Jul 10, 2017 | Research Updates
Margaret Weiss, M.D., Ph.D.
Director, Child and Adolescent Psychiatry
University of Arkansas Medical Sciences
A recent Special Communication in JAMA Pediatrics (Bui, Dieleman, Hamavid, & et al., 2017) noted that spending in child health has continued to rise by 56.2% between 1996 and 2013. The largest health condition leading to health care spending for children was well-newborn care in the inpatient setting. It came as somewhat of a surprise to learn that ADHD was the second largest source of spending increase was ADHD. 63.9% of this was on ambulatory care and 35.4% on retail pharmaceuticals. ADHD care in 2013 cost 20.6 billion, or $240 per child or .13 of the GDP. Increased spending on mental health caused 24.8% of the increase in overall child health spending, and within this increase in ADHD pharmaceutical spending was the largest source of spending increases. This project is the most sophisticated attempt to aggregate health care spending by condition as well as age, gender and type of care.
The prevalence of ADHD in this age group has remained stable, although it is possible that there is improved access to care, especially for girls or children with predominant attention problems. Nonetheless, these data challenge us to determine whether we are spending our health care dollars for ADHD treatment optimally and whether this growth in spending has been matched by a comparable increase in child well-being, outcomes, and adult outcomes.
Bui, A. L., Dieleman, J. L., Hamavid, H., & et al. (2017). Spending on children’s personal health care in the united states, 1996-2013. JAMA Pediatrics, 171(2), 181-189. doi:10.1001/jamapediatrics.2016.4086
Jul 10, 2017 | Research Updates
Margaret Weiss, M.D., Ph.D.
Director, Child and Adolescent Psychiatry
University of Arkansas Medical Sciences
Our practice guidelines, text books, journals and drug labels tell us a great deal about the diagnostic indications for use of medications, how long to maintain them, and how to start them. However, there are few if any protocols to guide clinicians as to how and when to reassess when medications are still needed, to guide discontinuation strategies, or to distinguish withdrawal effects from true return of symptoms.
This is a clinical concern. Children may be started on medication during a difficult period, and then maintained on the drug because ‘it worked when we started it’ and ‘they get worse when it is stopped’. Patients do not distinguish acute rebound after abrupt discontinuation of medication from a true off-medication baseline. Children are admitted to our inpatient unit, often on many different medications and off label, and provided a medication ‘washout’, but we have no guidance as to how sequence or pace medication discontinuations. Patients who have been maintained on the same drugs for long periods of time may be receiving their follow up care in primary care clinics or walk in clinics where the time, effort, education and care needed to undergo a change in medication are not routinely attended to.
Quite simply, it is easier to start drugs than stop them. We need to put as much care into the development of reassessment procedures, discontinuation protocols and careful and systematic re-evaluation for ongoing need for medication as we do into starting medications. This is most especially true where polypharmacy has become so extensive that it is difficult to evaluate any unique medication outcome or the patient’s true current baseline.
May 21, 2017 | Research Updates
Blog by Roberta Waite EdD, MSN, RN and Meghan Leahy MS, NCC
Roberta Waite, EdD
Drexel University
Research suggests that college students with ADHD are more likely to fail and have to repeat classes, have lower grade point averages, and leave college before obtaining a degree in comparison to students without ADHD (Advokat, Lane, & Luo 2011; Antshel et al. 2011; DuPaul et al. 2009). In January each year, clinical practices see an influx of college students with ADHD, specifically freshman who struggled during their first semester, including being placed on academic probation.
Very often, the students and their parents are shocked by the poor performance in the first semester. These students were generally successful in high school, scored well on standardized tests, and were expected to continue along the same trajectory in their post-secondary career. In meeting with these clients, it becomes apparent that their understanding of course content is not the problem. The main complaints include: inability to focus in the classroom, trouble with taking notes, difficulty handing in assignments on time, being repeatedly absent or late for class, lack of time management skills, and an inability and/or reluctance to ask for help. Said differently, the experience of college students with ADHD is characteristic of ADHD being a performance problem and not a knowledge problem.
Meghan Leahy, M.S.
