Increase in online ADHD diagnoses for kids poses ethical questions
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In 2020, in the midst of a pandemic, clinical protocols were altered for Ontario health clinics, allowing them to perform more types of care virtually. This included ADHD assessments and ADHD prescriptions for children – services that previously had been restricted to in-person appointments. But while other restrictions on virtual care are back, clinics are still allowed to virtually assess children for ADHD.
This shift has allowed for more and quicker diagnoses – though not covered by provincial insurance (OHIP) – via a host of newly emerging private, for-profit clinics. However, it also has raised significant ethical questions.
It solves an equity issue in terms of rural access to timely assessments, but does it also create new equity issues as a privatized service?
Is it even feasible to diagnose a child for a condition like ADHD without meeting that child in person?
And as rates of ADHD diagnosis continue to rise, should health regulators re-examine the virtual care approach?
Ontario: More prescriptions, less regulation
There are numerous for-profit clinics offering virtual diagnoses and prescriptions for childhood ADHD in Ontario. These include KixCare, which does not offer the option of an in-person assessment. Another clinic, Springboard, makes virtual appointments available within days, charging around $2,600 for assessments, which take three to four hours. The clinic offers coaching and therapy at an additional cost, also not covered by OHIP. Families can choose to continue to visit the clinic virtually during a trial stage with medications, prescribed by a doctor in the clinic who then sends prescribing information back to the child’s primary care provider.
For-profit clinics like these are departing from Canada’s traditional single-payer health care model. By charging patients out-of-pocket fees for services, the clinics are able to generate more revenue because they are working outside of the billing standards for OHIP, standards that set limits on the maximum amount doctors can earn for providing specific services. Instead many services are provided by non-physician providers, who are not limited by OHIP in the same way.
Need for safeguards
ADHD prescriptions rose during the pandemic in Ontario, with women, people of higher income and those aged 20 to 24 receiving the most new diagnoses, according to research published in January 2024 by a team including researchers from the Centre for Addictions and Mental Health and Holland Bloorview Children’s Hospital. There may be numerous reasons for this increase but could the move to virtual care have been a factor?
Ontario psychiatrist Javeed Sukhera, who treats both children and adults in Canada and the U.S., says virtual assessments can work for youth with ADHD, who may receive treatment quicker if they live in remote areas. However, he is concerned that as health care becomes more privatized, it will lead to exploitation and over-diagnosis of certain conditions.
“There have been a lot of profiteers who have tried to capitalize on people’s needs and I think this is very dangerous,” he said. “In some settings, profiteering companies have set up systems to offer ADHD assessments that are almost always substandard. This is different from not-for-profit setups that adhere to quality standards and regulatory mechanisms.”
Sukhera’s concerns recall the case of Cerebral Inc., a New York state-based virtual care company founded in 2020 that marketed on social media platforms including Instagram and TikTok. Cerebral offered online prescriptions for ADHD drugs among other services and boasted more than 200,000 patients. But as Dani Blum reported in the New York Times, Cerebral was accused in 2023 of pressuring doctors on staff to prescribe stimulants and faced an investigation by state prosecutors into whether it violated the U.S. Controlled Substances Act.
“At the start of the pandemic, regulators relaxed rules around medical prescription of controlled substances,” wrote Blum. “Those changes opened the door for companies to prescribe and market drugs without the protocols that can accompany an in-person visit.”
Access increased – but is it equitable?
Virtual care has been a necessity in rural areas in Ontario since well before the pandemic, although ADHD assessments for children were restricted to in-person appointments prior to 2020.
But ADHD assessment clinics that charge families out-of-pocket for services are only accessible to people with higher incomes. Rural families, many of whom are low income, are unable to afford thousands for private assessments, let alone the other services upsold by providers. If the private clinic/virtual care trend continues to grow unchecked, it may also attract doctors away from the public model of care since they can bill more for services. This could further aggravate the gap in care that lower income people already experience.
This could further aggravate the gap in care that lower income people already experience.
Sukhera says some risks could be addressed by instituting OHIP coverage for services at private clinics (similar to private surgical facilities that offer mixed private/public coverage), but also with safeguards to ensure that profits are reinvested back into the health-care system.
