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More Data About Gifted People with ADHD

Apr 13, 2020 | Stephen Faraone, Ph.D.

More Data About Gifted People with ADHD

I recently came across a paper from Tom Brown that adds to the growing scientific literature about smart people with ADHD, which I blogged about last year (http://tinyurl.com/qckgatx).  Dr. Brown’s study measured executive functions in 157 ADHD adults with an intelligence quotient (IQ) in the top 9 percent of the population.  The executive functions of the brain regulate cognitive processes in a manner that allows for the effecting planning and execution of behaviors.  We know from many studies that both children and ADHD have deficits in executive functions which impair their ability to manage time and keep themselves organized.  Dr. Brown extends that literature by showing that three out of four ADHD adults with high IQ scores were significantly impaired on tests of executive functioning.  They had problems in many areas: working memory, processing speed, and auditory verbal working memory relative.

The lesson from this literature is clear.  Smart people can have ADHD.  Their high IQs will help them do better than the average person with ADHD, but they may not achieve their potential without appropriate diagnosis and treatment.

For more evidence based info about adult ADHD go to: www.adhdinadults.com.

References about High IQ ADHD

Brown, T. E., Reichel, P. C. & Quinlan, D. M. (2009). Executive function impairments in high IQ adults with ADHD. J Atten Disord 13, 161-7.

Antshel, K. M., S. V. Faraone, et al. (2009). “Is adult attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ?” Psychol Med 39(8): 1325-1335.

Antshel, K. M., S. V. Faraone, et al. (2010). “Executive functioning in high-IQ adults with ADHD.” Psychol Med 40(11): 1909-1918.

Antshel, K. M., S. V. Faraone, et al. (2007). “Is attention deficit hyperactivity disorder a valid diagnosis in the presence of high IQ? Results from the MGH Longitudinal Family Studies of ADHD.” J Child Psychol Psychiatry 48(7): 687-694

Katusic, M. Z., R. G. Voigt, et al. (2011). “Attention-deficit hyperactivity disorder in children with high intelligence quotient: results from a population-based study.” J Dev Behav Pediatr 32(2): 103-109.

 

Managing ADHD in College Students During COVID-19

Apr 10, 2020 | Editorial, Recent

Managing ADHD in College Students During COVID-19

Afton Kapuscinski, Ph.D. & Kevin Antshel, Ph.D.

Syracuse University

The dynamic and rapidly developing COVID-19 pandemic has affected us all. Rather than focusing on the totality of the impact, we are electing to focus on what we know best: college students with ADHD. Below, we outline ideas to help college students with ADHD cope and function well despite the substantial disruptions caused by COVID-19. Managing ADHD during a global pandemic is, to our knowledge, not a topic that has been previously investigated. Thus, when developing these considerations, we relied upon our knowledge of the science of clinical psychology as well as our combined near 30-years of clinical experience working with college students with ADHD.

College students, especially those who were living away from home, are likely to be experiencing significant disruption to their daily lives. Not only has their primary residence suddenly changed, but they have also lost social supports, as well as the structure provided by academic and extracurricular obligations. Before COVID-19, many studies reported that college students with ADHD were already at increased risk for depression and anxiety. The jarring changes to daily life and uncertainty about when normal life will resume may well increase prevalence rates of depression and anxiety in students with ADHD. While some feelings of fear and loss are normative  (COVID-19 is a legitimate threat), those with pre-existing anxiety and depression may have a more difficult time managing the intensification of these emotions.

When channeled appropriately (e.g., not at panic levels), fear and anxiety can be quite adaptive and help us follow CDC guidelines cautiously to “flatten the curve”. However, very high levels of anxiety often lead to difficulty with concentration and completing tasks. Additionally, a larger, more long-term concern is the potential for depression to set in as weeks of social distancing and restriction of activities likely turns into months. In an effort to help with both proximal anxiety as well as the greater distal threat (depression) in an already vulnerable population, several of the following may be beneficial to consider for college students with ADHD:

