Stephen_Faraone_PhD_ADHD_in_AdultsEditor’s Note:  It is important to read the FULL Blog post.

Suicide is one of the most feared outcomes of any psychiatric condition.  Although its association with depression is well known, a small but growing research literature shows that ADHD is also a risk factor for suicidality.  

Suicide is difficult to study. Because it is relatively rare, large samples of patients are needed to make definitive statements.  Studies of suicide and ADHD must also consider the possibility that medications might elevate that risk. 

For example, the FDA placed a black box warning on atomoxetine because that ADHD medication had been shown to increase suicidal risk in youth.   A recent study of 37,936 patients with ADHD now provides much insight into these issues (Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B. M., Lichtenstein, P. & Larsson, H. (2014). Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348, g3769.).    In Sweden, such large studies are possible because researchers have computerized medical registers that describe the disorders and treatments of all people in Sweden.  Among 37,936 patients with ADHD, 7019 suicide attempts or completed suicides occurred during 150,721 person years of follow-up.  This indicates that, in any given year, the risk for a suicidal event is about 5%. 

 

Ask the ADHD Experts  Prescribing ADHD Medications

For ADHD patients, the risk for a suicide event is about 30% greater than for non-ADHD patients.  Among the ADHD patients who attempted or completed suicide,the risk was increased for those who had also been diagnosed with a mood disorder, conduct disorder, substance abuse or borderline personality.  This is not surprising; the most serious and complicated cases of ADHD are those that have the greatest risk for suicidal events.  

The effects of medication were less clear.   The risk for suicide events was greater for ADHD patients who had been treated with non-stimulant medication compared with those who had not been treated with non-stimulant medication.  A similar comparison showed no effect of stimulant medications. 

This first analysis suffers from the fact that the probability of receiving medication increases with the severity of the disorder.  To address this problem, the researchers limited the analyses to ADHD patients who had had some medication treatment and then compared suicidal risk between periods of medication treatment and periods of no medication treatment.  This analysis found no increased risk for suicide from non-stimulant medications and, more importantly, found that for patients treated with stimulants, the risk for suicide was lower when they were taking stimulant medications.  This protective effect of stimulant medication provides further evidence of the long-term effects of stimulant medications which have also been shown to lower the risks for traffic accidents, criminality, smoking and other substance use disorders.

http://medicalwritingtraining.com/Raising children is not easy. I should know. As a clinical psychologist, I’ve helped parents learn the skills they need to be better parents. And my experience raising three children confirmed my clinical experience. Parenting is a tough job under the best of circumstances but it is even harder if the parent has ADHD. For example, an effective parent establishes rules and enforces them systematically. This requires attention to detail, self-control and good organizational skills. Given these requirements, it is easy to see how ADHD symptoms interfere with parenting. These observations have led some of my colleagues to test the theory that treating ADHD adults with medication would improve their parenting skills. I know about two studies that tested this idea. In 2008, Dr. Chronis-Toscano and colleagues published a study using a sustained release form of methylphenidate for mothers with ADHD. As expected, the medication decreased their symptoms of inattention and hyperactivity/impulsivity. The medication also reduced the mothers use of inconsistent discipline and corporal punishment and improved their monitoring and supervision of their children. In a 2014 study, Waxmonsky and colleagues observed ADHD adults and their children in a laboratory setting once when the adults were off medication and once when they were on medication. They used the same sustained release form of amphetamine for all the patients. As expected, the medications reduced ADHD symptoms in the parents. This laboratory study is especially informative because the researchers made objective ratings of parent-child interactions rather than relying on the parent’s report of those interactions. Twenty parents completed the study. The medication led to less negative talk and commands and more praise by parents. It also reduced negative and inappropriate behaviors in their children. Both studies suggest that treating ADHD adults with medication will improve their parenting skills. That is good news. But they also found that not all parenting behaviors improved. That makes sense. Parenting is a skill that must be learned. Because ADHD interferes with learning, parents with the disorder need time to learn these skills. Medication can eliminate some of the worst behaviors but doctors should also provide the adjunct behavioral or cognitive behavioral therapies that could help ADHD parents learn parenting skills and achieve their full potential as parents.
 

REFERENCES
Chronis-Tuscano, A., K. E. Seymour, et al. (2008). “Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting.” J Clin Psychiatry 69(12): 1938-1947.
Waxmonsky, J. G., D. A. Waschbusch, et al. (2014). “Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial.” CNS Drugs 28(7): 665-677.

