ADHD Overview
The Marshmallow Test, "Willpower" and ADHD
The most puzzling feature of ADHD is that it is situationally specific. Virtually all children and adults with ADHD have at least a few specific activities in which they are able to focus their attention very well for long periods of time, are able to keep several different things in mind simultaneously, are able to sustain their efforts for challenging tasks, and can prevent themselves from acting too impulsively—all this even though they have great difficulty in demonstrating those same skills for many other tasks that they recognize as important.
Growing Up With ADHD: Clinical Care Issues
“Growing Up With ADHD: Clinical Care Issues,” was published in the January 2016 issue of Psychiatric Times, a publication distributed to all psychiatrists in the U.S. It describes why young adults with ADHD often do not get the help they need when they are no longer being cared for by their pediatrician. It includes some suggestions for how they can be provided more adequate care.
10 Myths about ADHD
This article, reprinted with permission from ATTENTION magazine (June, 2013 issue), is comprised of excerpts from the first chapter of Dr. Brown’s book, A New Understanding of ADHD in Children and Adults: Executive Function Impairments (Routledge, 2013).
ADHD: From Stereotype to Science
This article describes an updated understanding of ADHD. Published in Educational Leadership, a national magazine for teachers and school administrator, it describes how ADHD is not primarily a problem of behavior, but more a problem with the management system of the brain. The article explains how ADHD involves working memory problems which impact reading and writing. Parents may want to share this with teachers and read it for themselves.
Inside the ADD MIND
Dr. Brown’s new model of the management system of the brain is described in this edited excerpt from the first chapter of his recent book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults. The article includes a diagram of the new model of executive functions and describes why people with ADD/ADHD can pay attention very well for tasks that really interest them, while they have great difficulty in making themselves pay attention to other tasks that they recognize as important.
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Reprinted with permission from the April/May issue of ADDITUDE magazine
The World Federation of ADHD Guide
This 124 page ebook sponsored by the World Federation of ADHD was written by leading ADHD experts around the world. It provides accurate information about the causes of ADHD, assessment of ADHD over the lifespan, as well as medications and psychosocial treatments for children, teens, and adults with ADHD.
Chapter 4 was contributed by Dr. Thomas E. Brown and Dr. Ryan J. Kennedy regarding Psychooscial Treatments for ADHD.
A New Approach to Attention Deficit Disorder
Written for educators, this article describes how ADD is no longer seen as a simple behavior disorder, but as a complex syndrome of impairments in the management system of the brain. Examples of students in elementary and high school illustrate how ADD can impact learning and academic productivity at different ages and stages in school. Some guidelines for assessment are included and the importance of early identification is emphasized.
The Myths & Facts about ADD/ADHD
This list of 10 common myths about ADD and facts to counter those myths was published with the article above in Educational Leadership magazine. The information comes from Dr. Brown’s book, Attention Deficit Disorder: The Unfocused Mind in Children and Adults (Yale University Press, 2005).
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Reprinted with permission from the February, 2007 issue of Educational Leadership, a magazine for leaders in education.
Executive Functions
A New Approach to Attention Deficit Disorder
Written for educators, this article describes how ADD is no longer seen as a simple behavior disorder, but as a complex syndrome of impairments in the management system of the brain. Examples of students in elementary and high school illustrate how ADD can impact learning and academic productivity at different ages and stages in school. Some guidelines for assessment are included and the importance of early identification is emphasized.
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ADD/ADHD and Impaired Executive Function in Clinical Practice
This article, intended for physicians or psychologists who are evaluating adults for ADHD, describes how executive function impairments associated with ADHD can be recognized in clinical practice. It emphasizes that diagnosis of ADHD does not require esoteric neuropsychological tests; it describes chronic difficulties in daily life that are characteristic of adults with ADHD. The article also notes that the DSM-IV requirement for age of onset “before 7 years has been shown to be invalid. Practical suggestions about initiating and monitoring medication treatment is also included.” Thomas E. Brown in Current Attention Deficit Disorder Reports, 1: 37-41, 2009
AD/HD Early Adulthood Challenges
The late teens and early twenties present multiple challenges to every young adult, but for those with ADD/ADHD, these challenges may be especially difficult. This article describes specific ways in which those with ADHD often have difficulty with linking school to a career, managing money, developing and sustaining satisfying relationships, seeking and keeping a job, moderating substance use, and utilizing adequate medical care.