“This would be especially useful for folks who do not have the income, the means to pay out of pocket,” he said.
Concerns of misdiagnosis and over-prescription
Some for-profit companies also benefit financially from diagnosing and issuing prescriptions, as has been suggested in the Cerebral case. If it is cheaper for a clinic to do shorter, virtual appointments and they are also motivated to diagnose and prescribe more, then controls need to be put in place to prevent misdiagnosis.
The problem of misdiagnosis may also be related to the nature of ADHD assessments themselves. University of Strathclyde professor Matthew Smith, author of Hyperactive: The Controversial History of ADHD, notes that since the publication of Diagnostic and Statistical Manual of Mental Disorders in 1980, assessment has typically involved a few hours of parents and patients providing their subjective perspectives on how they experience time, tasks and the world around them.
“It’s often a box-ticking exercise, rather than really learning about the context in which these behaviours exist,” Smith said. “The tendency has been to use a list of yes/no questions which – if enough are answered in the affirmative – lead to a diagnosis. When this is done online or via Zoom, there is even less opportunity to understand the context surrounding behaviour.”
Smith cited a 2023 BBC investigation in which reporter Rory Carson booked an in-person ADHD assessment at a clinic and was found not to have the condition, then had a private online assessment – from a provider on her couch in a tracksuit – and was diagnosed with ADHD after just 45 minutes, for a fee of £685.
What do patients want?
If Canadian regulators can effectively tackle the issue of privatization and the risk of misdiagnosis, there is still another hurdle: not every youth is willing to take part in virtual care.
Jennifer Reesman, a therapist and Training Director for Neuropsychology at the Chesapeake Center for ADHD, Learning & Behavioural Health in Maryland, echoed Sukhera’s concerns about substandard care, cautioning that virtual care is not suitable for some of her young clients who had poor experiences with online education and resist online health care. It can be an emotional issue for pediatric patients who are managing their feelings about the pandemic experience.
“We need to respect what their needs are, not just the needs of the provider,” says Reesman.
In 2020, Ontario opted for virtual care based on the capacity of our health system in a pandemic. Today, with a shortage of doctors, we are still in a crisis of capacity. The success of virtual care may rest on how engaged regulators are with equity issues, such as waitlists and access to care for rural dwellers, and how they resolve ethical problems around standards of care.
Children and youth are a distinct category, which is why we had restrictions on virtual ADHD diagnosis prior to the pandemic. A question remains, then: If we could snap our fingers and have the capacity to provide in-person ADHD care for all children, would we? If the answer to that question is yes, then how can we begin to build our capacity?
This article is republished from healthydebate under a Creative Commons license. Read the original article.
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Sunflower Seeds vs Pumpkin Seeds – Which is Healthier?
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Our Verdict
When comparing sunflower seeds to pumpkin seeds, we picked the pumpkin seeds.
Why?
Both seeds have a good spread of vitamins and minerals, but pumpkin seeds have more. Sunflower seeds come out on top for copper and manganese, but everything else that’s present in either of them (in the category of vitamins and minerals, anyway), pumpkin seeds have more.
There is one other thing that sunflower seeds have more of than pumpkin seeds, and that’s fat. The fat is mostly of healthy varieties, so it’s not a negative factor, but it does mean that if you’re eating a calorie-controlled diet, you’ll get more bang for your buck (i.e. better micronutrient-to-calorie ratio) if you pick pumpkin seeds.
If you’re not concerned about fat/calories, and/or you actively want to consume more of those, then sunflower seeds are still a fine choice.
When it comes down to it, a diverse diet is best, so enjoying both might be the best option of all.
Want to get some?
We don’t sell them, but here for your convenience are example products on Amazon:
Sunflower Seeds | Pumpkin Seeds
Enjoy!
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What causes the itch in mozzie bites? And why do some people get such a bad reaction?
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Are you one of these people who loathes spending time outdoors at dusk as the weather warms and mosquitoes start biting?
