Stephen_Faraone_PhD_ADHD_in_Adults

The Journal of Attention Disorders has published two papers about a new formulation of mixed amphetamine salts that uses a triple bead technology (MAS-TB). This technology allows for a delayed release of the medication and enables a duration of effect up to sixteen hours.

This 16-hour effect is significantly higher than existing stimulant medications which on average last for 8-10 hours. This new formulation is based on patient desire to experience beneficial medication effects from morning through evening.

Previously, Spencer et al. (https://www.ncbi.nlm.nih.gov/pubmed/19012813) reported a 7-week, randomized, double-blind, multicenter, placebo-controlled, parallel-group, dose-optimization study of 272 adults with ADHD.   They found that MAS-TB significantly reduced ADHD symptoms, behavioral measures of executive dysfunction and increased quality of life ratings. (Other studies have confirmed the benefit of select medications not only for ADHD symptoms, but for executive dysfunctions as well, although no ADHD medications treat executive dysfunction as well as they treat ADHD.)

An assessment of ADHD symptoms 13 to 16 hours post-dose confirmed the duration of action. The first new paper by Frick et al. (https://www.ncbi.nlm.nih.gov/pubmed/28413925) reported a 6 week, randomized controlled study comparing MAS-TB with placebo.   As with the prior study, MAS-TB significantly reduced ADHD symptoms. Mean ± SD pulse and systolic blood pressure increases at end of study were 3.5 ± 10.33 bpm and 0.3 ± 10.48 mmHg, which are medically non-consequential.  

In the second new study, Adler et al. (https://www.ncbi.nlm.nih.gov/pubmed/28412886) reported a long-term, open-label, safety study of MAS-TB in adults with ADHD. Of 505 enrolled participants, 266 completed the study.   Study discontinuation was more likely for patients taking higher (37.5-75 mg) vs. lower doses (12.5 and 25 mg). Blood pressure and pulse increases were observed at end-of-study. ADHD symptoms decreased modestly during the follow-up period.

The most frequently reported treatment emergent adverse events in both studies were insomnia, decreased appetite, and dry mouth. These observed side effects are similar to those seen for other stimulant medications, and are typically well managed by physicians when they occur by adjusting the dose or changing medications.

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ADHD is a difficult diagnosis to make, although there are several means for gathering the essential developmental and clinical data with which practicing clinician can make an accurate diagnosis. These include various symptom checklists, adult ADHD and executive functioning inventories, and structured interviews that target ADHD and diagnostic criteria, including onset, course, and impairment. However, there are many other conditions that can mimic the symptoms of ADHD in adults, making it challenging to differentiate whether the “attention deficits” with which patients present actually result from ADHD or from a different condition.

The purpose of this blog is to review some of the psychiatric disorders that should be screened for during an adult ADHD evaluation, as any one of these may create “attention deficits.” Some clinically-informed tips for differentiating each of these conditions from ADHD are also provided.

Depression

         Concentration difficulties and poor initiation and follow through on tasks are characteristic features of depression, which overlap with common features of ADHD. A patient in the midst of a depressive episode will likely endorse executive functioning problems related to motivation, emotional regulation, and organization/time management difficulties. A key difference with ADHD is the course and persistence of these issues inasmuch as the executive functioning deficits in ADHD reflect a chronic developmental lag, irrespective of mood state. A thorough developmental history with self- and observer-reports assessing childhood onset and persistence of ADHD symptoms can establish if there was a history of ADHD and related problems before the onset of depression. Moreover, as depression is an episodic condition, assessment of inter-episode executive functioning helps with this differential diagnosis, as executive functioning for depressed individuals improves as depression remits. Of course, many adults with ADHD have co-existing depressive symptoms, if not a full depressive disorder in adulthood. Their executive functioning may worsen with low mood but it continues to be problematic even after their mood improves.

Anxiety

            Establishing the onset and course of symptoms is, again, key to differentiating ADHD from most anxiety disorders. For anxieties related to specific, circumscribed triggers, such as social anxiety, panic attacks, and/or phobic stimuli, any “attention deficits” associated with these anxieties should not be apparent when an anxious individual is not facing these activating events. Moreover, these sorts of anxiety disorders do not manifest in the wide ranging, cross-situational functional deficits associated with ADHD, although anxiety can be quite impairing due to its ripple effects on other domains of life, such as someone who is housebound from agoraphobia.

Anxiety is the most common co-existing diagnosis in adults with ADHD, which usually kindles and magnifies over time as patients encounter greater difficulties managing roles and obligations that increasingly require intact executive functioning. Chronic, generalized anxiety, which can develop in childhood and persist into adulthood, is often associated with distraction and avoidance that can look very much like ADHD. However, there is often less executive dysfunction for purely anxious individuals in terms of organizational and time management skills, and there is less behavioral disinhibition, as anxious individuals tend to be overly inhibited. In fact, individuals with generalized anxiety may exhibit better performance on tasks and projects once engaged in them as they represent a distraction form their worries whereas for adults with ADHD these tasks are the triggers for their anxiety.

Bipolar Spectrum Disorders

            This is one of the more challenging differential diagnoses to make, as hypomania/mania involve restlessness and impulsivity and executive dysfunction, with the corresponding depressive episodes also characterized by several ADHD-like symptoms, as was mentioned above. The different course of these disorders helps to differentiate them. The executive dysfunction and attention difficulties associated with the bipolar spectrum symptoms “ride the wave” of the prevailing mood regardless of current external circumstances. An individual in the midst of hypomania/mania has a qualitatively different presentation that is uncharacteristic of the person, such as engaging in risky activities, reporting racing thoughts, and exhibiting pressured, disorganized speech. An individual with ADHD, on the other hand, is “consistently inconsistent” such that a person has difficulties managing a variety of circumstances across time and context that transcend any mood state, and these difficulties are very familiar to the person with ADHD and those familiar with this person.

