Blog – Page 15 – ADHD in Adults

Adherence to Stimulants in Adult ADHD

Anthony L. Rostain, MD MA on January 2, 2015

O’Callaghan, P. “Adherence to stimulants in adult ADHD.” J Atten Def Hyp Disord. (2014) 6:111-120.

This study uses a mixed-method design to investigate the factors that influence stimulant medication adherence in adults with ADHD. The author notes that adherence rates for pharmacotherapy in adults with ADHD is reported to be less than 12% which is a significant concern for clinicians treating this population. Stimulants have been shown to be highly effective in adults with ADHD with more than 70% experiencing a positive response, and with effect sizes in the range of 0.8-0.9 (Faraone, et al, 2006). Despite these impressive results, less than 50% of adult patients prescribed a stimulant medication are taking them after 3 months, and by 18 months, only 20% are still receiving treatment (Weisler, et al, 2006). This study sought to examine the reasons for low adherence using a combination of quantitative and qualitative methods in a sample of 67 adults (67% women) between the age of 19 and 64 years who were recruited from the community. Subjects were given the Adult ADHD Quality of Life Scale (AAQoL) (Brod et al 2005) and were asked if they were taking stimulant medications daily, as needed or not at all. Analysis of the total AAQoL and subscale scores showed no significant differences among the three adherence categories, indicating that adherence to medications was NOT correlated with reported quality of life.

The qualitative phase of the study involved a telephone interview of a subset of 18 adults (61% women) who were queried about their experiences with stimulant medications and about their perceptions of the benefits and adverse effects of taking them. They were also asked to explain how they made the decision to use or not use stimulants. The responses were examined using a thematic analysis program that classified the subjects’ answers into five categories of the Health Belief Model (Munro et al 2007): severity of ADHD symptoms, barriers of stimulants, benefits of stimulants, “cues to action” (that is, factors that activate the patient’s readiness to change), and self-efficacy (or confidence in one’s ability to take action).

The study found that all participants encountered barriers in their experience of taking stimulant medication. Physical side effects were highly reported by patients with a high AAQoL whereas psychological side effects were reported only by patients with low AAQoL scores. The positive benefits of stimulants were seen more often in patients with high quality of life yet, severity of ADHD symptoms was not associated with medication adherence. The most salient “cue to action” found in the study pertained to the quality of the clinician-patient relationship. The majority of patients with high quality of life had positive experiences with their health providers, whereas those with low quality of life reported frustration and dissatisfaction with their clinicians. This proved to be the most influential factor in reported ADHD quality of life. As it turns out, self-efficacy was not a significant theme reported by study participants.

This article provides insights into the reasons for stimulant medication adherence or non-adherence in adult patients with ADHD. It finds that the clinician-patient relationship is a strong predictor of ADHD quality of life but NOT of treatment adherence, and that perception of barriers to stimulant treatment is linked to the individual’s quality of life. Despite the limitations of the study (small sample size, predominance of females in the sample, lack of clear generalizability), it offers a glimpse into the contextual factors that influence treatment adherence and it underscores the critical importance of good communication between clinician and patient so as to promote the best possible outcomes.

References

Brod M, Perwien A, Adler L, et al (2005). Conceptualization and assessment of quality of life for adults with attention-deficit/hyperactivity disorder. Prim Psychiatry 12:58-64.

Faraone S, Biederman J, Mick E (2006). The age-dependent decline of attention deficit hyperactivity disorder: a meta-analysis of follow-up studies. Psychol Med 36:159-165.

Munro S, Lewin S, Swart T, Volmink J (2007). A review of health behavior theories: how useful are these for developing interventions to promote long-term medication adherence for TB and HIV/AIDS? BMC Pub Health 7:1-6.

Weisler R, Biederman J, Spencer T, et al (2006). Mixed amphetamine salts extended-release in the treatment of adult ADHD: a randomized, controlled trial. CNS Spectr 11:625-639.

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.

Using Stimulant Medications for Adult ADHD

p p on April 3, 2014

Editor’s Note: We interviewed several leading ADHD experts on treating ADHD in primary care and acquired some very interesting insights into how clinicians can learn about and treat ADHD in their practices.

