Standard ADHD Treatment
Attention Deficit Hyperactivity Disorder and Medical Treatment Options
Alternative ADHD Treatment
Alternative and Holistic Treatment for ADD/ADHD
Standard ADHD Treatment
ADHD (Attention Deficit Hyperactivity Disorder) and Medical Treatment Options*
by L. JAMES GROLD M.D. F.A.P.A
Disclaimer: None of this information, provided below, should be considered a replacement for the necessity of obtaining a consultation with a physician, who specializes in the treatment of this disorder. This information could be used to aid you in your discussions with your physician.)
ADHD is often an inherited disorder, comprising some combination of distractibility, hyperactivity, or impulsivity. Although it begins in childhood, some individuals improve as they reach adolescence, while others do not. There are many adults, who suffer from ADHD but are not aware that they have this condition.
Treatment of ADHD
There is no cure for ADHD. However there are medications that can help control the symptoms, as well as a variety of educational and therapeutic measures that can also help.
Medical Treatment of ADHD There are two main classes of medication that can help control the symptoms of ADHD. Stimulants help with problems of short attention span, distractibility, poor memory, and hyperactivity. Antidepressants help control emotional problems such as mood swings, irritability, outbursts, low frustration tolerance, depression, etc. Various other medications can be used for particular problems, such as explosive outbursts of rage. Another category of medication, which is undergoing testing, is represented by one medication only in the U.S. That medication is modafinil, a novel wake-provoking stimulant? approved for narcolepsy.
Stimulant Medications – Ritalin and Dexedrine
Ritalin (methylphenidate) and Dexedrine (dextroamphetamine) canhelp improve physical hyperactivity, mental hyperactivity (restlessness, short attention span, poor concentration), absent-mindedness and poor short-term memory, disorganization, and impulsivity (acting before thinking). Although Ritalin and Dexedrine work approximately the same way, nevertheless some people do better on Ritalin while others do better on Dexedrine.Ritalin and Dexedrine are stimulants that probably work by increasing the activity of the frontal lobes of the brain, which are actually under active in people with ADHD.
In most people, these drugs will have no effect or cause some mild stimulation such as you would get with a few cups of strong coffee. Individuals with ADHD will find that these medications produce a very different effect; they might feel both “relaxed” and “focused” at the same time. They become less absent-minded, less forgetful, less easily distracted, and less easily bored. They become better organized, are able to accomplish much more and become able to complete tasks.
Side Effects of Ritalin and Dexedrine: When a medication gives you a symptom that you did not want, we call that symptom a side effect. Many individuals take stimulants with few side effects. Others experience mild problems. Some are simply unable to tolerate stimulants. Often we can treat annoying side effects so the individual can continue to take the stimulant. Too many people stop their medication instead of working with their physician to find a way to decrease side effects.
Ritalin and Dexedrine have been the target of a long, intensive campaign of distortion and vilification by the “Church” of Scientology. This has led to media reports, and news releases claiming adverse results from use of Ritalin. As a result of these scare tactics, many individuals are uninformed about the benefits of these medications. Ritalin is a reliable medication that has been in use for over 40 years. When used carefully and as prescribed, stimulants are very effective and safe
Various side effects may be experienced. These are uncommon, and generally of little consequence. These drugs are very short acting (about 4 hours); so if they are not well tolerated any side effects soon disappear. Sometimes a change in dose is all that is required. Sometimes it is necessary to switch from Ritalin to Dexedrine, or vice versa, or try one of the newer drugs such as Wellbutrin (bupropion). Provigil (modafinil) is a different type of stimulant unrelated to Dexedrine or Ritalin and in some studies has been shown to be useful for ADDHD. Also essential fatty acids from various cold-water fish have been shown in some studies to benefit this condition.
Reduced appetite: This effect may be worse in the very young. It may improve after several weeks or months. If it continues to be problematic, one may reduce the dose or time a short-acting stimulant to wear off before mealtimes. In some cases we resign ourselves to eating a large breakfast and supper followed by a very small lunch. A late evening snack can also help. The appetite often decreases soon after taking these medications, so this effect can be avoided by taking the medication just before eating.