Reprinted from the February, 2006 issue of ATTENTION! Magazine, with permission from CHADD
Executive Functions: Six Aspects of a Complex Syndrome
This article, published in ATTENTION magazine, provides many examples from everyday life to illustrate the various types of cognitive impairments typical of children and adults with ADD/ADHD. Descriptions and explanations of these “executive functions” are edited excerpts from the 2nd chapter of Dr. Brown’s book, Attention Deficit Disorders: The Unfocused Mind in Children and Adults.
Comparison of Two Measures of Working Memory Impairments in 220 Adolescents and Adults with ADHD
Working memory is one of the most significant impairments of ADHD in adolescents and adults. This study demonstrated that a brief standardized story memory test is a more sensitive and relevant measure of working memory than is the digit span test often used for assessment of working memory in those with ADHD. Despite high IQ, most participants with ADHD scored significantly lower on the story memory test than do others in the general population.
Ryan J. Kennedy, D. M. Quinlan, and T.E. Brown. Journal of Attention Disorders (2016)
Executive Function Impairments in High IQ Children and Adolescents
This article reports a study of 117 children and adolescents with ADHD, all of whom have IQ scores of 120 or higher, placing them in the top 9% of their age groups. The study shows that extremely bright kids can suffer from ADHD in ways that seriously interfere with their schoolwork, especially as they meet the challenges of junior high and high school. Most of these kids scored very high on verbal and visual spatial abilities, but were impaired by much weaker abilities in working memory, processing speed and a variety of other executive functions. Thomas E. Brown, Philipp C. Reichel, and Donald M. Quinlan in the Open Journal of Psychiatry. (July, 2011). 56-65.
DSM-IV: ADHD and Executive Function Impairments
Attention-deficit/hyperactivity disorder (ADHD) is a medical condition that first appears in childhood, affecting 6% to 8% of children. In more than 60% of cases, impairments of ADHD extend into adulthood as well. Since it was first described 100 years ago, conceptualization of ADHD has gradually shifted from focus on hyperactive and impulsive behaviors to recognition of cognitive impairments as the central and most persistent symptoms of the disorder. Current research suggests that ADHD is essentially a developmental impairment of the brain’s executive functions-the management system of the brain’s cognitive operations. This article reviews the phenomenology of currently recognized symptoms of ADHD and suggests that there is one important executive function impaired in ADHD that is not included in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for the disorder: impairments in regulation of emotion. Thomas E. Brown, Ph.D. in Johns Hopkins University Advanced Studies in Medicine (2002) Vol. 2 (25): pp. 910-914.
Assessment of Short-Term Verbal Memory Impairments in Adolescents and Adults with ADHD
One hundred seventy-six adolescents and adults diagnosed with ADHD (DSM-IV criteria) were assessed with a measure of short-term verbal memory. The short-term verbal memory score of each subject was compared with their verbal abilities on two measures. Percentages of ADHD subjects with significant discrepancy between verbal IQ and short-term verbal memory were compared with the standardization sample for the verbal memory measure. Results: A majority of adolescents and adults diagnosed with ADHD demonstrated significant discrepancy between performance on the short-term verbal memory measure and verbal IQ. The percentage of ADHD subjects with a significant discrepancy between these two measures greatly exceeded the percentage of persons in the general population showing such a discrepancy. This brief measure of short-term verbal memory may be a useful measure to include in a comprehensive assessment for ADHD symptoms in adolescents and adults.
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Donald M. Quinlan, Ph.D. and Thomas E. Brown, Ph.D. in Journal of Attention Disorders, (2003) Vol. 6: pp 143-152.
Executive Function Impairments in High IQ Adults with ADHD
This article reports a study of 157 adults aged 18 to 55 years with ADHD, all of whom have IQ scores of 120 or higher, placing them in the top 9% of their age groups. The study shows that extremely bright adults can suffer from ADHD in ways that seriously interfere with their higher education and/or employment. The study highlights impairments of working memory, processing speed, and a variety of other executive functions that that be assessed with standardized measures. It also notes that many of these high IQ adults did not show significant ADHD impairments until they got into high school or college. Thomas E. Brown, Philipp C. Reichel, and Donald M. Quinlan in Journal of Attention Disorders. (2009) 13 (2) 161-167.
