The BrownLetter on ADD

A free quarterly newsletter of information and opinion about ADD/ADHD

February, 2006

In This Issue:

Blaming the Victim
Misguided Diagnosis for an Adult with ADHD

A 23-year-old woman recently came to me for a consultation after spending many hours and substantial income getting a neuropsychological evaluation for suspected ADHD at a major medical center in another state. She is very bright and had no history of behavior problems or substance abuse, but she had struggled intensely with attentional and working memory problems that resulted in severe academic underachievement from 9th grade onward.

She obtained a GED after she failed to meet high school graduation requirements. She then struggled for 5 years to complete a two-year degree in a community college. Meanwhile, she performed well in her job and excelled as an athlete and musician, though she often suffered from excessive perfectionism and depressed mood.

The evaluating clinician reported that although this woman reported many symptoms of ADHD during adolescence and adulthood, he could not make the diagnosis because she did not fully meet DSM-IV criteria. He refused to diagnose ADHD because the patient’s mother, when asked about ADHD symptoms during the patient’s childhood, did not recall noticing the requisite number of symptoms. Instead, he diagnosed the patient as suffering from “Self-Defeating Personality Disorder.”

This is an example of a clinician rigidly applying DSM-IV criteria for diagnosis of ADHD in a way that prevented desperately needed treatment. Adding insult to injury, by giving the patient a diagnosis of “Self-defeating Personality Disorder,” the clinician clearly implied that the she was the source and cause of her problems. In short, he was blaming the victim for her persistent suffering. I consider this not only a clinical error, but an unfortunate prejudice about ADD that is altogether too common, even among some skilled professionals.

This incident also illustrates a significant flaw in current DSM-IV criteria for ADHD. The specific criterion of “Some symptoms present before age 7 years” totally lacks empirical support. In chapter 7 of my recent book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults, I explained why many experts in the field have urged ignoring this requirement. We need more adequate diagnostic criteria for ADHD, especially for adults. We also need clinicians whose clinical judgment is less rigid and more compassionate.

Why Some Bright Students Fail

At Yale University, Dr. Donald Quinlan and I recently completed analysis of data from 74 students aged 7 to 18 years with IQ scores above 120, in the top 9% of the population, who had been referred for chronic underachievement. Most had no behavioral problems and were not hyperactive, but did have attentional disorders.

Despite excellent long term memory and strong verbal and perceptual abilities, these very bright students showed significant weakness on standardized tests of working memory and ability to focus attention. They were unable to recall accurately what they had heard or read just a few minutes earlier. Many also showed slowed processing speed that impaired output for writing tasks.

These high IQ students reported significant difficulties in organizing and getting started on their work. They often found it necessary to re-read passages multiple times in order to comprehend the assignment. Many did well on quizzes and tests, but received low or failing grades due to inattention and persistent failure to complete homework.

Parents and teachers were frustrated because these students appeared unmotivated to do assigned work. Yet everyone in the study had a favorite activity, such as computer games, tennis, drawing or playing guitar for which they regularly focused very well. Students claimed that they could focus easily on those tasks that especially interested them, though they were chronically unable to mobilize adequate attention or effort for their academic work.

Students in this study had experienced 2 to 10 years of deteriorating grades and demoralizing failures before their attentional problems were recognized. After 3 months of treatment with appropriate medication, 81% of these students had improved significantly in their academic work. Such intervention is important because an earlier study of high IQ adults with ADD showed that 42% had failed or dropped out of college or university due to attentional problems.

My recent book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults explains how such apparent problems with “lack of willpower” are often due to inherited, chemically-based neuronal circuits that manage executive functions of the brain.

Incidence of ADHD among children in the United States

The U.S. Centers for Disease Control (CDC) recently released results from a nationwide study that found approximately 7.8% of children aged 4 to 17 years had been diagnosed with ADHD. Of these, 56.3% were taking medication to alleviate their ADHD symptoms. Older estimates of 3 to 7% incidence now are outmoded, at least in the overall view.

The most interesting part of this study was the list of percentages diagnosed and medicated in each specific state. Alabama had the highest incidence at 11.1% while Colorado had the lowest rate at 5%. Medication treatment rates also varied widely from a low of 2.1% in California and a high of 6.5% in Arkansas.

The study didn’t offer any clues about what social and economic factors might be influencing the state to state differences. It seems likely, however, that even within each state there is considerable variability from one community to another as to how difficult or easy it is to get appropriate assessment and treatment for ADHD. For details of this study, see www.cdc.gov/mmwr/preview/mmwrhtml/mm543a2.htm.

