Mar 15, 2017 | Research Updates
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
Although ADHD symptom measures or inventories that combine measurements of symptoms with other manifestations of ADHD (e.g., executive functions) are typically used to measure treatment progress clinical outcome studies of psychosocial treatments for adult ADHD, symptom reduction is not the main treatment target of these treatments, primarily Cognitive-Behavioral Therapy for adult ADHD. Rather, it is the consistent implementation of skills and strategies for managing the effects of ADHD on functioning, thus, it is a very behavioral target.
I made this same point in a previous blog in which I reviewed studies of the role of negative thinking in ADHD. The cognitive modification facet of CBT for adult ADHD facilitates behavior change by challenging task-interfering thoughts that hamper efforts to use the coping skills that everyone agrees are helping in managing ADHD. Cognitive interventions are relevant for issues of procrastination, emotional management, and various other “pivot points” at which adults with ADHD have an opportunity to implement a coping plan (“I should put my keys on the hook by the door…”) versus being swayed by the moment (“… but I need to finish this text first. I’ll remember that the keys are in my bedroom.”).
Although these cognitions do not cause ADHD, they fit within the cognitive model adapted for ADHD insofar as they are a useful and portable means for implementing coping strategies. There is another level of cognition that is gaining empirical support in terms of understanding the experience of adults with ADHD and informing psychosocial treatment, namely, the level of core beliefs.
The core beliefs (often used interchangeably with the term schema) can be considered CBT’s version of the unconscious mind. Schemas (comprised of specific categories) reflect the meaning-making and categorization process that is a facet of human cognition and making sense of the world. The overarching belief categories represent specific themes, such as those of connection/disconnection with others, autonomy and performance, inhibition/disinhibition, etc. The core beliefs, representing the downstream expressions of these categories in terms of the “rules” for the world, are created from one’s developmental experiences, operate nonconsciously, and are greatly influenced by emotional associations with experience.
The CBT conceptualizations of adult ADHD that have informed treatment protocols and research on negative thoughts are based on observations that adults with ADHD are prone to developing negative belief systems based on recurring difficulties managing environmental demands across development, particularly if ADHD was undiagnosed. It is hypothesized that these difficulties or failure experiences are attributed to a sense of failure, inadequacy, incompetence, and/or a sense of self-mistrust, which are beliefs that may operate akin to self-defeating behaviors that magnify and are magnified by the hallmark features of ADHD.
Recent studies have specifically targeted and assessed maladaptive schema in samples of adults with ADHD compared with controls. The first study involved a survey of a nonclinical sample of 204 adults. ADHD symptoms were measured by the Adult ADHD Self-Report Scale (18-item version). The Young Schema Questionnaire (YSQ) was administered as the measure of schema/core beliefs, which is a psychometrically sound scale, with specific schema targeted based on CBT conceptualizations of adult ADHD. Measures of perceived stress and emotional well-being were also obtained. Of this non-clinical sample, 7.4% exceeded the screening threshold for likely ADHD.1
The findings indicated that more ADHD symptoms were associated with higher stress and lower emotional well-being. More to the point of schema, ADHD symptom severity was strongly and positively associated with endorsement all four of the targeted schema: Social Isolation, Defectiveness/Shame, Failure, and Insufficient Self-Control/Self-Discipline. There were also significant indirect effects such that more ADHD symptoms were associated with stronger maladaptive core belief that, in turn, were associated with higher perceived stress.
A second study examined schema endorsement in a clinical sample of 78 ADHD adults compared with 80 non-clinical controls, again using the YSQ. The adult ADHD group scored significantly higher than the control group in overall schema endorsement. When examining specific schema endorsement, the largest significant effect sizes (all large effects) were for (in descending order): Failure, Defectiveness/Shame, Emotional Deprivation, Subjugation, Mistrust/Abuse, Dependence/Incompetence, and Negativity.2
In addition to providing further support for the CBT model that informs the existing psychosocial treatment protocols, these studies also highlight a different level of cognitive intervention. That is, addressing this level of belief targets the visceral negative emotional reactions to coping strategies associated with failure experiences, explicit and implicit negative feedback from others throughout one’s life that gets internalized, and the ongoing difficulties managing the effects of ADHD that clinic-referred adults with ADHD carry with them at the start of treatment, making them prone to premature drop-out at the first sign of perceived “failure” or that “this is not working.” Taking care to acknowledge the unique challenges of managing ADHD, normalizing that treatment involves managing the invariable setbacks, and the importance of maintain an adaptive mindset can help build the treatment alliance and maintain engagement in treatment.