Comorbidities
AD/HD and Co-Occurring Conditions
Individuals with ADHD are six times more likely to have at least one additional psychiatric disorder sometime during their lifetime. Dr. Brown’s edited book, ADHD Comorbidities: Handbook for ADHD Complications in Children and Adults, published in January, 2009, describes how ADHD is different when the person also has an anxiety disorder, a mood disorder, a learning disorder, OCD, a sleep disorder, etc. In February , 2009 ATTENTION magazine published this article that summarizes key points from a section of the first chapter of that new book; it describes a new model for understanding ADHD and co-occurring conditions.
Assessment and Management of Sleep Problems in Youths With Attention-Deficit/Hyperactivity Disorder
A research work-group report.
Extended time improves reading comprehension test scores in adolescents with ADHD
Reporting on a study of 145 adolescents with ADHD, this article shows how reading comprehension difficulties of those with ADHD are related not so much to weak verbal abilities or weak basic reading skills, but to impairments of working memory and processing speed that are characteristic of ADHD. Results show that only 43% of the sample were able to score close to their verbal ability index when doing a timed reading test, but 78% were able to reach that goal when allowed modest amount of extended time on a standardized test of reading comprehension. Thomas E. Brown, Philipp C. Reichel, and Donald M. Quinlan in the Open Journal of Psychiatry. (October, 2011). 1: 79-87.
Unrecognized Attention-Deficit/Hyperactivity Disorder in Adults Presenting with Other Psychiatric Disorders+
Many adults with a diagnosed psychiatric disorder also have attention-deficit/hyperactivity disorder (ADHD). In many cases, comorbid ADHD is unrecognized and/or undertreated. Differential diagnosis of adult ADHD can be challenging because ADHD symptoms may overlap with other psychiatric disorders and patients may lack insight into their ADHD-related symptoms. Current ADHD diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision may prevent appropriate diagnosis of many patients with significant ADHD symptoms. Adults may not be able to provide a history of onset of symptoms during childhood, and it may be difficult to confirm that ADHD symptoms are not better accounted for by other comorbid psychiatric conditions. Comorbid ADHD is most prevalent among patients with mood, anxiety, substance use, and impulse-control disorders. ADHD can negatively affect outcomes of other comorbid psychiatric disorders, and ADHD symptoms may compromise compliance with treatment regimens. Furthermore, unrecognized ADHD symptoms may be mistaken for poor treatment response in these comorbid disorders. In these individuals, ADHD pharmacotherapy seems to be as effective in reducing core ADHD symptoms, as it is in patients who have no comorbidity. Limited evidence further suggests that ADHD therapy may help to improve symptoms of certain psychiatric comorbidities, such as depression. Therefore, management of ADHD may help to stabilize daily functioning and facilitate a fuller recovery. CNS Spectr CNS Spectr. 2008;13(11):977-984 . 2008;13(11):977-984
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By Russell A. Barkley, PhD, and Thomas E. Brown, PhD
Attention Deficit Disorders and Sleep/Arousal Disturbances
Many children, adolescents and adults with Attention Deficit Disorders report chronic difficulties with falling asleep, awakening, and/or maintaining adequate daytime alertness. These problems may be due to a variety of factors, including environment, lifestyle and psychiatric comorbidities. Impairments in sleep/arousal may also be related more directly to the underlying pathophysiology of ADD. This chapter describes clinical manifestations of sleep/arousal problems often associated with ADD and reviews behavioral and medication options for treatment. Thomas E. Brown and William J. McMullen in Annals of the New York Academy of Sciences (2001) Vol. 931, pp. 271-286
Fluoxetine and Methylphenidate in Combination for Treatment of Attention Deficit Disorder and Comorbid Depressive Disorder
Children and adolescents with attention deficit disorders and comorbid conditions who had shown inadequate treatment responses to methylphenidate (MPH) alone, were treated by addition of fluoxetine to the MPH. After 8 weeks in open trial, all 32 patients showed positive therapeutic responses in attention, behavior and affect. Thirty of the 32 children showed clinically significant responses and the other two had statistically, but not clinically significant responses. After 12 weeks of treatment one patient showed deterioration in clinical status. The children had improved report card grades in major subjects (p < .0001), and showed significant improvements (p < .0001) on the Children’s Global Assessment Scale (C-GAS), Conners Parent Rating Scale (CPRS) and Children’s Depression Inventory (CDI). No significant adverse effects were observed. These preliminary results suggest that fluoxetine and methylphenidate in combination may be safe and effective for some children with ADHD and with comorbid anxiety or depressive symptoms who do not show adequate responses to MPH or fluoxetine alone. G. Davis Gammon, M.D. and Thomas E. Brown, Ph.D. in Journal of Child and Adolescent Psychopharmacology (1993) Vol. 3, pp. 1-10.
