Stimulant Medication and Psychotic Symptoms in Offspring of Parents With Mental Illness

by Anthony L. Rostain, MD MA - September 8, 2016

Pediatrics 2016; 137(1);e20152486
“Stimulant Medication and Psychotic Symptoms in Offspring of Parents With Mental Illness”
MacKenzie, L.E., Abidi, S., Fisher, H.L. et al.

Treatment of ADHD with stimulant medications carries many known risks including the development of psychotic symptoms which is considered to be a rare adverse event. It is reported that between 0.25% – 1.5% of children taking stimulants develop psychotic symptoms. However, little is known about the nature of these symptoms or about the potential for higher rates of psychosis in at-risk populations such as the children of parents with serious mental illness (SMI). Case reports and a chart review report that the rate of stimulant-induced psychosis in this group ranges from 8% to 20%. The authors of this paper set out study the rates and types of psychotic symptoms in children with parents suffering SMIs such as major depression, bipolar disorder and schizophrenia. They carefully evaluated 141 children (ages 6-21 years, average 11.8 years) in a study of developmental psychopathology in offspring of parents with SMI in Nova Scotia entitled “Families Overcoming Risks and Building Opportunities for Wellbeing.” The study employed several standardized interviews to inquire into a variety of psychiatric conditions including the occurrence and the nature of psychotic symptoms experienced by these children. All youths and parents were interviewed using the Kiddie SADS and three other interviews that probe for prodromal syndromes, psychotic-like experiences and proneness to schizophrenia. The rates of psychotic symptoms were reported for the entire sample and the rates were compared between children receiving stimulant medications (N=24) and those who never took a stimulant. Moderators such as parental diagnosis and presence or absence of ADHD in the child were also analyzed.

Of the 24 children receiving stimulant medication, 15 (62.5%) developed psychotic and related symptoms compared with 32 (27.4%) of the remaining 117 participants who had never taken stimulants. The adjusted odds ratio for psychotic symptoms due to stimulant medication was found to be 4.41. Further analyses revealed a stronger effect of stimulant medication (OR: 4.51) and a very weak effect of ADHD (OR: 1.16) on the development of psychosis. No differences were seen in rates of psychosis when analyzing parental psychopathology. Psychotic symptoms were seen in 37.5% of children of parents with schizophrenia, 34% of parents with bipolar disorder and 32% of parents with major depressive disorder. All of the children with medication-induced psychosis had parents with either bipolar disorder or depressive disorder. By far, the most common psychotic symptoms reported were hallucinations. Lastly, a sensitivity analysis was conducted to determine the temporal relationship between stimulant treatment and the onset of psychotic symptoms. Of the 15 individuals with current stimulant use, 25% developed symptoms; of the 126 participants without current stimulant use, 5% were experiencing psychotic symptoms. The Odds Ratio of developing psychotic symptoms from stimulants was 7.25. Moreover, a subset of children clearly developed psychosis as a result of taking stimulants.

This study was extremely well designed and implemented. It is the first of its kind to carefully document the frequency and nature of psychotic symptoms in children of parents with SMI, and to quantify the considerable added risk to those prescribed stimulant medication. It convincingly demonstrates the substantial risk these children face and suggests that clinicians should be cautious whenever prescribing stimulant medications to this group, and should carefully monitor for the onset of serious adverse effects.

Non-Stimulant ADHD Medication (Guanfacine) as an Adjunct to ADHD Stimulant Medications

by Anthony L. Rostain, MD MA - August 18, 2016

A Research Review

Psychiatry Research 2016 236:136-141. DOI: 10.1016/j.psychres.2015.12.017 “Supplementary guanfacine hydrochloride as a treatment of attention deficit hyperactivity disorder in adults: A double blind, placebo-controlled study.” Butterfield ME, Saal J, Young B, Young JI.

Guanfacine hydrochloride is a selective alpha-2A partial agonist that is FDA approved for the treatment of ADHD in children and adolescents (see recent reviews by Faraone et al, 2013; Hirota et al, 2014 and Ruggiero et al 2014). It can be given alone or in combination with psychostimulant medication as its mechanism of action is complementary to these agents. Despite growing scientific evidence of its effectiveness for this age group, very little is known about the potential benefits of guanfacine for the treatment of ADHD in adults.

