Oct 31, 2016 | Research Updates, Uncategorized
Schrevel, S. J. C., Dedding, C., & Broerse, J. E. W. (2016). Why do adults with ADHD choose strength-based coaching over public mental health care? A qualitative case study from the Netherlands. Sage Open, July-September, 1-8. doi: 10.1177/2158244016662498
Overview and Recommendations by David Giwerc, MCAC, MCC
The coaching profession has had a relative scarcity of research documenting the benefits of ADHD Coaching for adults. However, a recently published study conducted in the Netherlands asked adults with ADHD about their experiences with different treatment modalities, including ADHD Coaching. The findings indicated that participants reported that they benefit from strength-based ADHD coaching and cited their dissatisfaction with the other current public mental health care options.
The study was conducted through 23 semi-structured interviews with ADHD clients, all older than 25 years-old, who were recruited from a private coaching center. All but one of the interviewees had an official diagnosis of ADHD, and all but one had experiences with mental health care prior to coaching. Most of them had established, years-long treatment histories and frequently described a series of negative experiences in the mental health care system. Five of the participants were taking prescribed stimulant medications.
The study asked why adults with ADHD prefer to pay out-of-pocket for coaching services rather than receive reimbursed public mental health care that is available to them.
All but one of the study participants cited the high value placed on the “optimistic strength-based and solution-focused approach” of ADHD coaching, which was cited as being different from their experiences in the “symptom-centered approach” of public mental health care. Coaching was perceived as a “joint venture” fostering hope and healing by reinforcing personal strengths and competencies, person-centeredness, and the belief that everyone is capable of overcoming mental illness to live a meaningful life.
Rather than becoming fixated on their problems, many of the participants found that coaching facilitated a simpler approach which encouraged them to search for solutions when confronted with problems. By participating in the coaching process, some participants described a greater sense of control over their pervasive problems by learning coping strategies that what worked for them.
The outcome form ADHD Coaching that was most frequently described by participants was increased insight. Participants noted that community-based therapy enabled them to understand themselves, what they are doing, and how and why they are doing it. In contrast, respondents reported that Coaching “lets you discover who you are, and what you are allowed to be. . . how your internal communication works, how you treat other people. They [coaches] teach you how to enjoy life, something very simple actually.”
This study highlights two important findings. First, some ADHD adults feel their needs are inadequately addressed by the mental health system, and second, these adults appeared to benefit from strength-based, specialized ADHD coaching.
Using a similar methodology, the research can be expanded to other countries in order to identify the perceptions and benefits of strength-based coaching for adults with ADHD.
Of course, the study is limited by the fact that the participants were recruited from a sample of individuals participating in an ADHD Coaching program, thus there is a self-selection bias, as individuals seeking Coaching may have done so because they were dissatisfied by community care. It is also unclear of the nature of community services available to participants in terms of targeting adult ADHD. Future studies may include a representative sample of individuals receiving a range of treatments for adult ADHD. Lastly, the training of the coaching process, specific models, competencies and strategies employed by ADHD Coaches are varied and studies specifying training standards and approaches used by ADHD Coaches will help the generalization of findings from future studies.
Oct 17, 2016 | Research Updates, Uncategorized
Affective lability is a term used in mood disorders where as emotional dysregulation is described in attention deficit hyperactivity disorder. At first glance these two terms might appear to make categorical distinctions yet the clinical presentation is often much more confusing. Richard-Lepouriel and colleagues (2016) wrote in their paper on the similarities of affective lability and emotional dysregulation that emotional dysregulation (term to describe both) can be “defined by excessive expression and experience of emotions with rapid and poorly controlled shift and emotions and abnormal allocation of attention to emotional stimuli.” Yet how can such a descriptive definition be clinically operationalized?
