June 1st, 2010

Recognizing and treating adult ADHD

Thomas E. Brown, Ph.D., recalls how one adult patient described a case of attention deficit hyperactivity disorder: erectile dysfunction of the mind.

“That captures the sense of helplessness and puzzlement folks have about this disorder,” says Brown, associate director of the Yale Clinic for Attention and Related Disorders. “Normal people can make themselves focus. For ADHD sufferers, it’s really tough. Everyone gets down on them, parents, teachers, bosses, spouses, even themselves.”

The estimated prevalence of adult ADHD is 4.4 percent, according to the National Comorbidity Survey. Only about 11 percent of eligible patients receive treatment. The disorder typically starts in childhood, but often goes unrecognized because the symptoms are similar to another psychological disorder or considered personality flaws not worth mentioning to a clinician. Women tend to be overlooked because as girls, they weren’t so rowdy at school that parents or teachers brought them in for evaluation.

Similarly, smart children with solicitous parents may have overcome youthful difficulties. But as they get older and are challenged by complex tasks they have to handle alone, they run into trouble, experts say.

Robert Reynolds, Ph.D., founder and director of Connecticut Educational Services, says behavioral manifestations of hyperactivity tend to “burn out” with age, but adults remain so disorganized and distractible that their lives don’t work out despite their best efforts and they can’t figure out why.

“They become depressed or anxious or, worse case scenario, develop a substance abuse problem that’s bringing them down,” Reynolds says.

Brown rejects the common notion of ADHD as a behavioral problem and says sufferers have a developmental impairment of executive functions (EFs), the brain’s cognitive self-management system. EFs include organizing, prioritizing, staying focused, sustaining effort, managing negative emotions and accessing working memory.

“It’s the executive functions that help us manage daily life that are screwed up in people with ADHD,” Brown says. “We’re talking about cases where these EFs have not developed adequately in the first place. Not those who may have lost it because of trauma or dementia.”

Even those with impaired executive functions might have a few domains in which they are intensely interested and can excel. Or they can accomplish a task if they feel “they have a gun to their head.”

“Under those two circumstances, the chemical dynamics of the brain change instantly; it’s not under voluntary control,” Brown says. “To clinicians or spouses it looks like a will power problem, but it’s not. This situational variability of symptoms is a big problem understanding adult ADHD.”

Reynolds attributes such variability to the theory of “attentional threshold,” which everyone has to some extent. Tasks or subjects we find interesting are above the threshold; those we find boring are below. People with ADHD have attentional thresholds set very high.

“Most of the real world is below their attentional threshold, that’s why they struggle,” Reynolds says.

Such subtleties can be difficult for clinicians to recognize, and if they don’t, their treatments may be ineffective. Reynolds describes a three-pronged approach to diagnosis: a subjective survey, such as the Jasper/Goldberg Screening Quiz, Attention-Deficit Scales for Adults (ADSA) or the Adult ADHD Self-Report Scale (ASRS); a detailed clinical interview; and computer-based real-time testing such as the Test of the Variables of Attention (TOVA) that measures responses to visual or auditory stimuli and compares them to a normative database.

“Put these three together, and you can develop pretty compelling evidence to determine whether a person has ADHD or not,” Reynolds says.

As for treatment, medication is usually the initial approach. Brown says eight out of 10 patients will function significantly better given the right amount of the right medication. Psychostimulants such as Concerta, Focalin and Adderall (Ritalin is less common these days, Brown says) are most often used to treat ADHD and work on the dopamine system. A newer, milder class of drugs, such as Strattera and Attentin, work on the norepinephrine system.

“Psychologists need to learn about these medicines so they can collaborate with physicians to identify patients with ADHD, assess the degree to which medications are working and possibly follow up with cognitive behavioral therapy (CBT),” Brown says.

CBT for ADHD is just starting to be studied in a rigorous way. Three scientific, randomized studies of psychosocial interventions for ADHD have been conducted in the U.S. In a 2005 study of 31 adults led by Steven A. Safren, Ph.D., of the Behavioral Medicine Service at Massachusetts General Hospital, CBT was found to be helpful over and above medication alone.

In a 2010 study of 88 adults led by Mary V. Solanto, Ph.D., of the ADHD Center at Mount Sinai Medical Center in New York, a specially-designed 12-week “meta-cognitive” regimen to teach executive functions was found to be significantly more effective than supportive therapy. Another, larger trial of a “novel treatment” from Safren will be presented in June at the World Congress of Behavioral and Cognitive Therapies in Boston.

Studies of medication interventions have generally shown a 30 percent reduction in ADHD symptoms, Safren says. To tackle residual symptoms, he recommends psychologists use an evidence-based treatment approach.

As in “skills before pills,” Reynolds says. He thinks medication ought to be the treatment of last resort in favor of skills-based approaches such as coaching and computer-based neural feedback training. “It’s not temporary like medication,” he says. “You can use what you learn for the rest of your life.”

By Nan Shnitzler

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