In view of concerns about the importance of finding suitable non-stimulant ADHD medications for this population, the authors carried out a randomized placebo controlled trial of extended release guanfacine (GXR) as supplemental treatment for subjects with a suboptimal response to stimulant-only medication treatment.

Subjects were recruited from local advertisements and from the clinic practice of the authors in suburban Detroit. Entry criteria included a current diagnosis of ADHD, current treatment with a stimulant medication, and suboptimal response to this medication as evidenced by a score of > 28 on the Attention Deficit Hyperactivity Disorder Rating Scale (ADHD-RS) or of > 4 on the Clinical Global Impression – Severity (CGI-S) Scale. Exclusion criteria included having another severe Axis I psychiatric disorder, along with subjects with a history of autism, chemical dependence or psychosis. Subjects with hypertension or any medical condition that might be exacerbated by the study medication. A total of 26 subjects in the age range of 19 – 62 years were recruited for the study, of which roughly 50% were women, and 85% were Caucasian. Subjects were randomly assigned to receive either placebo or incremental doses of GXR ranging from 1 to 6 mg daily on a weekly basis over a 10-week study period.

The primary outcome measures were the ADHD Rating Scale and the Clinical Global Impression – Severity. Secondary outcome measures included the Arizona Sexual Experience Questionnaire, the Fatigue Symptom Inventory, the Pittsburgh Sleep Quality Index, the Hamilton Anxiety Inventory and the Hamilton Depression Rating Scale. Baseline and weekly measures of cardiovascular status were collected throughout the study.

Contrary to the study authors’ expectations, although subjects in both the placebo and the treatment arms of the study showed significant improvements in both primary and secondary outcome measures, the two groups did not differ from one another. For instance, the mean ADHD-RS score of the placebo group decreased by 10.92 (from 35.23 to 24.31) and that of the GXR treated group decreased by 11.85 (from 35.92 to 24.08). The CGI-S score in the placebo group decreased by 1.00 and that of the GXR group by 0.85. There were no differences between the two groups on measures of tolerability, hemodynamics, sleep, anxiety or depression. Moreover, no treatment x time x group effects were noted.

The authors comment that several explanations can account for these findings including a strong placebo effect, a generalized study effect (i.e. participating in a clinical trial itself may be beneficial in and of itself), a “regression to the mean” effect for the placebo group, and a potential bias induced by participating in a clinical trial. Of note, there were no between group differences seen in fatigue, sleep problems, sexual functioning or in hemodynamic measures – a finding that supports the tolerability and safety of GXR in adult patients.

While this is a “negative study,” it is helpful in clarifying that GXR can be used safely in combination with stimulant medications, that it does not worsen other psychiatric symptoms (e.g. anxiety, depression) and that it may be a helpful adjunctive treatment for adults with ADHD whose stimulant medication is not sufficiently helpful in reducing their symptoms. Further research with a larger sample size and with measures taken to minimize the placebo effect are certainly warranted. In the meantime, clinicians who are considering using GXR can be reassured that it is well tolerated in this population.

Faraone SV, McBurnett K, Sallee FR, Steeber J, López FA (2013). Guanfacine extended release: a novel treatment for attention-deficit/hyperactivity disorder in children and adolescents. Clinical Therapeutics Nov;35(11):1778-93. doi: 10.1016/j.clinthera.2013.09.005

Hirota T, Schwartz S, Correll CU (2014). Alpha-2 Agonists for Attention-Deficit/Hyperactivity Disorder in youth: A Systematic Review and Meta-Analysis of Monotherapy and Add-On Trials to Stimulant Therapy. J. Amer.. Acad. Child Adolesc. Psychiatry 53(2):153–173.

Ruggiero S, Clavenna A, Reale L, Capuano A, Rossi F, Bonati M (2014). Guanfacine for attention deficit and hyperactivity disorder in pediatrics: A systematic review and meta-analysis. European Neuropsychopharmacology 24: 1578-1590.

