What can Doctors do about Fake ADHD?

Stephen V. Faraone, PhD on December 1, 2016

ADHD is a serious disorder that requires treatment to prevent many adverse outcomes. But, because the diagnosis of ADHD is based on how the patient responds to questions, it is possible for people to pretend that they have ADHD, when they do not. In fact, if you Google “fake ADHD” you’ll get many pages of links including a Psychology Today article on the topic and bloggers describing how they were able to fool doctors into giving them ADHD medications. Is fake ADHD a serious problem? Not really.

The Internet, it seems, is faking an epidemic of fake ADHD. I say that because we have decades of research that show many objective measures of abnormality and impairment in people who say they have ADHD. These include traffic accidents, abnormalities on brain imaging and molecular genetic differences. Some studies even suggest that ADHD adults downplay their ADHD symptoms. For example, one study diagnosed ADHD in children and then contacted them many years later when they were young adults. When they were interviewed as young adults, their responses to questions about ADHD suggested that they did not have the disorder. But when the same questions about the patient were asked to someone who lived with the patient as a young adult, it was clear that they still had ADHD. So rather than faking ADHD, many ADHD adults do not recognize that they have symptoms of the disorder.

That said, we also know from research studies that, when asked to pretend that they have ADHD, adults can fake the disorder. That means that they can learn about the symptoms of the disorder and make up examples of how they have had them, when they have not. This research suggests that this is not common, but we do know that some people have motives for faking ADHD. For example, some college students seek special accommodations for taking tests; others may want stimulants for abuse, misuse or diversion.

Fortunately, doctors can detect fake ADHD in several ways. If an adult is self-referred for ADHD and asks specifically for stimulant medication, that raises the possibility of fake ADHD and drug seeking. Because the issue of stimulant misuse has been mostly a concern on college campuses, many doctors treating college students will require independent verification of the patients ADHD symptoms by speaking with a parent, even over the phone if an in-person visit is not possible. Using ADHD rating scales will not detect fake ADHD and it is easy to fake poor performance on tests of reading or math ability. Neuropsychological tests can sometimes be used to detect malingering but require referral to a specialist. Researchers are developing methods to detect faking of ADHD symptoms. These have shown some utility in studies of young adults but are not ready for clinical practice.

So, currently, doctors concerned about fake ADHD should look for objective indicators of impairment (e.g., documented traffic accidents; academic performance below expectation) and speak to a parent of the patient to document that impairing symptoms of the disorder were present before the age of twelve. Because the issue of fake ADHD is of most concern on college campuses, it can also be helpful to speak with a teacher who has had frequent contact with the patient. In an era of large lecture halls and broadcast lectures, that may be difficult. And don’t be fooled by the Internet. We don’t want to deny treatment to ADHD patients out of undocumented reports of an epidemic of fake ADHD.
The best way for health professionals to determine if someone has ADHD by the way, is by performing a complete diagnosis. We teach that in our FREE online CME courses on ADHD in Adults.
 

References:
Harrison, A. G., Edwards, M. J. & Parker, K. C. (2007). Identifying students faking ADHD: Preliminary findings and strategies for detection. Arch Clin Neuropsychol 22, 577-88.
Sansone, R. A. & Sansone, L. A. (2011). Faking attention deficit hyperactivity disorder. Innov Clin Neurosci 8, 10-3.
Loughan, A., Perna, R., Le, J. & Hertza, J. (2014). C-88Abbreviating the Test of Memory Malingering: TOMM Trial 1 in Children with ADHD. Arch Clin Neuropsychol 29, 605-6.
Loughan, A. R. & Perna, R. (2014). Performance and specificity rates in the Test of Memory Malingering: an investigation into pediatric clinical populations. Appl Neuropsychol Child 3, 26-30.
Quinn, C. A. (2003). Detection of malingering in assessment of adult ADHD. Arch Clin Neuropsychol 18, 379-95.
Suhr, J., Hammers, D., Dobbins-Buckland, K., Zimak, E. & Hughes, C. (2008). The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Arch Clin Neuropsychol 23, 521-30.
Greve, K. W. & Bianchini, K. J. (2002). Using the Wisconsin card sorting test to detect malingering: an analysis of the specificity of two methods in nonmalingering normal and patient samples. J Clin Exp Neuropsychol 24, 48-54.
Killgore, W. D. & DellaPietra, L. (2000). Using the WMS-III to detect malingering: empirical validation of the rarely missed index (RMI). J Clin Exp Neuropsychol 22, 761-71.
Ord, J. S., Greve, K. W. & Bianchini, K. J. (2008). Using the Wechsler Memory Scale-III to detect malingering in mild traumatic brain injury. Clin Neuropsychol 22, 689-704.
Wisdom, N. M., Callahan, J. L. & Shaw, T. G. (2010). Diagnostic utility of the structured inventory of malingered symptomatology to detect malingering in a forensic sample. Arch Clin Neuropsychol 25, 118-25.

