Role of Neuropsychological Assessment in ADHD

Jan 2, 2020 | Research Updates

Role of Neuropsychological Assessment in ADHD

Kevin Antshel, Ph.D.
Professor of Psychology
Director of Clinical Psychology doctoral program
ADHD Lifespan Treatment, Education and Research (ALTER) program
Syracuse University

The role of neuropsychology in the assessment of ADHD is a controversial topic and one that generates considerable discourse on both sides of the argument. On the one hand, psychological assessment is often required by standardized testing agencies and universities for ADHD test accommodation determinations under the Americans with Disabilities Act (ADA). On the other hand, some in the field, most notably Russell Barkley, believe that such testing is not useful for diagnosing ADHD.

While supporting the use of IQ and academic achievement measures, Barkley is opposed to the use of performance based tests of executive functioning (EF) in diagnostic evaluations and suggests that the incremental validity of such tests (e.g., continuous performance tests) is quite low, largely due to high false negative classification rates, inability to differentiate diagnoses among disorders and the ease with which such tests can be feigned. In its’ place, Barkley asserts that EF rating scales are more useful, ecologically valid and cost-effective and should be used instead of EF tests. ADHD diagnostic practice parameters from several associations seem to agree with Barkley and either consider neuropsychological tests optional (American Academy of Child and Adolescent Psychiatry) or make no comment on their use (American Academy of Pediatrics).

Others1 believe that EF tests can make contributions to a comprehensive ADHD assessment. For example, neuropsychological tests could provide information about potential treatment targets (e.g., working memory predicts to reading and math attainment) and treatment approaches (e.g., poor EF response inhibition task performance predicts to better methylphenidate response). Factor scores or poor performance on a certain number of EF tasks seems to be a better predictor than single EF tasks. Others believe that performance-based tests and EF rating scales are both important to include as they provide different types of complementary information (EF tests: efficiency of cognitive abilities; EF rating scales: success in goal pursuit) and are weakly correlated (r=.19)2. Anecdotally, I have heard clinicians report that neuropsychological testing can be helpful to specify the ADHD phenotype, decipher some differential diagnoses, guide families and provide valuable information for interventions.

These diverging opinions leave the practicing clinician in a quandary. Given the clear public health, policy and educational implications of this conversation, my colleagues Russell Barkley, Mark Mahone and Russell Schachar and I will be discussing this issue at the APSARD conference. Please join us for continued conversation on this topic at our Lunch Session and Discussion Group on Sunday, January 19th from 12:30 – 2:30 PM. We hope to provide a thoughtful, balanced discussion of this important topic and welcome the input of others who have an interest in the role of neuropsychology in the assessment of ADHD!

1 Molitor, S.J., & Langberg, J.M. (2017). Using task performance to inform treatment planning for
youth with ADHD: A systematic review. Clinical Psychology Review, 58, 157-173.

2 Toplak, M. E., West, R. F., & Stanovich, K. E. (2013). Practitioner review: Do performance-
based measures and ratings of executive function assess the same construct? Journal of Child Psychology and Psychiatry, 54, 113–224.

NIMH Funded Web Portal That Helps Providers Implement the New ADHD Guideline

Dec 19, 2019 | Research Updates

NIMH Funded Web Portal That Helps Providers Implement the New ADHD Guideline

The mehealth portal is now available online at www.mehealth.com to pediatric providers, parents and educators working to improve quality of care for people with ADHD. Funded by a four-year, $2.8 million NIMH grant through the Cincinnati Children’s Hospital Medical Center, mehealth is free to users until 2021. Designed as a web-interface to deliver screening and treatment information, the newest updates to the portal incorporate the American Academy of Pediatrics’ (AAP) recently released and updated ADHD clinical practice guidelines, and are designed to help improve evidence-based care delivery in community settings.

In a 2016 trial, tested at 50 community-based pediatrics practices involving 199 physicians and 577 children with ADHD, use of mehealth resulted in improved ADHD medication treatment, and significant behavioral improvement over standard care.  The expanded and improved mehealth system has been now allows parents and teachers to develop and implement behavioral treatments as an important piece of integrative care.

During this next year, the mehealth team will be working with an advisory committee improve the portal’s effectiveness, and to work on making the technology available at no cost beyond the 2021 deadline.

Epstein JN, Langberg JM, Lichtenstein PK, Kolb R, Altaye M, Simon JO. Use of an Internet portal to improve community-based pediatric ADHD care: a cluster randomized trial. Pediatrics. 2011;128(5):e1201-e1208.

Do Some Foods Cause ADHD? Does Dieting Help?