  1. Be mindful of media consumption levels. Media headlines, news alerts and social media are likely to be rife with the most tragic and dramatic stories (e.g., celebrities who have died from COVID-19). Consuming excess media (probably defined by the extent to which catastrophizing occurs) likely leads to a loss of balanced perspective (Jenness et al., 2016) and the adoption of irrational beliefs (e.g., I won’t be able to graduate college). Consider silencing news alerts or using screen time limits to moderate media exposure.
  2. Establish routines. Everyone’s daily routines have been impacted. Rather than getting lost in a cycle of Netflix and gaming, it is important to re-establish routines. If uncertainty is the poison, routines are the antidote. In our experience, the importance of sleep-wake cycles as the first routine to re-establish cannot be overstressed (Lyall et al., 2018). Routines related to medication adherence, physical activity and coursework should be the next ones added to the daily schedules.
  3. Establish physical boundaries. Being at home 24/7 increases the risk for a blurring of boundaries between work and recreation. Develop specific places to do school work that are separate from recreation spots. If this is not possible, develop some rules (e.g., I won’t browse YouTube until after 3 PM).
  4. Maintain social supports. Stay connected in real time with sources of social support from college through phone calls, Facetime, and Zoom (e.g., virtual throwback dance parties!). It is unfortunate that the public health officials labeled it “social distancing”. In our opinion, “physical distancing” is a better term and belies the importance of not isolating.
  5. Maintain sources of reinforcement. COVID-19 has disrupted many of our existing sources of reinforcement (e.g., engaging in Greek life, attending a NCAA basketball game with friends, earning money working at a campus coffee shop). Find creative ways to derive pleasure, especially through activities that bring a sense of meaning and purpose. For example, developing new hobbies (e.g., biking, photography) might serve to reduce the reinforcement void.
  6. Limit use of substances. College students with ADHD are at increased risk for substance use problems. The distress caused by the pandemic in combination with reduced opportunities for rewarding activities may make substance use (alcohol and cannabis in particular) more enticing for those who are particularly vulnerable. We recommend being mindful that despite liquor stores being classified as essential services, heavy use can actually impair mood and academic functioning (Meda et al., 2017).
  7. Increase physical activity, especially outside. A significant body of research indicates that physical activity is beneficial for reducing inattention and anxiety and improving mood (Neudecker, Mewes, Reimers, & Woll, 2019). A sedentary lifestyle is therefore particularly problematic for college students with ADHD. Aiming for 7000 steps per day is a reasonable place to start. The old maxim, “What gets measured, gets done” suggests smartphone apps to track and plan physical activity may improve adherence.
  8. Reduce procrastination. Rather than saying, “I will do that later”, attach a specific time/date target to each important task, and use a planner to indicate when you will work on each task. Divide larger tasks into smaller tasks and connect each task to a specific time/date in your planner. Be mindful of how you “advertise” the task to yourself. A script, “What is in it for me to do this now?” can be useful for framing tasks in a way which increases engagement.

The above represents only a few of many possibilities. Please consider replying to this blog with your own ideas about what might be beneficial to consider for college students with ADHD during the COVID-19 pandemic!

 

Citations

Jenness, J. L., Jager-Hyman, S., Heleniak, C., Beck, A. T., Sheridan, M. A., & McLaughlin, K. A. (2016). Catastrophizing, rumination, and reappraisal prospectively predict adolescent PTSD symptom onset following a terrorist attack. Depress Anxiety, 33(11), 1039-1047. doi:10.1002/da.22548

Lyall, L. M., Wyse, C. A., Graham, N., Ferguson, A., Lyall, D. M., Cullen, B., . . . Smith, D. J. (2018). Association of disrupted circadian rhythmicity with mood disorders, subjective wellbeing, and cognitive function: a cross-sectional study of 91 105 participants from the UK Biobank. Lancet Psychiatry, 5(6), 507-514. doi:10.1016/S2215-0366(18)30139-1

Meda, S. A., Gueorguieva, R. V., Pittman, B., Rosen, R. R., Aslanzadeh, F., Tennen, H., . . . Pearlson, G. D. (2017). Longitudinal influence of alcohol and marijuana use on academic performance in college students. PLoS One, 12(3), e0172213. doi:10.1371/journal.pone.0172213

Neudecker, C., Mewes, N., Reimers, A. K., & Woll, A. (2019). Exercise Interventions in Children and Adolescents With ADHD: A Systematic Review. J Atten Disord, 23(4), 307-324. doi:10.1177/1087054715584053

 

Remote ADHD Research in the time of COVID

Apr 9, 2020 | Research Updates

Remote ADHD Research in the time of COVID

I was invited to write this blog after transitioning our ADHD Clinical and Translational Studies Program to tele-research. For several reasons, the actual technological aspects of the process were a relatively simple accomplishment. Writing this blog, less so.

