University Healthcare Provider Survey on ADHD

Lenard A. Adler, on October 29, 2015

This study provides the 2015 results of a survey of college and university health care providers (physicians, psychologists and nurses) about their knowledge about and treatment preferences concerning ADHD. The survey consisted of 37 forced choice questions, which took less than 15 minutes to complete; the overall response rate was somewhat low (8%), creating the possibility of sampling error, but never the less this is a sufficiently large sample from which interesting conclusions can be drawn. Even though about half of providers felt quite comfortable recognizing ADHD, over 90% still referred students to other providers to make an ADHD diagnosis. Over 90% of respondents felt that ADHD medication therapy was useful for treating ADHD and over 50% treated the students themselves or in consultation with a specialist. Nurse practitioners were more likely to refer students for treatment as compared to physicians. This survey highlights potential areas of improvement in the post-secondary school handling of ADHD in their students, including the potential for increased training re: diagnosis and treatment so that physicians and nurse practitioners in these settings will be more likely to diagnose and treat students in their institutions. This could lead to potential removal of barriers to care and treatment of university students with ADHD.

 

Thomas M1, Rostain A2, Corso R3, Babcock T4, Madhoo M . ADHD in the College Setting: Current Perceptions and Future Vision. Journal of Attention Disorders. 19(8):643-54, 2015. doi: 10.1177/1087054714527789. Epub 2014 Apr 17.

Medication Resistant Deficits in ADHD

Anthony L. Rostain, MD MA on October 8, 2015

“Possible Medication-Resistant Deficits in Adult ADHD”

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

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

ADHD: Facts or Fiction

Stephen V. Faraone, PhD on July 2, 2015

Many ADHD myths have been manufactured over the years.  Facts that are clear and compelling to most scientists and doctors have been distorted or discarded from popular media discussions of the disorder.   Sometimes, the popular media seems motivated by the maxim “Never let the facts get in the way of a good story.”  That’s fine for storytellers, but it is not acceptable for serious and useful discussions about ADHD.

ADHD Myths are easy to find.  These myths have confused patients and parents and undermined the ability  of professionals to appropriately treat the disorder.   When patients or parents get the idea that the diagnosis of ADHD is a subjective invention of doctors, or that ADHD medications cause drug abuse, that makes it less likely they will seek treatment and will increase their chances of having adverse outcomes.


Fortunately, as John Adams famously said of the Boston Massacre, “Facts are stubborn things.”  And science is a stubborn enterprise; it does not tolerate shoddy research or opinions not supported by fact.   ADHD scientists have addressed many of the myths about the disorder in the International Consensus Statement on ADHD, a published summary of scientific facts about ADHD endorsed by a of 75 international ADHD scientists in 2002.  The statement describes evidence for the validity of ADHD, the existence of genetic and neurobiologic causes for the disorder and the range and severity of impairments caused by the disorder.


Download The Consensus Statement


The Statement makes several key points:


The U.S. Surgeon General, the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, the American Psychological Association, and the American Academy of Pediatrics recognize ADHD as a valid disorder.

ADHD involves a serious deficiency in a set of psychological abilities and that these deficiencies pose serious harm to most individuals possessing the disorder.

Many studies show that the psychological deficits in people with ADHD are associated with abnormalities in several specific brain regions.

The genetic contribution to ADHD is routinely found to be among the highest for any psychiatric disorders.

ADHD is not a benign disorder. For those it afflicts, it can cause devastating problems.

Hundreds of studies have shown the effectiveness of ADHD medications and multiple therapies.

The facts about ADHD will prevail if you take the time to learn about them.   This can be difficult when faced with a media blitz of information and misinformation about the disorder.  In future blogs, I’ll separate the ADHD facts from the fiction by addressing several popular myths about ADHD.


Editor’s note:  Our Ask the ADHD Experts sessions are designed specifically for experts to present updates and the latest unbiased research information on ADHD and related disorders.  Ask your questions.  Get them answered.  Subscribe and learn.