Anthony Rostain, MD MA: Physicians are often afraid about prescribing stimulant medications because they’re not familiar with the diagnosis of ADHD and they’re not sure whether they’re legitimately correct in prescribing these medications. Let’s start first by examining ADHD as a diagnosis. It is a legitimate diagnosis.

There is a medical procedure for making the diagnosis that includes taking careful history, getting the patient to fill out scales, getting collateral information from important others who understand something about the patient’s behavior. In addition you have to gather developmental history and educational history. You have to be aware of all of the different facets of the patient’s functioning and understand that ADHD is impacting and impairing that individual.

Brendan Montano MD: With familiarity and use of stimulant medications in ADHD I know I became much more willing and able to use them. Also many pediatricians have no problem with stimulants and I feel that that will also occur when the primary care network begins to treat ADHD more vigorously, diagnose it and treat it. Our pediatric allies had been used to treating ADHD in childhood and they’d been familiarized and become comfortable with the use of stimulant medications. I believe the same thing will occur with our adult primary care providers. Familiarity and seeing the beneficial effect will give comfort to those who treat with stimulant medications. Remembering again there are some non-stimulants that are also quite effective. Now, it is important to be aware of the fact that stimulant medications can be diverted, they can be misused, they can be abused.

Stephen Faraone, PhD: And that’s a reasonable concern. However, today that concern is mitigated by several factors. First, we have new formulations of stimulants that are much less abusable than the immediate-release Ritalin many of you are used to. Second, there are now FDA-approved non-stimulant alternatives for ADHD. So you really do have a very large toolbox of therapies to use for adultswith ADHD.

Brendan Montano, MD: The more you become familiarized and screen for this illness, the more you become familiarized with treating the illness. So I became comfortable by seeing the beneficial effects and the outcomes which were otherwise not going to occur in my ADHD patients. The lack of training of primary care practitioners has created a shortage of treatment for adults with ADHD. We have methodological studies that prove there are 10 million undiagnosed adults with ADHD in the United States. I think the 10 million people who have this disorder really deserve for us to become familiarized not only with how to diagnose ADHD but how to treat it.

Anthony Rostain, MD: It’s important to keep in mind that if you follow sound clinical practice and document what you’re doing, including how you made the diagnosis of ADHD, that you informed the patient about treatment options and that you gave the patient all kinds of patient education materials to warn them about the danger of misusing the medication, then you’re following standard medical practice and you won’t be in any medical or legal difficulty.

ADHD Success Story #6 – ADHD and College Students

Anthony L. Rostain, MD MA on March 27, 2014

Let me tell you about a success story of mine, a college student who I’ll call Carrie. Carrie is about to finish her sophomore year in college after a very, very rocky start to her college career. She was a bright, enthusiastic and vivacious high school student who managed to get by through her intelligence, her energy, and being able, at the last minute, to get her work done. She also had very supportive teachers who gave her the benefit of the doubt if she did turn in assignments late.

Now, Carrie thought she might have ADHD but she never went for help. She actually was kind of skeptical about it and thought she just needed to try harder. So she was active in the high school drama club and actually went off to college hoping to become a playwright someday. So, after arriving at college, Carrie became very active in one of the drama clubs on her campus. She began to stage-manage and she started hanging out with all of the drama club students and was enjoying a great deal, and contributing great deal, to the activities of that organization. She also used the same studies, strategies that she had used in high school. So she talked a lot in class but never really read all of the assignments and she’d waited until the last minute to do the reading or to turn in the papers. She found herself cramming for the exams. It turned out that she ended up spending too much time with her extracurriculars and not enough time studying.

So after failing two classes in her spring semester, Carrie was asked to take an academic leave of absence from her college. She came back home and was evaluated in our program and we did in fact diagnose her with ADHD. We explained to her exactly how it was that she had managed to do fine until college and that she had managed to get by until she was in this unstructured learning environment. We spent a lot of time teaching her about adult ADHD, we started her on an ADHD medication, and she began coming for weekly cognitive behavioral trainings sessions.

