The Misdiagnosis of ADHD in Adults (1)

The-Misdiagnosis-of-ADHD-in-Adults-1-Christian-Jonathan-Haverkampf-psychiatry-series-1

The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11

CAADID.. 12

DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25

 

Introduction

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)

Attention

When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)

Communication

The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).

Autism

Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).

Trauma

Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).

OCD

Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).

Symptoms

Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.

Subtypes

It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)

Assessment

The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.

Communication

How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.

CAADID

The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)

DIVA

Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.

Questionnaires

Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.

Malingering

Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).

Comorbidity

High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).

Conclusion

Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy, the CFT logo with waves and leaves, Dr Jonathan Haverkampf, Journal of Psychiatry Psychotherapy and Communication, and Ask Dr Jonathan are registered trademarks.

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ADHD and Medication (3)

ADHD-and-Medication-3-Christian-Jonathan-Haverkampf-psychiatry-series

ADHD and Medication

Christian Jonathan Haverkampf, M.D.

Attention deficit hyperactivity disorder (ADHD) has become treatable with medication and psychotherapeutic approaches that have become available recently. This article provides a brief overview of some aspects of the medication used for ADHD.

The most widely used group of medication for ADHD comprises the stimulants. Stimulants such as methylphenidate and amphetamine are currently the most common treatment for ADHD. The substance used should fit the particular individual and the particular condition and situation.

Open and transparent communication between clinician and patient is of paramount importance in the case of ADHD for a successful treatment outcome.

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry

Table of Contents

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry. 1

Introduction. 5

The Prefrontal Cortex. 5

Substance Abuse. 6

Psychotherapy. 6

Social 6

Diagnosis of ADHD.. 7

Different Types of ADHD.. 7

EEG.. 8

Diagnosis of ADHD in Children. 8

Stability over Time. 9

Adult ADHD.. 10

Baseline assessment. 11

Medication. 11

Long-Term Effect. 12

Anxiety. 12

Tics. 12

Emotional Lability. 13

Smoking. 13

Medication Groups. 13

Methylphenidate. 13

Atomoxetine. 14

Extended Release. 14

Sex. 14

Medication for Children. 14

Consider offering. 15

Medication for Adults. 15

Consider offering. 15

ADHD Type and Medication. 16

Subtype. 16

Sleep. 16

Anxiety. 16

Genotype. 17

Dose Titration. 17

Abuse. 18

Coexisting Conditions. 18

Caution. 18

Psychosis. 19

Bipolar Disorder. 19

Aggression. 20

Seizures. 20

Priapism.. 20

Peripheral Vasculopathy, Including Raynaud’s Phenomenon. 20

Visual Disturbance. 20

Drug Dependence. 20

Pregnancy. 21

Monitoring. 21

Behavior. 21

Height. 21

Weight. 22

Cardiovascular System.. 22

Children and Adolescents. 23

Adults. 23

Tics. 23

Sexual Dysfunction. 23

Seizures. 23

Sleep. 24

Compliance. 24

Psychotherapy. 24

References. 25

Introduction

The use of medications to treat attention deficit hyperactivity disorder (ADHD) has increased. Using a common protocol and data from thirteen countries and one SAR, Raman and colleagues show increases over time but large variations in ADHD medication use in multiple regions across the world. (Raman et al., 2018)

While medication is effective, one needs to keep in mind that most mental health conditions, and particularly ADHD, is caused and maintained not only by neurobiology, but also by psychological, environmental and social patterns. Most patients would thus benefit from a combined approach. Safren and colleagues, for example, studied cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. The data showed that CBT for adults with ADHD with residual symptoms can be a feasible, acceptable, and potentially efficacious next-step treatment approach. (Safren et al., 2005)

The most widely used class of medication for ADHD is the group of stimulants, including methylphenidate and other substances. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. For years, it was assumed that stimulants had paradoxical calming effects in ADHD patients, whereas stimulating ‘normal’ individuals and producing locomotor activation in rats. It is now known that low doses of stimulants focus attention and improve executive function in both normal and ADHD subjects. Stimulants are frequently used to treat attention deficit-hyperactivity disorder. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower. On the other hand, well-monitored stimulant treatment may even reduce the risk for alcohol and substance use in adolescent ADHD. (Hammerness, Petty, Faraone, & Biederman, 2017)

The Prefrontal Cortex

At low doses that improve prefrontal cortex-dependent cognitive function and that are devoid of locomotor-activating effects, methylphenidate substantially increases norepinephrine and dopamine efflux within the prefrontal cortex. In contrast, outside the prefrontal cortex these doses of methylphenidate have minimal impact on norepinephrine and dopamine efflux. (Berridge et al., 2006) The prefrontal cortex regulates behavior and attention using representational knowledge, and imaging and neuropsychological studies have shown that the prefrontal cortex is weaker in subjects with ADHD. This cortical area is very sensitive to levels of catecholamines: moderate levels engage postsynaptic α2A-adrenoceptors and D1 receptors and improve prefrontal regulation of behavior and attention, while high levels impair prefrontal function via α1-adrenoceptors and excessive D1 receptor stimulation. Administering low doses of methylphenidate to rats improves the working memory and attentional functions of the prefrontal cortex, while high doses impair working memory and produce a perseverative pattern of errors similar to that seen in patients. The low dose improvement is blocked by either an α2-adrenoceptor or Dl receptor antagonist, suggesting that both norepinephrine and dopamine contribute to the beneficial actions of stimulant medications. (Arnsten, 2006)

Substance Abuse

Chang and colleagues found no indication of increased risks of substance abuse among individuals prescribed stimulant ADHD medication; if anything, the data suggested a long‐term protective effect on substance abuse. (Chang et al., 2014) However, one should still be vigilant towards stimulant misuse and diversion in ADHD patients.