Leahy Learning
This makes sense as studies have shown that students with ADHD can encounter problems with executive functions, for example, organizing and planning, time management, working memory, cognitive flexibility and inhibition (Barkley & Murphy 2011; Reaser et al. 2007). Second, students with ADHD have difficulties with sustained and focused attention, with carrying out tasks and experience frequent daydreaming, hyperactivity and impulsivity (Weyandt & DuPaul 2008). Finally, students with ADHD can struggle with other problems, for instance, difficulties with selecting main ideas and prioritizing, social functioning, as well as motor coordination (Reaser et al. 2007; Weyandt et al. 2013).
Overall, it is presumed that approximately 2–8% of all students in post-secondary education experience symptoms related to ADHD and at least 25% of college students with disabilities are diagnosed with ADHD (DuPaul et al. 2009). The Americans with Disabilities Act (ADA) mandates that colleges provide “reasonable accommodations” to those students with disabilities in order to provide them with access to education for which they are otherwise qualified. The domain of disabilities includes learning disabilities, which is the domain most relevant for students with ADHD (as the diagnosis of ADHD alone is not sufficient documentation, at least using the current ADA guidelines). Psychoeducational testing that documents the presence of a learning disability is necessary to justify the need for accommodations. The requirements for psychoeducational evaluations as part of a petition for accommodations in college are:
- Be conducted by an appropriately credentialed and qualified professional
- Be conducted within the past 3 years
- Be comprehensive including:
- a diagnostic interview
- measures of cognitive ability
- academic achievement
- Include recommendations for accommodations with a rationale based on the current needs and functional limitations of the individual
- Critical college entrance and placement exam accommodations may also require very specific justifications (e.g., exactly what increment of extra time is needed for exams and why) (Joyce & Grapin, 2012).
Students with ADHD are attending colleges and universities in growing numbers, yet funding for disability support services has been diminished on many campuses (DuPaul et al. 2009). Also, while there is extensive research determining how college students with ADHD struggle, there is a knowledge gap and lack of empirical evidence when it comes to knowing how effective the common accommodations actually are for these students and how often and how well students utilize them (Cawthon, Leppo, & Bond, 2015).
The typical scenario for applying for academic accommodations in colleges in the United States starts with students submitting their testing documentation to the campus Disability Office. Assuming that the documentation is approved as sufficient for documenting a disability, a Disability Office staff member meets with the student at the beginning of each semester to specify the accommodations that will be implemented. A letter is written to each of the student’s professors, informing them of the accommodations to which the student is entitled. Most often, the Disability Office will disseminate the information to faculty by e-mail, though on occasion students are expected to deliver letters to their professors. Subsequently, it is the student’s responsibility to follow up with the professor and to ensure any logistics to obtain the accommodations are in place (e.g. arranging for extended time can mean starting an exam early in a professor’s office, staying late in the classroom, or possibly having the test proctored in the Disability Office). Importantly, Titles II and III of the ADA delineate the scope of accommodations to which postsecondary students are permitted. Similar to Section 504 of the Rehabilitation Act of 1973, the ADA is a civil rights law and its Titles II and III pertain to schools that accept any type of federal funding, including universities, community colleges, and vocational schools (Becker & Palladino, 2016).
For many students who are away from home and their support system for the first time, following through with the multi-step process of utilizing accommodations may be overwhelming if they do not have the ability or confidence to self-advocate. If the student is already struggling with inattention and/or impulsivity, as well as various executive function issues, he or she may simply avoid the entire process. Others may meet with the Disability Office and obtain the letters, but never follow through with the professors to make use of the accommodations.
Ultimately, to help college students with ADHD be successful in the first year and beyond, it is important that they understand their own strengths and weaknesses, are prepared to self-advocate, are willing to ask for help, and develop strategies to support their executive function issues. Without these skills and strategies, reasonable accommodations alone will not ensure success.
Resources
Advokat, C., Lane, S., & Luo, C. (2011). College students with and without ADHD: comparison of self-report of medication usage, study habits, and academic achievement. Journal of Attention Disorders, 15(8), 656-66.