Female mosquitoes need blood to develop their eggs. Even though they take a tiny amount of our blood, they can leave us with itchy red lumps that can last days. And sometimes something worse.
So why does our body react and itch after being bitten by a mosquito? And why are some people more affected than others?
What happens when a mosquito bites?
Mosquitoes are attracted to warm blooded animals, including us. They’re attracted to the carbon dioxide we exhale, our body temperatures and, most importantly, the smell of our skin.
The chemical cocktail of odours from bacteria and sweat on our skin sends out a signal to hungry mosquitoes.
Some people’s skin smells more appealing to mosquitoes, and they’re more likely to be bitten than others.
Once the mosquito has made its way to your skin, things get a little gross.
The mosquito pierces your skin with their “proboscis”, their feeding mouth part. But the proboscis isn’t a single, straight, needle-like tube. There are multiple tubes, some designed for sucking and some for spitting.
Once their mouth parts have been inserted into your skin, the mosquito will inject some saliva. This contains a mix of chemicals that gets the blood flowing better.
There has even been a suggestion that future medicines could be inspired by the anti-blood clotting properties of mosquito saliva.
It’s not the stabbing of our skin by the mosquito’s mouth parts that hurts, it’s the mozzie spit our bodies don’t like.
Are some people allergic to mosquito spit?
Once a mosquito has injected their saliva into our skin, a variety of reactions can follow. For the lucky few, nothing much happens at all.
For most people, and irrespective of the type of mosquito biting, there is some kind of reaction. Typically there is redness and swelling of the skin that appears within a few hours, but often more quickly, after just a few minutes.
Occasionally, the reaction can cause pain or discomfort. Then comes the itchiness.
Some people do suffer severe reactions to mosquito bites. It’s a condition often referred to as “skeeter syndrome” and is an allergic reaction caused by the protein in the mosquito’s saliva. This can cause large areas of swelling, blistering and fever.
The chemistry of mosquito spit hasn’t really been well studied. But it has been shown that, for those who do suffer allergic reactions to their bites, the reactions may differ depending on the type of mosquito biting.
We all probably get more tolerant of mosquito bites as we get older. Young children are certainly more likely to suffer more following mosquito bites. But as we get older, the reactions are less severe and may pass quickly without too much notice.
How best to treat the bites?
Research into treating bites has yet to provide a single easy solution.
There are many myths and home remedies about what works. But there is little scientific evidence supporting their use.
The best way to treat mosquito bites is by applying a cold pack to reduce swelling and to keep the skin clean to avoid any secondary infections. Antiseptic creams and lotions may also help.
There is some evidence that heat may alleviate some of the discomfort.
It’s particularly tough to keep young children from scratching at the bite and breaking the skin. This can form a nasty scab that may end up being worse than the bite itself.
Applying an anti-itch cream may help. If the reactions are severe, antihistamine medications may be required.
To save the scratching, stop the bites
Of course, it’s better not to be bitten by mosquitoes in the first place. Topical insect repellents are a safe, effective and affordable way to reduce mosquito bites.
Covering up with loose fitted long sleeved shirts, long pants and covered shoes also provides a physical barrier.
Mosquito coils and other devices can also assist, but should not be entirely relied on to stop bites.
There’s another important reason to avoid mosquito bites: millions of people around the world suffer from mosquito-borne diseases. More than half a million people die from malaria each year.
In Australia, Ross River virus infects more than 5,000 people every year. And in recent years, there have been cases of serious illnesses caused by Japanese encephalitis and Murray Valley encephalitis viruses.
Cameron Webb, Clinical Associate Professor and Principal Hospital Scientist, University of Sydney
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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What are nootropics and do they really boost your brain?
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Humans have long been searching for a “magic elixir” to make us smarter, and improve our focus and memory. This includes traditional Chinese medicine used thousands of years ago to improve cognitive function.
Now we have nootropics, also known as smart drugs, brain boosters or cognitive enhancers.
You can buy these gummies, chewing gums, pills and skin patches online, or from supermarkets, pharmacies or petrol stations. You don’t need a prescription or to consult a health professional.
But do nootropics actually boost your brain? Here’s what the science says.