Careful therapeutic monitoring can reduce medical misuse and diversion of controlled medication among adolescents. They appear to be more prevalent among adolescents who misuse their controlled drugs. In a survey study by McCabe and colleagues, misusers were more likely than non-misusers to divert their controlled medications and to abuse other substances. The odds of a positive screening result for drug abuse were substantially higher among medical misusers compared with medical users who used their controlled medications appropriately. The odds of drug abuse did not differ between medical users who used their controlled medications appropriately and nonusers. Most adolescents who used controlled medications took their medications appropriately. (McCabe et al., 2011) In a literature review by Torgersen and colleagues, psychopharmacotherapy did not seem to affect substance use disorder. (Torgersen, Gjervan, & Rasmussen, 2008)

It is is also important to keep in mind the risk of not medicating ADHD. Empirical data indicates that ADHD is a significant risk factor for the development of SUDs and cigarette smoking in both sexes. (Wilens et al., 2011) One would also need to include the risk of self-medication with illegal drugs due to problems that can be caused or maintained by ADHD, such as unemployment or relationship difficulties (Haverkampf, 2017a).

Psychotherapy

Psychotherapy is often very valuable in combination with medication to alleviate the impairments of ADHD. The author has described communication-focused therapy for ADHD elsewhere. (Haverkampf, 2010, 2017d, 2018b) Unfortunately, while the efficacy of stimulants in reducing ADHD symptoms for adults is well documented in meta-analyses, there is a concerning lack of meta-analysis about other treatment interventions (Moriyama, Polanczyk, Terzi, Faria, & Rohde, 2013). Apart from reports using behavioral therapies, there are also several studies on the successful use of psychodynamic techniques

Social

The social and environmental aspects are often underestimated in the case of ADHD. Pfiffner and colleagues evaluated in their study the efficacy of the Child Life and Attention Skills (CLAS) program, a behavioral psychosocial treatment integrated across home and school, for youth with attention-deficit/hyperactivity disorder-inattentive type (ADHD-I). CLAS resulted in greater improvements in teacher-reported inattention, organizational skills, social skills, and global functioning relative to both PFT and TAU at posttreatment. Parents of children in CLAS reported greater improvement in organizational skills than PFT and greater improvements on all outcomes relative to TAU at posttreatment. Differences between CLAS and TAU were maintained at follow-up for most parent-reported measures but were not significant for teacher-reported outcomes. Direct involvement of teachers and children in CLAS appears to amplify effects at school and home and underscores the importance of coordinating parent, teacher, and child treatment components for cross-setting effects on symptoms and impairment associated with ADHD-I. (Pfiffner et al., 2014)

There are also several psychological models that have been helpful in the treatment of adults. Solanto and colleagues assessed the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills in thirty patients. General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale as well as improvement on the Brown ADD Scales. The findings indicated that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008)

Charach and colleagues in a review of the literature between 1980 and 2010. The available evidence suggested that underlying prevalence of ADHD varies less than rates of diagnosis and treatment. Patterns of diagnosis and treatment appeared to be associated with such factors as locale, time period, and patient or provider characteristics. The strength of evidence for parent behavior training as the first-line intervention for improved behavior among preschoolers at risk for ADHD was high, while the strength of evidence for methylphenidate for improved behavior among preschoolers was low. Evidence regarding long-term outcomes following interventions for ADHD was sparse among persons of all ages, and therefore inconclusive, with one exception. Primary school–age children, mostly boys with ADHD combined type, showed improvements in symptomatic behavior maintained for 12 to 14 months using pharmacological agents, specifically methylphenidate medication management or atomoxetine. (A Charach et al., 2011)

Diagnosis of ADHD

The clinical interview is the most important pillar in the process of diagnosing ADHD. Reflecting on the interaction with the patients and observing the communication patterns used is very helpful in the diagnosis and in the treatment of ADHD.

There is also the overall problem in the case of ADHD that, while the diagnostic criteria in the diagnostic manuals are quite clear, it may sometimes be diagnosed based on the individual heuristic criteria the therapist has developed over time. Since attention deficit can occur in several disorders and is not as pathognomonic as, for example, feeling depressed or anxious for depression and anxiety, respectively, it takes more complex algorithms to formulate a diagnosis. However, there still seem to be problems, which, however, are not uncommon in psychiatric diagnosis. The accuracy itself even seems to depend on the diagnosis. For some diagnoses, especially psychotic categories, administrative data were generally predictive of true diagnosis. For others, such as anxiety disorders, the data were less satisfactory. (Davis, Sudlow, & Hotopf, 2016)

Different Types of ADHD

ADHD is to a certain degree heterogeneous which can have a n efefct of how well a particular treatment modality or even a specific treatment works. Unfortunately, there are not many clear parameters that can help to optimize treatment. However, in speical circumstances there may be information available that can be helpful in designing a treatment plan.

