Sep 2, 2016 | Research Updates
Commentary by Dr. Margaret Weiss*: The gold standard for evaluation of outcome of working memory has to target real life improvement in those areas that are impaired.
Working Memory Training in Post-Secondary Students with ADHD: A Randomized Controlled Study
Mawjee K, Woltering S, Tannock R. PLoS One. 2015 Sep 23;10(9):e0137173
Abstract
Objectives: To determine whether standard-length computerized training enhances working memory (WM), transfers to other cognitive domains and shows sustained effects, when controlling for motivation, engagement, and expectancy.
Methods: 97 post-secondary students (59.8% female) aged 18-35 years with AttentionDeficit/Hyperactivity Disorder, were randomized into standard-length adaptive Cogmed WM training (CWMT; 45-min/session), a shortened-length adaptive version of CWMT (15 min/session) that controlled for motivation, engagement and expectancy of change, or into a no training group (waitlist-control group). All three groups received weekly telephone calls from trained coaches, who supervised the CWMT and were independent from the research team. All were evaluated before and 3 weeks post-training; those in the two CWMT groups were also assessed 3 months post-training. Untrained outcome measures of WM included the WAIS-IV Digit Span (auditory-verbal WM), CANTAB Spatial Span (visual-spatial WM) and WRAML Finger Windows (visual-spatial WM). Transfer-of-training effects included measures of short-term memory, cognitive speed, math and reading fluency, complex reasoning, and ADHD symptoms.
Results: Performance on 5/7 criterion measures indicated that shortened-length CWMT conferred as much benefit on WM performance as did standard-length training, with both CWMT groups improving more than the waitlist-control group. Only 2 of these findings remained robust after correcting for multiple comparisons. Follow-up analyses revealed that post-training improvements on WM performance were maintained for at least three months. There was no evidence of any transfer effects but the standard-length group showed improvement in task-specific strategy use.
Conclusions: This study failed to find robust evidence of benefits of standard-length CWMT for improving WM in college students with ADHD and the overall pattern of findings raise questions about the specificity of training effects.
The Highlighted Commentary can be viewed here.
Sep 2, 2016 | Research Updates
*Commentary by Dr. Margaret Weiss*: Empirical support for a much needed intervention!
A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents
Sprich, S. E., Safren, S. A., Finkelstein, D., Remmert, J. E. and Hammerness, P. Journal of Child Psychology and Psychiatry. (2016)
Abstract
Objective: To test cognitive behavioral therapy (CBT) for persistent attentiondeficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents.
Methods: Forty-six adolescents (ages 14–18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT). Trial Registration
Results: Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: −12.93, −8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: −7.21, −3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: −1.39, −.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report.
Conclusions: This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.
The Highlighted Commentary can be viewed here.
Sep 2, 2016 | Research Updates
Commentary by Dr. Margaret Weiss*: Like Strongest Families this innovative intervention has the potential to provide direct access to instruction on management of ADHD in the classroom where that expertise does not otherwise exist. Intervention with the teacher has a powerful impact on the life of the child.
Web-Based Intervention for Teachers of Elementary Students With ADHD: Randomized Controlled Trial: Corkum P, Elik N, Blotnicky-Gallant PA, McGonnell M, McGrath P. J Atten Disord. 2015 Sep 11. pii: 1087054715603198
Abstract
Objective: To test the acceptability, satisfaction, and effectiveness of a web-based intervention for teachers of elementary school-aged children with ADHD.
Method: Elementary classroom teachers (N = 58), along with their students with ADHD, participated in a randomized controlled trial. The program consisted of six sessions that included evidence-based intervention strategies for reducing ADHD symptoms and impairment in the classroom setting. Teachers also had access to a moderated Discussion Board and an online ADHD coach. Questionnaire data were electronically collected from teachers and parents pre-intervention, post-intervention (6 weeks), and after an additional 6-week follow-up.
Results: Intent-to-treat analyses found significant improvements based on teacher (but not parent) reports of core ADHD symptoms and impairment for the Teacher Help for ADHD treatment group. Teachers reported a high level of acceptability and satisfaction.
Conclusion: Web-based ADHD interventions have the potential to reduce the barriers to treatment utilization and implementation that are common problems for school-based ADHD interventions.
