Anthony L. Rostain, MD MA – Page 2

College Students and Risky Behavior

Anthony L. Rostain, MD MA on April 9, 2015

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR. “ADHD Symptomatology and Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.

This study explores the relative contributions of “top-down” (i.e. effortful control) and “bottom up” (i.e. sensation seeking) mental processes to maladaptive risky behaviors in college students with ADHD. The authors review these constructs by pointing out that effortful aspects of self-regulation involve intact prefrontal circuits underlying executive functions whereas reactive behaviors not requiring conscious mental resources are influenced by emotional stimuli and are mediated by subcortical brain structures. Given that ADHD involves difficulties in both these domains of psychological functioning, it makes sense to explore which contribute to the onset of maladaptive risk-taking in college students with ADHD.

The authors studied 555 college students attending a southeastern university using an online survey for which they received class credit. Participants filled out standardized rating scales to assess outcomes. Of the total sample, 5.7% reported a history of an ADHD diagnosis and 10.8% reported elevated ADHD symptoms (> 1.5 SD above the mean) on an ADHD rating scale. There were two distinct patterns of risk behaviors: risky driving/financial behaviors and risky health behaviors. ADHD symptoms were highly correlated with these two factors as well as with sensation seeking and effortful control. More ADHD symptoms were associated with risky behaviors ONLY when effortful control was low. Sensation seeking was more highly associated with risky health behaviors but not risky driving/financial behaviors.

The authors note that the study’s reliance on self-report scales and measures limits its validity. ADHD individuals are known to underreport severity of symptoms. Moreover, it was not possible to detect the presence of antisocial behaviors (e.g. Conduct Disorder) that might have a greater impact on risky behaviors than ADHD symptoms. Finally, the fact that the study was conducted on a single campus may limit the generalizability of its findings to the entire population of US college students.

Despite these limitations, this paper reports interesting results suggesting that ADHD symptoms may not be as important as effortful control deficits and as high stimulus seeking in mediating the onset of risk behaviors in this population. These could be important targets for psychological therapies. It also points to the relevance of these two aspects of psychological functioning for preventive health efforts to reduce health, driving and financial risk behaviors, and for clinical approaches to dealing with patients presenting with maladaptive coping mechanisms.

ADHD and Risky Behavior in Adults

Anthony L. Rostain, MD MA on April 9, 2015

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR. “ADHD Symptomatology andTony_Rostain_AIA-5Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.

Dialetical Behavior Therapy, College Students, and ADHD

Anthony L. Rostain, MD MA on March 18, 2015

J Atten Disord. 2015 Mar;19(3):260-7. DOI: 10.1177/1087054714535951
“Pilot Randomized Controlled Trial of Dialectical Behavior Therapy Group Skills Training for ADHD Among College Students”
Fleming, A.P., McMahon, R.J., Moran, L.R., Peterson, A.P., Dreessen, A.

This article reports on the results of the first randomized controlled clinical trial of treatment program for college students with ADHD. Thirty-three college students with ADHD between the ages of 18 and 24 years were randomized to receive either group administered Dialectical Behavior Therapy (DBT) supplemented by individualized week coaching phone calls or a skills handouts (SH) intervention based on a published manual for adults with ADHD. The DBT intervention consisted of eight weekly 90 minute sessions and seven weekly 10-15 minute individual coaching phone calls designed to assist participants to address key areas of difficulty. A booster session was offered to subjects during the first week of the following academic quarter. Session topics included psycho-education about ADHD, mindfulness, daily planner use, chunking tasks, prioritization, structuring the environment, using social support, managing sleep, eating and exercise, emotion regulation, and troubleshooting about skills use. The SH material topics included psycho-education about ADHD and executive functioning, organization, planning, time management, structuring the environment and stress management. Outcome measures included the Barkley Adult ADHD Rating Scale IV (symptom measurement), the Brown ADD Rating Scales (as a proxy for executive functioning), the ADHD Qualify of Life Questionnaire, the Beck Depression and Anxiety Inventories, the Fie Facet Mindfulness Questionnaire, the subject’s GPA from the academic quarter prior to each assessment point, and performance on the Conners’ Continuous Performance Task (CPT). Both groups had similar baseline measures and treatment completion rates. At the conclusion of the study, compared to the SH participants, subjects receiving DBT and coaching phone calls showed significant improvement in treatment response rates (59-65% v 19-25%) and clinical recovery rates (53-59% v 6-13%). At follow up, DBT subjects showed greater improvements in ADHD symptoms, executive functioning and mindfulness. No differences between groups were seen in comorbid symptoms, GPA or on CPT measures, although a trend toward significance was reported. Of note, subjects in the SH group did have a treatment response rate of 25% which suggests this may be a cost effective alternative. Participants in the DBT group reported that mindfulness, planning and organization were the most helpful aspects of the program. Overall, these are promising results from a small RCT of a structured group-administered skills training program for college students with ADHD. While it is important to replicate this intervention on a broader scale, these results suggest that programs of this sort should be made more widely available to this population.