Supplementary GXR for Adult ADHD

by Anthony L. Rostain, MD MA - August 18, 2016

Psychiatry Research 2016 236:136-141. DOI: 10.1016/j.psychres.2015.12.017
“Supplementary guanfacine hydrochloride as a treatment of attention deficit hyperactivity disorder in adults: A double blind, placebo-controlled study.”
Butterfield ME, Saal J, Young B, Young JI.

Guanfacine hydrochloride is a selective alpha-2A partial agonist that is FDA approved for the treatment of ADHD in children and adolescents (see recent reviews by Faraone et al, 2013; Hirota et al, 2014 and Ruggiero et al 2014). It can be given alone or in combination with psychostimulant medication as its mechanism of action is complementary to these agents. Despite growing scientific evidence of its effectiveness for this age group, very little is known about the potential benefits of guanfacine for the treatment of ADHD in adults. In view of concerns about the importance of finding suitable non-stimulant medications for this population, the authors carried out a randomized placebo controlled trial of extended release guanfacine (GXR) as supplemental treatment for subjects with a suboptimal response to stimulant-only medication treatment.

Subjects were recruited from local advertisements and from the clinic practice of the authors in suburban Detroit. Entry criteria included a current diagnosis of ADHD, current treatment with a stimulant medication, and suboptimal response to this medication as evidenced by a score of > 28 on the Attention Deficit Hyperactivity Disorder Rating Scale (ADHD-RS) or of > 4 on the Clinical Global Impression – Severity (CGI-S) Scale. Exclusion criteria included having another severe Axis I psychiatric disorder, along with subjects with a history of autism, chemical dependence or psychosis. Subjects with hypertension or any medical condition that might be exacerbated by the study medication. A total of 26 subjects in the age range of 19 – 62 years were recruited for the study, of which roughly 50% were women, and 85% were Caucasian. Subjects were randomly assigned to receive either placebo or incremental doses of GXR ranging from 1 to 6 mg daily on a weekly basis over a 10-week study period.

The primary outcome measures were the ADHD Rating Scale and the Clinical Global Impression – Severity. Secondary outcome measures included the Arizona Sexual Experience Questionnaire, the Fatigue Symptom Inventory, the Pittsburgh Sleep Quality Index, the Hamilton Anxiety Inventory and the Hamilton Depression Rating Scale. Baseline and weekly measures of cardiovascular status were collected throughout the study.

Contrary to the study authors’ expectations, although subjects in both the placebo and the treatment arms of the study showed significant improvements in both primary and secondary outcome measures, the two groups did not differ from one another. For instance, the mean ADHD-RS score of the placebo group decreased by 10.92 (from 35.23 to 24.31) and that of the GXR treated group decreased by 11.85 (from 35.92 to 24.08). The CGI-S score in the placebo group decreased by 1.00 and that of the GXR group by 0.85. There were no differences between the two groups on measures of tolerability, hemodynamics, sleep, anxiety or depression. Moreover, no treatment x time x group effects were noted.

The authors comment that several explanations can account for these findings including a strong placebo effect, a generalized study effect (i.e. participating in a clinical trial itself may be beneficial in and of itself), a “regression to the mean” effect for the placebo group, and a potential bias induced by participating in a clinical trial. Of note, there were no between group differences seen in fatigue, sleep problems, sexual functioning or in hemodynamic measures – a finding that supports the tolerability and safety of GXR in adult patients.

While this is a “negative study,” it is helpful in clarifying that GXR can be used safely in combination with stimulant medications, that it does not worsen other psychiatric symptoms (e.g. anxiety, depression) and that it may be a helpful adjunctive treatment for adults with ADHD whose stimulant medication is not sufficiently helpful in reducing their symptoms. Further research with a larger sample size and with measures taken to minimize the placebo effect are certainly warranted. In the meantime, clinicians who are considering using GXR can be reassured that it is well tolerated in this population.

