The BrownLetter on ADD

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

January, 2009

In This Issue:

Extended time improves reading comprehension for adolescents with ADHD

In Chicago at the annual meeting of the American Academy of Child & Adolescent Psychiatry, a scientific poster reported a study of 145 adolescents with ADHD by Dr. Brown with associates Reichel, Kulkarni and Quinlan. These 13 to 18 yr old students were tested with full WISC or WAIS IQ tests to assess the strength of their basic verbal abilities and their executive functions. All then took word reading and decoding tests as well as a standardized reading comprehension test under both standard time and extended time conditions. Results showed that only 43% of students were able to complete the test within standard time while 78% were able to complete it with extended time. These students did not show exceptional weakness in basic reading skills and had very adequate basic verbal abilities, but were relatively weak in working memory and processing speed. Extended time helped most to compensate for their ADHD-related executive function impairments.

New Handbook on ADHD Complications edited by Dr. Brown

Treatment strategies for the many complicated forms of ADHD are covered in a new book edited by Dr. Brown and just released by American Psychiatric Press. This 456 page handbook includes 22 chapters prepared by 34 world-class experts to summarize research-based knowledge about ADHD and anxiety disorders, mood disorders, learning disorders, substance abuse, sleep disorders, OCD, autism spectrum disorders, oppositionality/aggression, Tourette syndrome, and developmental coordination disorder. Also included are chapters on how ADHD is different in preschoolers, children, adolescents and adults as well as chapters about genetics, assessment, medications, and treatment planning. The book begins with a chapter by Dr. Brown describing important changes in how ADHD is now being understood. Intended primarily for clinicians, researchers and advanced students, this book is titled: ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults (ISBN: 978-1-58562-158-3).

New Ideas about Relationships Between Attention and Reading

World-recognized experts in reading and dyslexia, Drs. Sally and Bennett Shaywitz of Yale, recently published an article emphasizing that attentional disruptions play a far greater role in reading problems than has generally been recognized. They note that while learning to decode words remains the most fundamental skill in reading, one also needs to utilize attention and working memory in order to be a fluent reader. They cite research indicating that prefrontal attentional circuits play a critical role in activating lower brain mechanisms specifically involved in language processing. They suggest that medications traditionally used to treat attentional disorders may be an effective adjunct to helping dyslexic readers to read more fluently with improved comprehension. This perspective has important implications for helping students with reading problems, with or without an ADHD diagnosis. S.E. Shaywitz and B.A. Shaywitz. (2008) Paying attention to reading: The neurobiology of reading and dyslexia. Development and Psychopathology. 20: 1329-1349.

Study compared Concerta and Strattera

Often questions arise as to whether a stimulant medication or a non-stimulant medication is better for treatment of ADHD. Many have strong opinions about this question, but until recently there was not a controlled study that fairly compared these two types of medication. Newcorn and colleagues reported a 20 site study of 516 children aged 6-16 yrs. with ADHD randomized to treatment with oros methylphenidate (Concerta), atomoxetine (Strattera) or placebo at a reasonable dose for six weeks.

Defining adequate response as at least a 40% reduction in ADHD rating scale score, 45% responded favorably to atomoxetine (ATX) and 56% to oros methylphenidate (MPH) while only 24% of those on placebo had comparable rating scale score reductions. Interestingly, of the 70 children who did not respond to MPH, 43% subsequently responded to ATX. And of the 69 children who did not respond to ATX, 42% later responded to MPH. These findings support the notion that while many individuals respond equally well to either MPH or ATX, some respond significantly better to one than to the other. If a patient does not respond well to one class of medication, a trial of the other class of medication is usually appropriate. Newcorn, J.H., et al. (2008). American J. of Psychiatry. 165: 721-730.

Unrecognized ADHD in adults with other psychiatric disorders

Although it is widely recognized that individuals with ADHD often have one or more additional psychiatric disorders, the converse is often overlooked. Russell A. Barkley and Thomas E. Brown collaborated on a review paper to emphasize that adults diagnosed with depression, anxiety disorder, bipolar disorder, substance abuse, etc. often also have ADHD which is not recognized by patient or clinician. These authors encourage clinicians to evaluate all adult patients for executive function impairments of ADHD, especially if the patient is not responding adequately to usual treatments for the recognized disorder. They emphasize that many adults with ADHD have not been recognized as having attentional problems in early childhood, especially if they were not hyperactive. The article describes diagnostic approaches and tools useful in assessing adults for possible ADHD. The writers note that successful treatment of previously unrecognized ADHD in persons with other disorders may help to improve not only ADHD symptoms, but also the previously diagnosed disorder. Barkley, R.A. and Brown, T.E. (2008). CNS Spectrum 13 (11): 977-984.

Many children with ADHD are treated with inadequate doses

Records of managed care organizations were reviewed by Mark Olfson and colleagues to assess patterns of dosing with stimulant medications for children 6 to 12 yrs with ADHD being treated not in controlled clinical trials, but in the general community. They studied records of 3,815 children treated with oros methylphenidate (Concerta), 1,960 treated with immediate release methylphenidate (MPH-IR), 1,847 treated with mixed amphetamine salts-extended release (Adderall-XR), and 1,937 treated with immediate release mixed amphetamine salts (MAS-IR). Data showed that average doses prescribed for these children tended to be considerably below doses found optimal in clinical trials.