A New Tool for Diagnostic Formulations
Circles Inside Squares

In its December, 2005 issue, the Journal of the American Academy of Child and Adolescent Psychiatry published an article in which I described a simple technique I’ve developed for presenting results of an evaluation to patients and their families. On a piece of paper I draw a large square in which I list some of the patient’s strengths. In the middle of that square I draw circles of different sizes, like a Venn diagram, to show each of the patient’s significant problems, such as ADHD, depression, reading disorder, etc., making the size of these overlapping circles fit the apparent size of the problem in the patient’s current life.

I then draw a larger square to encompass the first square. There I note specific supports and stressors in the patient’s family, school or work environment, and community. This then, provides a focus for discussion with patient and family about which problems are most important and how we should proceed in addressing them. Details are in the article which appeared in Vol. 44, No. 12, pp. 1309-1312. Click here to view a PDF of the full article on my website.

ADHD in Adolescents
New review article has been published

Much of the literature about ADHD is still focused exclusively on children. At the invitation of the American Academy of Pediatrics (AAP), a team of ten specialists in ADHD reviewed the research literature and standards of clinical practice to develop a summary of current information about how ADHD can be recognized, assessed and effectively treated in adolescents.

Results of our findings were published in the June issue of the medical journal, Pediatrics (2005) 115: 1734-1746. A PDF of this article can be found on my website using this link.

This article should be useful not only to pediatricians, but also to psychologists, psychiatrists, educators and parents who want to know what is currently known about those in this vulnerable age group who suffer from ADHD and are often overlooked.

“Booster Doses” with Longer Acting Stimulants

Longer acting stimulant medications for ADHD are often advertised as providing “all-day” coverage; some claim a duration of action of 12 hours, others claim only 8 to 10 hours. Often these estimates are based on group data from research studies that may or may not fit the experience of any particular child, adolescent or adult.

In real life there is considerable variability in how long these formulations last for one person compared to another. For some, the longer acting medications barely provide enough coverage from leaving home in the morning until the middle of the afternoon. For others, an early morning dose can last throughout most of the day and into the early evening.

Many students in junior high or high school are not able to get their homework done immediately after school. They may have an after- school job or sports team practice or other activities and not get home until 5 or 6 pm. Then they are left with homework assignments to complete, long after their ADHD medication has worn off.

Many adults with ADHD complain that their “all-day” medication for ADHD wears off well before they arrive home and have to deal with family responsibilities, coupled at times with a full evening of paperwork.

In a small study of adults seen at our clinic, 60% of those taking stimulant medication designed to last 10-12 hours reported that they needed a “booster dose” of stimulant medication taken in mid to late afternoon in order to get adequate coverage for their late afternoon and early evening activities.

For most, a dose of short-acting stimulant was sufficient; some who metabolized the medicine very quickly or who had exceptionally long schedules did better on twice daily dosing of the longer-acting stimulant.

There is, at present, virtually no research to guide the use of booster doses, but many clinicians find they are essential to providing adequate coverage of symptoms for adolescents and adults as well as for some children.

“Irritability” is very different in Bipolar Disorder than in ADHD

In child psychiatry there has been heated disagreement about how one can tell the difference between a child who has bipolar disorder with or without ADHD and a child who has just ADHD, but often tends to be grouchy. A recent paper by Eric Mick and colleagues at Harvard Medical School has helped to clarify this issue. They reported a study of 274 boys and girls aged 6 to 17 years with ADHD who had bipolar disorder (n=30), unipolar depression (n=100) or no history of depression or mood disorder (n=144).

Researchers scored the responses of mothers and children to 3 sets of questions on the KSADS interview scale that deal with irritability. One set identified “Oppositional-defiant type irritability”; another tapped for “mad/cranky irritability” and the third set queried for “super-angry/ grouchy/cranky irritability.” These ratings were done by interviewers blind to diagnostic ratings on these children.

“ODD-type irritability” was very common in all of the ADHD children, was least impairing and did not increase risk of a mood disorder. “Mad/cranky irritability” was common only in ADHD children with a history of mood disorder and was predictive of unipolar depression.

“Super-angry/grouchy/cranky irritability” was common only in ADHD children with bipolar disorder and was the most impairing. However, even among those with this super-angry type of irritability, not all had bipolar; 46% received the bipolar disorder diagnosis.