If we look at the DSM diagnostic criteria, there are multiple symptoms that overlap Bipolar Disorder-hypomania/mania and ADHD. In the DSM-IV, Bipolar Disorder/ADHD respective symptoms were more talkative than usual/talks excessively, distractibility/easily distracted, increased activity or physical restlessness/fidgets and restless, loss of normal social inhibitions/interrupts and butts in uninvited. In DSM 5, the symptom overlap continues with hypomanic/manic symptoms of increased talkativeness, racing thoughts, distractibility, psychomotor agitation, increase risky behavior compared to ADHD symptoms of talks too much in social situations, difficulty maintaining attention and distractible, fidgety and restless. And while not diagnostic criteria for ADHD, impulsive risky-taking behavior and sleep disturbance both overlap with Bipolar Disorder. In addition, both disorders require social/occupational distress or impairment be present.
While symptoms are descriptive, the etiology is unaddressed. Is this is a dysfunction with the accelerator (the rapidity of emotional intensity) or the lack of brakes (leading to impulsive expression)? The distinction can have neuropharmacologic implications. For example, the prescription for affective lability in bipolar disorder is a mood stabilizer, while emotional dysregulation in ADHD seems to respond to stimulants and atomoxetine. In contrast, no literature supports the use of ADHD medications for mood control in bipolar disorder and ADHD medications are discouraged in bipolar patients.
Do we learn anything from the pharmacologic action of respective disease appropriate medications? Not really. If we apply the concept of “dysfunctional accelerator”, mood stabilizers as lithium, lamotrigine, carbarmazepine, valproate, and atypical neuroleptics have different pharmacologic action, although the epileptic medications have the commonality of anti-seizure effect. At one time, it was thought that the anti-seizure characteristic was an explanation for the mood stabilization. However, the hypothesis of kindling has not proven to be a credible explanation for bipolar disorder after decades of research. Mood stabilizer heterogeneity may be in contrast to stimulant medications all of which have the commonality of increasing cerebral dopamine levels. Considering the “lack of brakes” concept, one might presume that elevations in dopamine levels mitigate emotional dysregulation by “applying the brakes” to impulsive emotional expression. And yet, while atomoxetine and alpha agents have downstream effects on dopamine that presumably explains their efficacy, their benefit on emotional regulation may result from the direct effect on noradenline or a neural system not yet identified.
I submit that affective lability and emotional dysregulation represents a conceptual difference without a clinical distinction. As a result, the use of symptom checklists at a single point in time is likely to render a compromised diagnosis. The response to medication is unlikely to provide any greater accuracy in diagnosis. What have been missing from DSM criteria have been the age of onset, longitudinal course of symptoms, and the presence of the symptoms/disorder in first-degree relatives. These three historical factors will increase the specificity of the diagnosis.
While there will be much debate over “who owns” emotional dysfunction, the mood disorder camp or the ADHD camp, the clinical use of emotional expression as a predominant determinant of the disorder will lead us astray.
David W. Goodman, M.D.
Richard-Lepouriel H, et al. Similarities between emotional dysregulation in adults suffering from ADHD and bipolar patients. J Affect Dis. 2016. 198:230-236.
Bender RE, et al. Life stress and kindling in bipolar disorder: review of the evidence and integration with emerging biopsychosocial theories. Clin. Psychol. Rev. 2011. 31: 383–398.
Oct 17, 2016 | Research Updates
Sheftall AH, Asti L, Horowitz LM, et al. Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics. 2016;138(4):e20160436
Suicide is the 10th leading cause of death among school age children. Despite this startling fact, most research examining risk factors for suicide in those under 18 has focused on adolescents. The lack of research on completed suicides in elementary-school aged children led researchers at Ohio State to examine data from the National Violent Death Reporting System (NVDRS). The researchers studied suicides in children and young adolescents from seventeen states that fully reported all violent deaths to the NVDRS. The researchers compared the characteristics of younger elementary-school age children (ages 5 to 11) to young adolescents (ages 12 to 14) who died by suicide to determine if there were any characteristics that distinguished these age groups. They reported that almost 60% of the children aged 5 to 11 who completed suicide and who had a prior mental health diagnosis had been diagnosed with ADHD. By contrast, among the young adolescents with prior mental health diagnoses, depression was the common mental health diagnosis.