Faraone SV, McBurnett K, Sallee FR, Steeber J, López FA (2013). Guanfacine extended release: a novel treatment for attention-deficit/hyperactivity disorder in children and adolescents. Clinical Therapeutics Nov;35(11):1778-93. doi: 10.1016/j.clinthera.2013.09.005
Hirota T, Schwartz S, Correll CU (2014). Alpha-2 Agonists for Attention-Deficit/Hyperactivity Disorder in youth: A Systematic Review and Meta-Analysis of Monotherapy and Add-On Trials to Stimulant Therapy. J. Amer.. Acad. Child Adolesc. Psychiatry 53(2):153–173.
Ruggiero S, Clavenna A, Reale L, Capuano A, Rossi F, Bonati M (2014). Guanfacine for attention deficit and hyperactivity disorder in pediatrics: A systematic review and meta-analysis. European Neuropsychopharmacology 24: 1578-1590.

ADHD Parenting among ADHD Adults

by Anthony L. Rostain, MD MA - July 21, 2016

Journal of Clinical Child and Adolescent Psychology. 2014. DOI: 10.1080/15374416.2014.963858

“The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD”

Dawson, A.E., Wymbs, B.T., Marshall, S.A., Mautone, J.A., Power, T.J.

This paper reports on the extent to which parental ADHD impacts child and parent functional outcomes of a multimodal family-school intervention designed to boost academic performance of 139 school-aged children with ADHD.

The initial results of this randomized controlled trial (N = 199) comparing an experimental intervention, the Family School Success Program (FSS) to an active-control condition, Coping with ADHD through Relationships and Education (CARE), revealed that participants in each group showed gains in the primary targeted outcomes.

For children, these included rates of completing homework, academic productivity, and symptoms of ADHD and oppositional defiant disorder (ODD) as measured by the Swanson, Nolan and Pelham Questionnaire (SNAP). Parental outcomes included parents’ view of their efficacy as their child’s educator, quality of the parent-teacher relationship, and quality of the parent-child relationship. While both groups showed improvements, there were modest treatment effect sizes seen in the FSS group as compared to the CARE group in ratings of homework performance, self-reported parenting practices, and overall quality of school-family relationships (Power et al, 2012).

The last two outcomes were also better in the FSS group at a follow-up assessment conducted by the researchers three months after the conclusion of the study.

Given growing concern regarding the role that parental ADHD may play in moderating the effectiveness of treatments for children with ADHD (a topic that is thoroughly reviewed in the introduction section of this paper), these investigators went on to examine the impact of parental ADHD symptoms on the study’s outcomes.

Parental ADHD was determined by administering a self-report scale, the Conners’ Adult ADHD Rating Scale (CAARS) to 139 of the parent participants in the study. Both dimensional and dichotomous ADHD variables were created but only the latter was used in the analysis because of the small size of the ADHD group (N = 23, or roughly 16% of the total).

Results showed that parental ADHD did not affect treatment outcome for either the experimental (FSS) or the control (CARE) condition at the end of the study period. However, at the three month follow-up assessment, parental ADHD was associated with declines in treatment gains only in the FSS group, particularly in the quality of parent-teacher relationship and the child’s homework performance. This finding surprised the investigators who hypothesized that ADHD parents in both groups would show declines in outcomes as compared to non-ADHD parents.

They concluded that the control condition may have provided ADHD parents with greater opportunities to develop strategies and to practice problem-solving skills on their own, whereas ADHD parents in the experimental condition might have become overly dependent on study clinicians to implement the parenting practices that were the focus of the intervention.

This study illustrates the importance of modifying parent-focused treatment interventions to the specific characteristics of the patient and family. In particular, when parents of ADHD children also exhibit the symptoms of ADHD, it may be helpful to provide additional opportunities for them to develop strategies, cultivate resources, and practice parenting skills aimed at helping their ADHD children succeed at school.

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

Power, T.J., Mautone, J.A., Soffer, S.L. Clarke, A.T., et al (2012). “A family-school intervention for children with ADHD: Results of a randomized clinical trial.” Journal of Clinical Child and Adolescent Psychology. 80: 611-623 DOI: 10.1037/a0028188.