Parental ADHD and FSS (Family School Success)

Anthony L. Rostain, MD MA on June 4, 2015

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

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

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

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

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

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

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

 

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

 

Symptom Manifestations and Impairments in College Students with ADHD

Anthony L. Rostain, MD MA on May 26, 2015

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

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

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

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

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

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

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

Love, Sex and ADHD

Stephen V. Faraone, PhD on May 21, 2015

As a researcher who has devoted most of the past three decades to studying ADHD, I am surprised (and somewhat embarrassed) to see how little research has focused on how ADHD affects the romantic side of life. There are over 25,000 articles about ADHD listed on www.pubmed.gov, but only a few have provided data about love, sex and ADHD. Bruner and colleagues studied ADHD symptoms and romantic relationship quality in 189 college students. Those students who had high levels of both hyperactivity-impulsivity and inattentiveness reported that the quality of their romantic relationships was relatively low compared with students who had low levels of ADHD symptoms. Another study of 497 college students found that ADHD symptoms predicted a greater use of maladaptive coping strategies in romantic relationships and less romantic satisfaction. A study of young adults compared conflict resolution and problem-solving in romantic couples. It found that ADHD symptoms were associated with greater negativity and less positivity during a conflict resolution task and that higher symptoms predicted less relational satisfaction. But this was not true of the ADHD member of the couple only had inattentive symptoms, which suggests that the severity of ADHD symptoms might drive relationship problems. Unlike the studies of adults, the romantic relationships of adolescents with and without ADHD did not differ on levels of aggression or relationship quality, although only one study addressed this issue.


What about sex? The study of adolescents found that, irrespective of gender, adolescents with ADHD had nearly double the number of lifetime sexual partners. That finding is consistent with Barkley’s follow-up study of ADHD children. He and his colleagues found that ADHD predicted early sexual activity and early parenthood. Similar findings were reported by Flory and colleagues in retrospective study of young adults. Childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. When my colleagues and I studied 1001 adults in the community, we found that adults with ADHD endorsed less stability in their love relationships, felt less able to provide emotional support to their loved ones, experienced more sexual dysfunction and had higher divorce rates.


The research literature about love, sex and ADHD is small, but it is consistent.


 

REFERENCES

Bruner, M. R., A. D. Kuryluk, et al. (2014). “Attention-Deficit/Hyperactivity Disorder Symptom Levels and Romantic Relationship Quality in College Students.” J Am Coll Health: 1-11.

Biederman, J., S. V. Faraone, et al. (2006). “Functional impairments in adults with self-reports of diagnosed ADHD: A controlled study of 1001 adults in the community.” J Clin Psychiatry 67(4): 524-540.

Canu, W. H., L. S. Tabor, et al. (2014). “Young Adult Romantic Couples’ Conflict Resolution and Satisfaction Varies with Partner’s Attention-Deficit/Hyperactivity Disorder Type.” J Marital Fam Ther 40(4): 509-524.

Rokeach, A. and J. Wiener (2014). “The Romantic Relationships of Adolescents With ADHD.” J Atten Disord.

Barkley, R. A., M. Fischer, et al. (2006). “Young adult outcome of hyperactive children: adaptive functioning in major life activities.” J Am Acad Child Adolesc Psychiatry 45(2): 192-202.

Flory, K., B. S. Molina, et al. (2006). “Childhood ADHD predicts risky sexual behavior in young adulthood.” J Clin Child Adolesc Psychol 35(4): 571-577.

Overbey, G. A., W. E. Snell, Jr., et al. (2011). “Subclinical ADHD, stress, and coping in romantic relationships of university students.” J Atten Disord 15(1): 67-78.

mTBI and ADHD

Lenard A. Adler, on May 14, 2015

A systematic review of the literature and a meta-analysis investigating the relationship between mild traumatic brain injury (mTBI) and ADHD has been completed. The study indicates that mTBI is cerebral concussion and that there has been increasing interest from the coverage in the lay press re: the effects of mTBI in professional sports.

The authors hypothesize that individuals with ADHD commonly have a history of being risk-takers and have higher accident rates, which may predispose them to mTBI. Conversely, it has been hypothesized that mTBI could create a secondary ADHD-like condition.

The authors used reasonable inclusion criteria re: the studies included in the analyses (including being original research which examined ADHD and mTBI, used diagnostic criteria for ADHD and differentiated ADHD from learning disorders and mTBI from other types of TBI). They found five articles which met entry criteria for the meta-analysis; most, but not all, of the trials involved children.