Antshel, K. Hargrave, T., Simonescu, M., Kaul, P., Hendricks, K. & Faraone, S. (2011). Advances in understanding and treating ADHD. BMC Medicine. Retrieved from https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-9-72
Barkley R. A. & Murphy K. R. (2011). The nature of executive function (EF) deficits in daily life activities in adults with ADHD and their relationship to performance on EF tests. Journal of Psychopathology and Behavioral Assessment, 33, 137-158.
Becker., S. & Palladino, J. (2016). Assessing faculty perspectives about teaching and working with students with disabilities. Journal of Postsecondary Education and Disability, 29(1), 65-82.
Cawthon, S. W., Leppo, R., Ge, J. J., & Bond, M. (2015). Accommodations use patterns in high school and postsecondary settings for students who are deaf or hard of hearing. American Annals of the Deaf, 160(1), 9-23.
DuPaul, G., Weyandt, L., O’Dell, S., & Varejao, M, (2009). College students with ADHD: Current status and future directions. Journal of Attention Disorders, 13(3), 234-250.
Gormley, M. J., DuPaul, G. J., Weyandt, L. L., & Anastopoulos, A. D. (2016). First-year GPA and academic service use among college students with and without ADHD. Journal of attention disorders, Online ahead of print. doi: 10.1177/1087054715623046
Jansen, D., Petry, K., Ceulemans, E., Van der Oord, S., Noens, I., & Baeyens, D. (2017). Functioning and participation problems of students with ADHD in higher education: which reasonable accommodations are effective? European Journal of Special Needs Education, 32(1), 35-53.
Joyce, D. & Grapin, S. (2012). Facilitating successful postsecondary transitions for students with disabilities, Communique, 41 (3), 20-24.
Prevatt, F. (2016). Coaching for college students with ADHD. Current Psychiatry Reports, 18(12), 110.
Quinn, Q. (2016). ADHD and the college student: The everything guide to your most urgent. Journal of the American Academy of Child and Adolescent Psychiatry, 55(1), 3.
Reaser, A., Prevatt, F., Petscher, Y., & Proctor, B. (2007). The learning and study strategies of college students with ADHD. Psychology in the Schools, 44(6), 627-638.
Weyandt, L., DuPaul, G. J., Verdi, G., Rossi, J. S., Swentosky, A. J., Vilardo, B. S., … & Carson, K. S. (2013). The performance of college students with and without ADHD: Neuropsychological, academic, and psychosocial functioning. Journal of Psychopathology and Behavioral Assessment, 35(4), 421-435.
Weyandt, L. L., & DuPaul, G. J. (2008). ADHD in college students: Developmental findings. Developmental disabilities research reviews, 14(4), 311-319.
May 15, 2017 | Research Updates
Stephen Faraone, Ph.D.
Professor of Psychiatry
SUNY Upstate Medical University
ADHD is a serious disorder that requires treatment to prevent many adverse outcomes. But, because the diagnosis of ADHD is based on how the patient responds to questions, it is possible for people to pretend that they have ADHD, when they do not. In fact, if you Google “fake ADHD” you’ll get many pages of links including a Psychology Today article on the topic and bloggers describing how they were able to fool doctors into giving them ADHD medications. Is fake ADHD a serious problem? Not really. The Internet it seems, is faking an epidemic of fake ADHD. I say that because we have decades of research that show many objective measures of abnormality and impairment in people who say they have ADHD. These include traffic accidents, abnormalities on brain imaging and molecular genetic differences. Some studies even suggest that ADHD adults downplay their ADHD symptoms. For example, one study diagnosed ADHD in children and then contacted them many years later when they were young adults. When they were interviewed as young adults, their responses to questions about ADHD suggested that they did not have the disorder. But when the same questions about the patient were asked to someone who lived with the patient as a young adult, it was clear that they still had ADHD. So rather than faking ADHD, many ADHD adults do not recognize that they have symptoms of the disorder. That said, we also know from research studies that, when asked to pretend that they have ADHD, adults can fake the disorder. That means that they can learn about the symptoms of the disorder and make up examples of how they have had them, when they have not. The research discussed above suggests that this is not common, but we do know that some people have motives for faking ADHD. For example, some college students seek special accommodations for taking tests; others may want stimulants for abuse, misuse or diversion. Fortunately, doctors can detect fake ADHD in several ways. If an adult is self-referred for ADHD and asks specifically for stimulant medication, that raises the possibility of fake ADHD and drug seeking. Because the issue of stimulant misuse has been mostly a concern on college campuses, many doctors treating college students will require independent verification of the patients ADHD symptoms by speaking with a parent, even over the phone if an in-person visit is not possible. Using ADHD rating scales will not detect fake ADHD and it is easy to fake poor performance on tests of reading or math ability. Neuropsychological tests can sometimes be used to detect malingering but require referral to a specialist. Researchers are developing methods to detect faking of ADHD symptoms. These have shown some utility in studies of young adults but are not ready for clinical practice. So, currently, doctors concerned about fake ADHD should look for objective indicators of impairment (e.g., documented traffic accidents; academic performance below expectation) and speak to a parent of the patient to document that impairing symptoms of the disorder were present before the age of twelve. Because the issue of fake ADHD is of most concern on college campuses, it can also be helpful to speak with a teacher who has had frequent contact with the patient. In an era of large lecture halls and broadcast lectures, that may be difficult. And don’t be fooled by the Internet. We don’t want to deny treatment to ADHD patients out of undocumented reports of an epidemic of fake ADHD.