Insomnia: This is usually the result of taking stimulants too late in the day. People are remarkably different in this respect – some have no disturbance of sleep with an evening dose, or even sleep better, while others find they cannot take a dose after mid-afternoon. Remember to look at the amount of coffee you drink. Sleep difficulty is more frequent with the longer-acting stimulants such as Dexedrine Spansules. However, the sleep problem is sometimes due to the ADDHD not the medication. If the sleep problem is truly due to medication effect, give the last dose earlier in the day. Sometimes clonidine or guanfacine help one settle down for sleep. We also counsel the individual on establishing good sleep habits.
Irritability: Sometimes irritability may be due to the ADDHD or another psychiatric disorder. If the irritability is truly due to the stimulant, there are several options. Reduce the stimulant dose, switch to a different stimulant, add clonidine/guanfacine, or use another class of medications to treat the ADDHD.
Emotional Flatness: may be the result of too high a dose. It may be necessary to lower the dose.
Sadness, Increased Sensitivity, Crying Easily: may be a sign of too high a dose. Lowering the dose usually causes this to disappear immediately.Blood Pressure Changes: Sometimes the blood pressure may be mildly elevated or even reduced. If this occurs, it may be necessary to stop stimulants, change medications, or take a blood pressure reducing medication as well.
Rebound: Some people who take short acting methylphenidate or amphetamine experience irritability or depression for an hour as the stimulant wears off. Sometimes this is worse than the individual’s behavior before the medication was started. One can avoid rebound by spacing the doses closer together, giving a smaller dose after the final larger dose, or by switching to a longer acting stimulant. (Longer acting stimulants come in a variety of different forms at the present time.)
Headache: If this does not improve with time, we may reduce the dose or switch to another stimulant. Sometimes caffeine restriction helps.
Jittery feeling: Eliminate caffeine or other stimulant-type medications. A small dose of a beta-blocker (a type of blood pressure medication) can block tremor or jitters.
Gastrointestinal upset: Take the medication with meals or eat smaller, more frequent meals.
Depression: This may be a delayed effect of stimulant medication. It may be more common with the long-acting stimulants. Screening for a history of depression, and treating co-existing depression can minimize this. If the depression truly is related to the medication, one may switch to another class of medications to treat the ADDHD. These second-line medications would include the tricyclic antidepressants and bupropion (Wellbutrin, Provigil and/or Essential Fatty Acids.)
Anxiety: If an individual is anxious, the stimulants can exacerbate the symptoms. The treatment of this side effect is similar to that of depression.
Blood glucose changes: Individuals with diabetes mellitus or with borderline metabolic problems may experience an abrupt rise in blood sugar. Such individuals can often take stimulants but may need closer monitoring of their diabetic control.
Increased blood pressure: Stimulants may cause increases in blood pressure or pulse. This is usually not significant at normal doses in most people. Individuals on very high doses of stimulants or individuals at risk for blood pressure problems should be monitored more closely. Some adults may opt to continue the stimulant and add a blood pressure medication.
Psychosis or paranoia: These are rare side effects. They may occur in an individual who is already predisposed to a bipolar disorder or another psychotic disorder. Psychosis may also occur when someone takes a stimulant overdose. It is important to screen for and treat certain other psychiatric disorders prior to starting a stimulant.
Tics and stereotyped (repetitive) movements: In the past we rarely gave stimulants to individuals with tics because we believed that the stimulant would make the tics worse. Recent data seems to indicate that low to moderate doses of amphetamine or methylphenidate do not necessarily make tics worse. If an individual has tics, or develops them while on a stimulant, it should be discussed with the prescribing physician.
AVOID CERTAIN MEDICATIONS: If you are taking Ritalin (methylphenidate) or Dexedrine (dextroamphetamine), you should avoid over-the-counter cough and cold preparations containing phenylephrine, pseudoephedrine, and phenylpropanolamine (Sudafed, Actifed, Dimetapp, Dexatrim and others) and also any health food store preparations containing ephedra (Ma Huang). These can cause a dangerous increase in blood pressure.
Addiction: There is no evidence that these medications are addictive, if used the way they are intended. People with ADHD are the last people who would abuse their medications, since the medications produce no “high” for them, and if taken at greater frequency or dosage produces an unpleasant jitteriness. There is much more of a problem with adolescents (and some adults) insisting they do not need the medications then there is with people taking these meds. for inappropriate reasons. Adolescents and adults with ADHD who have not been treated frequently often begin to self-medicate their behavior, moods, and ADHD problems with drugs or alcohol. Often, their addiction is difficult to treat until they receive appropriate treatment for their ADHD.
