The BrownLetter on ADD

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

February, 2007

In This Issue:

Proposed New Diagnostic Criteria for Adult ADHD

When adults are assessed for possible attention deficit disorders, most clinicians use the DSM-IV diagnostic criteria for ADHD. These 18 items were developed on the basis of research that included no adults, only children aged 4 to 17 years.

There are many problems with using these criteria to diagnose adults. They do not pick up many of the problems important for adults with ADD. And when used with the stipulated cutoff at 6 of 9 items from either inattention or hyperactivity/impulsivity symptoms, only the most impaired 1-2% of adults are recognized as having ADHD; when used with children, the most impaired 7% of children are identified using the 6 of 9 item cutoff. Most experts acknowledge that some flexibility and clinical judgment are needed to adapt DSM-IV criteria for diagnosis of ADHD in adults.

DSM-V is scheduled for publication in 2011. Many are hoping that it will include new diagnostic criteria for adults. Russell Barkley and Kevin Murphy recently published a list of 9 symptoms for diagnosing ADHD in adults; they selected these after testing 91 items in research with adults. They suggest that if an adult has significant impairment from 6 or more of these symptoms in 2 or more settings, they warrant diagnosis for ADHD.

Symptoms suggested by the Barkley-Murphy research are all related to executive functions and include:

  • Easily distracted by extraneous stimuli.
  • Often makes decisions impulsively.
  • Often has difficulty stopping activities or behavior when he/she should.
  • Often starts a project or task without reading or listening to instructions.
  • Often shows poor follow-through on promises or commitments to others.
  • Often has trouble doing things in proper order or sequence.
  • Often drives a motor vehicle faster than others (excessive speeding)
  • Often has difficulty sustaining attention to tasks or leisure activities.
  • Often has difficulty organizing tasks and activities.

It will take years before the DSM-V committee actually decides what changes should be made in diagnostic criteria for ADHD. Meanwhile, these items can be useful to clinicians assessing adults. (From ADHD Report, Guilford Press, 2006)

Treatment for ADHD in Preschool Children

Many preschool children are brought by their parents to be evaluated for possible ADHD. Most children brought in before age 7 years for an ADHD evaluation have fairly severe problems with hyperactivity and impulsivity that may present serious safety risks to themselves and/or to others, especially to peers and younger siblings. Until now there have been just a few small research studies to provide guidance about use of medication for treating ADHD in such young children.

Our government’s National Institute of Mental Health (not a pharmaceutical company) funded a six site study to learn about the safety and effectiveness of stimulant medication treatment for children aged 3 to 5.5 years. Results from that study which included 165 children with severe ADHD were published in the November, 2006 issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

This Preschool ADHD Treatment Study (PATS) began treatment not with medication, but with an intensive 10 week course of small group parent training designed to help parents learn to deal more effectively with their ADHD preschoolers. If a child’s behavior responded well to changes resulting from the parent training, medication was not used. Only about 10% responded well enough to the parent training that medication treatment was not utilized.

This study used ratings from both parents and teachers on several rating scales to evaluate responses of the children on trials of several different doses of methylphenidate (MPH) and on placebo. Results showed that 92% of the preschoolers tolerated the medication, although these younger children tended to have more difficulty with side effects that older children usually do. Side effects seen in some children during this study, mostly at higher doses, included reduced appetite, difficulty sleeping, stomachaches, irritability, social withdrawal and lethargy.

Overall, the data of this large, well-controlled study demonstrated that most preschoolers with severe ADHD can safely benefit from treatment with MPH when their doses are started low (2.5 mg of MPH twice daily) and carefully adjusted over several weeks to an optimal level for each individual. Average doses for these 3 to 5.5 year olds were about 15 mg total daily dose (± 8.1 mg per day). Effects were not as dramatic as with the older children evaluated in the MTA study; the researchers suggested that for some of these preschoolers, doses used in the study were probably too low to be optimally effective.