Nov 19, 2019 | Research Updates

If we are to read what we believe on the Internet, dieting can cure many of the ills faced by humans. Much of what is written is true. Changes in dieting can be good for heart disease, diabetes, high blood pressure and kidney stones to name just a few examples. But what about ADHD? Food elimination diets have been extensively studied for their ability to treat ADHD. They are based on the very reasonable idea that allergies or toxic reactions to foods can have effects on the brain and could lead to ADHD symptoms. Although the idea is reasonable, it is not such an easy task to figure out what foods might cause allergic reactions that could lead to ADHD symptoms. Some proponents of elimination diets have proposed eliminating a single food, others include multiple foods and some go as far to allow only a few foods to be eaten so as to avoid all potential allergies. Most readers will wonder if such restrictive diets, even if they did work, are feasible. That is certainly a concern for very restrictive diets.

Perhaps the most well-known ADHD diet is the Feingold diet (named after its creator). This diet eliminates artificial food colorings and preservatives that have become so common in the western diet. Some have claimed that the increasing use of colorings and preservatives explains why the prevalence of ADHD is greater in Western countries and has been increasing over time. But those people have it wrong. The prevalence of ADHD is similar around the world and has not been increasing over time. That has been well documented but details must wait for another blog.

The Feingold and other elimination diets have been studied by meta-analysis. This means that someone analyzed several well controlled trials published by other people. Passing the test of meta-analysis is the strongest test of any treatment effect. When this test is applied to the best studies available, there is evidence that exclusion of fool colorings helps reduce ADHD symptoms. But more restrictive diets are not effective. So removing artificial food colors seems like a good idea that will help reduce ADHD symptoms. But although such diets ‘work’, they don’t work very well. On a scale of one to 10 where 10 is the best effect, drug therapy scores 9 to 10 but eliminating food colorings scores only 3 or 4. Some patients or parents of patients might want to this diet change first in the hopes that it will work well for them. That is a possibility, but if that is your choice, you should not delay the more effective drug treatments for too long in the likely event that liminating food colorings is not sufficient. You can learn more about elimination diets from: Nigg, J. T. and K. Holton (2014). “Restriction and elimination diets in ADHD treatment.” Child Adolesc Psychiatr Clin N Am 23(4): 937-953.

Keep in mind that the treatment guidelines from professional organization point to ADHD drugs as the first line treatment for ADHD. The only exception is for preschool children where medication is only the first line treatment for severe ADHD; the guidelines recommend that other preschoolers with ADHD be treated with non-pharmacologic treatments, when available. You can learn more about non-pharmacologic treatments for ADHD from a book I recently edited: Faraone, S. V. & Antshel, K. M. (2014). ADHD: Non-Pharmacologic Interventions. Child Adolesc Psychiatr Clin N Am 23, xiii-xiv.

How do undiagnosed but symptomatic adults compare with those diagnosed with ADHD?

Aug 28, 2019 | Research Updates

BLOG POSTING BY:

Stephen Faraone, Ph.D. SUNY Upstate Medical University

The study team began with a representative sample of 69,972 U.S. adults aged 18 years or older who completed the 2012 and 2013 U.S. National Health and Wellness Survey. These adults were invited to complete the Validate Attitudes and Lifestyle Issues in Depression, ADHD and Troubles with Eating (VALIDATE) study, which included 1) a customized questionnaire designed to collect data on sociodemographic and clinical characteristics and lifestyle, and 2) several validated work productivity, daily functioning, self-esteem, and health-related quality of life (HRQoL) questionnaires. Of the 22,937 respondents, 444 had been previously diagnosed with ADHD, and 1,055 reported ADHD-like symptoms but had no previous clinical diagnosis.

There were no significant differences between the two groups in terms of age, education, income, health insurance, and most comorbid disorders. But those who had not been previously diagnosed were significantly more likely to be first-generation Americans (p<.001), nonwhite (p<.001), unemployed (p=.024), or suffer from depression, insomnia, or hypertension.

After matching the two groups for sociodemographic characteristics and comorbid conditions, covariate comparisons were made between 436 respondents diagnosed with ADHD and 867 previously undiagnosed respondents. Among respondents who were employed, diagnosed individuals registered a mean work productivity loss of 29% as opposed to 49% for the previously undiagnosed (p<.001). They also registered a 37% level of activity impairment versus a 53% level among the undiagnosed (p<.001). On the Sheehan Disability Scale, which ranges from 0 (no impairment) to 30 (highly impaired), the diagnosed group had a mean of 10, as opposed to a mean of 15 for the undiagnosed (p<.001). Diagnosed respondents also significantly outperformed undiagnosed ones on the Rosenberg Self-Esteem Scale (19 versus 15, on a scale of 0 to 30, p<.001), and on two quality-of-life scales (p<.001).