  1. ADHD, Predominantly Inattentive Presentation (ADHD-I)

Patients have difficulty paying attention. They are easily distracted but do not have significant symptoms of impulsivity or hyperactivity. This is sometimes called attention-deficit disorder (or ADD).

  • ADHD, Predominantly Hyperactive-Impulsive Presentation (ADHD-H)

Patients who have this type of ADHD have symptoms of hyperactivity and feel the need to move constantly. They also struggle with impulse control. Inattention is not a significant issue. This type is seen most often in very young children.

  • ADHD, Combined Presentation (ADHD-C)

Patients with this type of ADHD show significant problems with both hyperactivity/impulsivity and inattention. Children may gradually have less trouble with hyperactivity/impulsivity as they get into their teen years.

In a study by Mullins and colleagues, children with ADHD varied more in the size and direction of their time reproduction errors than control children. Those with ADHD-C demonstrated more intraindividual variability than did those with ADHD-I in the size of their errors. The data provided support for a relationship between sustained attention and time reproduction.(Mullins, Bellgrove, Gill, & Robertson, 2005)

EEG

Arns and colleagues demonstrated in their study that the EEG phenotypes as described by Johnstone, Gunkelman & Lunt are identifiable EEG patterns with good inter-rater reliability. Furthermore, it was also demonstrated that these EEG phenotypes occurred in both ADHD subjects as well as healthy control subjects. The Frontal Slow and Slowed Alpha Peak Frequency and the Low Voltage EEG phenotype discriminated ADHD subjects best from controls (however the difference was not significant). The Frontal Slow group responded to a stimulant with a clinically relevant decreased number of false negative errors on the CPT. The Frontal Slow and Slowed Alpha Peak Frequency phenotypes have different etiologies as evidenced by the treatment response to stimulants. In previous research Slowed Alpha Peak Frequency has most likely erroneously shown up as a frontal theta sub-group. Furthermore, the divergence from normal of the frequency bands pertaining to the various phenotypes is greater in the clinical group than in the controls. Investigating EEG phenotypes provides a promising new way to approach EEG data, explaining much of the variance in EEGs and thereby potentially leading to more specific prospective treatment outcomes. (ARNS, GUNKELMAN, BRETELER, & SPRONK, 2008)

Diagnosis of ADHD in Children

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001. (American Academy of Pediatrics, 2000)

Bruchmüller and colleagues sent a case vignette to 1,000 child psychologists, psychiatrists, and social workers and asked them to give a diagnosis. The results were that in the non-ADHD vignettes, 16.7% of therapists diagnosed ADHD. In the boy version of these vignettes, therapists diagnosed ADHD around 2 times more than they did with the girl vignettes. Their study suggested that there may be an overdiagnosis of ADHD and that the patient’s gender influences diagnosis considerably. (Bruchmüller, Margraf, & Schneider, 2012) It is unclear whether the problem is that therapists do not adhere enough to diagnostic manuals and diagnostic criteria, or if there are other factors, such as issues with the diagnostic criteria or diagnostic algorithms. Another explanation could be that a significant amount of information gets lost in the interaction with the patient. Especially, if the time allowed for the meeting is very limited, there is the risk of both over- and underdiagnosis where maybe several other issues are involved, such as trauma, anxiety or depression, for example.

This guideline has been developed to advise on the treatment and management of attention deficit hyperactivity disorder (ADHD). The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, service users and carers, and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with ADHD while also emphasizing the importance of the experience of care for them and their carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps; future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, people with ADHD and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists. ((UK, 2018)

While the disorder continues to be viewed as one of inattention and/or hyperactive-impulsive behavior, theories of ADHD are beginning to focus more on poor inhibition and deficient executive functioning (self-regulation) as being central to the disorder. Clinicians should be aware of these problems and the adjustments that need to be made to them when dealing with special populations that were not represented in the field trials used to develop these criteria. (Barkley, 2003)

Kadesjo and Gillberg examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2–4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more—and 67% at least two—comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behavior problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions. (Kadesjö & Gillberg, 2001)

Stability over Time

Children rarely remain in the HT classification over time; rather, they sometimes desist from ADHD but mostly shift to CT in later years.  In a study on a sample of 118 4- to 6-year-olds who met DSM-IV criteria for ADHD, Lahey and colleagues showed that the number of children who met criteria for ADHD declined over time, but most persisted. Children who met criteria for the combined subtype (CT, n = 83) met criteria for ADHD in more subsequent assessments than children in the predominantly hyperactive-impulsive subtype (HT, n = 23). Thirty-one (37%) of 83 CT children and 6 (50%) of 12 children in the predominantly inattentive subtype (IT) met criteria for a different subtype at least twice in the next 6 assessments. Children of the HT subtype were even more likely to shift to a different subtype over time, with HT children who persisted in ADHD mostly shifting to CT in later assessments. The subtypes exhibited consistently different mean levels of hyperactive-impulsive symptoms during years 2 through 8 that corresponded with their initial subtype classifications, but initial subtype differences in inattention symptoms diminished in later years. Conclusions  In younger children, the CT and IT may be stable enough to segregate groups for research, but they seem too unstable for use in the clinical assessment of individual children. (Lahey, Pelham, Loney, Lee, & Willcutt, 2005) The authors suggested a continuous hyperactivity-impulsivity rating model in the diagnosis.