They then examined the relative risk for one disorder being associated with the other disorder, based upon the temporal sequence of disorder onset. The authors found that there was no increased risk for TBI if ADHD occurred first.
However, if mTBI occurred first or if the temporal sequence was unclear there was about a two times elevated risk for ADHD. The overall finding of increased relative risks of ADHD and mTBI is important and highlights the need for clinicians to screen for the potential of these co-occurring disorders.
 

Reference:
J Atten Disord. 2014 Oct;18(7):576-84. doi: 10.1177/1087054714543371. Epub 2014 Jul 21. Mild traumatic brain injury and ADHD: a systematic review of the literature and meta-analysis. Adeyemo BO1, Biederman J2, Zafonte R1, Kagan E3, Spencer TJ3, Uchida M3, Kenworthy T3, Spencer AE3, Faraone SV4.

Atomoxetine, ADHD and Executive Function Deficits

Lenard A. Adler, on April 30, 2015

Atomoxetine and the Treatment of Executive Dysfunction
ADHD Patients with Executive Dysfunction: Atomoxetine vs Placebo Studies

Although they are not included in the formal DSM-5 criteria for adult ADHD, studies have shown that clinically significant executive dysfunction can occur in one-third to one-half of all adults with ADHD. Executive functions are a set of neuropsychological parameters including: 1) working memory, 2) awareness of one’s self in the environment, 3) higher level cognitive functions of prioritization, planning and time estimation/planning and 4) emotional control. Symptoms of ADHD are separate from executive dysfunction and both should be considered in possible treatment design for the particular patient.

There have been two recent reports on the response of executive functions to the non-stimulant atomoxetine used to control ADHD symptoms. (Adler LA, Clemow DB, Williams DW, Durell TM.. Atomoxetine Effects on Executive Function as Measured by the BRIEF-A in Young Adults with ADHD: A Randomized, Double-Blind, Placebo-Controlled Study. PLoS One. 2014 Aug 22;9(8):e104175. doi: 10.1371/journal.pone.0104175. eCollection 2014. and Adler L, Tanaka Y, Williams D, Trzepacz PT, Goto T, Allen AJ, Escobar R, Upadhyaya HP, Executive function in adults with attention-deficit/hyperactivity disorder during treatment with atomoxetine in a randomized, placebo-controlled, withdrawal study. J Clin Psychopharmacol. 2014 Aug;34(4):461-6. doi: 10.1097/JCP.0000000000000138.) Both studies present data on changes in the Behavior Rating Inventory of Executive Function-Adult (BRIEF-A, which is a 75 item, self-report clinical measure of executive function).

The first study presents the changes in BRIEF-A ratings in a study of atomoxetine (40-100 mg/day) versus placebo in young adults with ADHD. Significant effects of atomoxetine vs. placebo were seen on the major indices in the BRIEF, Global Executive Composite (GEC), Behavioral Regulation Index (BRI), and Metacognitive Index (MI), and a number of brief subscales. In other words, the non-stimulant atomoxetine had measureable effects on both ADHD symptoms and executive dysfunction when compared with the administration of a placebo.

The second trial was a randomized, withdrawal study of atomoxetine vs. placebo in patients who previously responded to an open label trial of atomoxetine. Atomoxetine significantly improved the executive function major indices and some subsets compared with placebo, which was maintained for 25 weeks or more. The executive function of patients in the placebo group worsened but did not return to baseline levels after randomization.

In both of these studies the overall effect size on measures of executive dysfunction was less than core ADHD symptoms observed for atomoxetine. Also, the effect on symptoms of emotional control subsets was somewhat less than seen on other subsets. Clinicians should be aware of co-travelling symptoms of executive dysfunction in their adult patients with ADHD and should consider whether to target these symptoms as part of the treatment plan.

PTSD and ADHD

Lenard A. Adler, on April 17, 2015

J Atten Disord. 2014 Feb 24.
The Neuropsychological Profile of Comorbid Post-Traumatic Stress Disorder in Adult ADHD.
Antshel KM, Biederman J, Spencer TJ, Faraone SV.