Oros Methylphenidate, ADHD and Executive Function Deficits

Anthony L. Rostain, MD MA on March 12, 2015

Proven ADHD Medications for Adults – OROS-methylphenidate

Many studies have documented that ADHD patients have difficulties with the type of complex brain processes neurologists call “Executive Functions” (EF). A 2011 study of ADHD in Adults for example found roughly 40% have executive function deficits (EFDs) (Biederman, et al. 2011). EFs help us organize our lives, manage time, remember complex material and complete complex sequences of behavior. A deficit in executive function is therefore one of the common symptoms of Adult ADHD.
A recent study on medication for ADHD in adults examines the effects of OROS-methylphenidate on executive function deficits (EFDs) (Tannetje I. et al.. “OROS-methylphenidate efficacy on specific executive functioning deficits in adults with ADHD: A randomized, placebo-controlled cross-over study.” European Neuropsychopharma-cology. Available online 17 January 2014, ISSN 0924-977X. http://dx.doi.org/10.1016/j.euroneuro.2014.01.007). The authors used a randomized, placebo-controlled cross-over design to examine the effects of a 72 mg dose of OROS-MPH on 22 subjects’ performance on two versions of the Continuous Performance Test (CPT), a measure of sustained attention and working memory.

Study subjects were stimulant medication-naive. 25% had no Continuous Performance Test (CPT) deficits, 50% had a few CPT deficits, and 25% had multiple deficits, which is consistent with the Biederman study previously noted. Compared with placebo, OROS-MPH improved performance only on reaction time variability (RTV), a measure of sustained attention. High RTV indicates a deficit in information processing and functional integration. Patients with higher EFDs and more severe ADHD symptoms had a better response to medication. Differences in commission errors and discriminative ability between placebo vs OROS-MPH individuals were not noted. In addition, there was a poor relationship between objective and subjective efficacy of the medication.

The findings of this well designed experimental study are interesting in several ways. First, even with a small sample, robust effects of OROS-MPH vs. placebo were seen on Response Time Variability (RTV). In individuals with ADHD, RTV has been shown to be highly responsive to stimulant medication (Kofler, et al, 2012). This study confirms this finding.
Second, this study validates the use of an objective neurocognitive test to measure the responsiveness of adults with ADHD to pharmacologic treatment. An objective test of medication response could help to allay public health concerns about ADHD treatment options and the safety and efficacy of stimulant medications for ADHD symptoms in adults.

Thirdly, the RTV finding is compelling. While there remains a great deal of controversy about the role of EFDs in the etiology of ADHD, it is reasonable to assert that RTV has a great deal of salience to the phenomenology of the disorder, especially in adults. Indeed, trouble maintaining sustained attention is the most common subjective complaint reported by adults with ADHD, and is arguably the most constant neurocognitive impairment seen in this population. Clearly it is not unique to ADHD, but it certainly comprises a core feature of the disorder, and has become a central construct in neuropsychological and neuroimaging research.

The authors are honest in their appraisal of the limitations of the study (most notably the small sample size and the heterogeneity of sample subjects’ performance on the CPT at baseline), and they are very reasonable in recommending that more research be undertaken to document the clinical relevance of using the CPT in patient care, as well as to extend our understanding of the underlying neuropsychology of ADHD.

