver's seat, cause they have to be comfortable to come off the medication and if they want to do so, then we gradually taper down over a period of several months, possibly. And what we're looking at as we're coming down on the medication is again, does the anxiety recur? If so, is it less severe? Can you treat it with therapy or is it, again, bad? Do we need to go back on medications. Again, not unreasonable. Depression, unfortunately, there just isn't really good systematic data in terms of what to do there. In adults, the recommendations for first episode to treat for at least a year. For recurrent episodes of depression to treat for longer periods. In kids, we, again just really don't have good data.

Dr. Alain Katic (26:02):

So what I find myself doing is taking the adult paradigm and applying it to kids. And so again, I would generally recommend treating a child with depression for at least a year. If one achieves a response on the medication and then, again, possibly coming off and seeing how it goes, but you know, cautiously monitoring of symptoms, recur, resuming medication. For conditions like bipolar disorder and again, the autism spectrum disorder, you know, those symptoms tend to be more persistent. And unfortunately you're looking at probably more chronic and longer term treatment of medications. You know, it's not unreasonable. Possibly as children are developing, say some of their outbursts as we were talking a minute ago, are subsiding. Do they need, you know, as many medications or that high of a dose? You know, again, I think it really needs to be done systematically with a plan of how to take her off the medications. With the stimulants, you just stop those, but with the others, systematically, gradually tapering and carefully observing for any recurrence. And if so having a plan, you know, to resume medication or what to do next,

Amy Lerman (27:22):

Thank you. Another parent was curious to know whether there are particular behaviors that Abilify is more effective at treating than Risperidone? And whether Abilify can be given in addition to Risperidone.

Dr. Alain Katic (27:40):

It can. That's not the preferred modality. It's really, you know, one tries to stay away from combinations of atypical anti-psychotics if possible. And I mean, that being said, I do have a small subset of patients where that just seems to be what works best for them. You know, your concern with multiple agents of that sort is frankly, that you're stacking the deck in essence from a side effect standpoint. So, but they can be used together. Now, you know, is one again, better than another for certain symptoms? Uh, no, that just, you know. I mean, I think doctors at times have a sort of ideas in their head about what may work a little better for this or that based on their own experience. But is there research data that clearly indicates that this drug is better for depressive symptoms or anxiety symptoms? No, there just simply isn't. And when you look at it, I mean, if you bothered to read the studies that the FDA approves these drugs on. What they tend to show is that these drugs are effective across the spectrum of symptoms. Okay. So whatever the depression symptoms are for an antidepressant or whatever the ADHD symptoms are against the inattentive and hyperactive symptoms, these drugs work equally well across the spectrum of that disorder symptoms.

Amy Lerman (29:11):

At what point or age do you determine when you should check for ADHD or anxiety disorders for a child that is on the spectrum?

Dr. Alain Katic (29:21):

Oh, gosh. Yeah, that's a tough one. I don't know that there's a particular age that one is looking at. It really, it tends to either sort of manifest itself or it doesn't really. And then, you know, it's unlikely that you're going to be looking at a lot of that prior to the age of say four or five. As a child is progressing into school, ADHD symptoms...not that they become more prevalent or more, uh, they become more problematic in essence. It's not that they're getting worse, but because of the demands that are being placed on the child. One can also see anxiety symptoms begin to develop in children as they get into either sort of pre-teen years or early adolescents. Though anxiety symptoms can also manifest themselves in young children, four or five, six years of age. So it's, um, that's a hard question to answer in terms of when to look for? At what age to look for these symptoms emerging?

Amy Lerman (30:27):

Okay. Thank you. Uh, the next question says, would you recommend trying a different extended release stimulant if your child is on one, but still needs booster doses throughout the day. Increasing the extended release morning dose cause irritability.

Dr. Alain Katic (30:45):

Yeah, so a couple of things. Yes, I think it's reasonable to look at other extended release medications. You know, there are some of the newer ones, for instance, I'm not sure if your child is on a Ritalin-based one, but Adhansia, which is a new Ritalin-based stimulant that possibly can last up to 14 hours from a single dose and may not require as, you know, extra or booster doses later in the day. But there is also a subset of children who simply seem to go through long acting stimulants faster than one would expect and where you are having to use booster doses. But it's absolutely reasonable to try and switch to other long-acting stimulants and see if you can get a better fit because it can occur. And again, as I said earlier, these give you quick answers. You will literally know within a few days to a week or two, if you've made the right decision.

Amy Lerman (31:50):

How do stimulants typically affect someone with ADHD that also has high-functioning autism and acute hearing sensitivity and high anxiety?