Stephen_Faraone_PhD_AIA_2016_XM7MQd

Adult ADHD is a Risk Factor for Broken Bones

Although some people view the impulsivity and inattentiveness of ADHD adults as a normal trait, these symptoms have adverse consequences, which is why doctors consider ADHD to be a disorder. The list of adverse consequences is long and now we can add another: broken bones.   A recent study by Komurcu and colleagues examined 40 patients who were seen by doctors because of broken bones and 40 people who had not broken a bone.  After measuring ADHD symptoms in these patients, the study found that the patients with broken bones were more impulsive and inattentive than those without broken bones.

These data suggest that, compared with others, adults with ADHD symptoms put themselves in situations that lead to broken bones.  What could those situations be?  Well, we know for starters that ADHD adults are more likely to have traffic accidents.   They are also more likely to get into fights due to their impulsivity.   As a general observation, it makes sense that people who are inattentive are more likely to have accidents that lead to injuries.  When we don’t pay attention, we can put ourselves in dangerous situations. 

Who should care about these results?  ADHD adult patients need to know about this so that they understand the potential consequences of their disorder.  They are exposed to so much media attention to the dangers of drug treatment that it can be easy to forget that non-treatment also has consequences.  Cognitive behavior therapy is CBT_treats_Executive_Dysfunction_Free_ADHD_CME_CJkZtualso useful for helping patients learn how to avoid situations that might lead to accidents and broken bones.

This study also has an important message for insurance administrators and how they make decisions about subsidizing or reimbursing treatment for ADHD.  They need to know that treating ADHD can prevent outcomes that are costly to the healthcare system, such as broken bones.   For example, in a study of children and adolescents, Leibson and colleagues showed that healthcare costs for ADHD patients were twice the cost for other youth, partly due to more hospitalizations and more emergency room visits. 

Do these data mean that every ADHD patient is doomed to a life of injury and hospital visits?   Certainly not.  But they do mean that patients and their loved ones need to be cautious and need to seek treatments that can limit the possibility of accidents and injury.

REFERENCES

Komurcu, E., Bilgic, A. & Herguner, S. (2014). Relationship between extremity fractures and attention-deficit/hyperactivity disorder symptomatology in adults. Int J Psychiatry Med 47, 55-63.

Leibson, C. L., S. K. Katusic, et al. (2001). “Use and Costs of Medical Care for Children and Adolescents With and Without Attention-Deficit/Hyperactivity Disorder.” Journal of the American Medical Association 285(1): 60-66.

Stephen_Faraone_PhD_AIA_2016_XM7MQd.png.jpgADHD itself is associated with sleep difficulties, independent of ADHD medications. Thus, it is very important that sleep quality is assessed prior to treatment so that the changes due to treatment can be correctly inferred.

In clinical trials of stimulant medications for ADHD, insomnia is typically noted a side effect of the medications. But most of these studies have used subjective patient or parent reports of sleep quality. A new meta analysis, reviews 9 studies of a total of 246 patients enrolled in randomized controlled trials of a stimulant medication. To be included, studies must have had an objective measure of sleep quality, either polysomnography or actigraphy. The analysis showed that stimulant medications led to a) a longer time to get to sleep; b) worse sleep efficiency and c) a shorter duration of sleep. Some of these sleep measures worsened with an increasing number of doses and a shorter time on medication.
Given the adverse effects that lack of sleep can have on cognition and behavior, these data provide further impetus for clinicians, parents and patients to monitor the effects of stimulant ADHD medication on sleep and to take appropriate action (e.g., dose reduction, change of medication) as warranted.
 

REFERENCES
http://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+26598454
http://www.ncbi.nlm.nih.gov/pubmed/?term=cortese%5Bau%5D+sleep%5Bti%5D+meta%5Bti%5D

Stephen_Faraone_PhD_ADHD_in_Adults

ADHD itself is associated with sleep difficulties, independent of ADHD medications. Thus, it is very important that sleep quality is assessed prior to treatment so that the changes due to treatment can be correctly inferred.

(Editor’s Note: See our Ask the ADHD Experts session on ADHD and Sleep.)

In clinical trials of stimulant ADHD medications, insomnia is typically noted a side effect of the medications. But most of these studies have used subjective patient or parent reports of sleep quality. A new meta analysis, reviews 9 studies of a total of 246 patients enrolled in randomized controlled trials of a stimulant medication.