References:
Harrison, A. G., Edwards, M. J. & Parker, K. C. (2007). Identifying students faking ADHD: Preliminary findings and strategies for detection. Arch Clin Neuropsychol 22, 577-88.
Sansone, R. A. & Sansone, L. A. (2011). Faking attention deficit hyperactivity disorder. Innov Clin Neurosci 8, 10-3.
Loughan, A., Perna, R., Le, J. & Hertza, J. (2014). C-88Abbreviating the Test of Memory Malingering: TOMM Trial 1 in Children with ADHD. Arch Clin Neuropsychol 29, 605-6.
Loughan, A. R. & Perna, R. (2014). Performance and specificity rates in the Test of Memory Malingering: an investigation into pediatric clinical populations. Appl Neuropsychol Child 3, 26-30.
Quinn, C. A. (2003). Detection of malingering in assessment of adult ADHD. Arch Clin Neuropsychol 18, 379-95.
Suhr, J., Hammers, D., Dobbins-Buckland, K., Zimak, E. & Hughes, C. (2008). The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Arch Clin Neuropsychol 23, 521-30.
Greve, K. W. & Bianchini, K. J. (2002). Using the Wisconsin card sorting test to detect malingering: an analysis of the specificity of two methods in nonmalingering normal and patient samples. J Clin Exp Neuropsychol 24, 48-54.
Killgore, W. D. & DellaPietra, L. (2000). Using the WMS-III to detect malingering: empirical validation of the rarely missed index (RMI). J Clin Exp Neuropsychol 22, 761-71.
Ord, J. S., Greve, K. W. & Bianchini, K. J. (2008). Using the Wechsler Memory Scale-III to detect malingering in mild traumatic brain injury. Clin Neuropsychol 22, 689-704.
Wisdom, N. M., Callahan, J. L. & Shaw, T. G. (2010). Diagnostic utility of the structured inventory of malingered symptomatology to detect malingering in a forensic sample. Arch Clin Neuropsychol 25, 118-25.
May 5, 2017 | Research Updates
J. Russell Ramsay, Ph.D.
Associate Professor of Clinical Psychology
University of Pennsylvania, Perelman School of Medicine
For a long time, at least for this writer, knowledge about the relationship of ADHD and the military was based on a lot of hearsay, rumor, and second- and third-hand accounts. However, a recent peer-reviewed article provides data on estimated prevalence rates of ADHD in the United States Army using the Adult ADHD Symptom Self-Report Scale Screener (ASRS-S)1. The ASRS-S was administered to over 21,000 active duty soldiers as part of the Army Study to Assess Risk and Resilience in Servicemembers (Army STAARS). The larger STAARS assessment battery included experiential and psychological measures and included the 6-item ASRS-S.