References
Biederman J, Mick E, Fried R, Wilner N, Spencer TJ, Faraone SV (2011). “Are stimulants effective in the treatment of executive function deficits? Results from a randomized double blind study of OROS-methylphenidate in adults with ADHD.” Eur. Neuropsychopharmacol., 21: 508–515.
Kofler MJ, Rapport MD, Sarver DE, Raiker JS, Orban SA, Friedman LM, E.G. Kolomeyer EG (2013). “Reaction time variability in ADHD: a meta-analytic review of 319 studies.” Clin. Psychol. Rev., 33 795–811.
Tamm, L, Narad ME, Antonini TN, O’Brien KM, Hawk Jr. LW, J.N. Epstein JN (2012). “Reaction time variability in ADHD: a review.” Neurotherapeutics: J. Am. Soc. Exp. NeuroTherapeutics, 9: 500–508.

One Year on ADHD Medications

Anthony L. Rostain, MD MA on February 19, 2015

Fredriksen M, Dahl AA, Martinsen EW, Klungsoyr O, Haavik J, Peleikis DE “Effectiveness of one-year pharmacological treatment of adult attention-deficit/hyperactivity disorder (ADHD): An open-label prospective study of time in treatment, dose, side-effects and comorbidity.” European Neuropsychopharm 2014 24: 1873-1884.

This new study from Norway provides useful information about the long-term drug treatment of adult ADHD. Prior studies are small, of short duration (e.g. 4-10 weeks) or have problems with high dropout rates or selection biases (i.e. patients with comorbid conditions are often excluded). This naturalistic study examined 250 patients treated with ADHD drugs for one year.
The patients had a mean age of 32.6 years, virtually all of whom (98%) had never been previously diagnosed with ADHD, and none of whom had received prior treatment. Diagnoses and assessments of outcomes were conducted with state-of-the-art methods. Exclusion criteria included any major psychiatric disorder considered to be in immediate need of treatment, any medical contraindications to stimulant treatment, prior use of stimulant medication in adulthood, and the presence of autism spectrum disorder or intellectual disability (IQ < 70).

All study subjects received methylphenidate (MPH) as the first-line medication. Doses were flexibly titrated from 5 mg three times daily to 20 mg three times daily in the in the first six weeks, and to a maximum of 40 mg three times daily during the subsequent study period (one year). Extended-release MPH was offered at the 3-month visit and dosage could be decreased if subjects experienced intolerance. If MPH was not tolerated or ineffective, two alternative medications were offered: d-amphetamine (up to 50 mg daily) or atomoxetine (in doses ranging from 25 mg to 120 mg daily). Outcome measures were obtained at 3, 6 and 12 months after the initiation of treatment. In addition, all subjects received psychoeducational supportive counseling at all follow up visits.

At the end of 12 months, 92% of subjects (N=232) completed the study and 70% (N=163) remained on a medication. Of those on medication, 79% were taking MPH, 15% were taking d-amphetamine, and 6% were on atomoxetine. Mean daily dosages of medications prescribed (60 mg, 30 mg and 40 mg respectively) suggests the subjects were adequately treated. Given the small number of subjects on d- amphetamine or atomoxetine, drug-drug comparisons of treatment effects could not be carried out.

Overall, subjects still taking medication at the end of the 12 month study period were significantly more improved with respect to their ADHD symptoms and had better functional outcomes compared to those who either discontinued treatment or were never medicated. Subjects on the highest doses reported the best outcomes, and an inverse relationship was observed between side effects and effectiveness of treatment. Interestingly, the outcomes of those who discontinued were intermediate between those who never started a medication and those who stayed on one. Prominence of side effects was cited as the most likely reason for stopping medication (almost half), and discontinuation of treatment occurred most often during the first six weeks of treatment. Comorbid anxiety and bipolar disorders, non-alcohol substance use disorders and cumulative amounts of side effects were associated with less effectiveness.