Mood problems clearly overlap with ADHD and this approach could be helpful to sorting the diagnostic questions out. The article can be found in Biological Psychiatry (2005) 58: 576-582.

ADD and “Executive Function”
2 Conflicting Models

Over recent years there has been increasing talk about ADD as a disorder of “executive functions” (EF), the brain’s management system. As more is learned about this disorder, it becomes increasingly clear that the most damaging and most persistent symptoms of ADD are not usually hyperactivity/ impulsivity, but the wide variety of attentional impairments that are closely linked to EF.

There are now two different models to describe how EF is related to ADD. One model, used by many researchers, claims that EF functions are impaired only in those persons with ADHD who obtain very low scores on neuropsychological tests called “tests of EF.” If this definition is used, only about 30% of children or adults with ADHD are found to have significant EF impairments.

The other model, presented in slightly different versions by Dr. Russell Barkley and by me, claims that all persons with ADHD suffer from impairments of EF, that ADHD essentially is impairment of EF. Dr. Barkley sees this as true only for those whose ADHD includes significant hyperactivity/impulsivity symptoms; I argue that EF impairments are the essence of all subtypes of ADHD.

This argument hinges on how EF are defined. In Attention Deficit Disorder: The Unfocused Mind in Children and Adults, I’ve explained why I believe that the so-called neuropsychological “tests of EF” do not adequately measure EF impairments; my claim is that problems with EF are seen more clearly in how a person performs tasks of daily life that require self-management with attention and working memory.

For those who wish to learn more about these two conflicting viewpoints and how they can affect diagnosis of ADHD, I’ve written an article that soon will be published in the first of two special issues of the International Journal of Disability, Development and Education. These special editions will both contain results and conclusions drawn from a variety of research and treatment studies from ADHD experts in Australia, the Netherlands, the UK and the US. More information about the journal can be found at www.tandf.co.uk/journals/titles/1034912x.asp.

ADHD and Challenges of Early Adulthood
A new article

Early adult years present especially difficult challenges for many individuals with ADHD. I’ve written a new article about these challenges that appeared in the February issue of ATTENTION magazine. Topics covered include: linking school to a career, managing money, seeking and keeping a job, moderating substance use, developing and sustaining satisfying relationships, and utilizing adequate medical care. A PDF of this article is posted on my website and can be accessed by clicking this link.

Two Useful new books

A. Kids in the Syndrome Mix of ADHD, LD, Asperger’s, Tourette’s, Bipolar and More by Martin T. Kutscher (Jessica Kingsley Press, 2005).

Most books about ADHD for parents and teachers mention that a child with ADHD is more likely than others to have one or more additional learning or psychiatric problems, but few writers actually provide advice about how parents and teachers can deal effectively with these more complicated children and adolescents. This practical, upbeat guide offers useful information and sensible advice about how medications and behavioral strategies may need to be adjusted according to the particular combination of problems of a particular child in this “syndrome mix”.

B. Treating Explosive Kids: the Collaborative Problem-Solving Approach by Ross W. Greene and J. Stuart Ablon. (Guilford Press, 2006)

Ross Greene’s earlier book, The Explosive Child (HarperCollins, 1998), provided an excellent clinical description of children and adolescents, many with ADHD, mood disorders and/or autistic spectrum disorders, who tend to have meltdowns and explosive outbursts that are not easily controlled or prevented by conventional behavioral treatment interventions. This new book describes practical, developmentally-based approaches for solving everyday problems with these children in ways that are less likely to throw gas on the fire. Like his previous book, this one offers practical strategies that should be useful to clinicians seeking to help those who struggle to care for children with these difficult challenges.

News From My Office

I’m happy to report that my new book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults, has been getting a good reception. It went into a second printing just 3 months after its release and contracts have already been signed for translation into Chinese and into Spanish.

Reviewers of the book, thus far, have been kind. From Mary Beth Regan in the Baltimore Sun: “Brown’s book is thorough and compassionate. Consider it essential reading if you are concerned about a child or an adult who may be struggling with this syndrome.” And from Kathleen Nadeau in ADDitude magazine: “This intelligent book does a better job of explaining AD/HD than any book in recent memory. It’s a must-read for anyone with an interest in AD/HD, whether of a personal or professional nature.”

We are making some improvements in my website. Changes should make it easier to navigate and will include a few new features including a listing of the schedule for my upcoming presentations in the U.S. and abroad. Click here to check out the site and then click the box on the site to send a copy to an interested friend or colleague.