Both diagnoses are associated with sleep difficulties, although there are differences here, too. Sleep disruption in bipolar disorder is characterized by episodes (tied to hypomanic/manic episodes) of little need for sleep but nonetheless having a great deal of energy, albeit often spent on reckless or at least ill-advised actions. Adults with ADHD commonly report sleep difficulties, though more often characterized by delayed sleep onset or procrastinating on sleep despite being tired; however, unlike individuals in the midst of hypomania/mania, ADHD adults end up sleeping in too late and miss obligations, or suffer the consequences of sleep debt, such as feeling tired and fatigued, often compensating with excessive caffeine intake.

Obsessive-Compulsive Disorders

            Obsessive-compulsive disorders, and related spectrum disorders, such as trichotillomania and excoriation, involve some sort of cognitive impulse or physical urge that is associated with significant anxiety or sense of discomfort for which the individual engages in a neutralizing behavior for relief, which insidiously negatively reinforces and maintains the behavior pattern. For OCD, this might involve a mental or physical ritual when faced with feared stimuli, such as thinking through a series of prayers to counteract a “bad” thought or excessive checking to ensure an oven is turned off to counteract the feared image of returning home to find the house burned down. Skin-picking, hair pulling or other neutralizing behaviors are carried out to relieve a somatically based discomfort, such as imperfection on one’s skin or a need to feel the sensation of a hair being plucked from a follicle. These behaviors ultimately reinforce the initial impulse and maladaptive responses.

These impulses are distracting inasmuch as they chronically and significantly consume one’s attention, which may sound like distractibility consistent with ADHD, particularly for “pure obsessionals” in the OCD category. These conditions can co-exist with ADHD, often in very complex cases. A thorough developmental interview examining the age of onset and specific type of symptoms described helps to make the differential diagnosis. Structured diagnostic interviews for mood, anxiety, and other psychiatric disorders can help identify OCD and the impulse control disorders and the manner in which they create distractions and attention difficulties. The distractions are limited to these stimuli and careful probing can identify the culprit of the triggering stimuli and neutralizing behaviors, rather than the wide-ranging triggers for executive functioning problems in ADHD.

Trauma

            Persistent cognitive and emotional reactions to traumatic experiences and ongoing life disruption constitute post-traumatic stress disorder (PTSD). This and other trauma and stress-related disorders result in difficulties with concentration and memory, including a continuum of intrusive thoughts and images, and dissociative states that look like the sorts of distractibility and attention deficits seen in ADHD. However, in cases in which the onset of these difficulties can be traced to a distinct trauma (particularly early childhood trauma), PTSD is the more appropriate diagnostic formulation

This being said, not everyone who experiences a traumatic event necessarily develops PTSD. So, it is possible that in the absence of a clear trajectory of PTSD, that a course of onset of ADHD may be established. Similarly, ADHD and its executive function and motivational deficits cover a broader range of symptoms and impairments than simply attention and may co-exist with PTSD, but care must be taken to confirm these ADHD-specific features and as distinct from dissociative states or cognitive intrusions. Cases in which there is a clear developmental onset of ADHD and a trauma occurs afterwards represent another pattern of this comorbidity, such as an individual who was diagnosed with and treated for ADHD since early adolescence but has developed PTSD after suffering a serious car accident in her mid-twenties.

Summary

            The evaluation of ADHD requires at least screening for all other feasible explanations for the apparent attention deficits and other characteristic symptoms. This exercise has parallels with the “null hypothesis” in research but has important clinical implications for treatment selection. Evidence-supported treatments exist for all of the “other” conditions reviewed here and an accurate diagnosis helps direct patients to the right ones for their presentations. A clinically-informed diagnostic formulation is also essential in complex cases with multiple comorbidities to help sort through the different clinical issues, their overlaps, and to support a competent treatment plan.

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Childhood ADHD is known to persist into adolescence and adulthood in 40-70% of patients. However, its presentation changes with age; symptoms of hyperactivity become less prominent, while difficulties with attention and impulsivity may remain, and executive function problems become increasingly important[i]. Due to this evolving presentation, those with a childhood history of ADHD may not meet full ADHD diagnostic criteria, as adults. Yet, even high-functioning individuals who perform adequately on neuropsychological testing may continue to experience executive dysfunction, emotional dysregulation, and psychosocial impairment in their personal and professional lives[ii]. Over the last decade, longitudinal follow-up studies of clinic-referred adults who had childhood ADHD have begun to characterize the deleterious effects of childhood ADHD on adult functioning in various domains.

Recently, Voigt and colleagues from the Barbaresi group recently published the first prospective, population-based study documenting adult academic outcomes among patients with research-identified (including DSM-IV diagnostic criteria) childhood ADHD versus non-ADHD referents[iii]. The study sample, drawn from a 1976 to 1982 birth cohort, was unique in that 1) both ADHD and No-ADHD study subjects were members of a population-based sample, not clinic-referred individuals; 2) the subjects’ lifetime medical and school records were available to the investigators; and 3) the Barbaresi group has followed this birth cohort for over 15 years.

