CCHMC Center for ADHD

Tanya Froehlich, M.D., M.S.
Associate Professor of Pediatrics
Cincinnati Children’s Hospital Medical Center

Established in 2005, the Center for ADHD at Cincinnati Children’s Hospital Medical Center (CCHMC) is composed of a multi-disciplinary team of investigators across several divisions including Behavioral Medicine and Clinical Psychology, Developmental and Behavioral Pediatrics, and General and Community Pediatrics. Our Center is one of the largest centers in the country devoted entirely to improving the care of children and adolescents with ADHD. The Center is actively involved in providing state-of-the-art, evidence-based assessment and treatment services for children and adolescents with ADHD, as well as working with community-based organizations to improve care for children with ADHD. Clinical services offered by our Center include comprehensive evaluations and consultation for children and teens, parent group interventions for preschool and school-aged children, academic skills group programs for adolescents in grades 6-10, and frustration management groups for children aged 8 to 11 years old. We also offer a 7-week Summer Treatment Program (STP) for children aged 7-12 years of age. The Center serves over 400 patients per year across these clinical services.

In addition to our clinical services, our Center has eleven current research projects federally-funded by the National Institutes of Health (NIH), the Institute of Education Sciences (IES), and Agency for Healthcare Research and Quality (AHRQ). This research focuses primarily on developing new and innovative ways to understand, evaluate and treat ADHD. Examples of the exciting research at the Center for ADHD include: a) an NIH-funded randomized, double–blind, placebo-controlled trial designed to study the neurobehavioral effects of methylphenidate (MPH) treatment; b) an NIH-funded randomized clinical trial examining the effectiveness of a driving intervention to address ADHD-related driving impairment in ADHD teens; c) an IES-funded study examining the impact of sleep problems on the academic and social functioning of adolescents with and without ADHD across the transition from middle to high school; d) an AHRQ-funded randomized clinical trial testing the effectiveness of an online behavioral intervention for elementary-school aged children with ADHD; e) IES- and NIH-funded studies evaluating academic, socioemotional, and neuropsychological-related impairments experienced by children with sluggish cognitive tempo; f) an NIH-funded study to develop intervention strategies to address medication adherence in teens with ADHD; g) an NIH-funded study that will adapt an academic-focused executive functioning intervention with demonstrated effectiveness in young adolescents with ADHD for middle school students with high-functioning autism; h) an NIH-funded study to determine genetic predictors of methylphenidate response.

Our Center has also developed and tested Internet-based software (mehealth for ADHD) to improve the quality of ADHD care of community-based pediatricians nationwide. This software a) facilitates online collection of parent and teacher rating scales, b) promotes parent-teacher-pediatrician communication, c) provides feedback to pediatricians regarding their provision of quality ADHD care, and d) gives access to quality improvement tools. Two clinical trials have demonstrated that use of the software dramatically improves evidence-based ADHD care among community-based pediatricians and significantly improves the treatment outcomes of children treated by pediatricians using the software. Our Center for ADHD currently supports the software which is used by approximately 600 pediatricians nationwide.

ADHD On Flash Drive

Gregory Mattingly MD
Associate Clinical Professor,
Washington University
President, Midwest Research Group

In a world where each of us spends many hours per day “connected” one must ponder how high intensity digital stimulation modifies the brain and behavior. Not only adults but children are continuously exposed by their phones “blowing up” with group texts, snap chat, instagram and the like.

Our modern digital age comes with many advances but important questions remain:
Does social media influence my child’s attention?
Does being “logged on “ increase my child’s chance of having ADHD?
Does a digital world have an effect on ADHD?

How many times have each of us pondered these questions?
How do you best answer a patient or family?

A recent article in JAMA Psychiatry explored these issues in a study of 3,051 15 to 16 year old 10th grade students. (JAMA. 2018;320(3):255-263) At 2 year follow up, children who did not meet criteria for ADHD at baseline were examined to see if their level of high frequency digital media use influenced their development of ADHD symptoms.

At 2 year follow up, those with low digital media use had a 4.6% rate of ADHD like symptoms, those with moderate use had a 9.5% rate and those with high frequency digital media activities had a 10.5% rate of ADHD like symptoms.