Dr. Alain Katic (32:03):

Well, that's, that's a good question. Uh, let me take a first pass at it this way. When you look at one of the challenges in treating patients with autism is that they present with a number of other symptoms. ADHD-type symptoms, anxiety symptoms, mood symptoms. But when you look at treatment with medications and when you look at what studies have shown, their response to those treatments is often not as robust as one sees in the original conditions. Let me give you an example. Trying to treat ADHD in a patient with autism. Um, many studies. Well, let me back up. If you look at ADHD treatment with stimulants in most studies will show 80 to 90% efficacy or very powerful efficacy. In patients with autism, the response rates dropped to 30 to 50%. Okay. So why is that?

Dr. Alain Katic (33:07):

Well, in my opinion, it's because ADHD and autism is different than ADHD without autism. And so it gets more complicated. And then, you know, you touched on the other sorts of issues in terms of hypersensitivity to sounds and anxiety. So that's where you then end up looking at combination of medication treatments, but also need to realize that the responses that you're going to get from these treatments may not be as robust as one would like. Another example, being in patients on the autism spectrum, they present with OCD like symptoms. And I stress the "like", because those studies have shown that Prozac, which is approved in OCD are effective, it's not going to be as effective, unfortunately, as in a patient who just has OCD without the autism spectrum. And not to try to dissuade you. It's again, reasonable to try and you may see a response and sometimes you might see really a robust response, but you also have to prepare yourself for, you know, how much has this helped? What are the side effects? Is it worth holding onto this medication? Is it providing enough benefit to warrant its ongoing use?

Amy Lerman (34:32):

We have one here that says, do you believe that genetic testing is an effective way to find the best starting point?

Dr. Alain Katic (34:42):

I'm smiling because I really wish it was. So here's, here's my take on that. The mom earlier mentioned Genomind, there's a number of companies, GeneSight. And the problem with those is that the science has gotten ahead of the clinical studies. And so these gene tests, basically what they're looking at are what are called cytochrome P450 enzymes. So these are enzymes in your liver that metabolize medications. And we do know which drugs go through which enzyme systems. These gene tests show on these various enzymes are you a normal metabolizer or a slow metabolizer or a fast metabolizer, and thus one can figure out how that might affect the blood level of the medication that goes through that pathway. They then also look at a number of the neurotransmitter transporter genes. And what is your profile on those various genes?

Dr. Alain Katic (35:43):

Now here's the lead. They then try to make guesses as to what your profile on that neurotransmitter transporter gene might mean in terms of your response to a medication, and then combine it with the enzyme data and then create these algorithms. This might be a better medication, that might be a better medication. GeneSight did depression trials in adults, and they did show that if you picked the better drug, you had a two times higher response rate than if you pick a not so good drug that was in one of their studies. In another study, they failed to show that that was true. So the problem here is we're trying to get towards personalized medicine, but we're not there yet. More studies need to be done to understand how to use these tests and can they guide doctors. The way I tend to use them is in patients, who've had strange side effects and problematic responses to medications or who've been on multiple medications and seem to repeatedly fail—don't respond to those medications, in the hopes that, you know, might this test be able to guide my choices, narrow my choices towards better ones. But, you know, again, I think it's an interesting area. I hope it leads to better sort of decision trees for us, but it's still a little early to be able to say that we're there.

Amy Lerman (37:20):

Very good. Okay. Here's another one. Do you ever recommend nonmedical interventions before starting medication? If so, what do you frequently recommend?

Dr. Alain Katic (37:33):

So, in ADHD, in all honesty, no. I don't typically. There are some, I think the FDA recently approved a computer game, basically, that one can use to treat ADHD. There is neurofeedback, and studies have shown, you know, some efficacy in treating ADHD symptoms. But it's not something that I'm typically recommending as, uh, in lieu of medication or most definitely not as a first line if patients, sorry, parents and patients want to go down those paths. I don't think it's unreasonable. Now when it comes to anxiety disorders, yeah, there are many times where, depending on the severity of the symptoms, where I would recommend Cognitive Behavioral Therapy. CBT has been shown to be equally effective to medications. And in the long run, I think is actually more effective. Not in that they provide a better response, but what studies have shown and what you can see clinically is that meds, and CBT are equally effective in treating anxiety.

Dr. Alain Katic (38:47):

However, when you stop the medication, as I said earlier, anxiety disorders are chronic and many times the anxiety will come back. With CBT, patients, it takes them longer, frankly, for those symptoms to come back. So they sustain their response to CBT longer than they do to medications. And studies have actually shown that with CBT, you are literally causing changes in your brain that are similar to what medications do. So it's not just learning how to manage better. You are literally causing changes in how your brain is firing or functioning that correlates with what medications do. So again, that is a very powerful treatment and one that I definitely recommend whether by itself, before medications or even with medications,

Amy Lerman (39:36):

That's a very helpful answer, I know, for many of us parents and educators. Do you recommend giving weekends or summers off medication?