Assessments
Medication
Atomoxetine (Strattera) and Stimulants in Combination for Treatment of Attention Deficit Hyperactivity Disorder: Four Case Reports
Atomoxetine and stimulants have both been demonstrated effective as single agents for treatment of attention deficit hyperactivity disorder in children, adolescents and adults. However, attention deficit hyperactivity disorder symptoms in some patients do not respond adequately to single-agent treatment with these medications, each of which is presumed to impact dopaminergic and noradrenergic networks by alternative mechanisms in different ratios. Four cases are presented to illustrate how atomoxetine and stimulants can be utilized effectively in combination to extend duration of symptom relief without intolerable side effects or to alleviate a wider range of impairing symptoms than either agent alone. This combined pharmacotherapy appears effective for some patients who do not respond adequately to monotherapy, but because there is virtually no research to establish safety or efficacy of such strategies, careful monitoring in needed. Thomas E. Brown, Ph.D. in Journal of Child and Adolescent Psychopharmacology, (2004) Vol. 14: pp. 129-136.
Clinical utility of ADHD symptom thresholds to assess normalization of executive function with lisdexamfetamine dimesylate treatment in adults
This analysis assessed the relationship of various cutoff scores of the ADHD Rating Scale IV (ADHD-RS-IV) to levels of improvement in ADHD-related executive function (EF), measured by the Brown ADD Scale for Adults (BADDS), which may provide a measure of clinically meaningful EF improvement after ADHD treatment.
Impact of atomoxetine on subjective attention and memory difficulties in perimenopausal and postmenopausal women
Perimenopausal and postmenopausal women frequently report midlife onset of
impairments of attention, organization, and short-term memory. We sought to determine whether these cognitive symptoms in healthy women in the menopause transition without a history of ADHD would respond to treatment with atomoxetine(ATX), a medication demonstrated to be effective in reducing similar cognitive impairments in adults with ADHD.
New onset executive function difficulties at menopause: a possible role for lisdexamphetamine
Reports of cognitive decline, particularly in the domains of executive functions (EFs), are common among menopausal women. This study aims to detertime the impact of the psychostimulant lisdexamfetamine (LDX) on subjective and objective cognitive function among menopausal women who report new-onset EF complaints.
Open-label administration of lisdexamfetamine dimesylate improves executive function impairments and symptoms of attention-deficit/hyperactivity disorder in adults.
Executive function (EF) impairment in attention-defi cit/hyperactivity disorder (ADHD) may account for behavioral symptoms such as poor concentration, impaired working memory, problems in shifting among tasks, and prioritizing and planning complex sets of tasks or completing long-term projects at work or school. Poor self-regulation and control of emotional behaviors frequently are seen in patients with ADHD. This study assessed EF behaviors in adults with ADHD at baseline and after 4 weeks of treatment with lisdexamfetamine dimesylate (LDX).
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By Thomas E. Brown, Matthew Brams, Joseph Gao, Maria Gasior & Ann Childress
Lisdexamfetamine Effects on Executive Activation and Neurochemistry in Menopausal Women with Executive Function Difficulties
During the menopause transition, many women with no history of executive functioning deficits report cognitive difficulties in domains including working memory, organization,focus, and attention (Epperson et al, 2011). This midlife onset of executive difficulties may be a result of reduced
estradiol modulation of the executive system (Shanmugan and Epperson, 2014). Lisdexamfetamine (LDX) has been suggested to be a safe and effective treatment option for these women. However, the mechanism by which LDX improves executive functioning in these women is not known. Here we investigated the effects of LDX on brain activation and neurochemistry, hypothesizing that LDX would be associated with increased activation and decreased glutamate in executive regions.