Drug Interactions: Antihistamines may interact with stimulants, causing mild confusion. Alcohol does not interact directly with Ritalin or Dexedrine. However some people find that drinking alcohol while on stimulants leads to a “hangover” the next day. Many people on stimulants lose interest in alcohol, finding they are happier without it. Whenever You Are In Doubt about a possible interaction, call your physician and, Stop the Stimulants until you get a reading as to whether to continue the medication. Stimulants are short acting – they leave the body quickly. If you are in doubt about the interaction of stimulants and other medications, you can always stop the stimulants while you get medical advice.
Starting Out With Stimulants: Some experimentation is required to determine the best dosage and timing for Ritalin or Dexedrine. Keep a record of what you take, how much you take, when you take it, and how it affects you. After a while you will be able to determine patterns that help you choose your best dosage and timing.
Avoid caffeine when beginning to take stimulant drugs. Some people find that caffeine in coffee, tea, chocolate or soft drinks will over stimulate them when they are taking Ritalin or Dexedrine. Others find that caffeine has no effect or even interferes with the benefits of these drugs.
Try to avoid changes in other medications, and big changes in lifestyle while you are experimenting with the dosage and timing of stimulant medications. If you are changing more than one thing at a time, it will be very difficult to determine what is causing what.
Dosing Ritalin and Dexedrine: Ritalin is better absorbed if taken on an empty stomach, 15 – 30 minutes before a meal, or 1 hour after. (Children usually take it with a meal, since it sometimes makes them less hungry if they take it before eating). You will probably be prescribed one 10-mg tablet before breakfast and lunch. See what effect this has on your hyperactivity, restlessness, concentration, memory, and ability to sit still or finish things, etc. Jitteriness, if it occurs, will wear off in an hour or two.Tolerance to Ritalin (needing an increased dose as time goes on) does not occur. Once you find the right dose, you rarely need to change it, and if you do, it is only by very small amounts.
Timing of Regular (Short Acting) Ritalin: Since regular Ritalin (not the SR or Sustained Release form) lasts for about 4 hours, most people end up taking it before breakfast and before lunch. In this way, the morning dose overlaps slightly with the before-lunch dose, resulting in a sustained effect all day.
Some people find a smaller dose before supper keeps them calm and focused in the evening and provides a good night’s sleep. Others find that a dose before supper keeps them awake at night. Sometimes people have an unpleasant “withdrawal” or “let-down” feeling when the Ritalin wears off at the end of the afternoon. This can often be avoided by taking a smaller dose before supper.
Common schedules for Ritalin include: 1.20 mg before breakfast, 20 mg before lunch.2.20 mg before breakfast, 20 mg before lunch, and 10 mg before supper.3.10 mg before breakfast, 10 mg before lunch, and 10 mg before supper.
Timing Of Regular (Short Acting) Dexedrine: Since regular Dexedrine lasts for about 4 hours, most people end up taking it before breakfast and before lunch. In this way, the morning dose overlaps slightly with the before-lunch dose, so there is a sustained effect all day.
Some people find a smaller dose before supper keeps them calm and focused in the evening and allows a good night’s sleep. Sometimes people have an unpleasant “withdrawal” or “let-down” feeling when the Dexedrine wears off at the end of the afternoon. This can often be avoided by taking a smaller dose before supper.
Common schedules for Dexedrine include: 1.10 mg before breakfast, 10 mg before lunch.2.10 mg before breakfast, 10 mg before lunch, and 5 mg before supper.3. 5 mg before breakfast, 5 mg before lunch, and 5 mg before supper.
Long-Acting form of Ritalin: Metadate or Concerta Concerta comes in a 18 mg. and 36 mg. dose. Most individuals eventually find that 36 mg. two times a day is the proper dose. Concerta may be given once a day and is effective for many children throughout the school day.
Some people prefer not to take stimulant medications on the weekend, if their lives are quieter and less demanding then. Others find these drugs are so helpful that they prefer to take them every day. The answer is to do what works best for you. There is no medical reason to have “medication holidays.”