References
1 Miklosi, M. et al. (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. et al. (2016). Early maladaptive schemas in adult patients with attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder. Online ahead of print. doi: 10.1007/s12402-016-0211-8
Mar 15, 2017 | Research Updates
*Commentary by Dr. Margaret Weiss: Now that we are identifying children with ADHD and ASD we need to know more about how to manage this population.
Attention-Deficit Hyperactivity Disorder and Autism Spectrum Disorder Samuele Cortese Psychiatric Symptoms and Comorbidities in Autism Spectrum Disorder (2016)
DOI: 10.1007/978-3-319-29695-1_6
Abstract
Previous versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) did not allow the possibility of diagnosing attention-deficit/hyperactivity disorder (ADHD) in individuals with autism spectrum disorder (ASD). However, this veto has been removed in the current version of the DSM (DSM-5), highlighting the need for screening and appropriately managing, when present, symptoms of ADHD (i.e., inattention and/or hyperactivity/impulsivity) in individuals with ASD. Evidence from neuroimaging and genetic studies points to shared but also specific neurobiological underpinnings across the two disorders. While there is a large body of research on the pharmacological and non-pharmacological treatments of ADHD, evidence on the management of ADHD symptoms in individuals with ASD needs further investigation. Future studies should explore pathophysiologically based, rather than symptomatic, intervention strategies for ADHD associated with ASD.
Mar 15, 2017 | Research Updates
*Commentary by Dr. Margaret Weiss: Clinical guidelines inform practice, but this type of empirical research has the potential to assure that clinical practice also informs clinical guidelines and assure their feasibility.Further evidence for the benefit of prescribing health.
The challenges of implementing ADHD clinical guidelines and research best evidence in routine clinical care settings: Delphi survey and mixed-methods study Charlotte L. Hall, John A. Taylor, Karen Newell, Laurence Baldwin, Kapil Sayal, Chris Hollis British Journal of Psychiatry Open Jan 2016, 2 (1) 25-31; DOI: 10.1192/bjpo.bp.115.002386; Open Access
Abstract
Background: The landmark US Multimodal Treatment of ADHD (MTA) study established the benefits of individualised medication titration and optimisation strategies to improve short- to medium-term outcomes in attention-deficit hyperactivity disorder (ADHD). This individualised medication management approach was subsequently incorporated into the National Institute for Health and Care Excellence (NICE) ADHD Clinical Guidelines (NICE CG78). However, little is known about clinicians’ attitudes towards implementing these medication management strategies for ADHD in routine care.
Aims: To examine National Health Service (NHS) healthcare professionals’ consensus on ADHD medication management strategies.
Method: Using the Delphi method, we examined perceptions on the importance and feasibility of implementing 103 ADHD treatment statements from sources including the UK NICE ADHD guidelines and US medication management algorithms.
Results: Certain recommendations for ADHD medication management were judged as important and feasible to implement, including a stepwise titration of stimulant medication. Other recommendations were perceived as important but not feasible to implement in routine practice, such as weekly clinic follow-up with the family during titration and collection of follow-up symptom questionnaires.
Conclusions: Many of the key guideline recommendations for ADHD medication management are viewed by clinicians as important and feasible to implement. However, some recommendations present significant implementation challenges within the context of routine NHS clinical care in England.
Mar 8, 2017 | Research Updates
Mary Solanto, Ph.D.
To the Editor: Two longitudinal studies of epidemiological cohorts published in JAMA Psychiatry—one conducted in Brazil1 and the other in the United Kingdom2—have found evidence for adult-onset attention-deficit/hyperactivity disorder(ADHD) in substantial proportions of adults with ADHD. These studies, plus an earlier one from NewZealand,3 challenge the longstanding conceptualization of ADHD as a disorder necessarily beginning in childhood. The strengths of these studies include large sample sizes and longitudinal prospective birth cohort designs. Thus, the childhood diagnostic data were collected in childhood and not dependent on retrospective (and possibly biased) reports.
