The BrownLetter on ADD

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

November, 2007

In This Issue:

High IQ Children and Adults with ADHD

Often high IQ children and adults who suffer from ADD/ADHD are told by parents, educators and clinicians that they cannot have this disorder because they are so bright. Many seem to assume that being very bright protects individuals from having ADHD. Recent research at Harvard and at Yale has demonstrated that individuals with high IQ can and do suffer from ADD/ADHD.

In the J. of Child Psychology and Psychiatry (2007, 48: 7 pp. 687-694) Antshel and colleagues at Harvard reported on samples of children with IQ ≥ 120, 49 with ADHD diagnosis and 92 matched controls. They found that, in comparison to controls, those with ADHD repeated grades more often, needed more academic supports, had more comorbid psychopathology, and were rated by their parents as having more functional impairments.

ADHD was also shown to have elevated incidence rates in relatives of those with high IQ and ADHD. When compared with a group of high IQ children without ADHD and to normal IQ children without ADHD, those with both high IQ and ADHD had a much higher incidence of ADHD among their relatives than did high IQ controls as well as normal IQ controls (23% vs 2.5% vs. 5.9%). These data suggest that the ADHD of those in the high IQ sample cannot be explained as a consequence of their having high IQ.

My colleagues and I recently completed two somewhat similar studies at Yale. We presented these data at the convention of the American Psychological Assn; they are not yet published, but are being submitted for publication. In our study of 157 adults with ADHD and IQ ≥ 120, we found that 73% were significantly impaired on at least 5 of 8 measures of executive function (working memory index and processing speed index on the WAIS-IQ test, index score for short term memory of stories just heard; 5 cluster scores of Brown ADD Scale). In our study of 117 children with high IQ and ADHD (ages 6 to 17 yrs) 62% showed significant impairment in at least 5 of 8 similar EF measures. Details of these two studies will be announced at publication.

Meanwhile, taken together, these three studies offer substantial evidence to support the notion that ADHD does occur in very bright children and adults. In some ways, these very bright individuals with ADHD may be at greater risk than many others because their ADD impairments often are not recognized by educators, parents or themselves until they have suffered years of frustration and underachievement in school.

Brain Matures a Few Years Later in ADHD, But Follows Normal Pattern

Our National Institute of Mental Health (NIMH) recently released results of a new brain imaging study that compared brain development of 223 children with ADHD to that of matched controls. Each was scanned at least twice at 3 year intervals. This study looked at brain development in 40K specific sites in the cortex; previous studies have examined only more global regions.

Results showed that, on average, the usual process of cortex thickening and then gradually pruning to develop more efficient circuits, took about 3 years longer in children with ADHD than in controls. This may be one factor that contributes to slower maturation of executive functions in individuals with ADHD. However, these structural differences do not explain why ADHD symptoms are alleviated with medication treatment in about 80% of individuals with ADHD. Neurochemical problems are clearly implicated in core symptoms of ADHD, along with structural delays demonstrated in this study.

Controversy Over MTA Results at 36 Months

Initial findings of the MTA study, published in 1999, reported outcomes for 579 children aged 7 to 9 years who had been carefully diagnosed with ADHD and had been randomly assigned to one of 4 groups for treatment:

  • a regimen of carefully managed medication treatmenta comprehensive program of behavioral and psychosocial treatmentsa combination of both the medication and psychosocial/behavioral treatments
  • intermittent evaluations with encouragement to find treatment in the community

The purpose of that study was to assess the effectiveness of each of these treatments in relation to one another, to find out:

  • Was a comprehensive package of carefully monitored medication with extensive psychosocial treatment better than just carefully monitored medication?
  • Was a well-conducted program of behavioral/psychosocial treatment alone more or less effective than treatment with just medication alone?
  • How did usual treatment options in the community compare in effectiveness with these carefully designed and rigorously executed treatment options of the study?

After 14 months of these controlled treatments, results showed that all four of the treatment options were helpful in alleviating ADHD symptoms for many of the children treated, though those treatments that included medication worked best. The surprising result was that mean scores of children in the group who received combined medication and psychosocial treatments were not significantly better for core symptoms of ADHD than the scores of those who received only the carefully managed medication. There was evidence that the combined treatment was more helpful for some other aspects of functioning, but not for the core ADHD symptoms.