How to Avoid False Positives and False Negatives when Diagnosing Adult ADHD?

Stephen V. Faraone, PhD on November 3, 2016

A recent paper by Margaret Sibley and colleagues addresses a key issue in the diagnosis of adult ADHD. Is it sufficient to only collect data from the patient being diagnosed or are informants useful or, perhaps, essential, for diagnosing ADHD in adults. Dr. Sibley presented as systematic review of twelve studies that prospectively followed ADHD children into adulthood. Each of these studies asked a simple question: What faction of ADHD youth continued to have ADHD in adulthood. Surprisingly, the estimates of ADHD’s persistence ranged from a low of 4% to a high of 77%. They found two study features that accounted for much of this wide range. The first was the nature of the informant; did the study rely only on the patient’s report or were other informants consulted. The second was the use of a strict diagnostic threshold of six symptoms. When they limited the analysis to studies that used informant and eliminated the six symptom threshold, the range of estimates was much narrower, 40% to 77%. From studies that computed multiple measures of persistence using different criteria, the authors concluded: “(1) requiring impairment to be present for diagnosis reduced persistence rates; (2) a norm-based symptom threshold led to higher persistence than a strict six-symptom DSM-based symptom count criterion; and (3) informant reports tended to show a higher number of symptoms than self-reports.” These data have clear implications for what clinicians can do to avoid false positive and false negative diagnoses when diagnosing adult ADHD. It is reassuring that the self-reports of ADHD patients tend to underestimate the number and severity of ADHD symptoms. This means that your patients are not typically exaggerating their symptoms. Put differently, self-reports will not lead you to over-diagnose adult ADHD. Instead, reliance on self-reports can lead to false negative diagnoses, i.e., concluding that someone does not have ADHD when, in fact, they do. You can avoid false negatives by doing a thorough assessment, which is facilitated by some tools available at www.adhdinadults.com and described in CME videos there. If you think a patient might have ADHD but are not certain, it would be helpful to collect data from an informant, i.e., someone who knows the patient well such as a spouse, partner, roommate or parent. You can collect such data by sending home a rating scale or by having the patient bring an informant to a subsequent visit. Dr. Sibley’s paper also shows that you can avoid false negative diagnoses by using a lower symptom threshold than what is required in the diagnostic manual. In fact, the new DSM 5 lowered the symptom threshold for adults from six to five. Can you go lower? Yes, but it is essential to show that these symptoms lead to clear impairments in living. Importantly, this symptom threshold refers to the number of symptoms documented in adulthood, not to the number of symptoms retrospectively reported in childhood. To be diagnosed with ADHD in adulthood, one must document that the patient had at least six impairing symptoms of ADHD prior to the age of 12.
 

REFERENCE
Sibley, M. H., Mitchell, J. T. & Becker, S. P. (2016). Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry 3, 1157-1165.

Neural Correlates of ADHD

Lenard A. Adler, on September 29, 2016

Neural Correlates of Symptom Improvement Following Stimulant Treatment in Adults
with Attention-Deficit/Hyperactivity Disorder, Zhen Yang, PhD, Clare Kelly, PhD, Francisco X. Castellanos, MD, Terry Leon, MS, Michael P. Milham, MD, PhD, and Lenard A. Adler, MD
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY, p. 1–10,DOI: 10.1089/cap.2015.0243

Several prior studies have examined effects of stimulant medications on functional connectivity during resting state fMRI (R-fMRI). This study appears to be the first study to examine effects of ADHD treatment on functional connectivity in adults. Nineteen adults with ADHD were received two, six minute R-fMRI scans at baseline and after three weeks of single-blind treatment with amphetamine (mixed amphetamine salts (MAS) or lisdexamfetamine (LDX)).