Nevertheless, I submit that these unexpected results may reflect the method used to diagnose the disorder in children. Specifically, the DSM-III ADHD diagnostic criteria in use at the time of initiation of the New Zealand study did not allow for diagnosis of the inattentive subtype or presentation of ADHD, whichcomprises45%4 of all children with ADHD. Children with the inattentive subtype would similarly not have been recognized in the Brazil study,1 which used the 5-item hyperactivity subscale of the Strengths and Difficulties Questionnaire to screen the participants. Exclusion of predominantly inattentive cases would result in a significantly reduced occurrence of childhood ADHD among the Adults with ADHD. Children in the UK study2 were diagnosed as having the disorder on the basis of the full DSM-IV criteria for ADHD, which recognized the subtypes, which may explain why it reports a much higher percentage of adults with ADHD having onset in childhood (32.5%) than did the New Zealand study (10%) or the Brazil study (12.6%).
I see 100 adults per year for evaluation and/or treatment of ADHD, most of whom have clear onset of symptoms in childhood, with an additional number reporting onset in adolescence. Thus, I believe it would be premature to implement a diagnosis of an “adult-onset ADHD” without understanding more fully why clinical samples differ from the epidemiological samples reported in these studies.
Author Affiliations: Department of Psychiatry, New York University School of Medicine, New York (Solanto); Department of Child and Adolescent Psychiatry,
New York University School of Medicine, New York (Solanto).
Corresponding Author: Mary V. Solanto, PhD, Department of Psychiatry, New York University School of Medicine
Published Online: February 15, 2017. doi:10.1001/jamapsychiatry.2016.2741
Conflict of Interest Disclosures: None reported.
1. Caye A, Rocha TB, Anselmi L, et al. Attention-deficit/hyperactivity disorder trajectories from childhood to young adulthood: evidence from a birth cohort
supporting a late-onset syndrome. JAMA Psychiatry. 2016;73(7):705-712.
2. Agnew-Blais JC, Polanczyk GV, Danese A,Wertz J, Moffitt TE, Arseneault L. Evaluation of the persistence, remission, and emergence of attention-deficit/
hyperactivity disorder in young adulthood. JAMA Psychiatry. 2016;73(7):713-720.
3. Moffitt TE, Houts R, Asherson P, et al. Is adult ADHD a childhood-onset neurodevelopmental disorder? evidence from a four-decade longitudinal cohort
study. Am J Psychiatry. 2015;172(10):967-977.
4. Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: ameta-analytic review. Neurotherapeutics. 2012;9(3):490-499.
Feb 22, 2017 | Research Updates
David Pomeroy, M.D.
Physician/Owner at ADD Center of Bellevue
There is an absence of clinical rationale in policies for authorizing medications in treatment of ADHD and excessive burden upon the clinician. These are some examples from my practice:
1- “Long acting meds are simply a convenience for adults”
a. The background for this policy included reference to the January 2000 article in American Family Physician journal, at which time there were no FDA approved long-acting stimulants.
b. Another reference was from 2004, article by Timothy Wilens M.D.; this was after limited experience with only 2 long-acting medications by that time.
c. After supplying documentation from the European consensus statement on treatment for adult ADHD ( 2011) and the guidelines from the Canadian ADD Resource Alliance for treatment of adults with ADHD, this criterion was dropped. However in its place was a requirement that any medication prescribed for adults with ADHD had to be done so by a “mental health specialist”. This included prescribing methylphenidate 5 mg tablets twice daily.
2- Requiring prescriptions for ADHD to be written by or in consultation with a “mental health specialist”. This would require the patient to be seen in consultation by a psychiatrist or psychiatric nurse practitioner.
a. There are not enough of either of those specialists to see all the patients with adult ADHD;
b. Unless someone has particular interest in the field of ADHD, their basic training does not include nearly enough information nor experience to render an opinion on appropriate medication use.
c. A Family Practitioner or internist or pediatrician can acquire the knowledge and training necessary by attending conferences and workshops, especially those presented by professional organizations devoted to the field of ADHD.
3- Limiting the number of capsules per day.
Any of the extended release formulations of stimulants have a wide range in duration of effectiveness in different patients, thus a single XR 30 mg capsule of Adderall may be effective for 10 hours in some patients, or only 6 hours in others. Allowing only a single capsule of XR for someone in whom it is effective for only 6 hours would require 2 or 3 booster doses of IR tablets to cover the entire day. Compliance with such a regimen would be low even in her typical patients; many studies confirm that compliance with t.i.d. dosing of any medication is quite low.
4- In order to advocate for one’s patients, the clinician can appeal the decision, often through a laborious process.
a. Obtaining a copy of the policies used to make the decisions often requires a request in writing, or repeated requests by telephone.
b. Medication history must often be supplied, with dates and dosages and effects of medication; if meds were prescribed by other clinicians in the past, these details are not always available. Regardless, it takes time to dig that information out of any charting system.
c. Often the patient has to designate in writing the clinician as a “authorized representative”.
d. Some denials simply state that the medication does not meet requirements of the formulary, and these must be met before medication can be considered. However which medications are on the formulary are not included in the letter of denial, requiring someone to check a website and sort through formularies, which often differ within a given insurance carrier’s plans.
