Dec 5, 2016 | Research Updates
Dr. Kevin Antshel, Ph.D. is an Associate Professor of Psychology and Director of the Clinical Psychology doctoral program at Syracuse University. Dr. Antshel also directs the ADHD Lifespan Treatment, Education and Research (ALTER) program at Syracuse University. He will be chairing a symposium at the 2017 APSARD Annual Meeting on “ADHD in College Students”.
ADHD is a prevalent neurodevelopmental disorder that persists into adulthood. More than half of children with ADHD will attend a 2- or 4-year university, with prevalence rates of ADHD in college students estimated to be 5%. At least 25% of college students receiving disability services have ADHD. Thus, ADHD exists on college campuses. Despite ADHD existing in greater numbers on college campuses, our knowledge and understanding of ADHD in college students is relatively limited.
By virtue of their college student status, college students with ADHD have had higher academic success during elementary, middle and high school and likely have better coping skills and higher general abilities than individuals with ADHD from the general population. At the same time, college students with ADHD are likely to experience a different set of stressors than young adults with ADHD who are not enrolled in college. In this way, college students with ADHD may represent a distinct category of individuals with ADHD who face a distinct set of challenges.
The symposium that I am chairing brings together four clinical researchers who all have expertise in college students with ADHD. This symposium aims to provide the audience both breadth and depth of coverage into the central issues that are relevant to ADHD on college campuses.
The first paper that will be presented is from Dr. Arthur Anastopoulos from the University of North Carolina – Greensboro: http://www.uncg.edu/hdf/facultystaff/Anastopoulos/Anastopoulos.html. Dr. Anastopoulos will present data from his NIH-funded study investigating the 4-year trajectory of college students with ADHD with a particular emphasis on understanding moderators and mediators of functional outcomes.
Dr. Lawrence Lewandowski from Syracuse University: http://asfaculty.syr.edu/pages/psy/lewandowski-larry.html will present the second paper. Dr. Lewandowski will present data on the use of academic accommodations for college students with ADHD. In his talk, Dr. Lewandowski will focus on what the Americans with Disabilities Act (ADA) stipulates about accommodations as well as how well academic accommodations work for college students with ADHD.
The third paper that will be presented as part of the “ADHD in College Students” symposium will be from Dr. Brooke Molina from the University of Pittsburgh: http://www.psychology.pitt.edu/person/brooke-molina-phd. Dr. Molina will present data from her NIH-funded study of stimulant medication misuse and diversion in college students with a focus on prevention within the primary care setting.
I will present the fourth and final paper in this symposium: http://asfaculty.syr.edu/pages/psy/antshel-kevin.html
My talk will present data regarding how college students both with and without ADHD perceive ADHD and how these perceptions may be related to the malingering of ADHD.
We look forward to a great symposium at the 2017 APSARD conference and hope that you will join us from 1:30 – 3:30 PM on Saturday January 14th!
Dec 2, 2016 | Research Updates
Dr. John Mitchell, Ph.D. is an Assistant Professor of Psychiatry and Behavioral Sciences at Duke University School of Medicine and the Duke ADHD Program. He will be presenting at the 2017 APSARD Annual Meeting on “A Mindfulness Intervention for ADHD in Adulthood Workshop”
Mindfulness-based interventions, or MBIs, involve the teaching of mindfulness meditation practices. The practice of mindfulness meditation has received widespread attention in the popular press. Further, there are numerous books and online resources available to people looking to add mindfulness meditation practices to their own daily routine (e.g., see https://health.ucsd.edu/specialties/mindfulness/programs/mbsr/Pages/audio.aspx as one of many resources freely available). However, is there a scientific basis for all the buzz around mindfulness? The short answer: yes. There’s over 4,000 peer-reviewed publications devoted to the topic of mindfulness (https://goamra.org/resources/). In fact, MBIs have now been actively studied among various medical, psychiatric, and non-clinical populations. To date, many of these studies have demonstrated improvements among individuals with depression, anxiety, and substance use, just to name a few (e.g., see the special issue of American Psychologist devoted entirely to MBIs http://psycnet.apa.org/journals/amp/70/7/ for a thorough review of where the field is at currently). These interventions involve teaching both formal meditation exercises, such as focusing on your breath, and informal exercises to apply mindfulness in everyday life, such as mindfully eating.