African American Adults with ADHD – Cultural Barriers and Reduced Access to Care

by Anthony L. Rostain, MD MA - March 24, 2016

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Clin Psychiatry. 2015; 76(3):279-283.
“Cultural Background and Barriers to Mental Health Care for African American Adults”
Rostain, A.L., Ramsay, J.R., Waite, R.

This article delineates key patient and provider cultural biases that interfere with access to care for African American Adults with ADHD. It provides an important framework for understanding how these biases come about and what clinicians can do to address them. A brief review of the relationship between psychiatry and African Americans points out that beginning with slavery and continuing through the Tuskegee experiment, there is a legacy of racism in American medicine that influences the way patients view health care providers (and vice versa).

For instance, drapetomania was a clinical diagnosis given to slaves who demonstrated resistance to the institution by running away, refusing to follow rules, destroying property and fighting the plantation slave owners. In this fashion, psychiatry played an important role in supporting racism and racist beliefs. Similar analogies can be made to the ways that psychiatry classified homosexuality as a mental illness.

The point of this historical review is to underscore the longstanding mistrust that exists within the African American community toward medicine in general and psychiatry in particular. Add to this, the stigma associated with mental illness and substance abuse, it becomes easier to understand why many African American adults fail to seek treatment for disorders like ADHD.

The article goes on to discuss barriers to obtaining mental health treatment including patient factors (e.g. low income, lack of health insurance, fear and other negative attitudes) and health care system factors (e.g. limited access to culturally and technically competent providers and provider biases). Without question, higher rates of poverty and of lack of insurance among the minority population leads to markedly reduced access to care. The article points out that whereas rates of adequate mental health treatment among whites is 33%, the figure drops to 12% for African Americans. Moreover. white
children are twice as likely to receive ADHD medication as African American children. Cultural biases among providers may lead them to be insufficiently attuned to the presence of ADHD in adult patients, ascribing the symptoms of ADHD, such as inattention, restlessness and disorganization either to personal failing (e.g. lack of self-discipline) or to environmental factors (e.g. low SES, lack of education) rather than to the influence of ADHD.

The paper concludes with practical recommendations for clinicians to address these barriers including providing accurate science based information, listening and being sensitive to stigmatizing experiences that African American patients may have encountered, and recognizing the deleterious effects of conscious and unconscious biases among well-meaning providers.

Locomotor Activity and Diagnosing ADHD

by Anthony L. Rostain, MD MA - January 21, 2016

This article reviews existing evidence for the use of locomotor activity measures in diagnosing ADHD. The authors conducted a meta-analysis of published studies using motion measures to compare patients with ADHD with controls and then conducted a case control study using the McLean motion activity test (MMAT) on a sample of child, adolescent and adult ADHD patients (N=81) and matched controls (N=91).

The meta-analysis procedure involved searching several electronic medical databases and selecting only articles which used validated methods for diagnosing ADHD, which compared ADHD subjects to healthy controls and which reported data in ways that enabled the authors to calculate the effect sizes as measured by standardized mean differences (SMD) between study groups. A total of 18 studies were chosen, 13 of which involved actigraphy measures and 5 which used motion tracking systems. The combined sample sizes were 570 ADHD patients (305 children and adolescents and 265 adults) and 515 controls (equally divided between youth and adults). The SMD (or effect size) between ADHD subjects and controls was 0.64 using actigraphy measures and 0.92 using the motion tracking systems. The SMD or pooled effect size for youth was 0.75 and for adults was 0.73, indicating that excessive motion is seen as often in adult ADHD patients as in children and adolescents. This contradicts the prevailing view that excessive motor activity is less prominent in adults as compared to youth with ADHD.

The authors then conducted a case control study comparing ADHD patients and controls. Patients were diagnosed using a comprehensive assessment procedure consisting of structured psychiatric interviews, Conners’ rating scales and the BRIEF (a measure of executive functioning). Subjects were administered the MMAT, an infrared motion tracking system that measures the micro-movements of participants during a Go/No-Go task (15 minutes for youth and 20 minutes for adults). ADHD groups differed significantly from controls on most motion measures, with an effect size of 0.83 for adults and 0.45 for children and adolescents. Reaction time variability was also significantly greater in the ADHD sample across all ages (p<0.05). Interestingly, there were no differences in excessive motion seen among the different ADHD subtypes (combined vs inattentive vs hyperactive vs NOS).

