Stephen_Faraone_PhD_ADHD_in_Adults

If you’ve ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our “Primer” about ADHD, http://rdcu.be/gYyV. Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process.   That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD.  The rule of thumb is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition.  Stimulants are typically the first line treatment due to their greater efficacy compared with non-stimulants.  When considering any medication treatment for ADHD, safety is the first concern which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered.  For very young children (preschoolers) family behavior therapy is typically used prior to medication.  Clinicians also must deal with personal preferences.   Some parents and some adolescents and adults with ADHD simply don’t want to take stimulant medications for the disorder.  When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.   If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate of amphetamine is more appropriate.  Here there is very little guidance for doctors.  Amphetamine compounds are a bit more effective but can lead to greater side effects.   Genetic studies suggest that a person’s genetic background provide some information about who will respond well to methylphenidate but we are not yet able to make very accurate predictions.    After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.  There is no simple rule here; the choice will depend upon the specific needs of each patient.  Many children benefit from longer acting medications to get them through school, homework and late afternoon/evening social activities.  Likewise for adults.  But many patients prefer shorter acting medications especially as these can be used to target specific times of day and can also lower the burden of side effects.   For patients taken down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists.  There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases.  Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient’s response must be closely monitored as there is no guarantee that the first choice of medication will work out well.  In some cases efficacy is low or adverse events are high.  Sometimes this can be fixed by changing the dose and sometimes a trial of a new medication is indicated.  If you are a parent of a child with ADHD or an adult with ADHD, this trial and error approach can be frustrating.  But don’t lose hope.  In the end, most ADHD patients find a dose and a medication that works for them.   Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.  You can read details about these in my other blogs but for here the main point is to find an evidenced-based treatment.  For children the biggest evidence base is for behavioral family therapy.  For adults, cognitive behavior therapy (CBT) is the best choice.   With the exception of preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment.  The reason is that the medications are much more effective and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.  

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

Stephen V. Faraone, PhD - ADHD in Adults


The diagnosis of ADHD should only be done by a licensed clinician and that clinician should have one goal in mind: to plan a safe and effective course of evidenced-based treatment.  The infographic below gives a summary of this diagnostic approach over time, which my colleagues and I prepared for our “Primer” about ADHD, referenced below.

.   A key point that parents of ADHD youth and adults with ADHD should keep in mind is that there is only one way to diagnose ADHD.  An expert clinician must document the criteria for the disorder as specified by either the Diagnostic and Statistical Manual of the American Psychiatric Association, which is now in its fifth edition (DSM-5) or the World Health Organizations International Classification of Diseases (ICD-10).  The two sets of criteria are nearly identical.  These criteria are most commonly applied by a clinician asking questions of the parent (for children) and/or patient (for adolescents and adults).  For children, information from the teacher can be useful.  Some clinicians get this information by having the parent ask the teacher to fill out a rating scale.  This information can be very useful if it is available.   

When diagnosing adults, it is also useful to collect information from a significant other which can be a parent for young adults or a spouse for older adults.  But when such informants are not available, diagnosing ADHD based on the patient’s self-report is valid.  As the infographic indicates, any diagnosis of ADHD should also assess for comorbid psychiatric disorders as these have implications for which ADHD medications will be safe and effective.  And because a prior history of cardiovascular disease or seizures frequently contraindicate stimulants, these must also be assessed.

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

 

Stephen_Faraone_PhD_ADHD_in_Adults
Although ADHD was conceived as a childhood disorder, we now know that many cases persist into adulthood.  My colleagues and I charted the progression of ADHD through childhood, adolescence and adulthood in our “Primer” about ADHD,
http://rdcu.be/gYyV.   Although the lifetime course of ADHD varies among adults with the disorder, there are many consistent themes, which we described in the accompanying infographic.   Most cases of ADHD start in utero, before the child is born.  As a fetus, the future ADHD person carries versions of genes that increase risk for the disorder.  At the same time they are exposed to toxic environments.  These genetic and environmental risks change the developing brain, setting the foundation for the future emergence of ADHD.  In preschool early signs of ADHD are seen in emotional lability, hyperactivity, disinhibited behavior and speech, language and coordination problems.  The full blown ADHD syndrome typically occurs in early childhood but can be delayed until adolescence.   In some cases, the future ADHD person is temporarily protected from the emergence of ADHD due to factors such as high intelligences or especially supportive family and/or school environments.  But as the challenges of life increase, this social, emotional and intellectual scaffolding is no longer sufficient to control the emergence of disabling ADHD symptoms.  Throughout childhood and adolescence the emergence and persistence of the disorder is regulated by additional environmental risk factors such as family chaos along with the age dependent expression of risk genes that exert different effects at different stages of development.  During adolescence, most cases of ADHD persist and by the teenage years, many youth with ADHD have onset with a mood, anxiety or substance use disorder.   Indeed, it is essential for parents and clinicians to monitor ADHD youth for early signs of these disorders.  Prompt treatment can prevent years of distress and disability.  By adulthood, the number of comorbid conditions has increased, including obesity, which likely has effects of future medical outcomes.   The ADHD adult tends to be very inattentive by shows fewer symptoms of hyperactivity and impulsivity.  They remain at risk for substance abuse, low self-esteem, occupational failure and social disability, especially if they are not treated for the disorder.   Fortunately, there are several classes of medicine available to treat ADHD that have been shown to be safe and effective.  And the effects of these medications are enhanced by cognitive behavior therapy as I’ve written about in prior blogs.

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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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.

J_Russell_Ramsay_AIA_lDQiPt

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.

Betsy_Busch_with_creds_aB8shI Jessica_Uno_w_creds_QOALfX  
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

 

Stephen_Faraone_PhD_ADHD_in_Adults

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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Stephen_Faraone_PhD_ADHD_in_Adults

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.