The researchers concluded that among the young children who committed suicide, impulsivity is linked to higher risk of suicide. Supporting this conclusion is the fact that many of the elementary school aged children who died from suicide were experiencing a major conflict with their family or their friends prior to the event. Many killed themselves by hanging or strangulation in their homes, suggesting that these children may have not planned their attempts beforehand, highlighting that impulsivity in the context of family or social stressors can potentially be lethal. Another important finding was of the 16 elementary school-aged children for whom drug testing was available and who carried a diagnosis of ADHD, only 1 child had evidence of amphetamine at the time of death. This suggests that many of the children with ADHD in this sample may not have been in active treatment at the time of death; thus, they were not benefitting from the impulsivity-reducing effects of stimulant medication. The majority of the children who committed suicide were African-American boys, a surprising finding given that among U.S. adults, Caucasians are significantly more likely than African-Americans to commit suicide. It has been well documented in other studies that African-American children are less likely to receive adequate treatment for mental health disorders than their Caucasian peers. This research study lends further support to the view that mental health disparities may be endangering the lives of African-American children, especially those with untreated ADHD. Since impulsivity may be a major risk factor for completed suicide in elementary school-aged children, this study can help guide suicide prevention efforts in this age group by encouraging the teaching of problem-solving skills in crisis situations. Hopefully, it will encourage pediatricians, educators and others who work with elementary-school aged children to provide extra supervision and support for them during times of conflict with family members or peers, and to refer those with risky behaviors for mental health treatment. Equally important, this study points out the life-threatening aspects of ADHD and the urgent need to take the diagnosis and its treatment seriously. As Dahlsgaard and others have already noted, ADHD is associated with premature mortality. With growing concerns about youth suicide as a public health problem in the U.S., this study makes an important contribution to the scientific literature.
Reference
Søren Dalsgaard, Søren Dinesen Østergaard, James F Leckman, Preben Bo Mortensen, Marianne Giørtz Pedersen
“Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study”
The Lancet, Volume 385, Issue 9983, 30 May–5 June 2015, Pages 2190-2196
Lisa Adler MD
Anthony Rostain MD
Oct 14, 2016 | Research Updates, Uncategorized
This is an everyday issue in real world clinical practice.
The old adage of “Treat mood and anxiety first” before treating ADHD has long been considered the recommended standard of care when confronted with patients with ADHD comorbid with significant mood or anxiety symptoms.
Recent findings by Chen et al from a nationwide longitudinal study of ADHD and comorbid major depression (MDD/ADHD) may cause clinicians to rethink this strategy. Their study identified 1,891 patients with MDD/ADHD and compared them with 1,891 age and sex matched patients with major depression only in a 1-year longitudinal study. Patients with MDD/ADHD had 232% the risk of treatment resistance to multiple antidepressants compared with patients with major depression without ADHD. Their study went on to find that individuals receiving regular treatment for ADHD had a significantly lower risk for antidepressant treatment resistance. In conclusion, “Patients who had dual diagnoses of major depression and attention deficit hyperactivity disorder were more likely to have treatment resistance to antidepressants… prompt and regular treatment for attention deficit hyperactivity disorder would reduce this risk”.
This study highlights the fact that when ADHD symptomatology are driving functional impairments and exacerbating underlying mood disorders, anxiety disorders or substance abuse, that concomitant treatment of ADHD and these associated conditions often yields the best overall therapeutic response.
How will these findings influence your clinical practice?
How do these results change the way we teach our colleagues to manage patients with depression and co-ocurring ADHD?
