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Current Clinical Psychiatry

Series Editor
Jerrold F. Rosenbaum, MD

For further volumes:


http://www.springer.com/series/7634
Craig B.H. Surman
Editor

ADHD in Adults
A Practical Guide to Evaluation
and Management
Editor
Craig B.H. Surman
Massachusetts General Hospital
Department of Psychiatry
Harvard Medical School
Boston, MA, USA

ISBN 978-1-62703-247-6 ISBN 978-1-62703-248-3 (eBook)


DOI 10.1007/978-1-62703-248-3
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Preface

International specialists created this guide to the identification and treatment of


Attention Deficit Hyperactivity Disorder (ADHD) in adults. They offer advice for
practical, comprehensive, and personalized care, drawing from their extensive
experience and unique expertise. Their chapters distill the clinical implications of
over three decades of research. This guide can help clinicians of any specialty adopt
best practices for assessment and treatment of ADHD in adults.
Through international contributions, the guide presents a state-of-the-art consen-
sus on clinical care for ADHD in adulthood. The initial chapter describes the condi-
tion and its importance. The next few chapters explain diagnosis and treatment
planning. Subsequent chapters explore treatment options in detail. The final chapter
addresses common dilemmas in clinical practice. The Appendix includes material
that facilitates assessment and treatment, including brief guides and inventories that
can be photocopied for clinical use.
Here are some highlights of how the chapters that follow address practical clini-
cal concerns:
• ADHD is a biologically based, highly heritable syndrome impairing daily life
roles that onsets in childhood and often persists into adulthood. A primer on the
neurobiology and clinical importance of ADHD is offered in the initial chapter,
ADHD in Adults: a Clinical Concern.
• The diagnosis is made primarily through a clinical encounter. The chapter on
Clinical Assessment of ADHD in Adults introduces a practical approach to cap-
turing current and historical symptoms of ADHD, using the Adult ADHD
Symptoms and Roles Inventory (ASRI), and a Differential Diagnosis inventory.
These resources are also found in the Appendix, along with a step-by-step
Diagnosis Checklist.
• ADHD manifests differently in different individuals. The Clinical Assessment
chapter and the ASRI facilitate comprehensive evaluation of impact through a
focus on function in life roles. A Treatment Planning chapter offers a systematic
approach to tailoring intervention to the strengths, challenges, and individual
goals of a patient. The take-home principles of this chapter are summarized in a

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vi Preface

Treatment Planning and Tracking guide in the Appendix for easy clinical refer-
ence. The chapters on ADHD in Families and on Adolescence and Young
Adulthood explore how assessment and treatment can be adapted to different life
contexts. Assessment of ADHD impact is aided by the self-report Weiss
Functional Impairment Rating Scale in the Appendix.
• Several medication and non-medication supports are useful. Chapters on
Treatment Planning, Stimulant Pharmacotherapy, Non-stimulant Drug
Treatments, and Psychosocial Treatment describe how to choose and optimize
interventions. Treatment History and Treatment Tracking forms in the Appendix
facilitate capture of information needed to choose initial treatments and monitor
them.
• Adults with ADHD are often burdened by other challenges. This includes orga-
nizational problems beyond core ADHD symptoms (self-regulatory or organiza-
tional difficulty), as well as any condition which compromises optimal brain
function. Several chapters detail how to identify and support these conditions.
The chapters on Clinical Assessment, Treatment Planning, and Neuropsychological
Assessment present practical approaches to evaluating complex presentations. A
Differential Diagnosis and Neurological Comorbidity Inventory in the Appendix
guides clinicians to identify comorbidity. Clinical management of specific
comorbidities is reviewed in the chapters on Common Comorbidities and the
chapter on Adolescence and Young Adulthood.
• Many conditions other than ADHD manifest in poor control of attention or
behavior. The Clinical Assessment and Treatment Planning chapters guide dif-
ferentiation from other conditions. The Differential Diagnosis and Neurological
Comorbidity Inventory also facilitate thorough differential diagnosis.
• ADHD impacts other people. The Assessment and Treatment Planning chapters
emphasize the importance of assessing impact on relationships. The ADHD in
Families chapter offers a detailed exploration of the relational impact of ADHD,
and practical ways of intervening. The ASRI third-party self-report inventory, in
the Appendix, also facilitates identification of symptoms that impair
relationships.
• Clinicians can face tough decisions in complicated presentations of ADHD. All
chapters emphasize pragmatic approaches to clinical decisions. The final chapter
presents one clinician’s approach to common dilemmas practice in an urban
setting.
This text is thus an extraordinary effort to inform and advise clinicians in the
identification and support of ADHD in adults. The principles and strategies set forth
in this guide will help the reader develop or refine clinical approaches that suit the
population they work with. The reader is also encouraged to rely on local standards
of clinical practice if they conflict with any recommendation in this guide. Hopefully,
our work will foster adoption of thoughtful support of ADHD in adulthood.

Boston, MA, USA Craig B.H. Surman, MD


Disclosures

Daniela de Bustamante Carim, MPsy, Stephanie Daffner, PhD, Helenice


Charchat Fichman, ScD, Thomas Jans, PhD, Georgios Paslakis, MD, Anton
Pesok, MD, and Michael Schredl, PhD have no disclosures to make.
Barbara Alm, MD MPsy has completed studies within the last 5 years supported
by Eli Lilly and Medice, and has been on German Advisory Boards for Eli Lilly and
Medice.
Philip Asherson, MB, BS, MRCPsych, PhD has received funding for his research
from the UK Medical Research Council, The Wellcome Trust, the National Institute
of Mental Health and Action Medical Research; as well as from Pharmacological
companies (Janssen-Cilag, Shire and Vifor Limited). In addition he has received
educational grants from Janssen-Cilag, Shire, Flynn Pharma and Eli-Lilly, and has
acted as a consultant for the same companies. Funds received from pharmaceutical
companies have been donated to research into ADHD at Kings College London.
Inmaculada Escamilla, MD, PhD has received research funding from the Alicia
Koplowitz Foundation and Eli Lilly. She has served on a speaker’s bureau for
Janssen. She received a teaching grant from the Alicia Koplowitz Foundation. Also,
she has received funding for continued medical education from Lilly, Janssen and
Shire.
Laura Knouse, PhD reports receiving income from Guilford Publications.
Paul Hammerness, MD, in the past 5 years, has participated in CME activities/
professional talks supported by the following pharmaceutical companies: Abbott,
Eli Lilly, Forest, McNeil, Ortho-McNeil Janssen, and Shire. Dr. Hammerness has
participated in speaker training and served on an advisory board for Shire. Dr.
Hammerness has participated, as an investigator/principal investigator, in research
studies funded by the following pharmaceutical companies/companies: Abbott,
Bristol Myers Squibb, Cephalon, Eli Lilly, Forest, GlaxoSmithKline, Johnson &
Johnson, McNeil, Merck, New River, Novartis, Organon, Ortho-McNeil Janssen,

vii
viii Disclosures

Pfizer, Shire, and Takeda and Elminda Ltd. Dr. Hammerness has also received
honoraria from Reed Medical Education (a logistics collaborator for the MGH
Psychiatry Academy). Dr. Hammerness has received royalties from Greenwood
Press (ADHD; Biographies of Disease series; 2008) and an advance from Harlequin
Press (Organize Your Mind, Organize Your Life; 2012).
Christian Jacob, PD, MD is a member of an advisory board for Medice and holds
lectures that were supported by Medice.
Steven Safren, PhD reports receiving royalties from Oxford University Press for
publication of treatment manuals.
Esther Sobanski, MD receives research funding for an ongoing study with Novartis;
has received research funding for a study with Janssen-Cilag completed within the
last 5 years; has completed an investigator initiated trial with Eli Lilly within the
last 5 years; has served on German and International Advisory Boards for Eli Lilly
and Shire and a German Advisory Board for Medice.
Craig Surman, MD has received research support from the United States National
Institutes of Health, Abbott, Alza, Cephalon, Eli Lilly, the Hilda and Preston Davis
Foundation, Johnson and Johnson, Magceutics, McNeil, Merck, New River, Nordic
Naturals, Organon, Pamlab, Pfizer, Shire, and Takeda; has given lectures supported
by Janssen-Ortho, McNeil, Novartis, and Shire; and has been a consultant/advisor
for Dannone, McNeil, Shire Somaxon, and Takeda. Dr. Surman has also received
honoraria from Reed Medical Education (a logistics collaborator for the MGH
Psychiatry Academy, which is supported by commercial entities). Dr. Surman has
received royalties for a book published with Berkeley Penguin, titled “FAST
MINDS: How to Thrive If You Have ADHD Or Think You Might.”
Acknowledgements

This volume is the collective work of professionals specializing in Attention Deficit


Hyperactivity Disorder. I am grateful to my coauthors for the enthusiasm they
brought to this project, and the unique, thoughtful, and expert guidance they offer
within. I am grateful to the Chair of our Department of Psychiatry, Jerry Rosenbaum
MD, for suggesting this project, which was expertly facilitated by developmental
editor Michael D. Sova, and Richard Lansing of Humana Press.
This work would not be possible without the prior work of many professionals
who demonstrated the importance of identifying and treating ADHD in adults. I am
extremely fortunate to have worked under the support and guidance of one of these
pioneers, Joseph Biederman MD.
The clinical and research acumen demonstrated by the authors in this volume is
the product of extensive training and mentorship. I wish to thank particular people
who have strongly shaped my own approach to clinical care and research. They
include, foremost, my parents Lezlie Surman RN, and Owen Surman MD, who
taught me by example that empathy is a key to all healthy relationships. My contri-
bution to this book also draws heavily from what I have learned from Russell
Barkeley PhD, Robert Brooks PhD, Thomas Brown MD, Robert Doyle MD, Zeina
el-Chemali MD, Stephen Faraone PhD, David Goodman MD, Mark Greenberg
PhD, Steven Safren PhD, Susan Sprich PhD, Thomas Spencer MD, Mark Stein
PhD, Paul Wender MD, and Timothy Wilens MD. I wish also to thank all the staff
of our Department for their support of the field and of work.
It is my hope that the knowledge in this volume also faithfully reflects the experi-
ence of the individuals with ADHD who have entrusted us with their experiences
and look to us for the best support we can offer.

Boston, MA, USA Craig B.H. Surman MD

ix
Contents

1 ADHD in Adults: A Clinical Concern ................................................. 1


Philip Asherson
2 Clinical Assessment of ADHD in Adults ............................................. 19
Craig B.H. Surman
3 Treatment Planning for Adults with ADHD ....................................... 45
Craig B.H. Surman
4 Neuropsychological Assessment of ADHD
and Executive Function Deficits in Adults .......................................... 59
Daniela de Bustamante Carim and Helenice Charchat Fichman
5 Stimulant Pharmacotherapy for Adults with ADHD ........................ 71
Paul Hammerness
6 Non-stimulant Drug Treatments for Adults with ADHD .................. 89
David Coghill
7 Psychosocial Treatment for Adult ADHD........................................... 119
Laura E. Knouse and Steven A. Safren
8 Managing ADHD in Adults with Common Comorbidities ............... 137
Esther Sobanski, Georgios Paslakis, Michael Schredl,
Stephanie Daffner, and Barbara Alm
9 Managing ADHD in Adolescence and Young Adulthood:
Emerging Comorbidities and Tailored Treatment ............................. 155
Inmaculada Escamilla
10 ADHD in Families ................................................................................. 169
Thomas Jans and Christian Jacob

xi
xii Contents

11 Clinical Dilemmas in the Assessment and Management


of ADHD in Adults: A Psychiatrist’s View from
an Urban Hospital Clinic...................................................................... 191
Anton Pesok
Appendix ........................................................................................................ 197
Author Biographies ....................................................................................... 217

Index ............................................................................................................... 223


Contributors

Barbara Alm, MD, MPsy Department of Psychiatry, Central Institute for Mental
Health, University of Heidelberg, Mannheim, Germany
Philip Asherson, MB, BS, MRCPsych, PhD MRC Social, Genetic, Developmental
Psychiatry Centre, Institute of Psychiatry, King’s College London, London, UK
Daniela de Bustamante Carim, MPsy Department of Psychiatry, Santa Casa da
Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil
David Coghill, MB, ChB, MD Division of Neuroscience, Medical Research
Institute, University of Dundee, Dundee, Scotland, UK
Stephanie Daffner, PhD Department of Psychiatry and Psychotherapy, Central
Institute of Mental Health, Medical Faculty Mannhein, University of Heidelberg,
Mannheim, Germany
Inmaculada Escamilla, MD, PhD Department of Psychiatry and Medical
Psychology, University of Navarra Clinic (Madrid Campus), Madrid, Spain
Helenice Charchat Fichman, ScD Department of Psychology, Catholic University
of Rio de Janeiro (PUC-RJ), Rio de Janeiro, Brazil
Paul Hammerness, MD Clinical and Research Program in Pediatric
Psychopharmacology and Adult ADHD, Massachusetts General Hospital, Boston,
MA, USA
Christian Jacob, PD, MD Department of Psychiatry, Psychosomatics and
Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
Thomas Jans, PhD Department of Child and Adolescent Psychiatry,
Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg,
Germany
Laura E. Knouse, PhD Department of Psychology, University of Richmond,
Richmond, VA, USA

xiii
xiv Contributors

Georgios Paslakis, MD Department of Psychiatry and Psychotherapy, Central


Institute for Mental Health, Medical Faculty Mannhein, University of Heidelberg,
Mannheim, Germany
Anton Pesok, MD Department of Psychiatry, Beth Israel Deaconess Medical
Center, Boston, MA, USA
Steven A. Safren, PhD Department of Psychiatry, Massachusetts General Hospital
and Harvard Medical School, Boston, MA, USA
Michael Schredl, PhD Sleep Laboratory, Central Institute for Mental Health,
University of Heidelberg, Mannheim, Germany
Esther Sobanski, MD Department of Psychiatry and Psychotherapy, Central
Institute for Mental Health, Medical Faculty Mannhein, University of Heidelberg,
Mannheim, Germany
Craig B.H. Surman, MD Adult ADHD Research Program, Massachusetts General
Hospital, Boston, MA, USA
Chapter 1
ADHD in Adults: A Clinical Concern

Philip Asherson

Abstract ADHD is an established disorder with widespread development of clinical


services for children and adolescents. Cross-sectional and longitudinal studies also
demonstrate the continuity of symptoms and impairments into adult life in many
cases. This chapter provides an overview of the key clinical concerns and impact of
ADHD on adults and emphasizes the importance of ADHD to adult psychopathology.
The range of impairments is broad. At one end of the spectrum are high functioning
individuals who cope well in many aspects of their lives, but struggle with symptoms
such as chronic disorganization, restlessness, inability to relax, irritability, and
difficulty sleeping. On the other hand, some individuals with ADHD are among the
most dysfunctional in society, having considerable difficulties maintaining
themselves in employment, completing simple everyday tasks, developing relation-
ships, controlling their temper and being drawn into antisocial behavior, and drug
and alcohol abuse. The severity of the symptoms of ADHD in some cases explains
the frequent difficulty non-specialists can have in distinguishing ADHD from other
mental health problems such as bipolar and personality disorders. The overall
conclusion is that ADHD is a distinct condition that often has serious consequences
for adults as well as children and adolescents. Because ADHD in adults is a common
source of personal and societal suffering, because it is highly treatable, because it
compounds other disorders, and because services for adults with ADHD are limited,
ADHD deserves the full attention of those working in adult mental health.

P. Asherson, M.B., B.S., M.R.C.Psych., Ph.D. (*)


MRC Social, Genetic, Developmental Psychiatry Centre, Institute of Psychiatry, King’s College
London, De Crespigny Park, London SE5 8AF, UK
e-mail: philip.asherson@kcl.ac.uk

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 1
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_1,
© Springer Science+Business Media New York 2013
2 P. Asherson

Introduction

ADHD is an established disorder with widespread development of clinical services


for children and adolescents. Many countries have access to either child and
adolescent mental health or pediatric services with expertise in the diagnosis and
treatment of ADHD. The disorder is estimated to affect around 5% of children
globally [1] who, depending on the severity of the condition and the co-occurrence
of additional mental health or psychosocial problems, need medical, social, or
educational interventions. Follow-up studies of children with ADHD find that around
15% retain the full diagnosis by the age of 25 years, and a further 50% are in partial
remission with persistence of some symptoms associated with continued clinical and
psychosocial impairments [2]. There is therefore a clear need for the development of
effective diagnostic and treatment services for ADHD in adult life.

Definition and Etiology of ADHD

ADHD is a clinical syndrome defined in both the DSM-IV (attention deficit


hyperactivity disorder) and the tenth edition of the International Classification of
Diseases (hyperkinetic disorder) by the presence of high levels of hyperactive,
impulsive, and inattentive behaviors when they begin during early childhood, are
persistent over time, pervasive across situations, and lead to clinically significant
impairments. Although the clinical syndrome is consistently associated with a wide
range of social, environmental, neurobiological, and genetic variables, none of these
are sufficiently sensitive or specific to predict the syndrome in clinical practice. The
diagnosis therefore remains a descriptive one, based on the identification of a pattern
of symptoms and behaviors that typically cluster together in the population and lead
to a characteristic pattern of impairments and long-term outcomes.
Investigations into the etiology of ADHD suggest that the disorder is best
conceptualized as the extreme and impairing tail of one or more quantitative traits
that are found throughout the general population, resulting from multiple genetic
and environmental risk factors [3]. This type of complex etiology is seen in a diverse
range of common disorders such as cardiovascular disease, diabetes, asthma,
anxiety, and depression, and in this sense ADHD should be seen as similar to many
other common mental health and medical disorders. However, recent evidence also
finds that rare chromosomal abnormalities called copy number variants (CNVs:
duplication or deletions of sub-microscopic chromosomal regions) and severe early
deprivation may confer moderate to large risks on development of the disorder in
some cases [4, 5].
1 ADHD in Adults: A Clinical Concern 3

The Diagnostic Validity of ADHD in Adults

Many misconceptions surround the disorder and its treatment, particularly when
ADHD persists into the adult years [6]. One common misconception, that ADHD
does not persist into adulthood, is not supported by any of the follow-up studies of
children and adolescents with ADHD. The disorder is found to persist into adulthood
in the majority of cases, either as the full blown condition or with persistence of some
symptoms associated with impairments [2]. Furthermore, worldwide prevalence
studies of ADHD in adults estimate rates to be between 2.5 and 4.3% [7–9], indicating
that this is one of the most common adult mental health conditions, alongside other
common conditions such as anxiety and depression. As such a full understanding of
ADHD is needed by all those working in adult mental health; and further research is
needed to fully characterize the nature of ADHD in adults, quantify its contribution
to adult mental health, and provide a better understanding of its relationship to co-
occurring symptoms, syndromes, and disorders.
One concern that is often expressed is whether ADHD can be clearly delineated
from other common mental health conditions. However, the disorder has a clearly
defined pattern of symptoms and associated features. Delineation of the diagnostic
construct from other disorders has been reviewed in detail and is based upon the
following considerations [10].
1. The symptoms that define ADHD are reliably identifiable, with test–retest
reliabilities in the range of 70–80% for informant and self-ratings. There is strong
evidence for clustering of the symptoms used to define ADHD in both clinical and
population samples. The majority of studies support a two-factor model of hyper-
activity-impulsivity and inattention in both children and adults. However recent
studies suggest that ADHD is best perceived as having three main components
consisting of an inattention factor, a hyperactivity-impulsivity factor, and a general
factor that combines symptoms from both symptom domains [11].
2. While ADHD symptoms cluster together and are separable from other symptom
clusters, ADHD symptoms can often be identified in individuals with
neurodevelopmental problems such as autism spectrum disorder and dyslexia.
The overlap of these conditions has been shown to result from shared genetic
influences [12, 13]. Other disorders commonly develop in people with ADHD
including behavioral and emotional problems such as oppositional defiant
disorder and conduct disorder during childhood; and antisocial personality
disorder, substance abuse disorders (including alcohol and tobacco), anxiety and
depression in adults. Overall, ADHD occurs in around 10–20% of people with
common mental health problems according to epidemiological and clinical
research [14–19]. Current research is focused on delineating the causal
mechanisms involved in the development of comorbid mental health problems in
people with ADHD, which include early prenatal risk factors, social exclusion,
parenting factors, genetic risk factors, and common neurobiological pathways.
3. Symptoms of ADHD appear to be on a continuum, in the same way that anxiety,
depression, blood pressure, and weight are continuously distributed throughout
4 P. Asherson

the population [3]. Indeed, as with symptoms of anxiety and depression, ADHD
symptoms are experienced by most people at times. The disorder is distinguished
from the normal range by the number, severity, and persistence of symptoms,
and their association with significant levels of impairment.
4. ADHD symptoms have been tracked from childhood through adolescence and
into adult life. They are relatively stable over time [20–23] with variable outcome,
in which around two-thirds show persistence of some symptoms associated with
clinically significant impairments [2]. In adults the profile may change with a relative
persistence of inattention compared to hyperactivity-impulsivity [21, 24], although
both sets of symptoms commonly persist and may create functional impairment
in adults.
5. The symptoms that define ADHD are associated with significant clinical and
psychosocial problems throughout the lifespan. There are numerous studies on
functional impairments in ADHD that clarify it is a disorder that impacts multiple
domains [6]. These include subjective complaints of distress from symptoms of
ADHD, difficulties coping with activities of daily life, problems with educational
achievement that are not accounted for by general cognitive ability, impaired
family and social relationships, and increased rates of antisocial behavior, drug
abuse, and alcohol abuse. Difficulties with mood regulation are recognized as a
core problem that is often associated with ADHD in adults and can be the main
presenting complaint in some cases [25–27]. Common problems associated with
ADHD in adults that are well documented include the development of anxiety
and depression, unemployment, poor work performance, lower educational
performance, and increased rates of traffic violations and accidents [14, 28–31].
High rates of ADHD within the criminal justice system [32] and drug and alcohol
addiction services [33, 34] are a particular concern and suggest that we are not
doing enough during childhood to prevent some of the more serious consequences
of ADHD.
6. There is strong evidence for both genetic and environmental influences in the
etiology of ADHD. Family, twin, and adoption studies indicate it is a familial
disorder which is predominantly influenced by genetic factors. Heritability of
ADHD symptoms assessed in childhood and adolescence is estimated to be
around 76% [35]. Twin studies using self-ratings in adults give lower estimates of
genetic effects [36], in the order of 30–40%. However, recent twin studies from
Sweden and the UK indicates that this is the result of rater effects, since similar
high heritabilities to that seen in children and adolescents are seen when parent
ratings are taken into account (references).
In keeping with all other psychiatric disorders at this time, no single measure
has been found to be sufficiently predictive of the clinical disorder to be used as
a diagnostic test. Genetic associations have been identified that passed genom-
ewide levels of significance for two dopamine system genes in a meta-analysis
of available data, namely, the dopamine D4 and D5 receptor genes [37]; and ADHD
is consistently associated with both neurobiological [38, 39] and environmental
measures [40–42]. However, when evaluating the many cognitive and neuroimaging
measures associated with ADHD in adults [38, 43–46], it remains unclear which
1 ADHD in Adults: A Clinical Concern 5

reflect shared causal processes (mainly shared genetic effects) and which might
reflect key processes that mediate between the etiological factors and symptoms
of ADHD [47].
An important advance has been the recent finding of rare chromosomal duplica-
tions and deletions (CNVs) in some children with ADHD compared to controls
[4]. Within the normal range of general cognitive ability (IQ) such chromosomal
defects were seen in around twice as many children with ADHD (14%) as unaf-
fected controls (7%); who were in all other measured ways identical to ADHD
children who did not carry genetic CNVs. More recent research has confirmed
these findings [48]. The other important discovery was that some of the variants
identified in ADHD involve genes that are also implicated in neurodevelopmen-
tal disorders such as autism and schizophrenia (see also [49]) confirming the
neurodevelopmental origins of ADHD and providing direct molecular data for
the observation of shared genetic risks between ADHD and autism spectrum
disorders [50, 51].
7. Treatment effects of stimulant medication (methylphenidate and amphetamines)
and atomoxetine have been well documented in numerous controlled studies of
ADHD in children and adults. These medications are very successful in reducing
ADHD symptoms, with moderate to large effect sizes in the range of 0.4–1.2,
with an associated impact on measures of global function and clinical impair-
ment [10, 52, 53]. In adults improvements have been noted in other domains,
particularly unstable or volatile moods [54–56]. The longest controlled trial of
stimulants in adults to date shows treatment effects of medication over a 6-month
period [57]; and in clinical practice we see continued benefits over many years.
Non-pharmacological treatments have also been shown to be important with a
growing evidence base for the complementary use of psychoeducation and
cognitive behavioral approaches alongside pharmacological treatment [58].

Societal Burden of ADHD in Adulthood

The early onset and persistence of ADHD impairments into adult life leads to con-
siderable economic as well as personal and social burdens on society. The economic
burden in children was estimated to be around twice that of controls because of the
higher rates of service use including inpatient, outpatient, and emergency services
[59]. When the disorder persists into adulthood high economic costs are associated
with employment problems (increased sickness leave, less productivity, and unem-
ployment) as well as increased heath care costs [60–62]. The arguments for provid-
ing comprehensive clinical services for adults with ADHD therefore go beyond the
individual care of people with mental health problems, to enhance national wealth
(as well as health) by helping people with ADHD to contribute effectively to soci-
ety. This is particularly important for ADHD because the availability of effective
pharmacological and non-pharmacological treatments suggests that considerable
savings can be made through effective treatments. Further work is now needed to
6 P. Asherson

evaluate the effectiveness of clinical interventions during childhood to improve the


long-term negative outcomes of ADHD, as well as enhancing performance and
reducing rates of psychiatric comorbidities.

The Need for Clinical Services for ADHD

National and international guidelines have been developed in several countries that
recognize the need for clinical management of ADHD in adults and provide a con-
sistent approach to the disorder and its clinical management. The strong consensus
among experts within and between the different guidelines is striking in terms of the
clinical criteria that are adopted, understanding of the impairments that are linked to
ADHD in adults and the effects of both pharmacological and non-pharmacological
treatments. As such, clinical guidelines, and efforts such as that of this text to foster
their practical application, provide a consistent basis on which to establish much
needed clinical services for this group of patients.
The current state of limited services for ADHD in adulthood can be devastating to
individuals and their families. This will come as no surprise to the vast majority of
child and adolescent psychiatrists and pediatricians, who have followed many patients
with ADHD through initial diagnosis and treatment into the adolescent and adult years.
They are well aware of the persistent course of the disorder into adult life and have
been demanding proper transitional arrangements to be put in place for their patients
for some years [65]. Furthermore, because of the highly familial nature of ADHD,
with approximately 20% of first degree relatives of an ADHD proband also having
ADHD [3, 66], they are well aware of the high proportion of parents of children with
ADHD who present with similar problems. Even in communities with highly advanced
medical services, ADHD often goes unrecognized and unaddressed.

Common Patterns of ADHD Presentation in Adulthood

1. Patients diagnosed and treated in childhood or adolescence who require transi-


tion to adult mental health and/or primary care services for continued treatment
and support.
2. Adults who dropped out of treatment as adolescents now seeking further
treatment.
3. A large group of people with ADHD who were not diagnosed as children but
present for the first time in adulthood.
Dropping out of treatment during adolescence is a recognized problem for
chronic medical and mental health conditions. Adolescent services therefore need to
find ways to engage with young adult patients and provide them with as much infor-
mation and support as possible, whether they are compliant with medication and
psychological treatment programs or not. Increased awareness of ADHD and
treatment options for ADHD has also contributed to generational differences in the
1 ADHD in Adults: A Clinical Concern 7

age at which ADHD is identified. For example in the UK very few children were
diagnosed and treated for ADHD before the mid-1990s, leaving a large cohort of
adults who never had the opportunity to be diagnosed during childhood. However,
even now some forms of ADHD continue to be missed during childhood depending
on the clinical presentation and expertise of schools and local services to recognize
the disorder. For example, girls with primarily inattentive subtype and no comorbid
behavioral problems may be thought to be slow learners rather than having a specific
difficulty with ADHD, or boys with oppositional and conduct problems may be
thought to have a primary behavioral problem with underlying ADHD being missed.
Primary care physicians, mental health professionals and teachers therefore need to
be aware of ADHD as a treatable condition and be sensitive to the different mani-
festations of the disorder.

Nosological Considerations and Comorbidity

Chapter 2 in this text addresses assessment of ADHD in adulthood, but particular


characteristics of the clinical presentation merit exploration in this discussion of
clinical validity. The diagnosis of ADHD in adults differs from the evaluation of
adult onset mental health conditions in that it requires establishing longitudinal per-
sistence of the condition since childhood. The “symptoms” are trait-like and abnor-
mal compared to developmental comparison groups, but do not show the typical
change from the pre-morbid state seen in most adult mental health disorders. While
in children the diagnosis is traditionally based on parent and teacher descriptions of
childhood behavior, many of which can be measured in terms of performance, ADHD
also creates functional challenges that can only be evaluated subjectively. For
example, individuals may complain of underperformance relative to their potential,
or the extra time and effort that it takes to accomplish tasks. However, it is also
important to recognize that there are distinctive characteristics of the mental state
examination: symptoms such as multiple distracted thought process, mind on the go,
forgetfulness, and feeling fidgety and restlessness. Thus while screening instruments,
such as the World Health Organization (WHO) Adult ADHD Self Rating Scale [67]
facilitates diagnosis, it is important to understand that clinical identification depends
on familiarity with the basic syndrome and how it most commonly presents.
Several authors describe how ADHD symptoms manifest differently in child-
hood and adulthood [68–71]. Motor hyperactivity may be replaced by a subjec-
tive sense of restlessness, difficulty in relaxing or settling down, and dysphoria
when inactive. Concentration deficits often persist in a lack of attention to detail,
the need to re-read materials several times, forgetting activities and appointments,
losing things and losing the thread of conversations. Thoughts are often unfo-
cused and the mind on the go all the time. Mood changes can be rapid shifts into
depression or excitability, irritability, and temper outbursts that interfere with per-
sonal relationships. Disorganization can also be prominent, where tasks are not
completed, problem solving is lacking in strategy, and time management is particu-
larly poor. Where present, the impulsivity of childhood may continue and leads to
8 P. Asherson

problems in teamwork, abrupt initiation, and termination of relationships and a


tendency to make rapid and facile decisions without a full analysis of the situa-
tion. While most people experience such symptoms some of the time in their
lives, the trait-like nature of ADHD symptoms means that individuals with
ADHD experience these to an impairing degree most, if not all, of the time. Part
of the disability that arises from ADHD is therefore the persistent (chronic and
trait-like) nature of the symptoms which as a result have a deep and enduring
impact on peoples’ lives.

Comorbidity Broadens Clinical Impact and Clinical Challenges

The challenge and importance of identifying and managing ADHD is underscored


by its overlap with, co-occurrence with, and contribution to risk for comorbid
conditions. Disorders for which there are considerable symptom overlaps include anxiety,
depression, bipolar disorder, and personality disorder (particularly borderline or emo-
tionally unstable personality traits). ADHD is a risk factor for development of all of
these conditions or of exacerbation of their manifestation. As previously noted, increased
rates of neurodevelopmental disorders also complicate clinical assessment and inter-
vention, such as autism spectrum disorders and dyslexia and behavioral problems
such as antisocial behavior and drug and alcohol abuse.
When considering the relationship of ADHD to comorbid symptoms there are
three main categories to consider: (1) symptoms of ADHD that mimic other disorders;
(2) symptoms of overlapping neurodevelopmental disorders that share etiological risk
factors with ADHD; and (3) ADHD as a risk factor for the development of other co-
occurring mental health conditions.
Symptoms of ADHD: Some symptoms represent alternative expressions of ADHD
but can lead to mistaken diagnoses. Examples include symptoms of mood instability
such as poor anger control, irritable and changeable moods which are commonly
seen as associated features of ADHD; and which may respond to stimulants when
treating adults with ADHD. Such symptoms overlap with broad concepts of bipolar
disorder in addition to the emotional instability that is part of some personality dis-
order diagnoses [25]. Other symptoms often seen in ADHD, such as ceaseless dis-
tractible thought processes, avoidance of situations due to impatience, irritability
when waiting in queues and situations requiring attention, or organization challenges
while shopping or traveling, can give the impression of an anxiety disorder. Low
self-esteem is another common problem that develops in people with ADHD and can
lead to primary diagnoses of dysthymia or depression, especially when considered
alongside other ADHD disturbances such as sleep problems (mainly initial insomnia
and disrupted sleep patterns), distractibility, and unstable mood.
The separation from personality disorder is a particularly tricky nosological
problems, since both ADHD and personality disorder are defined as trait-like conditions
that start during childhood or adolescence and reflect the extremes of normal behav-
ioral traits when they lead to significant impairment. Problems of classification arise
1 ADHD in Adults: A Clinical Concern 9

because when the criteria for adult personality disorders were developed they did
not take into account the potential role of neurodevelopmental disorders such as
ADHD and autism spectrum disorders, which also give rise to trait-like symptoms
and behavioral problems. The evolving nosology of personality will hopefully facil-
itate distinction between identifiable neurodevelopmental disorders and ‘tempera-
mental’ or ‘character trait’ disorders. The need for such a change in approach by
clinicians working with adults is particularly pertinent because of the availability of
treatments known to be effective for ADHD. It is therefore important that patients
who present with symptoms and behavioral disturbances of a chronic or trait-like
nature (that do not represent changes from the pre-morbid mental state as in most
adult onset disorders) are at least screened for ADHD so they can be referred for a
full diagnostic assessment where this is indicated.
Neurodevelopmental disorders: Some symptoms seen in adults with ADHD repre-
sent co-occurring neurodevelopmental disorders. Research has shown that there are
strong clinical and etiological associations between ADHD, other disorders of exec-
utive function, autism spectrum disorders, dyslexia, general learning difficulties,
and disorders of coordination. Family and twin studies indicate that these result
from shared genetic risk factors that are likely to represent the pleiotropic effects
(multiple different effects) of genes. These comorbidities are important because
they do not usually respond to the standard treatments for ADHD and are a source
of continued impairment for some patients.
ADHD as a risk factor for development of co-occurring conditions: ADHD confers
risk for the development of disorders such as antisocial behavior and substance use
disorders in adulthood. While the risk factors that mediate the development of such
behavioral problems include environmental risks such as maltreatment, there is
now good evidence that genetic factors are also involved. Recent research found
that the catechol-O-methyltransferase (COMT) val/val polymorphism, a genetic
variant of the COMT gene that leads to low dopamine levels, is associated with the
development of antisocial behavior and related phenotypes, but only in people
with ADHD and not in controls [72]. Further work suggested that this association
is mediated by poor development of social cognition [73]. These data suggest that
ADHD itself can be viewed as an early risk factor that interacts with both genetic
and environmental risks to influence the development of co-occurring behavioral
disorders such as conduct disorder and antisocial personality disorder.
The reasons for increased risk of substance abuse in people with ADHD are
complex and at least three basic mechanisms are likely to be involved. First we
know that ADHD is associated with novelty seeking and risk-taking behaviors
that are known risk factors for substance abuse disorders. This aspect of ADHD
may reflect core cognitive deficits within the subcortical reward pathways and
altered responses to rewards and reinforcers [74]. Secondly, having ADHD as a
child is likely to increase exposure to psychosocial risk factors for substance
abuse; such as poor social interactions, difficulties with education, being
suspended or expelled from schools, and development of conduct problems.
Finally, we know that patients report reductions in ADHD symptoms from the
10 P. Asherson

use of various substances, and it is not uncommon for adults with ADHD to
report using either cannabis or alcohol to help them slow down and relax in the
evenings or to get off to sleep. These different components to risk of substance
abuse are important to understand because current evidence from clinical trials
does not strongly support the efficacy of stimulants in the treatment of ADHD in
substance abuse patients [52], suggesting that more work is required to fully
understand individual SUD patients and provide a full range of treatments to
target multiple underlying problems. Chapter 8 on common comorbidities in
ADHD explores management of such presentations further.

Real-Life Impairments in Adults with ADHD

The most compelling evidence for the clinical importance of ADHD and its man-
agement comes from the experience of our patients. ADHD presents with a wide
range of impairments from relatively high functioning individuals who nevertheless
present with a range of symptoms and difficulties in completing certain types of
tasks to those that are severely impaired and may have considerable difficulties in
key aspects of their life. Some examples of the types of problems that people
commonly present with are listed in Table 1.1. These examples are all from people
who fulfilled the full diagnostic criteria for DSM-IV ADHD both as children and
adults and for whom treatment with medication and psychoeducation had a
considerable impact on improving the presenting complaint.
The nature of the underlying symptoms that people with ADHD experience can
also be seen by asking people to describe the type of changes in their mental state
they experience when being treated for ADHD. The symptom response to
pharmacological treatments such as methylphenidate and atomoxetine is highly
characteristic and can usually be easily delineated by asking patients to compare the
way they feel when they are on or off such medications. Examples of typical clinical
presentations that have subsequently responded to treatment for ADHD, from
patients attending my London clinic, are listed in Table 1.2.

Executive Function and Alternative Etiological Models of ADHD

How we understand the neurobiological processes that lead to ADHD symptoms is


an area of considerable research effort and scientific debate. One important
conceptualization of ADHD that has been highly influential, based on careful clini-
cal observation, is a disorder characterized mainly by impairments in aspects of
executive function [75, 76]. As is explored in chapter 4 on neuropsychological
assessment in this text, executive functions can be evaluated behaviorally or through
neuropsychological tests. These are higher order processes involved in the control
of many important processes required for self-regulation of important cognitive
functions, allowing for organization of behavior to attain future goals.
1 ADHD in Adults: A Clinical Concern 11

Table 1.1 Typical complaints responsive to treatment in adults with ADHD


Patient Main presenting complaints
26-year-old mother Disorganized. Ceaseless mental activity. Unable to work
and difficulty completing simple tasks such as
shopping. Treated for anxiety/depression but uses
cannabis to “calm thoughts.” Difficulty managing her
two children who both have a diagnosis of ADHD
22-year-old male student Inability to cope at college. Repeated first year of
college for third time despite high IQ, high motiva-
tion, supportive family, and good education. Robust
inattention
18-year-old man with borderline IQ Low IQ (around 70). Behavioral problems. Lacks
insight. Binge drinking. Main presenting complaint
was extreme irritability and aggression at home
30-year-old female student Irritable and volatile moods. Treated for depression.
Only retains lecture material by recording and
transcribing notes. Managed to pass college
examinations but took considerable time and effort to
complete studies
25-year-old unemployed man Unemployed. Sitting around at home. Severe inner
restlessness. Unable to focus for more than a few
minutes. Grossly distractible and unfocused thought
processes
35-year-old man Extreme impulsiveness. Has had many verbal and
physical fights. Very poor attention span and ability
to plan ahead, but main problems reported as
constant restlessness, severe mood instability, over
reactions to minor setbacks, and impatience

Brown describes six main areas of functional deficits that are relevant to
adults with ADHD: (1) activation (organizing, prioritizing, and activating to work);
(2) focus (focusing, sustaining, and shifting attention to tasks); (3) effort (regulating
alertness, sustaining effort, and processing speed); (4) emotion (managing
frustration and regulating emotions); (5) memory (utilizing working memory
and accessing recall); (6) action (monitoring and self-regulating action) (Brown
[75]). Barkley’s model encompasses a similar set of functional deficits, but
differs from Brown’s model by highlighting behavioral inhibition as the main
deficit that leads to clinical manifestations of the disorder [77]. Barkley argues
that inhibition leads to deficits in “metacognition” which include verbal and non-
verbal working memory, planning and problem solving, and emotional self-
regulation.
Both descriptions of ADHD are particularly relevant to our understanding of ADHD
in adults because they provide a good account of the range of difficulties experienced
by people with ADHD. However, while these descriptions of executive functions hold
considerable face validity in terms of functional deficits experienced by people with
ADHD in real-life situations, they may not relate directly to more narrow concepts of
executive function when measured directly using tests of neurocognitive function. For
example Willcutt et al. [46, 78–81] have pointed to the involvement of multiple
12 P. Asherson

Table 1.2 Typical response to ADHD pharmacotherapy in an adult with ADHD


Task/activity Reported change with stimulant medication
Restlessness I no longer notice any particular restlessness or fidgeting
Sleep I fall asleep more easily and then sleep better (reduced mental and physical
overactivity in the evening)
Unstable moods My moods are far more stable and I no longer feel anxious or depressed
(experienced similar amount of improvement in mood stability and in
core symptoms of ADHD)
Sustained effort/ “I’ve managed to get through work items that require sustained effort—
focus even tedious things like reviewing program codes for consistency of
style” (normal levels of effort required, less boredom reported)
“I have noticed small changes around the house, bills paid, table cleared,
laundry done and put away” (normal levels of effort required)
Reading “I’ve found myself quietly reading a book for an hour without having to get
up, having my mind wander, or losing track of where I was on the
page”
Mind wandering “One of things that I found surprising was that I guess I was expecting to
feel more ‘alert’ or ‘awake’, but I actually just feel clear-headed”
(ceaseless, unfocused mental activity reduced)
Self-esteem/ “I have the confidence to decide when I want to work on something and for
confidence how long. Believe me such confidence is a new thing”

neuropsychological deficits in ADHD, including both cortical and subcortical processes


and both executive and non-executive functions [82]. Furthermore a recent study of
evoked response potentials (ERP) in adults with ADHD found impairments in orient-
ing to cues that preceded deficits in inhibitory processing, suggesting that response
inhibition is not a core deficit in adults with ADHD [83] and that sensory processing
deficits are involved. It is important also to appreciate that many adults who meet full
clinical criteria for ADHD lack demonstrable neuropsychological deficits.
One particularly interesting hypothesis is the developmental hypothesis from
Halperin and coworkers [78, 79], who followed up children into young adulthood
and defined both persistent and remitting groups with childhood ADHD. He pos-
ited the existence of two main processes involved in the developmental course of
ADHD. First, an early appearing and enduring subcortical dysfunction affecting
state regulation and/or arousal processes that is indexed by reduced reaction time
and increased reaction time variability. Second, a pre-frontally mediated dysfunc-
tion of executive control, indexed by measures of response inhibition, which
depending on maturational processes, leads to persistence or remission of ADHD.
The two processes model highlighted by Halperin is also reflected in recent
research that found that in ADHD, a familial cognitive factor indexed by slow and
variable reaction times explained around 82% of the genetic effects on ADHD,
while a second familial cognitive factor indexed by commission errors (and omis-
sion errors) in a Go/NoGo task explained around 13% of the genetic effects [80,
84]; and the arousal attention model of ADHD (see Johnson et al., [39] for
review).
1 ADHD in Adults: A Clinical Concern 13

Overall these studies point towards a complex set of underlying brain capacities
involved in the etiology, course, and outcome of ADHD that explain the deficits of
self-regulation that afflict people with ADHD in real-life situations. Thus there are
neuropsychologically plausible explanations for the core difficulties in self-regula-
tion seen in ADHD—including differences in speed of cognitive processing, control
of attention, control of behavior, and control of emotions.