Stimulants and Sports
Stimulants may be very helpful in “slower” sports where a lot of concentration is required, such as baseball, golf, bowling, and gymnastics. In sports where there is a lot of action and excitement, such as hockey, basketball, football, soccer, running and cycling stimulants are not necessary and may be detrimental.
After a while you will learn, which activities need stimulants, and which do not. Many people need medications in the late afternoon, and a few need them in the evening. Certain tedious, repetitive jobs require more stimulants than others. Things that are enjoyable and interesting maybe easier to do without medication. Experiment, and keep a diary. After a while you will find what works best for you.
A few people seem to be very sensitive to stimulants, and do well on tiny doses, such as 1 mg. to 2 mg of Ritalin or 0.5 mg. to 1 mg of Dexedrine. In these people, higher doses cause drowsiness, lethargy, and emotional “flatness.” This is more common in older people.
A few people seem to need much higher doses, such as 30 – 120 mg of Ritalin or 20 – 60 mg of Dexedrine. This may be as a result of poor absorption from the intestinal tract or other contributing factors.
Dr. L. James Grold is on the board of directors for ADDRferral, He received a Bachelors Degree in biology from Stanford and an MD at that university. He was appointed by USC as an assistant clinical professor to teach medical students and psychiatric residents. Dr. L. James Grold was elected to be a Life Fellow in the Amer. Psych Assoc. and also a Fellow in the Amer. Board of Forensic Psychiatry. He is the medical director and psychiatric consultant for 1-800-Therapist, and served as the medical director of two psychiatric hospitals.Top
Alternative ADHD Treatments
Behavioral techniques for managing the child with ADHD are not intuitive for most parents and teachers. To learn them, caregivers may need help from qualified health care professionals or from ADHD support groups. At first, the idea of changing the behavior of a highly energetic, obstinate, child is daunting. It is futile and damaging to try to force an ADHD child to be just like most children. It is possible, however, to limit destructive behavior and to instill a sense of self-worth that will help overcome negativity toward life, which is one of the great dangers of this disorder.
Behavioral Techniques at Home
Bringing up an ADHD child, like bringing up any child, is a process. No single point is ever reached where the parent can sit back and say, “That’s it. My child is now OK, and I don’t have to do anything more.” Self-worth will evolve from the child’s increasing ability to step back and consider the consequences of an action and then to control that action before taking it. But this does not happen overnight. A growing ADHD child is different from other children in very specific ways and presents challenges at every age.
Setting Priorities for the Parent. Parents must first establish their own levels of tolerance. Some parents are easy going and can accept a wide range of behaviors, while others can’t. To help a child achieve self-discipline requires empathy, patience, affection, energy, and toughness. Some tips to help the parent are as follows:
Parents should prepare a list giving priority to those behaviors they think are most negative, such as fighting with other children or refusing to get up in the morning. The least negative behaviors on the bottom of the list should be ignored temporarily or even permanently (e.g. refusing to wear anything but red T-shirts). Certain odd behaviors that are not hurtful to the child or to others may be an indication of creative or humorous attempts to adapt (e.g. making up silly songs or drawing violent pictures). These should be accepted as part of the child’s unique and positive development, even if they seem peculiar to the parent. It is important to keep in mind that no one is a saint. Loving parents who occasionally lose their tempers will not damage their children forever. In fact, non-abusive open disapproval or dismay is far less destructive to both parent and child than harboring resentment beneath a false calm. Establishing Consistent Rules for the Child. Parents must be as consistent as possible in their approach to the child, which should reward good behavior and discourage destructive behavior. Rules should be well defined but flexible enough to incorporate harmless idiosyncrasies. It is very important to understand that ADHD children have much more difficulty adapting to change than do children without the condition. (For example, the child should do homework every day but might choose to start it after a TV show or computer game.)