Greg Mattingly MD 
Chen et al. Eur Neuropsychopharmacol. 2016 Sep 22. pii: S0924-977X(16)30562-4. doi: 10.1016/j.euroneuro.2016.09.369. [Epub ahead of print] Attention – deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: A nationwide longitudinal study.
The comorbidity between attention deficit hyperactivity disorder ( ADHD ) and major depression is common. However, the influence of ADHD comorbidity in the response or resistance to antidepressants remains unknown among patients with major depression. 1891 patients with major depression and ADHD and 1891 age-/sex-matched patients with major depression only were enrolled and followed for 1 year in our study. Use of antidepressants and ADHD medications during 1-year follow-up period were assessed. Antidepressant resistance was defined as treatment failure in two or more than two different antidepressants for adequate treatment dose and duration. Patients with major depression and ADHD had an increased risk of treatment resistance to antidepressants (odds ratio [OR]: 2.32, 95% confidence interval [CI]: 1.63-3.32) compared with patients with major depression only after adjusting for demographic characteristics and other psychiatric comorbidities. Regular treatment for ADHD would reduce this risk (OR: 1.76, 95% CI: 0.72-4.27).
Anxiety (OR: 3.15, 95% CI: 2.24-4.44) and substance use (OR: 2.45, 95% CI: 1.16-5.17) disorders were also associated with an elevated likelihood of resistance to antidepressants during the follow-up. Patients who had dual diagnoses of major depression and ADHD were more likely to have treatment resistance to antidepressants compared with patients with major depression only. Prompt and regular treatment for ADHD would reduce this risk.
Oct 10, 2016 | Research Updates
Are There Character Strengths Associated With Adult ADHD?: Comparison of ADHD Adults and Controls on the VIA Inventory of Strengths.
Ramsay, J. R., Giwerc, D., McGrath, R. E., & Niemiec, R. (2016, January 15).
Background: On the one hand, it is well documented that a lifetime diagnosis of ADHD is associated with many life impairments. On the other hand, there has been the suggestion in some popular outlets that there are “gifts” associated with ADHD, such as increased creativity. In order to examine the question of whether there are strengths associated with ADHD, the VIA Inventory of Strengths (VIA), a self-report inventory that is commonly used in Positive Psychology, was administered to a group of self-identified adults with ADHD (n=99) and a control group of non-ADHD adults (n=54). The normative database for the VIA (n=479,367) provided a third group for comparison.
Methods: Participants were recruited from the database of an ADHD Coaching training program and from links to the VIA survey on social media sites.
The VIA is a 120-item inventory comprised of 24 different character strengths. It was predicted that the non-ADHD group would score significantly higher than the ADHD on character strengths most indicative of intact self-control: Self-Regulation, Perseverance, and Prudence. Based on the “gift” view of ADHD, it was predicted that the ADHD group would score significantly higher than the non-ADHD group on character strengths most associated with creativity and “big picture” thinking: Creativity, Curiosity, and Kindness.
Results: The overall ANOVA for 20 of the 24 VIA character strengths was statistically significant (p < .05). Post hoc comparisons of each of these 20 groups using Tukey’s Studentized Range Test were performed. As predicted, the non-ADHD group scored significantly higher than the ADHD group on the character strengths associated with intact self-control, with large effects sizes for Perseverance and Prudence, and a moderate effect size for Self-Regulation. Conversely, the hypothesis that the ADHD group would score higher than the ADHD group on character strengths associated with creativity and “big picture” thinking was not supported, with there being no significant group differences on Creativity, Curiosity, or Kindness.
An interesting result was that the non-ADHD group scored significantly higher than the ADHD group on the character strength of Hope.
Conclusions: The notion that there are “gfits” associated with ADHD were not supported by this study as measured by the self-report VIA. The ADHD group scored low on domains associated with self-regulation, consistent with the common difficulties reported by ADHD adults. Combined with the finding of a low score on Hope, these characteristic difficulties associated with ADHD likely undermine the pursuit and expression of potential areas of competency or skills by ADHD adults that could be fostered in treatment.