What are nootropics and how do they work?
Romanian psychologist and chemist Cornelius E. Giurgea coined the term nootropics in the early 1970s to describe compounds that may boost memory and learning. The term comes from the Greek words nӧos (thinking) and tropein (guide).
Nootropics may work in the brain by improving transmission of signals between nerve cells, maintaining the health of nerve cells, and helping in energy production. Some nootropics have antioxidant properties and may reduce damage to nerve cells in the brain caused by the accumulation of free radicals.
But how safe and effective are they? Let’s look at four of the most widely used nootropics.
1. Caffeine
You might be surprised to know caffeine is a nootropic. No wonder so many of us start our day with a coffee. It stimulates our nervous system.
Caffeine is rapidly absorbed into the blood and distributed in nearly all human tissues. This includes the brain where it increases our alertness, reaction time and mood, and we feel as if we have more energy.
For caffeine to have these effects, you need to consume 32-300 milligrams in a single dose. That’s equivalent to around two espressos (for the 300mg dose). So, why the wide range? Genetic variations in a particular gene (the CYP1A2 gene) can affect how fast you metabolise caffeine. So this can explain why some people need more caffeine than others to recognise any neurostimulant effect.
Unfortunately too much caffeine can lead to anxiety-like symptoms and panic attacks, sleep disturbances, hallucinations, gut disturbances and heart problems.
So it’s recommended adults drink no more than 400mg caffeine a day, the equivalent of up to three espressos.
2. L-theanine
L-theanine comes as a supplement, chewing gum or in a beverage. It’s also the most common amino acid in green tea.
Consuming L-theanine as a supplement may increase production of alpha waves in the brain. These are associated with increased alertness and perception of calmness.
However, it’s effect on cognitive functioning is still unclear. Various studies including those comparing a single dose with a daily dose for several weeks, and in different populations, show different outcomes.
But taking L-theanine with caffeine as a supplement improved cognitive performance and alertness in one study. Young adults who consumed L-theanine (97mg) plus caffeine (40mg) could more accurately switch between tasks after a single dose, and said they were more alert.
Another study of people who took L-theanine with caffeine at similar doses to the study above found improvements in several cognitive outcomes, including being less susceptible to distraction.
Although pure L-theanine is well tolerated, there are still relatively few human trials to show it works or is safe over a prolonged period of time. Larger and longer studies examining the optimal dose are also needed.
3. Ashwaghanda
Ashwaghanda is a plant extract commonly used in Indian Ayurvedic medicine for improving memory and cognitive function.
In one study, 225-400mg daily for 30 days improved cognitive performance in healthy males. There were significant improvements in cognitive flexibility (the ability to switch tasks), visual memory (recalling an image), reaction time (response to a stimulus) and executive functioning (recognising rules and categories, and managing rapid decision making).
There are similar effects in older adults with mild cognitive impairment.
But we should be cautious about results from studies using Ashwaghanda supplements; the studies are relatively small and only treated participants for a short time.
4. Creatine
Creatine is an organic compound involved in how the body generates energy and is used as a sports supplement. But it also has cognitive effects.
In a review of available evidence, healthy adults aged 66-76 who took creatine supplements had improved short-term memory.
Long-term supplementation may also have benefits. In another study, people with fatigue after COVID took 4g a day of creatine for six months and reported they were better able to concentrate, and were less fatigued. Creatine may reduce brain inflammation and oxidative stress, to improve cognitive performance and reduce fatigue.
Side effects of creatine supplements in studies are rarely reported. But they include weight gain, gastrointestinal upset and changes in the liver and kidneys.
Where to now?
There is good evidence for brain boosting effects of caffeine and creatine. But the jury is still out on the efficacy, optimal dose and safety of most other nootropics.
So until we have more evidence, consult your health professional before taking a nootropic.
But drinking your daily coffee isn’t likely to do much harm. Thank goodness, because for some of us, it is a magic elixir.