A comparison group of healthy controls (HC) was scanned once at baseline. Potential amphetamine effects on the entire connectome relating to R-fMRI were examined through a data driven analytic approach. Clinical effects of amphetamines on ADHD symptoms were examined via the prompted ADHD Rating Scale (ADHD-RS) administered by a clinician and the Adult Self Report Scale (ASRS) v1.1 Symptom Checklist. MAS and LDX both significantly improved ADHD symptoms on the ADHD-RS and ASRS. Functional connectivity analyses showed that stimulants altered multivariate connectivity in medial prefrontal cortex (MPFC)/paracingulate gyrus and the dorsolateral PFC. Seed based correlation analyses were defined for the left DLPFC and bilateral MPFC. Functional connectivity analyses showed that amphetamines decreased positive functional connectivity between: a) left DLPFC and bilateral dorsal ACC, right insula and left insula and b) bilateral MPFC. These reductions in functional connectivity led to a pattern of function similar to the healthy controls, which is important as the increased functional segregation of these units may be involved in the improvement with amphetamine treatment. Although these results cannot be directly translated into the clinic, they hold open the promise that, in the future, imaging methodologies may be useful for either predicting or tracking treatment response.

Collateral Information in Adult ADHD

Lenard A. Adler, on March 3, 2016

Breda,V;, Rovaris, DL; Schneider Vitola, E.; et al.

Does collateral retrospective information about childhood attention- deficit/hyperactivity disorder symptoms assist in the diagnosis of attention- deficit/hyperactivity disorder in adults? Findings from a large clinical sample.

Australian & New Zealand Journal of Psychiatry, 1–9, DOI: 10.1177/0004867415609421.

Collateral information is commonly used in making the diagnosis of ADHD in a child or adolescent. The role of collateral information in making the diagnosis in adults presenting for evaluation for ADHD has been less well investigated.

This is an investigation of the relative importance of childhood collateral information in making a diagnosis of ADHD in an adult presenting for evaluation. 449 adults with ADHD and 143 controls were evaluated for the diagnosis of ADHD and co-morbidities with a modification of the K-SADS, ADHD symptoms with the SNAP-IV, and current/childhood impairment with the Barkley Current and Childhood Symptom scales. Collateral childhood ADHD symptoms/impairments were also evaluated with the Barkley Childhood Symptom Scale, completed by a first or second degree relative.

A diagnosis of ADHD via patient or collateral report required full childhood symptom onset prior to the age of 12. A subset of adults with ADHD were also treated with methylphenidate immediate release (0.13-1.23 mg/kg/day); treatment response was measured via changes in SNAP-IV from baseline to endpoint.

The data analyses were performed on three cohorts: 1) adults with ADHD where there was agreement as to childhood symptoms from the subject and informant (n=277), 2) adults with ADHD where there was disagreement between subjects and informants (n=172) and 3) controls. ADHD patients (all) vs. controls did not significantly differ in terms of age, gender, years of education or income, but did have significantly more school failure problems with discipline and problems with the law. The levels of impairment for the ADHD cohort were quite similar (collateral agreement + vs. -), except that the group with collateral and patient childhood agreement had higher levels of school suspensions and problems with discipline. It is not that surprising that the collaterals and subjects had better agreement in these areas as school suspensions and discipline problems are more likely to be remembered by both subjects and collaterals.

The ADHD cohorts (collateral agreement + vs. -) had similar levels of co-morbidity and treatment response to methylphenidate. The combined ADHD cohorts had higher rates of tobacco use, bipolar disorder, current ODD, conduct disorder and non-alcohol SUD than controls. A salient finding of this investigation is that 40% of subjects with adult ADHD had collateral informants who were unable to extensively corroborate their symptoms.

Limitations of this study include the self-report nature of the SNAP-IV and the fact that this scale has not been validated for adults. Also, of note, the subjects with adult ADHD had full childhood onset of the disorder retrospectively, which is a more stringent criteria than utilized in DSM-IV. It is not clear how utilizing more strict childhood criteria will influence the generalizability of these findings to clinically evaluated subjects using DSM-IV or DSM-5 guidelines.

Clinicians remain the final and optimal arbiter in establishing a diagnosis of adult ADHD; it remains up to clinicians to integrate information from all sources in establishing this diagnosis, be it from the subject, current significant others, collateral informants about childhood or clinician observations during the interview.

Locomotor Activity and Diagnosing ADHD

Anthony L. Rostain, MD MA on January 21, 2016

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

 

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

 

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

 

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

 

 

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

Training the ADHD Brain

Stephen V. Faraone, PhD on April 2, 2015

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

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

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

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

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

Diagnosing and Monitoring ADHD

Lenard A. Adler, on December 8, 2014

The American Academy of Pediatrics (AAP) published guidelines for the diagnosis and treatment of ADHD, which include using DSM-IV criteria to evaluate ADHD, using rating scales from multiple sources to assist in making the diagnosis and monitoring for treatment effects and side effects and inclusion of psychosocial treatment paradigms in treatment recommendations (American Academy of Pediatrics. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics, 105, 1158–1170. http://dx.doi.org/10.1542/peds.105.5.1158.)  This just published study by Epstein and colleagues examined the rates of evidence based care and potential sources of clinician and patient centered variability in a chart review of over 1500 patients, 188 pediatricians in 50 different practice settings in Ohio since the publication of the AAP guidelines for ADHD.  The authors found:

 

Diagnosis: There was an underutilization of parent and teacher rating scales in making the ADHD diagnosis (occurring in slightly over 55% of the sample); about 30% of the patients did not fulfill DSM-IV criteria for ADHD.