Adult ADHD

The diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults is a complex procedure which should include retrospective assessment of childhood ADHD symptoms either by patient recall or third party information, diagnostic criteria according to DSM-IV, current adult ADHD psychopathology including symptom severity and pervasiveness, functional impairment, quality of life and comorbidity. The author has discussed the diagnosis of adult ADHD in greater depth elsewhere. (Haverkampf, 2018c)

A valid and reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview, neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the combination of cognitive behavioral therapy and medication. (Davidson, 2008)

The Wender-Utah Rating Scale (WURS) and the Childhood Symptoms Scale by Barkley and Murphy try to make a retrospective assessment of childhood ADHD symptoms. The Connors Adult ADHD Rating Scales (CAARS), the Current Symptoms Scales by Barkley and Murphy (CSS), the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. or the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.) are self-report rating scales focusing mainly on the DSM-IV criteria. The CAARS and the CSS have other report forms too. The Brown ADD Rating Scale (Brown ADD-RS) and the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.) are instruments for use by clinicians or significant others. Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3. This makes the instruments useful to follow the course of the disease quantitatively. Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. The most comprehensive procedures are the Brown ADD Diagnostic Form and the Adult Interview (AI) by Barkley and Murphy. An instrument of particular interest is the Wender Reimherr Interview (WRI) which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

Baseline assessment

Before starting medication for ADHD, people with ADHD should have a full assessment, possibly through their GP, which should include also:

  • a review to confirm they continue to meet the criteria for ADHD and need treatment
  • a review of mental health and social circumstances, including:
    • presence of coexisting mental health and neurodevelopmental conditions
    • current educational or employment circumstances
    • risk assessment for substance misuse and drug diversion

care needs There should also be a review of physical health, including also:

  • a medical history, taking into account conditions that may be contraindications for specific medicines
  • current medication
  • height and weight (measured and recorded against the normal range for age, height and sex)
  • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
  • a cardiovascular assessment
  • an electrocardiogram (ECG) if the treatment may affect the QT interval.

One should refer for a cardiology opinion before starting medication for ADHD in cases including also:

  • history of congenital heart disease or previous cardiac surgery
  • history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
  • shortness of breath on exertion compared with peers
  • fainting on exertion or in response to fright or noise
  • palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
  • chest pain suggesting cardiac origin
  • signs of heart failure
  • a murmur heard on cardiac examination
  • blood pressure that is classified as hypertensive for adults

Medication

Stimulants are the classic medication which is used in the treatment of ADHD. If it is used correctly and for the correct indication, it can help patients have a significant improvement in their quality of life.

However, treatment success in the individual and treatment success on average in a large group can diverge significantly. A clinician’s skills in using the medication can play a significant role. In a large Canadian study, Currie and colleagues found little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit. (Currie, Stabile, & Jones, 2014)

Long-Term Effect

While methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction, it there is little evidence that methylphenidate (MPH) medication leads to long-term-term academic gains in ADHD. In a study by Hale and colleagues, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. Robust cognitive and behavioral MPH response was achieved for children with significant baseline executive working memory (EWM) / self-regulation (SR) impairment, yet response was poor for those with adequate EWM/SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. (Hale et al., 2011)

There is overall little evidence to suggest that the type of treatment in the present affects the severity of ADHD in the future. A study by Molina and colleagues has shown that or intensity of 14 months of treatment for ADHD in childhood (at age 7.0–9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. (Molina et al., 2009)

Anxiety

Compared to parent and teacher reports of anxiety, child reported comorbid anxiety shows foremost the largest associations with the neurocognitive dysfunctions observed in children with ADHD. (Bloemsma et al., 2013) In another study, overall rates of individual anxiety disorders, as well as age of onset and severity of illness were not significantly different in the presence of comorbid ADHD. School functioning in children with anxiety disorders was negatively impacted by the presence of comorbid ADHD. Frequency of mental health treatment in children with anxiety disorders was significantly increased in the presence of comorbid ADHD. ADHD had a limited impact on the manifestation of anxiety disorder in children suggesting that ADHD and anxiety disorders are independently expressed. (Hammerness et al., 2010)

Tics

Findings in a study by Gadow and Nolan suggest that the co-occurrence of diagnosed ADHD, chronic multiple tick disorder and anxiety represents a particularly troublesome clinical phenotype, at least in the home setting. Comorbid anxiety disorder was not associated with a less favorable response to immediate release methylphenidate in children with ADHD and chronic multiple disorder, but replication with larger samples is warranted before firm conclusions can be drawn about potential group differences. (Gadow & Nolan, 2011)