Conclusion: ADHD in Adults Is a Concern Worthy


of Greater Attention

Overall we can see that evidence converges to strongly support the validity of ADHD as
a distinct clinical syndrome. Because ADHD in adults is a common source of personal
and societal suffering, because it is highly treatable, because it compounds other
disorders, and because services for adults with ADHD are limited, ADHD deserves the
full attention of those working in adult mental health. Practitioners can apply the
techniques for assessment and treatment offered in this guide to help the many thousands
of patients who present with some of or all of their problems related directly to
ADHD.

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Psychol Med. 2010;40(6):1027–37.
Chapter 2
Clinical Assessment of ADHD in Adults

Craig B.H. Surman

Abstract Initial evaluation of an adult presenting with possible ADHD should


determine if the diagnosis is present, identify traits commonly associated with
ADHD, and establish a basis for treatment decisions. This chapter offers a practical
guide to screening for ADHD, as well as step-by-step diagnosis of ADHD in adults.
The approach detailed here is based on Diagnostic and Statistical Manual criteria,
extensive experience operationalizing those criteria and is consistent with expert
consensus guidelines. The chapter includes how to differentiate ADHD from other
conditions, and conditions that are important not to miss because they may pose a
contraindication to some forms of ADHD treatment. It has long been recognized
that a subset of individuals with ADHD have more extreme difficulty with organiza-
tion. This chapter offers a guide to identifying these “self-regulation” challenges
that are not defined as core symptoms of ADHD, but are a common burden in this
population.

Introduction

The manifestations of ADHD may be quite clear, or, in some adults, hidden by
avoidance of challenges and compensatory efforts. ADHD impacts each patient
differently, depending on their characteristic strengths and challenges. It can be helpful
to appreciate that at the core, ADHD symptoms describe problems controlling what a
person engages in—the moment-by-moment selection of mental and physical activities.
In ADHD, it often appears that mental and physical activity are under less native
control—more at the whim of what does and does not naturally engage the person. It
may be useful to consider ADHD as a condition marked by limited control over what

C.B.H. Surman, M.D. (*)


Adult ADHD Research Program, Massachusetts General Hospital,
55 Fruit Street, WRN 705, Boston, MA 02114, USA
e-mail: csurman@partners.org

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 19
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_2,
© Springer Science+Business Media New York 2013
20 C.B.H. Surman

a person engages while developing a personalized treatment plan, as discussed further


in the next chapter. Thus, identification of ADHD requires careful evaluation of the
effort it takes an individual to control their mental and physical activity.
ADHD diagnosis, by definition, requires a comprehensive clinical interview
covering both ADHD criteria and alternative explanations for symptoms. While
some screening tools and tests correlate with a diagnosis of ADHD, current clinical
understandings of the condition do not require performance of any screen or test.
Screening does offer a chance to efficiently determine the whether full diagnostic
assessment should occur. Although a full assessment may be a lengthy process, it
can be adapted to different clinical settings by spreading evaluation out over time,
or across a team of clinicians.
This chapter addresses both efficient screening for ADHD in adults, and a guide
to in-depth assessment. It is organized around high-yield questions and time-saving
inventories that have proven useful in clinical care. An abbreviated guide to use of
the inventories, and blank copies of inventories, are found in the Appendix.

When to Evaluate a Patient for ADHD

ADHD impacts approximately 4% of adults [1], can have profound impact (as
detailed in the previous chapter), and is accompanied by high rates of other mental
health conditions [2]. This supports the argument that all patients presenting with
functional impairment or mental health conditions should be screened for ADHD.
While many patients with ADHD present in states such as depression or anxiety that
deserve prioritization over ADHD, identification of ADHD may clarify traits that can
be supported subsequently, and offer hope for a better level of long-term function.
It is high-yield early in a clinical discussion to inquire what particular struggles
or problems bring them to the assessment. It is important to identifying if there is
impairment in function that merits an evaluation—traits without impairment are
usually insufficient to warrant intervention.
Even if a patient presents with documentation of ADHD or a longstanding
“diagnosis” of ADHD, it should not be assumed that it remains a source of impairment
worthy of treatment. Prior clinicians may not have performed a comprehensive
evaluation, and, as discussed further in the next chapter, manifestation of ADHD
can change with time and context.

Diagnosis Depends on Quality of Information

ADHD cannot be evaluated well without good information about the patient’s mental
health and function. Because individuals may have “blind spots” or distort their
report of challenges, it is important to gather information from third parties where
useful. Consider, for example, gathering information from any third party who initiated
2 Clinical Assessment of ADHD in Adults 21

the evaluation—in some cases, the referring party (such as a spouse or parent) may
be better able to articulate struggles of concern. Third-party symptom history can be
gathered on a self-report form such as that offered in the Appendix. School records,
early school assessments, and old clinical records also offer useful perspectives on
the historic presence of ADHD. In some cases, mismatch between self and other
observations is very informative, identifying differences in perspective or values
with key people in their environment. Thus involving a third party offers a chance
to evaluate self-observation capacity, and to characterize the interpersonal context in
which their concerns arise. For example, some individuals begin to have concerns
about their function when they begin to live with a person who values cleanliness
and lack of clutter more than they do, or who can highlight struggles that they don’t
share. However, information should be gathered in ways that do not compromise
privacy. While it is commonplace to get teacher perspectives on symptoms of younger
patients with ADHD, there may be repercussions of sharing the ADHD diagnosis
with an employer as an adult.
The fact that medications for ADHD can be abused or misused also raises appro-
priate concern that patients may present as having ADHD to meet unhealthy goals.
There is no objective way to completely eliminate concern that individuals are
misrepresenting themselves as having ADHD, because there is no “test” for ADHD.
It is also inappropriate to deny assessment or treatment to patients with bona fide
ADHD due to such concern. Particular clinical contexts that merit more extensive
procedures to ensure good information from patients include substance abuse
populations, forensic populations, and individuals in highly competitive environments—
all places where either misuse or abuse may be more prevalent.
As with any disorder, a clinician ideally will only make the diagnosis where
they are confident the criteria are met. It will require different kinds of evalua-
tion to achieve this confidence in different patients. Individuals vary in their
ability to notice and to report symptoms of ADHD, and in what they consider
impairing. While some patients can vividly describe their challenges, it may
take obtaining third party reports to carefully inventory ADHD traits in many.
Where one is unsure whether to make the diagnosis, obtaining the perspective
of other clinicians, or pursuing other therapeutic avenues may facilitate both
comprehensive support of the patient and understanding of their commitment to
healthy therapeutic goals.
Clinicians sometimes ask whether particular interviewing approaches, tests, or
office practices like drug screens or frequent visits will improve identification of
patients who should not receive stimulants. If a clinician is thinking this way, it
should be considered a possible sign that there is insufficient comfort with diagnosing
or treating the patient. Neuropsychological evaluation or other tests of brain function
is sometimes viewed as a way to objectively determine cognitive abilities. However,
there is no requirement in the DSM clinical diagnosis of ADHD that the patient
must perform poorly on such testing. Although some clinicians highly value various
measures for their correlation with a diagnosis of ADHD, even in the presence of
robust test-identified attention and executive challenges, the diagnosis should not be
made unless the DSM diagnostic criteria are fulfilled.
22 C.B.H. Surman

Similarly it is useful to understand that no inventory of symptoms or symptom


scale is sufficient to make a diagnosis—it remains up to the clinician to determine if
criteria are met no matter how information is gathered. In addition to this guide and its
rating scales, there are other valuable tools for assessment of adults with ADHD avail-
able. There is a difference between an inventory of current symptoms and instruments
that can be scored based on current symptoms to identify likelihood of a clinical diag-
nosis. The scales in this volume are meant to enrich a clinical assessment process, not
to indicate how a person’s symptom burden compares to the general population or
individuals with confirmed ADHD disorder. Several screeners and current-symptom
based instruments are available [3–8]. Guides to operationalizing assessment of ADHD
in adults based on DSM-IV criteria have also been developed [9, 10].
This chapter discusses screening for ADHD using a publicly available screening
tool, and clinical evaluation of the diagnosis relying on a unique inventory, the
ADHD Symptoms and Role Impact Inventory (ASRI). The ASRI is found in the
Appendix in clinician, self-report and third-party report versions, for capture of
current impact of ADHD and its historical onset. This inventory is unique in that it
emphasizes impact of symptoms on role function, which is essential for diagnosis
and treatment planning. The ASRI Guide (also in the Appendix) is unique in that it
presents experience-tested language for capturing symptom severity, as well as
common examples of role impact, for used in interviews. The Adult ADHD
Diagnostic Checklist, found in the Appendix, can be used to ensure the rest of a full
diagnostic assessment occurs, as is described in this chapter.

Screening for ADHD

In some clinical settings it is practical to screen for ADHD before conducting a full
evaluation, which may be a lower clinical priority and time consuming. A number
of screening tools are available which have been shown to correlate with clinical
diagnosis of ADHD. These screening tools are not sufficient, however, to differentiate
between ADHD and other conditions which can present like ADHD.
The ASRS is suitable for screening patients in English because it is in the public
domain, has been adopted by the World Health Organization, and applied in the
large National Comorbidity Survey-Replication study [11]. The scale was devel-
oped to differentiate, based on DSM-IV current symptom traits, individuals with
and without ADHD. It was not designed to differentiate ADHD from other disor-
ders—this is important to understand, because false positives might occur more
often in comorbid settings.
The ASRS screener is the first 6 items of a longer 18-item self-report scale that
can be used to inventory ADHD symptoms in adults [12, 13]. If an individual indicates
four of these six items occurring at the frequency indicated in gray in Fig. 2.1, it is
highly suggestive of ADHD. In a sample of adults with and without ADHD, the
instrument had 69% sensitivity and 99% specificity for ADHD. However, it should
be noted that the specificity is likely to be lower in community samples with high
rates of comorbid conditions that could present like ADHD. When someone endorses
2 Clinical Assessment of ADHD in Adults 23

Please answer the questions below, rating yourself on each of the criteria shown using

Very Often
Sometimes
the scale on the right side of the page. As you answer each question, place an X in the
box that best describes how you have felt and conducted yourself over the past 6

Rarely
Never

Often
months. Please give this completed checklist to your healthcare professional to discuss
during today’s appointment.
1. How often do you have trouble wrapping up the final details of a project,
once the challenging parts have been done?
2. How often do you have difficulty getting things in order when you have
to do a task that requires organization?
3. How often do you have problems remembering appointments or obligations?

4. When you have a task that requires a lot of thought, how often do you avoid
or delay getting started?

5. How often do you fidget or squirm with your hands or feet when you have
to sit down for a long time?
6. How often do you feel overly active and compelled to do things, like you
were driven by a motor?

Fig. 2.1 Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist. If four or more marks
appear in the darkly shaded boxes then the patient has symptoms highly consistent with ADHD in
adults and further investigation is warranted [reprinted from [11], with permission from Cambridge
University Press]. This screener is also available in the Appendix.

symptoms on the screener, the screen can be enhanced by briefly asking for related
examples and to clarify their frequency in recent days to determine whether they are
impairing. As this chapter explores later, in some cases ADHD traits are compensated
enough that they are not a source of significant impairment. Unless there is a func-
tional concern, a full evaluation of diagnosis may not be warranted.

Diagnostic Interviewing for ADHD in Adults

This section offers a guide to interviewing an adult with ADHD. Where useful, types
of questions that may be high-yield are offered in bold items marked >>, but clinicians
should come up with their own versions and tailor the interview to the patient.

Identify Current Concerns

>> “What is not going the way you would like it to day to day? What kinds of
tasks take more effort than you feel they should?”
A question like this helps identify what the individual is concerned about, offer-
ing a chance to determine mutual goals for work with them. The word “tasks” is
chosen because individuals are likely to be able to talk about hands-on activities,
although ADHD clearly can impact patterns of non-“task” thought patterns and
communication patterns. Questions like this also acknowledge concern not only for
consequences of personal challenges, but also the effort it takes to manage them day
to day. Style of day to day function needs to be understood in detail to identify
ADHD, and where a person struggles it counts towards fulfillment of the diagnostic
criteria that impairment is present.
24 C.B.H. Surman

>> How are you feeling in the past week? Are you suffering emotionally, feeling
anxious, preoccupied, or under stress? Is it a typical week?
Whether one interviews to identify ADHD or other conditions first, the assessment
should comprehensively identify factors impacting wellbeing and function. This
chapter does not offer a guide to comprehensively identifying all mental health
conditions—but later in this chapter, we discuss major features differentiating
ADHD from other comorbid conditions.
Problems related to attention, memory, organization, and control of behavior are
part of several disorders and can also be brought on by uncomfortable or stressful
circumstances. Where extreme mental states or circumstances are present, it may be
impossible to thoughtfully evaluate what problems are due to ADHD versus preoc-
cupation or mental health compromise of brain function. If the patient can recall a
recent period when they were free of major stressors or comorbidity, the interview
might focus on determining if criteria were met at that time. In addition, when a
patient’s chief complaint is about anxiety, mood, or another comorbidity, it may be
worth explaining that you want to understand whether they historically have had chal-
lenges controlling attention and behavior to see if that has added to their distress.
Ideally, however, the ADHD symptom inventory can be collected using recent
contemporaneous information. ADHD symptoms may occur more in particular
roles or settings—so it helps to know what the patient has been doing recently. For
example, symptoms contributing to school or work-based challenges are best
inventoried while the individual is in those settings.

Determining if the Individual Fulfills ADHD Criteria

DSM criteria for ADHD require presence of current symptoms of inattention,


impulsivity, and/or hyperactivity. Sufficient data has accumulated to offer criteria
specific to adults, and this has been reflected in the evolution of DSM ADHD criteria.
Historically, application of DSM criteria to adults has required some extrapolation
from the criteria for childhood symptoms. The DSM V development process
reflected the desire to have adult-specific criteria. The guidelines offered here are
based on assessment techniques developed with extensive clinical and research
application of DSM-IV ADHD criteria. It will take some time before the utility and
limitations of differences in DSM-IV and DSM-V criteria are understood.
The core question in ADHD diagnosis should be whether there is impairment
due to limited control of attention and activity pattern that is not explained by
another condition. There are four criteria to satisfy:
1. Presence of sufficient current symptoms
2. Pervasive presence of these symptoms since childhood
3. Symptoms cause clinically significant impairment in two or more settings
4. Symptoms are not explained by another disorder
2 Clinical Assessment of ADHD in Adults 25

1. Current symptoms: Are sufficient subtype symptoms present


DSM-IV criteria for children has required presence of six of nine listed symptoms
of inattention, or six of nine current symptoms of impulsivity/hyperactivity, or
both. The symptoms are described in the ADHD Symptom and Role Impact
Inventory (ASRI) later in this chapter. Their pattern determines whether the diag-
nosis would be considered inattentive subtype, impulsive/hyperactive subtype, or,
where both are met, combined subtype. However, research and clinical experience
suggest that occurrence of four or more current symptoms from either category is
abnormal, and is a useful threshold for discriminating adults with and without
ADHD. For example, one research group found that four or more of these symp-
toms fell at the 93rd percentile of a sample of the general population [14], and that
in a community sample 95–99% of non-ADHD individuals fell below this thresh-
old [15, 16]. A study from our research group demonstrated that individuals who
never met full DSM-IV ADHD criteria, but reported a chronic history of three or
more inattentive or three or more impulsive/hyperactive symptoms, did not have
the same level of clinical pathology as individuals who currently met full criteria
for ADHD. A study has also suggested that requiring six hyperactive-impulsive
symptoms could exclude about half of the individuals falling 1.5 standard devia-
tions above the population mean for these traits [17]. In total, such studies suggest
that four or more current symptoms from either subscale identify individuals likely
to suffer from an ADHD syndrome.
While impulsivity is considered a core feature of the impulsive/hyperactive
subtype of ADHD, only three of the nine impulsive/hyperactive symptoms
directly reflect poor control of impulse—difficulty waiting, interrupting/intruding
on others, and speaking out of turn. The DSM-V development process included
exploration of adding more impulse control symptoms to the hyperactive/impul-
sive subtype traits. It is the opinion of this author that it will take significant
experience with newer criteria to determine their utility. At present the evidence
basis for treatment of adults with ADHD is more firmly rooted in the DSM-IV
symptom pattern.
>> Please think about a recent, typical week. I want to know how often these
things occur, or how much effort it takes to avoid or manage them. Also, I will
ask how they impact your daily life.
This is a way of introducing current symptom evaluation based on a symptom
inventory. It can be efficient to use a self-report or informant-report inventory, as
well as conducting a symptom interview. It may be efficient to focus an interview
about ADHD symptoms with items endorsed on self and informant inventories.
However, it is important to make sure the ratings reflect understanding of the symptoms
being reviewed, and a clinician should interview to identify how they would rate
these symptoms. This chapter describes a clinical interview using the ASRI, and the
clinician, self-report and informant report versions of the ASRI are found in the
Appendix. Key principles for effective administration of a symptom inventory are
presented below:
26 C.B.H. Surman

Focus on a Recent Time Period

Capturing a recent time period may be hard when patients want to share the worst
situations they have been through. It can be useful to know about the time 3 years
ago that the patient locked their car keys in their car with their car running—but day
to day traits should be the focus of the rating scale, to determine how pervasive
ADHD is in day to day life. It helps to repeatedly reminding the patient that you
want to know about a recent, typical week.

Word Questions to Reflect Adult Experience of Symptoms

Where ADHD persists into adulthood, symptoms of inattention tend to remain


prominent. However, overt impulsive and hyperactive behavior tends to diminish.
Put another way, as individuals with impulsive or hyperactive traits grow up, the
restlessness often remains in the form of internal impulse or urges. Children who
ran in the hallways of school are not likely to run in the corridors at work, but they
may get up for unnecessary and frequent breaks to just move around. Impulsive
symptoms may be related to verbal communication—interrupting others, talking
more than needed—but many patients describe the consequences of emails sent
without thinking, decisions to leave jobs or even end relationships based on emo-
tional reactions. Interviewing adults for symptoms of hyperactivity and impulsivity
requires sensitivity to the impulses they may be actively controlling, and the contexts
(like sitting, lingering with others) they avoid.

Compensatory Burden Should Count Towards Symptoms Count

Adults with ADHD have learned ways to cope with ADHD symptoms, and may
even avoid contexts that demand the focus and behavior control skills they lack.
Simply asking about day-to-day problems may miss compensatory efforts. For
example, if one asks how often a patient loses things, they may say never—but if
you ask the same patient how often they have to look for things they misplaced, they
may say “all the time—I find it eventually, so it’s never lost.” Often people have
little basis for comparing how much effort it takes to do mundane tasks—they may
not recognize that their long hours at work, need to double-check work, or reliance
on advance preparation or reminders is unusual. Where compensatory efforts are
effective and efficient—such as a habit of checking whether one has their keys, wallet
and identification card before leaving home, they should not contribute in measure-
ment of symptom burden. Compensation should be a burden to count towards the
severity of a symptom.
2 Clinical Assessment of ADHD in Adults 27

Determine Severity from Frequency of Symptoms, Consequence


and Compensation

It may seem efficient to ask patients whether they consider the impact of a trait
“mild, moderate, or severe,” but the clinician should determine if they agree. A rating
scale based on frequency may be useful for quick self-report of symptom occurrence.
But determining severity of a condition requires appreciation of the impact and
burden of symptoms as well. Thus it is useful to capture severity of impact and
burden when rating ADHD symptoms.
Symptom severity can be seen as a product of symptom frequency, efforts
required to minimize impact of symptoms, and the actual impact of symptoms. It is
helpful to establish guidelines for rating mild, moderate and severe, to improve the
ease of this process in the moment. Here is an example of frequency or function
criteria used to evaluate each level of severity:
– Severe symptom: occurs very frequently OR very compromising of function in a
life role
– Moderate symptoms: occurs often OR could impair ability to fulfill an important
life role
– Mild: occurs sometimes OR is not likely to impact a life role

Use Symptom Queries to Gather Unique Information

A particular day to day challenge may be seen as a product of more than one symp-
tom on the ADHD symptom list. For example, difficulty paying attention to infor-
mation presented is part of both trouble paying attention and trouble listening in one on
one conversations. Difficulty finding things may be a result of poor organization—
yet misplacing things and organizational skills are captured in separate symptoms.
It is useful to try to see each symptom question as a chance to identify a unique
dimension of the disorder. Thus, different aspects of “paying attention” might be
assessed in separate items reflecting one-on-one conversations versus gathering of
information such as in a meeting, while reading, or during note taking. Similarly, it
is useful to use scale items to seperately identify memory challenges and organiza-
tional skills.

Establish Whether Clinical Symptom Threshold Is Met

Count up the number of traits that you rated at the moderate or severe level. Are at
least four symptoms present at the level of moderate within either the inattentive or
the impulsive/hyperactive subset of symptoms? Also note if there is anything
informative about the pattern observed—does the person fall solidly into inattentive
subtype with very little impulsive/hyperactive traits? Or is the opposite pattern evident?
Clinical experience suggests that a pattern marked solely by impulsive or hyperactive
28 C.B.H. Surman

traits merits special differential diagnosis attention, as it is a rare presentation in


adults with ADHD. In addition, as noted above, the three separate symptoms of
impulsivity deserve special consideration. If a person met only impulsive traits, it
may be particularly important to keep this in mind while exploring alternative
conditions that would explain the differential diagnosis.

Discussion of Role Function Helps Ground Discussion of ADHD Impact

The inventory below also offers a chance to empathically appreciate the impact of
attention and behavior control challenges, in the major settings–or roles–of a
person’s life—useful for appreciating whether the impairment and “two or more
settings” criteria are met. Impact in a single setting merits exploration of what
specific challenges are present there and nowhere else. For example, a learning dis-
ability my cause difficulty engaging school work, leaving self-care, home life and
relationships intact. Explore roles that are important to the individual, that involve
different dimensions of daily life.

Note Examples of Consequences

It is very helpful to make note of—and discuss—typical examples of how each


symptom impacts a person. This offers a more concrete way to talk about the impact
of ADHD, and track the severity of its manifestations. For example, if a person
spends 20 min a day looking for things, that can be noted in the space for rating
severity of misplacing things. Procrastination in a college student might be tracked
by what time they get around to starting homework. To follow accuracy with details,
the number of times an office worker makes “careless” mistakes might be
followed.

Speaking the “Language” of ADHD: Prompts and Examples


for ADHD Symptoms

To understand if someone has ADHD, one must understand their pattern of control
over attention and behavior. Evaluation of ADHD symptoms is an exercise in empathy
for cognitive challenges. It can help to think, “What would be hard for me to do if I
was this person, and had their strengths and challenges?”
The self-report, informant report, and clinician forms of the ASRI (all found in
the Appendix to be copied for clinical use) facilitate exploration of current symptom
burden, related impairment in roles, and the age of symptom onset. The language in
these inventories identifies common ADHD manifestations in adults.
The guidance presented in this chapter for use of the ASRI is also summarized in
the Appendix. The language and examples offered below reflect the author’s interpre-
tation of the intention of DSM criteria. Many similar questions and examples of role
2 Clinical Assessment of ADHD in Adults 29

impairment are useful. Language should be tailored to an individual’s circumstances


to capture the theme of the symptoms.
The prompts that follow should be taken as one example of how one can determine
whether symptoms are present in day to day function. Many similar kinds of
questions could be useful (Table 2.1).
2. Age of onset: Determining the longitudinal course
>> What age did you first have these kinds of challenges? When did other
people first talk about them? Do you remember periods of time when you
didn’t have these challenges? Were they part of your life during times when
you felt and functioned at your best? Did you “grow out of” some of these
challenges?
Systematic identification of age of onset of ADHD is central to identifying
whether this developmental condition is present. The ASRI Clinician, Self, and
Informant recording sheets has space to record age of onset of traits endorsed. Some
clinicians prefer to start with a historical perspective, asking about childhood
experiences and how challenges then persist to the present day. Whether one starts
with current symptom and asks their onset, or gathers data about how childhood
manifestations persist, these kinds of questions may help determine the pervasiveness
of the symptoms in a person’s life. Some people can note particular times when they
didn’t have these traits—and that can be a clue to whether an alternative diagnosis
is more important (see section below on differential diagnosis). Alternatively, there
may be environmental factors that meant that certain life periods were more free of
problems (see discussion of age of onset criteria below). It is also important to
consider how organized the childhood environment was, and whether a disorganized
or struggling family could be the source of organizational challenges.
While it is important not to “lead the witness,” it is also important to orient the
patient to what kinds of examples are helpful. One might inquire: “What do you
remember about your classroom experiences? Did you get in trouble in class? Can
you give me examples?” Another relevant example: “Were you expected to do tasks
at home? Do you recall whether and how you got them done?” Asking about a
specific trait, find out how often it occurred and whether it was remarkable to others
or caused problems. “You said you misplaced a lot of things as a child—did your
parents comment on that or have to help you find things? How often?”
It is often hard for adults to recall enough details of their childhood, so third
party reports are very useful. Giving patients homework to obtain old school records,
or records from prior evaluations can be useful. It also is useful to have patients ask
someone else, if they are comfortable, to fill out a rating scale with queries about
onset (See Appendix for ASRI Informant inventory).
>> Did your teachers, parents, or friends comment about problems with focus
or behavior when you were little? How hard was it for you to behave as expected,
to get along with others, to take care of schoolwork or household chores?
While DSM-IV required onset of some ADHD symptoms by age 7, there is evi-
dence that report of ADHD symptoms by age 12 is consistent with a clinically
impairing syndrome. Individuals who met full criteria for DSM-IV ADHD but had
30 C.B.H. Surman

Table 2.1 Questions exploring symptoms of ADHD in adults


Inattentive traits
Difficulty being accurate with details
Prompt: How much effort does it take to be accurate or catch mistakes in your work? How
often do you make errors that matter?
Difficulty sustaining attention
Prompt: How much effort does it take to pay attention when you should? How often do you
miss presented information because of mind wandering?
Difficulty listening in conversation
Prompt: How hard is it to listen to someone who is speaking directly to you? How often do you
miss what people say to you?
Difficulty sticking to and finishing actions
Prompt: How much effort does it take to stick with a task and not start a new one? How often
do things go unfinished?
Difficulty organizing
Prompt: How much effort does it take to stay organized? How often do you wish things your
space or activities were more organized?
Putting off tasks requiring mental effort
Prompt: How hard is it to get around to work that you need to complete? How often do you
need a deadline to get things done?
Often losing important items
Prompt: Do you have to be careful not to misplace things? How often do you spend more than
10 min a day looking for things?
Forgetfulness
Prompt: Does it take special effort to remember things you need to do? How often are you
upset that you forgot something?
Often distracted by things in environment
Prompt: Is it hard to tune out distractions around you? How often does distraction keep you
from accomplishing tasks?
Hyperactive/impulsive traits
Hyperactivity/Impulsivity
Fidgeting
Prompt: How much effort does it take to be still when sitting? How often is your fidgeting
upsetting to you or others?
Restless
Prompt: How much effort does it take for you to sit as long as you should? How often do you
interrupt activities to get up?
Excessively in motion
Prompt: Is it hard to stop yourself from moving too much? How often are you more in motion
than other people?
Excessively loud
Prompt: Does it take effort for you to control the “volume” of your voice or presence? How
often do you wish you had controlled it better?
Excessive internal drive
Prompt: Is it hard to linger at activities? How often does the urge to stay busy cause problems?
Talking excessively
Prompt: Does it take effort not to talk longer than you need to? How often do you wish you had
stopped talking sooner?
(continued)
2 Clinical Assessment of ADHD in Adults 31

Table 2.1 (continued)


Speaking at the wrong time in conversation
Prompt: How hard is it not to speak before your turn? How often do other people ask you to let
them finish?
Difficulty waiting
Prompt: How hard is it to wait, such as in a line at a supermarket, or in light traffic? How often
do you avoid lines or leave them?
Intruding on others
Prompt: Is it hard not to interrupt others people when they are already in a conversation? How
often do you intrude on other people?

symptom onset by age 12 appear to have similar life consequences of the condition
as those with onset by age 7 [16, 18]. See the note about subthreshold presentations
that follows below. Operationally, therefore, it is appropriate to count the presence
of only a few symptoms within either the inattentive or impulsive/hyperactive cate-
gory as enough to fulfill the onset criteria.
It is common to hear that some traits did not appear until later in life. A college
students or adult entering the workforce may note, for example, forgetting things,
misplacing things and having trouble organizing only recently, but problems getting
around to mental effort tasks, listening, and attending to presentations back to early
grade school. When particular traits did not occur until a particular point in time, it
helps to understand why that might be. In some cases, it may be clear that this is
related to the emergence of ADHD-sensitive roles—such as greater self-organization
responsibilities. In others, concern about symptoms emerges with change in daily
demands, personal priorities, or available supports.
3. Symptom-related impairment in two or more settings
Two or more roles of the individual’s life must be impacted by the ADHD
symptoms—for a period of at least 6 months. It is efficient to collect examples of
role impairment during review of current symptom burden. You may want to review
the examples of role impairment typically caused by ADHD symptoms that are
noted in Table 2.2, and reiterated in the Guide to the ASRI in the Appendix.
Symptom-related problems appear in very different patterns between individuals,
and it may take exploring low-interest, effortful situations or situations requiring
low activity to identify examples of role impairment. If needed, the ASRI examples
of impairment can be reviewed with an individual to prompt identification of simi-
lar issues.
However, there may be roles that are difficult to evaluate—either because of lack
of good information from the patient, or because they are deferred or avoided roles.
Third party reports may help—whether through review of a work progress report, or
direct interview of a loved one. Scales have also been developed and validated which
identify kinds of impairment that are common in adults with ADHD, including the
Weiss Functional Impairment Rating Scale—Self-Report [19] and ADHD Impact
Module for Adults (AIM-A) [20].
It is hard to evaluate function in a role the person is not currently active in.
Fortunately, patients can often explain how they functioned the last time they were
32 C.B.H. Surman

Table 2.2 Examples of Adult Role Impairment Due to ADHD Symptoms


Role impairment due to inattentive traits
Difficulty being accurate with details
Self/home: Filling out School/work: Careless Relationships: Missing
forms incorrectly mistakes, missed important details in emails
instructions
Difficulty sustaining attention
Self/home: Mind School/work: Gaps in class Relationships: Trouble
wandering while reading or meeting notes following the theme in group
conversations
Difficulty listening in conversation
Self/home: Not hearing School/work: Not hearing Relationships: Other people
requests from others at instructions have to repeat themselves
home
Difficulty sticking to and finishing actions
Self/home: Frequently School/work: Partially Relationships: Difficulty staying
sidetracked from completed tasks pile up on topic in conversations
everyday tasks
Difficulty organizing
Self/home: Mess makes School/work: Overwhelmed Relationships: Less likely
it hard to use personal due to poor planning and to organize social activities
spaces (desk, closet) prioritizing
Putting off tasks requiring mental effort
Self/home: Mail left School/work: Staying up Relationships: Lack of
unopened, paying bills late to prepare work for the preparation for shared activities
late next day upsets others
Often losing important items
Self/home: Personal time School/Work: Takes longer Relationships: Overreliance on
consumed by looking for to complete work because others to keep track of personal
items like keys or phone of looking for needed items items
Forgetfulness
Self/home: Having to School/work: Forgetting Relationships: Forgetting
return to get things left assignments or instructions to call or meet with others
behind
Often distracted by things in environment
Self/home: Need to School/work: Inefficient at Relationships: Difficulty
isolate from reminders working around others listening with conversations
of other tasks to get or activity nearby
personal tasks done
Role impairment due to hyperactive/impulsive traits
Fidgeting
Self/home: Self- School/work: Disrupting Relationships: Physical
conscious of own classes or meetings by movements misinterpreted
fidgeting tapping on a desk, as anxiety, lack of interest
bouncing legs
Restless
Self/home: Hard to sit School/work: Frequently Relationships: Difficulty sitting
long enough to sort disengaging from tasks and through activities, conversations
through mail, manage meetings to get up upsets others
bills
(continued)
2 Clinical Assessment of ADHD in Adults 33

Table 2.2 (continued)


Excessive motion
Self/home: Requires School/work: Poor Relationships: Hard to enjoy
exercise to feel performance at tasks low-action activities with others
physically calm requiring sitting
Excessively loud
Self/home: Excitability School/work: Excessive, Relationships: Volume or
detracts from quality of distracting presence in intensity makes other people
communication with class or meetings uncomfortable
others
Excessive internal drive
Self/home: Rarely taking School/work: Taking on too Relationships: Others find the
time to relax many new activities or person to be rarely “present”
responsibilities because of urge to move on
Talking excessively
Self/home: Talking too School/work: Lose other’s Relationships: Talking more
much creates inefficient interest in classes or than other people limits depth
communication with meetings of relationships
service providers like
doctors
Speaking at the wrong time in conversation
Self/home: Interrupting School/work: Hard to listen Relationships: Annoying other
limits information while trying to “hold the people, limiting chance to build
gathering from others thought” and not interrupt? relationships
Difficulty waiting
Self/home: Leaving or School/work: Acting Relationships: Upsetting others
avoiding necessary lines without waiting for input with impatience
(shopping, finding food) from others
Intruding on others
Self/home: Others are School/work: Being bossy Relationships: Offending others
less willing to assist or “taking charge” limits with impolite, intrusive style
because of impolite, collaboration.
intrusive behavior

in a particular role. But a 43-year-old woman who has been out of school for
22 years but thinking about taking classes may have little idea how she would
function as a mature student. One might extrapolate from her ability to focus in
work meetings and complete tasks for her job to imagine how school function
would go—but full evaluation of her school capacities might take re-enrollment
in classes. The more one has to “imagine” whether there would be impairment in a
role, the less confident one should be about the diagnosis. The mental exercise of
imagining how traits limit options is important for considering the potential future
impact of traits also—such as thinking how a person who thrives on stimulation
would handle lengthy solo desk-based projects at a job they are considering. Below
find further discussion of factors to consider in determining if impairment is
present.
34 C.B.H. Surman

Factors to Consider in Evaluating Impairment

Impairment is a relative term—and it may be helpful to consider which if any of the


factors in the following table should be accounted for in determining whether
impairment is present. Some patients will talk as if they are impaired by symptoms
of ADHD, but further evaluation determines that they are overly critical of
themselves, and another person would not consider them impaired. Patients who
excel by social standards can still have ADHD, either manifesting in extensive
efforts to compensate or not performing to their potential.
In assessing impairment, it may be helpful to consider the difference between
performance enhancement and accommodation of a clinical problem. It is appropriate
to facilitate a person’s ability to apply their native capacities where it allows a
person to overcome impairment to thriving. If ADHD traits limit ability to apply
native capacities, then their reduction is an appropriate clinical goal. This purpose
should be contrasted with seeking to “enhance” functional capacities where there is
no impairment in ability to apply native capacities. A common example of the latter
would be a student who does not have ADHD, but takes a stimulant to stay up late
and study more intensely for exams (Table 2.3).

4. Are impairing symptoms due to another condition: Explore the differential diagnosis
Evaluating whether this criteria is fulfilled can take up much of the interview time,
if patients have other forms of mental health distress. It must be emphasized again
that many preoccupying or mentally compromising states, and some physical con-
ditions such as endocrine disorders, pain, or drug withdrawal, can impair cognitive
control of attention or behavior. Because ADHD is a disorder of childhood onset,
time course is very useful to differentiate it from other conditions. Many other
mental health conditions are episodic—so identifying if ADHD has been present
between episodes is useful.
>> “Can you think of the most recent time that you were free of (feeling down,
irritable, sad, anxious etc.)—did you have these focus (or restlessness or impul-
sivity) challenges then?” “How about when you were feeling and function-
ing your best—was it a struggle to pay attention (or be at rest, or control your
behavior) then?”
Preoccupying states of mind compromise control of attention just as ADHD.
Asking a patient to share what they think about when their mind wanders can be a
very quick way to identify anxiety, mood or other distress in patients. For example,
patients have revealed that it is hard to focus because they keep obsessing about a
concern, or their thoughts are dark or otherwise mood related. The following are
related questions to ask:
>> Is it hard to put worry or nervous thinking out of your mind? Imagine your-
self in that weekly meeting (choose a relevant recent example) that you always
have trouble paying attention to—what does your mind wander to? Is it to
thoughts with a particular mood to them, like nervous, concerned or upset
thoughts? Are distressing thoughts a burden that is hard to put out of your
mind when you are doing tasks?
2 Clinical Assessment of ADHD in Adults 35

Table 2.3 Identifying ADHD-Related Impairment


Evaluate what else explains impairment besides ADHD
Would a different choice of role or environment eliminate burden?
Are current demands straining an area of functional weakness other than ADHD?
Consider impact of resolving symptoms
Would absence of ADHD symptoms allow the person to thrive?
Consider how beliefs and values distort patient’s evaluation of impairment
Will symptoms impact the person’s life as much as they think they will?
Are the patient’s personal goals unhealthy?
Decide if treatment facilitates healthy native capacities or is inappropriate enhancement
Would treatment eliminate a barrier to healthy, adaptive function

It is valuable to characterize the type of internal distracted thinking that is


occurring—to differentiate between mind wandering and distressed preoccupation.
Where a person endorses concerned or obsessive type thinking, this may raise the
importance of looking for an anxiety disorder; if down or depressed, a depressive
etiology should be sought. For example, a businessman thought he had ADHD because
he couldn’t read reports on other companies, because he would quickly obsess over
why his company wasn’t doing the things he read about. Cognitive behavioral therapy
helped resolve his anxious thoughts, and he now rarely struggles to read.
The diagnostic assessment should include a screen for all major mental health
disorders, as well as major medical conditions. It helps to have a structured way
such as a checklist or a template to go through other possible diagnoses, as the list is
long. However, it can be efficient to ask the following kinds of questions to identify
patterns of past suffering.
>> Have you ever had a time in your life when you were unable to function as
you normally do? Or where you suffered distress?
>> Are there particular ways that you struggle besides ADHD symptoms?
What kinds of things are hard for you to do?
>> Are you worried or concerned more than you should be? Is it hard to get
worry or concerns off your mind even when you are busy?
>> Are your moods and feelings unpredictable?
>> Are there things that you spend time doing that you wish you didn’t? Or
that upset other people?
These kinds of questions may engage the patient in discussion of other dimen-
sions of personal struggle beyond ADHD. They do not replace systematic assess-
ment of other Axis I, II or III DSM conditions.
It may be very appropriate to defer evaluation of ADHD where another major syn-
drome is present. Discussion of how to manage ADHD in the setting of comorbidity
can be found in chapters on common comorbidity and adolescent ADHD in this text.
To determine all the potential conditions in a person’s life—and the relative
impact of ADHD traits among them—it is useful to identify all the conditions that
36 C.B.H. Surman

Table 2.4 Distinguishing Between ADHD and Other Conditions Compromising Cognitiona
Type of condition Differential features Differential measures
Other mental health condition Onset and pattern of symptoms, Clinical interview
absence of criteria for other
disorders
Other learning or “processing” Impairment specific to learning, Neuropsychological
disorder, e.g., dyslexia communicating, or manipulating testing
information
Executive function deficits Disorganization not due to focus, Neuropsychological
(beyond ADHD) restlessness, or impulsivity; poor testing
planning, judgement, sense of
time, or routines
Pervasive developmental/ autistic Social skills deficits; lack of mutual Clinical interview
spectrum relationships
Developmental encephalopathies History of neurologic insult; family Neuropsychological
[genetic (e.g., mitochondrial) history; developmental delay; testing; genetic
or acquired (e.g., fetal severity of mental status testing
alcohol) syndromes] impairment; broad mental
function deficits; physical
deficits
Brain trauma (e.g., post Onset following trauma; broad Brain imaging
concussive syndrome) mental function impairment
Acute delirium/encephalopathy Fluctuating attention; organ system Laboratory testing;
impairment; poisoning; alcohol, toxicology
substance use; peripheral screen; workup
neurologic symptoms for occult illness
(e.g., urinary
tract infection,
chest infection)
Dementia Pattern of onset (decline later in Neuropsychological
life); new memory, executive testing; brain
function or behavior impairment imaging
Endocrine disorder Physical symptoms (e.g., fatigue, Laboratory testing
weight change in thyroid
dysfunction); broad decline in
mental function
Seizure disorder Pattern and late onset of symptoms Sleep-deprived EEG
Sleep disorder Pattern and onset of symptoms; Sleep study;
presence of snoring, restlessness, actigraphy;
ease of napping despite full sleep-related
sleep. Iron deficiency habit inventory;
laboratory
studies
Dietary intolerance (e.g., food Gastrointestinal symptoms; Food allergy testing;
allergy; gluten sensitivity) confirmed association with a elimination diets
food
Neurotoxicity Toxin exposure; neurologic or other Laboratory testing
physical symptoms of toxic (e.g., lead)
exposure
a
This is not a comprehensive list. Any condition impacting brain function could share ADHD
symptoms
2 Clinical Assessment of ADHD in Adults 37

Table 2.5 Some Medical Conditions that may Contraindicate ADHD Treatmentsa,b
Type of contraindication Relevant agents
Arrhythmia, structural or other cardiac defect Tricyclic antidepressants prolong QT
interval; most ADHD medications impact
heart rate, contractility, blood pressure
Agents with sympathomimetic properties Agents (e.g., caffeine, theophylline,
pseudoephedrine) with sympathomimetic
properties may compound sympathetic
side effects of ADHD medication
Monoamine oxidase inhibitors (antidepressants, ADHD medication combined with MAOI
linezolide), other drugs may promote hypertensive reaction,
serotonin syndrome; ADHD medications
may impact effect of other agentsb
Past or current psychosis (e.g., hallucinations, ADHD medications could exacerbate or
paranoia); past or current states of agitation cause recurrence
(e.g., hypomania/mania)
Elevated intraocular pressure (e.g., narrow ADHD medications could exacerbate
angle glaucoma)
Substance misuse or abuse Stimulants may be abused
Tic disorder Some ADHD medications could exacerbate
Untreated hyperthyroidism Some ADHD medications could exacerbate
Untreated hypertension Some ADHD medication could exacerbate
a
Specialty consultation or management, including careful education, manages some risks
b
Drug–drug interactions are not detailed on this list because of their variety, and it is important to
check for updated interactions whenever prescribing

may be present. It can help to mentally suspend for the purposes of full assessment,
any DSM requirements stating that some conditions cannot exist in the presence of
others.
There are many causes of mild encephalopathy that can look like ADHD.
Neuropsychiatric conditions, such as learning disabilities, are often comorbid with
ADHD. Many conditions that compromise ability to focus or create restlessness can
be differentiated from ADHD by presence of ADHD symptoms when the conditions
were not present, symptoms unique to the conditions, or medical findings associated
with them. Table 2.4 offers a list of typical conditions worth considering, with possible
ways of differentiating them from ADHD. An adapted version of this table is in the
Appendix for use in both differential diagnosis and identifying comorbid conditions
that compromise cognitive ability.
Special attention should be given to any condition that ADHD medication treatment
might exacerbate, many of which are summarized in Table 2.5. A version of this table
is adapted for clinical use in the Appendix. Stimulants, for example, may be abused,
and all sympathomimetics may exacerbate agitation or psychosis. Cardiovascular risk,
and screening for cardiovascular risk, is discussed in detail in the chapter on stimulant
treatment. As emphasized in the next chapter, other conditions causing cognitive
compromise can impact adherence to treatment recommendations.
38 C.B.H. Surman

Identify Traits and Comorbidity that May Influence


Treatment Plan

The process of differential diagnosis is also an opportunity to inventory conditions


and traits that compound impairment or complicate management. These include con-
ditions or traits that strain the cognitive, physical or emotional wellbeing of a patient.
Conceptually, it is important to understand that anything that compromises ability to
compensate for ADHD, produces symptoms similar to those of ADHD, or creates
mental distraction will exacerbate symptom severity. Comprehensive evaluation of such
conditions and circumstances is important to holistic support of the patient.
Because ADHD is a cognitive disorder that strains adaptive function, it is useful to
use the initial history-taking as a chance to identify patterns of strengths and chal-
lenges relevant to adaptation. It may be efficient to directly ask an individual where
they have struggled and where they have thrived in the past. It can also be useful to
think about mismatches between the person’s abilities or opportunities and their
achievements. A common sign that organizational challenges beyond core ADHD
traits are present includes onset of new or greater struggle once individuals are more
independent—for example, on arrival to college. This transition point often brings out
difficulties with organization and self-structure as the scaffolding provided to children
falls away. Another important indicator of strengths and challenges might be struggles
occurring in particular job environments or social roles—try to discern if there is a
pattern suggesting that struggles are due to a learning style, or challenges with inter-
personal, communication or other skills.
The following chapter offers more perspective on how to identify factors which
exacerbate an individual’s ADHD-related struggles.