There were two scoring methods used for the ASRS-S to establish prevalence estimates. The first was the composite obtained from the sum of the numeric ratings provided by respondents to each of the six items (scored on a 0-4 Likert scale), with a score > 14 being considered positive for ADHD. The second scoring method was the item-response, which identified the number of specific items rated at or above the threshold considered positive for ADHD, with > 4 items considered positive for ADHD.
The sample was predominantly male and under the age of 30 years-old. The results indicated that 7.6% of the servicemembers screened positive for ADHD using the composite score and 9.0% screened positive using the item-response score. Native American/Alaskan Native respondents endorsed significantly higher rates – about 1.5 times greater – than White respondents (who were used as the reference group) on both the composite and item-response scores. Although there were no age differences on the composite score, the 25-29 and 30-39 year-old groups had a significantly higher risk for screening positive for ADHD than the 18-19 year-old group, which served as the reference group, again both older groups at around 1.5 times greater risk. There were no follow-up evaluations reported to confirm a full diagnosis of ADHD, so the findings reflect servicemembers who screened positive.
As informative as these findings are, another benefit of this article was obtaining some accurate information about ADHD and the US Army regulations (and reportedly Army regulations on ADHD are similar to other branches within the Department of Defense). According to Army regulations cited in the article, a diagnosis of ADHD is a medical disqualifier for service unless individuals demonstrate passing academic performance and have not taken any medications in the past 12 months. Thus, soldiers are permitted to have ADHD as long as they have not taken any medication in the past year (presumably medications for ADHD, but this was not made clear).
Assuming that a more comprehensive evaluation would result in a full diagnosis of ADHD for at least of percentage of those screening positive, the paradox noted by the authors is that a servicemember can have ADHD but may not take advantage of evidence-based pharmacologic treatment for it. There may be some rationale for these regulations from a military standpoint, but from a clinical standpoint it would seem that there are many military personnel in active duty who may have and are not being treated for ADHD. The incidence of any co-existing conditions (and whether these conditions are being treated) for those who screened positive for ADHD was not noted, nor was it mentioned whether the same regulations cited for ADHD would apply to common ADHD comorbidities, such as depression and anxiety. Apart from addressing the potential need for follow-up diagnostic evaluations for active duty personnel who screened positive for ADHD and any subsequent treatment needs, many of these servicemembers (and the ones who have served before them) will require appropriate assessment and treatment as they reintegrate into civilian life and their roles outside the military.
1Kok, B. C., Reed II, D. E., Wickham, R. E., & Brown, L. M. (2016). Adult ADHD symptomatology in active duty army personnel: Results from the Army Study to Assess Risk and Resilience in Servicemembers. Journal of Attention Disorders, online ahead of print. doi: 10.1177/1087054716673451
Apr 11, 2017 | Research Updates
Blog by Roberta Waite EdD, MSN, RN and Meghan Leahy MS, NCC
Meghan Leahy, M.S. Leahy Learning
While many more primary care providers (PCPs), including advanced practice nurses, physicians, and physician assistants, are recognizing adult ADHD and acknowledging that it is more than a disorder of childhood, the recognition of ADHD in adults in primary care is still an area in need of improvement. Many PCPs report that they do not feel that they have adequate training on the topic, and that overall they feel that adult ADHD is not well understood by the medical community.
Roberta Waite, EdD
Drexel University
Screenings for mental health conditions such as depression (using the PHQ-2/PHQ-9) and anxiety (using the GAD-7) among adult populations have increased in primary care settings. However, screening for adult ADHD remains relatively uncommon. Therefore, fundamental knowledge related to screening for adult ADHD within primary care is important.
Distinguishing the clinical presentation of ADHD among adults is different from affected children and adolescents. ADHD adults may present with more functional impulsivity, as well as prominent feelings of internal restlessness (versus running around or being disruptive). Many undiagnosed ADHD functioned well enough to get through primary and secondary school, but eventually hit a ceiling in terms of their ability to cope and adapt when their symptoms become more apparent.
Apart from the core symptoms, these untreated adults with ADHD are likely to struggle with implementing and completing tasks, poor time management, and distractibility, especially in academic or job-related activities. Interpersonal relationships may suffer from the difficulties, too. Moreover, untreated ADHD may also present with comorbid conditions, such as substance use disorder, mood instability, sleep disorders, and obesity. There are effective treatments for adult ADHD that have the potential to be cost effective in terms of the likelihood of improved functional outcomes and reducing costs to society.