Sep 3, 2016 | Research Updates
The short answer is “yes”. The US Center for Disease Control’s (CDC) review of ADHD starts with the statement: “Attention-deficit/hyperactivity disorder (ADHD) is a serious public health problem affecting a large number of children and adults” (http://www.cdc.gov/ncbddd/adhd/research.html). My colleagues and I recently reviewed the ADHD literature. That let us to describe ADHD as “…a seriously impairing, often persistent neurobiological disorder of high prevalence…” (Faraone et al., 2015). Figure 1, which comes from that paper provides an overview of the lifetime trajectory of ADHD associated morbidity.
Figure 1: Lifetime Morbidity Associated with ADHD (Click to Enlarge)
Figure 2: ADHD, Injuries and Pharmacologic Treatment
Especially compelling data about ADHD and injuries comes from a recent paper, in Lancet Psychiatry, which used the Danish national registers to follow a cohort of 710,120 children (Dalsgaard et al., 2015a). Compared with children not having ADHD, those with ADHD were 30% more likely to sustain injuries than other children. Pharmacotherapy for ADHD reduced the risk for injuries by 32% from 5 to 10 years of age. Pharmacotherapy for ADHD reduced emergency room visits by 28.2% at age 10 and 45.7% at age 12.
These results are shown in Figure 2, taken from the publication. The Figure compares the prevalence of injuries among three groups. ADHD children treated with medication, ADHD children not treated with medication and children without ADHD. The Figure shows how the ADHD risk for injuries occurs for all age groups. It also shows how the risk for injuries drops with treatment so that by age 12, the prevalence of injuries among treated ADHD children is the same as the prevalence of injuries for children without ADHD.
Documented examples of ADHD-associated injuries which impact day-to-day functioning include: severe burns (Fritz and Butz, 2007), dental injuries (Sabuncuoglu, 2007), penetrating eye injuries (Bayar et al., 2015), hospital treated injuries (Hurtig et al., 2013), and head injuries (DiScala et al., 1998). In one study (DiScala et al., 1998), when compared to other children admitted to hospital for injuries, ADHD children were more likely to sustain injuries to multiple body regions (57.1% vs 43%), to sustain head injuries (53% vs 41%), and to be severely injured as measured by the Injury Severity Score (12.5% vs 5.4%) and the Glasgow Coma Scale (7.5% vs 3.4%).
Injuries are a substantial cause of ADHD-associated premature death. This assertion comes from the work of Dalsgaard et al. (2015b) based on the same Danish registry discussed above. In this second study, ADHD was associated with an increased risk for premature death and 53% of those deaths were due to injuries. They reported the risk for premature death in three age groups: 1-5, 6-17 and >17. For all three age groups, they found a greater risk for death in the ADHD group. For ages 6 to 17 and greater than 17. The ADHD associated risk for mortality in remained significant after excluding individuals with antisocial or substance use disorders.
There are currently no data about the effect of ADHD treatment on ADHD-associated premature death. We do, however, know from the data reviewed above that ADHD treatment reduces injuries and that half the deaths in the ADHD group were due to injuries. From this, we infer that ADHD treatments could reduce the risk for ADHD-associated premature death.
Two other ADHD-associated morbidities, obesity and cigarette smoking, have clear medical consequences. In a meta-analysis of 42 cross-sectional studies comprising 48,161 people with ADHD and 679,975 controls, my colleagues and I reported that the pooled prevalence of obesity was increased by about 40% in ADHD children compared with non-ADHD children and by about 70% in ADHD adults compared with non-ADHD adults (Cortese et al., 2015). The association between ADHD and obesity was significant for ADHD medication-naïve subjects but not for those medicated for ADHD (, which suggests that medication reduces the risk for obesity.