Although MBIs on the surface might seem counterintuitive for individuals with ADHD—for example, think about asking someone who struggles with distractibility and restlessness to close their eyes, sit still, and focus on their breath—there’s actually a strong case to be made for that application of mindfulness meditation practice for ADHD. MBIs are thought to have a beneficial impact through different mechanisms, such as improving attentional functioning and emotion regulation. Over the years as the mechanistic research has developed, researchers have increasingly identified individuals with ADHD as a population that may be particularly responsive to MBIs. After all, ADHD is a disorder characterized by difficulty with both attention and emotion regulation. Further, other behavioral characteristics that mindfulness has been demonstrated to improve are typically implicated as problematic in ADHD as well, such as mind wandering.
Since 2008 when the first pilot trial of mindfulness for ADHD was published by Dr. Lidia Zylowska and colleagues (https://www.ncbi.nlm.nih.gov/pubmed/18025249), this has been a topic of increasing scientific interest among ADHD researchers. There are now reviews that establish the empirical status of MBIs for individuals with ADHD (http://guilfordjournals.com/doi/abs/10.1521/adhd.2016.24.2.1, https://www.ncbi.nlm.nih.gov/pubmed/25908900, https://www.ncbi.nlm.nih.gov/pubmed/26740931). One recent meta-analysis indicated that MBIs particularly appear to have a particularly beneficial impact among adults with the disorder (https://www.ncbi.nlm.nih.gov/pubmed/26838555)
At the annual APSARD conference, we’ll discuss what MBIs are, why they are applicable to adults with ADHD, and establish the current evidence-base of MBIs for adults with ADHD. In addition, although self-help materials for adults with ADHD have been published (http://www.shambhala.com/the-mindfulness-prescription-for-adult-adhd.html), there are currently no clinician materials to guide practitioners in administering a MBI for adults diagnosed with ADHD. Therefore, those attending this workshop will also learn about a MBI adapted for adults with ADHD called the Mindful Awareness Practices (MAPs) for ADHD Program. This particular intervention has been tested in open-label and randomized trials. Attendees will be exposed to a session-by-session description of the MAPs for ADHD Program.
Nov 21, 2016 | Research Updates
*Commentary by Dr. Margaret Weiss: This changes our preconception of ADHD in women as somehow more benign.
Gender Differences in Associations Between Attention-Deficit/Hyperactivity Disorder and Substance Use Disorder
Cæcilie Ottosen, BSc, Liselotte Petersen, PhD, Janne Tidselbak Larsen, MSc, Søren Dalsgaard, MD, PhD
Journal of the American Academy of Child & Adolescent Psychiatry
Abstract
Objective: To examine gender differences in the association between attention-deficit/hyperactivity disorder (ADHD) and substance use disorder (SUD), and to explore the impact of comorbid psychiatric conditions.
Method: This was a cohort study of all children born in Denmark in 1990-2003 (n=729,560). By record linkage across nationwide registers, we merged data on birth characteristics, socioeconomic status, familial psychiatric history, and diagnoses of ADHD, comorbidities, and SUD. Hazard ratios (HR) with 95% CIs were estimated by Cox regression and adjusted for a range of variables.
Results: ADHD increased the risk of alcohol abuse (HRfemales=1.72 [1.42-2.08], HRmales=1.57 [1.37-1.79]), cannabis abuse (HRfemales=2.72 [2.12-3.47], HRmales=2.24 [1.86-2.70]) and other illicit substance abuse (HRfemales=2.05 [1.54-2.73], HRmales=2.42 [1.98-2.96]), compared to individuals without ADHD. In the overall estimates, no gender differences were found. Among individuals with ADHD without comorbidities, females had higher SUD risk than males, as did females with ADHD and conduct disorder (CD). Comorbid CD, depression, bipolar disorder, and schizophrenia further increased the risk of SUD in ADHD, compared to non-ADHD. Autism spectrum disorder in males with ADHD lowered the SUD risk.
Conclusion: ADHD increased the risk of all SUD outcomes. Individuals with ADHD without comorbidities were also at increased risk and some comorbid disorders further increased the risk. Females and males with ADHD had comparable risks of SUD, although females had higher risk of some SUDs than males. Females with ADHD may be perceived as less impaired than males, but they are at equally increased risk of SUD.
Nov 16, 2016 | Research Updates
Russell Ramsay, PhD
University of Pennsylvannia
Cognitive-behavioral therapy (CBT) is considered an evidence-supported, psychosocial treatment that has been found to be effective through several outcome studies, including randomized trials comparing CBT with active control treatments. Two recent outcome studies have extended research on CBT for adult ADHD in terms of the benefits of this treatment approach.