Dr. Alain Katic (39:47):

Um, so I think this question is specifically directed to ADHD medications cause the answer for the others would be no. Because again, antidepressants, antianxiety medicines, mood stabilizers, they can take time to work. You want to maintain their efficacy. If you come off, symptoms recurred and now you gotta wait weeks for it to show, for it to potentially work. With stimulants, you know, ADHD is always there and so treating it seven days a week is absolutely reasonable. Like any other condition, ADHD is a spectrum and by that, what I mean, there are patients who are more severely impaired and those who are less. And can patients come off of medications on the weekends/summers and do well even with their ADHD symptoms? Sure! You know, along the milder end of the ADHD spectrum. And then when they go back on their medication, when school starts or they go back to work, the response again is immediate. So I don't think it's unreasonable with stimulant medications to come on and of. Really, I tend to let families make that decision.

Amy Lerman (40:59):

Can I ask? Can I tag a question onto that though? Have you ever heard personally from children, who somehow internalize the change, and notice, you know, whether or not how it's affecting them? If they're able to recognize how it affects the people that they're with, whether or not they're getting reprimanded more and whether or not that affects their self-esteem?

Dr. Alain Katic (41:26):

Yes, most definitely. I mean, I have patients of mine who they simply prefer to stay on their medication seven days a week. They'll describe to me, I simply do better, and that can be from feeling calmer, less impulsive. And not only just impulsive in blurting out answers or, you know, running out into the street after a ball, but less impulsive in a mood or fashion. That they're less irritable, that their fuse is longer, as well as also, there's just that they're more, um, more efficient. Better able that, you know, completing household chores, et cetera. And so, I've most definitely had patients who've told me that, you know. But other patients, again, don't like how they feel on the medications. They want to be off of it, or, you know, in terms of one of the parts of your question, no, they're not aware of how their symptoms affect others and aren't aware necessarily of how that feedback that they're getting maybe negatively affecting them in terms of getting in trouble or getting reprimanded. Yeah.

Amy Lerman (42:37):

Right. Thank you very much. How do stimulant medications affect someone with ADHD and sensory processing disorder?

Dr. Alain Katic (42:47):

Well, that's a tough question in that there isn't a good blanket answer to it. In all honesty, there's a very good chance that patient can do quite well on ADHD medications and that you won't get in any sort of exacerbation of their sensory processing disorder. Um, is it possible that you could see some worsening of those symptoms, you know, a heightened sensitivity? It is possible, but I would not allow it to dissuade me from trying a trial of a medication and I'm thinking of a stimulant, if the ADHD symptoms are clearly causing, you know, functional interference.

Meredith Krimmel (43:33):

I have a question. Do you find that anxiety and ADHD present similarly in young children?

Dr. Alain Katic (43:39):

You know, that's a good question. It's a tough one. There's definitely an overlap for some patients and, you know, what? So yes and no. ADHD, you know, again, the core symptoms are inattention and hyperactivity, daydreaming, restlessness, et cetera. Now, anxiety, depending on the types of anxiety that you're talking about, can it interfere with your attention? Sure, it can. And so there can be that interplay. But the other thing that you also see sometimes kids with ADHD can, again, have that short fuse, be irritable, right? And maybe a little explosive, but that can also be driven by anxiety, you know. And if you're sort of anxious or say you're obsessive, and someone's interfering with your obsession, you might sort of, you know, get a little angry, right? And so, there's definitely an interplay that can occur there. I hope I answered your question.

Meredith Krimmel (44:39):

You did. And like, on top of that, at what point do you think if a parent suspects their child might have ADHD or anxiety, at what point do you usually recommend looking into assessment and treatment options?

Dr. Alain Katic (44:50):

Well, you know, again, if it's interfering, then you most definitely should look into assessment. Whether that be, you know, psychological testing, educational assessment, try to rule out learning disabilities, but also look at learning differences, but also look at, you know, the possibility of ADHD symptoms. And, you know, typically again...Well, typically many times, you know, this can be as young as six, seven years of age. At other times, if the symptoms are more mild, you can see patients, you know, not present until they're, you know, later elementary or early middle school. You know, it's a common entry points to just using ADHD as an example, you know. You have the sort of pre-kindergartener and those are the really hyperactive kids who are, you know, sort of disruptive than the others who may be making until about third grade. And now, again, in third grade, you know, the academic demands begin to increase a bit and children start to falter middle school. You have now six, seven teachers. How are you going to stay organized, keep up with your work, high school, you know, some make it all the way to college before they're diagnosed.

Amy Lerman (45:58):

Question. Does reducing or eliminating food dyes or sugar have any clinically significant benefit in treating ADHD?