Nenad Naumovski, Professor in Food Science and Human Nutrition, University of Canberra; Amanda Bulman, PhD candidate studying the effects of nutrients on sleep, University of Canberra, and Andrew McKune, Professor, Exercise Science, University of Canberra
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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How To April Fool Yourself Into Having A Nutrient-Dense Diet!
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These nutrient-dense foods pack such a punch you only need a bit added to your meal…
- “Have 5 servings of fruit per day”—popular wisdom in the West
- “Have 7 servings of fruit per day!”—generally held as the norm in Japan
- “Have these 12 things that are mostly fruit & veg & nuts each day”—Dr. Greger’s Daily Dozen
- “Does the pickle that comes with a burger count?”—an indication of how much many people struggle.
For what it’s worth: pickles are a good source of some minerals (and some healthy gut bacteria too), but are generally too high in sodium to be healthy for most people beyond in the most modest moderation.
But! It can be a lot easier, and without sitting down to a salad buffet every day!
Here are some sneaky tips:
(call it our nod to April Fool’s Day, because tricking yourself into eating more healthily is a top-tier prank)
Beyond soups and smoothies
Soups and smoothies are great, because we can take a lot of nutrients that way without actually oing much eating. And if we’ve a want or need to hide something, blending it does a fine job. However, we’re confident you already know how to make soups and smoothies. So…
Sauces are another excellent place to put nutrients—and as a bonus, homemade sauces will mean skipping on the store-bought sauces whose ingredients all-too-often look something like “sugar, water, spirit vinegar, glucose-fructose syrup, modified maize starch, maltodextrin, salt…”
Top things to use as a main base ingredient in sauces:
- Tomato purée—so much lycopene, and great vitamins too! Modest flavour, but obviously only sensible for what you intend to be a tomato-based sauce. Use it to make anything from marinara sauce to ketchup, sweet-and-sour to smoky barbecue.
- Lentils/beans—if unsure, red lentils or haricot beans have a very mild taste, and edamame beans are almost not-there, flavor-wise. But cooked and blended smooth, these are high-protein, iron-rich, flavonoid-heavy, and a good source of fiber too. Can be used as the base of so many savory creamy sauces!
- Corn—that yellow color? It’s all the lutein. Home-made creamed corn goes great as a dipping sauce! Added spices optional.
Vegetables that punch above their weight
Sometimes, you might not want to eat much veg, but a small edible side-dish could be appealing, or even a generous garnish. In those cases, if you choose wisely, you can have a lot of nutrients in a tiny portion. Here are some that have an absurd nutrient-to-size ratio:
Cacao nibs—one for the dessert-lovers here, but can also garnish a frothy coffee, your morning overnight oats, or if we’re honest, can also just be snacked on! And they keep for ages. Botanically technically a fruit, but we’re going to throw it in here. As for health qualities? Where to begin…
They:
- are full of antioxidants and fight inflammation
- boost immune health
- help control blood sugar levels
- improve vascular function and heart health
- and even fight cancer, which is a many-headed beast, but for example:
…which is starting to look like a pattern, isn’t it? It’s good against cancer.
Brussels sprouts—if your knee-jerk reaction here wasn’t one of great appeal, then consider: these are delicious if done right.
Buy them fresh, not frozen (nothing nutritionally wrong with frozen if you like them—we’re just doing the extra-level tastiness here). Wash them and peel them, then cut twice from the top to almost-the-bottom, to quarter them in a way that they still stay in one piece. Rub them (or if you’re going easier on the fats, spray them) with a little olive oil, a tiny touch of lemon juice, and sprinkle a little cracked black pepper. Sautée them. We know people will advise roasting, which is also great, but try the sautée approach, and thank us later.
Four sprouts is already a sufficient daily serving of cruciferous vegetables, and provides so many health benefits, with not just a stack of vitamins and minerals, but also have anti-cancer properties, are great for your heart in multiple ways, and reduce inflammation too. They’re literally one of the healthiest foods out there and you only need a tiny portion to benefit.
Kale—Don’t like the taste/texture? That’s OK, read on… No surprises here, but it’s crammed with vitamins and minerals.
- If you don’t care for the bitter taste, cooking it (such as by steaming it) takes that away.