Ask_the_ADHD_Experts_-_Prescribing_MedicationsTo be included, studies must have had an objective measure of sleep quality, either polysomnography or actigraphy. The analysis showed that stimulant medications led to a) a longer time to get to sleep; b) worse sleep efficiency and c) a shorter duration of sleep. Some of these sleep measures worsened with an increasing number of doses and a shorter time on medication.

Given the adverse effects that lack of sleep can have on cognition and behavior, these data provide further impetus for clinicians, parents and patients to monitor the effects of stimulant ADHD medication on sleep and to take appropriate action (e.g., dose reduction, change of medication) as warranted.

REFERENCES

J Am Acad Child Adolesc Psychiatry. 2009 Sep;48(9):894-908. doi: 10.1097/CHI.0b013e3181ac09c9.
Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies.
Cortese S1, Faraone SV, Konofal E, Lecendreux M.

Pediatrics. 2015 Dec;136(6):1144-53. doi: 10.1542/peds.2015-1708.
Stimulant Medications and Sleep for Youth With ADHD: A Meta-analysis.
Kidwell KM1, Van Dyk TR2, Lundahl A2, Nelson TD2.

http://medicalwritingtraining.com/Professor Larry Seidman is world renowned for his neuropsychology and neuroimaging research. In addition to all of his creative science, he has found the time to create what he calls “Neuropsychologically Informed Strategic Psychotherapy (NISP) in Teenagers and Adults with ADHD.” Let’s start with what NISP is not. NISP is not cognitive behavior therapy (CBT). CBT emphasizes teaching patients to identify thinking patterns that lead to problem behaviors. NISP describes how the interpersonal interaction we call psychotherapy can help patients increase self-regulation and self-control. NISP treatments vary in duration from brief psycho-educational interventions of one to five sessions to much longer term therapies of indefinite duration. The duration of therapy is tailored to the needs and goals of the individual. The methods of NISP can be adaptively applied into well-known therapy modalities such as CBT and family therapy. By creating a solid therapeutic alliance, NISP improves adherence to medications and addresses ADHD’s psychiatric comorbidities and functional disabilities. NISP is “neuropsychologically informed” because it follows a comprehensive neuropsychological assessment of strengths and weaknesses. This leaves the therapist with an understanding of the patient’s personal experience of ADHD, the meaning of the disorder, how it affects self-esteem, and how cognitive deficits limit the ability to self-regulate and adapt to changing circumstances. Attending to the patient’s strengths is a key feature of Prof. Seidman’s method. ADHD is a disorder and it usually has serious consequences. But ADHD people also have strong points in their character and their neuropsychological skills. These sometimes get lost in assessments of ADHD but, as Dr. Seidman indicates, by addressing strengths, patient outcomes can be improved. A NISP assessment also seeks to learn about the psychological themes that underlie each patient’s story. He gives the all too common example of the patients who view themselves as failed children who have not tried hard enough to succeed. A frank discussion of neuropsychological test results can be the first step to helping patients reconceptualize their past and move on to an adaptive path of self-understanding and self-regulation.

Prof. Seidman’s approach seems sensible and promising. As he recognizes, it has not yet, however, been subject to the rigorous tests of evidenced-based medicine (my blog on EBM: http://tinyurl.com/ne4t7op). So I would not recommend using it as a replacement for an evidenced-based treatment. That said, if you are a psychotherapist who treats ADHD people, read Prof. Seidman’s paper. It will give you useful insights that will help your patients.

 
REFERENCES
Seidman, L. J. (2014). Neuropsychologically Informed Strategic Psychotherapy in Teenagers and Adults with ADHD. Child Adolesc Psychiatr Clin N Am 23, 843-852. (In: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.)

Stephen Faraone, PhD, ADHD in AdultsMany ADHD myths have been manufactured over the years.  Facts that are clear and compelling to most scientists and doctors have been distorted or discarded from popular media discussions of the disorder.   Sometimes, the popular media seems motivated by the maxim “Never let the facts get in the way of a good story.”  That’s fine for storytellers, but it is not acceptable for serious and useful discussions about ADHD.