Toward an Adequate Understanding of Attention Deficit Disorders

Recently I was invited to write a guest editorial for the Brazilian Journal of Psychiatry about current developments in assessment and treatment of ADHD. In it I tried to identify some of the important changes that have been occurring in our understanding of this disorder. The editorial, published in Rev. Bras. Psiquiatr. 2006: 28 (4) 261-262 is reprinted here with permission from the publisher: Throughout the world, the syndrome identified in DSM-IV as Attention Deficit/Hyperactivity Disorder (ADD) is being increasingly diagnosed in children, adolescents and adults, most of whom find treatment quite helpful.

Yet many clinicians and others remain skeptical about the validity of this diagnosis, particularly in adults. For some, this skepticism rests upon an overly simplistic understanding of the ADD syndrome; they assume that this is simply a childhood behavior disorder that persists in some adults who remain hyperactive.

Barkley & Murphy recently published data showing that adults with ADD are distinguished from community or clinical controls not by hyperactivity, but by a variety of impairments in executive functions.1 Although there are conflicting views of how best to describe the relationship of executive functions to ADD, data from multiple sources indicate that ADD is essentially a complex syndrome of impairments in development of the brain’s selfmanagement systems.2

Key elements of this emerging model include:

  1. ADD is essentially a complex disorder in the unfolding development of the brain’s executive functions, its management systems.

    Although early decades of research on ADD were concerned with disruptive behavior, recent years have brought increasing emphasis upon cognitive impairments involved in this disorder. These include chronic problems with focusing attention on tasks, utilizing working memory, organizing work, getting started on tasks, and sustaining effort to complete them in a timely way, etc.

    These cognitive functions might be compared to the work of the conductor of a symphony orchestra who selects what is to be played, directs each musician to play his or her specific part in the same piece at the same time, signals the moment to bring in one section and fade out another, and generally oversees and manages the overall performance. Persons with ADD tend to have chronic impairments in their ability to perform a wide range of complex self-management functions that are essential to age-appropriate performance in school, family life, employment and social relationships.3

  2. ADD symptoms may be noticeable during early childhood, but often are not apparent until the individual encounters challenges of adolescence or adulthood.

    Networks that support the brain’s executive functions develop slowly, from early childhood until well into the early twenties. Many are localized in the prefrontal cortex, but they operate in conjunction with neural circuits in the limbic region and cerebellum. These complex circuits do not reach full maturity until late adolescence or early adulthood.

    Some cases of ADD impairment are apparent in preschool years, for example, the child who is kicked out of daycare because of inability to meet minimal demands for self-regulation: keeping hands to self, complying with instructions, listening to the adults.

    Others with ADD may function well in early school years; their impairments may not become apparent until their capacity for executive functions is more fully challenged, e.g. in secondary school when they no longer have one teacher most of the day to guide them and when they must manage for themselves multiple tasks from multiple teachers.

  3. ADD appears to be a problem of insufficient willpower, but it is actually a problem in the chemical dynamics of the brain. Many who know individuals with ADD are puzzled by the fact that all seem able to focus very well for a few selected tasks in which they have strong personal interest, e.g. playing a sport or video game, doing mechanical work, or creating art or music. Yet these same individuals have chronic difficulty in exercising executive functions required for focus on many other necessary daily tasks of school, household, or employment.

    When asked about this puzzling discrepancy, most with ADD explain that they can focus well on tasks that really interest them, or when a gun is to their head, yet they are chronically unable to get themselves to exercise these same functions for many other tasks important to them in daily life. For example, they tend repeatedly to avoid starting an assignment until very shortly before its final deadline. Such patterns of behavior might be seen simply as laziness or lack of willpower, but research has demonstrated that there is a chemistry to motivation. In about 80% of those with ADD such problems are alleviated by medication treatments that facilitate more adequate release and reloading of dopamine and/or norepinephrine in critical neural synapses.3

    Medication-induced alleviation of ADD symptoms is always temporary, persisting only so long as the medication is active; this is comparable to eyeglasses that improve impaired vision only when worn. But medication is the single treatment demonstrated effective for alleviating impairments in the neural substrate that supports executive functions impaired in ADD.4

    The more complex model of ADD discussed here describes a syndrome that is important not only in itself, but also because it tends to occur in conjunction with many other psychiatric disorders. In most cases, ADD onsets much earlier than mood disorders, anxiety disorders, substance use disorders, etc. Noting this, Kessler et al. have questioned whether effective treatment of ADD in childhood might influence the onset of subsequent disorders, and whether treatment of ADD in adults might have any effect on the severity or persistence of comorbid disorders.5 To address these important questions adequately, clinicians and researchers need to appreciate and study the complexity of ADD across the lifespan.