The authors conclude that locomotor hyperactivity is a core constituent feature of ADHD even in adults and across all diagnostic subtypes. They further suggest that objective locomotion measures may be useful in improving the process of diagnosing difficult cases of ADHD. While it is still premature to suggest that movement measurement devices like the MMAT are necessary for diagnosing ADHD in most patients, there is certainly a role for using them in clinical practice. Future research will help delineate additional uses for these tools in diagnosing other neurodevelopmental disorders.

Murillo LG, Cortese S, Anderson D, DiMartino A, Castellanos FX (2015). “Locomotor activity measures in the diagnosis of attention deficit hyperactivity disorder: Meta-analyses and new findings.” Journal of Neuroscience Methods Epub ahead of print March 11, 2015. DOI: 10.1016/j.jneumeth.2015.03.001.

ADHD and Hyperactivity – Children, Teens, Adults

by Anthony L. Rostain, MD MA - January 21, 2016

Anthony L. Rostain, MD MA - ADHD in Adults

This article reviews existing evidence for the use of locomotor activity measures in diagnosing ADHD. The authors conducted a meta-analysis of published studies on ADHD using motion measures to compare patients with ADHD with controls and then conducted a case control study using the McLean motion activity test (MMAT) on a sample of child, adolescent and adult ADHD patients (N=81) and matched controls (N=91).

Methods
The meta-analysis procedure involved searching several electronic medical databases and selecting only articles which used validated methods for diagnosing ADHD, which compared ADHD subjects to healthy controls and which reported data in ways that enabled the authors to calculate the effect sizes as measured by standardized mean differences (SMD) between study groups. A total of 18 studies were chosen, 13 of which involved actigraphy measures and 5 which used motion tracking systems. The combined sample sizes were 570 ADHD patients (305 children and adolescents and 265 ADHD adults) and 515 controls (equally divided between youth and adults). The SMD (or effect size) between ADHD subjects and controls was 0.64 using actigraphy measures and 0.92 using the motion tracking systems. The SMD or pooled effect size for youth was 0.75 and for adults was 0.73, indicating that excessive motion is seen as often in adult ADHD patients as in children and adolescents. This contradicts the prevailing view that excessive motor activity is less prominent in adults as compared to youth with ADHD.

The authors then conducted a case control study comparing ADHD patients and controls. Patients were diagnosed using a comprehensive assessment procedure consisting of structured psychiatric interviews, Conners’ rating scales and the BRIEF (a measure of executive functioning). Subjects were administered the MMAT, an infrared motion tracking system that measures the micro-movements of participants during a Go/No-Go task (15 minutes for youth and 20 minutes for adults). ADHD groups differed significantly from controls on most motion measures, with an effect size of 0.83 for adults and 0.45 for children and adolescents. Reaction time variability was also significantly greater in the ADHD sample across all ages (p<0.05). Interestingly, there were no differences in excessive motion seen among the different ADHD subtypes (combined vs inattentive vs hyperactive vs NOS).

Conclusions
The authors conclude that locomotor hyperactivity is a core constituent feature of ADHD even in adults and across all diagnostic subtypes. They further suggest that objective locomotion measures may be useful in improving the process of diagnosing difficult cases of ADHD. While it is still premature to suggest that movement measurement devices like the MMAT are necessary for ADHD diagnosis in most patients, there is certainly a role for using them in clinical practice along with established ADHD resources. Future research will help delineate additional uses for these tools in diagnosing other neurodevelopmental disorders.

Murillo LG, Cortese S, Anderson D, DiMartino A, Castellanos FX (2015). “Locomotor activity measures in the diagnosis of attention deficit hyperactivity disorder: Meta-analyses and new findings.” Journal of Neuroscience Methods Epub ahead of print March 11, 2015. DOI: 10.1016/j.jneumeth.2015.03.001.

Medication Resistant Deficits in ADHD

by Anthony L. Rostain, MD MA - October 8, 2015

J Atten Disord. 2014 Jun 26, p.1-11. doi: 1087054714538659.