ADHD Myths are easy to find.  These myths have confused patients and parents and undermined the ability  of professionals to appropriately treat the disorder.   When patients or parents get the idea that the diagnosis of ADHD is a subjective invention of doctors, or that ADHD medications cause drug abuse, that makes it less likely they will seek treatment and will increase their chances of having adverse outcomes.

Fortunately, as John Adams famously said of the Boston Massacre, “Facts are stubborn things.”  And science is a stubborn enterprise; it does not tolerate shoddy research or opinions not supported by fact.   ADHD scientists have addressed many of the myths about the disorder in the International Consensus Statement on ADHD, a published summary of scientific facts about ADHD endorsed by a of 75 international ADHD scientists in 2002.  The statement describes evidence for the validity of ADHD, the existence of genetic and neurobiologic causes for the disorder and the range and severity of impairments caused by the disorder.

Download The Consensus Statement

The Statement makes several key points:

  • The U.S. Surgeon General, the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, and the American Academy of Pediatrics recognize ADHD as a valid disorder.
  • ADHD involves a serious deficiency in a set of psychological abilities and that these deficiencies pose serious harm to most individuals possessing the disorder.
  • Many studies show that the psychological deficits in people with ADHD are associated with abnormalities in several specific brain regions.
  • The genetic contribution to ADHD is routinely found to be among the highest for any psychiatric disorders.
  • ADHD is not a benign disorder. For those it afflicts, it can cause devastating problems.
  • Hundreds of studies have shown the effectiveness of ADHD medications and multiple therapies.

The facts about ADHD will prevail if you take the time to learn about them.   This can be difficult when faced with a media blitz of information and misinformation about the disorder.  In future blogs, I’ll separate the ADHD facts from the fiction by addressing several popular myths about ADHD.

Editor’s note:  Our Ask the ADHD Experts sessions are designed specifically for experts to present updates and the latest unbiased research information on ADHD and related disorders.  Ask your questions.  Get them answered.  Subscribe and learn.

http://medicalwritingtraining.com/As a researcher who has devoted most of the past three decades to studying ADHD, I am surprised (and somewhat embarrassed) to see how little research has focused on how ADHD affects the romantic side of life. There are over 25,000 articles about ADHD listed on www.pubmed.gov, but only a few have provided data about love, sex and ADHD. Bruner and colleagues studied ADHD symptoms and romantic relationship quality in 189 college students. Those students who had high levels of both hyperactivity-impulsivity and inattentiveness reported that the quality of their romantic relationships was relatively low compared with students who had low levels of ADHD symptoms. Another study of 497 college students found that ADHD symptoms predicted a greater use of maladaptive coping strategies in romantic relationships and less romantic satisfaction. A study of young adults compared conflict resolution and problem-solving in romantic couples. It found that ADHD symptoms were associated with greater negativity and less positivity during a conflict resolution task and that higher symptoms predicted less relational satisfaction. But this was not true of the ADHD member of the couple only had inattentive symptoms, which suggests that the severity of ADHD symptoms might drive relationship problems. Unlike the studies of adults, the romantic relationships of adolescents with and without ADHD did not differ on levels of aggression or relationship quality, although only one study addressed this issue.

What about sex? The study of adolescents found that, irrespective of gender, adolescents with ADHD had nearly double the number of lifetime sexual partners. That finding is consistent with Barkley’s follow-up study of ADHD children. He and his colleagues found that ADHD predicted early sexual activity and early parenthood. Similar findings were reported by Flory and colleagues in retrospective study of young adults. Childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. When my colleagues and I studied 1001 adults in the community, we found that adults with ADHD endorsed less stability in their love relationships, felt less able to provide emotional support to their loved ones, experienced more sexual dysfunction and had higher divorce rates.

The research literature about love, sex and ADHD is small, but it is consistent.

 
REFERENCES
Bruner, M. R., A. D. Kuryluk, et al. (2014). “Attention-Deficit/Hyperactivity Disorder Symptom Levels and Romantic Relationship Quality in College Students.” J Am Coll Health: 1-11.
Biederman, J., S. V. Faraone, et al. (2006). “Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community.” J Clin Psychiatry 67(4): 524-540.
Canu, W. H., L. S. Tabor, et al. (2014). “Young Adult Romantic Couples’ Conflict Resolution and Satisfaction Varies with Partner’s Attention-Deficit/Hyperactivity Disorder Type.” J Marital Fam Ther 40(4): 509-524.
Rokeach, A. and J. Wiener (2014). “The Romantic Relationships of Adolescents With ADHD.” J Atten Disord.
Barkley, R. A., M. Fischer, et al. (2006). “Young adult outcome of hyperactive children: adaptive functioning in major life activities.” J Am Acad Child Adolesc Psychiatry 45(2): 192-202.
Flory, K., B. S. Molina, et al. (2006). “Childhood ADHD predicts risky sexual behavior in young adulthood.” J Clin Child Adolesc Psychol 35(4): 571-577.
Overbey, G. A., W. E. Snell, Jr., et al. (2011). “Subclinical ADHD, stress, and coping in romantic relationships of university students.” J Atten Disord 15(1): 67-78.