For this follow-up study, an academic achievement battery was administered to 232 young adults (mean age 27 years) with research-identified ADHD and 335 referents (mean age 28 years) from the birth cohort. The battery included tests of basic reading, vocabulary, passage comprehension, and arithmetic. After controlling for age, sex, comorbid learning disability status, and maternal education level, Voigt, et al. found that participants with childhood ADHD scored 3 to 5 grade equivalents lower on all academic tests, compared with their non-ADHD peers. All findings had moderate-to-large effect sizes (Cohen’s d= -.55 to -.82). 

Interestingly, only 68 of the 232 (29%) participating childhood ADHD cases met the DSM-IV diagnostic criteria for adult ADHD. Yet, there was no significant difference in test scores between childhood ADHD cases with remitted and persistent ADHD, even after controlling for the presence of a co-morbid learning disability (LD). Voigt, et al. believe that this lack of difference indicates that ADHD alone is responsible for the poorer acquisition of academic skills during childhood and adolescence. Academic underachievement in math and reading is strongly associated with lower academic motivation, shorter duration of education, and longer-term socioeconomic adversity, as Biederman and Faraone demonstrated, over a decade ago4. Consistent with their findings, Voigt’s study highlights ADHD as an independent risk factor for poor long-term academic outcomes, predicting far-reaching challenges for adult well-being.

Regarding potential interventions, Voigt, et al. suggest that their findings demonstrate that early and continuous academic interventions for ADHD should be the norm for students with ADHD, since it has a chronic course and long-term consequences, even in those whose ADHD eventually remits. Unfortunately, very few students with ADHD get more than in-class accommodations, under Section 504 of the Rehabilitation Act. While ADHD can qualify many children for specific remedial academic instruction with an Individualized Educational Plan (IEP), when ADHD is considered under the “Other Health Impairment” category of disabilities, few children with ADHD actually receive these services, unless they have a comorbid LD. Based on the positive outcomes from remedial tutoring and teaching of strategies to cope with executive dysfunction demonstrated by other studies, Voigt, et al. advocates for the more frequent inclusion of students with ADHD in formal remedial education programs. Other studies suggest that long-term treatment with stimulant medication can protect many children with ADHD from repeating a grade, and may even protect some from some of ADHD’s common psychiatric comorbidities5. Both pharmacotherapy and educational intervention are likely to produce the best outcomes.

Voigt, et al.’s findings also suggest another mechanism for the association between ADHD and poorer adult outcomes. If childhood ADHD interferes with the acquisition of foundational academic skills, perhaps it also hinders the development of other life skills important to navigating adulthood successfully. With so much at stake, it becomes crucial for patients diagnosed with ADHD as children to receive adequate and ongoing multimodal treatments, with adjustments over time as new challenges appear. Multiple interventions and careful follow-up throughout the lifespan must become the norm in the treatment of those with ADHD, as it is for all other chronic medical disorders.

 

References:

  1. Faraone SV, Asherson P, Banaschewski T, Biederman J, Buitelaar JK, Ramos-Quiroga JA, Rohde LA, Sonuga-Barke EJS, Tannock R, Franke B. Attention-deficit/hyperactivity disorder. Nature Reviews Disease Primers 2015; Aug 6: 15020.
  1. Torralva T, Gleichgerrcht E, Lischinsky A, Roca M, Manes F. “Ecological” and Highly Demanding Executive Tasks Detect Real-Life Deficits in High-Functioning Adult ADHD Patients. Journal of Attention Disorders 2012; 17(1): 11–19.
  1. Voigt RG, Katusic SK, Colligan RC, Killian JM, Weaver AL, Barbaresi WJ. Academic Achievement in Adults with a History of Childhood Attention-Deficit/Hyperactivity Disorder. Journal of Developmental & Behavioral Pediatrics 2017; 38(1): 1–11.
  1. Biederman J, Faraone SV. The effects of attention-deficit/hyperactivity disorder on employment and household income. MedGenMed 2006; 8(3): 12.
  1. Biederman J, Monuteaux MC, Spencer T, Wilens TE, Faraone SV. Do stimulants protect against psychiatric disorders in youth with ADHD? A 10-year follow-up study. Pediatrics 2009; 124(1): 71-78.

 

 

J Russell Ramsay AIA lDQiPt

Assessment and Treatment Monitoring Tools for Adult ADHD

Despite the evidence that ADHD is a distinct condition from other psychiatric and neurodevelopmental disorders that affect adults, it is a challenging one to assess because of its overlap with other conditions. It is fortunate that there are several evidence-supported pharmacologic and psychosocial treatments available to adult ADHD. However, accurate assessment and measurement strategies during treatment are needed to optimize outcomes. Even for clinicians who may not specialize in ADHD, screening tools are needed to determine if further evaluation or specialized treatment is indicated for patients suspected of having ADHD.

There are several options of various symptom measures, adult ADHD inventories that go beyond DSM symptomatology, and additional means for assessing executive functioning, impairment, and screening measures that are available to practicing clinicians who perform diagnostic evaluations and/or provide treatment. This blog will provide a general overview of essential topics that are covered in greater detail in a recently published article, including a review of a menu of specific assessment and tracking tools relevant for clinical practice.1

Structured Diagnostic Interviews

            Although often associated with research, there are several structured diagnostic interviews that can be used to systematically guide the evaluation of ADHD in adults. All of them adhere to existing DSM criteria as well as assessing for age of onset, symptoms in multiple settings, and evidence of impairment. Even those developed during the advent of DSM-IV can be easily adapted to the changes in DSM-5 regarding age-of-onset criterion and reduced number of symptoms required for the diagnosis in adults.