This study raises many intriguing questions:
Do short bursts of digital stimulation increase the rate of developing ADHD or ADHD like symptoms?
Are individuals with subsyndromal ADHD drawn to high frequency digital media activities?
Does our digital world increase the risk of ADHD?
Could sustained digital stimulation with increasing cognitive demands; as in the Akili intervention decrease the development of such symptoms? (JAMA Published online June 13, 2018)

In short, is the brain malleable to digital stimulation? Do brief quantas of high stimulus activity prime the brain to desire brief high stimulus activity and perhaps impair the ability to maintain sustained attention during low stimulus activities? Do certain digital activities increase the risk of ADHD symptoms and others build resilience against such symptoms?

Fascinating questions that excite and intrigue our field and the patients for whom we care.

Program and Expertise Center Adult ADHD at PsyQ, the Hague, The Netherlands

J.J. Sandra Kooij, M.D., Ph.D. Associate Professor of Psychiatry at VUMc, Amsterdam

In 2002, I founded Program and Expertise Center Adult ADHD at Parnassia, later PsyQ, the Hague, The Netherlands. The aim was to serve patients, to teach colleagues in assessment and treatment, and to do research to increase knowledge on this highly frequent disorder in adult psychiatry (www.psyq.nl). We started with a team of 5 professionals and 100 adult patients, and we currently treat around 1000 patients annually with a team of 45 professionals. Meanwhile PsyQ, a mental health care provider that offers specialized programs for 10 disorders, expanded to 34 locations around the country, and we got the chance to educate every team about adult ADHD. In addition, every referred patient was screened for ADHD (and other disorders) before entering the system. This way, matched care was delivered, even when patients or their GPs were not aware of their condition(s). This pioneering process is described in more detail in my book Adult ADHD. Diagnostic Assessment and Treatment (2012, Springer).
The team had to develop everything, from the Diagnostic Interview for ADHD in adults (DIVA 2.0), to methods for psycho-education, medication management, coaching and group CBT

 

The National PsyQ ADHD Team in 2013 at the 10 year anniversary

ADHD Network
Meanwhile, we had started the Adult ADHD Network for professionals, that later fused with the Child ADHD Network of pediatricians and psychiatrists. This new ‘ADHD Network‘ reflects the lifespan perspective of ADHD.
(www.adhdnetwerk.nl).

European Network Adult ADHD
Also the European Network Adult ADHD (ENAA) was founded in 2002, to exchange knowledge and experience, and inspire professionals in the same pioneering position around Europe. ENAA currently unites 74 professionals from 28 countries (www.eunetworkadultadhd.com). This network published its first Consensus Statement on Diagnosis and Treatment of Adult ADHD in 2010. The updated, open access version has just been submitted.

DIVA Foundation
The DIVA Foundation started distributing the DIVA 2.0 in Dutch for free from 2007 to lower the threshold for appropriate assessment of ADHD in adults. The interview is now available in 20 languages worldwide (www.divacenter.eu). Due to the increased license fee by the APA for use of the DSM-criteria, it may be necessary in the near future to ask payment for downloads. There is also a DIVA 2.0 app available in the App and Google stores that contains all languages. The DIVA 2.0 was validated in 2 studies and is increasingly used in research. The next edition, DIVA-5, based on the DSM-5 criteria is underway in many languages.

Top Mental Health acknowledgement
In 2008, the Program and Expertise Center was acknowledged the Top Mental Health status in the Netherlands (www.topggz.nl), for excellent patient care, innovative research and education on adult ADHD. The work of the team is re-evaluated every 3 years and has prolonged this Top Mental Health acknowledgement up to today.

Lifespan ADHD Clinic
In 2011, we started the Lifespan ADHD clinic together with Lucertis, a child and adolescent mental health care provider. The aim was to bring parents and children together at the same location for treatment, to be able to work more closely together, to take better care of adolescents who tend to quit treatment at age 15, and to develop care for older people with ADHD. The idea was highly appreciated by patients and professionals, but proved difficult to organize due to different financial and organizational systems and different management. We are still trying to become one team with one budget to overcome these difficulties.