Over the course of the next few months, she began to get more and more comfortable with the diagnosis and with figuring out what she needed to do to get difficult tasks done. She managed to get a job in selling tickets in local theater company and eventually she decided to take some courses in community college. She did extremely well and she really figured that she was now ready to go back to college.

She went back this past year and has done exceptionally well, getting most As and a few Bs, keeping herself very organized and able to balance the lifestyle that she wants. She’s able to get the studying done that she wants, she’s able to participate in the drama club and guess what, she’s pursuing her dream of becoming a playwright and is now a full-fledged English major in good standing.

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ADHD Success Story #1: Eva

p p on March 18, 2014

Eva O’Malley, ADHD Adult: My son’s ADHD was diagnosed when he was six and I call it his gift to me because it eventually got me to where I am now. After so many years of researching and looking for answers and going to doctors, I started to become very clear about some of these behaviors that are existing in my world as well.

Adults with ADHD often get labeled with some very mean things like “lazy”, “rude”, “crazy” – things that you know are attributable to some of their symptoms, and it hurts. I’m guilty of doing this to my children because my daughter was diagnosed when she was 20.

I couldn’t understand why a 20-year old could not do these basic things.

After I was diagnosed it was easier for me to be aware that people’s behavior is not necessarily all that’s going on. And just to look past the behavior and to look into what’s driving the behavior is more important. So those labels then fall off of the people that are “rude” and the people that are “lazy.”

My daughter’s issues all of a sudden became crystal clear once I was diagnosed. It wasn’t selfishness, it wasn’t laziness. It was ADHD.

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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 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.

ADHD Success Story #5 – James

Anthony L. Rostain, MD MA on March 4, 2014

Let me tell you about a patient of mine named James who is 27 years old and has had a history of some serious substance abuse problems. Now James was diagnosed with ADHD in elementary school, and around middle school decided he didn’t want to take medications anymore. Beginning in late middle school and early high school he started experimenting with marijuana and alcohol, and eventually began to use other substances like cocaine, and finally, by the time he was finishing high school – and he barely graduated – James was using prescription opiates.

After high school he worked for a few years as a janitor, but this addiction to OxyContin got the better of him. He finally was in an accident, got a DUI, and was court mandated for treatment; and they discovered that he not only had an alcohol abuse problem, he also had marijuana and opiate addition. For this he was given the diagnosis of polysubstance abuse and was started in an outpatient treatment in our facility.

So James was started on suboxone to help him withdraw from opiates, and he was also started on citalopram because he was complaining of depression; and he was able to maintain sobriety, but he had a real tough time concentrating and getting simple things done. He wasn’t completing simple tasks around the house. He tried to go back to work and found it very difficult to stay focused on his job duties, and was reprimanded for coming in late.

So as a result, we then were asked to consult with, and lo and behold, we realized that, even though he was being treated for addition, he still had the ADHD that plagued him as a child. So we added OROS methylphenidate, and we began having him come for weekly cognitive behavioral therapy sessions in which he relearned what ADHD really is for someone his age, and where we began to help him overcome some of his negative attitudes about learning routines and doing things that required mental effort.

James had dreams, wanted to do something with his life, but had always avoided them and had turned to substances to help him with things that made him anxious like social relationships.

As time went on, James began to talk about wanting to start his own business, and lo and behold, he was able to get started in this business. He sells collectibles online, and over the last few months he’s been so successful that he’s actually hired an assistant. What James likes to say now is that he wished that he had continued his treatment for administered; maybe he would have avoided substance use disorder. But he takes it all in stride.

He’s got a wonderful attitude, feels very positive about his life, and actually has offered to go and talk to some of the other patients in the recovery program to help them realize that some of them may, in fact, have ADHD that they ought to get treated.

So, I bring up this story of James in order to get you to think about the fact that maybe some of your patients who are in your office with other problems like substance use or alcoholism, or people who can’t quit smoking, maybe some of them have ADHD underlying all of their difficulties, and it would be worthwhile for you to learn how to assess them and maybe begin them in treatment because it could make a huge difference to their lives.