ADHD Symptom Measures

            As with the structured interviews, there are multiple adult ADHD symptom checklists that can be used in the diagnostic evaluation as well as in monitoring treatment progress. Again, even those symptom measures published using DSM-IV criteria can be adapted to DSM-5. Several of the measures provided normative data with regarding the percentile rank of different scores, including symptom count and overall symptom rating scores.

Adult ADHD Inventories

            There are several adult ADHD inventories that often build on the foundation of the extant diagnostic criteria but cast a wider net in terms of other clinically-relevant manifestations of ADHD. These inventories are more likely to include items related to emotional regulation, issues related to organization and procrastination, which may offer a better means for tracking progress in terms of functioning in day-to-day life. These measures may be particularly relevant in tracking progress in psychosocial treatment, where functional impairments and the targets of treatment more than pure symptom improvement.

Executive Functioning Inventories

            Following up on the point made above about treatment promoting functional improvements, executive functioning inventories provide another useful means for assessing this aspect of the clinical presentation of adults with ADHD. It is most often issues related to poor time management, disorganization, and poor initiation and follow through on tasks that lead individuals to seek treatment. Emotional regulation issues are also captured in these scales and other executive functioning issues that are not represented in the official diagnostic criteria.

Functional Impairment/Quality of Life Inventories

            Many evaluations are asked to assess and address level of impairment, not to mention that evidence of impairment is one of the criteria for establishing whether symptoms reflect a diagnosable disorder. Although there are other ways to make the case for the existence of impairment, such as academic disruption or workplace evaluations, these measures provide another means to do so, as well as a way to track the effects of treatment on these life domains.           

Selecting and Using Interviews, Measures, and Inventories

            The primary guiding principle is that the clinical data gathered from these tools cannot be taken at face value and each must be considered as one component of the overall clinical picture, which includes a thorough clinical and developmental interview. A related principle is that these measures may be necessary for establishing a diagnosis of ADHD, but no one is sufficient. Many of the scales include observer rating forms which allows a means for collecting collateral data with which to make a diagnosis and/or assess treatment progress.

Summary

            The evaluation of ADHD requires a thorough evaluation of emergence and persistence of symptoms across time and establishing evidence of impairments, including gathering collateral data and ruling out other diagnoses. Similarly, because it is a neurodevelopmental disorder, treatment focuses on the effective management of symptoms and impairments and tracking progress is more challenging than a condition that is episodic. However, there are many useful clinical tools available to clinicians in practice that help improve diagnostic accuracy, assessment of treatment progress, and, ultimately, clinical outcomes.           

Reference

1Ramsay, J. R. (2017). Assessment and monitoring of treatment response in adult ADHD patients: current perspectives. Neuropsychiatric Disease and Treatment, 13, 221-232. doi.org/10.2147/NDT.S104706

 

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I have too often seen on the Internet or media the statement that ADHD is a recent invention of psychiatrists and/or pharmaceutical companies.  Such statements ignore the long history of ADHD that my colleague and I reviewed in our “Primer” about ADHD, http://rdcu.be/gYyV.   As you can see from The Figure, ADHD has a long history.  The first ADHD syndrome was described in a German medical textbook by Weikard in 1775.  That’s not a typo.  The ADHD syndrome had been identified before the birth of the USA.   Dr. Weikard did not use the term ADD or ADHD, yet he described a syndrome of hyperactivity and inattention that corresponds to what we call ADHD today.  As you can see from the Figure, ADHD-like syndromes were described in Scotland in 1798 and in France in the late 19th century.  The first description of an ADHD-like syndrome in a medical journal was by Dr. George Still in 1901 who described what he called a ‘defect of moral control” in The Lancet.  The discovery that stimulant drugs are effective in treating ADHD occurred in 1937 when Dr. Charles Bradley discovered that Benzedrine (an amphetamine compound) improved the behavior of children diagnosed with behavioral disorders.  In subsequent years, several terms were used to describe children with ADHD symptoms.  Examples are Kramer-Pollnow syndrome, minimal brain damage, minimal brain dysfunction and hyperkinetic reaction.  It was not until the 1980s that the term Attention Deficit Disorder (ADD) came into widespread use with the publication of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM).   During the ensuing decades, several changes were made to the diagnostic criteria and the term ADD was replaced with ADHD so as not to overemphasize either inattention of hyperactivity when diagnosing the disorder.  And, as the graphic below describes, these new and better diagnostic criteria led to many breakthroughs in our understanding of the nature of the disorder and the efficacy of treatments.   So, if you think that ADHD is an invention of contemporary society, think again.  It has been with us for quite some time.