Emotional Lability

Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder. Although these symptoms are impairing and disruptive, relatively little research has addressed their treatment, likely due to the difficulty of reliable and valid assessment. Promising signals for symptom improvement have come from recent studies using stimulants in adults, children and adolescents. Similarly, neuroimaging studies have begun to identify neurobiological mechanisms underlying stimulants’ impact on emotion regulation capacities. (Posner, Kass, & Hulvershorn, 2014)

Smoking

Individuals suffering from ADHD have a significantly higher risk of cigarette smoking. Stimulant treatment of ADHD may reduce smoking risk. Schoenfelder and colleagues examined the relationship between stimulant treatment of ADHD and cigarette smoking in a meta-analysis. The study revealed a significant association between stimulant treatment and lower smoking rates. the effect was larger in samples with more severe psychopathology. Implications for further research, treatment of ADHD, and smoking prevention are discussed. (Schoenfelder, Faraone, & Kollins, 2014)

Medication Groups

Common stimulants include:

Methylphenidate (Methylphenidate®, Concerta®), a norepinephrine-dopamine reuptake inhibitor

Dextroamphetamine (Dexedrine®), the dextro-enantiomer of amphetamine

Dexmethylphenidate (Focalin®), the active dextro-enantiomer of methylphenidate

Lisdexamfetamine (Vyvanse®), a prodrug containing the dextro-enantiomer of amphetamine

There are also mixed amphetamine salts, such as Adderall®, a 3:1 mix of dextro/levo-enantiomers of amphetamine.

Atomoxetine (Strattera ®) is a norepinephrine (noradrenaline) reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder (ADHD).

There are also some antidepressants that have mild stimulant effects. Further information can be found in the author’s book An Overview of Psychiatric Medication (Haverkampf, 2018a)

Methylphenidate

Methylphenidate is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms:

  • moderate-to-severe distractibility
  • short attention span
  • hyperactivity
  • emotional lability, an
  • impulsivity.

The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Non-localizing neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted.

Atomoxetine

In pediatric patients with ADHD and comorbid symptoms of depression or anxiety, atomoxetine monotherapy appears to be effective for treating ADHD. (Kratochvil et al., 2005) In the study by Kratochvil and colleagues, anxiety and depressive symptoms also improved, but the absence of a placebo-only arm did not allow the investigators to conclude that these effects are specifically the result of treatment with atomoxetine. Combined atomoxetine and fluoxetine therapy were, however, well tolerated.

Extended Release

When prescribing stimulants for ADHD, one needs to consider modified-release once-daily preparations for the following reasons:

  • convenience
  • improving adherence
  • reducing stigma (because there is no need to take medication at school or in the workplace)
  • reducing problems of storing and administering controlled drugs at school
  • the risk of stimulant misuse and diversion with immediate-release preparations
  • their pharmacokinetic profiles.

Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels.

Sex

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD. (Nussbaum, 2012)

Medication for Children

Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician’s assessment of the chronicity and severity of the child’s symptoms.

Methylphenidate should not be used in children under 6 years, since safety and efficacy in this age group have not been established.

Consider offering

  1. Methylphenidate as the first line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,
  3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  4. Atomoxetine or Guanfacine if:
  5. they cannot tolerate methylphenidate or lisdexamfetamine or
  6. their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Medication for Adults

Consider offering

  1. Lisdexamfetamine or Methylphenidate as first-line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

Methylphenidate for those who have had a 6‑week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

  • Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  • Atomoxetine if:
  • they cannot tolerate lisdexamfetamine or methylphenidate or
  • their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service:

  • guanfacine for adults
  • clonidine for children with ADHD and sleep disturbance, rages or tics
  • atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
  • other medication than that listed above.

ADHD Type and Medication

Subtype

In a study by Barbaresi and colleagues, there was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. (Barbaresi et al., 2014)

Sleep

Differences in sleep problems seem to be a function of ADHD subtype, comorbidity, and medication. In a study by Mayes and colleagues, children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children. (Mayes et al., 2008) Linear regression analyses by Corkum and colleagues showed that (1) dyssomnias were related to confounding factors (i.e., comorbid oppositional defiant disorder and stimulant medication) rather than ADHD; (2) parasomnias were similar in clinical and nonclinical children; and (3) the DSM-IV combined subtype of ADHD was associated with sleep-related involuntary movements. However, sleep-related involuntary movements were more highly associated with separation anxiety. (CORKUM, MOLDOFSKY, HOGG-JOHNSON, HUMPHRIES, & TANNOCK, 1999)

Anxiety

ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder, ADHD co-occurring with ODD/CD (oppositional defiant disorder / conduct disorder) but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes separate from ADHD without this phenomenology. Jensen and colleagues found evidence of main effects of internalizing and externalizing comorbid disorders. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. (JENSEN et al., 2001)

Genotype

Stein and colleagues studied the relationship between DAT1 3′-untranslated region (3′-UTR) variable number tandem repeats (VNTR) genotypes and dose response to MPH. Children were genotyped for the DAT1 VNTR and evaluated on placebo and three dosage levels of OROS® MPH. Children who were homozygous for the less common, 9-repeat DAT1 3′-UTR genotype displayed a distinct dose–response curve from that of the other genotype groups, with an absence of typical linear improvement when the dose was increased from 18 mg to 36 and 54 mg. (Stein et al., 2005)