“Possible Medication-Resistant Deficits in Adult ADHD”

Maruta, J., Spielman, L.A., Tseretopoulos, I.D., Hezghia, A., Ghajar, J.

This article reports on neurocognitive and visual tracking performance of adult subjects with ADHD on and off stimulant medication in an effort to clarify the precise attention impairments seen in this population. Twenty-three adults with ADHD and forty-six two-for-one matched normal controls were assessed on a variety of neurocognitive and visual tracking measures. Adult ADHD subjects were tested on and off their prescribed stimulant medication, and results of test performance were compared using paired t test statistical analysis. Tests included the Attention Network Test (ANT), the Spatial Span subtest of the Wechsler Memory Scale, a circular visual tracking test, and a reaction time test. None of the ANT metrics or visual tracking tests demonstrated differences between controls and ADHD patients on medication. However, significant differences were seen in the spatial span tests and in the reaction time tests when they were administered after attention-demanding tasks. These results suggest that for adults with ADHD, stimulant medications can improve visual tracking, reaction time and alerting and orienting, but they do not seem to improve visual-spatial working memory or susceptibility to cognitive fatigue. These findings are worthwhile considering when advising patients about the benefits of taking stimulant medication insofar as some aspects of cognitive functioning may not improve as dramatically as others do.

Parental ADHD and FSS (Family School Success)

by Anthony L. Rostain, MD MA - June 4, 2015

Journal of Clinical Child and Adolescent Psychology. 2014. DOI: 10.1080/15374416.2014.963858

“The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD”

Dawson, A.E., Wymbs, B.T., Marshall, S.A., Mautone, J.A., Power, T.J.

This paper reports on the extent to which parental ADHD impacts child and parent functional outcomes of a multimodal family-school intervention designed to boost academic performance of 139 school-aged children with ADHD. The initial results of this randomized controlled trial (N = 199) comparing an experimental intervention, the Family School Success Program (FSS) to an active-control condition, Coping with ADHD through Relationships and Education (CARE), revealed that participants in each group showed gains in the primary targeted outcomes. For children, these included rates of completing homework, academic productivity, and symptoms of ADHD and oppositional defiant disorder (ODD) as measured by the Swanson, Nolan and Pelham Questionnaire (SNAP). Parental outcomes included parents’ view of their efficacy as their child’s educator, quality of the parent-teacher relationship, and quality of the parent-child relationship. While both groups showed improvements, there were modest treatment effect sizes seen in the FSS group as compared to the CARE group in ratings of homework performance, self-reported parenting practices, and overall quality of school-family relationships (Power et al, 2012). The last two outcomes were also better in the FSS group at a follow-up assessment conducted by the researchers three months after the conclusion of the study.

Given growing concern regarding the role that parental ADHD may play in moderating the effectiveness of treatments for children with ADHD (a topic that is thoroughly reviewed in the introduction section of this paper), these investigators went on to examine the impact of parental ADHD symptoms on the study’s outcomes. Parental ADHD was determined by administering a self-report scale, the Conners’ Adult ADHD Rating Scale (CAARS) to 139 of the parent participants in the study. Both dimensional and dichotomous ADHD variables were created but only the latter was used in the analysis because of the small size of the ADHD group (N = 23, or roughly 16% of the total). Results showed that parental ADHD did not affect treatment outcome for either the experimental (FSS) or the control (CARE) condition at the end of the study period. However, at the three month follow-up assessment, parental ADHD was associated with declines in treatment gains only in the FSS group, particularly in the quality of parent-teacher relationship and the child’s homework performance. This finding surprised the investigators who hypothesized that ADHD parents in both groups would show declines in outcomes as compared to non-ADHD parents. They concluded that the control condition may have provided ADHD parents with greater opportunities to develop strategies and to practice problem-solving skills on their own, whereas ADHD parents in the experimental condition might have become overly dependent on study clinicians to implement the parenting practices that were the focus of the intervention.