Note on Subthreshold Cases

The sine qua non of clinical diagnosis is impairment related to the condition. It is
appropriate to diagnoses subthreshold ADHD—or ADHD not otherwise specified
(NOS) in DSM language—where the overlap with ADHD full diagnosis is large,
impairment related to the traits are present, and there is no better explanation of the
traits. It is worth noting, however, that research data suggests that less than three current
symptoms in an ADHD subcategory, and onset after age 12, information is less likely
to correlate with full ADHD type impairment. This has led to incorporation of later
onset and lower current symptom burden requirements in the DSM-V adult criteria.

Treatment as a Method of “Assessment”

Medications for ADHD, particularly stimulants, may enhance aspects of cognitive


function such as vigilance, sustained attention, or alertness in individuals without
ADHD. Therefore, a trial of stimulant treatment is not a good “test” of whether the
2 Clinical Assessment of ADHD in Adults 39

diagnosis is present. However, it may take a treatment trial to understand the poten-
tial benefit of a treatment trial. This may seem like an obvious statement, but it is
important to see such trials as a part of the exploration of appropriate clinical inter-
vention, rather than as establishing the diagnosis. In any treatment intervention,
following an initial adequate trial, the associated reduction in impairment should be
reviewed to determine if continuation is merited. This may take, in some cases,
periods off and on treatment to understand treatment impact. Approach to initiating
a treatment trial is discussed further in the chapter on stimulants in this volume.

Self-Regulatory Problems Are Commonly Associated


with ADHD

It is clear that some individuals have self-regulation problems that extend beyond
the focus, restlessness and impulsivity challenges highlighted in the DSM core cri-
teria of the disorder—although they may be considered as separate attributes, prob-
lems with organizing personal schedule—such as sleep habits, eating habits or
exercise habits, and problems controlling emotional expression are now thought to
be common in, and etiologically very closely related to, ADHD in many individuals.
A full evaluation of factors contributing to poor self-regulation of behavior extends
beyond inventory of ADHD, to understanding the extent of self-regulatory chal-
lenges in domains like daily patterns and control of internal states or expression of
them, such as emotion control.

Characterize the Extent of Organizational Challenges

Evaluation of ADHD should also assess a person’s ability to organize themselves


beyond ability to control attention and impulse so that appropriate supports can be
set up. Only one item in the diagnostic criteria for ADHD—the symptom of
“disorganization”—explicitly mentions organizational challenges. ADHD individuals
present with varying forms of organizational challenges that are not explained solely
by difficulty controlling attention, restlessness, or impulsivity—and varying level
of skills to deal with them. See Table 2.6 for questions that can help identify patterns
of difficulty organizing behavior.
Executive function deficits beyond the core traits of ADHD predict additional burden
in daily life [21–24] and indicate need for specialized supports. The chapter on
neuropsychological assessment in this guide notes how tools like the Behavior Rating
Inventory of Executive Function and the Barkley Deficits in Executive Functioning
Scale inventories can be applied to screen for and characterize these challenges, and
how neuropsychological tests can be applied to document related cognitive capacities.
However, in clinical care settings the patient or people who know them can be
interviewed to determine level of organizational challenges and skills.
40 C.B.H. Surman

Table 2.6 Questions That Explore Executive and Self-regulatory Skills


– What habits—like using a planner, making lists—do you use to stay organized?
– When you have to plan or organize an activity, how does that go?
– Do you have trouble prioritizing?
– Is it hard for you to make choices?
– Do you have a good sense of time?
– Are you often late for things?
– Are you flexible if plans change?
– Are you consistent with organizational habits like putting things away, using a planner?
– Do you protect time for all the priorities in your life?
– Do you outsource things you are not good at?
– What kinds of tasks do you rely on other people for?

It can be helpful to help patients see that there is a difference between core ADHD
traits and broader organizational challenges. For example, there is a difference between
one’s ability to attend—ability to focus during a task like studying, for example—and
the executive skills necessary to stay on top of a study schedule. The latter requires
choosing what to study, deciding when to study it, and sticking with the study schedule.
Ability to prioritize, to keep track of time, and to monitor performance is also critical
executive skills that are often impaired in the ADHD population.
It may be generalized that medications often help people with ADHD get around
to, stick with, and finish tasks, but do not add executive skills. Some patients appre-
ciate the following metaphor: medication for ADHD is to behavior pattern as a
deeper keel is to a boat - one still has to chart a course and steer, but it is easier to
keep on course. Thus, some patients will experience ability to focus more, but end
up focusing on the wrong tasks. The subset of individuals with strong organiza-
tional skill deficits are likely to still suffer from these challenges despite medication
treatment. The following chapter explores personalization of treatment for individu-
als with poor self-regulatory and organizational capacities.

Poor Control of Emotional Expression Is an Example


of Poor Self-regulation Related to ADHD

The connection between ADHD and poor control of emotional expression is evidence of
the importance of appreciating that ADHD broadly impacts an individual’s function.
A subset of adults with ADHD has worse problems with control of emotional expres-
sion. Our research group and others have found that this may be a majority of adults
with ADHD [25–27]. Traits like irritable, angry, and overreactive emotion in adults with
ADHD correlate with worse quality of life and impaired role function [28]. The combi-
nation of ADHD and such deficient emotional self-regulation was more common in
siblings of adults who had ADHD suggesting it may be a familial variant of ADHD and
may occur with ADHD for genetic reasons [27].
Deficient emotional self-regulation can be separated from other emotion-related
clinical diagnoses by the absence of pertinent criteria, such as additional emotional
2 Clinical Assessment of ADHD in Adults 41

or physical symptoms. For example, while deficient emotional self-regulation


symptoms may occur in, for example, a state of irritable depression or hypomanic
irritability, these conditions require that an individual is stuck in a prolonged mood.
While oppositional defiant disorder is identified typically in childhood, its traits
include poor control of interpersonal reactions and emotion-laden tension with others.
However, as it is conceptualized, the traits of oppositional defiant disorder highlight
difficulty with authority figures. Of note, oppositional defiant traits can persist into
adulthood [29] and often diminish with successful treatment of ADHD. Poor regu-
lation of emotion is a feature of some personality disorders, but full criteria for the
pattern of interpersonal function need not be met to have these traits.
There is limited experience to date applying inventories for poor control of emo-
tional expression in clinical settings. There has been little exploration of whether
these emotional control symptoms are responsive to pharmacotherapy for ADHD.
It is clear that in some patients they are not. It may be rational to consider cognitive
behavioral therapies for such patients.

Questions to Identify Difficulty with Emotional Self-Regulation


– Do you over-react emotionally?
– Do you often get frustrated or angry
– Do you often regret decisions made or actions taken while emotional?
– Do other people think your emotions cause problems?
– Do you wish you had more control over how you express emotions?

Getting to Know the Patient Helps Difficult Diagnoses

It is important to stress that in complex presentations it may not be possible to determine


if a person has ADHD. Limited recall of past symptoms, difficulty determining if
impairment is present, and presence of other mental health conditions are common
reasons to defer making a diagnosis. In cases where possible ADHD cannot be
separated from other conditions, it may take treating the other conditions to deter-
mine if ADHD is residual. This manual includes chapters on common comorbidity
and disorders manifesting in adolescence and explores them in more detail.
It may be easier to make a diagnosis once one knows the patient better, has
obtained third party information, or has obtained more historical records about the
patient. However, these efforts should be pursued to address the core question—is
there impairment due to ADHD—rather than as an academic exercise.
There are many pressures to evaluate patients quickly. Diagnosis of ADHD requires
confident understanding of the patient. It is thus worth restating that evaluations can
be spread over multiple appointments, or shared with a treater that can get to know the
patient over many appointments. It can help to enlist the patient as a collaborator in
this exploration—giving them homework, such as the Self and Informant versions of
the ASRI at the back of this textbook, or a question to consider with you over the
course of a few appointments, such as the relative importance of ADHD traits versus
other challenges like learning style issues, anxiety or mood symptoms.
42 C.B.H. Surman

Offering a Diagnostic Impression

If the individual meets criteria for ADHD in adulthood, the subtype should be
specified and explained—are inattentive, impulsive/hyperactive (a rare presentation
in adults) or both (combined) type criteria fulfilled? In addition to identifying other
comorbid conditions and challenges, self-regulatory problems such as poor
emotional control or difficulties with executive capacities beyond core ADHD traits
should be highlighted as important issues.
It is helpful to review with a patient which of the issues they have discussed are
due to ADHD versus self-regulatory problems, because there are different supports
for each. This can be done by reflecting back on day to day examples they raised
in the interview. For example, reviewing content from the ASRI, a clinician may
say “you said you were concerned that you put off work to the last minute, and get
easily side tracked, so you end up working late. This is an example of how inatten-
tive type ADHD impacts you.” Reflecting on exploration of their self-regulatory
abilities beyond core ADHD symptoms, a clinician might say “You also said that
it is hard for you to know where to start on a project, and that you lose track of time
and are often late for meetings—these are examples of what we call executive
function challenges that come along with your ADHD.” This kind of discussion
helps clarify the connection between their experiences and the condition you can
help them treat.
A diagnosis of ADHD will mean different things to different people. Asking the
patient directly what they already know about ADHD, what having it means to
them, or what questions they have about it can identify what kinds of education
will help. Some individuals will be interested in resources to understand the neu-
robiology of ADHD, and the previous chapter offers a rich resource of factual
perspectives on ADHD that may be helpful for education in the office. Others will
be looking for resources to learn about treatment. It is helpful to identify a com-
munity or online group that offers evidence-based and medically factual informa-
tion to consumers, such as Children and Adults with ADHD (CHADD), or the
Canadian ADHD Resource Alliance (CADDRA). Because patients have quick
access to information of varying qualities, it is also important to ask patients to
bring concerns or questions they generate from their own research in for
discussion.
Diagnostic impressions are empowering when they help individuals understand
themselves or make healthy changes. The impact of receiving a diagnosis can be
profound. For some patients it offers explanation for a lifetime of struggles, an
explanation they can hold in mind instead of self-blame. It is useful to discuss
ADHD as a set of “challenges,” and to make it clear that there are treatments and
skills that make these challenges much more manageable. Treatment planning
should be rooted in this kind of productive perspective, giving the patient a hopeful
mental framework for adapting to ADHD. The next chapter complements this one,
describing a collaborative approach to personalized treatment planning for adults
with ADHD.
2 Clinical Assessment of ADHD in Adults 43

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Guilford Press; 1998.
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disorder: are late onset and subthreshold diagnoses valid? Am J Psychiatry.
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21. Biederman J, Petty C, Fried R, et al. Impact of psychometrically defined deficits of executive
functioning in adults with attention deficit hyperactivity disorder. Am J Psychiatry.
2006;163(10):1730–8.
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years: a prospective longitudinal follow-up study of grown up males with ADHD. Acta
Psychiatr Scand. 2007;116(2):129–36.
23. Biederman J, Petty C, Fried R, et al. Functional outcomes associated with self-reported executive
function deficits in adults with ADHD. Paper presented at: 2005 AACAP/CACAP Joint Annual
Meeting; 18–23 Oct 2005, Toronto, Canada; 2005.
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predictive utility of executive function (EF) ratings versus EF tests. Arch Clin Neuropsychol.
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activity disorder. J ADHD Relat Disord. 2010;1(2):5–37.
26. Reimherr FW, Marchant BK, Olson JL, et al. Emotional dysregulation as a core feature of
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deficit hyperactivity disorder: a family risk analysis. Am J Psychiatry. 2011;168(6):617–23.
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Chapter 3
Treatment Planning for Adults with ADHD

Craig B.H. Surman

Abstract This chapter presents how to personalize a treatment plan for an adult
with ADHD. Treatment goals should be personalized, and appropriate treatment
approaches chosen. The chapter reviews: how to prioritize core ADHD versus other
self-regulatory challenges; the major dimensions of distress that clinical care should
address; what medication is and is not likely to impact; factors that can be changed
to improve cognitive performance and ability to engage; how to recognize when
non-medication supports are indicated; principles for mitigating the effects of
organizational challenges or difficulty establishing habits; options for optimizing
environmental accommodation at school, work, or home; and the importance of
adapting treatment goals and plans over time.

Introduction

The previous chapter was a guide to identification of ADHD and common self-
regulation problems that accompany ADHD. This chapter offers perspectives and
principles useful in planning treatment in the absence or presence of broader self-
regulation problems. This chapter provides guidance on collaborative exploration
of treatment goals and treatment planning. The chapter also guides a clinician in
how to think about the place of medication and non-medication treatments in ADHD
clinical care. Detailed guidance on specific forms of medication and non-medication
treatment is explored in detail in later chapters of the text. A Treatment Planning form
in the Appendix can be copied by the owner of this text to record treatment targets
and a plan to meet these targets, both at initial evaluation and in follow-up visits.

C.B.H. Surman, M.D. (*)


Adult ADHD Research Program, Massachusetts General Hospital,
55 Fruit Street, WRN 705, Boston, MA 02114, USA
e-mail: csurman@partners.org

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 45
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_3,
© Springer Science+Business Media New York 2013
46 C.B.H. Surman

Targeting Role Impairment

As discussed in Chap. 2, it is useful to separate out behavioral problems that are


closely related to core ADHD traits and those that are manifestations of other execu-
tive function challenges. It is useful to pick day-to-day examples of both as targets of
treatment. Ideally, targeted traits should be meaningful and worthy of work by the
patient—such as those that contribute to later hours at work, poorer performance on
evaluations, or strain on relationships. The ADHD Symptoms and Roles Impact
Inventory (ASRI) allows systematic identification of challenges that are closely
related to ADHD symptoms. The ASRI was discussed in detail in Chap. 2 and is
found in the Appendix. While going through such a current-symptoms inventory,
poignant and frequent challenges should be noted. They might include trouble focus-
ing in class, reading documents at work, difficulty listening in conversations, or
difficulty staying with a household task without starting another. Ideal ADHD-
symptom treatment targets are ones that occur frequently—and occur in the absence
of other clear potential exacerbation—such as distractions, fatigue, or lack of
resources for the task. For example, with a student it may be better to choose to target
the scenario of ability to sit and read in a library when well rested, rather than ability
to read in the dorm common room late at night. At least a few types of ADHD chal-
lenges should be chosen as treatment targets and tracked during treatment. These
targets can be recorded on the ADHD Treatment Planning sheet in the Appendix.
In establishing treatment targets, it is useful to think of challenges that reflect core
ADHD traits and those that reflect more extensive executive challenges. These self-
regulatory challenges can also be recorded on the ADHD Treatment Planning sheet
in the Appendix. For example, lets us take the example of how difficulties at work
can be separated conceptually into those due to core ADHD symptoms and those due
to more extensive organizational difficulties. Asking a patient which ADHD symp-
toms apply might prompt them to explain that they procrastinate, have trouble focus-
ing when they sit down to do work, and are distracted by sounds around them while
they try to work. Asking how they schedule and manage their day may reveal execu-
tive challenges that are not explained by core ADHD traits such as poor sense of
time, difficulty prioritizing or planning, or unhealthy sleep habits that lead to fatigue.
They might also describe frustration with coworkers due to poor control of emo-
tional expression. As this chapter explores, self-regulatory challenges beyond core
attention issues require particular support.

Goals of Clinical Intervention

Table 3.1 offers one way of looking at the goals of clinical intervention for individuals
with ADHD. Broad clinical goals should include managing other conditions that
compromise brain function, fostering better self-organizational habits, and advocat-
ing for environmental accommodation.
3 Treatment Planning for Adults with ADHD 47

Table 3.1 Main goals of clinical intervention for adults with ADHD
Decrease:
– ADHD symptoms
– Comorbid physical, mental health conditions
– Other forms of suffering that are “internally distracting” and compromise cognition
Increase:
– Habits for self-regulation
– Match of environment with personal motivation, strengths, and challenges

Many conditions produce encephalopathy or mild compromise of cognitive


performance and should be identified and treated. For a longer list, see Table 2.4 in
Chap. 2, and the Differential Diagnosis and Cognitive Comorbidity checklist in the
Appendix, but these include conditions like sleep apnea, vitamin B12 deficiency,
hyperthyroidism, or allergies. As discussed below, any forms of suffering can
preoccupy the mind, compromising cognitive abilities, and should be identified as
treatment targets.
Beyond exploring the role of other clinical conditions, it is important to explore
ways that a person’s choices and actions might reduce the burden of ADHD. Individuals
can be empowered to choose environments that fit them better and to adopt more
adaptive patterns of thought or habits. Many adults with ADHD are already aware of
these options. But for some it is empowering simply to realize that there are options
for a better fit between their capacities and daily demands. Facilitating the ability to
help individuals develop adaptive approaches to their challenges should be a major
treatment goal for an adult with ADHD.

What Will Medication Help?

Unless contraindicated, medication should be the first-line intervention for core


ADHD symptoms—the symptoms that constitute the DSM current symptom criteria
for ADHD and are detailed in the ASRI. It is helpful to understand, and convey to the
patient, what effect medication is likely to have. ADHD medications can help a per-
son maintain focus, be at physical rest, and control impulsive behavior, but it often
does not change executive function capacities like ability to plan, prioritize, make
decisions, self-monitor, or keep track of time. One way of explaining this to patients
is to explain that if they are more focused on medicine, they still may be applying
themselves to the wrong tasks or do them at the wrong time. A student may become
even better at keeping up with their online blog, for example, but still go to bed too
late and feel overwhelmed while trying to do larger assignments that take planning,
like papers. It will take better choices and skill development to manage such self-
regulatory problems. While the saying “pills don’t teach skills” is true, reduction in
ADHD symptoms makes it easier to get around to, stick with, and finish executive
skill-building “homework.”
48 C.B.H. Surman

Table 3.2 Implication of self-regulatory challenges for ADHD therapy


Expect impact of executive/organizational challenge
– Often persist despite ADHD symptom reduction by medicine
– May be late for office visits or miss them
– May not adhere easily to medication or skill-building “homework”
– Poor self-care patterns (sleep, eating, exercise) strains mental health
Build on past organizational efforts
– Have organizational habits (e.g., scheduling, lists, reminders) helped in the past?
– Are there such habits they have never tried?
– What has helped them learn or maintain habits in general?
– What will maximize the chances of adoption of better executive habits?

What Factors Influence Best Structure of Non-medication


Treatment?

To benefit from an intervention, a patient has to be able to engage in it. It is useful


to take stock early of whether the very ADHD and related executive function challenges
that you want to help someone with will also limit their ability to use the help
offered. In the case of therapies involving “homework,” or practice of new skills,
management of core ADHD traits like forgetfulness and procrastination may vastly
improve adherence. Other factors that could impede engagement in treatment should
be identified and addressed where possible. These could include limitations in
interpersonal efficacy, difficulty prioritizing personal needs, lack of time, poor self-
esteem, lack of long-term goals, or depressive or anxious ideation.
Exploring past efforts at self-improvement—successful and unsuccessful—is a
useful way of anticipating factors that may impact treatment adherence. For example,
an individual may present having bought books on self-organization that they barely
read—indicating limits to their ability to explore and implement strategies on their
own. When asked how they have learned academically in the past, the same person
might explain that they learned alongside others—talking it through and with hands-on
practice. Adding an interactive, interpersonal element to ADHD treatment might
make a big difference in what a person can take from treatment. Exploring factors
in past learning and growth is also important because it give patients the message
that they possess strengths they can capitalize on.
Table 3.2 summarizes some implications of self-regulatory challenges for
treatment planning.

A Model of Factors Impacting ADHD

Treatment will be most successful when a patient shares a common perspective with
the clinician. As with all collaborative treatment, this means a mutual understanding
of the diagnosis, how it is relevant in a person’s life, and what can be done about it.
3 Treatment Planning for Adults with ADHD 49

Table 3.3 Clinical questions to explore influences on ADHD manifestation


Engageability
– Do ADHD medications improve ability to engage tasks?
– Are tasks more engaging with clearer or smaller steps?
– Are there particular abilities to capitalize on (e.g., ability to visualize plans)?
– Are there cognitive demands to avoid (e.g., reading in a patient with dyslexia)?
– Can the task be made more naturally interesting? (e.g., collaboration)
Internal distraction
– What else is compromising cognition? (e.g., stress, mental health, chronic pain)
– Is thinking style undermining? (e.g., negative or obsessive thinking)
External distraction
– Can sensory distraction be managed? (e.g., sounds, surrounding activity)
– Can alternative actions be eliminated (e.g., isolate from others, Internet, phone)
– Can demands be reduced? (e.g., eliminate obligations)

It is useful to develop a shared view with the patient about the factors that influence
how their ADHD manifests. The following sections, and Table 3.3, offer a theoretical
framework for identifying what factors contribute to ADHD-related challenges.
It is important to point out that the factors discussed here were created to fit patterns
observed in patients with ADHD—not based on understanding of biological circuits
or neuropsychological processes. Sharing the theoretical framework that follows
with patients may give them a way of monitoring what they can do to minimize the
impact of their ADHD. Some individuals will be interested in what brain functions
or regions are responsible for the pattern of factors presented here. Because of its
role in planning and monitoring behavior, the faculties implicated in this model are
likely to include prefrontal cortex function. However, it is one of several structures
in circuits that influence and facilitate control of behavior.
The factors potentially impacting manifestation of ADHD found in Table 3.3 and
discussed below come from two main ideas—(1) individuals with ADHD and
broader self-regulatory problems have limited ability to control what they engage in
and (2) the brain can be “distracted” or compromised from its control of engagement.
For this discussion, ADHD inattentive symptoms can be seen as poor control over
how sensory input, thoughts, and intentions are engaged; ADHD impulsivity traits
can be seen as poorly controlled engagement in physical, verbal, and emotional
expression; and ADHD hyperactivity traits can be seen as poor control over engagement
of internal drive and physical activity.

ADHD as a Disorder of Engagement Control

Many adults with ADHD say something like: “its not that I can’t pay attention—it
is more that I can’t pay attention when I want to!” Thinking with patients about how
they engage in the options before them at each moment can help identify barriers to
their efficacy. Individuals can relate to the idea that boring or difficult things are
50 C.B.H. Surman

harder to engage for anyone. It is as if the ADHD brain finds boring things even
more boring. The pattern of symptoms in ADHD is often influenced by the fact that
the ADHD brain has a harder time applying mental effort—thus areas where there
is less natural ability or less interest are often particularly compromised.
Helping a patient understand their pattern as a product of difficulty controlling
what they engage in is an entre into discussion of what they can do to improve their
chances of gaining control over engagement. Impulsivity can result from poor con-
trol over choices. Poor engagement in choices leads to mistakes in what to buy,
what to email, what to say, or when to wait. Hyperactivity/restlessness, in this
“engagement” perspective on ADHD, is a manifestation of poor control over urge
that leads to trouble controlling “pace” or, to use an engine metaphor, activity level
at idle. This makes it hard to feel at ease or participate in low-activity moments.
It is clear that medication, as discussed in the following chapters, can dramatically
improve the engageability of everyday tasks for individuals with ADHD. But
besides helping patients through adjustment of brain chemistry, there are other factors
to address towards improving engagement in tasks. Patients often can relate to being
more likely to stray from tasks without clear steps or goals, or where the task is
particularly hard for them, or where the task is boring. While it is often as if medication
makes tasks more interesting, it will take effort and practice to learn new skills like
how to break tasks down into more engageable steps or find more interesting
endeavors. Thinking about what makes some tasks more engageable can help a
person capitalize on their natural capacities to advantage.
One common experience for adults with ADHD is of being able to get things
done under deadlines or other forms of pressure. It can also be useful to explore
whether a patient capitalizes on, or is a victim of, stress and pressure. For example,
it can make it easier to engage in work where there is accountability to others—it is
highly organizing to have regular deadlines in the form of due dates and meetings
with colleagues or supervisors. On the other hand, many individuals with ADHD
find themselves driven by pressure that is the result of their own disorganization.
Some adults with ADHD seem to be at the mercy of what they have the urge to do
or what is most novel to them at a particular moment. As they become more used to
a given task or role, they may tire of it and gravitate to more interesting challenges.
As a result, many ADHD patients with impulsive characteristics find obligations
piling up that are hard to meet. The accumulated stress can reach the point where the
person feels clouded and distracted—surrounded by unfinished demands.

Coach Patients to Capitalize on Strengths and Interests


and to Accommodate Challenges

Where tasks are less interesting and more challenging, ADHD traits will tend to be
more prominent. Areas of relative cognitive strength may be identified by finding
out what roles the person is most successful in. For example, does the patient
3 Treatment Planning for Adults with ADHD 51

manage household tasks well, but struggle at school and work? When a pattern of
struggle can be identified, this begs the question of why this pattern is present. Does
this reflect a neurobiologically based challenge, such as a learning disability? Has
the person missed out on learning necessary skills to succeed at the role? Is the
environment in some way badly matched to the person’s comfort or success?
There are some cognitive challenges, such as learning or social disabilities, that
should receive their own therapeutic support. It is also important to recognize the
pattern of non-ADHD cognitive burdens so that they are not attributed to ADHD.
For example, to identify and track ADHD-related impairment in someone with dys-
lexia, it may be useful to think whether their ADHD symptoms are isolated to read-
ing activities. One might explore, for example, focus in conversations, tendency to
misplace things, and other contexts requiring control of attention that are indepen-
dent of reading. However, because treating ADHD may make sustained mental
exertion easier, treatment of ADHD can certainly improve ability to compensate for
hardwired longstanding difficulties such as dyslexia, other learning disabilities, or
social skill deficits.

Capitalize on What Is Naturally Salient and Natural Abilities

As this chapter has emphasized, where tasks are interesting and require faculties
that a person is good at, they are often easier to engage. It is worth noting that it is
not just what is consciously interesting—what a person knows they like to do—that
should be identified. It is also helpful to explore a person’s default path of behavior,
to understand what they naturally gravitate towards. In exploring naturally motivated
behaviors, it can be interesting to consider or even discuss with patients the concept
that the human brain has a system to identify what is “salient”—what is meaningful—
to apply itself to. This would include goals like food, sex, shelter—but also less
essential goals. This salience function allows us to register what is worthy of
engagement out of a universe of possible thoughts, feelings, and actions. Tasks that
are salient in this sense will receive commitment of more brain resources—and thus
ADHD symptoms may occur less during such tasks (just consider the child with
ADHD tuning out in class but extremely successful at their video games). ADHD
symptoms, of course, can occur during very meaningful tasks—but salience helps
engagement with them. Stress or pressure around a task will also help register a task
as salient—but too much compromises ability to engage it.
It can be a useful perspective for treatment planning to remember that each person
has their own pattern of what is most salient to them—and that there may be more
salient ways to pursue tasks and even treatment. Asking a patient about tasks that
they find easier to engage in under different circumstances might reveal some of the
personal factors that help them engage. One common example is that working on a
project with other people can make it easier to prioritize and focus on, compared
with working alone.
52 C.B.H. Surman

Looking at patterns of impairment across roles can also help identify individual
abilities that may be capitalized on while adapting to ADHD. Sometimes review of
current ADHD symptoms, such as with the ASRI detailed in Chap. 2 and the
Appendix, highlights such areas of relative strength. For example, if an individual
denies problems losing things or being forgetful, they may have strong memory capa-
bilities. Individuals who deny trouble staying on top of their schedule or keeping
their personal space organized may have strong organizational abilities. Memory
and organization skills are major assetss to people with ADHD. Helping patients see
how these traits already help them cope can allow them to generalize application of
these strengths.
Past successes may be an indicator of how salience and fit with strengths can be
maximized for current and future endeavors. For example, the high school student
who benefited from talking through homework assignments with parents may
benefit from similar interpersonal support during transition to college. A worker
who thrived at a past job where there were weekly meetings where progress and
goals were reviewed may improve their productivity by setting up regular meetings
with a coworker for the same purpose.

Identifying Internal and External Distraction

Internal Distraction

The phrase “internal distraction” may be a useful way of discussing factors that
contribute to cognitive compromise other than ADHD. Cognitive compromise
comes in many forms—including suffering from physical as well as mental discom-
fort. Patients with physical or psychiatric illness often describe cloudy mentation
and functional compromise. Even in the absence of a comorbid medical condition,
the experience of living with the chronic challenge of ADHD can produce a style of
thinking that is a source of distraction.
It may be helpful to discuss the effect of other sources of cognitive compromise
by using a computer analogy. Like a computer running multiple programs at the
same time, the brain can be seen as a collection of faculties operating at the same
time. There may be programs, so to speak, like a pattern of self-doubt or worry, or
like brain centers busy processing pain, that somehow take away from other brain
system functions like control over engagement. Reduction of any cognitive compromise
therefore should be a treatment goal.
Distracting thoughts occur commonly in ADHD individuals—extraneous
thoughts that some people say are like “popcorn” popping up in their minds.
Behavioral strategies may help, such as the technique of writing these thoughts
down in one consistent place to get them off the mind, or turning them into action
items in a schedule for later. This and other adaptive strategies are a core component
of cognitive behavioral therapy, as discussed in Chapter 7 on psychotherapy for
3 Treatment Planning for Adults with ADHD 53

ADHD in this guide. Sources and styles of preoccupation should be identified as


potential targets for improving cognitive well-being and function. As discussed in
Chap. 2, it is high yield to understand if there are particular themes on the minds of
the ADHD patient—preoccupations that are indicators of other clinical targets.
Some patients can identify themes of worry or distress that prompts distracting
thoughts or that contribute to their restlessness. Identifying and changing such
compromising thought patterns is another core component of cognitive behavioral
interventions discussed in Chapter 7.

External Distraction

Distraction by environmental stimuli is a common complaint for individuals with


ADHD. But even ideas, such as reminders of alternative activities may be enough
to distract a person. Some individuals find they are more productive when they iso-
late themselves not only from sounds and noise but also from the Internet or paper-
work that would facilitate engaging in a lower priority task. Particular tasks may
need their own space and time, free of clutter or other plans. Find out if individuals
already gravitate towards environments that are conducive to their productivity. Do
they seek out libraries or cafes where the environment is conducive to focusing and
being industrious? Do they turn off the Internet or their cell phones to limit inter-
rupting distractions?

Accommodations

Environmental accommodations will be helpful if they increase the ability of a person


to do a task. The themes presented in Table 3.3 can be considered in thinking about
how an environment may or may not be accommodating—does the workplace,
home, school, or other setting foster engageability of tasks, and minimize internal
or external sources of cognitive compromise? The Americans with Disabilities Act,
and similar legislation in other countries, has formalized the ability of individuals to
seek “reasonable” accommodations that eliminate barriers to work or learning. This
has become commonplace in many school settings, where standard accommoda-
tions may include copies of class notes, extra time to double check answers, and
quieter environments for schoolwork or test-taking. Accommodation in work and
home settings often take more creativity.
In the case of work, it is helpful to understand that it is unlikely that an employer
will be legally required to modify the job description for which a person was hired.
A clinician can do a great service by helping people seek jobs that capitalize on
their natural abilities and offer best structure for their productivity. It can be helpful
to discuss the idea that a person’s brain is typically not highly capable at all kinds
of tasks—so that it is adaptive to be able to outsource to a “peripheral brain,”
54 C.B.H. Surman

Table 3.4 Approaches to accommodation


• Reduce sources of internal or external distraction
• Clarify goals and steps to achieve them
• Increase accountability (communication, supervision, or collaboration with others)
• Optimize chance for accuracy (e.g., extra time to double check work)
• Make tasks more interesting (e.g., present work to others, make it part of a bigger purpose)
• Match workflow to best style (e.g., hands-on, active, changing roles)
• Outsource weaker skills to human or electronic “peripheral brains” that:
– Capture information (e.g., note taker, recording pen, or other device)
– Allocate time (planner, electronic calendars)
– Remind (regular meetings, alarms)

whether it be another person or an electronic device. The table outlining methods


of accommodation offers high-yield factors to consider when attempting to
improve productivity (Table 3.4).

Principles for Improving Self-Regulatory Habits

As this chapter and the previous one has emphasized, there are important patterns
of distress that may not improve with medication management alone. These include
the kinds of self-regulatory challenges discussed in Chapter 2 including trouble
organizing personal items and activities, poor control of emotional expression, and
unhealthy patterns of exercise, eating, and sleep. A tendency towards such dysregu-
lated patterns of behavior often with challenges adopting new routines and habits.
Predicts that an individual will have difficulty adopting new organizational routines
and habits.
Earlier, this chapter emphasized that reviewing a person’s prior track record
following through on homework and adopting organizational techniques or routines
may predict obstacles to adapting to ADHD. While some adults with ADHD may
quickly implement a new organizational habit such as choosing a priority for each
day, or writing down distracting thoughts, others will stray from practicing the new
habit. Many of these patients seem to struggle broadly with adopting or sticking
with new habits. A subset of adults with ADHD also do not live by consistent
rhythms of activity—when asked what time they awake, eat, or sleep such patients
will respond they do not have regular patterns.
Clinical experience suggests that many individuals can identify critical moments
where better habits would be useful—but their adoption may be more elusive. The
purpose of the habits we would want these individuals to adopt is varied—such as
improved sleep pattern, better study or work pattern, a regular exercise program, or
better eating habits. The list of habits in Table 3.5 has been very useful in clinical
experience, but there has been limited study of best practices for habit change in
individuals with self-regulatory problems.
3 Treatment Planning for Adults with ADHD 55

Table 3.5 Approaches that may foster adoption of a critical habit


– Pick one high-yield habit at a time to change
– Explain why the habit is useful
– Explain that practice can make habits more automatic
– Automate reminders to practice the habit
– Anticipate distractions or “pitfalls” related to the practice
– Promote self-monitoring of practice and success with the habit
– Use short-term rather than long-term rewards
– Build in natural accountability
– Anticipate tolerance to the habit and plan shifts to an alternative

A Practical Example of Fostering Habit Change: Changing


Sleep Habits

Here is an example of how these approaches might apply to improving sleep habits.
Sleep is often dysregulated in individuals with ADHD and is discussed further in
Chapter 8 which reviews common comorbidities. Intervention can start with educa-
tion about the importance of sleep for good daytime function as well as standard
recommendations for sleep hygiene. Next, an analysis of which of these recommen-
dations are not being fulfilled may identify a critical habit the individual could
adopt. Typical “rules” of sleep hygiene include creating a wind-down period and
avoiding interesting activities or light before bedtime. With practice these cues help
match “biological night” to appropriate sleep periods. It is common for an adult with
ADHD that has self-regulation challenges to find themselves involved in television,
computer, or other stimulating activities late in the evening, inconsistent with wind-
ing down the day. Once the individual has been educated about the importance of a
period of low activity and low light before bed, let us consider that it is decided that
the new habit to foster is initiation of wind-down time.
In this scenario, an alarm might be set to initiate wind-down activities 90 min
before bedtime. “Pitfalls” to this plan should be identified. To do so, one can look at
the current “default” pattern of activity, and how it leads away from the desired goal.
Common evening pitfalls in adults with trouble regulating sleep patterns include
“trying to get one more thing done,” opening their computer when it could wait,
checking email “one last time”—all examples of poor executive control, and lack of
healthy habits. Another common pitfall is putting off bedtime preparation until
medication controlling ADHD has worn off, and compounds end-of-the-day fatigue
to make bedtime tasks harder. Then the person is more likely to procrastinate about
bedtime preparation, watch one more TV show, or check for social messages online
one more time. Getting ready for bed as early as possible, recording weekday eve-
ning TV shows to watch on weekends, and leaving the computer at work might be
ways of avoiding the pitfalls.
Success with practice of the new habit should be tracked wherever it is easiest—
such as in a place the person will stumble across it each day or where a reminder can
56 C.B.H. Surman

be established, such as on a handheld device. Some people will respond to a short-term


reward—for example, allowing themselves to read a short story in bed only if they
are in bed a half hour before bedtime. It is often more effective to add interpersonal,
real-time influences to foster accountability. For example, many individuals only
settle into healthy bedtime routines when they are living with other people that have
those habits! Sometimes there are other ways of involving other people to create
interpersonal accountability—committing to having to be somewhere early in the
morning (so getting to bed is more important), a friendly bet that you can change
your pattern, a phone call to a family member each night at the wind-down time.
Some people with organizational struggles will have particular difficulty sticking
with a habit. It seems to take different people different lengths of time to solidify a
habit—and some will always need a reminder for certain habits. Sometimes it helps to
anticipate needing to reinvent habits. For example, a person may have found that getting
ready for bed as soon as they get home has made a big difference in fostering a healthy
routine—but they find themselves being less consistent with this over time. They might
find they keep their bedtime routine in check by finding a new, “shinier” way to fulfill
the health need. For example, they might focus instead on allowing themselves time for
a relaxation period, or a relaxing hobby, or focus on trying out non-electronic life at
home—a “dark screens time” where all electronics are off.
Many successful individuals who do not run by routine and ritual are constantly
picking up new strategies from self-help books, the Internet, coworkers, or friends.
A key teaching point, however, is that there are critical moments—whether they are
decisions or pitfalls—that need to be monitored and managed. Clinicians can do great
service by helping individuals determine these critical moments—like initiating a
wind-down time at night—so they have a clear goal for their adaptive approaches.

Treatment Planning Over Time

Treatment recommendations should be adapted over time, as severity of ADHD can


change, life roles change, available supports change, or new conditions straining
cognitive capacity occur. The clinician and patient should regularly ask: “what are
the current challenges and are we using the best tools for the job?” Long-term care
is facilitated by clearly establishing treatment goals at the outset, as discussed above.
Both the clinician and patient can monitor success managing these goals over time,
serially using tools like the ASRI and the ADHD Treatment Planning form provided
in the Appendix. It may be helpful to use habit-ensuring strategies to facilitate
such monitoring—such as reminders, rewards, or enlisting a significant other to
participate in the serial evaluations. When it is hard to tell what a medication or
other therapy is providing, it may help to ask patients to take a break from it. Such
treatment holidays should not be imposed where there is sufficient evidence of
treatment effect already, but can be presented as a chance to gather more current
information about what the best intervention is for that time in a person’s life. It has
been helpful to have patients pick a time once a year to go off of treatment. If a holiday
3 Treatment Planning for Adults with ADHD 57

Table 3.6 Useful questions to review periodically during treatment


– Are ADHD symptoms causing impairment?
– What organizational problems persist?
– Would new habits (e.g., planning, prioritizing, use of reminders) improve role function?
– What symptoms would occur off current therapy/treatment or on less? Would a treatment
holiday help determine that?
– Could internal forms of cognitive compromise or external distractions be better managed?
– Could change in the environment (physical space, people, expectations, opportunities) offer
better structure or better complement abilities?
– Can treatment be adapted to match what is naturally interesting, meaningful, or motivating?

is conducted, sufficient time away from a treatment should be allowed to determine


the new level of native function. How a patient functions initially on cessation of a
treatment can be insufficient to know how they would operate over the longer term.
For example, many individuals have continued benefit for a few days after stopping
a stimulant or have “withdrawl” experiences like fatigue abruptly after stopping a
stimulant. It should not be assumed that is how they would feel off medication over
the longer term. Tapering off medication may avoid “withdrawal,” and breaks of at
least several days to two weeks may be more appropriate in the case of stimulants.
Longer breaks may be needed to evaluate untreated function after stopping
nonstimulants.
In the case of cognitive behavioral or other interpersonal skill supports, individu-
als often initially maintain their recently learned adaptive habits, but lose them
without ongoing interpersonal support. “Refresher” or “booster” sessions can reju-
venate habits learned in a therapy, coaching, or in a group. Interventions should be
sustained, changed, or discontinued based on the best evidence available about cur-
rent needs (Table 3.6).
It can be useful to anticipate the need to revise treatment plans for adults with
ADHD based on factors such as those discussed in this chapter. Such treatment
plan revision is particularly important as life changes present new roles, challenges,
or supports. It is helpful to prompt individuals to plan ahead how they might best
adapt to major transitions such as entry into the workforce, setting up a household,
becoming a parent, changing jobs, promotion within jobs, departure of children for
college, or retirement from career. Some individuals will adapt more fluidly than
others as types of tasks, competing demands, and fit with the environment change.
Individuals should be encouraged to seize opportunities to learn new skills, find
endeavors and environments that are a better fit, and outsource weaker skills to
technology and other people.
When supporting ADHD over time, it helps to be sensitive to the idea that
whether ADHD is impairing to an individual depends in part on their subjective
experience of the challenges they face. It helps to understant, therefore, what a per-
son values—and that can change with time. Impairment is not just the product of
how abilities match daily demands. Personal priorities can shift to or away from
roles and contexts that ADHD and self-regulatory challenges impact. For example,
58 C.B.H. Surman

impairment associated with ADHD may drop with reduction in self-consciousness


over time about having ADHD traits.
This chapter has offered several perspectives on treatment planning for individuals
with core ADHD symptoms and other organizational challenges. Optimal clinical
support requires creation of a personalized treatment plan that supports challenges
and capitalizes on strengths. The chapters that follow offer expert review of the
tools available to help adults with ADHD thrive.
Chapter 4
Neuropsychological Assessment of ADHD
and Executive Function Deficits in Adults

Daniela de Bustamante Carim and Helenice Charchat Fichman

Abstract Neuropsychological assessment facilitates comprehensive evaluation and


intervention for patients with ADHD in adulthood. Referrals for neuropsychological
assessment are typically made to characterize an individual’s strengths and challenges
and to document the severity and type of cognitive deficits. Neuropsychologists are
often called on to confirm a diagnosis of ADHD or to establish that an individual
should be eligible for disability accommodation. A neuropsychological profile based
on testing can provide evidence for the likelihood of ADHD and facilitate compre-
hensive care of such patients. However, there is no “test” to definitively determine if
ADHD is present, and the diagnosis should be made based on fulfillment of diagnostic
criteria as detailed elsewhere in this book. Neuropsychological assessment is also
useful to characterize a wide range of challenges such as problems with learning,
information processing, or interpersonal skills. We refer the reader elsewhere for
these applications as is relevant to the understanding of particular cases. This chapter
focuses instead on the assessment of ADHD and poorly regulated behavior through
neuropsychological assessment.