The main reason for the ease and rapidity of our digital transformation was that we are housed in a Research 1 academic medical center with impressive capacities and infrastructure. The technology for digital research, digital education, and digital therapeutics has existed in abundance for decades (see Marhefka et al, 2020). Once the administrative barriers at our institution were dropped, I made quick use of pre-vetted digital research tools that are regulatory compliant, and have been in use across many health fields with the exception of psychiatry. Our Information Technology and Infosec data security departments offered us options of using technology provided by small private vendors, developing our own apps, assembling a series of Google apps, or using a selection of internal resources.

Though I will try to present some useful information, it would not be feasible to write a review of all the potential applications useful for flipping a research program to tele-research in this space. Nor, I think, would the bulk of the clinically-oriented APSARD membership be interested in such finely detailed technology reviews. But, there is a commonality of interest shared between clinicians and clinical researchers in this transition to high-tech practice.  The same forces that pushed our team to tele-research also pushed most clinicians’ practices online. This is uncharted territory for many psychologists and psychiatrists who worry about what we miss when we are not physically present with a patient, participant, or client.

We responded to an emergency, driven by a desire to protect our patients and our teams. We all sought to adhere to our fields’ regulatory and practice standards. We share common concerns about building rapport and maintaining alliances with our patients in the digital environment. We share the need to harness tech tools, collect accurate self-reports, and make professionally sound observations at a distance. Ultimately, as we shifted our work modalities, we upheld our ethical obligations to our participants, and maintained the superior standard of care for which we are regarded. Now that we are a month into the social-distancing of our lab, the immediate actions that our lab’s principle investigator took to protect us is reflected in the guidance being issued by our local and external IRBs, and the compliance teams with which we work.

We have had successes worth maintaining after life returns to normal. We established secure databases that disseminate and archive consents and self-report scales. They are attractive, easy to use, and regulatory compliant. They are automatically time stamped, date stamped, and audited, and viewable by both the respondent and the study team member on the back end of the interface. When paired with video-conferencing, this provides a good substitute for face-to-face meetings. Our research partners are able to use these same databases with their own participants, making multisite data collection and single IRB coordination both simpler and more secure. The videoconferencing also allows our clinicians to provide continuous care while travelling, or when otherwise off-site. It also allows busy patients to receive care when they cannot attend a scheduled appointment, preventing data loss and encouraging continued compliance with our protocols.

There are some serious challenges to still overcome in our digital shift. We have no way of performing virtual fMRI at the moment. While I am watching the development of wearables and portable technologies with interest, none yet provide the same type of data. With an abundance of caution, we paused a study that collected saliva for genotyping, lest we unintentionally expose the collectors and ship COVID-19 pathogen to our colleagues’ lab. This is not a problem with a lack of technology or distance resources. This is a complication of the unprecedented time in which we live. We also have some difficulty with drug dispensation and return for our clinical trials at the moment. We can courier drug directly from the sponsor to participants, and count drug over video-call, then have the couriers pick up the drug to return to the sponsors. But drug returned to our site will sit in our institution’s mail-room until personnel can be on-campus to receive them. Right now, the Samaritan’s field hospital is at the end of our block, and no one is entering our building. And external vendors can be unreliable. I watched with great annoyance as the VSee telehealth free platform, recommended by our institution, fell apart AFTER we submitted several applications for approvals for their use. Fortunately, Zoom and even FaceTime are HIPPA compliant, institutionally approved, and free alternatives for video calls. These are useful for research, since researchers do not need integrated payment features.  This week, though, our city’s Department of Education pulled out of using Zoom for their classes due to privacy and security issues. I am waiting to see whether this impacts our research program, or whether the housing of Zoom behind our institutional firewalls enables us to remain compliant with Zoom. FaceTime can be ‘buggy’ when there are multiple parties on the call, as often happens with research visits. I have other platforms in the bullpen, just in case.