After the initial 14 months, the MTA study provided no more treatment for any of the children enrolled. All were encouraged to seek ongoing treatment in the community; but some got it, some didn’t. There is no way to know the adequacy of that treatment; nor is there adequate information about additional factors impacting the development and functioning of these children. Yet the researchers have continued to monitor how the children who participated in that 14 month treatment program are doing. They plan to continue this monitoring for a full decade after the initial 14 months.

Results of the followup after 3 years were recently published. These have brought a flurry of claims and counterclaims about how to understand the effectiveness of treatment for ADHD. Some of this debate has been picked up by various public media where even some very reputable media outlets have announced that medication treatment for ADHD does not have beneficial effects over the longer term.

Unfortunately, the facts of the situation seem to be getting lost as various partisans argue for or against the longer term effectiveness of medication treatments for ADHD. Some of these children are continuing to get various treatments for ADHD; others are not. But none have been getting ongoing treatment that is carefully controlled and monitored to make fair comparisons of treatment options possible.

Under such conditions, it makes little sense to compare years later how those who received this or that treatment over the initial 14 months compare to those who received a different treatment for that initial period. There are far too many intervening variables to allow fair comparisons! Moreover, given that ADHD tends to be a chronic condition, why would one expect treatment effects to persist long after the treatment has ended?

This might be compared to a study of children with diabetes given various treatments for 14 months after which they are no longer systematically provided any treatment. How could effects of those interrupted treatments for diabetes, usually a chronic disorder, be assessed adequately years later? How could one control for the effects of treatments given or not given in the community? How could one control for multiple developmental and environmental challenges these children encounter in the intervening years?

It is unrealistic to expect 14 months of treatment, however effective, to have lasting effects upon children with ADHD whose treatment for this usually chronic condition has been interrupted!

Adjusting DSM-IV Diagnostic Criteria for ADHD in Adults

Diagnostic criteria for ADHD in the DSM-IV stipulate that at least some (though not all) symptoms of ADHD should have been noticeable before age 7 years in an individual diagnosed with ADHD. Those DSM-IV criteria also require that an adult have at least 6 of 9 symptoms of Inattention and/or Hyperactivity-Impulsivity to be diagnosed with ADHD. No empirical data support these requirements for adults and some prominent ADHD researchers have suggested that both requirements should be modified. Now more adequate empirical data provide support for making such changes.

Faraone and colleagues published a study (American J. of Psychiatry 2006, 163: 1720-1729) comparing a group of 127 adults who fully met DSM-IV criteria for ADHD, a group of 79 adults who met all requirements except the onset-before-age 7, a group of 41 adults who had ADHD symptoms, but did not meet the 6 of 9 threshold, and a group of 123 adults who had no ADHD.

Findings indicated that there were no significant differences between the full-ADHD and the late-onset ADHD adults in their current level of ADHD impairments or in their rates of risk for comorbid mood, disruptive behavior, substance use, or anxiety disorders. There were also no differences between these groups in their rates of learning disability, repeated grades, or placement in special classes. They also had lower grade and occupational levels. Moreover, both groups had comparable rates of ADHD in their relatives. Overall, results strongly argue that late-onset (meaning ADHD symptoms that were not apparent by age 7 years, though generally noticeable by age 12 yrs) is a valid form of ADHD that warrants diagnosis and treatment.

Comparisons between those adults who had fewer than 6 of 9 ADHD symptoms and the other groups were not as clear-cut. The subthreshold group was more impaired than those without ADHD in their need for academic tutoring in childhood, grades achieved in school, occupational status, and number of traffic citations received. They did not have comparable rates of ADHD heritability in their relatives. This does not mean that they did not suffer from ADHD; the fact that this group was considerably smaller than the late-onset and full-ADHD groups may explain the lower rates. However, more research is needed to clarify where the cutoff should be drawn for number of symptoms required for diagnosis of ADHD in adults.