Managing Aggression. Some useful tips for managing aggression include the following:
Parents should try to give little attention to mildly disruptive behaviors that allow this energetic child to let off some harmless steam. The parent will also be wasting energy that will be needed when the negative behavior becomes destructive, abusive, or intentional. The use of “time-out,” isolating the child immediately for a short period of time, is an effective measure for allowing both the caregiver and the child to cool down. The child should immediately (and without emotion) be removed from a situation in which he or she is endangered or is endangering others. The child should view time out as a way of cooling off and getting a distance on their behavior, not as isolation from others. To channel physical aggression and impulsivity in the ADHD toddler, the parents must teach them to use verbal responses. (A parent may need to allow verbal responses that would be unacceptable in another child.) When the ADHD child becomes older and if the verbal responses become intentionally abusive and socially undesirable, then the parent must redirect this form of aggression into more acceptable activities, such as competitive one-on-one sports, energetic music, video games, or big colorful paintings. Sometimes a parent can anticipate situations when an ADHD child is likely to misbehave, but all too often the child explodes for no apparent reason. If the blow-up occurs in public, the parents should complete their activities and leave as quickly as possible. Establishing a Reward System. Children with ADHD respond particularly well to reward systems. One study reported that they performed equally well when encouraged either by a direct reward for a correct response or with the use of a system called response-cost. With this system, the child is given the reward first and allowed to keep it if their behavior remains appropriate.
Some suggested tips for rewarding the ADHD child are as follows:
Creating charts with points or stars for good behavior or completed tasks is helpful for young children. It is important to give points for even simple positive behaviors, which may be taken for granted in other children (e.g. responding happily to a change in plans, changing an obscenity to a more acceptable expletive). Rewards for any child can include playing a favorite game with the child, extending bedtime by an hour, or allowing an extra half-hour of TV. Rewards of food or gifts should be used infrequently, if at all. They can create other problems, such as being overweight, having a bad diet, or making continuous demands for objects. A reward system should rotate different types of rewards, because such children are easily bored. ADHD children respond better with small rewards promised in the short term than large rewards offered in the future. One approach that employs both short- and long-term rewards uses a system that gives the child points for specific positive behaviors. As the children accumulate points, they can use them for larger tangible rewards, such as a favorite video game or CD. Rewards should be promised only when caregivers are fairly certain they can follow through. ADHD children respond with much greater frustration than non-ADHD children to disappointment, and are likely to have a strong (and noisy) negative reaction. A parent must remember that this response is part of the ADHD child’s make-up and not necessarily in their control. Improving Concentration and Attention. Research indicates that ADHD children perform significantly better when their interest is engaged. Parents should be on the lookout for activities that hold the child’s concentration. One very interesting experiment reported that when children with ADHD performed word puzzles in front of a mirror that they did as well as non-ADHD children. The intent of the experiment was to focus attention back to the self and so avoid external stimuli. Some activities that help an ADHD child to focus are as follows:
Many ADHD children are particularly lured by the computer, which is a very promising tool. Although many video and computer games are based on repetitive violent events governed by hand-eye coordination, a number of games are available that offer problem-solving techniques using characters, narrative, and humor. Swimming, tennis, and other sports that focus attention and limit peripheral stimuli are often appealing. ADHD children often do not do well with team sports, although if a child is interested in baseball, positions such as pitching or catching are preferable to the outfield, where attention easily wanders. Some experts are enthusiastic about martial arts, such as Tae Kwon Do, which can offer an appropriate and controlled emotional outlet, help to focus attention, and teach self-restraint, self-discipline, and tolerance. Care should be taken to select an instructor who makes such goals a priority. Learning an instrument may be one of the best ways for an ADHD child to develop a more rhythmic and balanced sense of self. Music, even simply listening to it, is in any case is often very important for these children. (Parents may have to tolerate music that does not please them.) Management at School
Even if a parent is successful in managing the child at home, difficulties often arise at school. The ultimate goal for any educational process should be the happy and healthy social integration of the ADHD child with his or her peers.