D.d.B. Carim, M.Psy. (*)


Department of Psychiatry, Santa Casa da Misericórdia do Rio de Janeiro,
Rua J. Carlos, 05 apto 202, Jardim Botânico, Rio de Janeiro 22461130, Brazil
e-mail: dcarim@uol.com.br
H.C. Fichman, Sc.D.
Department of Psychology, Catholic University of Rio de Janeiro (PUC-RJ),
Rio de Janeiro, Brazil

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 59
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_4,
© Springer Science+Business Media New York 2013
60 D.d.B. Carim and H.C. Fichman

A Neuropsychological Model of ADHD and Executive Function


in Adults

Cognitive neuropsychology utilizes an executive dysfunction model to address the


cognitive and behavioral challenges associated with ADHD, as well as the organiza-
tional challenges that accompany ADHD. Hypofunction in neural circuits involving
the dorsolateral prefrontal and orbitofrontal cortex is hypothesized to contribute to
this dysfunction [1]. Clinical manifestations in patients with lesions in these brain
circuits have encouraged the distribution of executive functions in two major groups:
(1) the “cold” functions, involving cognitive aspects and the dorsolateral areas and (2)
the “hot” functions, involving emotional and behavioral aspects and the orbitofrontal
areas [2, 3]. The neuropsychological model is described in Fig. 4.1.
There is consensus that the prefrontal cortex is responsible for executive functions
(EFs) [4, 5]. The executive functions have been understood as a set of goal-directed
complex tasks. EFs allow us to organize our behavior along time and meet immediate
requirements. Through the use of these skills we can plan and organize tasks, keep
focused, and persist until the task is finished. They also enable us to manage
emotions and monitor our thoughts so that we can work in a more effective manner
[6]. Lesak (1995) classically defines EFs as “the mental skills that enable a person to
successfully engage in a goal-directed, independent, autonomous, efficient and
socially adapted behavior”.

Fig. 4.1 Neuropsychological model


4 Neuropsychological Assessment of ADHD... 61

EFs are a complex construct, and the term EF is used to mean different things.
There are several synonyms: supervision functions, frontal functions, control
functions, supervisory system, etc. In addition, many processes are included within
the EF category, such as: inference, problem solving, decision making, selective
inhibition of behavior, working (operational) memory, among others. Several
authors have been discussing whether the executive function is a unitary or multidi-
mensional system [7–10], but they seem to agree the term is a construct for a set
of interrelated functions: anticipation, planning and organization, initiating
planned action, inhibiting distracting interference, process monitoring, shifting
between actions and operational memory. These skills are essential to independent
function and problem solving.
EF symptoms appear to be heritable and therefore may be genetically determined,
but environmental factors also play an important role. Emotional, cultural, and
socioeconomic stressors might exacerbate EF challenges.

Conducing a Neuropsychological Assessment

A neuropsychological report will be effective if it identifies barriers to quality of life


and the functional success of the patient with ADHD and their family, and offers
recommendations that can inform accommodation, behavioral therapy, and neuropsy-
chological rehabilitation. To this end, the assessment should collect information on the
current and past mental health status, functional challenges, and environmental
resources of a patient as well as their performance on standardized cognitive tasks.
Assessment relevant to ADHD includes characterization of behavioral and cognitive
attributes consistent with the executive function model presented above. As noted
previously, the diagnosis of the adult with ADHD is clinical [11]. There is no
neurobiological or neuropsychological test capable of determining the ADHD
diagnosis [12]. Neuropsychologists have plenty of resources available to ensure capture
of clinical information appropriate to identifying ADHD in adults.
The neuropsychological assessment should also more broadly identify weaknesses
and strengths within the domains of cognition, behavior, and mood. Identification of
possible concern within these domains indicates need for targeted therapeutic
intervention, carried out by different health care professionals (phonoaudiologist,
psychiatrist, occupational therapist, among others).
Behavioral traits are assessed through interviews (structured and non-structured)
and scales. Cognitive traits are assessed through standardized neuropsychological
tests and less structured tasks. The assessment should be comprehensive and
adjusted to each individual. Direct observation of behavior is an essential aspect of
the assessment process.
The neuropsychological assessment thus consists of the following stages:
1. Historical interview (structured and non-structured).
2. Standardized scales.
3. Neuropsychological tests.
4. Behavioral observation during tasks.
62 D.d.B. Carim and H.C. Fichman

History

The clinical assessment of ADHD in adults is addressed in chap. 2 in this text, but
it is worth emphasizing key elements and approaches to ensure efficient and system-
atic assessment. The history should inventory the primary concerns, challenges, or
abnormalities in personal, social, educational, medical, marital, and professional
development, as well as family psychiatric history. Current functional strengths and
challenges should also be reviewed, with attention to their duration historically.
Recall of both past and current function may be inaccurate. Therefore, third-party
reports—particularly from parents or old school records—reveal important aspects
such as age of onset of traits. Current functioning can be reported by people with
whom the adult with ADHD lives.
It is notable that ADHD documentation should include age of onset of traits,
burden of current symptoms, whether two or more domains of life are impaired, and
careful consideration whether there is evidence of an alternate source of these traits
or related impairment. The professional not familiar with the information necessary
for the history of the adult with ADHD can benefit from semistructured forms. Some
examples are as follows:
– Structured Clinical Interview for DSM-IV Criteria for DSM Axis I [13].
– Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID)—enables
the assessment of symptoms comprised the DSM-IV and the assessment of the
symptoms related to childhood and teenage years [14].
– Mini-International Neuropsychiatric Interview—enables the assessment of the
symptoms comprised the DSM-IV and the assessment of the symptoms related
to childhood and teenage years [15].
– Brown Attention-Deficit Disorder Scales [16].
– Schedule for Affective Disorders and Schizophrenia (K-SADS) [17].

Scales

Assessment scales are useful to investigate the presence and pattern of ADHD
symptoms, to identify other conditions, and to aid in the process of differential diagnosis
[18–21]. The presence of psychiatric comorbidities is quite common in the adult
with ADHD and many of these mimic ADHD symptoms, complicating the clinical
picture [22]. Self-report and informant-report scales are available, but need to be
supplemented with clinical interview to determine fulfillment of criteria.
Relevant scales to assess symptomatology and severity of ADHD in adults
include:
– World Health Organization Adult Self Report Scale [23].
– Adult Self-Report Scale (ASRS) [24].
4 Neuropsychological Assessment of ADHD... 63

– Barkley’s Current Symptoms Scale—Self Report Form—self-reported scale


[25].
– Conners’ Adult Attention-Deficit Rating Scale (CAARS)—current symptoms
[26].
– ADHD Rating Scale—current symptoms (ADHD-RS) [27].
– Brown’s Attention Deficit Disorder Scales (BADDS) [28].
– Wender Utah Rating Scale—allows investigating the severity of current symp-
toms according to the Wender-Utah criteria, which emphasizes the role of emo-
tion dysregulation more than DSM criteria [29].

Neuropsychological Tests and Tasks

Historically, the clinical assessment of EFs has been challenging given its dynamic
definition [30]. Up until recently, neuropsychologists mainly relied on experimental
assessments of EFs. Among these assessment methods, classic tests such as the
following stand out: (a) Wisconsin Card Sorting Test—WCST [31]. Although
WCST is not an efficient instrument to distinguish adults with ADHD from control
subjects, it was one of the first resources used to investigate executive functioning;
(b) Trail Making Test [5], designed to assess sustained visual attention, visual
search, sequence, and cognitive flexibility. (c) The Tower Test and the Maze Test,
which are aimed at assessing planning skills.
Some instruments are useful to assess inhibition control, such as, for instance,
the Stroop Test [32] and the Continuous Performance Test (CPT). Operational
memory is assessed through several tasks, such as mental solving of mathematical
problems, digit sequence repetition, and the Corsi block task [33].
It is often difficult, however, to correlate these measurements with real-life
behavior. Many situations in which EFs surface in daily life are difficult to directly
translate from standardized tests and, therefore, critical aspects of EFs can be
completely excluded in an assessment. Fluid strategy and goal-directed problem
solving, for example, may not be as easily assessed by tests as other EF domains. In
addition, the structured nature of a typical assessment situation does not simulate all
real-life demands on EFs. That is, in assessment situations, the examiner provides
the structure, the organization, direction and planning, as well as tips and monitoring
necessary for the individual’s good performance. In this way the examiner acts as an
external executive control [34].
Dawson and Guare [6] state that the most complex cognitive task within the
repertoire of a psychologist is less complex than the real-world demands on executive
skills. Thus there is no way to determine with certainty how well these tests map
onto the real world. Standardized assessments of behavior therefore offer an eco-
logically valid and practical approach to assessment of EF.
Behavioral measurement of EF can also be correlated with performance on tests
and in the natural environment, to identify the possible neuropsychological basis of
64 D.d.B. Carim and H.C. Fichman

functional impairment. Such behavioral assessment measures include: behavioral


assessment of the dysexecutive system (BADS), a measure which correlates with
daily problems due to executive disorders [32]. Another related instrument is the
Supermarket Test; however, this instrument’s preliminary data have not been published
yet [35]. In 2000, Gioia et al. [36] developed the BRIEF (Behavior Rating Inventory
of Executive Function), which has been widely adopted to assess metacognitive,
behavioral, and emotional executive skills in daily life. A neuropsychological
assessment can utilize such behavioral measures to ecologically identify what
domains of executive function contribute to daily struggles.

A Case-Based Guide to Neuropsychological Assessment

The following is an example of one approach to a neuropsychological assessment in


an adult with possible ADHD. Where specific instruments or tests are mentioned,
others may be interchangeably appropriate.
Step 1: Identify the main behavioral and cognitive strengths and challenges
relevant to the patient’s life history.
Methodology: Semistructured interview with Conners’ Adult ADHD
Diagnosis Interview.

Case Report

LT, a 29-year-old woman who graduated from law school, is studying to take a
competitive examination required as part of applying to be a civil police chief.
However, she has been studying for 5 years, without taking the test. The patient says
her main complaint is that she cannot focus on her studying and she struggles to
relearn material from relevant prior courses in university and for the competitive
examination. The patient struggles to organize her daily life and often does not fol-
low through on activities she planned to do. She often forgets where she places
objects. Her husband complains that she is not capable of managing household
chores (washing clothes, buying groceries and supplies, etc.). At home, they often
run out of food and basic hygiene supplies.
She reports that performance anxiety keeps her from taking the test or seeking
another profession. She often feels sad and thinks negatively of herself. She is look-
ing for a neuropsychological assessment to understand what is keeping her from
personal growth. In addition to cognitive difficulties, she reports having mood insta-
bility. She has many “anger” outbursts and over-reacts, “making a tempest in a
teapot.”
The patient struggled to learn during school. Her mother and private tutors helped
guide her studies at home. The mother says that since the first years of childhood
she was very active and talked fast, making it difficult for others to understand her.
She quickly learned to read and write, but made many errors in writing. She would
omit and change words and letters. She showed reading comprehension difficulties.
4 Neuropsychological Assessment of ADHD... 65

Her notes were quite disorganized. As a result of these problems, she failed the sixth
and seventh grade of school. She began to show lower self-esteem and avoidant
behavior regarding academic assessments or challenging activities.
The mother says the patient did not automate routines well since early years of
childhood and did not engage in sports activities or hobbies for long periods of time.
She denies previous neurological and psychiatric history. The patient shows normal
psychomotor and cognitive development. She was never on a psychoactive medica-
tion. She denies using illicit drugs, smoking, or drinking.
Step 2: To describe the intensity of symptoms related to her primary com-
plaint and presence of symptoms of potentially relevant neuropsychiatric
syndromes.
Methodology: use of scales and inventories.
Total scores (where relevant) and select endorsed items are noted for each scale
below.
Beck Depression Inventory (BDI) [37]: (total score: 3—low)

– I do not sleep as well as I used to sleep.


– I lost over one pound without going on a diet.
– I am less interested in sex than in the past.
– Trait-State Anxiety Inventory (IDATE) [38]: (total score: 30—mild).
– I do not rely on myself.

Barratt impulsiveness scale [39]—Version 11

– I have fast thoughts.


– I find it hard to sit still for long periods of time.
– I am easily bored.
– I talk fast.

Brown ADHD Scales [16]—75—ADHD highly probable


– Experiences excessive difficulty getting started on tasks.
– Feels excessively stressed or overwhelmed by tasks that should be manageable.
– Is disorganized; has excessive difficulty keeping track of plans, money, or time.
– Intends to do things but forgets.
– Produces inconsistent quality of work; performance quite variable—slacks off
unless “pressure” is on.
– “Spaces out” involuntarily and frequently when doing required reading; keeps
thinking of things that have nothing to do with what is being read.
– Gets lost in daydreaming or is preoccupied with own thoughts.
– Frequently feels discouraged, depressed, sad, or down.
Behavior Rating Inventory of Executive Function [36] (self-report/informant-
report).

– Behavioral Regulation Index (self-report t score 55/informant-report t score 58).


– Metacognition Index (self-report t score 68/informant-report t score 64).
– Global Executive Composite (self-report t score 61/informant-report t score 62).
66 D.d.B. Carim and H.C. Fichman

Step 3: Cognitive assessment focused on EF to determine the relationship


between cognitive functions and behavior self-regulation.
Methodology:
– WAIS-III [40] (global cognitive functioning)
– Finding: The patient shows global cognitive functioning and intelligence level
compatible with her age group (Global IQ—Average).
– Wisconsin Card Sort [31]: 3/6 categories, many perseverative errors.
– Finding: cognitive inflexibility.
– Cancelation of letters [5]:
– (organized)—49 s, three omission errors.
– (disorganized)—45 s, eight omission errors.
– Finding: fast processing information speed generated elevated attention errors
(omissions). Deficit in regulation of processing information speed.
– Trail making test [5]:
– Number sequence forms—31 s, zero errors.
– Numbers and letters’ sequence form—56 s, three errors.
– Finding: inhibitory control deficit and cognitive inflexibility.
– Mazes [5]—35 s, three errors.
– Finding: Fast performance with trial and error answers. Planning failure.
– Copy of Rey complex figure [5]—2 min 10 s—26 (disorganized, with perse-
verative errors).
– Finding: Planning and monitoring failure.
– Stroop [32]:
1. Color naming: 13 s.
2. Color naming of words: 15 s.
3. Color naming of words written in colors different than the name: 26 s, four
errors.
– Finding: inhibitory control deficit and difficulty with divided focus.
– Digits (WAIS-III): 11—Average
– Direct order repetition: 6.
– Reverse order repetition: 4.
– Finding: mild reduction in working memory processing.
– Wechsler Memory Scale (WMS) [32]
– Focus and concentration index (WMS): 70—Low.
– Global memory index (WMS): 87—Low average.
– Finding: Verbal episodic memory deficit due to reduction in working memory
processing.
Step 4: Interpretation of the results and integration with clinical history,
scales, and diagnosis profile.
The findings demonstrate an executive disorder, particularly involving “cold”
functions more than “hot” functions, to apply the conceptualization of EF that we
offered earlier. A neuropsychological model of her impairment is described in
4 Neuropsychological Assessment of ADHD... 67

Fig. 4.2 Neuropsychological model: LT, 29 years old

Fig. 4.2. The patient shows impairment in selective focus, planning and monitoring
goal-oriented behaviors, and low capacity for operational (working) memory. Other
milder deficits include difficulty with inhibitory control and self-regulation, which
would produce impulsiveness, greater sensitivity to frustration, and inflexible or
avoidant thought/behavior patterns.
As noted previously, further evaluation not discussed in this ADHD and
EF-focused chapter would be necessary to provide a comprehensive impression
of neuropsychiatric conditions. The extent of such further exploration should be
tailored to questions presented by the referring clinician and to avoid overlap
with prior evaluations. For example, it is usually appropriate to screen for all
DSM-IV [41] psychiatric conditions in individuals with ADHD, because of high
rates of comorbidity. (In this case, for example, exploration of anxiety disorders
would be appropriate given her report of possible performance anxiety.) Her
performance problems also may merit screening for relevant neurologic impair-
ments such as dyslexia, or problems with information processing, or fine-motor
coordination.
68 D.d.B. Carim and H.C. Fichman

Step 5: Recommendation of a neuropsychological rehabilitation program


focused on cognitive and behavioral deficits.
In the case of the patient, a neuropsychological rehabilitation program was
recommended with the following elements:
– Education about the impact of attention deficit/hyperactivity disorder and executive
function challenges on adults—including information about available treatment
resources.
– Communication to her current or future treaters indicating that she will benefit
from support for EF deficits, in addition to treatment for ADHD.
– Practice identifying and challenging negative thinking that undermines her
adaptation efforts and re-orienting with positive attitude towards her goals (see
Chapter 7 in this text on cognitive behavioral support for ADHD).
– Practice in relaxation and other anxiety reduction techniques.
– Education in use of a planning system that is appropriate to her challenges. For
example, having a planning time that allows her to (1) identify priorities; (2)
break down tasks into achievable goals, and (3) assign them to herself on a
schedule.
– Education in use of automated reminder systems—timers to allocate time t for
tasks and alarms to remind her to confirm she is on task or transition between
activities.
– Creation of a study program to prepare for her competitive examination—including
a study schedule and self-evaluation schedule.
– Adapting to her EF challenges by capitalizing on what has helped her succeed at
effortful tasks and learn in the past. For example, this might include (1) structured
learning opportunities such as review classes, a study partner, or study groups,
(2) making learning interpersonal with a sophisticated tutor or expert on the
study topic, or (3) learning materials in a format that is best for her, such as from
recordings, writing out material, or teaching it to someone else.
– Introduction to the concepts of working memory and what facilitates long-term
storage—such as increasing interest or associations to the material (e.g., use of
acronyms or making material into stories).
– Identification of whether she meets criteria for accommodations on her standardized
exam, such as extra time to complete testing, or testing in quiet area. Similarly,
she may benefit from these accommodations as well in future classes or from
being given a complete set of class notes.
– Identification of possible new strategies for maintaining home organization, and
practice of new strategies that she identifies as high yield. Attention should be
given to what will most naturally help her adopt new organizational habits.
– Regular review with a professional or significant people in her life of how well
she is reducing unproductive behavior and adopting more productive behavior.
4 Neuropsychological Assessment of ADHD... 69

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Chapter 5
Stimulant Pharmacotherapy for Adults
with ADHD

Paul Hammerness

Abstract This chapter is a review of stimulant treatment for attention deficit


hyperactivity disorder (ADHD) in adults, drawing on the clinical literature, emerging
guidelines on the topic, and clinical experience. The chapter includes a practical
approach to initiating therapy and recommendations on monitoring for effective-
ness and for adverse effects. Special emphasis is given to the cardiovascular impact
of stimulants and related clinical recommendations.
This chapter is a “how to” guide to clinical decision-making and practice rele-
vant to the prescription of stimulant class medication for adults with attention deficit
hyperactivity disorder (ADHD). This chapter teaches:
– How to choose target symptoms and problems for treatment?
– The evidence from clinical trials for stimulant efficacy in adult ADHD.
– Use of a rating scale to monitor treatment effect on symptoms and functioning.
– Contraindications to stimulant treatment.
– Cardiovascular risk of stimulant treatment for ADHD.
– How to manage common side effects.
– How to monitor safety, side effects, and establish ongoing need for treatment.

When Is Medication Indicated for ADHD?

The American Academy of Child and Adolescent Psychiatry Practice Parameter for
ADHD states that a well thought out psychopharmacological intervention is the
primary and most efficacious treatment for all individuals with ADHD [1]. Emerging
clinical guidelines for adult ADHD identify medication treatment as central to

P. Hammerness, M.D. (*)


Clinical and Research Program in Pediatric Psychopharmacology and Adult ADHD,
Massachusetts General Hospital, 185 Alewife Brook Parkway,
Suite 2000, Cambridge, MA 02138, USA
e-mail: phammerness@partners.org

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 71
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_5,
© Springer Science+Business Media New York 2013
72 P. Hammerness

a comprehensive treatment plan [2–4]. Of available agents, stimulant class medications


are consistently recommended as first line [1–4].
While the UK National Institute for Health and Clinical Excellence guideline
explicitly states that ADHD medication is indicated only in the setting of moderate
to severe levels of impairment [3], this threshold is not explicit in other guidelines
[1]. In clinical experience, individuals present for help when symptoms of ADHD
are causing significant functional impairment and distress. Moreover, as emphasized
in the chapter on ADHD assessment (chapter 2) in this guide, the presence of
significant impairment is a fundamental criteria to meet diagnostic threshold (i.e.,
DSM-based), the necessary first step prior to initiation of a medication.
As has been well described in the initial chapters of this text, ADHD can impact
all domains of life. Impairment can be found in work and academic settings; in
personal and professional relationships; during social time; related to self-care and
physical health; in other routine aspects of daily living, e.g., driving or shopping for
food. As emphasized in the chapter on assessment (chapter 2) in this text, comprehen-
sive treatment is based on a rich understanding of how ADHD and other personal
challenges combine to create the presenting pattern of distress. As was also dis-
cussed earlier, having a significant relative or long-time friend come to or contribute
to an initial appointment can provide a helpful perspective.
Patients should be informed of the known evidence base on medication treatments as
well as the limits of our understanding. In particular, there is limited information about
longer-term (>1–2 years) efficacy and safety of medications for adult ADHD. Initial
conversations with patients ought to provide sufficient facts about ADHD so patients
can determine the relative importance of treating ADHD in their lives and the possible
benefit of non-pharmacologic therapies for ADHD (e.g., organizational/vocational
counseling—see chapters on therapy (chapter 7) and on neuropsychologically
informed accommodation (chapter 4) in this text). It is also important to discuss opti-
mal timing of a medication trial. A “big-picture” message to patients is that while
medication is first line treatment for adults with ADHD, clinical experience does not
support ADHD medication to be a necessary, lifelong treatment for all patients. Given
the variable duration of the disorder, the potential impact of education and organi-
zational/behavioral changes, and the fact that impairment related to ADHD may only
show up in some contexts, it is reasonable to expect that some adults may discontinue
medication over time or require medication only during specific times in their life; e.g.,
in the context of a new managerial position, family demands, or returning to school.

Questions that Focus on Impairment Meriting Treatment


• “Over the years, how has ADHD affected your job?”; “Have you lost work
due to ADHD?”
• “If your spouse was here, what would he/she say about how ADHD causes
problems for you?”
• “Why now, why is it important to change how you function at this specific
time of your life?”
5 Stimulant Pharmacotherapy for Adults with ADHD 73

What Are Appropriate Medication Targets?

With the patient, identify specific ADHD symptoms as initial medication targets.
Do not consider broad complaints that stray from specific diagnostic (i.e., DSM)
criteria as initial targets, such as “to get my life together.” For example initial medication
targets for an individual could be to (1) stop losing items on a daily basis, (2) stay at
the desk and focus for 30–45 min without getting up due to loss of attention, and (3)
sit through meals with less restlessness. We know from research and experience that
stimulants can improve the fundamental symptoms of ADHD related to these goals,
such as losing/misplacing items and inattention/restlessness. By focusing the patient
on situations that highlight specific deficits, symptoms of ADHD can be described
and documented in a relatively straightforward, objective manner.
As described in detail in chapter 2 on assessment of ADHD in adults, it may be
helpful to use an instrument like the ADHD symptoms and role impact inventory
and related prompts (see Appendix) to identify the most important symptoms and life
functions to target. This process also allows clarification for clinician and patient
which symptoms have the greatest impact.
Patients often establish goals based on what they think is “important” to improve
or what they perceive to be a priority. Patients may even say “its not that I have a
really important job or anything….” Clinicians can help a patient understand that
trouble focusing when talking to loved ones or helping a child with homework is
ADHD-related impairments as much as inattention in the workplace. While initial
medication targets should be specific, the goal is to treat ADHD symptoms
wherever they may be impairing. The aim of medication is improvement in ADHD
symptoms throughout settings, at work, home, school, socially—any moment of
improved focus, or reduced impulsivity, in whatever context, may be an important
success.
It is also important to educate patients that some symptoms may not respond. For
example, while medication often helps individuals get around to, stick with, and
finish tasks, medication may not improve more complex cognitive (e.g.,
organizational) skills such as the ability to plan or to have a keen sense of time.
Patients and treaters should anticipate that some symptoms may require further
supports.

Communicating Appropriate Treatment Goals


• “I suggest your goal for the week could be not losing keys, phone or
wallet.”
• “I know you want to be more organized, but let’s aim for staying focused
on your morning desk-work as a start.”
• “Sounds like your goal is to be more patient waiting in lines this week.”
• “Let me know if you feel more calm, more able to sit through meals with
your family, not being the first one up.”
74 P. Hammerness

From Evidence to Practice: Do Clinical Trials


Inform Clinical Care?

Although adult ADHD has been described since the 1970s [5], it is only in the past
decade that large-scale clinical trials have been conducted in adult populations,
resulting in a number of (US FDA) approved agents. It is important to know the
typical characteristics of adult subjects in clinical trials; the more your patient
diverges from the average clinical trial subject, the less applicable the clinical literature
may be to your clinical practice. This is important to keep in mind and to share with
patients.
Typical adult ADHD clinical trial subject characteristics can be seen in an exami-
nation of two recent randomized controlled trials (RCTs) of extended duration
methylphenidate (total N = 589) conducted in the USA [6] and abroad [7]. The clinical
trial literature is largely based upon medically and psychiatrically healthy young
adults. Consistent with this, the typical subject in these trials is an adult in his or her
late 1930s, generally psychiatric healthy, without significant current comorbidity.
A recent review of adult ADHD RCTs in the scientific literature from 1985 to
2008 by Faraone and Glatt [8] documents the robust efficacy of stimulant class
medications in adults with ADHD, similar to that observed in children. A mean
effect size (ES) of 0.73 (large) was documented across five contemporary RCTs
(years 2006–2008) of once daily, extended duration stimulants (N = 1 dexmeth-
ylphenidate extended release; N = 2 osmotic-release methylphenidate; N = 1
lisdexamfetamine dimesylate; N = 1 mixed amphetamine salts extended release).
Effect size (ES) provides a way of appreciating the difference between placebo and
active treatments [9]. Despite a variety of ADHD outcome measures, the ES across
trials of extended release stimulants was very consistent. Conversely, although quite
high, ES was more variable across studies employing short acting, immediate-
release stimulants [8]. The mean ES (0.96) from these latter seven studies (N = 2
dexmethylphenidate; N = 4 methylphenidate; N = 1 mixed amphetamine salts) was
corrected (0.86), given differences in study methodology and publication bias.
Studies of immediate-release agents spanned two decades (years 1985–2006), thus
we can anticipate some degree of heterogeneity across subject samples.
Consistent with clinical experience, meta-analysis demonstrates stimulants to be
effective for all of the symptoms of ADHD highlighted by DSM criteria. Stimulants
work for adults with either subtype of ADHD (i.e., inattentive type vs. combined
hyperactive-impulsive/inattentive). Consistent with clinical experience, according
to the literature, age, gender, and formulation (MPH or AMP) do not appear to limit
the efficacy of stimulants [8].
Despite progress, the existing body of clinical research on ADHD medication
therapy has significant limitations. For example, little is known about what clinical
features impact how individuals respond to stimulants. Recent post hoc analysis of
long-term lisdexamfetamine dimesylate (LDX) treatment suggests that greater
symptom improvement may occur in patients with a more severe presentation at
baseline [10]. However, executive function (EFD) deficits, whether defined
5 Stimulant Pharmacotherapy for Adults with ADHD 75

behaviorally, or by neuropsychologically defined measures, such as working memory,


may not be similarly responsive to stimulants [11–13] (see discussion of executive
function deficits in the neuropsychological assessment chapter 4 of this text).
In addition, the evidence base for stimulants for adult ADHD tells us little about
the impact of stimulants upon long-term overall functioning. Prospective open trials
have demonstrated efficacy and tolerability of stimulant treatments for up to 2 years
[14], with very limited information beyond that time point. It is not known whether
the analysis of short-term responders will predict patients who can sustain adherence
over the long term [14, 15]. One practical limitation in providing answers about
long-term efficacy and safety is the minority of patients who remain on medication
over the longer term.

Monitoring Effectiveness with an ADHD Rating Scale

To monitor and optimize pharmacotherapy, it helps to isolate and monitor both


symptoms of ADHD and the daily impact of ADHD. Related principles for treatment
planning and monitoring are also discussed in chapter 4 on treatment planning. Scales
can be particularly useful for tracking ADHD response during medication therapy.
The ADHD symptom and role impact inventory in Appendix is one example, and
other scales tracking ADHD symptoms are described in chapter 2 on assessment in
this book. Rather than administering an entire symptom scale at each visit, it is most
important to revisit the most impairing traits and the role impairments that are most
important to primary treatment goals.
It is also efficient to give patients scales to take home to track symptoms and
progress on their target symptoms. Where appropriate, it is also helpful to encourage
them to have a loved one or friend to rate their observation of symptoms during
treatment. The Self Rated and Informant ADHD Symptom and Role Impact
inventories are thus useful to help track target symptoms (see Appendix).
Subjects’ response in clinical trials is closely assessed and tracked over time, in a
similar objective manner, often via a weekly examination of clinical ratings of ADHD.
Ratings by a clinician typically serve as the primary outcome measure, although self-
report may be completed as well. Within the first several weeks of initiating medication,
treatment ratings of ADHD symptoms often rapidly drop from baseline and can reach
a statistically significant separation from baseline over placebo within 2–4 weeks.
One can expect a decline in mean total ADHD rating score as well as in the inattentive
type and the hyperactive-impulsive type spectrum.
For example, at baseline (on the day of starting treatment), a subject may report
severe daily problems with forgetfulness, distractibility, inattention. Let us call this
imaginary subject Susan, and give her “3’s” for multiple symptoms on the ADHD
rating scale, rated from 0 to 3 (0 = none; 1 = mild; 2 = moderate; 3 = severe). Susan
reports that during the week leading up to her baseline appointment she forgot a
dental appointment which she had to reschedule twice due to poor planning; she
was getting very little done on an important report at work because “within 5 min”
76 P. Hammerness

of sitting at the computer she was listening to the conversation of co-workers or getting
off-task with email messages. In addition, her supervisor at work and her spouse
had each commented several times about her forgetfulness, saying it was as if she
was not listening to them. Susan admits in most conversations she trails off very
quickly, and often just smiles and nods, pretending to be listening. Throughout the
rating scale interview, Susan described inattentive type ADHD symptoms as occurring
every day, in nearly every setting, earning her multiple “3” (severe) ratings.
Now jump forward to week 4 on stimulant treatment, and Susan comes in reporting
she has not forgotten anything in the prior week. Once she was about to forget some
important papers, but she caught herself as she was leaving her office, and turned
around to grab them. She surprised her spouse by reminding him about some details
of social plans he had mentioned several days before, and she found herself
consistently sitting at her computer for upwards of 45 min, working effectively. She
also reports that when something distracts her, such as a person, a phone call, or an
email, she “can get back to what I was doing without a lot of problem.” Overall, she
received 0–1 scores (none–mild) on the ADHD rating scale. Susan provides an
example of how symptoms causing frequent impairment can subside to an occasional,
manageable burden within just a few weeks on medication.

Which Stimulant?

Stimulant class medications include methylphenidate (MPH) and amphetamine


(AMP) agents. Methylphenidate agents include racemic methylphenidate and
dexmethylphenidate. Amphetamine agents include dextroamphetamine (dAMP),
mixed amphetamine salts (MAS), and the pro-drug lisdexamfetamine (LDX). As
will be discussed, some patients appear to preferentially respond to or tolerate one
of these stimulant agents, or one formulation of one of these agents, over another.
Symptomatic improvement in persons with ADHD has been correlated with
stimulant binding to the dopamine transporter (DAT), with a subsequent increase in
monoamine concentrations in striatal and cortical regions that control the impulsivity,
inattention, and motor restlessness of ADHD [16, 17]. While both MPH and AMP
medications target the dopamine transporter (DAT), their mechanisms of action is
thought to differ. MPH increases DA due to blockade of the DAT, thus, the effects
of MPH are dependent on passive DA released within the synaptic cleft. Conversely,
AMP induces the release of vesicular DA from the terminal, using the DAT as a
carrier to actively unload vesicular stores [18–20].
There are two AMP agents approved in the USA for adult ADHD: (1) a mixed
amphetamine product (MAS-XR; ADDERALL XR®) and (2) a novel amphetamine
pro-drug [lisdexamfetamine (LDX); Vyvanse®]. Both are long acting formulations,
typically dosed as once daily in the morning. MAS-XR beads contain the neutral
sulfate salts of dextroamphetamine and amphetamine with the dextro isomer of
amphetamine saccharate and d,l amphetamine aspartate monohydrate; the beads
are designed to give a double-pulsed delivery (Shire, prescribing information).
5 Stimulant Pharmacotherapy for Adults with ADHD 77

LDX is a novel, therapeutically inactive pro-drug in which d-amphetamine is


covalently bonded to l-lysine. After the pill is swallowed, LDX is absorbed from
the gastrointestinal tract, and by first-pass intestinal and/or hepatic metabolism, it is
converted to dextroamphetamine and l-lysine (Shire, prescribing information).
There are two MPH agents approved in the USA for ADHD in adults at present:
(1) dexmethylphenidate hydrochloride extended release (d-MPH-ER; Focalin® XR)
and (2) extended release methylphenidate (OROS MPH; Concerta®). Both are long
acting formulations, typically dosed as once daily in the morning. d-MPH-ER is a
beaded capsule formulation, with an initial release of medication, followed by a
delayed second release, similar to a twice-daily dose of immediate-release d-
methylphenidate (d-MPH) (Novartis, prescribing information). Pre-clinical evi-
dence suggests that the mechanism of action, the inhibition of dopamine reuptake,
is accomplished primarily by the d-threo enantiomer of MPH, consistent with the
effect of single-isomer d-MPH [21]. OROS MPH uses osmotic pressure to deliver
methylphenidate at a controlled rate. The system has an immediate-release drug
overcoat that dissolves, providing an initial dose of methylphenidate. Water permeates
into the core of the table and as the osmotically active polymer excipients expand,
methylphenidate is released through a small hole, increasing over a period of 6–7 h
(McNeil Pediatrics, prescribing information).
Although these agents have been studied specifically for adult ADHD, clinical
experience suggests that all stimulants have robust efficacy in adults. For example,
agents that have been developed in children which we also commonly prescribe in
adults include short acting methylphenidate, bead release forms of racemic meth-
ylphenidate, a patch form of methylphenidate, short acting amphetamine or dextro-
amphetamine, and a long-acting bead release form of dextroamphetamine. Aggregate
data or experience does not demonstrate convincing superiority of one specific
stimulant over another. In addition, the evidence base does not show us which
medication is best for which patient. Individual practitioners may express preferences
for several specific stimulants, due to familiarity, but it is important to appreciate that
individual response pattern may merit multiple trials of differing agents.

Short Acting vs. Long Acting Stimulant

Guidelines generally recommend beginning with an extended duration/release (ER)


stimulant, instead of an immediate release (IR), short acting stimulant [1–3]. This
rationale is based upon several factors, including less abuse liability for ER vs. IR
forms. In addition, although this point has not established through research, ER
stimulants may offer a more even response with a superior side effect profile
throughout the day. Moreover, from a practical standpoint, once daily forms may be
a better overall approach for the poorly organized, poor planning ADHD subject.
The last point of difference between IR and ER formulations, ease of use, may
be the most important. Overall it is difficult to be compliant with any medication
over time. Without compliance, treatment does not have much chance of success.
78 P. Hammerness

It is intuitive that better compliance may occur with once-daily extended duration
agents, as compared to an immediate-release formulation which must be taken multiple
times/daily [22]. It may be useful to consider an IR agent when a long acting agent
does not sufficiently cover the day. IR forms can also be used to replace the ER
agent at chosen times, such as if a patient sleeps late on weekends or does not
require full day coverage.
In addition, ER forms may lessen the risk of stimulant abuse known to occur with
the IR agents. A rapid increase in blood level of IR medication forms may increase
the “likeability” of the drug. A very useful perspective on neuropharmacology
related to this topic can be found in reviewing the work of the Director of the US
National Institute on Drug Abuse (NIDA), Dr. Nora Volkow [23].
There has been only limited direct comparison of the difference in effects and
side effects between IR and ER stimulants. While the benefits of stimulants tend to
be similar across various release forms, there can be strong variation in side effect
profiles. In some cases, side effects may appear correlated with the expected pattern
of increase and decrease of medication in the blood stream. Some patients with have
mood, personality, or fatigue effects on a short acting agent but not on a long acting
version of the same active ingredient—while others may react more poorly to the
long acting version.
Finally, availability, coverage, and patient finances vary widely; these practical
matters must be addressed to ensure that the chosen prescription is (1) available
under a patient’s plan and (2) reasonable cost. Generic forms of ER stimulants are
beginning to emerge as well.

MPH vs. AMP Formulation

After deciding whether to start with an ER vs. an IR agent, the next decision point
is whether to decide between an MPH or an AMP class stimulant—if both are available.
At present, guidelines do not dictate one over the other. It is not unusual for patients
to come in with preconceptions of stimulants, with concerns about starting a
particular brand name agent. While patient preference may influence the choice, it
is important to address questions/fears that exist behind these choices.
There are now multiple studies of both methylphenidate and amphetamine products
in adults. At present, we cannot predict which stimulant will be most effective or
best tolerated for a given patient. Thus, it is helpful to clarify that one cannot predict
which stimulant type will be most effective and that it may take adequate trials of
both kinds of agents to establish which is optimally effective and tolerated.

When to Avoid Prescribing Stimulants

Although stimulant medications are generally well tolerated by healthy adults,


assess for potential contraindications prior to writing the first prescription and
document that these contraindications have been reviewed. Many of the
5 Stimulant Pharmacotherapy for Adults with ADHD 79

contraindications listed below may be managed sufficiently through specialty


evaluation or consultation. For those who meet one or more of the criteria as follows,
non-stimulant ADHD medication and/or a referral to organizational/behavioral
counseling can be considered. A list of contraindicating agents is also presented in
chapter 2 on assessment in this text.

Possible Contraindications to Stimulant Treatment


• Prior allergic reaction to stimulant class medications.
• Unstable medical condition or conditions where increase in sympathetic
nervous system activity: for example, hyperthyroidism, elevated eye pres-
sure (glaucoma), seizures.
• Active or a recent substance or alcohol use disorder.
• History of psychosis, bipolar disorder, or current, clinically significant
psychiatric comorbidity (major depression, mania, suicidality, anxiety,
agitation, tics).
• Personal cardiovascular disease or family history of early cardiac disease.
• Treatment with a monoamine oxidase inhibitor or other pressor agent.

Cardiovascular Screening

Current recommendations are to assess the patient’s personal and family cardiac
history prior to initiation of ADHD pharmacotherapy, looking for abnormal personal
or family cardiovascular history: e.g., have the patients themselves or their family
members experienced fainting or dizziness or chest pain or shortness of breath; has
there been sudden, unexplained death or “heart attack” in young family members.
The American Academy of Pediatrics (www.aap.org) is a one source for updated
information on screening recommendations.
Heart rate and blood pressure should be measured prior to initiation of therapy and
periodically while on therapy (see “Monitoring Cardiovascular Effects” below). Cardiac
symptoms or concerning vital signs should result in appropriate medical referral [24]
prior to initiation of stimulant treatment. At present, an electrocardiogram (ECG) is not
recommended for routine screening prior to stimulant treatment.

Dosing Pattern During a Stimulant Trial

If there are no contraindications to a stimulant treatment, and the formulation and


stimulant type has been chosen and is available/affordable to the patient, the stimulant
trial can begin.
Consistent with the clinical trial evidence, a response can be anticipated within
4–8 weeks. The trial may best be viewed as a collaborative experiment to establish
benefit for treatment goals. Daily dosing is usually most appropriate initially with
80 P. Hammerness

stimulants, as it allows maximal chance to assess benefit. Patients may wish to take
medication as needed, but can defer this approach until optimal efficacy has been
established. Also, starting and stopping medication may be uncomfortable—producing
side effects unique to initiation or wear-off of a dose.
It is recommended to begin with lowest dosage of tablet or capsule at first, to
allow for gradual titration. Gradual titration (dose change after 1–2 weeks minimum)
may improve tolerability and can reduce the risk of titrating through an effective
lower dosage too quickly.
While current recommendations and FDA dosing are not oriented to weight, it
may be helpful to be familiar with weight-based dosing, to orient to findings from
the clinical literature. For example, studies that included doses of approximately
1 mg/kg/day (70–90 mg/day) of MPH have demonstrated efficacy and are well
tolerated in adult clinical trials [25]. This is certainly a different dose range than
prescribed in children and some clinicians may not be familiar with the evidence
supporting efficacy and safety for adults in this dose range.

Monitoring Stimulant Treatment

Monitoring includes tracking of effectiveness and tolerability. It is best accomplished


over time with an engaged patient. Consistency of communication and follow-up are
critical to a successful medication treatment.