This flexibility of choice is an ephemeral thing in an institution as large as ours. At some point, these temporary freedoms will end. With our teams of regulatory specialists blessing any changes intended to protect participants, the Infosec data security unit providing lists of pre-approved platforms, and the Dean’s office waiving barriers to accessing these pre-approved tools, the bulk of our transition was made within a week. When these gifts are rescinded, similar feats will take months or years to accomplish. But, when normalcy returns, we will still have access to Virtual Private Networks (VPNs) to safely, securely, and HIPPA compliantly manage our regulatory and data archives. And, we will be allowed to retain what we have built behind our institutional firewalls. Our data, and systems, and participants will be secure. We will go back to having face-to-face meetings. But, we will retain the many valuable aspects of tele-research.

For additional reading about the use of technology in the research domain, read:

Marhefka, S., Lockhart, E. & Turner, D.A., (2020). Achieve Research Continuity During Social Distancing by Rapidly Implementing Individual and Group Videoconferencing with Participants: Key Considerations, Best Practices, and Protocols. AIDS and Behavior: Notes from the Field. https://doi.org/10.1007/s10461-020-02837-x

ADHD Increases Risky Decision Making: Evidence from a Meta-Analysis

Apr 3, 2020 | Stephen Faraone, Ph.D.

ADHD Increases Risky Decision Making: Evidence from a Meta-Analysis

Adults with ADHD are more likely to have accidents, to drive unsafely, to have unsafe sex and to abuse substances.    These ‘real world’ impairments suggest that people with ADHD may be predisposed to making risky decisions.  Many studies have attempted to address this but is only recently that their results have been aggregated into a systematic review and meta-analysis.   This paper by Dekkers and colleagues reports of 37 laboratory studies of risky decision making that studied a total of 1175 ADHD patients and 1222 controls.  In these laboratory tasks, research participants are given a task to complete which require that they make choices which have varying degrees of risk and reward.  Using the results of such experiments, researchers can score the degree to which participants make risky decisions. When Dekkers and colleagues analyzed the 37 studies together, they found substantial evidence that ADHD people are more likely to make risky decisions than people without ADHD.  The tendency to make risky decisions was greatest for those who, in addition to having ADHD, also had conduct or oppositional disorders, which both have features that indicate antisocial behavior and aggressiveness.     We cannot tell from these studies why ADHD patients make risky decisions.  One explanation is that it is simply the impulsivity of ADHD people that leads to rash, unwise decisions. Another theory postulates that risky decisions reflect deficits in one’s sensitivity to rewards and punishments.  If we are very motivated by reward and not aware of or affected by the possibility of punishment, then risky decisions will be common.  The studies analyzed in the meta-analysis were not designed to demonstrate a link between risky decision making in the lab and the real world risky decisions that lead to accidents and other outcomes.  It is reasonable to hypothesize such a link, which is why clinicians should consider risky decision making when planning treatments.   If you suspect deficits in this area, it will not change your approach to pharmacologic treatment but, given the potential adverse consequences of risky decisions, you should consider referring such patients to cognitive behavior therapy for adult ADHD as this talk therapy may be able to teach ADHD adults how to cope with their decision making deficits.

REFERENCE

Dekkers, T. J., Popma, A., Agelink van Rentergem, J. A., Bexkens, A. & Huizenga, H. M. (2016). Risky decision making in Attention-Deficit/Hyperactivity Disorder: A meta-regression analysis. Clin Psychol Rev 45, 1-16.

 

 

GUIDELINES, RESOURCES, AND TIPS FOR APSARD MEMBERS

Apr 1, 2020 | Events and Announcements

GUIDELINES, RESOURCES, AND TIPS FOR APSARD MEMBERS

Information re: COVID-19 for clinicians as of 3/24/20, compiled by Ellen Littman, PhD

 

 

APSARD members offer vital connection, support, advice, and structure to our patients as we ride out this time of uncertainty.  To experience an exemplar of remote connection: https://slippedisc.com/2020/03/believe-it-orchestra-plays-beethoven-9th-from-their-homes/

While you shelter in place, you can connect with your APSARD colleagues via the message board, which can be reached by logging into the APSARD website.

I hope this is helpful to you—stay safe!