Treatment Initiation: Medications were used in the vast majority of cases (93.4%); psychosocial treatments were not commonly recommended or used (13% of the time).  Less than ½ the sample had a visit or a phone call with the pediatrician’s office within the first month of starting treatment.  

Monitoring Treatment: Only 10% and 8% of the charts indicated that parent or teacher rating scales, respectively, were used to assess treatment response or side effect.  The average time to collection of these scales was quite long – over a year from the time of treatment initiation.

Practice Variables: Urban and rural practices used psychosocial treatments more commonly than suburban ones, while suburban practices had shorter times for follow up visits after starting treatment than urban practices.

The authors concluded that there is a need to improve the quality of ADHD care in the pediatric practices they surveyed.  Advances could be achieved in applying DSM criteria for ADHD, using rating scales from parents and teachers and using psychosocial treatments.  They suggest that improvements could be made in terms of education and the use of technology in the practice and patient level.

 

Even though this study was of pediatric PCPs (pediatricians), it has significant implications for the treatment of adults with ADHD by PCPs.  As there are no US practice guidelines for adults with ADHD, there is a clear need to educate PCPs about the appropriate use of the DSM for diagnosis and rating scales to monitor ADHD adults during treatment.  The above study does not address the issue of whether the cost of potential psychosocial treatments might create a barrier to their use, which could also be the case for adult ADHD (along with a smaller network of providers of these treatments for adults as compared to children).  The study did not assess the consequences of failing to document and monitor treatment efficacy and side effects.  The need for ongoing monitoring of patients with ADHD is certainly important when using stimulant and non-stimulant medications.

 

 

Source:

Variability in ADHD Care in Community-Based Pediatrics, Jeffery N. Epstein, Kelly J. Kelleher, Rebecca Baum, William B. Brinkman, James Peugh, William Gardner, Phil Lichtenstein and Joshua Langberg.  Pediatrics; originally published online November 3, 2014; DOI: 10.1542/peds.2014-1500.

ADHD Treatment More than Just Drugs

p p on March 11, 2014

Editor’s Note:  We combined two interviews into an intertwining post for you.

Anthony_L_Rostain_MD_MA_-_ADHD_in_AdultsAnthony Rostain, MD, MA: So ADHD medication is really only one part of what we call a multimodal approach to treating ADHD. The other components include patient education. It’s really important to sit down with the patient and educate them about what ADHD is and how it affects their life and to review the treatment options.

The next thing we recommend is self-education. It’s having the patient learn about online resources that can help them cope better with their ADHD.

The next component of treatment is ADHD coaching. Many people find it helpful to find somebody to coach them through the day, keep them on track, and give them ideas about how to organize their lives. Coaching is a growing resource for people with ADHD.

Robert Tudisco,Esq, ADHD Adult: A very interesting story about my boss who was an adult with ADHD. He was and still is a successful entrepreneur. Both of his children were diagnosed with ADHD and they were struggling in school. Both he and his son and his daughter were very successful after working with ADHD coaches. What he ultimately did was to decide to be able to create a network of coaches to provide support for all adults and students with ADHD.

He created this foundation and I actually ran it for him. The name of the organization is the Edge Foundation and they have a network of coaches that work with students all over the country, and in public schools in Washington State. My boss and I both really benefitted and were able to do the work we’re doing because we were diagnosed and we know that there’s a name for it and we understand it. I really think that puts us in a better position to help students and other adults. Now, there are also problem focused support groups.

Anthony Rostain, MD, MA: Some of these are sponsored by advocacy groups like CHADD. Others are sponsored by mental health facilities. But meeting with other people who share your problem and talking about it with others is a very helpful step to take.Then if indicated, there are a host of psychotherapists, in particular, cognitive behavioral therapy, which has been shown to really improve patient’s functioning and help patients to cope better with their ADHD.

Occasionally, individuals will need social skills groups to help them become better at managing friendships and other important relationships and were indicated in getting vocational assessment and vocational counseling, particularly in situations where the individual is having a hard time at their chosen occupation. We recommend all of these things in addition to medication in order to enhance functioning and help patients lead a better life. We cover these alternative approaches in our educational seminars with Free ADHD CME.