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

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Eight Pictures Describe Brain Mechanisms in ADHD

When my colleagues and I wrote our “Primer” about ADHD, http://rdcu.be/gYyV, the topic of brain mechanisms was a top priority.   Because so much has been written about the ADHD brain, it is difficult to summarize.   Yet we did it with the eight pictures reproduce here in one Figure.   A quick overview of this Figure shows you the complexity of ADHD’s pathophysiology.  There is no single brain region or neural circuit that is affected.   Figures (a) and (b) show you the main regions implicated by structural and functional neuroimaging studies.  As (c) shows, these regions are united by neural networks rich in noradrenalin (aka, norepinephrine) and dopamine, two neurotransmitters whose activity is regulated by medications that treat ADHD.  Figure (d) describes two functional networks.   The Executive Control network is, perhaps, the best described network in ADHD.  This network regulates behavior by linking dorsal striatum with the dorsolateral prefrontal cortex.  This network is essential for inhibitory control, self-regulation, working memory and attention.  The Corticocerebellar network is a well-known regulator of complex motor skills.  Data also suggest it play a role in the regulation of cognitive functions.   Figure (d) describes the Reward Networks of the brain that link ventral striatum with prefrontal cortex.   This network regulates how we experience and value rewards and punishments.   In addition to its involvement in ADHD, this network has also been implicated in substance use disorders, for which ADHD persons are at high risk. Figures (f) (g) and (h) complete the puzzle with additional regions implicated in ADHD whose role is less well understood.  One role for these regions is in the regulation of the Default Mode Network, which controls what the brain does when it is not focused on any specific task (e.g., daydreaming, mind wandering).  People differ in the degree to which they shift between the default mode network and networks like Reward or Executive Control, which are active when we engage the world.  Recent data suggest that the brains of ADHD people may be in ‘default mode’ when they ought to be engaged in the world.    

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

Faraone 8 Brain Images

Kevin Antshel, PhD, ADHD in AdultsAccording to statistics released in 2014 by the National Student Clearinghouse Research Center1, nearly 1 in 3 college students will drop out in their first year of college. While there are a variety of possible reasons (e.g., financial, etc.) for this sobering statistic, this finding highlights that transitioning to college can be challenging for a significant proportion of adolescents. For adolescents with ADHD, this transition period can be especially demanding. Adolescents with ADHD often move away from a structured environment (e.g., interventions and accommodations occurring at school, parent involvement, etc.) to the less structured environment of the college campus and greater demands for functional independence (e.g., managing medication without the involvement of parents).

A recently published qualitative study by Schaefer and colleagues2 addresses stimulant medication adherence in college freshmen with ADHD, a part of this transition towards independence. In this study, 10 second-semester college freshmen with ADHD (7 males, 3 females) were interviewed using a semi-structured interview guided by the Health Belief Model (HBM), a theory developed to explain health behavior decision-making3.

Using a Likert scale from 0 (not at all controlled) to 10 (fully controlled), college freshmen with ADHD reported having moderate ADHD control (M = 6.1, SD = 2.7). Using a similar Likert scale from 0 (parents not at all involved) to 10 (parents completely involved), college freshmen with ADHD reported that in high school, parental involvement was moderate (M = 6.8, SD = 3.0) yet in college, parental involvement decreased to low levels (M = 2.8; SD = 3.5). Medication barriers identified by the majority of surveyed college freshmen with ADHD included not feeling like taking the medication, difficulty adhering to a fixed medication schedule, difficulties obtaining a refill on time and that the medication interfered with other activities.

Six different themes (presented here in descending order) emerged from the qualitative interviews and were reported by the majority of the 10 freshmen. The theme that was unanimously raised by all freshmen with ADHD related to volitional non-adherence to stimulants. The reasons for this non-adherence were varied yet could be grouped into inaccurate disease beliefs (“outgrew my ADHD”), perceived lower academic demands (“light academic day and no need to take my stimulant”) and medication side effects. While the authors did not explicitly make this link, volitional non-adherence to daily stimulant medication prescriptions sets the stage for stimulant diversion / misuse. By having “extra” medication available, the possibility of stimulant diversion is increased. Consistent with this notion, a second theme that emerged from the interviews was centered on perceived pressure from peers to share stimulant medications. A third theme that emerged from the interviews was that poor ADHD self management had negative implications for academic performance. A fourth theme was that increased social support was needed. The last two themes related to being ill-equipped for the abrupt transition to independence and reluctance to use non-medication management strategies (e.g., failure to use of Office of Disability Services secondary to stigma).

The authors concluded by offering a number of clinical strategies for improving the transition to college for adolescents with ADHD. While not mentioned in the Schaefer et al. study, others have developed programs tailored towards helping adolescents with ADHD transition from high school to college. For example, the Accessing Campus Connections and Empowering Student Success (ACCESS) program developed by Anastopoulos and colleagues4 includes weekly group therapy and individual mentoring. Group treatment sessions address ADHD knowledge (e.g., including medication knowledge), behavioral strategies (e.g., how to access resources on campus) and cognitive skills (e.g., how think adaptively). ACCESS is currently being tested in a randomized controlled clinical trial study after initial pilot data were encouraging.

By virtue of their college student status, college students with ADHD have had higher academic success during elementary, middle and high school and likely have better coping skills and higher general abilities than individuals with ADHD from the general population. (In support of this view, the average age of ADHD diagnosis for the 10 college freshmen was 15.7 years in the Schaefer et al. qualitative study.) At the same time, college students with ADHD are likely to experience a different set of stressors than young adults with ADHD who are not enrolled in college. In this way, college students with ADHD may represent a distinct category of individuals with ADHD who face a distinct set of challenges. Efforts, like those of Schaefer et al., to understand how best to improve the transition of adolescents with ADHD to college are a clinically important topic.

College students, both with and without ADHD, are in the developmental period of “emerging adulthood,” a period of time between 18-25. Emerging adulthood consists of five dimensions: identity exploration (e.g., trying out different career goals), feeling-in-between adolescence and adulthood, possibilities (e.g., setting optimistic life goals), self-focus (e.g., becoming independent from parents), and instability (e.g., uncertainty and stress from exploring life options)5. The Schaefer et al. study did not use emerging adulthood as a framework for understanding the qualitative interview responses from the freshmen with ADHD. However, several of the emerging adulthood dimensions can be observed in the identified themes and individual freshmen responses.