Monitoring Cardiovascular Effects

Stimulant monitoring should include regular assessment of heart rate and blood
pressure, in addition to weight. Thus, clinicians ought to be familiar with what
constitutes a concerning vital sign in an adult. At present, BP that exceeds 120/80
on ³2 or more visits may be classified in the pre-hypertension range or if ³140/90,
as hypertension [26]. Elevations in heart rate are increasingly considered to be an
important CV risk factor with risk increasing in a continuous fashion above 60 bpm,
greatest risk if >90 bpm [27–29].
Clinicians should be aware of revised product labeling regarding cardiovascular
effects (http://www.fda.gov/bbs/topics/NEWS/2007/NEW01568.html), as well as
recent advisories by the American Heart Association [30], and clinical guidelines
[2]. The available literature does not support the use of routine ECG in the context
of monitoring stimulant treatment.
Any concerning cardiac history or vital sign can be jointly monitored by a
patient’s primary care physician or can result in a referral to a specialist for further
evaluation. It may be valuable for patients to self-monitor heart rate and blood pressure
as well. Measurements should be taken in the seated position, after a few minutes at
rest. It may be useful to collect readings at different intervals throughout the day,
including before dose, 1–2 h into a dose, and at the end of the day.
5 Stimulant Pharmacotherapy for Adults with ADHD 81

Monitoring Need for Medication

As emphasized in chapter 2 on assessment, ADHD symptoms can fluctuate and


evolve over time, thus monitoring treatment should include establishing whether
medication remains necessary over time. The burden of ADHD may lessen as
individuals learn about the condition and how to cope better with it. Significant
environmental change can also impact level of symptoms—e.g., change in the kinds
of tasks filling each work day, or having a new fulltime administrative assistant may
greatly improve the ability to be organized at work. Given the lack of knowledge
about the long-term safety of these agents, it may be clinically prudent to document
a reassessment of clinical necessity. There is no evidence at present that a similar
response cannot be immediately re-captured if medication taper and/or discontinuation
is not successful.
Conversely, patients may present with concerns that their symptoms are worse
or their medication seems less effective over time. These concerns require careful
assessment. Sometimes having a patient stop medication (for example, tapering
for a couple of days and stopping for a week) can clarify what effect medication
was having. While it is not common, some patients describe tolerance to the
effects of stimulants—it may be best to establish whether brief breaks in treatment
(such as stopping over weekends) or change to an alternate agent re-capture
efficacy. In the majority of patients, clinical experience is that a sense of fading
effect of treatment is often due to an increase in environmental demands or a
realization that while the initial improvement on stimulant was dramatic, impairing
symptoms do remain.
All patients should be monitored for emergence of novel medical or psychiatric
conditions—e.g., new onset seizure disorder, hypertension, major depression,
alcohol abuse which might alter the risk–benefit ratio of stimulant treatment, and
necessitate a period off medication or complete discontinuation.

Side Effects and Their Management

Generally, stimulant medications are well tolerated in healthy individuals, with mild
side effects commonly reported in clinical trials of stimulant agents, in children,
adolescents, and adults. A minority of subjects in clinical trials (~5–15%) discontinue
stimulant due to an adverse event [7, 31].
Patients should be informed of both common frequent side effects (e.g., low
appetite, insomnia, dry mouth) as well as less frequent serious possible events of
stimulant medications (e.g., mood change, “personality” change, hallucinations,
cardiac event).
In between visits, patients can self-monitor for side effects and call or return to the
office with any significant concerns about persistent or serious changes in how he/she
feels once starting the medication. Minor side effects, such as low appetite, headache,
stomach upset, may dissipate over the course of 1–2 weeks on a stable dose.
82 P. Hammerness

Common Stimulant Side Effects

• Low appetite.
• Gastrointestinal upset.
• Dry mouth.
• Headache.
• Insomnia.
• Physical tension.
• Irritability.
Side effect patterns vary between different forms of the same active agent. Therefore
a different formulation of an effective agent maybe appropriate where side effects
are bothersome, but not clinically serious, such as mild persistent low appetite or
headache or dry mouth. The decision might be to shorten the duration of action or
to switch to a different formulation with a different release/plasma concentration
profile.
If one stimulant type is associated with discomfort such as mild adverse mental
effects (such as mood worsening or change in personality), experience suggests that
it is best to switch to another agent; i.e., from MPH to AMP or from AMP to MPH,
or to consider a non-stimulant form of medication.

Managing Common Stimulant Side Effects

Physical discomforts of stimulants may decrease over several days or may be alleviated
by changing release pattern or active stimulant ingredient as described. Another
consideration to manage periods of discomfort that may be related to peaks or drops
in medication level is to divide the morning dose into two installments with a brief
time period between them.
In addition to the above, the following clinical actions can be considered when
facing the following common side effects:
Insomnia: (1) Identify if sleep difficulty existed prior to medication; (2) Emphasize
appropriate sleep hygiene (inquire about caffeine/energy drinks); (3) Consider
shorter acting stimulant formulation; (4) Identify possible sleep disorders—mela-
tonin has been recommended for sleep phase delay [2].
Dry mouth: (1) Identify whether hydration or healthier forms of chewing gum alle-
viates; (2) Consider impact on dental health—may suggest discussion with dentist.
Low appetite: (1) Carefully assess whether appetite is worse on medication; (2)
Consider frequent, smaller, healthy (adequate protein) meals or supplements; (3)
Reduce exposure/dose on weekends, or during less demanding times.
Stimulating effects (i.e., feelings of agitation): (1) Reduce caffeine or other stimulant
use—coffee, soda, energy drinks.
5 Stimulant Pharmacotherapy for Adults with ADHD 83

Blood pressure/heart rate: (1) Identify whether blood pressure or heart rate is in
concerning range (as discussed above); (2) Discuss cardiovascular risk factors,
address smoking, limited exercise, dietary habits including high salt intake; (3)
Refer and/or communicate concerns with medical colleagues.

Focus on Cardiovascular Safety of Stimulants

The cardiovascular impact of stimulants is worthy of special discussion as it has


been a subject of considerable concern. Cardiovascular effects can be considered in
a clinical encounter as objective effects, such as elevations in blood pressure and
heart rate, and subjective effects, such as experience of chest pain. Clinical trials
and post-marketing reports of cardiovascular adverse effects include both subjec-
tive and objective findings [32].
In terms of objective findings, clinical trials of healthy adults with ADHD have
demonstrated increases in blood pressure (BP; mean +1–5 mmHg) and heart rate
(HR; mean +4–10 bpm) during short-term treatment with immediate and sustained
release stimulants. However, only some studies found increases in blood pressure
and heart rate to be significantly different than those changes observed with pla-
cebo [6, 7, 14, 21, 31, 33–35]. It remains unclear whether there is a dose–response
relationship to these changes [21]. When reported, elevations in blood pressure
and heart rate on stimulants appear stable over time (i.e., lack of tolerance), with
similar findings reported in a large sample of adults treated openly for up to
24 months [36].
Notably, 5–10% of subjects (“outliers”) may have a greater BP or HR change on
ADHD medication [6, 31, 36]. Outliers are typically reported in clinical trials as
exceeding a threshold HR (e.g., >100 bpm) or BP (e.g., >140/90). In some trials an
outlier may be identified based upon one elevated reading while on medication.
A recent large (N = 401) RCT of OROS MPH (18–72 mg) in adults found up to 27%
with BP elevation (SBP > 140 mmHg or DBP > 90 mmHg) at 5-week endpoint;
however, similar BP elevations were found in up to 20% of placebo subjects [34]. In
this study, HR exceeded 90 beats per minute at endpoint in 10–14% of MPH-treated
subjects, as compared to 6% of the placebo group.
Consistent with the pediatric literature, clinical trials in adults have not found
a clinically significant change in electrocardiogram (PR, QRS, and QTC) param-
eters during treatment with methylphenidate [21, 33] or amphetamine class
stimulants [36].
In terms of subjective findings, clinical trials have documented adverse events
seemingly of a cardiovascular or cardiopulmonary nature associated with stimulants
in children and in adults. Complaints such as palpitations, tachycardia, and dyspnea
occur in up to ~20% of stimulant treated subjects and can occur more frequently than
on placebo [6, 7, 14, 21, 31, 36]. Despite these common subjective experiences, serious
cardiovascular events are rarely seen in large-scale clinical trials [34].
84 P. Hammerness

Outside of clinical trials, rare serious or fatal cardiovascular events have been
reported in children, adolescents, and adults taking stimulants, sufficient to raise
questions about the cardiovascular safety of ADHD medications [37, 38]. As
initially reviewed by the United States FDA Division of Psychiatry Products, the
rate of sudden death with stimulants in adults is below background rates available in
the literature [39].
Several large-scale cohort studies have recently reported on the relationship
between serious CV events and ADHD medication, finding no increased rates of
sudden death or serious cardiac events in very large samples (i.e., N > 1,000,000) of
children-young adults [40–45] and young-middle aged adults [46]. Following the
emergence of these multiple large-scale reports including that of Cooper [40], the
FDA updated the public with a safety announcement that there has not been shown
an association between use of certain ADHD medications and adverse cardiovascular
events (FDA Safety Announcement Nov 1, 2011).
However, given that individuals with baseline cardiovascular illness may be at
heightened risk, current clinical recommendations are to assess the patient’s personal
and family cardiac history prior to initiation of ADHD pharmacotherapy. Heart rate
and blood pressure should be measured prior to initiation of medication and periodically
during treatment. Changes in personal or family cardiac history, cardiac symptoms,
or concerning vital signs should result in appropriate referral. The available literature
does not support the use of routine electrocardiogram (ECG) in the context of
ADHD medication monitoring, although the merits of ECG screening are a topic of
ongoing debate [38].
Given the inherent medical and cardiovascular-specific risks which increase into
adulthood, much remains unknown about which individuals may be at heightened
CV risk. Clinicians working with adults can look to recent advisories by the
American Heart Association (AHA) on the topic of cardiovascular monitoring in
pediatric ADHD [30], as well as emerging guidelines for adults [2] and emerging
epidemiological data on the topic, such as that from the Agency for Health Research
and Quality (AHRQ: http://www.ahrq.gov/).

Summary

The clinical literature demonstrates short-term and long-term (1–2 year) efficacy
and general tolerability of stimulant class medications for healthy adults with
ADHD. These trials clearly suggest that response to stimulants is rapid and robust
in adult ADHD. This chapter presented experience-tested approaches to initiating
stimulant therapy as well as monitoring for effectiveness and adverse effects. At this
time, the factors that may predict whether an individual will benefit robustly from
long-term stimulant treatment have not been identified. Further study is needed to
assist practitioners in the decision-making process for individual patients, particu-
larly those with complex medical or psychiatric comorbidity.
5 Stimulant Pharmacotherapy for Adults with ADHD 85

The chapter concluded with a review of the cardiovascular impact of stimulants.


For healthy, medically screened adults, the typical cardiovascular impact of these
agents appears to be limited to elevations in blood pressure (+1–5 mmHg) and heart
rate (+4–10 bpm). Although subjective cardiovascular complaints are common,
serious cardiovascular events during exposure to these agents are rare, and at pres-
ent do not rise above background rates. Thus, there is no causal evidence at present
that these agents pose serious short term cardiovascular risk for medically healthy,
pre-screened adults. Clinicians should be aware of product labeling to reflect con-
cerns about adverse stimulant-related effects, including cardiovascular effects, and
be aware of updates from government and association resources, such as the FDA
and American Academy of Pediatrics in the USA.

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jama.2011.1830.
Chapter 6
Non-stimulant Drug Treatments
for Adults with ADHD

David Coghill

Abstract The psychostimulants (methylphenidate and amfetamines) are safe and


effective treatments for many adults with ADHD and should be considered as the
first-line pharmacological agents in many cases. However, prescribing choices
depend on more than just efficacy. Other important factors include the following:
adverse effects, toxicity, personal preferences, the presence of coexisting medical
and/or psychiatric problems, cost, and the potential for diversion. Fortunately sev-
eral non-stimulant alternatives with varying pharmacological profiles are available
and play an important part in the treatment of many adults with ADHD. This chapter
reviews several non-stimulant medications that may be considered when treating
adults with ADHD. We focus on those non-stimulant medications that are approved
for use in treating ADHD; atomoxetine and the a2-agonists clonidine and guanfa-
cine and those non-stimulants that, whilst not-approved, are commonly used in
clinical practice: bupropion, the tricyclic antidepressants desipramine and imip-
ramine, and modafinil. Whilst the intent here is to provide a practical clinical guide
rather than a systematic review, we review the (rather limited) evidence as a sound
understanding of this will inform clinical practice and is necessary if one is going to
have a full and frank discussion about treatment options with patients. First we dis-
cuss what is known about the mechanism of action of these drugs. We then sum-
marise the evidence supporting their use in the management of ADHD and their
safety and tolerability. Finally we try to bring this evidence together into a discus-
sion about the place of the various non-stimulants in clinical practice both as mono-
therapies and in combination with other drugs.

D. Coghill, M.B., Ch.B., M.D. (*)


Division of Neuroscience, Medical Research Institute, Ninewells Hospital and Medical School,
University of Dundee, Dundee DD19SY, UK
e-mail: d.r.coghill@dundee.ac.uk

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 89
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_6,
© Springer Science+Business Media New York 2013
90 D. Coghill

How Do the Non-stimulants Work? What Is Known About


the Mechanism of Action of the Various Non-stimulant
Medications Used to Treat Adults with ADHD?

As is commonly the case in psychiatry the mechanism of action of the medications


used to treat ADHD are incompletely understood. This is true even for the stimu-
lants—although there are those who like to suggest otherwise. It is, however, still
helpful to review what is known about their mode of action as it can give some
insight into their different therapeutic profiles and adverse effects. It also empha-
sises some of the reasons why certain drugs may be particularly important, or
unsafe, in particular circumstances.

Atomoxetine

Atomoxetine is the only non-stimulant medication that is approved for the treatment of
adults with ADHD. It is also the best characterised with respect to mechanism of action.
Atomoxetine selectively blocks the norepinephrine transporter, whilst having an almost
complete lack of affinity for the dopamine transporter (the site of action of the stimu-
lants). Its mechanism of action in ADHD is thought to be related, at least in part, to its
ability to inhibit reuptake of norepinephrine in the prefrontal cortex and basal ganglia.
Importantly animal studies have also found that whilst atomoxetine also increases lev-
els of dopamine in the prefrontal cortex it does not do so in either the striatum or the
nucleus accumbens. This is important as lack of a dopaminergic effect in the striatum
may be associated with a lower risk of tics and the lack of a dopaminergic effect in the
nucleus accumbens is likely to be associated with a lower potential for abuse.
If this were the full picture atomoxetine would probably be considered to be an
“atypical” stimulant. However, whilst most descriptions of atomoxetine’s mecha-
nism of action end here there is probably more to the story. For several reasons it
seems unlikely that a simple blockade of the norepinephrine transporter can fully
account for the clinical effectiveness of atomoxetine. First whilst the typical half-
life of atomoxetine is around 5 hours, clinical studies in children and adolescents
have demonstrated that the clinical effects last much longer than would be predicted
from such a short half-life [1]. Second whilst some of those who respond to atom-
oxetine show some clinical improvement within the first few weeks of treatment, it
appears that the main clinical effects often take several weeks to appear, develop
over time and are still increasing after 6–9 weeks of treatment [2]. In many ways
this resembles the profile of onset of action typically seen with antidepressants.
Third once the effects of atomoxetine have kicked in they seem to persist longer
than one would expect if these effects were solely due to a blockade of transporters.
This suggests a dual mechanism of action with a second phase that takes several
weeks to fully develop. Whilst the nature of this mechanism is not clear it is likely
that it will involve changes in activity of receptors and/or transporters which in turn
reflect alterations either their density or affinity. This probable dual mechanism of
action has significant clinical implications, which are discussed in a later section.
6 Non-stimulant Drug Treatments for Adults with ADHD 91

Unlike other drugs that block the norepinephrine transporter (e.g. the tricyclic
antidepressant (TCA) imipramine), atomoxetine appears to have little effect on sero-
tonin levels and has a very low affinity for the various neurotransmitter receptors in
the rat or human brain. This in turn suggests that it should be low risk for adverse
effects and/or drug interactions. However, as atomoxetine is metabolised via the cyto-
chrome P450 (CYP) 2D6 pathway, which plays an important role in the metabolism
of many common drugs there is a potential for drug/drug interactions via this mecha-
nism. Indeed several selective CYP2D6 inhibitors such as paroxetine, fluoxetine and
quinidine have been demonstrated to increase the exposure to atomoxetine. The CYP
2D6 pathway is known to be genetically highly variable and two main subpopulations
of metabolisers (extensive metabolisers [EMs] and the poor metabolisers [PMs])
have been identified. Fortunately this does not appear to have a clinically significant
impact on treatment and doses are not generally adjusted for genotype.

Bupropion

Bupropion is a unicyclic aminoketone antidepressant that has been demonstrated to


have some effect in reducing ADHD symptoms. Whilst the mechanism of action
(in both depression and ADHD) is not well understood, bupropion appears to selec-
tively inhibit the reuptake of dopamine, norepinephrine and serotonin. Whilst the
actions on dopaminergic systems are stronger than those of imipramine, the block-
ade of norepinephrine and serotonin reuptake is weaker than the TCAs. Bupropion
also exhibits moderate anticholinergic effects and has been demonstrated to be an
effective aid to smoking cessation, where it is thought that the increase in norepi-
nephrine attenuates nicotine withdrawal symptoms, whilst increases in dopamine
may reduce nicotine cravings and the urge to smoke.

Tricyclic Antidepressants

The TCAs imipramine and desimipramine have both been used to treat ADHD for
many years. Both bear some similarity to atomoxetine in that they are potent inhibi-
tors of norepinephrine reuptake and it is likely that their actions in reducing ADHD
symptoms occur through a similar mechanism to atomoxetine. However, as they also
impact a much broader range of neurotransmitter systems, their actions at these sites
may also contribute. Despite these similarities there are also important differences
between the TCAs and atomoxetine, and they impact significantly on both safety and
tolerability. Both drugs are also potent inhibitors of serotonin reuptake, although
desipramine is less potent in this respect than imipramine. TCAs also down-regulate
cerebral cortical b-adrenergic receptors and, with chronic use, sensitise post-synaptic
serotonergic receptors. In addition they block histamine H1 receptors, a1-adrenergic
receptors and muscarinic receptors, and this accounts for their sedative, hypotensive
and anticholinergic effects (e.g. blurred vision, dry mouth, constipation, urinary
92 D. Coghill

retention), respectively. Cardiovascular side effects include postural hypotension,


tachycardia, hypertension, ECG changes and congestive heart failure and these. Both
imipramine and desipramine are, however, less sedative and anticholinergic than the
tertiary amine TCAs like amitriptyline and clomipramine.

a2-Agonists

The a2-agonists clonidine and guanfacine were used off label to treat ADHD for
many years. Recently the FDA has approved long acting preparations of both drugs
for use in treating ADHD in children and young people aged 6–17 years. Neither
drug is yet approved for use in adults. The classical explanation of the a2-agonists’
mechanism of action in ADHD is that they act presynaptically on autoreceptors of
locus coeruleus neurons to decrease cell firing and subsequent norepinephrine
release. This is hypothesised to result in improved regulation of norepinephrine
systems with decreased arousal and a reduction in hyperactivity and impulsiveness.
More recent explanations suggest a more complex mechanism whereby in addition
to this indirect effect on the prefrontal cortex there are also direct effects. Guanfacine
has been shown to stimulate postsynaptic a2A-receptors in the prefrontal cortex and
to thereby improve attention, concentration and working memory. It is also possible
that this action at the prefrontal cortex may itself, in turn, improve regulation of
subcortical activity, and thus reduce hyperactivity and impulsivity. The two drugs
differ in their actions. Guanfacine is less sedating than clonidine and also have a
lower potency for lowering blood pressure. These differences may be explained by
differing affinities for the a2-receptors. Whilst both bind to a2A-receptors guanfa-
cine does so less strongly than clonidine. Clonidine, but not guanfacine, is also a
potent agonist at imidazoline receptors in the medulla, and also has a high affinity
for a2C-receptors in the locus coeruleus and binds to a2B-receptors in the thalamus
both of which may explain its greater sedative properties. Possibly because of its
increased potency and relatively short half-life, clonidine is associated with with-
drawal irritability that begins as the plasma levels decline, and results in a “rapid-on,
rapid-off” effect. In contrast and presumably because of its slower absorption and
longer half-life, this on/off effect is less prominent with guanfacine. These on/off
effects are somewhat attenuated with the long acting preparations approved for use
in children and adolescents.

Modafinil

Modafinil is considered by some to be a stimulant and by others a non-stimulant and


whilst we include it here this uncertainty should be noted. It is licensed for the treat-
ment of narcolepsy where it is thought to work by activating the neurons responsible
for the production of orexins, sleep-suppressing peptides. The precise mechanism
6 Non-stimulant Drug Treatments for Adults with ADHD 93

of action of modafinil in ADHD is unclear, although several in vitro studies have


shown that it inhibits the reuptake of dopamine by binding to the dopamine trans-
porter. Modafinil also activates glutamatergic circuits, while inhibiting GABA, and
has partial a1B-adrenergic agonist effects by directly stimulating the receptors.
Modafinil is thought to have less abuse potential than traditional stimulants and it
does not seem to be commonly associated with euphoric or pleasurable effects,
although like all CNS stimulants there have been reports of agitation and change in
mood or perception associated with it. The FDA denied approval of modafinil for
ADHD in children. There are reports of its use, similar to stimulants, by students
and academics as a “cognitive enhancer” [3].

How Good Are Non-stimulants at Treating ADHD in Adults?


What Is the Evidence Base for Non-stimulant Medications
in Treating Adults with ADHD?

With some exceptions the evidence base for either efficacy or effectiveness of non-
stimulant medications in adults with ADHD is somewhat sparse. Indeed a literature
search in this area identifies almost as many reviews as there are trials. In addition
to a general lack of evidence a further complication when trying to decide what to
use, and when, is the absence of head to head studies that compare the stimulants
and non-stimulants or the non-stimulants with each other. There have, however,
been several helpful systematic reviews and meta-analyses conducted that at least
allow for indirect comparisons to be made. In this section we first discuss the evi-
dence for each drug individually and then summarise the findings of the most recent
meta-analyses that make indirect comparisons between the different medications.
As there is often little or no data from adult studies we also highlight key findings
from studies in children and adolescents. Whilst care must be taken when extrapo-
lating results from one group to another (despite what it may seem like sometimes,
adults are not simply big kids!) it is better to have some indication of possible
effects than none at all.

Atomoxetine

Atomoxetine is the best studied non-stimulant treatment for ADHD and has been
fairly well studied in adults. In fact when one looks across the various published
studies, almost as many adult subjects have been included in placebo controlled ran-
domised controlled trials (RCTs) of atomoxetine as have been for the all of the long
acting stimulant preparations taken together. Three RCTs that compared atomoxetine
with placebo in adults with ADHD were conducted to support registration. The pre-
liminary crossover study included just 22 subjects and found that the mean ADHD
Rating Scale (ADHD-RS) score at the end of treatment with atomoxetine had
94 D. Coghill

significantly reduced from baseline whilst no significant effect was found for
placebo [4]. Further significantly more of evaluable adults had a significant (³30%)
improvement in symptoms with atomoxetine (11/22, 50%) than placebo (2/22, 9%).
The two pivotal trials both used an identical design. They were 10 week multi-
centre, randomised, double-blind, placebo-controlled, parallel group trials followed
a 4 week blinded discontinuation phase during which there was either abrupt dis-
continuation or a tapering of dose [5]. These studies included data on a total of 257
adults treated with atomoxetine compared to 258 treated with placebo. Atomoxetine
was given twice daily and the starting dose was 60 mg/day in both studies. This was
increased, if necessary, to 90 mg/day after 2 weeks, and 120 mg/day after 4 weeks.
Around 40% in each study received 90 mg/day (»1.3 mg/kg/day) and 35–40%
received 120 mg/day (»1.7 mg/kg/day). In both trials atomoxetine was superior to
placebo in reducing ADHD symptoms with reductions in the investigator rated
symptom measures being around 50% greater for atomoxetine than for placebo. The
effect sizes for the investigator rated measures were 0.35 in study I and 0.40 in study
II. These are considerably lower than the effect sizes seen in similarly designed tri-
als in children (0.63–0.77). As in paediatric trials a significant effect was seen early
in the study (there was a statistically significant separation by week 2). However,
the scores continued to improve throughout the trial and it seems likely that a longer
period of time is required for the maximal benefit to become apparent. Indeed recent
studies in children have suggested that 10 week trials may not be long enough to
capture the full effect [2] and it is possible that for adults this period is even more
prolonged.
As with all trials designed to apply for regulatory approval the entry criteria for
these pivotal trials were strict and restrictive. Patients with comorbid psychiatric
disorders, including depression or anxiety, were excluded as were those with either
current or past electrocardiogram or blood pressure abnormalities. Whilst this limits
generalizability of the results to the broader population seen in day to day clinical
practice it does help ensure that positive results are due to drug effects on ADHD
per se and not as a consequence of improving a comorbid condition. One comorbid-
ity that was allowed was emotional dysregulation, with around 1/3rd of patients
endorsing at least moderate baseline scores for three symptoms (temper, affective
lability and emotional over-reactivity). Interestingly these symptoms also showed a
greater improvement with atomoxetine than placebo (42% vs. 19% improvement,
p = 0.001) [6].
Both of the pivotal trials were followed up with non-comparative extension peri-
ods during which all subjects received atomoxetine (doses ranged between 50 and
160 mg/day). The mean length of follow up was 34 weeks and data were available
for a total of 384 subjects. During this period the efficacy established during the
RCT was continued and the investigator rated ADHD symptom scores actually
decreased further from 34.5 at the end of the RCT to 19.5 at the end of follow up, a
reduction of 43.5%. At the end of the follow up period 2/3rds of the subjects had
maintained a reduction of symptoms ³30%. The reductions in inattentive and hyper-
active/impulsive symptoms were similar. There was a suggestion, from post-hoc
analyses that a dose of >0.9 mg/kg/day are required for optimal response.
6 Non-stimulant Drug Treatments for Adults with ADHD 95

There have been three further double blind placebo controlled RCTs of atomoxetine
in adults. The first of these was a 6-month, RCT with atomoxetine given once daily
and was conducted to assess whether a longer period of treatment would improve
outcomes [7]. Atomoxetine was superior to placebo at all visits apart from week 2.
However, the anticipated increase in effect size was not realised (ES = 0.33). It is
possible that this was related to there being a higher than expected placebo response
or because the once daily dosing was less effective. As is often the case for longer
term trials the drop-out rates for both the atomoxetine (37.6%) and placebo (44.6%)
treated groups were high. A second study by this group investigated the efficacy of
Atomoxetine in adults with ADHD and co-morbid social anxiety disorder. This
large 12 week trial included a total of 442 adults and reported a greater reduction in
both ADHD and social anxiety symptoms with Atomoxetine compared to placebo
[8]. The third study included 147 adults with ADHD and co-morbid alcohol use
disorder in a 12-week RCT. Atomoxetine was again superior to placebo with respect
to ADHD symptom reduction. Interestingly the effect size (0.48) was larger than for
the other studies. Effects on drinking behaviour were inconsistent and inconclusive.
Importantly there was no evidence of a drug x drug interaction between alcohol and
atomoxetine.
All of the above studies were conducted in North America. Sobanski et al. [9]
compared atomoxetine and a waiting list control in a small (n = 64) 12 week RCT in
a German population. Mean change in the observer rated Conners’ Adult ADHD
Rating Scales (CARRS) DSM-IV total ADHD score was again greater in the atom-
oxetine group than the control group and treatment response (defined as ³30%
reduction on the CARRS) was 60.1% in the atomoxetine group compared to 0% in
the waiting list group. Significant improvements were also found for the other
efficacy measures. These included patient rated symptom scores, and ratings of self-
concept and emotional lability as well as a quality of life rating. Adler et al. [10]
reported the findings of a 4 year open label study of Atomoxetine in 384 adults with
ADHD who received treatment for up to 221 weeks. Whilst the major contribution
of this study is in demonstrating safety and tolerability, significant improvements on
the investigator rated Conners’ Adult ADHD Rating Scale, with ADHD symptom
scores falling by around 30% during treatment, and on the Sheehan Disability Scale
which improved by around 25%.
Taken together these studies provide clear support for the use of Atomoxetine in
adults with ADHD; however, they also suggest that the strength of effect in this
group is not as large as that seen in children and adolescents.

Bupropion

The efficacy of both sustained and extended release preparations of bupropion has
been investigated in adults with ADHD. Wilens et al. [11] conducted a RCT with a
total of 40 subjects receiving either bupropion SR (n = 21) or placebo (n = 19) under
double blind, placebo controlled conditions. The dose of bupropion was up to 200 mg
96 D. Coghill

bid. At the end of the 6 week trial bupropion treatment was associated with
a significant change in ADHD symptoms from baseline at the week-6 endpoint (42%
reduction), and this exceeded the effects of placebo (24% reduction). Using a cut-off
of ³30% symptom reduction to define “response”, 76% of those who received
bupropion were rated as improved, compared to 37% of those who received placebo.
Similar results were found using the Clinical Global Impression scale scores as
a measure of response, with 52% of the bupropion group reported as being “much
improved” to “very improved”, compared to only 11% of the placebo group. In con-
trast to these findings Kuperman et al. [12] were not able to demonstrate a significant
difference on clinical ratings between bupropion SR, methylphenidate and placebo
in a small 7 week parallel RCT with 30 subjects. The lack of a positive effect for
methylphenidate in this study leads one to question the validity of the findings. It is
possible that these findings were a consequence of several methodological issues
including: the very small sample size, a higher than expected placebo response rate
(which may itself be related to the subjects having less severe symptoms at baseline
lower rates of psychiatric co-morbidity than most other studies), and the use of rather
low doses of methylphenidate (0.3 mg/kg/dose) as well as doses of bupropion that
were lower than those used in the Wilens et al. study (up to 200 mg bid).
An extended release preparation of bupropion (bupropion XL) that allows for
once daily dosing was evaluated in a much larger 8 week double-blind, placebo-
controlled RCT that included a total of 162 subjects [13]. The dose of bupropion XL
was up to 450 mg/day. The proportion of responders in the bupropion treated group
(53%) was greater than that for the placebo group (31%) with a significant differ-
ence being seen as early as week 2. The effect size for the ADHD symptoms was
0.6. Interestingly the bupropion XL preparation appeared to provide continued
benefit throughout the day and into the evening. The one other RCT to have inves-
tigated the potential use of bupropion in adults with ADHD focused on a substance
misusing population. Levin et al. [14] enrolled 98 methadone-maintained patients
into a three-arm, 12-week trial designed to compare the efficacy of sustained-release
methylphenidate or sustained-release bupropion to placebo all of whom met
DSM-IV criteria for adult ADHD and 53% of whom also met DSM-IV criteria for
cocaine dependence or abuse. Bupropion XL was titrated up to 400 mg/day in a
single dose. Whilst a reduction in ADHD symptoms was observed in all three
groups, there were no significant differences in outcome between the different treat-
ments. The placebo response rate was again high (46%) and this may account for
the failure to find any effects for either methylphenidate or bupropion. These results
are less surprising that those described above for the Kuperman et al. study as sev-
eral other studies in adult substance misusers with ADHD have also failed to find an
effect for methylphenidate in this patient group. It may be that this group of patients
are particularly resistant to drug treatments for ADHD symptoms.
The efficacy of buproprion for ADHD is thus suggested by three positive studies
that used robust dosing. A negative study with robust dosing in a substance abuse
population suggests that it may not be effective in all ADHD populations. As with
other non-stimulant agents, further large, well-designed and conducted studies
would be helpful.
6 Non-stimulant Drug Treatments for Adults with ADHD 97

Tricyclic Antidepressants

Desipramine and imipramine have both been used for treatment of ADHD for many
years. Although the quality of evidence supporting the use of TCAs in the treatment
of ADHD is of relatively poor quality, this is more a reflection of when the studies
were conducted than a comment on their actual effectiveness. Studies in children
and adolescents suggest that the TCAs are more effective in addressing hyperactivity/
impulsivity than they are at improving attention/concentration [15]. There has been
only one RCT of desipramine in adults with ADHD, and none of imipramine.
Wilens et al. [16] conducted a 6-week, placebo-controlled, parallel group RCT of
desipramine vs. placebo in 41 adult patients with ADHD. The target dose of desip-
ramine was 100–200 mg and medication was given once daily. There were highly
significant differences in ADHD symptom reduction between the two groups in
favour of the desipramine treated group. For the desipramine treated group, clini-
cally and statistically significant improvements were found for the dimensions of
hyperactivity, impulsivity, and inattentiveness as well as for most individual symp-
toms (12/14) whilst there were no changes on any of these measures for the placebo
group. Just over 2/3rds (68%) of desipramine-treated subjects were considered pos-
itive responders compared to none in the placebo group. Response was independent
of dose, level of impairment at baseline, gender, or lifetime psychiatric comorbidity
with anxiety or depressive disorders.

a2-Agonists

There is very little formal evidence to support the efficacy of other non-stimulant
medications as treatments for adults with ADHD. The a2-agonists clonidine and
guanfacine were originally developed for the treatment of hypertension but have
been used for the treatment of various developmental disorders, including ADHD
and Tourette’s as well as substance misuse for over 30 years [17]. As noted above
long acting preparations of both drugs are now approved for the treatment of ADHD
in children and adolescents. A meta-analysis of 11 clonidine trials published between
1980 and 1999 in children and adolescents with ADHD (often with other comorbid
disorders) reported a combined effect size 0.58 [18]. More recently two pivotal
RCTs of an extended release clonidine preparation both supported the efficacy of
clonidine in children and adolescents with ADHD. In the first of these studies cloni-
dine was given in fixed doses of either 0.1 mg bid or 0.2 mg bid and compared to
placebo. This study included more pure ADHD cases than were included in the
previous trials. At both doses, improvements in ADHD symptoms were statistically
significantly superior in clonidine treated patients compared with placebo-treated
patients at the end of the 5 week study (unpublished data; Kapvay data information
sheet, Shionogi Pharma Inc.). The second trial investigated impact of adding clonidine
(in doses up to 0.2 mg bid) to a stimulant in patients who had previously demonstrated
98 D. Coghill

an inadequate response to stimulants alone. At the end of the 5 week study ADHD
symptoms were statistically significantly improved in the clonidine plus stimulant
group compared with the stimulant alone group (unpublished data; Kapvay data
information sheet, Shionogi Pharma Inc.).
There is a single small double blind cross-over placebo controlled trial compar-
ing guanfacine with dextroamfetamine and placebo in adults with ADHD [19]. One
significant drawback of this study, apart from the small sample size (n = 17) and
short duration (2 weeks for each arm), was that both of the active medications were
only given once daily despite both being recognised as being relatively short acting.
As a consequence subjects were asked to rate effects during the first 4 h after dos-
ing. The maximum dose of dextroamfetamine was 20 mg and that for guanfacine
2 mg. Both drugs were reported to significantly reduce a greater reduction in ADHD
symptoms than placebo. Interestingly whilst both drugs improved performance on
the Stroop Color subscale only guanfacine improved performance on the Color-
Word measures.
In children and adolescents initial open label trials suggested guanfacine that
may be an effective treatment for ADHD in daily doses from 1.5 to 4.0 mg
divided into three doses. These initial findings were confirmed in several small
scale RCTs in samples of children and adolescents with ADHD that was comor-
bid with either tic disorder or pervasive developmental disorder. More recently
there have been two large but still rather short (5–6 week) pivotal RCTs of an
extended release preparation of guanfacine in children and adolescents with non-
comorbid ADHD. In the first of these, 345 children and adolescents were ran-
domised to either guanfacine at 2, 3 or 4 mg/day or placebo for 5 weeks (with a
subsequent 3-week taper). All patients were started at 1 mg/day with doses
increase by 1 mg/week until the target dose was achieved. At week 5 each guan-
facine, at each of the three doses was superior to placebo on the clinician rated
ADHD-RS [20]. The second study followed a very similar design and reported
very similar results. In both studies there was evidence for dose-responsive
efficacy. Clinically relevant improvements began at the 0.05–0.08 mg/kg/day
dose range with additional benefits evident up to a dose of 0.12 mg/kg/day [21].
A third study evaluated once daily extended release guanfacine in children and
adolescents when given in combination with a psychostimulant in a 9-week,
double-blind, placebo-controlled, dose optimization study. Four hundred and
fifty-five children and adolescents with ADHD aged 6–17 years who had a sub-
optimal response to stimulants were titrated weekly over a 5-week dose-
optimization period to an optimal guanfacine dose (£4 mg/day). This dose was
maintained for a further 3-weeks then tapered over the next week. The guanfa-
cine was taken either in the morning or the evening whilst the current dose of
psychostimulant treatment continued to be given each morning. Mean reductions
in ADHD-RS-IV total scores at endpoint were significantly greater for the
extended release guanfacine/stimulant combination compared to the placebo/
stimulant combination for both morning and evening guanfacine dosing (reported
in, [22]). Unfortunately there are currently no data for extended release guanfa-
cine in adults with ADHD.
6 Non-stimulant Drug Treatments for Adults with ADHD 99

Other Non-stimulants

Modafinil has also been demonstrated to be an effective treatment for children and
adolescents with ADHD. Wigal et al. [23] summarised the results of three ran-
domised, double-blind, placebo-controlled studies (total n = 638) of modafinil in
this group. modafinil doses in these studies were between 170 and 425 mg/day.
Modafinil improved symptoms of ADHD compared to placebo according to teacher,
parent, and clinician ratings. Improvements were seen whether or not there had been
previous exposure to stimulant medication. Two further RCTs in children and ado-
lescents with ADHD also found modafinil to be superior to placebo [24, 25]. There
has been only one published RCT of modafinil in adults with ADHD. Taylor and
Russo [26] compared modafinil with dextroamfetamine and placebo in a short (2
weeks per arm), small (n = 22) randomised, double-blind, placebo-controlled, three-
phase crossover dose optimised trial. The mean dose of modafinil was just over
200 mg/day and for dextroamfetamine just over 20 mg/day both medications were
give bid. ADHD symptoms were improved with both active treatments. Performance
on the Controlled Oral Word Association Test (COWAT, using the letters C, F, and
L version) was also improved for both active medications but performance on Stroop
and Digit Span (Wechsler Adult Intelligence Scale version) tasks was not.
RCTs have been conducted in adults with ADHD for several cholinergic medica-
tions. These include nicotine and two analogue nicotinic agonists; ABT-418, a
transdermal nicotine agonist and pozanicline (ABT-089), an oral partial nicotine
receptor agonist. Both of the nicotine analogues were superior to placebo at reduc-
ing ADHD symptoms [27, 28] as was acute, but not chronic, nicotine [29]. To date,
nicotinic agents are not available on the market. A pilot study of galantamine, a
reversible acetylcholinesterase inhibitor, did not demonstrate superiority over pla-
cebo in reducing ADHD symptoms [30].
A randomised, double-blind, crossover study of methylphenidate and lithium,
with no placebo arm, in 32 adults with ADHD reported similar response rates for
both medications (48% methylphenidate, 37% lithium) and described significant
improvements on other behavioural problems frequently associated with ADHD,
including irritability, aggressive outbursts, antisocial behaviour, anxiety and depres-
sion [31]. Clearly the lack of a placebo arm is a significant drawback and makes
these results difficult to interpret; however, further studies of lithium in adults with
ADHD may be warranted.
Wilens et al. [32] conducted a randomised controlled trial (n = 126) of a novel
mixed monoamine reuptake inhibitor, (NS-2359) with equipotent reuptake block-
ade at the noradrenaline, dopamine and serotonin transporters. At a dose of 0.5 mg/
day there were no differences between NS-2359 and placebo on overall ADHD
symptoms of ADHD, although there was evidence of improvement in the inatten-
tive subgroup. It is possible that different doses would have resulted in different
findings but this has not yet been tested.
Whilst open label trials suggest that venlafaxine may be of benefit in ADHD with
comorbid anxiety and depression this has not been tested in placebo controlled
100 D. Coghill

trials [33]. There is some evidence that reboxetine, a close relative of atomoxetine,
may be beneficial in children and young people with ADHD but there is currently
no evidence in adults. A single case study has suggested that duloxetine, a serotonin
and norepinepherine reuptake inhibitor may also be an option in patients who are
resistant to other treatments [34].
A small (n = 9) open label study of oxcarbazepine, a structural variant of carbam-
azepine, in adults with ADHD reported a significant reduction during the treatment
period with no serious adverse effects [35]. Finally a small open-label study of
propranolol, in doses up to 160 mg 4 times a day, reported significant improve-
ments in both temper outbursts and ADHD symptoms in 11/13 subjects. Adverse
effects were generally mild; however, one subject became seriously depressed on
propanolol.

Comparisons Between Different Medications

Two recent meta-analyses have compared the various pharmacological treatments


for adults with ADHD. Both used different strategies and methods to report their
findings. In the first, Peterson et al. [36] used “relative risk” (RR; actually relative
benefit compared to placebo) to describe the effects of short and long acting stimu-
lants and bupropion. For all three groups response was more likely for the active
treatment than it was for placebo (pooled RR; shorter acting stimulants = 4.32, lon-
ger acting stimulants = 1.35, bupropion = 1.87). Further analysis suggested that the
shorter acting stimulants are more effective than either the longer acting stimulants or
bupropion. Faraone and Glatt [37] used a more traditional approach to compare short
and long acting stimulants and a range of non-stimulants (ABT-418, atomoxetine,
bupropion, modafinil and paroxetine) that were grouped together for the purpose of
the meta-analysis. The pooled effect sizes were; short acting stimulants = 0.96, long
acting stimulants = 0.73, non-stimulants = 0.39. Again further analysis suggested that
the effect sizes for the stimulants were greater than that for the non-stimulants.
Faraone and Glatt (2009) also calculated the number needed to treat (NNT) for each
medication. This is the number of patients that need to be treated for one subject to
be in remission. Although reported differently in the paper NNT are normally
rounded to the nearest whole number. For those drugs included in the Faraone
and Glatt study NNTs for the stimulants were between 2 and 4 and for the non-
stimulants they were; ABT-418 = 4, atomoxetine = 5, bupropion = 5. Thus the
non-stimulants were still rated as slightly inferior to the stimulants with respect
NNT but the different drug classes were closer than would be expected from the
effect sizes. This is a similar finding to that reported for children by Banaschewski
et al. [38]. They proposed that these results may suggest that whilst stimulants
are more powerful than atomoxetine in more severe cases they may be more simi-
lar when treating less severe cases. Taken together this data suggest that whilst the
stimulants do not appear to be quite as effective in adults as they are in children,
they are still more effective in reducing ADHD symptoms than the non-stimulants.
6 Non-stimulant Drug Treatments for Adults with ADHD 101

What Are the Main Safety and Adverse Effect Issues Associated
with These Non-stimulant Medications When They Are Used
to Treat Adults with ADHD?

All of the non-stimulant agents described in this chapter have some interactions
with the metabolism of other agents. If a patient is on another medication, it is best
to use an updated electronic interaction search, to determining if additional caution
is warranted.
Whilst the impact and adverse effect profiles of ADHD medications are some-
what similar across all age groups their impact and potential importance can vary
depending on the age of the patient. For example whilst growth retardation is no
longer a concern for the middle age patient effects on the cardiovascular system are
potentially both more relevant and serious. This section focuses on the safety issues
and adverse effects associated with the main non-stimulant medications used to
treat ADHD in adults.