In a study by Epstein and colleagues, youths and adults with ADHD showed attenuated activity in fronto‐striatal regions. In addition, adults with ADHD appeared to activate non‐fronto‐striatal regions more than normals. A stimulant medication trial showed that among youths, stimulant medication increased activation in fronto‐striatal and cerebellar regions. In adults with ADHD, increases in activation were observed in the striatum and cerebellum, but not in prefrontal regions. Conclusions: This study extends findings of fronto‐striatal dysfunction to adults with ADHD and highlights the importance of frontostriatal and frontocerebellar circuitry in this disorder, providing evidence of an endophenotype for examining the genetics of ADHD. (Epstein et al., 2007)

Some medication which is licensed for use in childhood may have to be continued off license in adults if there are no better alternatives and the patient has benefitted from it significantly. Psychotherapy may have to be adjusted to external and internal changes that are part of growing up.

Dose Titration

The dose should be titrated against symptoms and adverse effects in line with guidelines until optimized. This means reduced symptoms, positive behavior changes, improvements in education, employment and relationships, with tolerable adverse effects.

During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales, in children also by parents and teachers, and progress reviewed regularly.

Dose titration should be slower and monitoring more frequent if another condition is present, such as

  • neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability)
  • mental health conditions (for example, anxiety disorders [including obsessive–compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse)
  • physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury).
  • Think about using immediate- and modified-release preparations of stimulants to optimize effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect).
  • Addictions

Abuse

One needs to be particularly careful about prescribing stimulants for ADHD if there is a risk of addictions and/or diversion for cognitive enhancement or appetite suppression. One should not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated, if this may be an issue.

Coexisting Conditions

In ADHD the comorbidity for other conditions is quite high, which can play a significant role in treatment. The same medication choices can be offered to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD.

Studies indicate that co-occurrence of clinically significant ADHD and autistic symptoms is common, and that some genes may influence both disorders. However, the DSM basically does not allow for the concurrent diagnosis of ADHD and autism.

Children with the combination of ADHD and motor coordination problems are particularly likely to suffer from an autism spectrum disorder. These co-occurrences of symptoms are important since children with ASD in addition to ADHD symptoms may respond poorly to standard ADHD treatments or have increased side effects. Such children may benefit from additional classes of pharmacologic agents, such as α-agonists, selective serotonin reuptake inhibitors and neuroleptics. They may also benefit from social skills therapy, individual and family psychotherapy, behavioral therapy and other nonpharmacologic interventions. (Reiersen & Todd, 2008)

Caution

Stimulants need to be used with care and caution, and it is important to have as much information about the medical and psychological state of the patient as possible. The following list just gives some examples, but is by no means comprehensive or factually up to date:

  • Some contraindications for methylphenidate are marked anxiety, tension, and agitation are contraindications to Methylphenidate, since the drug may aggravate these symptoms. Methylphenidate is contraindicated also in patients known to be hypersensitive to the drug, in patients with glaucoma, and in patients with motor tics or with a family history or diagnosis of Tourette’s syndrome.
  • Methylphenidate is contraindicated during treatment with monoamine oxidase inhibitors, and within a minimum of 14 days following discontinuation of a monoamine oxidase inhibitor (hypertensive crises may result).
  • Because of possible effects on blood pressure, methylphenidate should be used cautiously with pressor agents.
  • Methylphenidate may decrease the effectiveness of drugs used to treat hypertension. Human pharmacologic studies have shown that racemic methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g., phenobarbital, phenytoin, primidone), and tricyclic drugs (e.g., imipramine, clomipramine, desipramine). Downward dose adjustments of these drugs may be required when given concomitantly with methylphenidate. It may be necessary to adjust the dosage and monitor plasma drug concentration (or, in case of coumarin, coagulation times), when initiating or discontinuing methylphenidate.

Stimulant medications cause a modest increase in average blood pressure (about 2-4 mmHg) and average heart rate (about 3-6 bpm), and individuals may have larger increases. While the mean changes alone would not be expected to have short-term consequences, all patients should be monitored for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, such as those with preexisting hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia.

Psychosis

Psychosis is an important, unpredictable side effect of stimulant medication. In the case of acute psychotic or manic episodes, ADHD medication should be stopped because it can exacerbate or even trigger them under certain conditions. Restarting the ADHD medication after the episode has resolved can be considered, taking into account the individual circumstances, risks and benefits of the ADHD medication. The potential for psychotic side effects are well known, but usually reported as rare. Long acting preparations appear to be a contributory factor to the development of psychotic side effects, while symptoms resolve with discontinuation of treatment. (Shibib & Chalhoub, 2009)

Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a preexisting psychotic disorder.