- If you don’t care for the texture, baking it with a little sprayed-on olive oil changes that completely (and is how “kale chips” are made).
- If you don’t care for either? Do the “kale chips” thing mentioned above, but do it on a lower heat for longer—dry it out, basically. Then either blend it in a food processor, or by hand with a pestle and mortar (it turns to powder very easily, so this won’t be hard work), and you now have a very nutrient-dense powder that tastes of very little. While fries are not a health food, an example here is that you can literally dust fries with it and they won’t taste any different but you got a bunch of vitamins and minerals added from a whole food source.
- If going for the above approach, do it in batch and make yourself a jar of it to keep handy with your seasonings collection!
Bell peppers—Working hard to justify their high prices in the grocery store, these are very high in vitamins, especially rich in carotenoids, including lutein, and as a bonus, they’re also full of antioxidants. So, slice some and throw them at whatever else you’re cooking, and you’ve added a lot of nutrients for negligible effort.
Garlic—once you’ve done the paperwork, garlic not only makes bland meals delicious, but is also a treasure trove of micronutrients. It has a stack of vitamins and minerals, and also contains allicin. If you’ve not heard of that one, it’s the compound in garlic that is so good for blood pressure and heart health. See for example:
- Lipid-lowering effects of time-released garlic
- Garlic extract lowers blood pressure in patients with hypertension
- Garlic extract reduces blood pressure in hypertensives
If an apple a day keeps the doctor away, just imagine what a bulb of garlic can do (come on, we can’t be the only ones who measure garlic by the bulb instead of by the clove, right?)!
But in seriousness: measure garlic with your heart—have lots or a little, per your preference. The whole point here is that even a little of these superfoods can make a huge difference to your health!
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I Contain Multitudes – by Ed Yong
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A little while back we reviewed a book (Planet of Viruses) about the role of viruses in our lives, beyond the obvious. Today’s book gives the same treatment to microbes in general—mostly bacteria.
We all know about pathogens, and we all know about gut microbiota and that some (hopefully the majority) there are good for our health. This book covers those things too, but also much more.
Pulitzer Prize-winning science writer Ed Yong takes a big picture view (albeit, of some very small things) and looks at the many ways microbes keep us alive, directly or indirectly. From the microbes that convert certain proteins in breast milk into a form that babies can digest (yes, this means we produce nutrients in breast milk that have been evolved solely to feed that bacterium), to those without which agriculture would simply not work, we’re brought to realize how much our continued existence is contingent on our trillions of tiny friends.
The style throughout is easy-reading pop-science, very accessible. There’s also plenty in terms of practical take-away value, when it comes to adjusting our modern lives to better optimize the benefits we get from microbes—inside and out.
Bottom line: if you’d like to learn about the role of microbes in our life beyond “these ones are pathogens” and “these ones help our digestion”, this is the book for you.
Click here to check out I Contain Multitudes, and learn more about yours and those around you!
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PCOS Repair Protocol – by Tamika Woods
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PCOS (Polycystic Ovary Syndrome) affects about 1 in 5 women, and the general position of the medical establishment is “Oh dear, how sad; never mind”.
…which leaves a lot of people suffering with symptoms with little to no help.
This book looks to address that, and while it doesn’t claim to cure PCOS, it offers a system for managing (including: reducing) the symptoms. The author, a clinical nutritionist by academic background, tackles this in large part via being mindful about what one eats, in the context of the gut and endocrine system specifically.
It’s not just “have a gut healthy diet and eat foods with these nutrients”, though (although yes: also that). Rather, the author walks us through in-depth quizzes and lab testing advice, to advise the reader on how to understand the root cause of your PCOS symptoms, and then address each of those with an individualized management plan.
The style is on the low-end of pop-science, notwithstanding the clinically-informed content. For those who like a very chatty informal approach, you’ll find this one perfect. For those who don’t, well, you won’t find this one perfect, but you will most likely find it informative all the same.
Bottom line: if you or someone you care about (do you know 5 women?) has PCOS, the information in here could make a difference.
Click here to check out PCOS Repair Protocol, and suffer less!
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