Thomas E Brown
Yale Clinic for Attention and Related Disorders,
Department. of Psychiatry, Yale University School of Medicine,
New Haven, CT, USA

References
1. Barkley RA, Murphy KR. Identifying new symptoms for diagnosing
ADHD in adulthood. ADHD Report. 2006;14(4):7-11.
2. Brown TE. Executive functions and attention deficit hyperactivity
disorder: implications of two conflicting views. Int J Disab Develop
Edu. 2006;53(1):35-46.
3. Brown TE. Attention deficit disorder: the unfocused mind in children
and adults. New Haven, CT: Yale University Press; 2005.
4. Barkley RA. Attention-deficit hyperactivity disorder: a handbook for
diagnosis and treatment. 3rd ed. New York: Guilford Press; 2006.
5. Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler
O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun
TB, Walters EE, Zaslavsky AM. The prevalence and correlates of
adult ADHD in the United States: results from the National
Comorbidity Survey Replication. Am J Psychiatry.
2006;163(4):716-23.

Atomoxetine Trials for Pervasive Developmental Disorders

The terms “Pervasive Developmental Disorders” (PDD) and “Autistic Spectrum Disorders” (ASD) are used to refer to autism, Asperger’s Disorder, PDD-NOS and several other less well known disorders that involve a wide range of chronic delays in development of reciprocal social interaction, communication, and stereotyped, repetitive behaviors. Individuals diagnosed with PDD or ASD range from slightly impaired to very severely impaired.

Researchers at Emory University recently reviewed charts for 83 children diagnosed with PDD or ASD and found that 78% also fulfilled DSM-IV diagnostic criteria for ADHD, even though ADHD was not the primary presenting complaint for most of them (Lee and Ousley, J. Child & Adolescent Psychopharmacology 16 (6) 2006, pp. 737-746).
This high percentage is very similar to what was found in two earlier studies of similar patients.

Thus far no medications have been demonstrated effective for treatment of core symptoms of PDD or ASD, but a few studies have shown that low doses of stimulant medications can be effective in alleviating ADHD symptoms in some individuals with PDD or ASD. Recently two small open label studies tested atomoxetine (Strattera) to see if this medication approved for treatment of ADHD is effective in treating ADHD symptoms that often appear in the complex children or adolescents diagnosed with PDD or ASD.

A study done at the University of Indiana tested atomoxetine over 8 weeks with 16 children and adolescents diagnosed with pervasive developmental disorders (autistic disorder, Asperger’s disorder and PDD-NOS). In addition to significant improvement in symptoms of ADHD, most of these patients also showed some improvement in irritability, social withdrawal, stereotypy and repetitive speech. Fourteen of these 6 to 14 year olds were able to tolerate the medication; two had to be withdrawn from the study because of excessive irritability.

These preliminary results raise the question of whether this medication may have some positive benefits for some individuals who suffer from autistic spectrum disorders in addition to ADHD symptoms. This preliminary study was reported by Posey, et al in Journal of Child & Adolescent Psychopharmacology 2006, 16 (5) pp. 599-610.

A similar pilot study done by Troost et al (J. Child & Adolescent Psychopharmacology, 2006, 16 (5) pp. 611-619.in the Netherlands found that atomoxetine significantly reduced problematic ADHD symptoms in children with PDD, but did not find improvement in PDD symptoms that were noted in the U.S. study. Both studies however, found that children with autistic spectrum disorders tend to have greater vulnerability to side effects of atomoxetine than do children with ADHD who do not have PDD. More research on these issues is clearly needed.