http://medicalwritingtraining.com/It sounds like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention. Two main approaches have been used: cognitive training and neurofeedback.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses. Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain. The idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process. Cognitive retraining helps people who have suffered brain damage, so was logical to think it might help the types of brain differences seen in ADHD people. Several software packages have been created to deliver cognitive training sessions to ADHD people. You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG). We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information. Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms. In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head. The patient is asked to do a task on the computer that is known to produce a specific type of brain wave. The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are. By modifying their behavior, patients learn to change their brain waves. The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied. If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine. My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals. The highest level of evidence is a meta-analysis of randomized controlled clinical trials. For my lay readers, that means that many rigorous studies have been conducted and summarized with a sophisticated mathematical method. Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms. They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective. You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.

Stephen_Faraone_PhD_ADHD_in_AdultsIt sounds like science fiction, but scientists have been testing computerized methods to train the brains of ADHD people with the goal of reducing both ADHD symptoms and cognitive deficits such as difficulties with memory or attention.   Two main approaches have been used: cognitive training and neurofeedback.  This of course is in addition to, not a replacement for, ADHD medications.

Cognitive training methods ask patients to practice tasks aimed at teaching specific skills such as retaining information in memory or inhibiting impulsive responses.  Currently, results from ADHD brain studies suggests that the ADHD brain is not very different from the non-ADHD brain, but that ADHD leads to small differences in the structure, organization and functioning of the brain.  CBT_rubricThe idea behind cognitive training is that the brain can be reorganized to accomplish tasks through a structured learning process.  Cognitive retraining helps people who have suffered brain damage, so was logical to think it might help the types of brain differences seen in ADHD people.  Several software packages have been created  to deliver cognitive training sessions to ADHD people.  You can read more about these methods here: Sonuga-Barke, E., D. Brandeis, et al. (2014). “Computer-based cognitive training for ADHD: a review of current evidence.” Child Adolesc Psychiatr Clin N Am 23(4): 807-824.

Neurofeedback was applied to ADHD after it had been observed, in many studies, that people with ADHD have unusual brain waves as measured by the electroencephalogram (EEG).  We believe that these unusual brain waves are caused by the different way that the ADHD brain processes information. 

Because these differences lead to problems with memory, attention, inhibiting responses and other areas of cognition and behavior, it was believed that normalizing the brain waves might reduce ADHD symptoms.  In a neurofeedback session, patients sit with a computer that reads their brain waves via wires connected to their head.  The patient is asked to do a task on the computer that is known to produce a specific type of brain wave.   The computer gives feedback via sound or a visual on the computer screen that tells the patient how ‘normal’ their brain waves are.  By modifying their behavior, patients learn to change their brain waves.  The method is called neurofeedback because it gives patients direct feedback about how their brains are processing information.

Both cognitive training and neurofeedback have been extensively studied.  If you’ve been reading my blogs about ADHD, you know that I play by the rules of evidenced based medicine.  My view is that the only way to be sure that a treatment ‘works’ is to see what researchers have published in scientific journals.   The highest level of evidence is a meta-analysis of randomized controlled clinical trials.   For my lay readers, that means that many rigorous studies have been conducted and summarized with a sophisticated mathematical method.   Although both cognitive training and neurofeedback are rational methods based on good science, meta-analyses suggest that they are not helpful for reducing ADHD symptoms.  They may be helpful for specific problems such as problems with memory, but more work is needed to be certain if that is true.

The future may bring better news about these methods if they are modified and become more effective.  You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.

As a reminder, adult ADHD tests can be administered easily and effectively to measure the effect of various approaches on ADHD symptoms in adults.

Cognitive Behavioral Therapy treats Executive Dysfunction