Atomoxetine

Neither the short term RCTs nor the long term open label studies of atomoxetine in
adults with ADHD identified any serious safety concerns, and adverse effects have
consisted primarily of pharmacologically expected noradrenergic effects. In the two
short term pivotal trials less than 10% of those taking atomoxetine dropped out due
to adverse effects. The most common adverse events in these RCTs were insomnia,
dry mouth, nausea, decreased appetite, erectile dysfunction, urinary hesitation and
constipation. A similar pattern of adverse effects was reported in the 4 year open
label trial conducted by Adler et al. [10]. Both short and long term studies were
associated with minor but significant weight reduction. Child and adolescent psy-
chiatrists often forget to enquire about sexual dysfunction when assessing adverse
effects. These are clearly even more relevant to adult patients and should always be
asked about.
Both short and long term studies also reported small but significant increases in
heart rate and increases in blood pressure were reported at the end of the 4 year
follow-up study. Whilst these appear to be of little consequence to most people,
combined data from controlled and uncontrolled ADHD clinical trials found that
some patients taking atomoxetine (approximately 6–12% of children and adults)
experience clinically relevant increases in heart rate (³20 bpm) and blood pressure
(³15–20 mmHg). Further analysis showed that approximately 15–32% of the
patients that had experienced clinically relevant changes in blood pressure and
heart rate during atomoxetine treatment had sustained or progressive increases
(Strattera Summary of Product Characteristics last updated on the electronic
Medicines Compendium: 08/12/2011, available at http://www.medicines.org.uk).
There is no evidence that atomoxetine increases QTc in individuals with normal
102 D. Coghill

baseline values. There is, however, no clear evidence about the effects of atomox-
etine on QTc in those with either congenital or acquired long QT or a family history
of QT prolongation.
Whilst not identified in clinical trials, a probable increase in seizures has been
seen in post marketing studies. The precise relationship between these and medica-
tion is not, however, clear. There are rare reports of liver injury, manifested by ele-
vated hepatic enzymes and bilirubin with jaundice and very rare reports of severe
liver injury, including acute liver failure. In both cases atomoxetine should be dis-
continued and not restarted. The summary of product characteristics also discusses
suicide-related behaviours (suicide attempts and suicidal ideation) and suggests that
patients who are being treated for ADHD should be carefully monitored for the
appearance or worsening of suicide-related behaviour.

Bupropion

No serious adverse effects were reported in the trials of either bupropion SR or


bupropion ER. Very few individuals dropped out of the trials as a consequence of
adverse effects and similar adverse effect profiles were seen for both preparations.
The most commonly reported adverse effects were headache, gastrointestinal prob-
lems, insomnia, aches and pains, dry mouth and chest pain. In the bupropion SR
studies there were no significant differences between bupropion and placebo in terms
of effects on vital signs whereas in the bupropion ER trial there were small but statis-
tically significant increases were seen in systolic blood pressure and heart rate rela-
tive to placebo. There were, however, not judged to be clinically significant. Those
treated with bupropion ER also experienced an average weight loss of 1.1 kg at the
end of the trial. Buproprion should, however, be used with caution in patients with a
history of seizures or who are at risk for seizures. Commonly, this means it is less
appropriate for patients with purging behaviours, such as those with bulimia nervosa,
binge drinkers, or individuals who are sleep deprived. Individuals with a prior abnor-
mal EEG, personal or family history of seizures, brain damage, cerebrovascular dis-
ease, or on multiple medications may also be at elevated risk of seizure. Seizure risk
may be higher in short acting preparations, and with escalation in dose. It therefore
may be prudent to increase dose slowly, avoid going over 400–450 mg, and educate
patients to watch for and report any neurologic symptoms immediately [39].

Tricyclic Antidepressants

The adverse effects and safety profiles of the TCAs in adults are well recognised and
there is no evidence to suggest that they are any different in ADHD than in other clini-
cal groups. As a consequence of their high affinity for the noradrenergic, cholinergic
and histaminergic receptors they are associated with wide range of adverse effects
including headache, dry mouth, dizziness, blurred vision, constipation, sweating,
6 Non-stimulant Drug Treatments for Adults with ADHD 103

sedation and drowsiness, as well as sleep disturbance, anxiety, weight gain, tremor,
lowering seizure threshold, cognitive impairment as well as changes in heart rate and
blood pressure. There are also significant concerns about the potential for inducing
arrhythmias, particularly through alternation of conduction manifesting in prolonga-
tion of the QT interval [40] and their association with sudden death [41]. A particular
worry with the TCAs is their narrow safety margin. This means that there is a very
real risk of death following overdose. Since the introduction of atomoxetine, which
has a similar pharmacological profile but a much greater safety margin, the TCAs are
only rarely used in the treatment of ADHD.

a2-Agonists

Both clonidine and guanfacine were originally marketed as anti-hypertensives and


clinical trials in children and adolescents reported initial lowering of blood pressure
(both systolic and diastolic) and heart rate with both. This seems to attenuate some-
what with longer term treatment. There is theoretical concern that rapid withdrawal
may lead to rebound hypertension and whilst this has not been documented in stud-
ies caution is advised.
Whilst ECG changes have not been reported particular concerns about the safety
of clonidine arose after case reports of sudden deaths in children treated with this
drug. It should be noted, however, that these tragic events all occurred in children
who were either on multiple medications or who had congenital heart malforma-
tions. A relatively large 16-week multicentre, double-blind trial did not note and
major cardiovascular events or EEG changes in ADHD children treated with cloni-
dine (with or without methylphenidate) vs. placebo or MPH alone. However, brady-
cardia and drowsiness were significantly more common in children treated with
clonidine compared with those not treated with clonidine. The most common
adverse events for both medications are sedation and fatigue, irritability and abdom-
inal pain. Sleep disturbances (e.g. insomnia or mid-sleep awakening), increased
aggression or self-injury, decreased appetite, constipation and perceptual distur-
bance are also relatively common. Whilst there have been case reports of hallucina-
tions and mania in children treated with guanfacine, the role of the medication in
these cases is not completely clear. No studies have specifically and systematically
assessed for psychotic symptoms in individuals with ADHD treated with
guanfacine.

Modafinil

The development of modafinil as a recognised treatment for ADHD was halted


when reports of serious rashes emerged. These usually occurred fairly soon after
initiation of treatment (1–5 weeks) although sometimes after more prolonged
104 D. Coghill

treatment (e.g. 3 months). Whilst these were rare and, within clinical trials, limited
to paediatric patients (incidence » 0.8%: 13 out of 1,585 paediatric patients with 0
out of 4,264 adults) care should still be taken with adults as rare cases of serious or
life-threatening rash, including Stevens-Johnson Syndrome (SJS), Toxic Epidermal
Necrolysis (TEN), and Drug Rash with Eosinophilia and Systemic Symptoms
(DRESS) have been reported in adults and children in worldwide post-marketing
reports, and rates of rash appear to be higher than the background rate expected. The
current clinical guidance is that modafinil should be discontinued at the first sign of
rash and not re-started.
Other relatively common adverse effects with modafinil include the following:
decreased appetite, abdominal pain, nausea, dry mouth, diarrhoea, dyspepsia, con-
stipation, insomnia, headache, blurred vision, tachycardia and palpitations. In clini-
cal experience, modafinil has also been associated with alteration in mood,
perception, and psychotic features. Whilst modafinil has limited potential as a drug
to “get high” with it has developed a reputation as a cognitive enhancer and is fre-
quently used as such by professionals, students and others [42].

When and for Whom Should Non-stimulants Be


Used to Treat Adults with ADHD?

Whilst there is clearly some evidence to support the use of several non-stimulant
medications in the treatment of ADHD in adults, a key question is when and for
whom should they be used. Whilst adult patients with ADHD are more likely to
present to primary care services, it is still recommended, in Europe at least, that drug
treatment is best initiated and optimised by secondary care/specialist services [43].

Choosing the Right First Treatment

It is generally agreed that most of the non-stimulant medications described in the


preceding sections (e.g. bupropion, tricyclic antidepressants, a2-agonists, modafinil)
should not generally be considered as first line treatments for ADHD. For atomox-
etine the situation is not quite so clear cut. Different international guidelines seem
have approached the question about “which treatment should be offered first?” from
very different perspectives. It is therefore maybe not surprising that they have come
to different conclusions. In the UK NICE do not classify specific medications as
first or second line but do very clearly state that: “Following a decision to start drug
treatment in adults with ADHD, methylphenidate should normally be tried first”.
And that: “Atomoxetine or dexamfetamine should be considered in adults unrespon-
sive or intolerant to an adequate trial of methylphenidate” [44]. The CADDRA
guidelines are less prescriptive and encourage the physician to consider a broad
6 Non-stimulant Drug Treatments for Adults with ADHD 105

range of demographic, clinical, attitudinal and economic factors and make more
emphasis of atomoxetine as a potential first line treatment (available at http://www.
caddra.ca).
An evidence based approach would tend to support the NICE approach over that
favoured by CADDRA, and that is the one we have adopted here. The effect sizes
and response rates for the stimulants (both methylphenidate and amfetamine based
products) are considerable higher than those reported for atomoxetine [36], and
therefore, whilst some individuals will certainly respond very well to atomoxetine
the probability that any particular, treatment naïve, individual with ADHD (child or
adult) will have an adequate clinical response is greater with a stimulant than atom-
oxetine (or any of the other non-stimulants). In addition as most of the safety con-
siderations are similar they cannot distinguish between the two classes of drug.
Looked at as a whole this evidence about efficacy, tolerability and safety suggests
that the stimulants should usually be offered as the first pharmacological treatment
in adults (as they are in children).
There are, however, situations when it may be appropriate to consider prescrib-
ing a non-stimulant, often atomoxetine, as a first treatment. The first, although often
left to the end of the list, is where a strong preference for a non-stimulant is voiced
by the patient themselves. Sometimes this preference is understandable based on
personal or family experiences but quite often, it is based on misinformation, often
from the internet or popular press, about stimulants and their potential risks. It is
therefore important that the clinician seeks to explore what lies behind such a request
and it is good clinical practice to fully, and openly, discuss with the patient what is
and is not known about both stimulant and non-stimulant treatments for ADHD,
emphasising the strengths and weaknesses of the different medications. Our clinical
experience suggests that when this is done, and the patient is fully appraised of the
relative potential benefits of each treatment approach, there will often be a change
in choice towards the stimulants. However, there will still be occasions when armed
with this information the patient will continue to voice a preference for a non-
stimulant, and this should of course be included as an important part of the decision-
making process.
A second reason for preferring a non-stimulant is duration of action across the
day. Whereas a child’s day is relatively short and, at least during school terms, rela-
tively uniform, adolescents and adults lead much more varied and unpredictable
lives and are often required to be on top of their game during the evening and into
the night. For adolescents and young adults, however, the day often does not start
until lunchtime. As a consequence, treatment with stimulant medications can be quite
limiting. Similarly if you are being treated with a 12 h preparation and do not get up
1 day until 2 pm, do you take your medication or not? If you do, it may not wear off
until 2 am and still be present in appreciable levels when you take the next day’s dose
on time—if you do not you will not have symptom cover until the next day. Of course
it would be possible to work around this with immediate release medication or an
8-h formulation, but a consistent daily approach that covers the whole day is often
attractive. If a longer duration of action is required, then atomoxetine may be an
appropriate choice. There is good evidence to suggest that despite the somewhat
106 D. Coghill

lower effect size, atomoxetine has a duration of action that extends across the day.
This may be related to the presumed neuroadaptive processes mentioned above.
This has the added benefit that, in contrast to the stimulants, once stabilised on ato-
moxetine, a missed dose does not necessarily mean a complete loss of effect. Both
of these factors can be very attractive to the individual who has a more varied life-
style or who tends to get into trouble late at night after the effects of stimulants have
worn off.
Another feature of atomoxetine often seen as positive by patients is the lack of a
rapid onset and off set of action seen with most stimulants. This is particularly so for
adolescents and young adults who do not like to be reminded that the medication
makes them “different”. With atomoxetine, and indeed bupropion or the extended
release a2-agonist formulations, the recognition that something has changed but that
you maybe did not notice it happening and therefore feel a continuity of self is seen
as very positive by many patients.
Another relatively common situation where atomoxetine is often considered as a
first treatment is the presence of a coexisting substance use disorder or where the risk
of diversion of stimulants is high. There is good pre-clinical and clinical evidence to
support the notion that atomoxetine is associated with a negligible risk of substance
abuse. Whilst this makes it an attractive option in such circumstances, these benefits
need to be weighed against the increased efficacy associated with the stimulants. It is
also important to recognise that the newer extended release stimulant preparations and
the amfetamine pro-drug lisdexamfetamine may be less abusable than the immediate
release preparations—although all stimulants can be abused and miss-used.
Unfortunately empirical evidence is thin and a recent study in adolescents with ADHD
and substance use disorder did not find any benefits of adding atomoxetine to a pack-
age of motivational interviewing and cognitive behavioural therapy with respect to
either ADHD or substance use related outcomes [45]. Whilst this study on its own is
not conclusive it does warn against making too many predictions about the potential
benefits of medications before they have been studied. Interestingly there is also some
evidence to suggest that stimulant medications may be less effective at reducing
ADHD symptoms in substance misuse populations than they are in non-substance
misusers. Whilst several open label and single blind studies (e.g. [46, 47]) studies have
suggested that bupropion may be an effective treatment for ADHD, in the context of a
substance use disorder, randomised controlled trials have been less convincing [14]
The presence of several other psychiatric comorbidities, such as tics, anxiety, and
psychosis, should also make the clinician stop to consider whether a non-stimulant
should be the first treatment offered. It has long been recognised that stimulants can,
on occasion, precipitate the onset of tics or worsen pre-existing tics. Whilst data
suggests that concern about this has been exaggerated, and that most patients with
tics do not experience a worsening when started on stimulants, it is important to
discuss these issues with the patient and to consider whether atomoxetine or an a2-
agonist (clonidine or guanfacine) should be offered. Atomoxetine is certainly effec-
tive in reducing ADHD symptoms in the presence of tics and may indeed reduce the
tics themself. The a2-agonists have been used to treat tics for many years and may
also be considered in such cases.
6 Non-stimulant Drug Treatments for Adults with ADHD 107

With respect to anxiety it was thought for many years that stimulants were less
effective in the presence of anxiety disorder; however, more recent data suggests
that this is not the case. However, whilst they may reduce the ADHD symptoms the
stimulants certainly do not reduce anxiety. On the other hand atomoxetine has been
demonstrated to reduce both ADHD and anxiety symptoms in such cases both in
adults [8] and children.
Even though there is no clear evidence to suggest a significant association
between stimulants and psychosis it is generally recommended that stimulants are
stopped if psychotic symptoms do occur. Alternatives are not entirely straight for-
ward as there is also potential risk with atomoxetine (and possibly modafinil and
bupropion). Since it decreases central norepinephrine activity, clonidine has been
investigated as an antipsychotic in older trials and some reports suggests a small
beneficial effect of clonidine augmentation on psychotic symptoms. It is therefore
possible that, whilst there is no data to support their use, clonidine and guanfacine
would be beneficial in such circumstances.

Cardiovascular Implications in Medication Choice

Due to a lack of specific evidence there are no clear guidelines for treating ADHD
in the context of known, or suspected, cardiac problems. Such situations are going
to be encountered more frequently with adult clinics than is the case in children’s
services. Whilst routine ECGs are not required for all patients starting an ADHD
medication, in cases where pre-existing cardiac problems are suspected it is impor-
tant to seek the opinion of a cardiologist to determine whether any specific consulta-
tion or tests are required before making the final decision about how to manage the
ADHD. In cases where there are known cardiac problems a frank discussion between
the patient, the ADHD specialist and a cardiologist is recommended. When consid-
ering the use of a medication in the presence of concurrent cardiovascular problems
such as congenital heart defects, or genetically mediated risk for sudden death (e.g.
long QT syndrome), unstable hypertension or coronary artery disease, the choice of
drug is not straightforward as many of the ADHD medications have potentially
negative effects on heart rate, blood pressure and cardiac functioning. In this respect
it is important to remember that atomoxetine, and possibly modafinil, have the
potential to have similar effects to the stimulants on vital signs and cardiovascular
status. Particular concerns about the safety of clonidine arose after case reports of
sudden deaths in children treated with this drug. It must be noted, however, that
these tragic events occurred in children who were taking multiple medications and/
or had congenital heart malformations and clinical trials have not suggested any
cardiac safety issues. Notwithstanding this it is still appropriate that caution is
applied if considering the a2-agonists in those with pre-existing cardiac conditions.
As with the stimulant medications it is important to screen patients for cardiac
symptoms such as light-headedness, frequent fainting (especially exercise
induced), or dizziness, and family history of sudden death, particularly at a
108 D. Coghill

young age (< 40 years), as these may indicate risk of cardiac problems which
sympathomimetic effects could exacerbate in the patient. Carefully monitor
heart rate and blood pressure in those treated with non-stimulants. Persistent
tachycardia (heart rate > 120 at rest) or hypertension (diastolic or systolic ³ 95th
centile) whilst not necessarily a contraindication to treatment should not be
ignored. Referral to the appropriate specialist should be considered as it is impor-
tant to exclude arrhythmia for those with tachycardia and treat hypertension in
those with raised blood pressure before continuing with medication.

Switching from Stimulants to Non-stimulants

In routine clinical practice probably the most common scenario for starting a
non-stimulant in an adult with ADHD will be as a consequence of either an inad-
equate response to, or intolerable adverse effects from, a stimulant medication.
Adequate pharmacological management of ADHD requires careful management.
It is essential that medications are titrated properly so that one can be sure that
the patient has received an adequate dose for an adequate period of time before
concluding that they have not responded. This is of course of paramount impor-
tance with the stimulants and indeed clinical experience suggests that one of the
most common reasons for non-response is treatment with an inadequate dose.
Before agreeing to switch medications clinicians should routinely ask them-
selves several questions in order to ensure that they have fully exploited the
potential of the current treatment approach (see Table 6.1). It should also be
borne in mind that experience suggests that of the 30% or so that fail to respond
to one of the stimulants (methylphenidate or amfetamine) around 2/3rds will
respond to the other class of stimulant whilst only 40% will respond to atomox-
etine. Therefore, if an individual fails to respond to a first stimulant and did not
experience significant adverse effects, then the second stimulant class should
probably be tried before considering a non-stimulant. When used this way the
majority of patients will respond to stimulant medications and the most common
reason for switching to a non-stimulant will be adverse effects rather than non-
response (Table 6.1).
Where a stimulant medication has been tried and found unsuitable due to adverse
effects, then it would seem sensible to try a non-stimulant, usually atomoxetine in
the first instance, rather than switching to a second stimulant. In particular atomox-
etine, or an a2-agonist, can be helpful in the presence of sleep or appetite problems
or where a stimulant has resulted in increased irritability, mood lability or low mood.
The incidence of extreme emotional constriction (feeling “zombie like”) with stim-
ulants is rare but also would suggest that maybe a non-stimulant should be consid-
ered. For the reasons outlined above where there has been a significant increase in
blood pressure or heart rate with a stimulant or where a stimulant has resulted in
significant growth retardation an a2-agonist rather than atomoxetine may be pre-
ferred as the next line of treatment.
6 Non-stimulant Drug Treatments for Adults with ADHD 109

Table 6.1 Adequate trials: Questions to ask before stopping one drug and starting another
Have I titrated the current drug properly?
Is the patient at the maximum (tolerated) dose?
Is this drug/preparation working well at any time during the day?
If so can I alter the pattern of drug level over the day by switching to a different preparation of
the same drug?
Is the medication working but effects limited by side effects?
If so, do they occur at particular times, suggesting change in dosing pattern or formulation
might avoid these effects?
Is there a behavioural explanation for the drug “wearing off”
Am I targeting the right symptoms?
Have I missed any comorbidity?
Is the diagnosis right?
Have I got good enough collateral information from others at college/work/home to fully
understand the current situation?
Are different informants in agreement about the effects of the drug?
If not where does the truth lie?
What else is going on in patient’s life/family life?

Initiating, Titrating and Monitoring Treatment for ADHD


with a Non-stimulant

Titration on to atomoxetine is usually relatively straightforward and it is usually


best to follow a protocol similar to that recommended in the Summary of Product
Characteristics (Table 6.2). For those weighing up to 70 kg, the initial total daily
dose should be approximately 0.5 mg/kg which should normally be increased after
7 days to approximately 1.2 mg/kg/day. For those weighing more than 70 kg, the
initial total daily dose should be 40 mg; the dose should be increased after 7 days up
to a maintenance dose of 100 mg/day. The usual maintenance dose is either 80 or
100 mg, which may be taken in once daily or divided doses. Whilst many authorities
recommend a trial of at least 6 weeks on a maintenance dose we recommend a trial
of at least 12 weeks at our clinic. There seem to be a significant minority of indi-
viduals who do respond well to atomoxetine but not until sometime into the third
month of treatment. Whilst this recommendation is based on clinical experience
there is evidence from more recent clinical trials suggesting that the effects of ato-
moxetine continue to increase up till at least 12 weeks and possibly longer [2]. It is
also worth noting that the effect sizes in some of the longer atomoxetine trials have
been larger than those seen in the initial shorter duration studies [48]. If these
findings are replicated they may start to make clinicians think again about whether
atomoxetine should be offered as a first line treatment more often.
Much less is known about the optimal titration and dosing strategies for the other
non-stimulants. In clinical trials bupropion XL has been titrated up to a maximum dose
of 450 mg/day over a 4 week period. Clinical effects were seen from the end of the first
week (at which point all subjects were on 150 mg/day). For extended release guanfa-
cine doses of up to 4 mg have been used in paediatric studies whilst the only adult study
110 D. Coghill

Table 6.2 Possible dosing and titration protocols for the most commonly used non-stimulant
medications for adults with ADHD
Drug Starting dose Titration Maintenance
Atomoxetine £70 kg. 0.5 mg/kg Increased after 7 days to 1.2–1.8 mg/kg/day (up to
for 1 week approximately 1.2 mg/ maximum of 100 mg/
kg/day day) in once daily or
divided doses
³70 kg. 40 mg for Increased after 7 days up to 80 or 100 mg/day in once
1 week 100 mg/day daily or divided doses
Bupropion (XL) 150 mg Increased weekly in 300–450 mg/day
increments of 150– depending on
300 mg, then if tolerated response
for a few weeks,
increase to maximum of
450 mg/day
Guanfacine 1 mg/day Increased weekly by 1 mg/ 1–4 mg/day depending
(extended day up to a maximum of on response
release) 4 mg
Clonidine 0.1 mg/day Increased weekly by 0.1–0.2 mg qd depending
(extended 0.1 mg/day up to a on response
release) maximum of 0.2 mg bd
Modafinil 100 mg/day Increased weekly up to a 200–400 mg qd or in
maximum of 400 mg/ divided doses
day, given qday or in depending on
divided doses (the usual response
daily dose for narco
lepsy is 200 mg/day)

used a maximum dose of 2 mg. Titration for guanfacine typically starts at 1 mg/day
increasing by 1 mg per week. For extended release clonidine the starting dose for chil-
dren is 0.1 mg/day. It is then titrated up to maximum dose of 0.2 mg bd with total daily
dose increased by 0.1 mg/week until desired response is reached. There are no compa-
rable adult data for ADHD treatment but it should be noted that 0.6 mg is the regular
upper limit for hypertension. It is possible that the use of clonidine and guanfacine to
treat ADHD in adults will be limited by the doses required, with the effective doses
required to reduce ADHD symptoms being associated with significant effects on blood
pressure. For both guanfacine and clonidine there is a risk of rebound hypertension if
the medication is stopped abruptly and it is therefore advised that these medications are
gradually tapered off over a period of a few weeks (decrease dose every 3–7 days).
For modafinil the doses in clinical trials have been up to 425 mg/day. The usual
daily dose for narcolepsy is 200 mg/day. Medication is titrated fairly rapidly over a
period of 2–3 weeks.
The tricyclics are now rarely used to treat ADHD due to their potential toxicity
in overdose and cardiac adverse effects. If they are considered, however, then the
typical dosing for imipramine will be an initial dose of 75 mg per day given in 3–4
divided doses increased gradually as required up to 200 mg per day. For desipra-
mine the recommended dose is between 100 and 200 mg/day either taken as a single
dose or split into several doses.
6 Non-stimulant Drug Treatments for Adults with ADHD 111

Monitoring Nonstimulant Treatment

Careful monitoring of longer term treatment effects, both positive and negative, is
as important as the initial titration. The use of structured tools to measure symptom
response and record and adverse effects and co existing problems is strongly recom-
mended. In clinical trials it has become standard practice for the clinician to use one
of the symptom based rating scales as a semi structured interview to assess clinical
response. We have adopted this practice within our own clinical practice and believe
it has allowed us to provide better symptom control and more individualised treat-
ment. It is also important to ask about diurnal changes in effect as these may require
and adjustment of dose or the timing of doses. Compliance should always be
enquired about and there should be regular discussion about ways to improve con-
cordance. A structured approach to eliciting adverse effects is also advisable. In
particular it should be remembered that patients often do not realise that psychiatric
effects can be induced by medication and therefore do not spontaneously report
these. Direct questioning about changes in affect, anger or personality should there-
fore be a routine part of the follow-up interview. Long-term monitoring of blood
pressure, pulse and weight is indicated.

Combining Medications

Whilst the use of the good pharmacological practices described above when initiat-
ing, titrating and monitoring medications treatments for ADHD will result in good
clinical responses in the majority of patients there will always be a minority with
partial or inadequate responses or for whom an adequate response is associated with
intolerable and dose limiting adverse effects. For this group it may be necessary to
consider combination treatments. This is one of the areas of ADHD practice for
which there are considerable differences either side of the Atlantic. Polypharmacy
is common in North America, particularly for paediatric ADHD, but it is still rela-
tively rare in Europe. Whilst it is likely that adult services in Europe are more com-
fortable with combination treatments than child and adolescent practitioners there is
still a strong preference for monotherapies over polypharmacy. There are clinicians
that like combining different stimulant preparations with each other—we, however,
restrict discussion here to combinations that include a non-stimulant. There has
been very little formal research into the efficacy and safety of combination treat-
ments in ADHD and therefore recommendations, even those often described as
“rational” tend to be based on theoretical assumptions and clinical experience rather
than evidence.
The combination that has received most attention until recently is that of a stimu-
lant and atomoxetine although data is only available for children and adolescents.
There are case reports of adolescents who had inadequate responses to either as a
monotherapy but who had a good response when both were given together [49].
112 D. Coghill

There are, however, also reports of increased adverse effects associated with this
combination. Wilens et al. [50] added OROS methylphenidate to atomoxetine in an
open label paediatric study. All children in this study were started on atomoxetine.
For those who only showed a partial response after 4 weeks of atomoxetine, OROS
methylphenidate was added and the combination treatment was given for a further
3 weeks. Whilst the combination was associated with a 40% reduction in symptom
scores it is not possible to say whether this reflected the continued improvement that
is often seen within the first few months of treatment with atomoxetine or was due
to added benefit from methylphenidate. Hammerness et al. [51] reported the toler-
ability data from the same study. The combination therapy was associated with
greater insomnia, irritability and appetite loss and increased diastolic blood pres-
sure. Sixteen per cent of the sample discontinued due to adverse events and most of
these occurred during the first week of combined treatment.
The a2-agonists have also been used in combination with stimulants. In the era
of immediate release stimulants this combination was first used to try and extend the
duration of action. Data is rather limited although there is a suggestion that combi-
nation treatment resulted in similar efficacy but with smaller doses of stimulant than
usual. Since the introduction of long acting stimulant preparations this practice has
now almost disappeared. Combinations of a2-agonists and stimulants are now more
commonly used in an attempt to enhance therapeutic outcomes. The rationale for
combination therapy here is that the primary effects of stimulants and a2-agonists
are mediated by different pharmacological mechanisms. Several studies have sup-
ported the use of a2-agonists to enhance stimulant efficacy; however, to date these
have all been conducted in paediatric samples. Palumbo et al. [52] compared cloni-
dine alone with clonidine plus methylphenidate in a 16 week randomised controlled
paediatric trial. The effect size for the combined treatment was 0.73 compared to
0.41 for methylphenidate alone. Other studies have included paediatric patients
with comorbid ADHD. The Tourette’s Syndrome Study Group used an identical
methodology to that of Palumbo et al. but only included patients with comorbid
ADHD and Tourette’s. They also found that combined treatment (methylphenidate
plus clonidine) was more effective than either active treatment alone for both ADHD
symptoms and tics [53]. There is also some suggestion that combination treatment
with clonidine and methylphenidate may be associated with a reduction in typical
stimulant side effects such as “drowsiness”, “irritability” and “feeling sad/happy”
mood [54]. More recently Kollins et al. [55] assessed the efficacy and safety of
clonidine extended-release combined with either methylphenidate or amphetamine
in a large randomised controlled trial. All subjects had an inadequate response to
stimulants and received either clonidine or placebo in combination with their base-
line stimulant medication. Again there was greater improvement in the combined
group vs. the stimulant alone group. Adverse events and changes in vital signs in the
combined group were generally mild. These findings should be seen against a his-
torical concern about cardiac risks of combining clonidine and stimulants—however,
most authorities now accept that this combination is generally safe [56].
There is also some evidence to support the safety and effectiveness of combining
extended release guanfacine with stimulants in children and adolescents. Spencer
6 Non-stimulant Drug Treatments for Adults with ADHD 113

et al. [57] recently reported the results of an open-label, dose-escalation study of 75


subjects with ADHD treated with suboptimal response to methylphenidate or amfet-
amine. Patients remained on their stimulant medication and were titrated onto
extended release guanfacine starting at 1 mg/day up to a maximum of 4 mg/day.
Participants remained on their highest tolerated dose for 3 weeks and were then
titrated off the drug over 3 weeks. The main goal of this study was to assess the safety
and tolerability of the guanfacine-stimulant combination. Although most subjects
reported at least 1 treatment-emergent adverse event during the study most of these
were mild to moderate in severity. The most common were upper abdominal pain
(25.3% of patients), fatigue (24%), irritability (22.7%), headache (20%), and somno-
lence (18.7%). Decreased blood pressure, heart rate, and ECG changes were also
reported in a small number of children. No syncopal events or light-headedness were
reported. The addition of extended-release guanfacine to stable stimulant doses in this
study also resulted in a significant reduction in ADHD symptom scores. These results
suggest that combining methylphenidate or amphetamine with guanfacine extended
release may be a useful and safe approach to managing paediatric ADHD in cases
where optimal response is not achieved with stimulants alone. As with atomoxetine
and clonidine, data is still required to know if the same can be said for adult patients.
Another reason to combine medications is to manage associated or comorbid dis-
orders. For ADHD, sleep difficulties represent a classic associated disorder. Clonidine
is often given in combination with methylphenidate in such circumstances. As noted
above the clonidine/methylphenidate combination is also popular for those with both
ADHD and a tic disorder. A combination of stimulant and atypical antipsychotic is
also often used in such situations. Where ADHD is comorbid with depression, a
combination of a stimulant and an antidepressant has been demonstrated to be effec-
tive. There is limited data supporting the combination of stimulants with fluoxetine,
sertraline and moclobemide (a reversible MAOI) in comorbid depression.

Future Directions

Clearly there is a need for considerable further study into the effects of non-stimulant
treatments for adults with ADHD. These include very basic studies to confirm effec-
tiveness and safety, the establishment of clear dosing guidelines, and the safety of
combining treatments. There are also several potential new non-stimulant drugs for
ADHD that have been through early phase development and which may or may not
be taken forward into the more general clinical arena. The ampakines are a new
class of modified benzamide compounds known to enhance attention span, alertness
and memory. They interact with the AMPA receptor and their action is theorised to
be due to facilitation of transmission at cortical synapses that use glutamate as a
neurotransmitter. This in turn may promote plasticity at the synapse, which could
translate into better cognitive performance. Animal studies suggest that their actions
may continue after they have left the system and unlike stimulants they do not seem
to have unpleasant, long-lasting side effects such as sleeplessness. They are being
114 D. Coghill

investigated across a range of conditions including Alzheimer’s, Parkinson’s,


schizophrenia and ADHD.
Histamine receptor antagonists, specifically H3 agonists, show a broad efficacy in
rodent models across several cognitive domains including improvements in atten-
tion and reduced impulsivity. Differences on H3 receptor expression levels in the
medial temporal cortex have been observed between brains of healthy persons and
patients suffering from Alzheimer’s Dementia, and this is consistent with the involve-
ment of H3 receptors in cognition deficits. Several companies are currently trialling
H3 antagonists for a variety of disorders with a particular focus on Alzheimer’s
Dementia and at least two molecules have reached phase II trial status for ADHD.
Serotonin has long been known to have a role in impulsivity but the precise
mechanisms are complex and not entirely clear. 5HT1A and 5HT1B receptors are
located both pre- and post-synaptically with opposite directions of effect. Agonists
binding to presynaptic 5HT 1A and 1B receptors limit serotonin functioning whilst
agonists binding to postsynaptic 5HT1A and 1B receptors mimic serotonin. Impulsivity
is complex with at least two aspects: reduced response inhibition (cannot wait);
increased delay aversion (will not wait). Serotonin manipulation can impact differ-
entially on these aspects. For example serotonin depletion leads to decreased response
inhibition without impacting on delay aversion. Eltoprazine is a serotonin 1A/1B
receptor agonist that has been shown to have anti-aggressive effects in animal stud-
ies. It has also been demonstrated to impair response inhibition but improve delay
aversion in rats. Unlike dexamfetamine these effects did not seem to breakdown at
high doses and at behaviourally effective doses there were no obvious effects on
striatal dopamine. A phase IIa trial has been completed and results reported in adults
with ADHD. The ADHD RS total score was reduced 42% compared to placebo and
the most common adverse effects were GI related (nausea, constipation, diarrhoea,
abdominal pain).
It is likely that other molecules are currently being trialed; however, given the
long lead time taken to get a new drug to market these are not likely to be clinically
relevant for many years. In the meantime as clinicians we need to continue to gather
evidence on current treatments and concentrate on providing high quality well
organised clinical care to ensure that we get the best out of the treatments currently
available to us and that our patients receive individually tailored treatments that, as
far as possible, optimise their outcomes.

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Chapter 7
Psychosocial Treatment for Adult ADHD

Laura E. Knouse and Steven A. Safren

Abstract Many adults with ADHD are likely to benefit from psychosocial
interventions that teach compensatory skills to manage symptoms and address func-
tional impairment. Based on the research literature and the authors’ experience
developing and implementing interventions, this chapter provides a practice-friendly
overview of skills-based treatment selection and implementation, emphasizing cog-
nitive-behavioral techniques. Principles are illustrated using case examples and
adjunctive treatment options are discussed.

Psychosocial Treatment for Adult ADHD

Although psychostimulants and other medications are often considered first-line


treatments for adult ADHD, psychosocial interventions are indicated for many
patients. Fortunately, skills-based cognitive-behavioral treatment for adult ADHD
is receiving increasing empirical support [1]. Psychosocial interventions, including
cognitive-behavioral treatment, may be appropriate for several subgroups of patients
who, taken together, likely constitute a large number of adults with the disorder.
Many adults with ADHD cannot take medications or are unwilling to engage in this
form of treatment. Others may not respond to medications. Other adults may show
a partial response to medication but, despite successful symptom reduction, they
may still display impairing symptoms that interfere with daily functioning. In many

L.E. Knouse, Ph.D. (*)


Department of Psychology, University of Richmond,
28 Westhampton Way, Richmond, VA 23173, USA
e-mail: lknouse@richmond.edu; leknouse@gmail.com
S.A. Safren, Ph.D.
Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School,
Boston, MA, USA

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 119
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_7,
© Springer Science+Business Media New York 2013
120 L.E. Knouse and S.A. Safren

clinical trials of ADHD medications, a 30% reduction in symptoms can qualify


a patient as a treatment responder [2]. For patients with high baseline levels of
symptoms, this leaves substantial room for further improvement.
Psychosocial treatment may also be indicated when the clinician identifies
deficits in compensatory skills or systems for managing time, tasks, and money as
a key contributor to the patient’s chronic impairment. ADHD often confers a dou-
ble-bind in which the very skills, strategies, and systems that might help patients
manage their symptoms are much harder to use because of those same symptoms.
Thus, adults with ADHD, throughout their life, may be less likely to develop and
maintain such systems on their own [3]. Finally, psychosocial intervention may be
indicated when a patient displays psychiatric comorbidity or impairment in specific
functional domains that is not fully addressed by pharmacological treatment. For
example, many patients with ADHD also meet criteria for depression or anxiety
disorders [4, 5], which may necessitate multimodal treatment. Because ADHD often
affects functioning in a variety of domains, additional non-pharmacological ser-
vices may be indicated including parent training, couples counseling, or vocational
rehabilitation. Given the chronic and impairing nature of ADHD, it would seem to
be the rare patient that would not benefit from some type of non-medication adjunc-
tive treatment. On the other hand, ADHD-focused psychosocial treatment would
not be appropriate for patients with serious symptoms that require clinical attention
such as suicidality or substance dependence. In addition, many clinicians question
whether concurrent medication treatment of ADHD symptoms is necessary for
patients to be able to access psychosocial interventions. While a recent randomized
controlled trial did not find that medication status moderated response to skills-
based treatment [6], further investigation of this question is necessary and multi-
modal treatment should always be strongly considered.
Among psychosocial interventions for adult ADHD, skills-based cognitive-
behavioral treatments (CBT) have recently received empirical support in larger
clinical trials. Solanto and colleagues [6] conducted a trial of 88 participants com-
paring a group-based CBT for ADHD, called “metacognitive therapy” to a support-
ive educational group, finding that metacognitive therapy resulted in a significantly
greater reduction in symptoms. After an initial successful small RCT [7] our group
at Massachusetts General Hospital [8] recently found, in a full-scale efficacy trial,
that individual CBT for adults with ADHD receiving medication treatment but
showing residual symptoms resulted in greater symptom reduction than an active
control condition, relaxation with educational support. These randomized controlled
trials constitute the most rigorous research evidence supporting psychosocial treat-
ment for adults with ADHD. Given research evidence supporting skills-based inter-
ventions and clinical experience with our approach, the following discussion of
general principles for psychosocial treatment for adults with ADHD will be heavily
based upon such structured approaches. Later in the chapter, however, we discuss
other types of psychosocial intervention. Readers interested in more detailed infor-
mation about the MGH treatment protocol are referred the published treatment
manuals [9, 10] and a recent practice-oriented article that includes online role play
videos of treatment techniques [11].
7 Psychosocial Treatment for Adult ADHD 121

Before discussing treatment planning and general principles for success in


skills-based treatment, we present the following case description based on patients
who participated in CBT in our clinic. This case study illustrates characteristics
commonly observed in adults with ADHD Combined Type who seek out this treat-
ment. Note connections between the patient’s core symptoms and functional impair-
ment and also note issues relevant to differential diagnosis. Later in the chapter, we
use a summary of this patient’s treatment to illustrate general treatment principles.

Clinical Case Study: Rob


Rob is a 51-year-old married man with two adult sons who presented to the
CBT program seeking skills and strategies to cope with chronic and impairing
procrastination, distractibility, and disorganization. He also exhibited promi-
nent hyperactivity and impulsivity including excessive talking, motor hyper-
activity, and a history of involvement in various business ventures, in which
he was often initially quite successful but eventually lost significant amounts
of money. Rob had started but never completed college. Garrulous, person-
able, and upbeat, Rob’s social skills appeared to serve as a coping mechanism.
Problematic, however, was his tendency to impulsively take on large projects
to help other people. Helping others often consumed so much of his time that
he did not attend to his own significant financial and relationship problems.
Rob had received a diagnosis of ADHD several years previously when one of
his sons was assessed and diagnosed with the disorder. He had taken a variety of
stimulant medications in the past and was taking a sustained release stimulant at
the time of intake. While he reported that medication definitely helped, he con-
tinued to experience significant and impairing symptoms well above the clinical
cutoff (above the 98th percentile on a self-report rating scale [12]). Further
assessment revealed that Rob lacked any systematic methods to manage time,
tasks, and money. Rob did not meet diagnostic criteria for any other disorder,
although he reported periods of depressed mood lasting up to a week triggered
when major problems “entered crisis mode.” Because of his impulsivity and
distractibility, bipolar disorder was initially a rule-out diagnosis for Rob.
However, he reported that he had “always been like this” and experienced these
symptoms in a consistent (not episodic) manner since childhood. Therefore,
ADHD was judged to be the most parsimonious explanation for his difficulties.