New Guidelines for Oppositional Defiant Disorder

New guidelines for assessment and treatment of Oppositional Defiant Disorder (ODD) were published in the January, 2007 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (46: 126-141). These guidelines, based on a review of the relevant research literature, include 11 specific recommendations for assessment and treatment of children and adolescents with ODD.

The guidelines describe ODD as a syndrome with “recurrent patterns of negativistic, hostile, or defiant behavior in at least one of three domains of functioning, lasting at least 6 months.” Usually this syndrome is identified initially in late preschool or early school age children. Only about 1/3 of those diagnosed with ODD eventually develop the more severe pattern of delinquent behavior that characterizes conduct disorder, but the intensity of angry and vindictive behavior, coupled with chronic problems in control of temper, can cause much stress in affected families. The psychiatric disorder most often seen with ODD is ADHD, usually a very difficult combination to manage.

These new guidelines emphasize the importance of including individual sessions with the child during evaluation and treatment. If clinicians meet only with the parents and other adults, it is likely to intensify the polarization between parents and child that is common in these families, causing the child to feel that the clinician is simply an agent of parental efforts to impose control.

Considerable evidence has demonstrated the value of several programs to help parents learn more effective ways to deal with their ODD child. Often parents and teachers unwittingly exacerbate the hostile, oppositional attitudes of such children. Key principles of effective intervention programs include:

  • Reduce positive reinforcement of disruptive behavior.
  • Increase positive reinforcement of prosocial and compliant behavior.

These two principles are empirical manifestations of the old adage, “You catch more flies with honey than with vinegar.” This is especially true with ODD kids.

  • Apply consequences and/or punishment for disruptive behavior.
  • Make parental response predictable, contingent, and immediate.

Although these guidelines appear simple to apply, effective use of them actually requires considerable skill to identify and implement optimum applications for a particular family. Typically this requires as much expertise as the careful titration of combined medication treatments.

The guidelines recognize that medications may be helpful in treatment of children with ODD, but they emphatically remind clinicians that medication should not be the sole treatment for this disorder.

Opportunity to assist in a useful research study

ADHD experts at the University of Western Australia are engaged in a research study to develop new organization and time management strategies for children and adolescents with ADHD. Students, parents and teachers can provide valuable assistance with this study by clicking on the appropriate link listed below and completing the questionnaire which takes only about 5 minutes. By completing the questionnaire you are consenting for your information to be used in the research and acknowledging that your privacy will be fully protected. Links are:

Students: http://savant.net.au/survey/50660

Parents: http://savant.net.au/survey/33027

Teachers: http://savant.net.au/survey/32249

If you want more information about this study, contact Professor Stephen Houghton at stephen.houghton@uwa.edu.au or Dr. Myra Taylor at myra.taylor@uwa.edu.au

Two Useful New Books

CHADD Educator’s Manual on Attention-Deficit/Hyperactivity Disorder. Landover, MD: CHADD, 2006.

This edited volume published by CHADD offers very practical information prepared for teachers and administrators in educational settings for students in preschool, elementaryschool, middle school and high school. Chapters describe current understandings of how ADHD appears in children at these various age levels and offers specific suggestions for how educators can adapt their approaches to provide needed understanding and support for students with ADHD.

The Bipolar Child-Third Edition. Dimitri Papolos, M.D. & Janice Papolos New York: Broadway Books, 2006.

This very practical book, now in its third edition, provides sensible discussion of bipolar mood disorders as they occur in children and adolescents. It includes medical information about diagnosis and medication treatment alternatives; it also includes perspectives of parents about the dilemmas of dealing the problems of bipolar children in school and family life.

News From My Office

Paperback edition and awards

My most recent book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults, is now available in paperback from Amazon.com and most bookstores. The book has been very well-received. A review in the New England Journal of Medicine commented: “The discussion of medication is superb…laced with nuance and evidence.” It won the Will Sollimene Award for excellence in medical communication and recently was named an Outstanding Academic Title of 2006 by CHOICE, the publication of the American Library Association.