ADHD Success Story #2: Robert’s Story

p p on February 27, 2014

Robert Tudisco: I was diagnosed with ADHD after a number of problems that I had in my life. Coming out of law school, I got what I think was probably the perfect job for someone with ADHD. I was a prosecutor in the South Bronx and it was tailor made for someone with ADHD. Everything was an emergency, the motto in the office was “baptism by fire,” and it was just an exciting place to be. When I left the DA’s office and I started a private practice, that’s when I really had some problems. I had to keep track of my time, I had to bill my clients, I had to run an office. It was all of those administrative tasks that were really a problem.

At the same time, I thought I was setting a bad example for my son and I was having some difficulty in my marriage. And so, I sought some help, I found out about ADHD, and I was diagnosed pretty quickly, and that was about 14 years ago and it started this whole journey. My ADHD diagnosis was a major turning point in my life. It really helped me understand a lot about how I grew up and the struggles that I had as a child. I always knew, when I was a child, that there was a lot more going on behind my eyes than I was getting credit for and that was enormously frustrating for me.

I really think that a lot of adults would benefit from a diagnosis and it’s just one of the barriers, I think, to a lot of adults getting diagnosed is that there aren’t more clinicians that are diagnosing adults with ADHD. I think it’s important to manage ADHD as an adult or a child in a multimodal way. I take medication for my ADHD. I actually take two types of medication but that’s just a part of a multimodal approach. I run religiously to manage my ADHD. I employ a lot coping mechanisms that I’ve developed over the years that work for me. They may not work for somebody else but that was a process that I went through.

I think the important thing to stress about medication is that it’s not a cure for ADHD. When it works, it can be a very effective tool that helps people make positive changes in their life. I also think it’s important to give myself permission to fail and kind of let myself off the hook. It’s very important for adults to have a sense of humor about their ADHD. And when something doesn’t work, try to look at why it didn’t work and that may help you come up with a better way to solve that problem. And so don’t piece it as a failure-failure, it’s a learning experience.

ADHD Success Story #3 – Parallel Interviews

p p on February 20, 2014

In two separate interviews, a clinician and an ADHD adult describe the two sides of ADHD symptoms and ADHD diagonsis.

Lenard Adler, MD: I can think of an adult in their forties, a male, who came in after having their seven year old child diagnoses with ADHD, and in fact identify that, as he’s having his symptoms, he coped with them not all that well, was in a managerial position but not functioning optimally, had been passed over for promotions on numerous occasions mainly because he didn’t met his deadlines.

Robert Tudisco, Esq, ADHD Adult: I had to keep track of my time, I had to bill my clients, I had to run an office. It was all of those administrative tasks that were really a problem. At the same time, I thought I was setting a bad example for my son and I was having some difficulty in my marriage. And so, I sought some help, I found out about ADHD.

Lenard Adler, MD: In discussing things with the patient and his wife, she described lots of instances around at home where he didn’t listen to her, to do lists just weren’t completed, things weren’t being done on the weekend and she kind of felt that she was not only taking care of their seven-year-old son but also taking care of the husband. So the diagnosis of ADHD became clear after thorough evaluation and, in fact, this individual went on to treatment with a non-stimulating medicine and actually did quite well.

Robert Tudisco, Esq: There have been so many benefits since I’ve been diagnosed with ADHD. I think I’m a better father. I’m certainly a better husband. My relationship with my wife is much more relaxed because we understand each other a lot better. We also understand that ADHD is not an excuse for what happens and we understand where the behaviors come from so we can kind of work around them in the future. And I really think that a lot of adults would benefit from a diagnosis and it’s just one of the barriers, I think, to a lot of adults getting diagnosed is that there aren’t more clinicians that are diagnosing adults with ADHD.

ADHD, Biofeedback, and Cognitive Training

Stephen V. Faraone, PhD on April 2, 0215

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. This of course is in addition to, not a replacement for, ADHD medications.

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. CBT_rubricThe 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.

As a reminder, adult ADHD tests can be administered easily and effectively to measure the effect of various approaches on ADHD symptoms in adults.