The Highlighted Commentary can be viewed here.
Aug 25, 2016 | Research Updates
Roberta Waite , EdD, PMHCNS-BC, FAAN, ANEF Professor and Assistant Dean of Academic Integration and Evaluation of Community Programs, Doctoral Nursing Department
By Roberta Waite and Meghan S. Leahy
Despite the availability of helpful and competent protocols for assessing and diagnosing ADHD in children, adolescents, and adults, there are many prevailing factors that make this job a difficult one. An accurate diagnosis of ADHD (or identifying a different condition causing “attention deficits”) matters because it is an essential step towards
obtaining effective treatment, of which there are several options available for ADHD. Hamed, Kauer, and Stevens (2015) conducted a systematic literature review examining the factors contributing to the misdiagnosis of ADHD (in either direction) and its downstream effects on treatment and outcome in the lives and treatment of children and adults suffering from ADHD, their families, and the community. We offer key insights from the article related to the diagnosis of ADHD, and explore what the research says, how it influences and aligns with reality, and what next steps are required to ensure that the process of attaining an accurate ADHD diagnosis is inclusive to a broader population.
ADHD does not discriminate; nevertheless, people are recognized and treated selectively. It impacts individuals across the life span and those of different racial and ethnic as well as cultural backgrounds. While it is estimated that 5-11% of children are affected by ADHD nationwide, approximately 4-5.9% of adults are affected by ADHD, in all age groups. When left untreated, ADHD often has myriad adverse consequences with factors such as: academic achievement, family relationships, substance use and dependence, financial viability, sustained employment, criminal behavior, and increased risks for comorbidity and mortality.
Meghan S. Leahy, MS, NCC Founder of Leahy Learning
What does this research mean in the reality of clinical practice? An accurate ADHD diagnosis has the potential to be life changing in many ways. Awareness of the
condition and its effects by itself permits patients to reframe their beliefs regarding themselves and the ongoing challenges they
have had to face. However, re-conceptualizing this new information is done through the lens of cultural factors which shape a person’s way of knowing; for members of under-represented groups, this view can differ from a dominant culture’s framework as it relates to mental health concerns, including how behaviors and “symptoms” essential to making the diagnosis are understood and communicated by patients.
Understanding the cultural and contextual factors that play a role in the assessment and treatment of ADHD is important since ways of knowing (i.e., universal understanding) about psychiatry and psychology for members of under-represented groups have historically been viewed as being embedded in larger ideologies, systems, and practices that may be viewed as inequitable at best, if not oppressive and outright discriminatory, at worst. Eliciting and understanding this frame of reference is required if we desire to accurately identify and provide treatment evenhandedly to all who have ADHD.
Hamed and colleagues highlight the importance of this charge when they argue that “The validity and accuracy of ADHD as a diagnosis is still questioned by some groups…one feature of ADHD diagnosis at issue is that it may be easily biased and lacks standardization, which is in part due to the subjectivity in evaluating children with ADHD.” Moreover, the authors contend that the decision regarding threshold for defining symptoms and/or impairment such that they warrant medical attention is viewed as subjective in nature.
Hamed and colleagues also identify the differences in viewpoints that exist among parents in diverse populations in regards to their children’s behaviors, including the cultural perceptions of other persons who constitute a child’s support network, including extended family and wider community. For example, the diagnosis of ADHD may be viewed as a means for creating business for both medical professionals and pharmaceutical companies, or that impulsive and hyperactive behaviors that are deemed “symptoms” by professionals, are considered “normal” (particularly for males) within a community. Research has consistently reported that greater numbers of Caucasians compared to Hispanics and African Americans are diagnosed with ADHD, but the Hamed et al. article raises the question of what are the additional factors behind this disparity? The answer is important because some of these children (or teens or adults) may actually have ADHD and their lives and the lives of their families may benefit from effective treatment.
In order to effect change in reality, what do researchers and clinicians need to do next? The article concludes that, “Strong partnerships between clinicians and patients with ADHD may be the best way to reduce the negative impacts of the disorder.” For this to happen, next steps should include:
- Support for more diverse and inclusive evidence-based research. This will occur through culturally responsive investigations using decolonizing, indigenous epistemologies, and research methodologies. Decolonizing frameworks and methods are particularly salient when learning more about persons from groups who have traditionally been colonized or who presently encounter institutionalized and systemic discrimination and oppression. These broader approaches will benefit ADHD research and produce a more inclusive and representative body of knowledge.