This study illustrates the importance of modifying parent-focused treatment interventions to the specific characteristics of the patient and family. In particular, when parents of ADHD children also exhibit the symptoms of ADHD, it may be helpful to provide additional opportunities for them to develop strategies, cultivate resources, and practice parenting skills aimed at helping their ADHD children succeed at school.

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

Power, T.J., Mautone, J.A., Soffer, S.L. Clarke, A.T., et al (2012). “A family-school intervention for children with ADHD: Results of a randomized clinical trial.” Journal of Clinical Child and Adolescent Psychology. 80: 611-623 DOI: 10.1037/a0028188.

Symptom Manifestations and Impairments in College Students with ADHD

by Anthony L. Rostain, MD MA - May 26, 2015

Gray SA, Fettes P, Woltering S, Mawjee K, Tannock R (2015). “Symptom manifestation and impairments in college students with ADHD.” Journal of Learning Disabilities. 2015 Mar 16. pii: 0022219415576523. [Epub ahead of print]

This article reviews what is currently known about the cognitive and academic impairments faced by post-secondary students with ADHD and then reports on a prospective study of symptoms and functional impairments in 135 ADHD university students. The authors point out that there is limited evidence available on the functioning of post-secondary students with ADHD, and that published studies reveal conflicting evidence. On the one hand, several studies reporting the results of objective tests of executive functioning (EF) in this population show little differences to peers without ADHD, whereas their self-reports of EF suggest they experience impairments in day-to-day cognitive functioning. Similarly, there are inconsistent findings regarding the academic performance of this population with some studies showing lower GPAs and higher rates of academic probation and other studies showing no differences between ADHD students and their non-ADHD peers. However, several papers document that by self-report, post-secondary students with ADHD struggle to keep up with academic demands.

In order to learn about the nature of symptoms and impairments in college students with ADHD, the authors conducted a brief, semi-structured telephone interview with students using the 6-item version of the Adult ADHD Self-Report Scale (ASRS) during which subjects were asked to provide real-life examples of behaviors for each of the symptoms. Qualitative interview data was analyzed along with symptoms of psychopathology, psychological distress, executive functioning, cognitive difficulties, “grit,” cognitive testing measures (IQ and neuropsychological battery), academic screening measures and self-reported GPAs.

All subjects were attending university, were between the ages of 18-35 years (mean age 23.7), had a previous diagnosis of ADHD, were registered with student disability services at their school, and met criterion scores on the ASRS administered by phone. Over 90% of the sample had completed at least 1 year of college and 58% was female. About 18% had a comorbid learning disability and 51% were taking an ADHD medication (97% taking stimulants).

Results of the study revealed that these students’ IQ scores were within the normal range and their performance on neuropsychological tests was also in the normal range. In marked contrast, this sample reported marked impairments in EF in daily life, especially with respect to time management, organization, problem solving, self-restraint, self-motivation, and self-regulation of emotions. Over 2/3 of the sample had scores in the 95th percentile on the Barkley Deficits of Executive Functioning Scale (BDEFS). The subjects also reported higher rates of cognitive difficulties in daily life, high levels of distress, lower levels of “grit,” and relatively high rates of anxiety, depression, obsessive compulsive symptoms, phobias, paranoia and psychoticism compared to normal controls. The mean GPA of the sample was 2.91 indicating acceptable to good academic progress.

The most salient aspect of the study was the qualitative descriptions provided by these ADHD students of their daily struggles with managing the demands of college life. The major problems they cited included hyperactivity (especially fidgeting), procrastination, and difficulty wrapping up the final details of projects they’d started. They reported trouble organizing time and materials, and often forgot to use coping strategies they had developed to overcome their difficulties. Time management problems and psychological distress were among the most prominent themes to emerge from the content analysis.

This study clearly demonstrates the extent to which college students with ADHD encounter considerable distress in meeting academic demands largely as a result of executive functioning difficulties that are better captured by self-report than by neuropsychological testing. It adds evidence to the argument that neuropsychological testing alone should not be used to determine eligibility for accommodations. It also documents the reported high levels of stress, distress and psychopathology in this population and points to the need for interventions that bolster EF, particularly with respect to time management, organization and handling negative emotions (distress).

Posts By: Anthony L. Rostain, MD MA