Dr. Alain Katic (46:07):

Yeah, unfortunately that has not been my experience that that's necessarily the case. At least not in a large percentage of patients. If it is, it might be in a very small percentage of patients. It's, uh, nobody has asked the CBD question tonight? But I think it's sort of in that similar sort of vein, and what I'm saying by that is if you think that that might be an issue, or you think that CBD could possibly work for some set of symptoms, do a study. And by that, what I mean is eliminate the dye and see if there's clearly a change. And if so, fantastic, you continue to eliminate it. If there isn't, okay, that's fine. Move on. Likewise with CBD, you know, you have your set of symptoms that you're trying to treat. There simply aren't enough studies out there to really warrant this, but look safe, do a study. These are the symptoms I want to see improve. If they do, great, I'm going to continue it. If they don't, I'm going to stop it. So that's the way I tend to think about these things is, you know, as long as it's not something harmful, do a study. This is what I want to see improve. If it does, fantastic, if it doesn't, scratch it off the list,

Amy Lerman (47:22):

Here's a good one. For a parent who is on the fence about medicating their child or very hesitant to go that route. How do you explain to the parents the benefits of being medicated in order to ease their concerns/worries about side effects or losing their child's personality?

Dr. Alain Katic (47:41):

You know, I think really, one has to be thinking about, naturally, there's a concern about medications. There's a concern about side effects, long-term effects. Though, there really don't appear to be any negative long-term effects, particularly, as you're thinking of stimulants. Is the impact, uh, so what I try and get parents to think about is the impact of the symptoms on their child's functioning. What you don't want to see, obviously, is that your child becomes down on themselves or demoralized, you know. I'm stupid. I can't do it. I'm always the last one to finish or the other sort of behavioral issue. I'm always in trouble. I mean, I'm no good. And if, you know, if you're seeing any of that sort of, those sorts of complaints, than I think, you know, your level of concern should rise really more towards, we really need to do something treatment wise. And, you know, I'm gonna just have to sort of take that leap, and, you know, let go of some of my worries about, you know, possible side effects.

Amy Lerman (48:50):

Okay. We've got two more. The first one is, do you recommend taking vitamin supplements with, or without medication for ADHD?

Dr. Alain Katic (49:00):

Um, I don't think they heard. I can say that I recommend them, in terms of that there's some improvement in the response to medication or, yeah, so, I mean, again, I think that's a safe thing. I just, I can't say that I think it helps or hurts.

Amy Lerman (49:15):

Thank you. For a parent who has heard only negative information about ADHD medication, what would you recommend they read to get a reliable information?

Dr. Alain Katic (49:27):

Oh, uh, that's a great question. And there's actually commonly recommend books and it's either Tom Wilens or Tim Spencer. Can't remember now, which one of them wrote the book. They're out of Mass. General Hospital. There's actually a primer on medications for your child. And it really goes through in much more detail than I did tonight. See if I, if you want to ask another question while I'm looking this up, I can tell you,

Amy Lerman (49:59):

Oh, that's lovely. Okay. There was one last question. And this one is for a child that has both an ADHD plus expressive-receptive language processing disorder. Do you feel that the non-stimulant drugs can actually cause more of a processing delay?

Dr. Alain Katic (50:19):

I can't say that, not necessarily, no. That's a, um, I don't know. I can't say that I do necessarily.

Amy Lerman (50:26):

Okay. Well, while you're pulling that up, I just, I'd really like to take a moment to thank all of you who joined us this evening and put questions into the chat because by your generous sharing, it really helped prompt other people to ask other questions. And I think that sometimes even when we don't ask a question, just by your asking, it really does speak to so many of us who are signed on here tonight. So, thank you to those of you that showed up and asked questions and thank you to those of you who attended and just listen so generously.

Dr. Alain Katic (51:15):

Some reason I'm not finding it, but to that parent who asked that question, the author is either Tim Wilens, W I L E N S, or Tom Spencer. And they're out of the Mass. General Hospital and actually wrote a really good book, as I said earlier, sort of medication treatment in children and very detailed and thorough. And so it's a good resource if you want something to look up,

Amy Lerman (51:41):

This was an amazing hour. Thank you so much for lending yourself to The Parish School community, The Carruth Center, our Unbabbled podcast and we're just, we're so grateful that you were here. Thank you. Thank you so much.

Dr. Alain Katic (51:58):

Thank you for having me, everyone. Stay safe, stay healthy.

Amy Lerman (52:02):

Absolutely. For those of you turning in tonight, we hope that you will tune in again. We have upcoming free adult education webinars and Q and A's scheduled almost every month. So please stay tuned for those and good night.

Meredith Krimmel (52:22):

Thank you for listening to the Unbabbled podcast. For more information on today's episode, please see our episode description for more information on The Parish School, visit parishschool.org. If you're not already, don't forget to subscribe to Unbabbled podcast on your app of choice. And if you like what you're hearing, be sure to leave a rating and review. A special thank you to Stig Daniels, Amanda Arnold and Stella Limuel for all their hard work behind the scenes. Thanks again for listening!