This lack of understanding and, in turn, confidence, leads most PCPs to refer adults seeking an ADHD diagnosis to a psychiatrist or a psychologist. This begs the questions: what happens to patients who are suffering from adult ADHD but do not have the resources or understanding of their symptoms to seek specialty assessment and specialty care from adult ADHD experts?
Within ambulatory care settings, early detection is needed which can be mobilized by increasing knowledge about adult ADHD among PCPs and integrated BHCs. While there are a multitude of validated, brief screening and rating scales for suspected ADHD – the Adult ADHD Self-Report Scale (recently revised for DSM-5), ADHD Clinician Diagnostic Scale, Barkley Adult ADHD Rating Scale-IV, and the Conners’ Screening Scale to name a few – many PCPs may not be aware of them or have access to them. Of course, a screening scale is not sufficient to confirm a diagnosis of adult ADHD, but requires a more comprehensive evaluation.
Some primary care settings increasingly offer integrated services, more and more including licensed behavioral health clinicians, some of which with ADHD expertise; in other cases, a patient would need to be referred to a specialist in the area if they screened positive and could not be treated by the primary practice. Having a seamless connection with an on-site ADHD specialist would be ideal for both the patient and providers in terms of trust, convenience, and timeliness.
Take Away Points
- Primary care providers include advanced practice nurses, physicians, and physician assistants and all are the frontline for patients’ physical and mental health.
- As the concept of integrated health becomes more popular, more practices include LPCs, LCSWs, psychologists, advanced practice psychiatric nurses, and LMFTs to provide a team approach to treatment with licensed primary care providers (PCPs).
- Screenings for depression and anxiety have increased, but PCPs report that the diagnosis and treatment of adult ADHD is still limited, mainly due to a lack of knowledge which in turn leads to diminished confidence in their ability to diagnose adult ADHD.
- Adult ADHD remains under recognized, underdiagnosed, and undertreated compared to other disorders such as mood, anxiety, or substance use, which impedes the appropriate care and management for almost 5% of the population.
- Undiagnosed and untreated ADHD can have a devastating impact on not only the affected individual, but their relationships with everyone around them – their partner, family, co-workers, friends – their professional careers, and their finances.
- Early detection is key, especially for patients suffering from adult ADHD but lacking the resources or understanding to seek and secure an accurate assessment and effective treatment can be an obstacle.
- While screenings and integrated services will improve outcomes, the best case scenario includes connecting with an on-site team member such as an integrated BHC with expertise in ADHD who evaluates the patient real time to provide treatment in a familiar environment with trusted professionals, thereby leading to the most successful rates of intervention and follow-up treatments.
Resources
Adler, L., Shaw, D., Sitt, D., Maya, E., & Morrill, M. (2009). Issues in the Diagnosis and Treatment of Adult ADHD by Primary Care Physicians. Primary Psychiatry, 16(5), 57-63. Retrieved from http://primarypsychiatry.com/issues-in-the-diagnosis-and-treatment-of-adult-adhd-by-primary-care-physicians/
Ginsberg, Y. Quintero, J., Anand, E., Casillas, M, & Upadhyaya, H. (2014) Underdiagnosis of ADHD in adult patients. A review of the literature, The Primary Care Companion for CNS Disorders, 16(3). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195639/
Hines, J., King, T., & Curry, W. The Adult ADHD Self-Report Scale for Screening for Adult Attention Deficit–Hyperactivity Disorder (ADHD). Journal f the American Board of Family Medicine, 25(6), 847-853. Retrieved from http://www.jabfm.org/content/25/6/847.long
Knutson, K. & O’Malley, (2010). Adult attention-deficit/hyperactivity disorder: A survey of diagnosis and treatment practices. Journal of the American Academy of Nurse Practitioners, 22(11), 593–601.
Waite, R., Vlam, R., Irrera-Newcomb, M., & Babock, T. (2013). The diagnosis less traveled: NPs’ role in recognizing adult ADHD. Journal of the American Association of Nurse Practitioners, 25, 302–308.