This study was well designed, excellently implemented and comprised of a large enough sample to be of significance to practicing clinicians. While its open-label design makes it possible that patients on medication were over-estimating the effectiveness of treatment, the results appear consistent with prior studies of this type. Naturalistic studies of treatment effectiveness can be helpful in validating current clinical practices and in setting reasonable expectations for patients and clinicians regarding likely treatment outcomes.

“Does Pharmacological Treatment of ADHD in Adults Enhance Parenting Performance?”

Anthony L. Rostain, MD MA on January 29, 2015

Treatment of ADHD in Adults Enhance Parenting Performance? Results of a Double-Blind Randomized Trial.” CNS Drugs (2014) 28:665-677.

This study examines the impact of pharmacologic treatment of parents with ADHD on their parenting performance. It has long been observed that parental ADHD reduces the efficacy of parenting behaviors and is often associated with higher rates of comorbid problems in their ADHD children (Hinshaw et al, 2000) and with lower response rates to intervention (Sonuga-Barke, et al 2002, Jensen et al, 2007). One prior study (Chronis-Tuscano et al 2010) examined the effects of OROS methylphenidate treatment of mothers with ADHD on parent-child interactions. The results showed some reduction in self-reports of inconsistent discipline and use of corporal punishment. It also found however no significant treatment effects on observed dyadic interactions.

The aim of this investigation was to test the impact of lisdexamfetamine (LDX) on observable parenting behaviors in adults with ADHD using a double-blind randomized design. The study participants consisted of parents of ADHD children (aged 5 – 12 years old) who met criteria for ADHD themselves as measured by the ADHD Rating Scale with adult prompts (>28) and with at least moderate severity on the Clinical Global Impressions Severity Scale. Parents with medical or psychiatric conditions that could be worsened by stimulant medication were excluded from the study. Children were eligible if they met DSM-IV criteria for ADHD along with Oppositional Defiant Disorder or Conduct Disorder, and were excluded if they met criteria for any other mental disorders.

A total of 30 parents (27% male) were enrolled in the study. In the initial open-label three-week LDX trial, subjects were given medication at increasing doses until an optimal dose was determined (either 30, 50 or 70 mg daily). In Phase I, parents were given either placebo or medication during each of the two weeks and were observed in a structured interaction with their children. In Phase II, parents were randomly assigned to receive placebo or medication (at optimal dose) for a 30-day period at the end of which they were assessed during another interaction with their children.

The results of the study revealed that during the parent-child interaction task, parents on LDX versus placebo gave fewer commands, praised their children more, and had children who exhibited lower rates of inappropriate behavior. There was also a trend seen in fewer verbalizations and more responsiveness to their children in parents taking LDX. In addition, lower parental ADHD symptoms at the end of the study period were significantly correlated with greater amounts of giving praise, improved children’s behavior, and reduction in commands given by parents. Side effects reported by subjects in the study were generally mild and well tolerated.

The authors of this paper conclude that LDX helps ADHD parents of children with ADHD to perform better in a structured parent-child interaction task as compared to parents who did not receive LDX. While this is a small N study, the results imply that LDX, an approved long acting stimulant treatment for ADHD in adults, can be helpful for parents of ADHD children who have ADHD themselves by improving their parent-child interactions. It suggests that clinicians should encourage these parents to seek adequate treatment for their ADHD symptoms, and that in so doing, there is a greater likelihood they will be better able to manage their children, and that psychosocial interventions like parent behavior training will be more effective helping ADHD children reduce their negative behaviors.

References

Chronis-Tuscano AM, Rooney M, Seymour KE, et al (2010). Effects of maternal stimulant medication on observed parenting in mother-child dyads with attention-deficit/hyperactivity disorder. J Clin Child Adolesc Psychol 39:581-587.

Hinshaw SP, Owens, EB, Wells KC, et al (2000). Family process and treatment outcome in the MTA: negative/ineffective parenting practices in relation to multimodal treatment. J Abnorm Child Psychol 28:555-568.

Jensen PS, Arnold LE, Swanson JM, et al (2007). Three-year follow up of the NIMH MTA study. JAACAP 46:989-1002.

Sonuga-Barke EJS, Daley D, Thompson M (2002). Does maternal ADHD reduce the effectiveness of parent training for preschool children’s ADHD? JAACAP 41:696-702.