In the first study (Wang et al., 2016), 10 adults with ADHD participated in a 12-session course of a published, manualized CBT designed for adult ADHD. In addition to completing pre- and post-rating scales for ADHD (symptoms and executive functioning), subjects also received resting-state functional magnetic resonance imaging scans before and after treatment. Twelve healthy control participants were matched by age and gender and also completed the clinical scales and received a single r-fMRI. The scans for the CBT group were used to compute changes in regional functional connectivity strength from treatment. Within the adult ADHD group, all participants were either medication naïve or had been off of prescribed medications at least 6 months prior to the study, thus none were medicated during CBT. The results indicated that, in addition to post-treatment improvement on self-ratings of ADHD symptoms and executive functioning (organization and self-monitoring), completion of individual CBT was associated with increased functional connectivity in the frontal-parietal network and cerebellum. Treatment was also linked to the lessening of pre-CBT deficits in right superior frontal gyrus when compared with healthy controls, with these improvements resulting from increased connectivity in the dorsal attention network. These particular changes had also been obtained in previous studies examining the effects of stimulant medications on the ADHD brain. The study is limited by the small sample size, that participants were not randomly assigned, and, although diagnosis included a structured diagnostic interview, outcome measures were based on self-report. Nevertheless, examining the effects of psychosocial treatment on brain functioning is an important level of evidence. Moreover, it should not be overlooked that positive clinical results were obtained in a sample of unmedicated adults with ADHD completing a course of CBT.
Whereas medication status in the Wang et al. (2016) was used to control for the effects of medication on r-fMRI scans, Cherkasova et al. (2016) directly examined the comparison of group CBT delivered to ADHD adults either with or without medications in a randomized clinical trial. Eighty-eight adults were randomized to a 12-session, manualized (unpublished) group CBT augmented with individual coaching check-ins either with or without medication. Treatment effects were obtained at the end of treatment and at 3- and 6-month follow-up, using unblended ratings and observer ratings. The results indicated that both groups attained significant improvements in symptoms and functional outcomes when compared with baseline. When comparing groups, CBT with medications outperformed CBT alone for both self- and observer-ratings but these differences in improvements diminished over time, with there being no significant differences between groups in observer ratings of functioning at 6-month follow-up, and the CBT without medication group improved more gradually throughout the follow-up measurements with initial differences diminishing to the point that they were no longer significant. Both groups continued to receive booster coaching sessions after the completion of the CBT group. The authors suggested that the CBT with medication group may have reached a peak of effectiveness quicker, with the nonmedication group needing more time to achieve similar improvements. The limitations of the study were that it was unblended insofar as there was not a placebo control for the nonmedication group, there was no control or “sham” treatment comparison group, and the sample was comprised of generally high-functioning individuals.
Nonetheless, the bar has been set higher for outcome research on CBT for adult ADHD. While none of these findings should be used to diminish the importance of medications in treatment options considered for adults with ADHD, individuals who refuse medications, cannot tolerate side effects, or for whom they are ineffective may still benefit from psychosocial treatment.
Wang, X., Cao, Q., Wang, J. Wu, Z., Wang, P., Sun, L., et al. (2016). The effects of cognitive-behavioral therapy on intrinsic functional brain networks in adults with attention-deficit/hyperactivity disorder. Behaviour Research and Therapy, 76, 32-39. doi: 10.1016/j.brat.2015.11.0030005-7967/
Cherkasova, M.V., French, L.R., Syer, C.A., Cousins, L., Galina, H., Ahmadi-Kashani, Y., & Hechtman, L. (2016). Efficacy of cognitive behavioral therapy with and without medication for adults with ADHD: A randomized clinical trial. Journal of Attention Disorders. Epub ahead of print. doi: 10.1177/1087054716671197
Nov 7, 2016 | Research Updates
By Sandra Kooij, MD PhD
PsyQ, psycho-medical programs, Expertise center adult ADHD, the Hague, The Netherlands
ADHD is related to several sleep problems, but the most frequent seems the delayed sleep phase syndrome, a disturbance of the circadian rhythm. Research of children and adults with ADHD (when compared to controls) shows that the majority of these individuals has a late sleep onset that is associated with a late onset of the sleep hormone melatonin (van der Heijden et al, 2005; van Veen et al, 2010). Melatonin is produced by the pineal gland in the brain when it is getting dark in the evening, and we wake up by light in the morning. The onset of the melatonin production helps to fall asleep. For most adults the onset of melatonin is around 9.30 pm; in ADHD children compared to controls this occurs at least 45 minutes later, and in adults with ADHD even 90 minutes (van der Heijden ea, 2005; van Veen ea 2010). After melatonin onset, it normally takes 2 hours to fall asleep, but in adults with ADHD it takes at least 3 hours (Bijlenga et al, 2013). So it does make sense that so many people with ADHD have difficulty falling asleep on time. This late onset of melatonin is driven by genes that regulate the biological clock, and those genes have been linked psychiatric disorders like ADHD and bipolar disorder (Landgraf et al, 2014). What the exact relationship is between this late sleep pattern and ADHD is still unknown.