- Educators and practitioners working with persons affected by ADHD should assess their philosophies of practice and education. Integration of a culturally sensitive awareness of individual biases (that we all have), with a focus on recognizing that patients from under represented communities (be it ethnic, racial, sexual, religious, etc.) may have experienced oppression, discrimination, and outright bigotry when dealing with mainstream institutions, such as medicine. These skills also represent sophisticated clinical practice and education in terms of cultivating a more responsive, effective, and equitable manner of learning and providing care within a system that fundamentally embodies Eurocentric principles.
- Meaningful partnerships are needed with families and professionals working with and providing care for persons affected by ADHD to support social justice efforts that encourage access to culturally relevant services and shared decision-making among various ADHD stakeholders.
Bermudez, J., Muruthi, B. & Jordan, L. (2016). Decolonizing research methods for family science: Creating space at the center. Journal of Family Theory & Review, 8(2), 192–206.
Fernando, S. (2014). Race and culture in psychiatry. Routledge. Retrieved from https://books.google.com/books?isbn=1317557689
Hamed, A. M., Kauer, A. J., & Stevens, H. E. (2015). Why the diagnosis of attention deficit hyperactivity disorder matters. Frontiers in Psychiatry, 6(168), 1-10. doi:10.3389/fpsyt.2015.00168
Kessler, R. C. , Adler, L. , Barkley, R., Biederman, J. , Conners, C. K… Zaslavsky, A. M. (2006). The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. American Journal of Psychiatry 163, 716 -723.
Kuja‐Halkola, R., Lichtenstein, P., D’Onofrio, B. M., & Larsson, H. (2015). Codevelopment of ADHD and externalizing behavior from childhood to adulthood. Journal of Child Psychology and Psychiatry, 56(6), 640-647. doi:10.1111/jcpp.12340
Russell, A. E., Ford, T., & Russell, G. (2015). Socioeconomic associations with ADHD: Findings from a mediation analysis. PLoS One, 10(6) doi:http://dx.doi.org/10.1371/journal.pone.0128248
Aug 25, 2016 | Research Updates
Stephen V Faraone, Ph. D Director of Medical Genetics Research and Professor in theDepartments of Psychiatry and Neuroscience & Physiology at SUNY Upstate Medical University
We know from many studies that ADHD is associated with a slightly lower intelligence quotient (IQ) and with problems in thinking known as executive function deficits. If that’s that case, you might think that people with a high IQ cannot have ADHD. You would be wrong. Data on groups sometimes mislead us about individuals. Although, on average, ADHD people have IQ scores that are about 9 points lower than others, there is a wide spread of IQs in both ADHD and non-ADHD people. So many people with ADHD have higher IQs than those without ADHD and vice-versa. Moreover, studies of people with high IQs support the idea that ADHD can be validly diagnosed among very intelligent individuals.
In a series of studies using the, Antshel and colleagues showed that the clinical profile of high IQ ADHD was very similar to what has been observed for ADHD in general. For example, like their less intelligent counterparts, high IQ ADHD children have an increased risk for mood, anxiety and disruptive behavior disorders. Children with a high IQ and ADHD showed a pattern of familial transmission as well as cognitive, psychiatric and behavioral impairments consistent with the diagnosis of ADHD. The degree to which ADHD persisted into adulthood was also similar between the two groups.
In studies of adults with ADHD, the same group concluded that “adults with ADHD and a high IQ display patterns of functional impairments, familiality and psychiatric co-morbidities that parallel those found in the average-IQ adult ADHD population.” Of particular interest, despite their high intelligence, High-IQ adults with ADHD show impaired executive functioning and their performance on tests of executive functioning predicted life impairments.