Mosholder and colleagues analyzed data from 49 randomized, controlled clinical trials in the pediatric development programs for these products. A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In about 90% of the cases, there was no reported history of a similar psychiatric condition. Hallucinations involving visual and/or tactile sensations of insects, snakes, or worms were common in cases in children. (Mosholder, Gelperin, Hammad, Phelan, & Johann-Liang, 2009)

Bipolar Disorder

ADHD in combination with bipolar disorder may be associated with more severe symptoms and worse outcomes of both conditions. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. The frequent coexistence with alcohol and substance abuse may further complicate treatment management. A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms.

Atomoxetine may be effective in the treatment of ADHD symptoms in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers. (Perugi & Vannucchi, 2015)

Aggression

Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been reported in clinical trials and the post-marketing experience of some medications indicated for the treatment of ADHD. Patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility.

Seizures

There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued.

Priapism

Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism usually developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.

Peripheral Vasculopathy, Including Raynaud’s Phenomenon

Stimulants are associated with peripheral vasculopathy, including Raynaud’s phenomenon. Signs and symptoms are usually intermittent and mild, although less frequently permanent tissue damage can occur. Signs and symptoms often improve after reduction in dose or discontinuation of the drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants.

Visual Disturbance

Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. However, in a study by Martin and colleagues in children, visual acuity increased significantly in the ADHD group after treatment with a stimulant. Also, more ADHD subjects had subnormal visual field results without stimulants, compared with controls, but with stimulants the difference was no longer significant. (Martin, Aring, Landgren, Hellström, & Andersson Grönlund, 2008)

Drug Dependence

Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression or another underlying condition may surface.

Pregnancy

The number of pregnancies exposed to ADHD medication has increased similarly to the increase in use of ADHD medication among women of childbearing age. Use of ADHD medication in pregnancy was associated with different indicators of maternal disadvantage and with increased risk of induced abortion and miscarriage.

Haervig and colleagues studied data from the Danish national health registries to identify all recorded pregnancies from 1999 to 2010. From 2003 to the first quarter of 2010, use of ADHD medication during pregnancy increased from 5 to 533 per 100 000 person‐years. Compared with unexposed, women who used ADHD medication during pregnancy were more often younger, single, lower educated, received social security benefits, and used other psychopharmaca. Exposed pregnancies were more likely to result in induced abortions on maternal request, induced abortions on special indication, and miscarriage compared with unexposed pregnancies. (Haervig, Mortensen, Hansen, & Strandberg-Larsen, 2014)

However, ADHD treatment could put both mother and baby at risk. This has to be balanced against the possible risks to the baby of continuing treatment. Although the data remain inadequate, the risk of the latter appears to be quite small overall, at least for methylphenidate, (Besag, 2014) while there is evidence, that the rates of fetal loss both through abortion and through miscarriage are increased with methylphenidate. Discussions about ADHD treatment with women of childbearing age should be balanced, open and honest, acknowledging the lack of information on the possible risks to the offspring of continuing treatment, while also drawing attention to the possible risks to both mother and child of discontinuing treatment. (Besag, 2014)

Monitoring

Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well‐tolerated, there are common, although less severe, as well as rare but severe adverse events that can occur during treatment with ADHD drugs. Cortese and colleagues reviewed the literature. The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviors and psychotic symptoms. Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment. (Cortese et al., 2013)

Behavior

Monitor the behavioral response to medication, and if behavior worsens adjust medication and review the diagnosis.

Height

Growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Research on the issue of growth suppression is lacking, mostly owing to insufficient follow-up on patients’ final heights. However, it has been argued that the rate of height loss seems relatively small and is likely reversible with withdrawal of treatment. (Goldman, 2010)

Weight

Some young adults are misusing prescription stimulants for weight loss. This behavior is associated with other problematic weight loss strategies. Interventions designed to reduce problematic eating behaviors in young adults may wish to assess the misuse of prescription stimulants. (Jeffers, Benotsch, & Koester, 2013) In the study by Jeffers and colleagues, undergraduates who reported using prescription stimulants for weight loss had greater appearance-related motivations for weight loss, greater emotion and stress-related eating, a more compromised appraisal of their ability to cope, lower self-esteem, and were more likely to report engaging in other unhealthy weight loss and eating disordered behaviors.

Weight should be measured at least once at 3 and 6 months after starting treatment in children over 10 years and young people, and at least once every 6 months thereafter. In adults, weight should be measured at least once every 6 months. Monitoring the BMI of adults is in many cases important.

If a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), stopping the medication or at least a break in treatment over school holidays to allow ‘catch‑up’ growth may be considered.

Cardiovascular System

Stimulants agents can increase heart rate and blood pressure and cause other cardiovascular symptoms. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality, heart rate and blood pressure should be monitored closely. Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).