Adherence to Stimulants in Adult ADHD

Anthony L. Rostain, MD MA on January 2, 2015

O’Callaghan, P. “Adherence to stimulants in adult ADHD.” J Atten Def Hyp Disord. (2014) 6:111-120.

This study uses a mixed-method design to investigate the factors that influence stimulant medication adherence in adults with ADHD. The author notes that adherence rates for pharmacotherapy in adults with ADHD is reported to be less than 12% which is a significant concern for clinicians treating this population. Stimulants have been shown to be highly effective in adults with ADHD with more than 70% experiencing a positive response, and with effect sizes in the range of 0.8-0.9 (Faraone, et al, 2006). Despite these impressive results, less than 50% of adult patients prescribed a stimulant medication are taking them after 3 months, and by 18 months, only 20% are still receiving treatment (Weisler, et al, 2006). This study sought to examine the reasons for low adherence using a combination of quantitative and qualitative methods in a sample of 67 adults (67% women) between the age of 19 and 64 years who were recruited from the community. Subjects were given the Adult ADHD Quality of Life Scale (AAQoL) (Brod et al 2005) and were asked if they were taking stimulant medications daily, as needed or not at all. Analysis of the total AAQoL and subscale scores showed no significant differences among the three adherence categories, indicating that adherence to medications was NOT correlated with reported quality of life.

The qualitative phase of the study involved a telephone interview of a subset of 18 adults (61% women) who were queried about their experiences with stimulant medications and about their perceptions of the benefits and adverse effects of taking them. They were also asked to explain how they made the decision to use or not use stimulants. The responses were examined using a thematic analysis program that classified the subjects’ answers into five categories of the Health Belief Model (Munro et al 2007): severity of ADHD symptoms, barriers of stimulants, benefits of stimulants, “cues to action” (that is, factors that activate the patient’s readiness to change), and self-efficacy (or confidence in one’s ability to take action).

The study found that all participants encountered barriers in their experience of taking stimulant medication. Physical side effects were highly reported by patients with a high AAQoL whereas psychological side effects were reported only by patients with low AAQoL scores. The positive benefits of stimulants were seen more often in patients with high quality of life yet, severity of ADHD symptoms was not associated with medication adherence. The most salient “cue to action” found in the study pertained to the quality of the clinician-patient relationship. The majority of patients with high quality of life had positive experiences with their health providers, whereas those with low quality of life reported frustration and dissatisfaction with their clinicians. This proved to be the most influential factor in reported ADHD quality of life. As it turns out, self-efficacy was not a significant theme reported by study participants.

This article provides insights into the reasons for stimulant medication adherence or non-adherence in adult patients with ADHD. It finds that the clinician-patient relationship is a strong predictor of ADHD quality of life but NOT of treatment adherence, and that perception of barriers to stimulant treatment is linked to the individual’s quality of life. Despite the limitations of the study (small sample size, predominance of females in the sample, lack of clear generalizability), it offers a glimpse into the contextual factors that influence treatment adherence and it underscores the critical importance of good communication between clinician and patient so as to promote the best possible outcomes.

References

Brod M, Perwien A, Adler L, et al (2005). Conceptualization and assessment of quality of life for adults with attention-deficit/hyperactivity disorder. Prim Psychiatry 12:58-64.

Faraone S, Biederman J, Mick E (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 36:159-165.

Munro S, Lewin S, Swart T, Volmink J (2007). A review of health behavior theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS? BMC Pub Health 7:1-6.

Weisler R, Biederman J, Spencer T, et al (2006). Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 11:625-639.

ADHD Success Story #6 – ADHD and College Students

Anthony L. Rostain, MD MA on March 27, 2014

Let me tell you about a success story of mine, a college student who I’ll call Carrie. Carrie is about to finish her sophomore year in college after a very, very rocky start to her college career. She was a bright, enthusiastic and vivacious high school student who managed to get by through her intelligence, her energy, and being able, at the last minute, to get her work done. She also had very supportive teachers who gave her the benefit of the doubt if she did turn in assignments late.