Research
Our research at the Expertise Center Adult ADHD in close cooperation with the Dept. of Psychiatry at VUMc Amsterdam, is currently focused on late sleep in ADHD and the impact on health in the long term, as well as on hormonal mood changes during the lifespan in women with ADHD. Older people (> age 60) were shown in our research to still suffer from ADHD in around 3% of the Dutch population, and we are now developing a treatment protocol, and evaluating the treatment wishes of this group and their response to stimulants.

Education
The Expertise Center Adult ADHD educated mental health care professionals and GPs annually with 20 (inter)national courses and several lectures at symposia on assessment and treatment of ADHD in adults and older people, and currently with a new course on Sleep and ADHD.
The Expertise Center participated with the ADHD Network in:
– online national education on adult ADHD for residents in psychiatry
– the Guideline for ADHD in adults of the Dutch Organisation of Psychiatry, that was published in 2015.

Digital Medicine: Super Brains for ADHD
Next step will be to improve access to care for the unmet need of ADHD patients by Digital Medicine: the ADHD app Super Brains, that can be used by patients on their own, as well is for blended care during professional treatment. The app contains self-tests, psycho-education on ADHD and comorbidities, coaching and CBT interventions, reminders, video chats, communities with other experience experts and professionals, lifestyle habits, and gamification. The expectation is that treatment may be more intensive, more effective and of shorter duration. The idea for Super Brains comes from an ICT company owner with ADHD, Rutger den Hollander, who wanted to develop digital medicine for himself, his family, and the rest of the world. PsyQ is investing in its development, and insurance companies are adopting the concept. Super Brains will be launched in the Netherlands this year, first for adults with ADHD, then for children and their parents. Other patient groups are waiting to adjust the app to their needs. Super Brains will be made available in English too. You will be informed by a new blog at that time!

Schema and Adult ADHD

J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine

Below is a link to an interesting article relevant to the psychosocial treatment of adult ADHD, particularly using cognitive behavioral therapy oriented approaches. A previous blog by this writer (Core Beliefs and Adult ADHD, 03/15/2017) highlighted two preliminary studies of the incidence of maladaptive schema in adults with ADHD and their potential contribution to difficulties following through on the effective implementation of coping strategies that are known to be helpful.1,2

Drawing on these the studies, the authors of the current paper consider the clinical implications of these initial findings.3 They highlight that a focus on schema and relevant interventions should be viewed as an extension of existing CBT approaches for adult ADHD. The authors note that while providing a clinically-informed tailoring of psychosocial treatment to individual cases, this very individualization makes it more difficult, though not impossible to conduct controlled research, witness a recent randomized outcome study of a tailored case-conceptualization based CBT approach for adult ADHD.4

References
1 Miklosi, M., Máté, O., Somogyi, K., & Szabó, M. (2016). Adult attention deficit hyperactivity disorder symptoms, perceived stress, and well-being. The Journal of Nervous and Mental Disease, 204, 364-369. doi: 10.1097/NMD.0000000000000472
2 Philipsen, A., Lam, A. P., Breit, S., Lücke, C., Müller, H. H., & Matthies, S. (2017). Early maladaptive schemas in adult patients with attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder, 9, 101-111. doi: 10.1007/s12402-016-0211-8
3 Lücke, C., Lam, A. P., Müller, H. H. O., & Philipsen, A. (2017). New psychotherapeutic approaches in adult ADHD – acknowledging biographical factors. Journal of Neurology & Neuromedicine, 2(7), 6-10.
4 Dittner, A. J., Hodsoll, J., Rimes, K. A., Russell, A. J., & Chalder T. (2018) Cognitive–behavioural therapy for adult attention-deficit hyperactivity disorder: a proof of concept randomised controlled trial. Acta Psychiatrica Scandinavica, 137, 125-137. doi: 10.1111/acps.12836

Link to article reviewed above:
http://www.jneurology.com/articles/new-psychotherapeutic-approaches-in-adult-adhd–acknowledging-biographical-factors.html