Why should this be a problem?
If you are a late person you may prefer to work in the afternoon, evening and/or night, why would that be a problem? The problem is that a late sleep pattern inevitably leads to a short sleep duration, and short sleep has been linked to numerous health problems in the long term. The preferred sleep duration for most people is 7-8 hours, but people working in for instance night-shifts seldom sleep longer than 5-6 hours. The same may be true for people with ADHD, who are evening types that live like they work in night shifts… Missing a few hours of sleep during a limited period will not pose risk, but when short sleep is a chronic pattern, it may lead to obesity, diabetes, cardiovascular disease and cancer (Kooij & Bijlenga 2013). So getting a sufficient number of hours of sleep seems pretty essential to prevent chronic diseases. Also, late sleep increases the vulnerability for mood disorders, especially (winter) depression and bipolar disorder (Lewy et al, 2009). So we better all take care of our sleep!
Take the MCTQ test: am I a late sleeper?
How to take care of longer sleep?
First, sleep hygiene measures may be helpful, starting with limiting light exposure after 9.30 pm. This is because the light emitted by lamps, TV, computer screen and mobile phone reduces the production of melatonin through the eyes (Fiqueiro et al, 2011), thereby delaying your sleep onset time. Developing a timed sleep ritual like taking a hot shower, reading a book using dim light etc. may be helpful as well. When this is not sufficient, 1-3 mg of short acting melatonin can induce sleep at an earlier time before 12 pm, usually one hour after ingestion, thereby increasing total sleep duration (Kooij & Bijlenga 2013). People waking up after a few hours of sleep using short acting melatonin, are advised to switch to the long acting variant. Melatonin is not addictive as are other sleep medications. It is essential to take melatonin on-time, which is after 4 pm and before 12 pm to have its desired effect. This is because melatonin not only acts as a sleep inducer, but it also resets the biological clock (Lewy et al, 2004). As the biological clock influences all physical processes in our body, we best take into account the right time window to prevent unwanted or unknown effects. Research has shown that melatonin is effective in adolescents in advancing sleep onset and increasing sleep duration, as well as in children with ADHD and sleep onset insomnia (Eckerberg et al, 2012; van Maanen et al, 2016; Hoebert et al, 2009).
Nov 1, 2016 | Research Updates, Uncategorized
Ryan J. Kennedy, Donald M. Quinlan, and Thomas E. Brown
Comparison of Two Measures of Working Memory Impairments in 220 Adolescents and Adults with ADHD. Journal of Attention Disorders. Online First, August 1, 2016. DOI: 10.1177/1087054716661232
This study compares two normed measures used in ADHD evaluations to assess impairments in working memory. Although individuals with ADHD may have excellent recall of long-term memories, they often report having chronic difficulty with their short term working memory (WM). They often forget things in the here-and-now: what others have just said to them, where they have put something, what they were about to do, what they have just finished reading, and so on. Measures compared were:
1) A normed story recall test consisting of two brief stories from the Wechsler Memory Scale read aloud to the patient only once. Immediately after each story is read aloud by the examiner, the patient is asked to retell it to the examiner, as close to verbatim as possible. Responses are then scored relative to age norms.
2) The Working Memory Index (WMI), a combination of two subtests from the Wechsler Adult Intelligence Scale–Fourth Edition: the digit span (forward and backward) and mental arithmetic. Both are administered orally.
Results support our hypotheses that adolescents and adults with ADHD tend to score significantly lower on both of these tasks, with significantly more difficulty on story memory, than do most persons of comparable age in the general population.
We suggest that the story memory task has more ecological validity than numerically-based measures of working memory. It provides an objective measure to assess an individual’s ability to pay attention to a sizable, but manageable, chunk of verbal information and to remember what has been heard. This is not so different from many daily life situations where one needs to pay attention to what someone is saying and keep it in mind long enough to understand and recall what has been said. The story memory task can be administered in approximately 10 minutes.