Likewise, a meta-analysis of 27 longitudinal studies assessed the risk for several addictive disorders with sample sizes ranging from 4142 to 4175 for ADHD and 6835 to 6880 non-ADHD controls (Lee et al., 2011). Children with ADHD were at higher risk for disorders of abuse or dependence for nicotine, alcohol, marijuana, cocaine, and other unspecified substances. Another meta-analysis (42 studies totaling 2360 participants) showed that medications for ADHD reduced the ADHD-associated risk for smoking (Schoenfelder et al., 2014). The authors concluded that, for ADHD patients, “Consistent stimulant treatment for ADHD may reduce the risk of smoking”. This finding is especially notable given that, for ADHD youth, cigarette smoking is a gateway drug to more serious addictions (Biederman et al., 2006).
Yes, ADHD is a serious disorder. Although most ADHD people will be spared the worst of these outcomes, they must be considered by parents and patients when weighing the pros and cons of treatment options.
REFERENCES
Bayar, H., Coskun, E., Oner, V., Gokcen, C., Aksoy, U., Okumus, S. & Erbagci, I. (2015). Association between penetrating eye injuries and attention deficit hyperactivity disorder in children. Br J Ophthalmol 99, 1109-11.
Biederman, J., Monuteaux, M., Mick, E., Wilens, T., Fontanella, J., Poetzl, K. M., Kirk, T., Masse, J. & Faraone, S. V. (2006). Is cigarette smoking a gateway drug to subsequent alcohol and illicit drug use disorders? A controlled study of youths with and without ADHD. Biol Psychiatry 59, 258-64.
Cortese, S., Moreira-Maia, C. R., St Fleur, D., Morcillo-Penalver, C., Rohde, L. A. & Faraone, S. V. (2015). Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. Am J Psychiatry, appiajp201515020266.
Dalsgaard, S., Leckman, J. F., Mortensen, P. B., Nielsen, H. S. & Simonsen, M. (2015a). Effect of drugs on the risk of injuries in children with attention deficit hyperactivity disorder: a prospective cohort study. Lancet Psychiatry 2, 702-9.
Dalsgaard, S., Ostergaard, S. D., Leckman, J. F., Mortensen, P. B. & Pedersen, M. G. (2015b). Mortality in children, adolescents, and adults with attention deficit hyperactivity disorder: a nationwide cohort study. Lancet 385, 2190-6.
DiScala, C., Lescohier, I., Barthel, M. & Li, G. (1998). Injuries to children with attention deficit hyperactivity disorder. Pediatrics 102, 1415-21.
Faraone, S. V., Asherson, P., Banaschewski, T., Biederman, J., Buitelaar, J. K., Ramos-Quiroga, J. A., Rohde, L. A., Sonuga-Barke, E. J. S., Tannock, R. & Franke, B. (2015). Attention deficit hyperactivity disorder. In Nature Reviews: Disease Primers.
Fritz, K. M. & Butz, C. (2007). Attention Deficit/Hyperactivity Disorder and pediatric burn injury: important considerations regarding premorbid risk. Curr Opin Pediatr 19, 565-9.
Hurtig, T., Ebeling, H., Jokelainen, J., Koivumaa-Honkanen, H. & Taanila, A. (2013). The Association Between Hospital-Treated Injuries and ADHD Symptoms in Childhood and Adolescence: A Follow-Up Study in the Northern Finland Birth Cohort 1986. J Atten Disord.
Lee, S. S., Humphreys, K. L., Flory, K., Liu, R. & Glass, K. (2011). Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review. Clin Psychol Rev 31, 328-41.
Sabuncuoglu, O. (2007). Traumatic dental injuries and attention-deficit/hyperactivity disorder: is there a link? Dent Traumatol 23, 137-42.
Schoenfelder, E. N., Faraone, S. V. & Kollins, S. H. (2014). Stimulant treatment of ADHD and cigarette smoking: a meta-analysis. Pediatrics 133, 1070-1080.