Skills-Based Treatment Planning: Choosing Targets


and Strategies

The first key step of treatment planning is a thorough diagnostic assessment fol-
lowed by a detailed functional analysis of the patient’s main problems in daily life.
Diagnostic assessment of ADHD in adults is often challenging, given the need for
122 L.E. Knouse and S.A. Safren

retrospective and collateral reporting and the complexities of differential diagnosis


and comorbidity [13]. Assessment is thoroughly addressed in chapter 2 in this book.
Here we wish to highlight specific elements of assessment that can be used to guide
psychosocial treatment planning.
First, the clinician must assess the patient’s goals for treatment. Selection of
treatment targets must be made collaboratively and must be tied to goals that
are meaningful and motivating to the patient. Patients are unlikely to be highly
motivated by, for example, the intrinsic pleasure of having a neat and orderly task
list. Salient goals help to motivate patients to use skills that, at first, feel clunky, bor-
ing, repetitive, and time-consuming. For example, if a patient reports chronic late-
ness, the clinician might be tempted to “jump in” with strategies to help the patient
to be more punctual. But if the patient’s primary goal is, instead, to improve his
relationship with his girlfriend, then the clinician’s emphasis may seem unimportant
and disconnected from the patient’s goals—a recipe for treatment drop-out. Any
intervention suggested by the clinician must be framed in terms of how it will con-
tribute to the patient’s meaningful goals. In the above example, the clinician might
write down the patient’s goal of improving his relationship with his girlfriend and
then engage the patient in a discussion of how his ADHD-related problems get in
the way. If chronic lateness is annoying to the patient’s girlfriend, learning behav-
ioral strategies to be on-time can be framed as a means to improving the relationship
rather than an end for its own sake. The clinician must avoid sounding like one more
moralizing voice telling the patient what he “should” do and instead offer interven-
tions consistent with the patient’s goals and values.
After establishing meaningful goals, the clinician can engage the patient in a col-
laborative functional analysis, identifying what behaviors get in the way of these
goals. This constitutes a list of treatment targets for skills-based intervention. In the
above example, chronic lateness was identified as interfering with the patient’s rela-
tionship. But not all lateness is created equal. The clinician must ask a series of
detailed questions and consider multiple hypotheses about what might be contribut-
ing to this patient’s difficulties before choosing a skill or strategy. Important ques-
tions include when and where the problematic behavior occurs (All situations or just
some situations? What differentiates problematic situations? Time of day?
Aversiveness of the task at hand? Presence of others?), what precedes the problem
behavior (Getting wrapped up in an interesting task?), what thoughts occur before
and during the behavior (“I can do this one more thing before I leave”), and what are
the consequences of the behavior, short- and long-term (What are the upsides of
leaving later than you should? What are the long-term downsides?). This process is
not limited to the treatment planning phase, but occurs continually throughout
skills-based treatment. The most successful patients learn to independently engage
in this type of functional analysis when trying to apply skills to their ADHD
symptoms.
Table 7.1 illustrates key problems for adults with ADHD that may emerge from
a functional analysis and behavioral strategies that could be useful. Note that with-
out a careful analysis of the problem, it is difficult to choose an appropriate strategy.
For example, a patient may report that he “forgets to take medication” about 50% of
7 Psychosocial Treatment for Adult ADHD 123

Table 7.1 Common categories of difficulties for adults with ADHD, behavioral strategies,
and examples
Problem Strategy to consider Example
Forgetfulnessa Calendar for all appointments Write down all appointments in
one calendar—do so until it
feels strange not to
Automate regularly occurring tasks Set up automatic draft for bills
Distractibilitya Eliminate key distractors Turn off notification sounds when
a new email arrives
Schedule activities strategically Schedule the most attention-
demanding tasks for the
morning
Avoidance Use desired activities as incentives Do 15 min of work on an avoided
project followed by 5 min on
a more interesting one
Increase awareness of problematic Post problematic thoughts linked
avoidance-related thoughts to avoidance—“I’ll just check
my e-mail really quick before
I start working,”—near
computer
Increase accountability Meet weekly with a group to
share goals and report back on
progress made (or not made!)
Build behavioral momentum Set goal to complete just the first
step of an avoided task
Difficulty using a skill Place visual cue in the physical Post-It reading, “CHECK
when and where it location where the skill is needed CALENDAR” in the middle
is needed of computer screen to cue this
skill before checking e-mail
Make sure the tools needed are Keeping calendar in a cell phone
easily accessible instead of on loose paper
Set up cues and warnings at critical Set cell phone to sound a “10-min
points in time warning” prior to work
departure time
a
Be sure to gather enough information to differentiate forgetting and distractibility from avoidance,
recognizing that both (or all three) may need to be addressed

the time. However, the proposed interventions strategy might be different if the
patient does not think of taking his medication at all on some mornings (forgetting)
than if he always thinks of it but continues to watch TV thinking, “I’ll grab it just
before I head out the door,” (avoidance).
Individual treatment usually proceeds best when clinician and patient focus on
just a few treatment targets and skills at a time. Helping a patient acquire a few
consistently well-executed skills is often much more effective than a “spaghetti at
the wall” approach in which the clinician makes a variety of recommendations for a
long list of problems in order to “see what sticks.” Due to problems with distractibil-
ity, too many suggestions can be particularly problematic for adults with ADHD.
Note that manuals used in treatment outcome studies and published for clinician use
must necessarily cover all possible skills found to be helpful for adults with ADHD
124 L.E. Knouse and S.A. Safren

as a group. However, in clinical practice, selecting only those skills judged to be


relevant to the patient’s functional difficulties and meaningful goals is a reasonable
method.
This section highlighted the following recommendations for selecting skills-
based treatment targets and strategies for adults with ADHD.
• Assess the patient’s goals for treatment and connect proximal treatment targets
and to-be-learned skills to these goals.
• Conduct a functional analysis of the patient’s presenting problems, employing
detailed questions to assess contexts, triggers, and consequences. Choose skills
and strategies that address these factors.
• Focus on consistent use of a few skills at a time.

Executing a Skills-Based Treatment Plan: Principles for Success

Effective psychoeducation is critical to the success of an intervention that will


require patients to commit to behavior change. The patient must have a clear view
of the role of cognitive and behavioral skills in coping with symptoms of ADHD. In
the same way that stimulant medications do not “cure” ADHD but instead amelio-
rate symptoms while they are used, skills are best viewed as compensatory in nature.
Skill use is not designed to correct the underlying neuropsychological deficits asso-
ciated with ADHD (e.g., executive functioning deficits in daily life) but instead
provides a way for patients to compensate for and cope with these deficits. In the
first session with patients, we review a cognitive-behavioral model that describes
how these primary deficits interfere with the development of compensatory skills
and also how failure experiences may contribute to patterns of thinking that contrib-
ute to further avoidance of skill use [9]. Psychoeducation proceeds best as an inter-
active dialogue with the patient rather than a lecture. As such, we ask patients to
give examples from their own lives, evaluating the extent to which this model of
how ADHD affects other areas of functioning fits with their experiences. Often, this
connection between what we know about ADHD’s pervasive effects and the patient’s
own experience is quite meaningful. Many patients become emotional during this
discussion because it validates their personal experience. To conclude this discus-
sion, the clinician can then map any to-be-used compensatory skills directly onto
this model of the patient’s presenting problems.
When a new skill is introduced during treatment, the “how” of skills practice is
one of the most critical predictors of success in skills-based intervention [14]. Patients
must practice compensatory skills in the “real world” long enough until, (1) they can
determine whether the skill is helpful and (2) the skill becomes less effortful. Many
patients report that they have previously tried many organizational strategies, planner
formats, and scheduling systems. Frequently, however, patients start using a new
system with enthusiasm only to stop after a few days when the novelty has worn off,
they discover that the skill is too onerous to maintain, and they have not yet experi-
enced the longer-term benefits of the skill. The patient must be encouraged to try the
7 Psychosocial Treatment for Adult ADHD 125

new skill consistently for a long enough period of time so that use becomes less
effortful and they have direct experience with longer-term benefits. For example,
writing down and tracking all to-be-done items on a task list can be initially tedious
and anxiety-provoking. The clinician should discuss this with the patient up front,
emphasizing that while it may seem like a time-consuming process in the short term,
it is likely to make the patient more efficient and less anxious in the long term.
Practicing skills from week to week also gives patient and clinician the opportunity
to refine and troubleshoot strategies over time so that the best system for that specific
patient can be developed. For this reason, “keeping it simple” at the outset is espe-
cially important as a complicated system is rarely sustainable. The patient must be
encouraged to start with a “good enough” system rather than a seemingly perfect but
unsustainable one.
Structured sessions are critical to helping patients target their efforts toward the
most important problems. Even if clinician and patient have agreed upon treatment
targets and skills, it can be hard to stay focused on these specific goals as the patient’s
life continues to unfold outside of the session. The clinician must balance focus on
agreed-upon targets with emotional responsiveness to the patient’s ongoing con-
cerns. We have found that it is helpful to be clear with patients about the focused
nature of treatment sessions, openly discussing how to get “back on track” when
sessions veer off topic. Adults with ADHD in particular are often tangential in ses-
sion. Sometimes this can be difficult for clinicians because in many cases, the “tan-
gents” are appealing, interesting, and even funny stories told by patients that can
engage the clinician away from more troubling, clinically important work that the
patient needs to confront. Most patients, however, are generally aware of this and
seem to appreciate an open discussion about how to keep the session on track.
Importantly, the patient should be encouraged to monitor the clinician in this regard
as well! A session format that is standard for cognitive-behavioral treatment is rec-
ommended: (1) set an agenda, (2) review skills practice from the previous week and
troubleshoot, (3) introduce new psychoeducation or skills training, and (4) assign
skills practice for the following week. In this way, emergent topics from the week
can be appropriately triaged during the agenda-setting process.
Although a structured session and specific treatment targets might make skills-
based treatment seem clinically rigid to the unfamiliar reader, the quality of the
therapeutic relationship is essential and there is ample room for creativity. Active
listening, validation, warmth, humor, and emotional responsiveness are all critical
clinician skills in this form of treatment. We are asking our patients to do something
that very, very difficult. If a patient does not trust his or her clinician and feel that
they are collaborating in the patient’s best interest, he or she is unlikely to persist in
therapy. A skilled clinician works collaboratively with the patient and takes a non-
judgmental, problem-solving orientation. We are clear with our patients that,
whether they have completed skills practice successfully or not, they should come
back to session and discuss their difficulties rather than avoiding treatment. We can-
not force them to change but will steadfastly support them in trying again.
Continued formal and informal assessment of patient progress serves many impor-
tant functions in skills-based treatment [15, 16]. In our practice, we have patients
126 L.E. Knouse and S.A. Safren

Fig. 7.1 Case example total


scores on the Barkley Current
Symptoms Scale [12]
(self-report) by week during
cognitive-behavioral treatment.
Dotted horizontal line
represents the clinical cutoff on
the scale for the patient’s age
and gender

complete weekly self-report symptom checklists such as the Current Symptoms Scale
[12] or the Adult ADHD Symptom Report Scale [17]. These ratings provide objec-
tive data to evaluate whether treatment is working and which skills may be contribut-
ing to success. The process also trains the patient to engage in periodic self-evaluation,
a critical step in engaging in active problem-solving instead of avoidant coping. From
week to week, these ratings provide an ongoing record of treatment progress that can
be used as feedback to the patient to reinforce skills maintenance efforts. For exam-
ple, the clinician can plot a patient’s weekly symptoms across sessions on a graph to
illustrate how consistent skill use has paid off over time (see section “Treatment
Summary” and Fig. 7.1).
Clinicians treating adults with ADHD in any modality should attend to medica-
tion adherence. For some patients, this will need to be a formal treatment target.
Pharmacy and medical claims data suggest that many patients with adult ADHD
discontinue medication after only a few months [18] and one study of adults with
ADHD found that self-reported medication adherence during a 2-week period aver-
aged only 86%, with ADHD symptom severity correlating negatively with adher-
ence [19]. Thus, adults with more severe ADHD take medications less consistently
and better adherence may be associated with improved symptom control and pos-
sibly fewer side effects. A detailed functional analysis of adherence problems is
essential to choosing the right strategy. Does the patient need an auditory or visual
reminder to cue medication-taking? Does she need to put the pill bottle in a more
obvious, accessible location? Does he have negative thoughts when he thinks about
taking his pills that trigger avoidance? Is the patient experiencing aversive side
effects that she is reluctant to discuss with her prescribing physician? A seemingly
straightforward behavioral issue like medication adherence can have very complex
causes and a thorough understanding of those causes is essential to selecting the
right intervention.
Even if a patient knows where, when, and how to use a skill, thoughts and beliefs
often play a critical role in whether that skill is actually used. If a patient makes
7 Psychosocial Treatment for Adult ADHD 127

overly negative interpretations or predictions about situations that have been


problematic in the past, this may reduce his motivation to persist in active problem-
solving or skill use. For example, if a patient in the early stages of learning to
consistently use a planner forgets to write down an appointment and misses the
appointment, she might think, “Great—here’s another example of something I failed
at,” and may give up on using the planner all together. Another commonly observed
example has to do with some patients’ aversion to arriving even a few minutes early
for appointments, often tagged to the automatic thought, “Sitting in the waiting
room is a waste of time.” The consequence is that the patient tries to do too many
other things before appointments and habitually arrives late. Interventions for this
patient might include weighing the pros and cons of arriving early and “wasting” a
few minutes versus persistent lateness. By engaging in problem-solving with the
therapist, the patient might develop a helpful behavioral strategy such as always
bringing some work to do so that the time waiting can be productive.
Impulsive and overly positive assumptions may also be problematic [20]. For
example, another patient learning to use a planner might, upon receiving a new
appointment, have the thought, “Oh, I don’t need to write this one down because it’s
important to me—I’ll definitely remember it.” This overly optimistic assumption
would also get in the way of consistent skill use. Clinicians should probe for and
attend to these patterns of thinking. The major CBT approaches for adult ADHD
include application of formal cognitive restructuring—strategies designed to
increase the patient’s awareness of problematic thinking patterns and to help patients
coach themselves more effectively [9, 21, 22]. Key cognitive errors, such as all-or-
nothing thinking, jumping to conclusions, and overgeneralization, can be identified
in the thinking patterns of adults with ADHD in either the positive or negative direc-
tion. For readers interested in the application of cognitive techniques, Ramsay and
Rostain [21] provide an excellent, comprehensive discussion and description of the
role of cognitive therapy strategies in treatment of adults with ADHD.
In addition to looking for internal cues that influence behavior, effective inter-
ventions guide patients in structuring their environments in a way that will support
skill use. Clinicians and theorists have noted that because ADHD appears to be a
disorder of performance rather than knowledge, interventions should be placed as
close as possible in space and time to the point at which the target behavior needs to
occur (i.e., the “point of performance” [23, 24]). Put another way, interventions
should reduce the patient’s working memory load as much as possible. A prime
example of a “point of performance” strategy is helping the patient to set up and use
visual and auditory reminders. For example, if a patient loses track of time when
getting ready in the morning, he might set a daily recurring reminder alarm on his
cell phone to go off 15 min prior to the target departure time. An example of putting
an intervention at the physical point of performance would be having a patient with
poor morning medication adherence Velcro her medication bottle to the handle of
the refrigerator, which she automatically opens every morning to get a glass of
juice.
When teaching skills in session, the more concrete the better. Many clients will
enthusiastically discuss several possible strategies in the abstract during session
128 L.E. Knouse and S.A. Safren

with every intention of executing those strategies over the following week.
Unfortunately, patients with ADHD often have extreme difficulty translating their
intention into action—the clinician must not collude with the patient in hypothetical
discussions. Clinicians should constantly ask questions focused on the specifics of
any skill to be practiced outside of session, and the degree to which achievement of
the skill in question is realistic. When will the patient need to use the skill? How will
he know it is needed and remember to use it? Where will she keep the tools needed
(e.g., task list)? What thoughts will arise when he is faced with choosing to use the
skill? What will get in the way of using the skill? How will she know if she used it
successfully? Actually practicing the skill in the session is one of the most effective
ways to increase the likelihood that it will occur in the “real world.” We often work
with patients on their task lists in session as well as having them practice distracti-
bility reduction techniques with us while trying to do boring tasks.
Involvement of significant others and family members in treatment can be incred-
ibly powerful, near disastrous, or somewhere in between—thus, it must be undertaken
with care, guided by a reasonable assessment of the risks and benefits in the context of
the individual patient’s relationship. The primary goal of family involvement in indi-
vidual treatment is to recruit the family member to support the patient’s change efforts.
We have found, however, that in many instances, spouses have been experiencing
long-term frustration with their partner with ADHD and this can make a difference in
the type of support the partner is able to provide. Individual therapy for ADHD is
likely not the place to try to fix a contentious relationship and, in our experience, sin-
gle sessions involving family members with heated relationships are at best unhelpful
and at worst a negative experience for all involved. (Patients with more severe rela-
tionship problems should be referred for couples work as addressed later). If the
patient reports, however, that her family member is generally supportive and inter-
ested in her work in therapy, the clinician can suggest that this family member attend
a session with the patient. The clinician can provide the family member with psycho-
education and help to initiate an ongoing dialogue about how he or she can be sup-
portive of treatment. We generally present psychoeducation about ADHD and the
CBT model and then describe the specific skills that are contained within the treatment
plan. The session might also include an open discussion about how the patient feels
the family member can be helpful—for example, providing gentle reminders about
skill use and working with the patient to set up organizational systems that will be
used by everyone in the household. Above all, the clinician should keep the focus on
the patient’s need for support rather than the family member’s complaints or
grievances.
This section outlined the following recommendations for executing skills-based
treatment for adults with ADHD.
• Provide psychoeducation about ADHD and the treatment model, connecting it
directly to the patient’s experience.
• Help patients consistently practice a few simple skills and “good enough” sys-
tems until they can see the benefits.
7 Psychosocial Treatment for Adult ADHD 129

• Use session structure to maintain focus on the most important problems and
strategies.
• Maintain a nonjudgmental working relationship and a problem-solving
orientation.
• Assess progress formally and informally throughout treatment.
• Assess and address medication adherence.
• Pay attention to and restructure thoughts and beliefs that hinder use of skills.
• Help patients put cues and interventions as close as possible in time and space to
when and where the target behavior will be performed.
• Help patients plan skill use as specifically and concretely as possible. Practice in
session as appropriate.
• Consider a session involving a family member to increase support for the patient,
but do so with care.

Treatment Summary
Rob’s treatment followed the “Mastering Your Adult ADHD” CBT manual
[9]. Rob was quite enthusiastic about learning new skills but admitted that
“sticking with it” had historically been difficult. In the early stages of treat-
ment, he identified filing his taxes on time (something he had not done for
several years) as a proximal goal to work toward using skills from session. In
terms of organization and planning skills, Rob benefitted most from keeping
a daily task list with priorities and due dates noted. He put a great deal of
effort into keeping all notes in one place on a simple legal pad, using the list
daily, and making a list for the next day. He noted that the list was a way to
“get real with myself” about what needed to be done. He found that talking to
other people about his new method was a way to stay consistent. To cope with
his distractibility, Rob benefitted most from collecting data on the length of
his attention span for “boring” tasks (like taxes) and structuring his work time
accordingly. He would often take short breaks between these 20-min work
periods, such as a quick walk outside.
While learning these new behavioral strategies was critical to his success,
equally important for Rob was work that focused on his thinking patterns. In
particular, Rob identified prominent overly positive thinking that occurred
throughout the day and led to avoidance and failure to use skills. Rob reported
thinking thoughts like, “Well, I’m a good person so this will just work out for
me” that often preceded poor decisions or avoidance behavior. Because such
thoughts occurred very fleetingly and were often negatively reinforced by a
reduction in anxiety, they were hard for Rob to recognize. He began to notice
and catalogue his most common “red flag” thoughts. He next decided to write
them on brightly colored Post-It Notes around his workspace so he could be
more aware when they happened. When he became aware that he was having

(continued)
130 L.E. Knouse and S.A. Safren

(continued)

a “red flag” thought, he would try to stop and “get real” about what he would
need to do to solve or cope with the problem at hand. Cognitive work also
focused on helping Rob see the costs of consistently sacrificing his own needs
for others. To help him bring these ideas to mind when he needed them, a
paper plate metaphor was discussed in session where Rob was asked to imag-
ine all of his commitments to himself and others as food piled onto a single,
flimsy, grease-soaked paper plate. When confronted with the opportunity to
take on another project, he then asked himself, “Can this really fit on my
plate?” as a way to cue more conscious decision-making about these issues.
Data collected using the Barkley Current Symptoms Scale [12] (self-report)
throughout the course of treatment indicated that significant symptom reduc-
tion took place in the latter half of the sessions (see Fig. 7.1). Rob believed
that this was due to the time it took to “get good at” using the skills and also
identified the cognitive work as critical to helping him use the skills when he
needed them. During treatment, Rob filed his taxes on time for the first time
in several years. He was very proud of this and of the skills he had acquired.
Several months after Rob completed treatment, he returned for a “skills
booster” and appeared to have returned to his baseline symptoms, reporting
that he had not been using skills consistently. He entered a “refresher course”
of CBT skills and experienced symptom reduction within just a few sessions.
Together, Rob and his clinician decided to taper treatment slowly over time to
help Rob maintain his skills. During these tapered sessions, Rob was respon-
sible for setting the session agenda and taking the lead role in session.

The following treatment summary illustrates the application of several of these


concepts with Rob, the patient described earlier.
As illustrated by Rob’s case, if a patient responds to skills-based CBT in the
short term, acute treatment may need to be augmented with interventions designed
to help with maintenance of gains. Although studies have demonstrated that treat-
ment responders can indeed maintain their CBT-related gains in the absence of
ongoing intervention [8], in our clinical experience some patients have difficulty
maintaining skill use without additional support. This point is illustrated by Rob’s
need to return to CBT in order to reengage with skill use—an option that should
always be open to patients who successfully complete a course of CBT. In our treat-
ment, we specifically address relapse prevention, normalize slips in skill use, and
encourage patients to return to therapy in the future if they need help reengaging
with skills or if new challenges arise. In some cases, a clinician might consider
tapering final sessions or continuing patients on “maintenance” CBT at lower fre-
quency. For example, a patient might complete 12–20 sessions of weekly CBT and
be tapered over time to once-a-month visits. In these maintenance visits, the clini-
cian can place more of the responsibility for planning and directing the session on
7 Psychosocial Treatment for Adult ADHD 131

the patient. As was the case for Rob, patients can be instructed to come to the ses-
sion having formulated the agenda and having identified which skills they would
like to discuss and troubleshoot. Finally, use of maintenance groups for “graduates”
of skills-based CBT is another cost-effective, potentially useful option for practices
that see larger numbers of adults with ADHD. Groups could be held monthly and
patients could be given the option to attend as-needed.

Review of Major Psychosocial Treatment Options

As discussed at the outset of this chapter, skills-based cognitive-behavioral inter-


ventions for adult ADHD have received the most rigorous empirical support. These
findings are both emerging and promising. Across open trials and randomized con-
trolled trials, these interventions have been associated with a large pre-to-post effect
size for self-reported symptoms (d = 1.12; see also this reference for more detailed
review of individual studies [1]). In 2010, two cognitive-behavioral treatment pro-
grams heavily targeting organization and planning skills—those of Safren et al. [8]
and Solanto et al. [6]—received empirical support in larger randomized controlled
trials with active control conditions. Both of these treatments qualify as Probably
Efficacious Treatments according to the standards established by the American
Psychological Association’s Division 12 [25]. Safren et al. [8] compared a 12-session
individual CBT intervention to relaxation training with educational support for 86
patients. Patients in this study were receiving medication treatment but had sufficient
residual symptoms to still meet criteria for the disorder. CBT was associated with
significantly greater reductions in blinded-assessor-rated and self-reported symp-
toms of ADHD and responders maintained their gains at 6- and 12-month follow-up
assessments. Solanto and colleagues [6] compared a 12-session group-based cogni-
tive-behavioral therapy to support group intervention for 88 adults diagnosed with
ADHD. She found that group CBT was associated with significantly greater reduc-
tions in inattentive symptoms by self-, other-, and blinded investigator-report.
Notably, only some patients in this study were on medication and medication status
did not appear to impact response to group CBT. Taken together, empirical evidence
supports the integration of skills-based cognitive-behavioral interventions into evi-
dence-based practice for adult ADHD.
Recently, researchers have started to examine the possibility that mindfulness-
based intervention might be helpful for adults with ADHD. The rationale appears to
be that if adults with ADHD could improve their attentional control via consistent
practice of mindfulness, they might decrease their inattention and impulsivity.
Zylowska and colleagues [26] conducted an uncontrolled feasibility study of 24
adults and 8 adolescents who completed an 8-week mindfulness training program.
They noted improvements in pre-to-post self-reported symptoms and also improve-
ments on neuropsychological test performance, although a control group would be
needed to rule out practice effects. Philipsen and colleagues [27] have also found
promising results applying group Dialectical Behavior Therapy (DBT) skills
132 L.E. Knouse and S.A. Safren

training for adults with ADHD in a large open trial. One key component of DBT is
mindfulness, although many other CBT skills are also taught. Together, these studies
suggest that additional controlled studies of mindfulness-based treatment for adult
ADHD are needed. In the meantime, patients interested in integrating mindfulness
practice into their self-care regimen should be encouraged to do so, given its dem-
onstrated benefits for stress reduction and growing evidence for effects on mood
and anxiety symptoms [28, 29]. However, mindfulness-based therapy cannot yet be
considered a primary treatment for adult ADHD.
With respect to alternative interventions for adult ADHD, coaching has become
an increasingly popular option. What is ADHD coaching and how does it differ
from skills-based treatment? The Institute for the Advancement of ADHD Coaching
defines it as, “… a designed partnership that combines coaching skills and knowl-
edge of the neurobiological condition known as Attention Deficit Hyperactivity
Disorder. AD/HD coaches assist the client to develop, internalize and integrate his/
her own tools, education and self-knowledge to direct and manage life and work
challenges. Coaches collaboratively explore strengths, talents, tools and new learn-
ing to increase self-awareness and personal empowerment. Coach and client design
strategies and actions and monitor progress by creating accountability in line with
goals and aspirations” (retrieved from: http://www.adhdcoachinstitute.org/joom2/
content/view/120/229/). Some researchers have questioned the distinction between
coaching and CBT [30] and descriptions of coaching programs often include behav-
ioral strategies and techniques [31]. In a prior review [32] we outlined several fac-
tors that distinguish coaching from cognitive-behavioral therapy. First, the ultimate
goal of CBT is to train the patient in domain-general skills that can eventually be
applied in a variety of contexts whereas coaching appears to target specific work,
academic, or personal goals. Second, CBT attends to the role of thoughts and feel-
ings in blocking or facilitating skill use—a feature not traditionally incorporated
into coaching [33]. Third, a CBT therapist’s goal is to make herself obsolete due to
the patient’s acquisition of skills, whereas in coaching there does not appear to be
any expectation that positive outcomes will persist beyond the end of the coaching
relationship. The most important difference between CBT and coaching is that the
CBT therapist is guided by scientific knowledge about relationships between
thoughts, emotions, and behavior applied flexibly to the patient using a comprehen-
sive functional analysis of the presenting problem. CBT scientist-practitioners also
regularly subject their interventions to scientific study. Although coaching has been
studied in a few open trials [31, 34, 35], the efficacy of coaching for adult ADHD
remains largely unstudied [30].
Coaching practitioners often emphasize that coaching is not a substitute for
psychotherapy but can be a useful adjunctive service for adults already receiving
ongoing medication or skills-based intervention [33]. To the point, two studies
by Stevenson and colleagues [36, 37] found positive results using a clinic-based
skills training approach for adult ADHD that included an individual support person
for each participant. The support person made weekly contact with the patient
to improve treatment adherence and enhance motivation. The increased account-
ability and social support provided by a coach in support of skill acquisition and
7 Psychosocial Treatment for Adult ADHD 133

application in CBT might be particularly powerful combination. This intriguing


possibility warrants further study. In the meantime, we recommend that patients
wishing to obtain ADHD coaching spend time “doing their homework” on the train-
ing, experience, and qualifications of ADHD coaches to obtain optimal professional
support. Integrating the coach into the patient’s team of providers will improve
communication and coordination of care.
Many patients and clinicians consider employing interventions that purport to
alter the underlying neurological or neurocognitive deficits of ADHD non-pharma-
cologically including neurofeedback, low-energy neurofeedback systems (LENS),
cerebellar retraining, and cognitive training approaches. Many of these systems are
commercially available—however, it is important to recognize the importance of
treatment outcome data when selecting or recommending treatments for any condi-
tion. Some of these treatments may not have any peer-reviewed data to support their
efficacy. A Medline database search for published research on both LENS and cer-
ebellar retraining and ADHD yielded no results. Neurofeedback training has been
studied in people with ADHD but methodological issues make it difficult to draw
conclusions about the true cause of any observed treatment-related change [38].
Ramsay [39] recently reviewed the evidence for neurofeedback and working mem-
ory training and concluded that empirical support for these treatment strategies in
adults with ADHD is currently “tentative and non-conclusive.” In addition, patients
should consider the costs associated with these interventions and that they may
require significant time commitment (e.g., 30–60 sessions in the case of neurofeed-
back training [40]). Of the treatments in this category, working memory training
appears to be receiving increased scientific support in improving executive func-
tions in children [41] and additional rigorous studies in adults with ADHD, such as
those conducted for medication and CBT, are hopefully on the horizon.
Because ADHD in adulthood is associated with impairment in multiple domains,
other types of intervention and consultation targeting specific areas may be indi-
cated. First, adults with ADHD and comorbid disorders may need integrated treat-
ment that also targets mood, anxiety, or substance use problems. Naturally there are
instances in which treatment of the comorbid disorder takes precedence over treat-
ment of the ADHD. Unfortunately, methods for integrating psychosocial treatment
of ADHD and other disorders have not yet been widely studied. Second, patients
may benefit from psychosocial modalities that target relationship difficulties (cou-
ples therapy), family functioning (family therapy), and parenting skills (behavioral
parent training [42]). Third, consultation in specific areas such as job skills (voca-
tional rehabilitation or counseling), financial management (financial planners), and
home organization (organizational consultation) may also be indicated. Finally,
support groups, such as those sponsored by Children and Adults with Attention-
Deficit Hyperactivity Disorder (CHADD), play a very important role for many
adults with ADHD, providing social support, validation, and a positive environment
that supports patients’ change efforts. Advocacy organizations like CHADD can
also provide information and support as patients advocate for themselves in educa-
tional settings and in the workplace. It must be emphasized that for most patients,
these resources are not a substitute for ongoing medication and skills-based
134 L.E. Knouse and S.A. Safren

treatments to manage core ADHD symptoms. However, clinicians should think


broadly about the ways in which the lives of their patients could be improved and
should consider recommending these types of services as appropriate.
This section reviewed major psychosocial treatment strategies, emphasizing the
following points.
• Skills-based cognitive behavioral treatments for adult ADHD have shown posi-
tive results in randomized controlled trials and are currently the only type of
psychosocial treatment with strong empirical support.
• Mindfulness practice has many benefits and patients should be encouraged to
add mindfulness-based practice to their self-care plan—however, these strategies
require further study as primary treatments for adult ADHD.
• Coaching can be potentially useful adjunct to medication or skills-based treat-
ment. Patients should carefully select their coach in consultation and integrated
with the other members of their care team. Further study of coaching efficacy is
needed.
• Clinicians should strongly consider referring patients to additional psychosocial
resources as appropriate including treatment for comorbid disorders, couples or
family therapy, parent training, vocational or organizational consultation,
financial planning, and support and advocacy groups.
This chapter highlights empirical findings and recommendations from our clini-
cal experience and treatment manuals [9, 10] in applying skills-based treatments for
adults with ADHD. We encourage readers to learn more about these approaches and
to seek out additional training and experience. Many patients are eager to learn
ways to manage their symptoms and to work with a clinician who has the skills,
experience, and empathy necessary to partner with them in improving their lives.

References

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Chapter 8
Managing ADHD in Adults with Common
Comorbidities

Esther Sobanski, Georgios Paslakis, Michael Schredl, Stephanie Daffner,


and Barbara Alm

Abstract The objective of this chapter is to assist clinicians in the management of


ADHD in the presence of comorbid psychiatric disorders. We review and discuss
data and treatment recommendations on those psychiatric disorders that most often
co-occur with adult ADHD, i.e., depressive, anxiety, substance use, and sleep disor-
ders. As most large-scale randomized controlled clinical trials exclude patients with
ADHD and comorbid psychiatric disorders, the majority of data and recommenda-
tions discussed in the chapter result from case reports, open-label studies, or are
based on expert opinions and our own clinical knowledge.

Treatment of ADHD and Depressive Episodes

Prevalence and Clinical Characteristics of Depressive Episodes


in ADHD

Whereas 15% of the general population suffers from a depressive episode during
a lifetime, clinical and epidemiological studies show that 30–60% of adults with
ADHD are 2–4 times more likely to suffer from a depressive episode during their

E. Sobanski, M.D. (*) • G. Paslakis, M.D. • S. Daffner, Ph.D.


Department of Psychiatry and Psychotherapy,
Central Institute for Mental Health, University of Heidelberg,
Postfach 12 21 20, Faculty of Medicine, Mannheim 68159, Germany
e-mail: Esther.Sobanski@zi-mannheim.de
M. Schredl, Ph.D.
Sleep Laboratory, Central Institute for Mental Health,
University of Heidelberg, Postfach 12 21 20, Mannheim 68159, Germany
B. Alm, M.D., M.Psy.
Department of Psychiatry, Central Institute for Mental Health, University of Heidelberg,
Mannheim, Germany

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 137
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_8,
© Springer Science+Business Media New York 2013
138 E. Sobanski et al.

lifetime [1, 2]. A recent population-based Swedish study found that ADHD was
associated with an odds ratio of 2.8 (95% confidence interval: 2.4–3.2) for Major
Depressive Disorder (MDD) and an odds ratio of 1.8 (95% confidence interval:
1.3–2.4) for stressful life events like divorce, financial trouble, and job loss consti-
tuting risk factors for depressive episodes [3]. In our own study on a clinical popula-
tion of adult ADHD patients and a population based sample, 55% of the ADHD
patients and 24.3% of the population-based group suffered from at least one depres-
sive episode during their lifetime [4]. Patients with ADHD had their first depressive
episode about 6 years sooner than the control group (26.9 ± 8.1 years vs.
32.4 ± 10.6 years) and women with ADHD were 2.5 times more likely than men
with ADHD to suffer from a comorbid depressive disorder (60.7% vs. 25.7%). This
is almost equal to the gender distribution of depressive disorders in the general
population, with women being two times more likely than men to be affected [5]. In
another sample of 116 adults with a current depressive episode, 16% suffered from
ADHD, and there was no difference in age of onset of the depressive episode in
patients with and without ADHD [6]. Another study in a cohort of 399 patients with
mood disorders found, as we did, that lifetime comorbid ADHD was associated
with earlier age of onset of depressive episodes (16.10 ± 12.44 years vs.
25.99 ± 15.49 years). In addition, the study showed a higher number of current psy-
chiatric comorbidities (panic disorder, agoraphobia, social anxiety disorder, sub-
stance abuse and dependence) and decreased quality of life in adults with ADHD
and mood disorders than in those with mood disorders alone [7].

Assessment of Depressive Episodes in ADHD

It can be difficult to distinguish between symptoms of inattention and hyperactivity


related to ADHD and mild to moderate depressive episodes if the patient primarily
complains about inability to concentrate, difficulty managing their daily lives, and
inner restlessness. In order to differentiate, it is helpful to assess the onset of the
described symptoms. Patients with a depressive episode often report a distinct
period in time where they experienced a change in their feeling and function whereas
patients with ADHD describe their symptoms as chronic and being present as long
as they can remember. However, because of the presence of inattentive symptoms,
underachievement and inner restlessness in both disorders, this is only helpful for
the differential diagnosis of ADHD and depressive episodes but not for assessing
the comorbidity between ADHD and depression. A systematic evaluation of mental
health burdens should clarify if depression or depressive symptoms are present in
addition to ADHD. Thus, to identify a depressive episode in adult ADHD, clinicians
should assess for specific depressive symptoms like depressed mood, markedly
diminished interest or pleasure in almost all activities, significant weight loss when
not dieting, or ruminating constantly being present for a period of 2 weeks or longer.
However, one should be aware that sleep-related symptoms, like insomnia, can also
be present in both disorders, and that due to chronic underachievement and failures
8 Managing ADHD in Adults with Common Comorbidities 139

patients with ADHD often suffer from demoralization and diminished self-esteem,
mimicking MDD symptoms. There is also accumulating evidence that ADHD itself
can be associated with symptoms of emotional dysregulation like irritability, fre-
quent moods swings with quick changes between neutral, euphoric, or sad mood
occurring several times a day, or temper outbursts [8–10] and that poor control of
emotion may occur as a familial variant of ADHD [11] which can be misdiagnosed
as bipolar disorder.

Treatment

To date, the treatment of adult ADHD and comorbid depressive disorders is not
sufficiently investigated. The following treatment recommendations are based on
our own clinical experience, expert opinions, clinical reviews, case reports, chart
reviews, open-label studies, and a placebo-controlled study [4, 12–17]. Taken
together, clinically significant depressive symptoms in ADHD must be consid-
ered in a comprehensive treatment plan. If a comorbid depressive episode is diag-
nosed, a treatment hierarchy should be established. The depressive episode should
be treated first, as there is anecdotal evidence of reduced efficiency of stimulant
treatment for ADHD symptoms in the presence of depressive symptoms. Despite
its noradrenergic action, findings to date do not support an antidepressant role for
atomoxetine in a current comorbid depressive episode in ADHD. After remission
of depressive symptoms presence of ADHD-symptoms should be evaluated again,
and if classified as present, treatment with stimulants or atomoxetine should be
initiated. It is our practice is to continue the antidepressant therapy for at least
6 months or longer depending on whether it is the first or a recurrent depressive
episode.

Stimulants

A case report gives evidence that comorbid depressive symptoms reduced the effect
of MPH. It reports of two adult patients with ADHD that responded well to meth-
ylphenidate (MPH) for a number of years but the effect of the medication was less-
ened by a depressive episode that co-occurred during treatment. After the depressive
symptoms receded the effect of the MPH was restored [12]. In one of our own stud-
ies, we treated 39 adult ADHD patients with an average of 0.5 mg of MPH/kg body
weight for 7 weeks. Patients with ADHD and clinical significant depressive symp-
toms (Beck Depression Inventory >18 points) at the beginning of the study exhib-
ited significantly more ADHD symptoms at the end of the study compared to patients
without comorbid depressive symptoms at study inclusion. In total 47% of the
patients with comorbid depressives symptoms showed insufficient response to MPH
compared to only 15% of patients without depressive symptoms [4].
140 E. Sobanski et al.

Atomoxetine

Data from two large-scale double-blind, placebo-controlled studies were retrospectively


analyzed for effect of comorbidity and showed that the therapeutic response to atom-
oxetine in terms of reduction of ADHD symptoms was reliably predicted by a lifetime
diagnosis of a depressive episode [18]. However, several studies found no evidence
that atomoxetine reduces depressive symptoms itself [18–21].

Combination of Antidepressants and Stimulants

A clinical observation of 11 adults with ADHD and a comorbid depressive epi-


sode revealed that optimum treatment success was reached by combining ven-
lafaxine and stimulants. Using MPH or a selective serotonin reuptake inhibitor
(SSRI) separately did not show adequate effects [16]. A retrospective analysis
of the treatment of 17 ADHD patients and a concurrent depressive episode
showed that 88% of the patients treated with a combination of stimulants and
antidepressants experienced a clinical relevant reduction of depressive and
ADHD symptoms. Compared to the combined-therapy group, only 33% of the
patients treated exclusively with stimulants experienced a clinical significant
reduction of ADHD and depressive symptoms [17]. In a prospective study of 98
patients with ADHD and mild affective symptoms treated with amphetamines,
paroxetine, or a combination of both, significantly more patients that received
amphetamines (85.7%) or combination-therapy (66.7%) reported a reduction of
ADHD symptoms compared to the patients treated with paroxetine only (20%).
In turn, affective symptoms responded considerably better when treated with
paroxetine (100%) or combined therapy (73.3%) than with amphetamines only
(20%) [13].

Treatment of ADHD-Inherent Symptoms of Emotional


Dysregulation

ADHD-inherent symptoms of emotional dysregulation like mood swings, irritabil-


ity, and temper outbursts must be distinguished from a comorbid depressive epi-
sode. If the symptoms are classified as ADHD-inherent emotional dysregulation, a
pharmacological treatment with stimulants or atomoxetine should be initiated, and
the outcome of emotional symptoms should be monitored. According to the results
of preliminary studies, treatment with methylphenidate or atomoxetine may leave
residual ADHD-related emotional symptoms. However, further study is needed to
clarify how these symptoms respond relative to the response in ADHD-core symp-
toms [8–10, 12].
8 Managing ADHD in Adults with Common Comorbidities 141

Treatment of Demoralization and Low-Self-Esteem

ADHD can be associated with low self-esteem and demoralization that does not
achieve a clinical severity level warranting a diagnosis of MDD. As these often
resolve with effective treatment of ADHD, one should start with the treatment of
ADHD.

Treatment of ADHD and Substance Use Disorders

Prevalence and Clinical Characteristics of Substance Use


Disorders in ADHD

The lifetime prevalence of substance use disorders (SUD) in the general population
has been mentioned estimated to be up to 15% [22], while the life-time prevalence
for comorbid SUD in adults with ADHD is approximately 2–3 times higher [23].
The lifetime prevalence for comorbid alcohol abuse dependence in ADHD is
17–45% and for comorbid drug abuse or dependence 9–30% [24]. No significant
differences were found between patients with ADHD and controls regarding the
preference for specific substances, except for nicotine consumption showing a
significantly higher prevalence among ADHD patients. Vice versa, studies among
patients with a SUD have revealed a comorbid ADHD in up to 25% of cases [25].
Various investigations suggest that the ADHD influences the course of a SUD in
terms of an earlier age of onset and a more frequent and intensive substance abuse
than without comorbid ADHD, leading to rapid progression from abuse to depen-
dence [26]. Especially patients with an ADHD and comorbid conduct disorders or
antisocial personality disorders are at high risk of developing a substance abuse disor-
der with an earlier age of onset, a higher degree of severity of the disorder, and higher
relapse rates to substance abuse than patients without these comorbidities [27].

Etiology of SUD in ADHD

Genetics

ADHD is a psychiatric disease disorder with a high heritability of up to 76% [28, 29].
Familial accumulation has also been found for SUD with assumed polygenetic inher-
itance mechanisms, as well as, environmental influences. Associations have been
described between SUD and genetic polymorphisms regarding the dopamine-D2
receptor A1 allele [30], polymorphisms of the dopamine-D1, -D2, -D4 and -D5
receptor, the dopamine transporter, and the monoaminooxidase A [31]. From the
142 E. Sobanski et al.

molecular genetics’ point of view there are possible links and common candidate
genes for both ADHD and SUD, especially with regard to polymorphisms of the
dopaminergic system [32].

Neuroanatomy

The mesolimbic reward system is part of the motivational system that regulates
behavior in concerning natural reinforcers like food, sex, and social interaction. It
consists of the ventral tegmentum, prefrontal cortex, nucleus caudatus, putamen,
nucleus accumbens, hippocampus, and amygdala and is the main target of all psy-
choactive substances. It acts by increasing the dopaminergic neurotransmission,
causing the development of tolerance and the subsequent need for continuously
increasing the drug dose. Thus, the mesolimbic reward system plays a central role
in emergence and perpetuation of SUD [33]. Recent functional imaging trials that
have applied reward paradigms have shown that the mesolimbic reward system is
also involved in ADHD. In studies using anticipated reward paradigms (e.g., mon-
etary gain), decreased activity in the ventral striatum was shown in unmedicated
adolescents with ADHD [34]. There is evidence that the decreased neuronal response
to reward in ADHD could be the origin of “sensation seeking” behavior that has
been linked to SUD [35] and that the decreased neuronal response towards reward
in ADHD could also be the reason for self-medicating through substance abuse.
These findings suggest that the mesolimbic system is an important interface between
SUD and ADHD.