What steps could APSARD take to address these issues?
1- Publish best practice parameters for the diagnosis and treatment of ADHD in adults. There are no such descriptions of best practices published in the United States.
2- Provide support in the form of information and references for clinicians to cite in the process of appealing decisions. Post marketing studies which establish higher dosages then FDA-approved as being safe and effective such as those by Biederman about OROS methylphenidate.
3- Publish a general statement countering the illogical criteria used in denying medications, such as those above. This could be attached to an appeal and thus provide the weight of a professional organization to the appeal.
4- Maintain a specific forum thread about Prior Authorizations and medication denials, by which members can exchange ideas and strategies on these issues. a. For instance, if the criteria and requiring medication for ADHD be written by a mental health specialist for those over age 19 is not applied to the diagnosis of Major Depression or Generalized Anxiety Disorder; this could be construed to be a discrimination on the basis of diagnosis. Because ADHD is an accepted disability under the Americans with Disabilities Act, such a policy may be in violation of this Act.
Jan 23, 2017 | Research Updates
Andrew A. Nierenberg, MD
Massachusetts General Hospital
Convergent evidence strongly suggests that children with bipolar disorder have high rates of comorbid ADHD. Given enough time, these children grow up and become adults; and when they grow up, many continue to have ADHD and bipolar disorder, and, as one would expect, those with ADHD have a worse course compared to those without ADHD. One could conceptualize this particular comorbidity as dysregulations in partially overlapping and related brain network circuits, each with distinct clinical trajectories – and more recent data suggests a complex relationship between genetic risks (Van Uulzen et al. Biol Psychiatry. 2016 Oct 18. pii: S0006-3223(16)32920-1. doi: 10.1016/j.biopsych.2016.08.040. [Epub ahead of print]).
The ADHD symptoms, while context specific, tend to be continuous and not episodic. The bipolar symptoms can be episodic (discrete mood episodes) as well as continuous (interepisodic depressive, manic, hypomanic, and anxiety symptoms). Since the treatments which can treat ADHD can potentially exacerbate manic and psychotic symptoms, it is unclear whether clinicians could prescribe the usual ADHD medications (stimulants and atomoxetine) with an acceptable margin of safety. Furthermore, because comorbid ADHD increases the risk of comorbid substance abuse in people with bipolar disorder, do stimulants increase the risk of exacerbating substance abuse or, as consistent with evidence for adolescents with ADHD, will stimulants actually decrease substance abuse? At the very least, clinicians will be concerned about the safety of ADHD treatments more than the effectiveness of these medications. Beyond clinician anxiety, what evidence exists for the treatment of comorbid ADHD and bipolar disorder in adults?
Roger McIntyre and colleagues published an open 4 week study of lisdexamfetamine for 45 patients with ADHD and bipolar disorder (Hum. Psychopharmacol Clin Exp 2013; 28: 421–427). Patients improved overall and specifically with ADHD symptoms without any exacerbation of manic or psychotic symptoms. The investigators acknowledge the limitations of interpreting an open short-term study. Nevertheless, this study suggests that a stimulant might be effective and safe in this population.
While not specifically focusing on bipolar disorder with comorbid ADHD, Alexander Victorin and colleagues took a different tack to examine the risks of using methylphenidate for over 2,000 people with bipolar disorder, especially the risk of treatment emergent mania (Am J Psychiatry. 2016 Oct 3:appiajp201616040467. [Epub ahead of print]). As one would expect, those treated with methylphenidate alone had a hazard ratio of 6.7 (95% CI=2.0-22.4). In contrast, when methylphenidate was added to a mood stabilizer, the hazard of mania was lower (hazard ratio=0.6, 95% CI=0.4-0.9). The main limitation of this study is that ADHD was not assessed. Nevertheless, this analysis suggests that methylphenidate may be reasonably safe if patients also take a mood stabilizer.
A search of pubmed using the terms “bipolar disorder”, “adult ADHD”, and randomized yielded no results. So in the absence of randomized controlled trials, limited data suggests that treatment of ADHD with comorbid bipolar disorder or bipolar disorder with comorbid ADHD in adults may be reasonably safe as long as an antimanic medication is given and clinicians follow patients closely.