Applying a linear regression mixed model to the matched sets, the diagnosed still scored 16 points better than the undiagnosed on the WPAI:GH Productivity Loss scale (p<.001), 14 points better on the WPAI:GH Activity Impairment scale (p<.001), 4.5 points better on the Sheehan Disability Scale (p<.001), almost 4 points on the Rosenberg Self-Esteem Scale (p<.0001), with comparable gains on the two quality-of-life scales (p<.001 and p<.0001).

The authors concluded, “This comparison revealed that individuals who had been diagnosed with ADHD were more likely to experience better functioning, HRQoL [health related quality-of-life], and self-esteem than those with symptomatic ADHD. This result appears to be robust, withstanding several levels of increasingly rigorous statistical adjustment.” That points to substantial benefits from the treatment that follows diagnosis of adult ADHD.

Complementary and Integrative Health Approaches to ADHD Treatment

Apr 26, 2019 | Research Updates

Beth Krone, Ph.D. and Jessica Downes J.D.

The National Center for Complementary and Integrative Health (NCCIH) at the NIH places health and mental health products and practices in the context of rigorous science for reference of the public and professionals. Their April digest focused on non-pharmaceutical approaches to ADHD management, at https://nccih.nih.gov/health/providers/digest/adhd, and https://nccih.nih.gov/health/providers/digest/adhd-science. Here is an infographic of their findings for your reference:

* Center for Evidence-Based Medicine

The FASE Study: Best Treatment of Delayed Sleep Phase Syndrome in Adult ADHD

Apr 26, 2019 | Research Updates

As an on-going feature of our blog forum, we invite members to submit brief write-ups about their current work and the programs they have to offer. In this spirit, we are happy to highlight an ongoing study of our colleagues in the Netherlands: Dr. Sandra Kooij, Dr. Denise Bijlenga, Dr. Suzan Vogel, and Dr. Emma van Andel at PsyQ Expertise Center Adult ADHD in The Hague, and prof. Dr. Aartjan Beekman at GGZ inGeest, Amsterdam UMC, VUmc, The Netherlands

The FASE Study: Best Treatment of Delayed Sleep Phase Syndrome in Adult ADHD
Dr. Emma van Andel, junior researcher at PsyQ Expertise Center Adult ADHD, The Hague, The Netherlands

Sleep problems are highly prevalent among adults with ADHD, of whom 78% in some samples suffer from Delayed Sleep Phase Syndrome (DSPS) [1,2]. Such sleep problems are often a source of worry and frustration for patients and can also aggravate ADHD symptoms. Sleep loss resulting from DSPS has been associated with increased risk of chronic diseases such as obesity, diabetes, hypertension, metabolic syndrome, cardiovascular disease, and even cancer [3,4]. ADHD has also been related to poorer health in some samples [5,6]. Even young and generally healthy people who suffer from both ADHD and DSPS may thus be at great risk to develop these chronic diseases.

The FASE study investigates whether this is indeed the case and if treatment focused specifically on DSPS can improve sleep, ADHD, and health. DSPS can be treated with sleep education, melatonin administration, and/or light therapy: relatively inexpensive and convenient interventions that may increase people’s well-being and perhaps lower the need for (high doses of) ADHD medication.

The FASE study offers 3 weeks of DSPS treatment to 51 adults (18-55y) with ADHD and DSPS. Treatment consists of sleep education plus either (1) melatonin, (2) placebo, or (3) melatonin and light therapy. A broad range of health variables is assessed at baseline, directly after treatment, and 2 weeks later.

This group of adults with ADHD and DSPS is expected to display a suboptimal health profile at baseline and improvements in sleep, ADHD symptoms, and physical as well as mental health after treatment. Preliminary baseline results already suggest suboptimal health outcomes at baseline. Inclusion is nearly complete, so the first results on the effects of the interventions are expected this summer.

The FASE study will give more insight into the relationship between ADHD and DSPS and their relation to health. It also evaluates which DSPS treatment can best improve people’s well-being and decrease their risk of developing chronic diseases.
More information about the FASE study can be found at https://www.trialregister.nl/trial/3831.

References

ADHD and DSPS
1. Van Veen et al., 2010: https://www.ncbi.nlm.nih.gov/pubmed/20163790
2. Bijlenga et al., 2019: https://www.ncbi.nlm.nih.gov/pubmed/30927228

Sleep loss and physical health
3. Knutson et al., 2010: https://www.ncbi.nlm.nih.gov/pubmed/21112022
4. Spiegel et al., 2005: https://www.ncbi.nlm.nih.gov/pubmed/16227462

ADHD and physical health
5. Instanes et al., 2016: https://www.ncbi.nlm.nih.gov/pubmed/27664125
6. Vogel et al., 2018: https://www.ncbi.nlm.nih.gov/pubmed/29940457