In sum, the Schaefer et al. study provides meaningful information about stimulant medication adherence, an important aspect of the transition to college for adolescents with ADHD. In addition to providing useful information about how to best facilitate a smooth transition to college, the Schaefer et al. study also intimates that efforts to improve stimulant medication adherence (and therein lessen stimulant diversion) are sorely needed for college students with ADHD.
 

References
1. Center NSCR. First-Year Persistence Rate of College Students Declines. 2014; http://nscnews.org/first-year-persistence-rate-of-college-students-declines/. Accessed February 20, 2017.
2. Schaefer MR, Rawlinson AR, Wagoner ST, Shapiro SK, Kavookjian J, Gray WN. Adherence to Attention-Deficit/Hyperactivity Disorder Medication During the Transition to College. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 2017.
3. Cummings KM, Jette AM, Rosenstock IM. Construct validation of the health belief model. Health Educ Monogr. 1978;6(4):394-405.
4. Anastopoulos AD, King K. A Cognitive-Behavior Therapy and Mentoring Program for College Students With ADHD. Cogn Behav Pract. 2015;22:141-151.
5. Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. The American psychologist. 2000;55(5):469-480.

David_Giwerc_ADHD_in_Adults_196_x_300_nDA7da

Psycho education is an integral part of the coaching process. It is during this phase of the coaching relationship that the coach educates the client about how and where the challenges of AD/HD are manifested in their life. The knowledgeable, well-trained certified AD/HD coach, from an accredited program, understands the ADHD brain and has the knowledge, language to clearly explain the bio-neurological nature of AD/HD. The coach conveys the invisible executive function challenges of ADHD in models, metaphors, stimulating language that attracts the attention of their client and significantly improves their understanding of their own type of ADHD.

Diagnosticians and physicians often do not have the time explain ADHD to their patients in ways they will understand so they leave their offices with a diagnosis they don’t understand. The diagnosis they are given makes them feel blind to what they have and how it manifests in their world. Coaches are trained to explain in simple, descriptive language how the invisible challenges of ADHD can be made more visible, to their clients, so they can learn to identify the specific situations, tasks and environments which could impede their ability to activate their brains and gain momentum with accomplishing an important goal or task.

For example, some people who have AD/HD tend to be visual processors and can sustain their focus by seeing or thinking in pictures. To improve the understanding of how and where AD/HD manifests, the coach will communicate with creative metaphors, models and language to support their clients with visualizing how AD/HD affects their life and how it can be managed.

The coach may describe the brain as an engine of a car which needs the “fuel of interest” to ignite it and the prefrontal cortex as the steering wheel which allows the driver to choose a positive intention or direction for the car to move towards their desired destination. The client can learn how stepping on the brain’s brakes, when the client feels disharmony in his body, allows him to pause and pay attention to what they are paying attention to and identify the emotion they are feeling in the moment.

By pausing to name the negative emotion, they are diminishing its impact. Without the pause, the dominant, unnamed emotion can lead to ruminative cycle of thinking which can impede any forward momentum. The skill of identifying a negative emotion in the moment, such as anger, frustration, sadness, anxiety, hopelessness, etc.is the foundation for learning the skill of emotional intelligence and is essential for improving emotional self-regulation. Rather than keeping the negative feeling repressed inside one’s body which can create negative chemicals like cortisol and increases stress, the skill of emotional intelligence improves self-regulation and can prevent the client from making impulsive decisions which can have dire consequences.

During the psycho education phase of coaching, the AD/HD coach shares information supported by scientific research about AD/HD. The credibility of this documented and proven body of knowledge from reputable and respected sources, such as health care institutions, organizations and other authorities on AD/HD illustrates and explains the client’s past inability to perform as a function of undiagnosed and untreated AD/HD, not because of being “broken” or having had a character flaw.

Understanding how AD/HD affects the brain and the life of an individual diminishes, and in many cases, eliminates years of self-blaming behaviors that have contributed to the low self-perception of the individual who has AD/HD and a continued cycle of failure.

If the client is to have a greater understanding and awareness of their ADHD challenges as behaviors of a bio-neurological brain wiring, which in certain situations is challenged, but in other situations can lead to success (situational variability), they can begin the process of accepting, understanding the specific situations, tasks where they can consistently experience success. The coach can then work with their clients to integrate the successful lessons learned and integrate them, more frequently, into their daily life.

Resources:

Thomas E. Brown, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (New York, Rutledge, 2013)

Russell Barkley, Taking Charge of Adult ADHD (New York, The Guilford Press, 2010)

David Giwerc, Permission to Proceed: The Keys to Creating a Life of Passion, Purpose and Possibility (Albany New York, ADD Coach Academy Press, Vervante, 2011)

Kristin Neff, Self-Compassion, Stop Beating Yourself Up and Leave Insecurity Behind (New York, HarperCollins Publsihers,2011)

Travis Bradberry & Jean Graves, Emotional Intelligence 2.0 (San Diego, TalentSmart,2009)

Kevin Antshel, PhD, ADHD in AdultsOccupational impairments are one of the most common outcomes for adults with ADHD. As a function of ADHD symptoms and associated problems such as psychiatric comorbidities and executive function impairments, adults with ADHD often experience difficulties finding and maintaining jobs and are at increased risk for being unemployed or underemployed. Given the variety of outcomes that are associated with occupational functioning (e.g., quality of life, socioeconomic status and subsequent healthcare access, etc.), efforts to understand ADHD in the occupational setting represent a clinically significant topic. Despite being an environment in which adults with ADHD spend considerable time, very few existing studies have considered how the occupational environment impacts ADHD.