This study is important as it is the first investigation to examine neuropsychological deficits in individuals with ADHD and PTSD; it also adds to our increasing understanding of the increased burden of having ADHD and PTSD. Prior studies have shown that PTSD may be a vulnerability factor for developing future ADHD. These studies indicate that clinicians should be careful in screening individuals with ADHD for co-morbid PTSD and that the combination of disorders may carry a higher neuropsychological burden.

Overall the group with ADHD (whether they had PTSD or not) had significantly lower scores on the battery of neuropsychological tests; however, the group with ADHD+PTSD had lower neuropsychological test scores on a number of measures versus the group with ADHD alone (WAIS full scale IQ and block design, ROCF copy accuracy and copy time and Stroop Color T-score). Measures of quality of life were not shown to be predictors of PTSD status.

This article describes an examination of potential differences in neuropsychological functioning between a cohort of adults with ADHD (n=186), ADHD with PTSD (n=20) and a non-ADHD control group (n=123) who received psychiatric evaluations and neuropsychological tests (including WAIS intelligence, tests of frontal executive function (Wisconsin Card Sorting Test, Stroop Color and Word Test) the California Verbal Learning Test (CVLT) the Rey-Osterrieth Complex Figure Test (ROCF) and an auditory working memory continuous performance task (CPT). The group with ADHD had lower socio-economic status and were more likely to be of non-Caucausian ethnicity. Interpretation of the findings of this trial is somewhat limited by the small cohort of ADHD+PTSD patients.

ADHD and Epilepsy

Lenard A. Adler, on April 16, 2015

Ettinger AB1, Ottman R, Lipton RB, Cramer JA, Fanning KM, Reed ML. Attention-deficit/hyperactivity Len_Adler_AIAdisorder symptoms in adults with self-reported epilepsy: Results from a national epidemiologic survey of epilepsy. Epilepsia. 2015 Jan 15. doi: 10.1111/epi.12897.


The purpose of this study was to examine symptoms of ADHD and resulting functional consequences in a large community cohort of individuals with epilepsy. There is a somewhat higher rate of ADHD observed in pediatric samples of ADHD, but little data exists in terms of the comparative rates of ADHD, co-morbidity and quality of life in adults with epilepsy.


This study is important because it extends the observation of higher rates of ADHD seen in studies of pediatric ADHD to adult ADHD; the observed prevalence rate of ADHD (using a proxy of being screen positive on the ASRS v1.1) was nearly three times in this population of adults with epilepsy as compared to the general population, with substantial functional consequences in these individuals. The study also highlights the need to examine adults with epilepsy for the possibility of co-morbid ADHD.


ASRS Professional Screener Download


This study examined through telephone survey as part of The Epilepsy Comorbidities and Health Study (EPIC), 1361 respondents who had been told they had epilepsy and were receiving anti-epileptic drugs (AEDs). The group was divided into a likelihood of having ADHD via the ASRS v1.1 Screener, if they had a total score on these six items > 14 (ASRS v1.1 Screen positive and ASRS v1.1 Screen negative). Measures of co-morbidity included depression: the Physicians Health Questionnaire (PHQ-9), and generalized anxiety disorder: the Generalized Anxiety Disorder Assessment 7 (GAD-7).


Quality of life and disability were assessed with the Quality of Life in Epilepsy Inventory 10 (QOLIE-10), Quality of Life and Satisfaction Questionnaire (Q-LES-Q) and the Sheehan Disability Scale (SDS). 251 of the 1361 (18.4%) respondents were found to be at risk for having adult ADHD (ADHD+). ASRS v1.1 Screener positive vs. negative cases were significantly more likely to have seizures and AED use, along with significantly higher depression and anxiety symptom scores. The ASRS v1.1 Screen positive cohort (controlling for covariates) had lower QoL and social functioning (Q-LES-Q) and increased family and occupational disability (SDS).


Potential confounds in the data include: 1) that a formal diagnosis of adult ADHD was not obtained (just individuals at risk for the disorder, but prior trials have found that a substantial proportion of screen positive individuals when assessed, actually have adult ADHD) and 2) the possible presentation of ADHD-like symptoms from epilepsy or treatment with AEDs.