Dear Dr. Quinn,
I am writing to you as a father whose 15-year-old daughter has the inattentive subtype of ADD. She has always been a “low energy” person, and currently, despite a regimen of Zoloft 150 mg. and Concerta 36 mg. she still often complains of fatigue. Medical work-up (anemia, thyroid, etc.) has all been normal.
Is this a phenomenon you have, in your medical experience, commonly observed, and if so, how have you approached it — biologically, psychosocially? The symptom itself interferes with her motivation to participate in the flow of life.
The work of you and your colleagues is providing a very valuable public service.
The situation you write about is common in girls with AD/HD, particularly the inattentive subtype. Dr. Russell Barkley has spoken about this and describes this type of ADD as having a “Sluggish Cognitive Tempo.” In a discussion on addconsults, here’s what he says about it: “Accumulating research is suggesting that a subset of AD/HD children qualifying for the Inattentive Type may have qualitatively distinct symptoms, comorbid disorders, and impairments than do Combined Type children.
“Evidence suggests that this subgroup may comprise 30 percent or more of children now placed in the Inattentive Type. This subset of children appears to manifest deficits in information processing in which they are sluggish, error prone, and poor at selective attention tasks.
“Clinically, they are described as having an increased level of lethargy, hypo-activity, daydreaming, spaciness, mental confusion or fogginess, and forgetfulness.
“As a result, they have been dubbed by some researchers as Sluggish Cognitive Tempo, or SCT. Not all children with the Inattentive Type of ADHD have SCT. Indeed, most probably do not. Those children and adults may simply be individuals who formerly had the Combined Type of ADHD but by virtue of further development, go on to lose some hyperactive symptoms such that they cannot qualify for the Combined Type any longer.
“They are thus switched to the Inattentive Type but should really be clinically conceptualized as being Combined Types (subthreshhold, or borderline, if you prefer).
“Others in the Inattentive Type are simply children with 11 symptoms of the Combined Type (6 inattention, 5 hyperactive-impulsive) who come up one symptom short of being called Combined Types. Again, they are best off thought of as borderline or subthreshhold Combined Types.
“But the sizeable SCT subset of Inattentive Type children seems to be quite different. They are often characterized socially as passive, reticent, and even apprehensive or shy. They may manifest more symptoms of anxiety or other internalizing symptoms, though these findings are still equivocal.
“They are much less prone to oppositional disorder and conduct disorder. While they have comparable levels of impairment in school settings the nature of those impairments may differ, with Combined Type children being more disruptive and not very productive while SCT children are more passive, withdrawn, prone to errors in their work, and far less disruptive.
“The few extant studies of treatment of these children suggest they may not be as responsive to stimulants as children with Combined Type disorder yet may be more responsive to social skills training and possibly other behavioral interventions. One recent study goes so far as to suggest that this SCT subset not be placed in social skills groups with Combined Type AD/HD children if the latter children manifest a propensity for antisocial behavior or early conduct disorder symptoms as some of the SCT children may actually acquire antisocial behavior by this formation of a deviant peer group in the clinic.
“Much more research needs to be done on this subset of inattentive children but most researchers today accept that they have some qualitative differences from other children with AD/HD. Some even believe that the evidence is sufficient to place them in a separate category of disorder (yours truly), while others argue for keeping them as a distinct subtype of AD/HD.”
I agree with this characterization and have found that some of these children actually need higher doses of stimulants. Given your daughter’s age, 36 mg of Concerta appears to be a low dose. One-third of all teens in a recent study with Concerta needed 72 mg to reduce symptoms.
I am glad to see that your daughter has had a medical work-up and that she is healthy. Another avenue to consider, however, is sleep deprivation. Many individuals with AD/HD do not get enough REM sleep. They had difficulty falling asleep, have frequent night wakings, and feel tired and have difficulty awakening in the morning. They then have excessive daytime sleepiness. Many women are put on Provigil for this or self-medicate with excessive amounts of caffeine.
Perhaps your daughter falls in this category. If so, you can improve her sleep by treating her with stimulants at bedtime as well. We are recommending another dose of Concerta in the late afternoon, so that it is still effective at bedtime and through the night allowing the patient to fall asleep and stay asleep. If she can nap during the day on her meds, there should be no problem giving them later in the day and it may solve her sleep problems.
Please keep in touch. Best wishes to you and your daughter.
Patricia O. Quinn, M.D.