Statistically significant pre–post increases of SBP, DBP and HR were associated with amphetamine and atomoxetine treatment in children and adolescents with ADHD, while methamphetamine treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. (Hennissen et al., 2017)

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, does not seem associated with an increased risk of serious cardiovascular events. Habel and colleagues examined whether current use of medications prescribed primarily to treat ADHD is associated with increased risk of serious cardiovascular events in young and middle-aged adults. Participants were adults aged 25 through 64 years with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine at baseline. The sample size was 443 198 users and nonusers. The multivariable-adjusted rate ratio (RR) of serious cardiovascular events for current use vs nonuse of ADHD medications was 0.83. Among new users of ADHD medications, the adjusted RR was 0.77. The adjusted RR for current use vs remote use was 1.03; for new use vs remote use, the adjusted RR was 1.02. (Habel et al., 2011) In the study including data about 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, Habel et al showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. (Habel et al., 2011)

Children and Adolescents

Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone carry an increased risk of sudden death, stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

Adults

Sudden death, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults have a greater likelihood than children of having serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems. Adults with such abnormalities should also generally not be treated with stimulant drugs.

Tics

If a person taking stimulants develops tics, one should consider whether the tics are related to the stimulant (tics naturally wax and wane) and the impairment associated with the tics outweighs the benefits of ADHD treatment. If tics are stimulant related, one may need to reduce the dose or switch the medication.

Sexual Dysfunction

Erectile and ejaculatory dysfunction are potential adverse effects of atomoxetine.

Seizures

If a person with ADHD develops new seizures or a worsening of existing seizures, their ADHD medication needs to be reviewed and any medication that might be contributing to the seizures stopped.

Patients with ADHD seem to be at a higher risk of seizures. However, ADHD medication was associated with lower risk of seizures within individuals while they were dispensed medication, which is not consistent with the hypothesis that ADHD medication increases risk of seizures. Wiggs and colleagues followed a sample of 801,838 patients with ADHD medication. Patients with ADHD were at higher odds for any seizure compared with non-ADHD controls (odds ratio [OR] = 2.33). In adjusted within-individual comparisons, ADHD medication was associated with lower odds of seizures among patients with (OR = 0.71) and without (OR = 0.71) prior seizures. Long-term within-individual comparisons suggested no evidence of an association between medication use and seizures among individuals with (OR = 0.87) and without (OR = 1.01) a seizure history. (Wiggs et al., 2018) Koneski and colleagues evaluated 24 patients ranging from 7 to 16 years of age who took MPH for 6 months. Inclusion criteria were at least two epileptic seizures in the previous 6 months and a diagnosis of ADHD based on DSM-IV criteria. There was an overall improvement in ADHD symptoms in 70.8% of patients, and there was no increase in frequency of epileptic seizures in 22 patients (91.6%). (Koneski, Casella, Agertt, & Ferreira, 2011)

Sleep

Changes in sleep pattern should always be asked for, the timing and dose of the medication adjusted. Immediate release methamphetamine should usually not be administered after 4pm.

Compliance

Experiences of adverse effects are a frequent explanation for discontinuation among youth. Despite impaired functioning during adolescence, many discontinue medication treatment. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short- and long-term adverse effects. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes. (Alice Charach & Fernandez, 2013).

Psychotherapy

Psychotherapy should always be part of a comprehensive treatment plan for ADHD. Communication-Focused Therapy® (CFT) as it was developed by the author focuses on internal and external communication patterns which has shown to be helpful in ADHD. (Haverkampf, 2017b, 2017d, 2017c)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

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A Review of Best Practice in the Treatment of ADHD (1)

A-Review-of-Best-Practice-in-the-Treatment-of-ADHD-1-Christian-Jonathan-Haverkampf-psychiatry-series

Treatment of ADHD in Adults

Treatment-of-ADHD-in-Adults-2-Christian-Jonathan-Haverkampf-psychiatry-series

Treatment of ADHD in Adults (1)

Adult attention-deficit hyperactivity disorder (ADHD) is a common mental health condition that has been estimated to affect one out of twenty people worldwide. It causes persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior. Adult ADHD can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems, which can severely reduce the individual quality of life. ADHD begins in childhood, but often is not recognized or diagnosed before adulthood. In adults, hyperactivity may decrease, but struggles with impulsiveness, restlessness and difficulty paying attention often continue.
Treatment for adult ADHD is similar to treatment for childhood ADHD, consisting of medication, psychological counseling (psychotherapy) and several supportive approaches. This article gives a brief overview of current approaches and Communication-Focused Therapy® as developed by the author.

Keywords: attention deficit hyperactivity disorder, ADHD, Communication-Focused Therapy®, CFT®, diagnosis, treatment, psychotherapy, psychiatry

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© 2019 Christian Jonathan Haverkampf

Communication-Focused Therapy (CFT) for ADHD (2)

Attention Deficit Hyperactivity Disorder (ADHD) is often treated mainly or exclusively with medication. However, psychotherapy should have an important place in the treatment of ADHD and may in lighter forms be the only therapy needed. Communication-Focused Therapy (CFT) is a psychotherapy developed by the author, which can be applied to several mental health conditions, including attention deficit disorder (ADHD). The focus is on the internal and external communication patterns the patient uses and on his or her basic parameters, the values, needs and aspirations. With awareness, reflection and experimentation these factors can be very helpful in a psychotherapeutic approach to treat ADHD.

Keywords: ADHD, attention deficit hyperactivity disorder, communication-focused therapy, CFT, communication, psychotherapy, treatment

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Communication-Focused Therapy (CFT) for ADHD (2) Christian Jonathan Haverkampf

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