Now, Carrie thought she might have ADHD but she never went for help. She actually was kind of skeptical about it and thought she just needed to try harder. So she was active in the high school drama club and actually went off to college hoping to become a playwright someday. So, after arriving at college, Carrie became very active in one of the drama clubs on her campus. She began to stage-manage and she started hanging out with all of the drama club students and was enjoying a great deal, and contributing great deal, to the activities of that organization. She also used the same studies, strategies that she had used in high school. So she talked a lot in class but never really read all of the assignments and she’d waited until the last minute to do the reading or to turn in the papers. She found herself cramming for the exams. It turned out that she ended up spending too much time with her extracurriculars and not enough time studying.

So after failing two classes in her spring semester, Carrie was asked to take an academic leave of absence from her college. She came back home and was evaluated in our program and we did in fact diagnose her with ADHD. We explained to her exactly how it was that she had managed to do fine until college and that she had managed to get by until she was in this unstructured learning environment. We spent a lot of time teaching her about adult ADHD, we started her on an ADHD medication, and she began coming for weekly cognitive behavioral trainings sessions.

Over the course of the next few months, she began to get more and more comfortable with the diagnosis and with figuring out what she needed to do to get difficult tasks done. She managed to get a job in selling tickets in local theater company and eventually she decided to take some courses in community college. She did extremely well and she really figured that she was now ready to go back to college.

She went back this past year and has done exceptionally well, getting most As and a few Bs, keeping herself very organized and able to balance the lifestyle that she wants. She’s able to get the studying done that she wants, she’s able to participate in the drama club and guess what, she’s pursuing her dream of becoming a playwright and is now a full-fledged English major in good standing.

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ADHD Success Story #5 – James

Anthony L. Rostain, MD MA on March 4, 2014

Let me tell you about a patient of mine named James who is 27 years old and has had a history of some serious substance abuse problems. Now James was diagnosed with ADHD in elementary school, and around middle school decided he didn’t want to take medications anymore. Beginning in late middle school and early high school he started experimenting with marijuana and alcohol, and eventually began to use other substances like cocaine, and finally, by the time he was finishing high school – and he barely graduated – James was using prescription opiates.

After high school he worked for a few years as a janitor, but this addiction to OxyContin got the better of him. He finally was in an accident, got a DUI, and was court mandated for treatment; and they discovered that he not only had an alcohol abuse problem, he also had marijuana and opiate addition. For this he was given the diagnosis of polysubstance abuse and was started in an outpatient treatment in our facility.

So James was started on suboxone to help him withdraw from opiates, and he was also started on citalopram because he was complaining of depression; and he was able to maintain sobriety, but he had a real tough time concentrating and getting simple things done. He wasn’t completing simple tasks around the house. He tried to go back to work and found it very difficult to stay focused on his job duties, and was reprimanded for coming in late.

So as a result, we then were asked to consult with, and lo and behold, we realized that, even though he was being treated for addition, he still had the ADHD that plagued him as a child. So we added OROS methylphenidate, and we began having him come for weekly cognitive behavioral therapy sessions in which he relearned what ADHD really is for someone his age, and where we began to help him overcome some of his negative attitudes about learning routines and doing things that required mental effort.

James had dreams, wanted to do something with his life, but had always avoided them and had turned to substances to help him with things that made him anxious like social relationships.

As time went on, James began to talk about wanting to start his own business, and lo and behold, he was able to get started in this business. He sells collectibles online, and over the last few months he’s been so successful that he’s actually hired an assistant. What James likes to say now is that he wished that he had continued his treatment for administered; maybe he would have avoided substance use disorder. But he takes it all in stride.

He’s got a wonderful attitude, feels very positive about his life, and actually has offered to go and talk to some of the other patients in the recovery program to help them realize that some of them may, in fact, have ADHD that they ought to get treated.

So, I bring up this story of James in order to get you to think about the fact that maybe some of your patients who are in your office with other problems like substance use or alcoholism, or people who can’t quit smoking, maybe some of them have ADHD underlying all of their difficulties, and it would be worthwhile for you to learn how to assess them and maybe begin them in treatment because it could make a huge difference to their lives.