Meanwhile, data from this study clearly argue that no adult should be denied a diagnosis of ADHD if they fully meet all other diagnostic criteria and simply did not show evidence of ADD impairments in early childhood.

Updated Assessment & Treatment Guidelines for ADHD released by AACAP

The American Academy of Child and Adolescent Psychiatry has published updated practice parameters for assessment and treatment of children and adolescents with ADHD (J. of American Academy of Child & Adolescent Psychiatry 2007, 46(7): 894-921. Unlike the 1997 version of their guidelines, these do not address assessment and treatment of adults with ADHD, but these updated parameters do provide useful, evidence-based guidelines for clinicians assessing and treating children and adolescents with ADHD, with and without various comorbid disorders. Detailed recommendations for dosing of various medication options is also provided. The parameters also advise that, except where there is strong evidence of need from medical history, EEG tests and brain imaging studies such as MRI, SPECT and PET are not recommended for evaluation of ADHD.

A New Long Acting Medication for ADHD

A new long-acting medication for ADHD is now available in the U.S. The brand name of this new product from Shire is Vyvanse. It is a pro-drug, meaning that it is made with a chemical bond that does not release its active ingredient until the drug is ingested and acted upon by an enzyme present in the stomach. If crushed and snorted, it does not give any “high.” The active ingredient in Vyvanse is dextroamphetamine, a medication used successfully for treatment of ADHD since the early 1940s. This medication, currently available in 3 sizes: 30 mg, 50 mg and 70 mg, delivers fairly smooth coverage for about 10 to 12 hours, usually without the “hills-and-valleys” effect sometimes caused by some longer acting medications. Preliminary reports indicate that 70 mg of Vyvanse is roughly equivalent to about 30 mg of Adderall-XR.

An Article for Educators about ADHD and Executive Functions

Educational Leadership, a respected publication for school administrators and teachers, invited me to write an article for educators about how understanding of ADHD has changed over recent years. That article, highlighting the importance of executive function impairments in ADHD and giving examples of how ADHD can be recognized in the classroom, is now available on my website in a PDF that can be downloaded for sharing with teachers or other educators who might benefit from updated information about ADD/ADHD.

Treatment of ADHD in Children with Epilepsy

Plioplys, Dunn and Caplan have provided a comprehensive review of research on psychiatric problems in children with epilepsy. They found that ADHD affects three to five times more children with epilepsy that children in the general population. They also reported a study from Iceland that found an elevated incidence of epilepsy in children with ADHD compared to normal controls. They cite several open-label studies indicating that children with well-controlled seizures and ADHD who were treated with methylphenidate had no recurrent seizures and an improvement in ADHD symptoms. (J. Amer Academy Child and Adolescent Psychiatry (2007) 46: 11, pp 1389-1402.

Methylphenidate in Bipolar Disorder with ADHD

Findling and colleagues conducted a double-blinded, placebo controlled study with youths aged 5 to 17 years diagnosed with both Bipolar Disorder and ADHD. All patients were already on medications to control their mood disorder, yet had sufficient impairments from ADHD to warrant an additional medication treatment for ADHD. Results were comparable to a previous study using mixed amphetamine salts with a similar population. Methylphenidate was clearly superior to placebo in treating ADHD symptoms in these youths whose bipolar symptoms were under control with mood stabilizing medications. (J. Amer Acad Child & Adolescent Psychiatry, 2007 46 (11) 1445-1453.

Atomoxetine for ADHD with Anxiety Disorders

Daniel Geller and colleagues have reported a double-blinded study that compared atomoxetine with placebo for treatment of children 8 to 17 years who had been diagnosed with ADHD and a comorbid anxiety disorder. Results indicated that ATX was effective in reducing ADHD symptoms in children with ADHD and comorbid anxiety disorders. There was also indication of some reduction in anxiety symptoms as rated by both clinician and self-report. Results suggest that ATX should be considered for treatment of children with both ADHD and one or more anxiety disorders. J. Amer Academy Child & Adolescent Psychiatry. 2007, 46(9), 1119-1127.