For example, in this community sample the mean daily dose of MPH-IR was 21 mg.; careful titration of this medication in the MTA study yielded a mean daily dose of 30.5 mg. Larger doses are not always better; but minimal doses are not always effective. Optimal dose of stimulants is best determined by titration (careful monitoring and adjustment according to each individual’s pattern of response over time). This study suggests that many parents and/or clinicians may avoid pushing to an optimal dose once even slight improvement in symptoms is seen. Olfson, M., Marcus, S. and Wan, G. (2009) Stimulant Dosing for Children with ADHD: A Medical Claims Analysis. J. Amer Academy of Child & Adolescent Psychiatry. 48 (1): 51-59.

Treatment of ADHD in young adults-CME on Medscape

Medscape-CME features a case-based CME module on individualizing treatment strategies for young adults (18 to 25 years) with ADHD. Medical professionals can earn CME credit by responding to questions about how best to assess and treat these cases prepared and discussed by Dr. Brown. Clinical examples include academic problems, job struggles, financial difficulties, social anxiety, alcohol and marijuana use, panic attacks, etc. Information includes tools for assessment, medication options and dosing, and resources for treatment. Until June, 2009 this CME module can be accessed at http://cme.medscape.com/psychiatry.

A new psychosocial treatment for adult ADHD

A new manualized program to teach adults with ADHD skills in planning, time management and organization has been developed and tested by Mary Solanto and colleagues at the Mt. Sinai School of Medicine in New York City. Thirty-eight adults aged 23 to 65 years participated in the 8 or 12 week program of group instruction and therapy that addressed target behaviors such as time estimation, effective use of daily planners, breaking down complex tasks, prioritizing, visualization of longer term rewards and consequences, “a place for everything and everything in its place” and flow-charting of goals. Results from rating scale data showed improvement of ADHD symptoms and related executive function skills. Solanto, M.V., Marks, D.J., et al., (2008) J. of Attention Disorders. 11 (6) 728-736.

Debate about “use of cognitive enhancing drugs by the healthy”

A recent issue of the journal, Nature, included a multi-participant debate discussion about pros and cons of the use of cognitive enhancing medications such as ADHD medications for enhancement of cognitive functioning in individuals who are essentially healthy and do not meet diagnostic criteria for any psychiatric disorder. Practical and moral implications of such medication use are discussed. Participants in the discussion call for “an evidence-based approach to the evaluation of the risks and benefits of cognitive enhancement” and for “enforce able policies concerning the use of cognitive enhancing drugs to support fairness, protect individuals from coercion and minimize enhancement-related socioeconomic disparities.”

They also call for “a programme of research into the use and impacts of cognitive enhancing drugs by healthy individuals” and for “physicians, educators, regulators and others to collaborate in developing policies that address the use of cognitive enhancing drugs by healthy individuals.” This article offers a thoughtful, reasonable approach to a complex set of questions that are often met with strong prejudice on one side or the other. Greely,H., Sahakian, B., Harris, J., et al. (2008) Nature. Doi: 10:1038/456702a.

 

Three useful books

Straight Talk about Psychiatric Medications for Kids by Timothy E. Wilens is now available in paperback in its 3rd edition. Parents considering psychiatric medication treatment for their son or daughter often face a bewildering array of conflicting information-and misinformation-from family, friends and media. Dr. Wilens, a top-notch psychopharmacologist, provides detailed, clearly understandable, research-based guidance on the pros and cons of various treatment options. (Guilford Press, 2009).

Adult Learning Disorders: Contemporary Issues edited by Lorraine Wolf, Hope Schreiber and Jeanette Wasserstein is an excellent collection of fairly technical chapters for professionals interested in learning disorders as they occur in adults. One particularly useful chapter by Lorraine Wolf and Edith Kaplan provides a thoughtful and sophisticated discussion of executive function and self-regulation in young adults. Unlike many others, this discussion integrates cognitive aspects of executive function with emotional and motivational aspects. Appreciation of both aspects is essential for understanding most students who struggle in college and university studies. (Psychology Press, 2008).

Buzzed: The Straight Facts about the Most Used and Abused Drugs from Alcohol to Ecstasy is now available in paperback in its 3rd edition. This very straightforward handbook provides detailed, practical, no-nonsense information about the wide variety of substances that are frequently used and abused. It is written in an easy-to-understand format that is useful for adolescents and their parents as well as for professionals. (W.W.Norton, 2008)

News from my office

During 2008 I enjoyed opportunities for international travel to talk with professionals in Hong Kong, Tokyo, Madrid, Helsinki, Reykjavik, Seoul, Utrecht, and Beirut. This brings to 40 the total number of foreign countries I have been privileged to visit. Such face-to-face contact in so many different countries with individuals who are concerned about persons with ADHD has taught me much about how universal ADHD impairments are and about how similar we all are, despite our many differences of culture and language. Plans thus far for 2009 include giving lectures in Barcelona, Hawaii, London, Japan, China and Vienna as well as a number of conferences in the U.S

I am grateful to the American Psychological Association for electing me to the distinction of Fellow of the Association “in recognition of outstanding and unusual contributions to the science and profession of Psychology.”