Why are these data important? Milioni and colleagues argue that among higher IQ adults with ADHD, a higher degree of intellectual efficiency may compensate for deficits in executive functions. This ability to compensate allows them to succeed in many tasks which otherwise might have been impaired by their ADHD symptoms. But, in many cases, such compensation is not sufficient or is too burdensome. When compensation fails, ADHD symptoms and other impairments emerge. When this occurs later in life, some clinicians are reluctant to diagnose ADHD. Caution is warranted, but clinicians need to know that the diagnosis of ADHD among high IQ is valid.
References:
Antshel, K. M., S. V. Faraone, et al. (2008). “Temporal stability of ADHD in the high-IQ population: results from the MGH Longitudinal Family Studies of ADHD.” J Am Acad Child Adolesc Psychiatry 47(7): 817-825.
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.
Mar 31, 2016 | Research Updates
ADHD and Negative Thinking
Cognitive-behavioral therapy (CBT) is a psychosocial treatment that has been adapted for use with adults with ADHD. Numerous clinical outcome studies, including several randomized trials comparing Cognitive Behavioral Therapy (CBT) with active control treatments have yielded positive results, often in combination with ADHD medications.
A common element in most CBT approaches for adult ADHD is the focus on behavioral skills training. ADHD is an implementation problem inasmuch as individuals describe being aware of what needs to be done to manage the effects of ADHD (not to mention other areas of life) but yet have difficulties consistently and effectively performing these skills. In fact, there has been some question as to whether the cognitive element of CBT – identifying and modifying maladaptive thoughts – is really essential in the treatment of adult ADHD apart from their relevance in cases of co-existing anxiety and depression.
However, several recent studies have started to identify the unique impact of negative thinking on adults with ADHD. These studies have illustrated that dysfunctional attitudes and cognitive-behavioral avoidance overlapped to contribute to co-existing depression and depressive symptoms1, are more prominent in cases of ADHD and co-existing depression but are also more prominent in cases of uncomplicated ADHD when compared to controls2, and uncomplicated ADHD was associated with higher levels of intrusive and worrisome thoughts when compared with controls3.
More recently, a chart review study of 44 adults assessed the correlation of ADHD with measures of self-reported distorted thoughts, depression, anxiety, and hopelessness4. A significant, positive correlation between distorted thoughts and a measure of ADHD was obtained; there was no correlation between ADHD and depression, anxiety, or hopelessness. Review of the most frequently endorsed categories of cognitive distortions indicated that “Perfectionism” (55%) was far and away the most frequently endorsed, followed by “Emotional Reasoning and Decision-Making” (17.5%, “Comparison to Others” and “Emotional Reasoning” (both 7.5%).
The combinations of findings indicate that the cognitive component of CBT is still relevant in helping adults with ADHD to better implement various effective behavioral coping strategies in their daily lives. The aforementioned distortions play a role in the cognitive-behavioral avoidance identified in the various other studies of negative thoughts and adult ADHD. Distorted cognitions are central to procrastination, emotional management, problem-solving, and various other coping domains commonly targeted in psychosocial treatment. Thus, although the implementation of behavioral skills in order to improve overall functional status and well-being are an important outcome of CBT for adult ADHD, it is increasingly appreciated that cognitive interventions play a central role in achieving these outcomes.
1 Knouse, L. E., Zvorsky, I., & Safren, S. A. (2013). Depression in adults with attention-deficit/hyperactivity disorder (ADHD): The mediating role of cognitive-behavioral factors. Cognitive Therapy & Research. 37, 1220-1232. doi: 10.1007/s10608-013-9569-5
2 Mitchell, J. T., Benson, J. W., Knouse, L. E., Kimbrel, N. A., & Anastopoulous, A. D. (2013). Are negative automatic thoughts associated with ADHD in adulthood? Cognitive Therapy and Research, 37, 851-859. doi: 10.1007/s10608-013-9525-4
3 Abramovitch, A., & Schweiger, A. (2009). Unwanted intrusive and worrisome thoughts in adults with Attention Deficit/Hyperactivity Disorder. Psychiatry Research, 168, 230-233. doi:10.1016/j.psychres.2008.06.004
4 Strohmeier, C., Rosenfield, B., DiTomasso, R.A., & Ramsay, J. R. (2016). Assessment of the relationship between cognitive distortions, adult ADHD, anxiety, depression, and hopelessness. Psychiatry Research, 238, 153-158. doi: 10.1016/j.psychres.2016.02.034