A very recently published paper1 fills this void and examines how young adults with ADHD perceive their occupational environment and the extent to which this environment influences their ADHD symptoms. Using a qualitative research design, one of the primary research questions that the authors investigated was the extent to which certain occupational settings are a better fit for young adults with ADHD. The participants in this study all were young adults with well defined ADHD that was diagnosed in childhood. All participants were ascertained from the Multimodal Treatment Study of ADHD (MTA)2 and were approximately 24 years of age at the time of their qualitative interview.

The majority of young adults with ADHD reported a connection between occupational environments and ADHD symptoms. While certain work environments intensified ADHD symptoms, other work environments ameliorated symptoms. The importance of the “goodness of fit” between occupational environment and person was a consistent theme that emerged from the qualitative interviews. A view that problems were environmental, not personal, helped to reduce feelings of inadequacy. The young adults with ADHD commonly reported that a highly stimulating environment provided the best person-environment fit. A highly stimulating environment was further operationalized as consisting of some of these elements: stressful work that is novel and requires multitasking, working in a busy and fast-paced environment, completing work that is physically demanding or hands-on in nature, and/or working on tasks that are intrinsically interesting.

The authors concluded that ADHD symptoms are occupationally context-dependent; work environments may either increase or decrease ADHD symptoms dependent upon the “goodness of fit”1. The authors further assert that future research should consider the effectiveness of occupational “fit” as a potential intervention. In my own clinical experiences, I can relate that person-environment fit indeed has a salient impact upon symptom and functioning levels. As I commonly tell parents of children with ADHD, “there is no better intervention than a great teacher who understands your child”. These recently published data suggest that the same principles may hold for young adults, albeit with a different environmental context. This paper is important and reinforces the notion that context “matters”. Rather than ADHD being static, it is more accurate to view ADHD as dynamic and an interaction between the person and the environment.

Similar research has been published in outlets that are likely not familiar to mental health professionals. In the entrepreneur literature, several recent papers have been published on the association between entrepreneurship and having an ADHD diagnosis3 or elevated ADHD symptoms4,5. These research groups have demonstrated positive relationships between ADHD and entrepreneurial intentions (commitment to performing a behavior that is necessary to start a business venture) and the link between ADHD and entrepreneurial orientation (generally considered to be the level of innovation, creativity, proactiveness and risk-taking that an individual possesses). These three studies as well as a case study6 suggest that it is hyperactivity-impulsivity symptoms, not inattention symptoms, that are positively linked to entrepreneurship. Similar to the MTA ADHD researchers described above, these entrepreneurship investigators also concluded that the functional outcomes associated with ADHD are dynamic and context-dependent.

While these entrepreneur data are interesting, much research remains to be done regarding the association between ADHD and entrepreneurship. For example, the existing studies have methodological constraints (e.g., the variance of entrepreneurial orientation explained by ADHD symptoms is low, common method bias [relying exclusively on self-report], etc.). Likewise, these entrepreneurship papers have considered entrepreneurial orientation and intention, not entrepreneurial success. Thus, future work should consider the extent to which individuals with ADHD experience successful outcomes as entrepreneurs. For example, in which industry and contexts/situations (e.g., managing finances, developing a new product, marketing, etc.) might individuals with ADHD experience entrepreneurial success? My suspicion is that there will be no, “one size fits all” conclusions. In other words, the entrepreneurship success is context-dependent and varies widely among adults with ADHD. The exciting part of this line of investigation, however, is the seismic shift in focus: conventional workplace liabilities associated with ADHD may emerge as abilities in an entrepreneurship context.
 

References
1. Lasky AK, Weisner TS, Jensen PS, et al. ADHD in context: Young adults’ reports of the impact of occupational environment on the manifestation of ADHD. Social science & medicine. 2016;161:160-168.
2. MTA Collaborative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of general psychiatry. 1999;56(12):1073-1086.
3. Dimic N, Orlov V. Entrepreneurial Tendencies Among People with ADHD. International Review of Entrepreneurship. 2014;13:187-204.
4. Thurik R, Khedhaouria A, Torrès O, Verheul I. ADHD symptoms and entrepreneurial orientation of small firm owners. Applied Psychology: An International Review. 2016;65:568-586.
5. Verheul I, Block J, Burmeister-Lamp K, Thurik R, Tiemeier H, Turturea R. ADHD-like behavior and entrepreneurial intentions. Small Business Economics. 2015;45:85-101.
6. Wiklund J, Patzelt H, Dimov D. Entrepreneurship and psychological disorders. Frontiers of Entrepreneurship Research. 2014;34:50-59.