Preparing the Teacher. Although teachers can expect that at least one student in every classroom will have ADHD, there is currently little training that prepares them for managing these children. The teacher should be prepared for the following behaviors in the ADHD child:
ADHD students are often demanding, talkative, and highly visible. Having the child sit in the front of the classroom may be helpful. Children with ADHD often require frequent reminders of or visual cues (such as posters) for rules and regulations. They frequently forget homework or miss assignments. Lack of fine motor control makes taking notes very difficult, and handwriting is often poor. Using a typewriter or computer can compensate for this. One useful skill that has helped some ADHD children is learning to type at an early age, around the third or fourth grade. Rote memorization and math computation, which require following a set of ordered steps, are often difficult. (ADHD children may do better with math concepts.) Many ADHD children respond well to school tasks that are rapid, intense, novel, or of short duration (such as spelling bees or competitive educational games), but they almost always have problems with long-term projects where there is no direct supervision. The Role of the Parent in the School Setting. The parent can help the child by talking to the teacher before the school year starts about their child’s situation:
The first priority for the parent is to develop a positive, not adversarial, relationship with the child’s teacher. The parent must acknowledge the teacher’s situation, for he or she must deal not only with the ADHD child’s behavior but also with the needs of all the other children. Frequent brief and sympathetic conversations with the teacher can be helpful and can lead to coordination of efforts, particularly if they provide reciprocal information about progress or setbacks. Finding a tutor to help after school may be helpful. Legal Issues. A number of legal issues have become both positively and negatively important in the management of ADHD in the classroom. In some districts teachers are not allowed to tell parents that they suspect their child has ADD or ADHD because of the risk of lawsuits, therefore preventing an unknowing parent from seeking help for their child. Parents sometimes report pressure by school administrators or teachers to put their children on medication or force them into special classrooms without clear educational justification. The schools, in these cases, may be acting illegally.
Special Education Programs. High-quality special education can be extremely helpful in improving learning and developing a child’s sense of self worth. Many families, however, may not have appropriate programs available for them. Programs vary widely in their ability to provide quality education. Parents must be aware of certain limitations and problems with special education:
Special education programs within the normal school setting often increase the child’s feelings of social alienation. If the educational strategy focuses only on abnormal behavior, it will fail to take advantage of the creative, competitive, and dynamic energy that often accompanies ADHD behavior. There is no federally funded special education category specifically targeted to ADHD. If, in fact, ADHD is as common as studies are indicating, the best approach may be to treat the syndrome as a variant of the norm and train teachers to manage these children within the context of a normal classroom.
Feingold Diet. A number of diets have been suggested for people with ADHD. The most popular is the Feingold diet, a salicylate- and additive-free diet, which requires rigorous vigilance over a child’s eating habits. BHT or BHA and artificial food colors are specifically avoided. Salicylates are very common and are present in aspirin and many foods. They include apples and cider, berries (all), Chili powder, cloves, grapes, oranges, peaches, peppers (bell & chili), plums, prunes, and tomatoes. One study that reported its efficacy suggested that it might not provide enough nutritive value, although the diet provides a wide range of healthy foods to select from. Some parents report great success with this diet, although it may be difficult to impose, particularly on an ADHD child. It is certainly wise, in any case, to avoid food with artificial colors and flavors and to provide a healthy balance of fresh, natural foods.
Zinc and Fatty Acids. One 2000 study compared groups of ADHD individuals who took primrose oil (an essential fatty acid), a psychostimulant, or placebo. In assessing the results, the authors suggested that primrose oil may benefit ADHD children who are moderately deficient in zinc. In fact, in those with borderline zinc levels, a combination of zinc and primrose oil was as effective as medications in reducing ADHD symptoms. (Neither zinc nor primrose oil had any effect on children who were not zinc deficient.) It is important to note that this study needs confirmation, and testing for trace minerals, such as zinc, is not standard procedure when evaluating children suspected to have ADHD.
Neurofeedback is an experimental approach that uses electronic devices to speed up or slow down brain wave activity. In one study, children given this treatment were taught certain high-level mental activities when feedback information indicated that they were fully concentrating. They attended four 50-minute sessions, usually twice a week. At the end of the study, Ritalin use had dropped from 30% to 6%. Significant improvement was reported in inattention, impulsivity, and response time, and IQs increased by an average of 12 points. A 1999 presentation at a professional meeting reported on a study suggesting that 85% of ADHD adults and children improved after 20 sessions. This study was not reviewed by other professionals, and critics have identified methodological problems with this and other studies on neurofeedback. For example, in the 1999 study, only 20% of the subjects had an actual diagnosis of ADHD. Nevertheless, the positive results from such studies warrant further research.
Daily massage therapy helps ADHD adolescents feel happier, fidget less, be less hyperactive, and focus on tasks, according to a study published in 1998.
Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians, including faculty at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.Top
Board of Editors
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital
Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center
Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital
John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital
Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children’s Hospital
Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital
Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General HospitalTop