Risperidone for ADHD with Aggression

Armenteros, Lewis and Davalos reported a placebo controlled pilot study in which they used risperidone for treatment resistant aggression and ADHD. All 25 children aged 7 to 12 years were stabilized on stimulant medications for their ADHD symptoms, but continued to exhibit significant aggressive behaviors. Results showed that parent reports indicated that all of the children receiving Risperdal and 77% of the placebo group showed at least 30% improvement on parent rating scales for aggressive behaviors. Researchers concluded that the Risperdal was well-tolerated and mildly effective when used in combination with stimulant meds for ADHD. Dosing of Risperdal was 1.08 mg/day, a fairly low dose. J. Amer Acad Child & Adolescent Psychiatry 2007. 46 (5) 558-565.

Useful Books

Quirky Kids: Understanding and Helping Your Child Who Doesn’t Fit In-When to Worry and When Not to Worry. Perri Klass and Eileen Costello (New York: Ballantine, 2003. Two perceptive pediatricians describe the complexities of children who seem to be outside the usual developmental patterns for their age, though not fully meeting diagnostic criteria for major mental illness. “They have a hard time fitting in…In particular, their ability to socialize with other children is impaired-sometimes mildly, sometimes severely.” Often these children are labeled “Asperger’s Syndrome”, “Non-Verbal Learning Disorder” “OCD” or “Sensory Integration Dysfunction.” The authors offer sensible advice for parents of these children.

Cognitive-Behavioral Therapy for Adult ADHD: An Integrative Psychosocial and Medical Approach. J. Russell Ramsay and Anthony L. Rostain. New York: Routledge, 2008. A well-thought out integrated plan for assessment and treatment of adults with ADHD is provided by these colleagues, a clinical psychologist and psychiatrist, who recognize the importance of utilizing appropriate medications and cognitive-behavioral treatment of adults with ADHD. Very practical advice is provided for clinicians seeking to provide care for these patients.

ADHD in Adults: What the Science Says. Russell A.Barkley, Kevin R. Murphy, and Mariellen Fischer. New York: Guilford Press, 2008. In this very substantial, comprehensive volume Barkley and colleagues have reviewed research information about adults with ADHD, including findings from their studies at the University of Mass and their longitudinal study in Milwaukee. Special strengths of the book are its focus on ADHD impairments in daily functioning, detailed attention to comorbid disorders in adults with ADHD and its offering of data to suggest more adequate diagnostic criteria for adults with ADHD. A very useful resource for researchers and for clinicians seeking research-based information about adults with ADHD.

News From My Office

Website in Spanish: Thanks to the generosity of a kind donor, several pages of my website, are now available in Spanish by clicking the link on the home page. When it is possible, more pages on site will be translated and posted.

Travels: During recent months I have enjoyed teaching at the HELP Group’s annual conference in Los Angeles, a regional ADD conference in Seattle, the Canadian national Learning Disabilities conferences in St. John’s, Newfoundland, a conference for educators in Toronto, the Learning and the Brain conference at Harvard, and regional medical conferences in Melbourne, Brisbane and Sydney, Australia. In December, I’ll be speaking at a statewide Learning Disabilities conference in Atlanta, then in January I’ll be presenting for regional medical conferences in Cairo, Egypt and Amman, Jordan.

Translations: My book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults, has now been translated into four additional languages: Chinese (Peking University Medical Press, Beijing, China); Portugese: Tanstorno de Deficit de Atencao: A Mental Desfocada em Criancas e Adultos. Artmed Publishers, Sao Paolo, Brazil; and Spanish : Trastorno por Deficit de Atencion: Una menta desenfocada en ninos y adultos. Masson, Barcelona. The edited book, Attention Deficit Disorders and Comorbidities in Children, Adolescents and Adults (American Psychiatric Press, 2000) was recently published in Dutch: ADHD en Comorbiditeit: gedurende de levensloop.(Harcourt Assessment BV Amsterdam.

Forthcoming: An updated version of Attention Deficit Disorders and Comorbidities in Children, Adolescents and Adults is currently in production by American Psychiatric Press and should be ready for release sometime in Spring, 2008.