Kevin Antshel, PhD, ADHD in AdultsNot every child with ADHD will matriculate to a four-year college, although the numbers are increasing. For example, a follow-up survey on post-secondary trajectoires of high school students with ADHD histories (N = 364) showed that 30% of the ADHD sample were currently in pursuit of a four-year degree; this figure was 9% higher than previously reported data from a comparable sample in 20061. Thus, more children with ADHD are becoming college students with ADHD. College students seeking on-campus ADHD evaluations and ADHD treatment and are also increasing in prevalence. The most recent data from the Association of University and College Counseling Center Directors (AUCCCD) annual survey, completed by 518 college counseling center directors, suggests that approximately 9% of the students seen during the 2014-2015 academic year presented at their counseling centers with concerns specifically related to ADHD2. To put this in perspective, this means that depending upon the size of the college, college counseling centers are seeing anywhere from 1 to 775 students per year with concerns specifically related to ADHD2. It is not possible to know which students the college counseling centers are not seeing and certainly there are plenty of students not seeking counseling centers for ADHD related concerns. Thus, the AUCCCD data likely represents an underestimate of the number of college students with concerns specifically related to ADHD.

College students with ADHD face significant difficulties in the college academic environment and are at greatly increased risk of poor academic achievement and failure. Clinical recommendations for working with college students with ADHD include (a) a combined approach of pharmacotherapy and psychosocial interventions, typically CBT; (b) meeting with the college student more than once per week, generally by having both group CBT and individual CBT interventions operating concurrently, (c) integrate clinical services with other providers on campus (e.g., Office of Disability Services, Counseling Center, etc.) in an attempt to improve and integrate service provision; (d) specifically target treatment adherence, including a discussion of how to handle stimulant diversion requests; (e) incorporate a discussion of emerging adulthood themes such as identity exploration, feeling-in-between adolescence and adulthood, setting realistic and optimistic life goals, and becoming independent from parents; and (f) consider adopting more of a “chronic” model for treating ADHD in college students (e.g., following students over their entire four year experience rather than treating for one semester)3.

In addition to treating college students with ADHD on campus, another issue that is present on college campuses is the college students that may be motivated to over report ADHD symptoms and malinger ADHD. College students have several incentives to over-report ADHD symptoms. A substantial number of students seek stimulant medication, most often with the intent to enhance academic performance4. Prevalence rates for stimulant misuse are the highest in college students (17%) compared to all other populations5. In addition to obtaining stimulant medication, some college students seek an ADHD diagnosis for the accompanying academic accommodations (e.g., extended time for examinations, etc.), also in the hope of improving grades6. Still others may seek an ADHD diagnosis as an external attribution for perceived academic failures7. Given these incentives, it is not surprising that elevated rates of ADHD malingering exist in college students8. Despite this, no existing strategies to detect ADHD malingering in college students have adequate sensitivity and specificity9. Given concerns about students feigning symptoms in order to acquire medication and/or academic accommodations along with the great difficulty in detecting ADHD malingering, it is not surprising that the vast majority of university health professionals are not comfortable diagnosing ADHD, with over 90% referring students off campus for ADHD evaluations10.

Our knowledge of ADHD in the college student population is nascent and we know far less about ADHD in this population compared to ADHD in children and adolescents. Increasing numbers of college students have ADHD diagnoses and are seeking on campus treatment services. Similarly, college students have several clear incentives to malinger ADHD symptoms. Given the difficulties in detecting ADHD malingering, the overwhelming majority of university health professionals refer students off campus. Researchers and clinicians should continue to develop more effective ADHD treatment options, including those designed to reduce stimulant diversion/misuse. Likewise, better understanding how to accurately detect ADHD malingering in this population is important for reducing public health costs for unwarranted assessments, backlogging an already significantly limited psychological resource on college campuses2 and creating an unfair advantage (e.g., receipt of inappropriate academic accommodations).
 

References
1. Kuriyan AB, Pelham WE, Jr., Molina BS, et al. Young adult educational and vocational outcomes of children diagnosed with ADHD. Journal of abnormal child psychology. 2013;41(1):27-41.
2. Association for University and College Counseling Center Directors. The Association for University and College Counseling Center Directors Annual Survey. Indianapolis, IN: AUCCCD; 2015.
3. He A, Antshel KM. Cognitive Behavioral Therapy for Attention Deficit / Hyperactivity Disorder (ADHD) in College Students: A Review of the Literature. Cogn. Behav. Pract. In press.
4. DeSantis AD, Webb EM, Noar SM. Illicit use of prescription ADHD medications on a college campus: a multimethodological approach. Journal of American college health : J of ACH. 2008;57(3):315-324.
5. Benson K, Flory K, Humphreys KL, Lee SS. Misuse of stimulant medication among college students: a comprehensive review and meta-analysis. Clinical child and family psychology review. 2015;18(1):50-76.
6. Williamson KD, Combs HL, Berry DT, Harp JP, Mason LH, Edmundson M. Discriminating among ADHD alone, ADHD with a comorbid psychological disorder, and feigned ADHD in a college sample. The Clinical neuropsychologist. 2014;28(7):1182-1196.
7. Suhr J, Wei C. Symptoms as an Excuse: Attention Deficit/Hyperactivity Disorder Symptom Reporting as an Excuse for Cognitive Test Performance in the Context of Evaluative Threat. Journal of Social and Clinical Psychology. 2013;32(7):753-769.
8. Suhr J, Hammers D, Dobbins-Buckland K, Zimak E, Hughes C. The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Archives of clinical neuropsychology : the official journal of the National Academy of Neuropsychologists. 2008;23(5):521-530.
9. Musso MW, Gouvier WD. “Why is this so hard?” A review of detection of malingered ADHD in college students. Journal of attention disorders. 2014;18(3):186-201.
10. Thomas M, Rostain A, Corso R, Babcock T, Madhoo M. ADHD in the College Setting: Current Perceptions and Future Vision. Journal of attention disorders. 2015;19(8):643-654.