Assessment of Substance Abuse in ADHD

Both ADHD and substance abuse may cause symptoms of hyperactivity, difficulty
concentrating, changes in mood, lack of energy and impetus, and decreased motiva-
tion. Thus, it can be difficult to make the diagnosis of ADHD in persons with an
active substance use disorder. The two disorders can often be separated after obtain-
ing a clear history from family and school reports, as ADHD symptoms precede
substance use or persist through periods of prolonged abstinence. However, in order
to reliably assess current ADHD-symptoms, the patient has to be abstinent from all
substances for at least a month. It is important to obtain a full history of substance
use, including the age of first use, the frequency and pattern of use, the mode of
ingestion, and previous treatment attempts. Further, it is important to carefully
screen all ADHD patients for indicators of substance use disorders including crav-
ing, tolerance, loss of control, withdrawal symptoms, excessive preoccupation with
substance use, and substance use despite social or legal consequences or conse-
quences for the own health. Including family members and partners in this process
will provide the clinician with a more detailed history and is advisable.
8 Managing ADHD in Adults with Common Comorbidities 143

Treatment of ADHD with Comorbid SUD

Protective Effect Against SUD

The efficacy of MPH in the treatment of ADHD has been validated in a large number
of studies and a meta-analysis [36–38]. However, the question of whether the MPH-
treatment of ADHD during childhood protects against or even promotes the later
development of a SUD, and whether the administration of MPH is justified in the
treatment of patients with ADHD and a manifest comorbid SUD remain
controversial.
A meta-analysis of a retrospective and five prospective studies regarding the
association of MPH-treatment during childhood and the development of SUD in
adolescence compared to a group of untreated children with ADHD showed a 1.9
times higher risk for SUD in the untreated group [39]. In the Multimodal
Treatment Study of children with ADHD (MTA-study) 579 children with ADHD
were prospectively examined in different treatment arms; children that received
intensive behavioral therapy or a combination of MPH-treatment and behavioral
therapy showed the lowest prevalence rates for substance abuse (13 and 16%,
respectively) [40].

Abuse Potential of Methylphenidate

MPH mainly causes a reversible blockade of the dopamine-transporter (DAT) lead-


ing to an increase of extracellular dopamine, particularly in the striatum. Depending
on dose, degree of DAT-blockade (at least 50%), and following a fast dopamine
increase in the nucleus accumbens an intravenous (i.v.) administration of MPH may
cause feelings of euphoria. This is not the case when MPH is given orally, as it then
slowly reaches maximum plasma concentrations (Cmax after 60 min vs. 4–10 min
after i.v. administration). The pharmacokinetics of intravenous MPH are similar to
that of cocaine, although MPH blocks the DAT much longer than cocaine (90 min
vs. 20 min). Thus, stimulating effects after repeated administration of MPH are self-
limited compared to the repeated administration of cocaine [41].
In an extensive review containing 28 preclinical and 32 clinical trials regarding
the abuse potential of MPH, Kollins et al. indicated an addictive potential following
intravenous applications of the drug, while oral treatment with MPH does not seem
to bear the potential of abuse [42, 43]. This fits the clinical observation that patients
with ADHD and comorbid substance abuse often report that MPH consumption
does not cause euphoria and that they felt more functional following MPH adminis-
tration. Nonetheless, a systematic review showed that 5–35% of college-age indi-
viduals use stimulants without a doctor’s prescription [44]. The primary source of
supply of inappropriately used MPH appears to be from patients who are prescribed
this medication due to their ADHD [45].
144 E. Sobanski et al.

Treatment

A few studies in ADHD patients with comorbid SUD treated with MPH support
a reduction not only of ADHD-related symptoms but also of craving and substance
abuse. A review of current trials concerning the reduction of ADHD-symptoms
through MPH-treatment and the influence of MPH on comorbid substance abuse
disorders shows inconclusive results although studies report neither severe side
effects of a treatment with MPH, nor MPH abuse or an exacerbation of comorbid
SUD [46–51].
To date, no evidence-based treatment algorithms for ADHD and comorbid SUD
are available. Some authors suggest that stimulant treatment in patients with SUD
should only be initiated when two other non-stimulant options, e.g., tricyclic antide-
pressants and/or selective noradrenergic antidepressants have shown unsatisfactory
clinical efficacy. Several other authors, however, have suggested a risk-adapted
treatment approach that takes into account the estimated risk for drug abuse before
the beginning of treatment [52, 53]. According to this approach, patients with SUD
who are permanently abstinent from substances are to be classified as a “low risk”
population and may receive stimulants as a first-choice treatment of ADHD. It is
still recommended to use slow-release preparations of stimulants in order to mini-
mize the risk of abuse, to regularly monitor the adherence to treatment, and to con-
tinuously provide information and advice to the patients.
Patients currently abusing a substance, but who are not dependent belong to the
“moderate risk” group. Long-acting stimulant preparations may be advisable for
some patients in this group, but the potential benefits of treatment should outweigh
the risk of giving ready access to an agent that may be abused. Some clinicians may
choose to monitor such patients through drug testing, but if such concern is war-
ranted, some clinicians would prefer to defer use of a stimulant agent. All stimulant
formulation can be abused, but one interesting alternative is lisdexamphetamine
(LDX), an amphetamine pro-drug formulation which requires metabolism to active
d-amphetamine to be active, and thus higher doses need to be taken to achieve the
same high as d-amphetamine [54]. Possible signs of an stimulant abuse (“lost” med-
ication, changes in affect and impetus, psychosis, intoxication) should raise particu-
lar concern about continued prescription of stimulant medication.
Patients with ADHD and a comorbid substance dependence belong to the “high
risk” group. Before considering medication for ADHD a detoxification treatment
should occur, and abstinence should be monitored closely. In cases of severe depen-
dence, rehabilitation treatment following acute detoxification will be necessary.
When a stable abstinence is not guaranteed but patients show relevant impairments
due to ADHD, treatment with non-stimulants, e.g., atomoxetine or bupropion,
should be preferred over stimulants [55, 56].
The quality of the physician–patient relationship and the motivation to maintain
abstinence are further factors that have to be considered when making the decision
about the type of medication for ADHD patients with a comorbid SUD. In addition,
even in stable abstinence, stimulants should cautiously be prescribed to patients
8 Managing ADHD in Adults with Common Comorbidities 145

with multiple or intravenous substance abuse in the past, those who have dealt with
illegal substances and patients with a comorbid antisocial personality disorder.
Comorbid ADHD should be addressed in the overall plan of the treatment of SUD
and should be treated promptly, as it has been shown that the timely therapy of
ADHD after detoxification treatment may improve the prognosis of the SUD as
well. The consequent utilization of psychotherapy (behavioral therapy) is an indis-
pensable part of treatment for all patients with an ADHD and comorbid SUD [57].

Treatment of ADHD and Anxiety Disorders

Prevalence and Clinical Characteristics of Anxiety


Disorders in ADHD

There is strong evidence for the comorbidity of ADHD in adults and anxiety disorders,
but prevalence rates for this comorbidity vary considerably among different studies.
Most data from epidemiological and clinical studies found high comorbidity of both
disorders with lifetime prevalence rates of anxiety disorders up to 25–50% [2, 58, 59],
while few studies did not find anxiety disorders to be overrepresented in clinical sam-
ples of adults with ADHD [60, 61]. The National Comorbidity Survey Replication
(NCS-R) found adult ADHD and anxiety disorders to be highly comorbid (47.1%)
compared to a control group (19.5%) [2] with the most common anxiety disorder being
social phobia (29.3%) and agoraphobia (19.1%). Biederman et al. observed higher
levels for social phobia (32%) and generalized anxiety disorders (32%) and Barkley
et al. found significantly higher anxiety scores (17%) in the ADHD group compared to
the control group (clinical vs. community control group 14% vs. 1%) [58, 62]. Most
studies obtain congruently elevated lifetime prevalence rates for social phobias in
20–34% of adults with ADHD but lifetime rates for generalized anxiety disorders vary
considerably (10–45%) among different studies. A study by our group that compared
seventy clinic-referred adults with ADHD to a community control group found a higher
but not statistical significant rate of anxiety disorders in the ADHD group (34.3% vs.
25.7%) [4]. Consistent with other studies we found elevated rates of social phobia
(18.8% vs. 10%) but did not find higher rates of generalized anxiety disorders.
There are only few studies assessing subtypes of adult ADHD and comorbid
anxiety. Wilens et al. examined 109 adults with ADHD and determined the DSM-IV
subtypes [63]. They found significantly higher rates of all anxiety disorders in adults
over a lifetime with the combined subtype compared to the inattentive subtype.
Also, they found women to have higher rates of comorbid anxiety disorders than
men. Cumyn et al. found more anxiety disorders in the combined subtype group,
and found that women were more likely to have panic disorder [64]. In our own
study, we found patients with ADHD and anxiety disorders to have significantly
more inattentive symptoms than patients with ADHD only. We did not find any dif-
ferences between the groups for hyperactive or impulsive symptoms.
146 E. Sobanski et al.

Few studies have examined the prevalence and functional impairments of ADHD
within a sample of anxiety disorder patients. Manchini et al. examined the preva-
lence of ADHD in 149 anxiety disorder patients referred to an anxiety disorder
clinic [65]. They found a higher prevalence of ADHD in adults in this clinic (15%)
than would be expected in the general population (4%), and 45% of patients
fulfilling diagnostic criteria for childhood ADHD showed ADHD as adults.
Additionally, they found anxiety patients with ADHD in childhood to have an ear-
lier onset of the anxiety disorders, more mood and substance use disorders, and
more severe anxiety symptoms. Another retrospective study evaluated 85 adult
panic patients for the prevalence of ADHD and for the outcome of the two disor-
ders [66]. 23.5% of the panic patients presented having met criteria for ADHD in
childhood and 9.4% met in adulthood. The comorbid group showed a more severe
course of the anxiety disorder, had lower grades in school, was less likely to be
married, and showed higher rates of adversity in childhood. In a recently published
study van Ameringen et al. evaluated patients in an anxiety disorder clinic, assess-
ing 97 anxiety patients of whom 32 adults met criteria for ADHD [61]. The level
for childhood ADHD was 36.1% and 33% for current ADHD. Only seven (22%) of
them had been treated before. The type of anxiety disorders did not differ between
patients with and without ADHD, but the comorbid patients had higher anxiety
symptom severity. Social phobia was the most frequent anxiety diagnosis for
patients with ADHD.

Assessment of Anxiety Disorders in ADHD

In adults the differential diagnosis between ADHD and an anxiety disorder is often
a diagnostic challenge because of the overlapping symptoms of both disorders, e.g.,
poor concentration, restlessness, irritability, inner tension, worry, sleeping prob-
lems, and low stress-tolerance. It is often difficult to decide whether the symptoms
are related to ADHD or to an anxiety disorder. ADHD patients suffer primarily
from inattention, lack concentration, and disorganization. As a consequence they
often feel overwhelmed with their daily life and worry about their chronic under-
achievement. On the other hand poor concentration during conversation, reading,
or management of daily living and inner restlessness can be caused by an anxiety
disorder. Patients may report anxiety in social situations, which can be caused by
social phobia or by being anxious about controlling ADHD symptoms in a social
situation. Procrastination can be a behavior associated with phobia but can also be
because of ADHD. Furthermore, there is accumulating evidence that ADHD itself
can be associated with symptoms that are also present in anxiety disorders like
irritability, hyper-arousal, or reduced stress-tolerance.
For diagnostic purpose one must differentiate between a comorbid anxiety disor-
der, anxiety symptoms resulting from chronic underachievement, and ADHD-
inherent anxiety-like symptoms like reduced stress-sensitivity, hyper-arousal, and
irritability.
8 Managing ADHD in Adults with Common Comorbidities 147

Thus, in the clinical evaluation of adults with ADHD one has to go over the
DSM-IV criteria for both diagnoses. First, one has to assess systematically for ADHD
symptoms and then for the different anxiety disorders according to DSM-IV (social
phobias, panic attacks, generalized catastrophic thinking, worrying about the future).
It can be helpful to differentiate both disorders by age of onset and the course (epi-
sodic vs. chronic) of the symptoms. Anxiety starts later in life, symptoms are
fluctuating, the course is episodic whereas ADHD symptoms which have a lifelong
chronic course and are consistently present in different situations and over time.

Treatment

There is very limited empirical data to inform recommendations regarding treat-


ment for comorbid ADHD and anxiety disorders. Expert-based clinical practice is
to treat the most severe and impairing disorder first. After having assessed both
disorders, one has to decide which disorder should be treated first, considering the
severity of both disorders, or if both are equally impairing one can choose to treat
both disorders simultaneously. ADHD associated anxiety symptoms may improve
or vanish when the ADHD is treated, while symptoms due to a separate comorbid
anxiety disorder will not change, and require specific interventions, e.g., psychop-
harmacological therapy and/or psychotherapy—primarily cognitive behavioral
therapy.
If ADHD symptoms are treated first because they cause the most impairment (for
example with stimulants), one has to assess anxiety symptoms again after control-
ling ADHD-symptomatology. In a 6 week placebo-controlled study Spencer et al.
examined treatment with MPH in 146 adults with ADHD of whom 9% had a current
anxiety disorder. They found that the anxiety disorder did not affect the response to
MPH, and patients with and without an anxiety disorder showed similar treatment
response to stimulants. ADHD associated anxiety symptoms improve or vanish
when ADHD is treated successfully. If the anxiety disorder is the most impairing
mental condition, it should be treated with an SSRI or venlafaxine (evidence based
treatments). After the anxiety disorder has been stabilized, one has to reassess the
ADHD symptoms and decide if and which treatment is necessary. Also, if the anxi-
ety disorder is only mild or moderate one can try to start by treating the ADHD and
observe the anxiety symptoms. In many patients mild anxiety symptoms improve
while treating ADHD.
In case both disorders are equally impairing, one can treat both disorders simul-
taneously by combining medication after considering drug-interactions. Careful
reevaluation of side effects and interactions is necessary. The choice of medication
should be made with consideration for the preference of the patient and the risk
profile. Adler et al. showed in a large-scale randomized placebo-controlled study
conducted in adults with ADHD and comorbid social anxiety disorder that ADHD
and anxiety symptoms improved effectively after treatment with atomoxetine com-
pared to placebo after 14 weeks [67]. Thus, atomoxetine might be used as first
148 E. Sobanski et al.

choice in patients with ADHD and comorbid social anxiety disorder as it seems to
treat both disorder with one drug. Further, one can consider cognitive behavioral
therapy for both disorders, which is proven to have good effects for both disorders,
however, with less effect size than treatment with stimulants for ADHD.

Treatment of ADHD and Sleep Disorders

Prevalence and Clinical Characteristics of Sleep


Disorders in ADHD

Adult ADHD patients frequently report sleep problems [68, 69]; depending on the
methodology of the study, more than 70% of adult ADHD patients complained
about their sleep [70]. Two polysomnographic studies [71, 72] confirmed that sleep
problems, like nocturnal awakenings, are more frequent in adult ADHD patients
compared to controls. However, patients not only report problems at sleep onset and
maintaining sleep but also reduced feelings of being refreshed in the morning—
a parameter with high correlation to the severity of daytime ADHD symptoms
[68]—and increased daytime sleepiness [69]. These sleep difficulties were found in
untreated patients without psychiatric comorbidity, i.e., they seem to be an inherent
part of the ADHD symptomatology and cannot be attributed to comorbid disorders
or treatment with stimulants [73]. Studies further indicate that there is an overlap
between restless legs syndrome and ADHD [74]; a relationship that seems plausible
because of the shared dopaminergic dysfunction. The polysomnographic studies
[71, 72] showed an elevated index for periodic limb movements during sleep,
a symptom closely related to the restless legs syndrome. The question whether or
not sleep disordered breathing (e.g., sleep apnea syndrome) can be found more often
in patients with ADHD is still unanswered [75]. But as sleep disordered breathing
can cause ADHD symptoms in children and adults, it is important to include ques-
tions about this group of sleep disorders into the diagnostic procedure.

Assessment of Sleep Disorders in ADHD

Given the high frequency of sleep disturbances in adult ADHD, the evaluation of the
patient’s sleep should be included in the ADHD assessment. The state-of-the-art
assessment of sleep encompasses three steps. First, a complete sleep history should
be taken. Questions about bedtime schedules, difficulties falling asleep, nocturnal
awakenings, whether or not sleep is restorative, daytime sleepiness, urge to move the
legs (often accompanied by uncomfortable sensations in the legs) at sleep onset,
nocturnal leg cramps, snoring, and breathing pauses [76] should be included. The
anamnesis can be complemented by using sleep diaries (1-week periods are frequently
8 Managing ADHD in Adults with Common Comorbidities 149

used) and/or questionnaires like the Pittsburgh Sleep Quality Index [77] or the
Epworth Sleepiness Scale [78]. If there are any symptoms (snoring, observed breath-
ing pauses, non-restorative sleep, daytime sleepiness) that are suggestive for sleep
relating breathing disorders, an ambulatory screening of the nocturnal breathing
should be carried out in order to confirm or rule out a clinically relevant breathing
disorder. If sleep history and/or the ambulatory screening are not conclusive, the
patient should be assessed for one or two nights in the sleep laboratory. Periodic limb
movement disorder without concomitant restless legs syndrome, for example, can
only be properly diagnosed by using polysomnographic recordings.

Treatment of Sleep Disorders in ADHD

When sleep-related problems are present in ADHD, the first step is to decide if they
are ADHD-inherent or due to a separate sleep disorder like restless legs syndrome
or sleep related breathing disorder.
If sleep-related problems are classified as ADHD-inherent, a pharmacological
treatment of ADHD should be initiated, and the associated sleep-related symptoms
should be monitored during the course of the treatment. Two open-label studies [70,
72] showed that the sleep quality of adults with ADHD treated with MPH improved.
However, randomized controlled trials, including polysomnographic measures, are
still missing. Because cognitive-behavioral treatment strategies are very effective in
treating insomnia symptoms [79], another option is the use of behavior therapy
techniques like sleep restriction or stimulus control in patients with ADHD and
persistent insomnia complaints. However, there are no studies available, assessing
the efficacy of sleep specific behavior interventions in adults with ADHD.
If the sleep problems are classified as separate sleep disorder a specific therapy
should be started. Overall, studies suggest that specific treatment of comorbid sleep
disorders is beneficial for adult ADHD patients but systematic research in this area
is still at the beginning. The beneficial effect of dopaminergic treatment of comor-
bid restless legs syndrome on ADHD symptomatology was reported for several
cases in children; but clinical findings for adults have not yet been published.
Similarly, treatment with iron sulfate showed positive effects in some ADHD chil-
dren with comorbid periodic limb movement during sleep [75]. Although dopamin-
ergic agents, such as levodopa/carbidopa, pramipexole, and ropinirole, should be
applied in adult ADHD patients with comorbid restless legs syndrome and/or peri-
odic limb movements during sleep as soon as possible, little is known about the
interaction between ADHD specific medication and these dopaminergic agents
regarding the effect on day-time ADHD symptomatology.
It is still an unresolved matter if sleep disordered breathing disorders occur in
association with ADHD. However, as it has been well documented that it can mimic
ADHD-symptoms especially attention problems the following treatment hierarchy
regarding sleep disordered breathing disorders and suspected ADHD should be
established. The sleep disordered breathing disorder should be treated first, as several
150 E. Sobanski et al.

clinical observations [80, 81] indicated that ADHD daytime symptomatology


improved if the comorbid sleep related breathing disorder had been treated with
Continuous Positive Airway Pressure (CPAP). Thus, under stable CPAP-therapy
patients should be evaluated again for ADHD-symptoms. If still present, a specific
therapy with stimulants or atomoxetine should be initiated.

Conclusion

Currently, there are no approved evidence-based guidelines providing treatment


algorithms for adults with ADHD and comorbid mental health disorders. Nonetheless,
there is general consensus that a thorough differential diagnosis must reveal whether
the assessed coexisting symptoms are ADHD-inherent, which can be the case for
anxiety traits, sleep problems, and symptoms of emotional dysregulation or dimin-
ished self-esteem, or if they are due to a separate comorbid psychiatric disorder. If
associated symptoms are classified as ADHD-inherent, ADHD should be treated
specifically, and the associated symptoms should be clinically monitored. If they are
classified as a separate psychiatric disorder, the most impairing psychiatric disorder
should be treated first. After remission of the comorbid psychiatric disorder, pres-
ence of ADHD-symptoms should be evaluated again, and treated in a fashion which
will not exacerbate comorbidity.

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Chapter 9
Managing ADHD in Adolescence and Young
Adulthood: Emerging Comorbidities
and Tailored Treatment

Inmaculada Escamilla

Abstract The prevalence of ADHD in adolescence ranges from 4 to 6%. In this


age range, the disorder may manifest in difficulty fulfilling academic, personal and
social responsibilities. Adolescents with ADHD often struggle to maintain routines,
organize their time, be effective interpersonally, inhibit stimulus-seeking behav-
iors, and control their emotional reactions. Around 75% of adolescents with ADHD
have at least one comorbid disorder. The most frequent are Conduct Disorder (15–
30%), Substance Abuse Disorder (30–70% depending on the drug), and Mood or
Anxiety Disorders (20–40%). The presence and severity of these disorders leads to
under-diagnosis of ADHD, and management of ADHD may prevent or reduce mor-
bidity associated with comorbid conditions. Collection of data by interview is
sufficient to identify a diagnosis of ADHD across the lifespan. Neuropsychological
evaluation may be critical to confirm learning disabilities and need for possible
learning accommodation in this age group. Academic supports and accommoda-
tions may be helpful both in straightforward ADHD and in the presence of other
learning disabilities. Severe outcomes associated with ADHD can occur in this age
range, including illegal behavior, risky sexual activities or motor accidents.
Psychopharmacology improves ADHD in adolescents and is clinically observed to
reduce many but not all of these poor outcomes. It is useful to look for risk factors
of worse prognosis and to anticipate persistence into adult life to design a specific
support and treatment plan.

I. Escamilla, M.D., Ph.D. (*)


Department of Psychiatry and Medical Psychology,
University of Navarra Clinic (Madrid Campus), Calle General Lopez Pozas, 10,
Madrid 28036, Spain
e-mail: iescamilla@unav.es

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 155
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_9,
© Springer Science+Business Media New York 2013
156 I. Escamilla

Introduction

ADHD persists into adolescence in 75% of the cases diagnosed in childhood and the
prevalence in adolescence is 4–6% [1]. New problems associated with ADHD often
manifest in adolescence with increased responsibilities and behavioral expectations.
Consequently, ADHD interferes with healthy development and complicates the
transition to adulthood. Early detection and appropriate therapeutic approach pre-
vents and minimizes many of these complications [2, 3].

Clinical Features of ADHD in the Adolescent

The importance of formally utilizing accepted criteria for ADHD in making


a diagnosis has been emphasized in the chapter 2 on ADHD assessment in this
volume. There are some special considerations, however, in assessing individu-
als during the age of transition into adulthood and young adulthood. Research
suggests that the core childhood symptoms shift with development: hyperactiv-
ity and impulsivity often decline by adolescence, while attention problems
appear to remain more constant [1]. When present, impulsivity and deficits in
executive function outside the core traits of ADHD contribute to more profound
problems, including consequences reflecting poor planning, judgement, and
emotional control.
As discussed in the neuropsychological assessment chapter 4 in this text, execu-
tive functions are typically understood as a neuropsychological construction, refer-
encing the neurological processes that allow self-regulation. Clinically, executive
function capacities allow self-reflection, self-control, planning, delay of gratification,
persistence of intention, set shifting, selection and control of attention, mood and
affect regulation.
Challenges for adolescents with ADHD include difficulty keeping jobs or fulfilling
academic responsibilities, in part due to poor organization of time and behavior and
trouble otherwise maintaining routines. In these adolescents, professional and voca-
tional instability is common. These patients may frequently change the focus of
their university studies on more than one occasion, and their performance can be
low in spite of having a high Intelligence Quotient (IQ). Additionally, adolescents
who have ADHD often show stimulus-seeking behaviors. Adolescents with ADHD
exhibit riskier sexual behaviors, and are at higher risk of unwanted pregnancies and
sexually transmitted diseases [2].
ADHD traits such as risk-taking may also influence the opportunities that ado-
lescents can take advantage of as they grow into adulthood. Risk-taking adolescents
with ADHD may struggle to meet structured academic and social expectations, yet
succeed at risky and exciting occupations (e.g., entrepreneurial ventures or sales).
ADHD may be channeled into creative productivity with the right support and nur-
turance. In adolescence the consequences of problems with social skills and adap-
tive functions can be very stressful to relationships.
9 Managing ADHD in Adolescence and Young Adulthood... 157

Special Issues in the Diagnosis of ADHD in Adolescents

ADHD criteria such as those in DSM-IV-TR [4] may be applied for all ages, but the
ongoing development of nosological criteria, as evidence in the development of DSM-
V, recognizes that historically description of many items is more appropriate to chil-
dren than to adults and older adolescents. Thus, there are considerations particular to
this stage of development that should be taken into account: (a) although hyperactivity
significantly decreases in adolescence, some manifestations like tapping of fingers
on a desk, cracking the knuckles of the hands, breaking pens in their hands, biting
nails or restlessness can be symptomatic of adolescent ADHD; (b) Patients with inat-
tentive subtype ADHD frequently were not diagnosed in their childhood. This group
is more likely to include females or males who did not have disruptive behavior dur-
ing school that would have alerted parents or teachers to problems. They can come to
our clinic later in life showing anxiety, mood or obsessive symptoms and with very
low self-esteem; (c) A highly organized home life can mitigate the expression of
many ADHD symptoms. That is, ADHD problems become ever more manifest as
environmental demands become more complex and, concurrently, external support is
increasingly limited. This frequently happens in adolescents and more in young adults;
(d) Some adolescents found strategies to compensate for their deficiencies. They did
not fail to achieve specific life goals, and may even perform well, but describe expend-
ing excessive amounts of time and energy in order to do so. The excessive effort to
compensate, and often at great personal and social cost, becomes the marker for func-
tional impairment; (e) Adolescent ADHD can be under-diagnosed because organiza-
tional challenges may be explained as normal for this age group; (f) The presence of a
comorbid disorder (substance abuse, antisocial behavior and the anxiety and mood
disorder in the adult patients) can distract the focus of attention on ADHD.

Retrospective History of ADHD Symptoms

Sometimes not enough information is available to evaluate whether core ADHD


symptoms are present during childhood. So, the presence of one of these factors
may be a good marker for diagnostic risk: family history of ADHD, personal his-
tory of perinatal or other risk factors to develop ADHD and symptoms of low self-
esteem against a backdrop of solid functional capacities. As a result, interviews with
parents or significant others may be necessary to unveil the existence of these fac-
tors and earlier excessive impulsivity, disorganization, inattention to detail, forget-
fulness and refuse to do things which require a mental effort.

Neuropsychological Assessment

Psychological and neuropsychological testing can be useful to clarify the reason for
functional challenges such as attention, executive functions, and learning disabilities
(see also the chapter 4 dedicated to neuropsychological assessment in this text).
158 I. Escamilla

However, such testing is often required by schools, testing agencies and other
institutions to determine eligibility for accommodations or extra help. But there is
no specific neuropsychological profile of ADHD. No test to date has specific enough
sensitivity and specificity to make a diagnosis of ADHD. People can compensate for
their deficits during the relatively brief period of a test, and ADHD requires func-
tional impairment due to related symptoms in two or more life settings—which
cannot be evaluated by a neuropsychological test. Comorbid ADHD conditions
(anxiety, mood, etc.) can confuse interpretation as many neuropsychological fea-
tures including executive dysfunction are common in these comorbid conditions.
Testing also has limited sensitivity, as not all people who have ADHD have deficits
in all, or even some, measures of executive functions [5].
• Neuropsychological testing is useful for these following aims in adolescents
transitioning to adulthood: (a) Designing a therapeutic and accommodation
plan for adolescents and young adults who are still in the process of completing
their education; (b) detecting the presence of a learning disability other than
ADHD such as the DSM category of Learning Specific Disorder; (c) anticipat-
ing impact of and designing supports for individual patterns of executive dys-
function [6]; (d) permitting the individual to better understand himself or herself
and to recognize strengths as well as challenges with a goal of supporting self-
esteem; (e) providing objective information to augment (but not to supercede)
diagnosis; (f) to establish status relative to legal proceedings, and eligibility for
academic or other services.

Medical Mimics

While several forms of encephalopathy can mimic ADHD, some forms are particu-
larly relevant to the assessment of adolescents and young adults because of their
elevated frequency during those years. Head injury and lead toxicity are likely the
two most common causes of acquired inattentive/hyperactive and executive syn-
dromes. Seizure disorders of all types can be mistaken for inattentive ADHD.
Endocrinopathies, particularly thyroid disorders, can lead to extremes of arousal
and/or irritability but are unusual [5]. Substance abuse risk elevates in adolescence
and young adulthood, and agents of abuse or addiction itself can grossly impair
function. As discussed in the chapter 8 on common comorbidities in this guide,
clinicians should have specific plans for identifying substance use and prioritize its
treatment.

Comorbidity and the Transition to Adulthood

ADHD commonly occurs with other comorbid psychiatric conditions. 80% of patients
with ADHD have at least a comorbid disorder and about 40% have at least two [3]. Boys
as well as girls with ADHD are at high risk for developing psychopathological comorbidity.
9 Managing ADHD in Adolescence and Young Adulthood... 159

Just as problems associated with ADHD change depending on age, comorbidity also
varies with the period of development and the environment of the patient (“develop-
mental comorbidity”) [7]. Comorbid disorders may be present before the appearance of
first definite ADHD symptoms (“pre-comorbidity” such as temperament factors, sleep
disturbance, autism spectrum disorders and atopic eczema). They may coincide with the
time when ADHD symptoms reach a clinically significant level (“simultaneous comor-
bidity”: enuresis, encopresis, developmental learning problems). The majority of comor-
bidity, however, appears after the onset of ADHD in the course of disease
(“post-comorbidity”: tic disorder, Oppositional Defiant Disorder (ODD), anxiety disor-
ders, depression, obsessive compulsive disorders (OCD), eating disorders (ED), bipolar
disorder (BD), conduct disorder (CD) and substance abuse disorders (SUD), obesity
and personality disorders (PD)). Conduct Disorders, substance use disorders, learning
disabilities, and sleep problems may be the most frequent disorders in older adolescents
and young adults with ADHD. Mood and anxiety disorders become more frequent as an
adult and bipolar Disorder (BD) starts more frequently in early adolescence. Eating
disorders also start most frequently in early adolescence, although these can persist as a
young adult and obesity can become even more frequent at this age. Personality disor-
ders are frequent in the young adult but some traits can already be seen in older
adolescence.

Bipolar Disorder

This manual addresses bipolar disorder (BD) in detail in this chapter because it
often emerges before adulthood and early identification is critical. An epidemio-
logic study suggests that children and teenagers with ADHD have up to a tenfold
increased risk for bipolar disorder [3]. In that particular study, bipolar disorder was
diagnosed in 11% of ADHD subjects at baseline and in another 12% at 4-year fol-
low-up. The prevalence of ADHD and BD comorbidity varies depending on the
subtype of ADHD or BD involved and age. Higher rates of bipolar disorder have
been reported in patients presenting with the combined type of ADHD compared to
patients with either the inattentive or the hyperactive-impulsive subtypes of ADHD.
On the other hand, bipolar disorder patients with comorbid ADHD are more likely
to be diagnosed with BD-I. Some studies have found very high rates of BD among
individuals with ADHD, highest in younger children, lower in adolescents, and
lowest in adults. These rates are significantly higher than the prevalence of BD in
the general population, usually estimated at about 1% for BD and up to 5% when
including all bipolar spectrum disorders [8].
BD and ADHD patients may experience similar symptoms: racing thoughts,
hyperactivity, talkativeness, impulsivity, and distractibility. BD can be distinguished
by the prominence of mood symptoms, and symptoms of grandiosity, flight of ideas,
decreased judgment, and hypersexuality are more specific to BD. ADHD is associ-
ated with hyperactivity, while an increase in goal-directed activity can be seen in
BD. ADHD patients often have problems with anger and irritability, but generally
160 I. Escamilla

this is reactive rather than prolonged, episodic agitation of higher severity seen in
BD. BD can be associated with significant aggression and violence, which in the
majority of cases puts both the patient and the person at risk [9].
Where BD occurs comorbidly with ADHD, it has different clinical characteris-
tics than BD without ADHD. Comorbid ADHD/BD patients experience mania
symptoms 3–5 years earlier, their first mood episode is more likely to be depressive
and they have a more severe course than BD patients [8, 10, 11].
In spite of their similarities and comorbidity, neuropsychology and functional
neuroimaging studies demonstrate different findings for these disorder [11]. That
suggests that ADHD and BD are distinct syndromes that may coexist together.
In clinical practice ADHD/BD patients are often treated for BD only, but may
experience improvement in both conditions. Following BD treatment, some ADHD/
BD patients might not fulfill the DSM-IV criteria for ADHD anymore. However,
BD patients often complain about residual symptoms even with successful treatment
of BD, and often report challenges with focus, concentration and/or memory [8].
Many medications used to treat ADHD may exacerbate bipolar disorder, and such
treatment should proceed only when a patient is well mood stabilized and closely
monitored, and where potential benefits outweigh the risks associated with bipolar
decompensation [12]. Interestingly, one report identified a higher risk of activation
of mania by antidepressants in youths with ADHD (26%) compared with those
without ADHD (6%). These switches could be predicted by the presence of baseline
conduct disorder, school behavior problems and a positive showing of a mood disor-
der in a parent [13].

Eating Disorders

Adolescents and young adults are at risk for developing eating disorders, and there
is evidence that the eating disorder (ED) bulimia nervosa is more common among
girls and women with ADHD. Adolescents with ADHD should be screened for
symptoms of ED, in particular symptoms of binging, and adolescents with BN,
binge-eating disorders (BED), or Eating Disorder Not Otherwise Specified
(ED-NOS), should be screened for symptoms of ADHD.
Multiple studies suggest the association between ADHD and ED [14]. A retro-
spective case–controlled study on four populations (two adult = 742 and two pediatric
n = 522) found that Bulimia Nervosa (BN) prevalence for the pediatric ADHD group
and for the pediatric control group were respectively 1% and 0%. The analysis of the
two populations of adult women showed a BN prevalence of 11.2% among the
ADHD group, and 2% for the control group. The findings suggested that adult women
with ADHD might present a higher risk of developing BN [15]. An observational
study conducted in a sample of morbidity obese adolescents from a pediatric clinic
found a positive correlation between the scores in Conners scale for ADHD and
BITE (Investigatory Test-Edinburg, for BN) independently of their anxiety and
depression scores previously measured [16]. And finally, a 5-year case–controlled
9 Managing ADHD in Adolescence and Young Adulthood... 161

follow-up study in a sample of ADHD girls diagnosed with DSM-III-R found that the
prevalence of ED was 16% in the ADHD group, and 5% in the control group [17].
The most frequent ED disorder found in the ADHD group was BN while that in the
control group was Anorexia nervosa (AN). The authors suggested that adolescents
with ADHD present a higher risk of developing an ED, especially BN [17]. Mikami
et al. designed the first study which divided ADHD subjects by subtype [18]. Girls
with ADHD combined type at baseline showed higher severity of eating pathology at
follow-up than girls without ADHD. Girls with ADHD-Inattentive type were inter-
mediate between these two groups. Baseline impulsivity symptoms, as opposed to
hyperactivity and inattention, best predicted adolescent eating pathology.
The association between obesity and ADHD has also been consistently described
in adult patients. This association had also been found in the younger ADHD popu-
lation. It is reported that 57.7% of the children and adolescents with morbid obesity,
hospitalized in a clinic for treatment, satisfy the diagnosed criteria for ADHD, and
none of the patients met criteria for an ED diagnosis [19].
To date, the etiology of eating dysregulation comorbidity and ADHD are not
well understood. Furthermore, although there are reports of improvement in ED and
weight management with treatment of ADHD, there have been no systematic stud-
ies of these interventions. Because ADHD medications may reduce appetite, they
should be prescribed cautiously in individuals who may misuse these agents because
of their ED.

Sleep Disruption

As explored elsewhere in this volume, sleep disorders deserve special attention in


ADHD patients. Here we discuss restless leg syndrome and delay of sleep onset
(sleep onset insomnia, which may be due to initial insomnia or sleep phase delay),
as they are very disruptive to function in young adults. Sleep disturbances can pro-
duce symptoms mimicking or exacerbating ADHD. It is thus critical to foster
healthy sleep habits in young adults, and to treat their sleep disorders [20].

Restless Legs Syndrome

In some study samples up to 44% of subjects with ADHD have been found to have
Restless Leg Syndrome (RLS) or RLS symptoms, and up to 26% of subjects with
RLS have been found to have ADHD or ADHD symptoms [21]. At the same time,
in ADHD clinics, RLS rates can be quite low. Several hypotheses have been pro-
posed to explain the association between RLS and ADHD [22], including iron
deficiency (which is a cofactor in dopamine synthesis) [22]. Some experts recom-
mend treating with iron supplements when the concentration of ferritin in plasma is
lower than 35 mg/l.
162 I. Escamilla

Some case reports with both RLS and ADHD have demonstrated the efficacy of
low doses of dopaminergic agents (levodopa, pergolide and ropinirole) in children
diagnosed with both conditions who were previously unsuccessfully treated with
psychostimulants [23]. However, although dopaminergic agents are considered the
first-line treatment for adults with RLS, they are not approved for use in children
with RLS.

Sleep-Onset Insomnia

Clinically it is often appreciated that some individuals go to bed later, wake up later,
have longer sleep latency, and less efficient sleep. It has been reported that medica-
tion-free children with ADHD and sleep-onset insomnia (SOI) exhibit a delayed
evening increase in endogenous melatonin levels (dim) in 73% of the cases [20].
Therefore, it has been hypothesized that SOI in ADHD is a circadian rhythm disor-
der [24]. Melatonin may be helpful in children and adults to manage sleep phase
delay. Studies have been conducted in children with ADHD with SOI ranging in age
from 6 to 14 years; however, the safety of melatonin treatment in children has not
been well evaluated. In one study, treatment with melatonin doses between 3 and
6 mg, administered within a few hours of the scheduled bedtime, was effective and
well tolerated [25]. Experts recommend careful consideration before recommend-
ing melatonin in prepuberty patients because of its potential effect on the hyphotha-
lamic–pituitary–adrenal axis.
Considering that a delayed evening increase in endogenous melatonin levels
might contribute to SOI in children with ADHD, some investigators have evaluated
the effect of light therapy in this population. For example, a 3-week open trial was
beneficial and improved subjective and objective measures of ADHD. More con-
trolled studies to assess the efficiency of light therapy in children with ADHD are
necessary to assess its evidence-based role in treatment [20].

Conduct and Oppositional Defiant Disorder

Conduct Disorder (CD) and Oppositonal Defiant Disorder (ODD) are common in
children and adolescents with ADHD (around 50% of ADHD children have one of
these) [3]. In some, these disorders persist, and in the older adolescent or young
adult CD can easily be confused with Antisocial Personality Disorder, and at the
same time, ODD may manifest as narcissistic or grandiose traits. ODD is a distinct
pattern of angry, resentful, and disagreeable stubbornness relative to requirements
of authority. In adults, ODD traits include the need to externalize blame, control
others, and argue. A child who is oppositional and defiant tells an adult that he or she
“cannot tell me what to do.” An adult who is oppositional argues with the doctor,
fights the system, blames his boss, or blames his child’s teacher. According to
a 10-year follow-up study recently published, the persistence of ODD into adulthood
9 Managing ADHD in Adolescence and Young Adulthood... 163

for children with ADHD and ODD is low, approximately15% [26]. CD may be
more persistent, as at least a third of children with ADHD continued to have this
diagnosis in adulthood.
In this same study, the authors found other instructive patterns that match clinical
experience. Independent of comorbid CD, ODD was associated with major depres-
sion in adult age (age = 21.7%). CD conferred a much larger risk for antisocial per-
sonality disorder than ODD in young adults, and CD, not ODD, was associated with
significantly increased risk for psychoactive substance use disorders, smoking, and
bipolar disorder [26]. Comorbidity with CD and/or substance use disorders is a risk
factor for antisocial personality disorder and illegal conduct in adulthood. Thus, CD
may deserve more different treatment and support than ODD for best prognosis.

Substance Use Disorders

In studies of adolescents with a substance use disorder (SUD), the rates of comorbid
ADHD have been noted to range from 23 to 31% [27]. Children with ADHD have
two to four times the probability of developing a SUD, and this increases significantly
if associated with BD or CD [28]. Those with ADHD are at greater risk for earlier
onset substance abuse, about 3.5 years earlier. Cannabis is the most commonly used
illicit substance among adolescents, including those with ADHD. There is evidence
that treatment of ADHD significantly reduces risk for substance use in younger
individuals with ADHD [29] although this effect may attenuate by adulthood. For
example, an observational study conducted by Joseph Biederman and colleagues
showed that untreated ADHD subjects were about twice as likely as those receiving
a stimulant to develop substance abuse [30].
There is a high rate of diversion as well as misuse of ADHD medications. A survey
of young adults from the same group found higher rates of misuse or diversion (selling
or sharing) of stimulants in individuals with ADHD than those without ADHD. However,
they found that all patients who misused or diverted stimulants had a lifetime history of
SUD, and that all misuse was with immediate-release stimulant medications [31]. As
explored elsewhere in this volume, it is preferable to prescribe non-stimulant agents
where substance misuse is a concern, and long-acting stimulant treatments where stim-
ulant therapy is appropriate. It is also advisable to recommend that medication be dis-
pensed by a parent or other guardian, and that young patients keep their medication a
secret from peers. As individuals transition to taking medication independently, it is also
essential to consider what supervision can help prevent misuse of ADHD treatment.

Personality Disorders

ADHD may be a risk factor for having a personality disorder (PD). A longitudinal
study of adolescents age 7–11 years old, found that at 16–26 years old those with
ADHD had a higher prevalence of personality disorder than those who never had
164 I. Escamilla

ADHD [32]. ADHD participants had an increased risk for personality disorders in
late adolescence, specifically Borderline (BPD) (OR = 13.6), Antisocial (OR = 3.3),
Avoidant (OR = 9.77) and Narcissistic (OR = 8.69) personality disorders. Importantly,
those with ADHD that persisted into adulthood were at higher risk for Antisocial
(OR = 5.26) and Paranoid (OR = 8.47) personality disorders when compared to those
in whom ADHD remitted, but not the other personality disorders. Retrospectively,
nearly 90% of a sample of adults with personality disorders reported clinically
significant ADHD symptoms in childhood.
Although the link between ADHD and personality disorders may be phenom-
enological (i.e., overlapping diagnostic criteria), the disorders could theoretically
co-occur because of common neurobiological and/or environmental risk. It may
also be that children with ADHD interact with their families and other significant
individuals in such a way that these relationships increase the likelihood of devel-
oping personality disorders [33]. But certainly the vast majority of individuals
with ADHD do not meet diagnostic criteria for a personality disorder, suggesting
there may also be protective factors.
Retrospective studies had found an association between ADHD and BPD in
adults with severe self-image disturbances, impulsivity, aggressivity, or conduct dis-
order [34]. The risk increases exponentially when it is associated with more than
one of these factors, so that the risk may be increased to 70% with all of them [35].
The presence of such traits should prompt specific psychotherapeutic treatment—in
particular, recommendation of dialiectical behavior therapy or other therapies
designed to help BPD. While medication is not thought to robustly impact BPD, an
open label study suggests that methylphenidate treatment improved symptoms of
both ADHD and BPD [36].

Prognosis of ADHD in Adult Life

A recent 10-year follow-up study suggests factors predicting poor prognosis for
ADHD and persistence into adulthood [37]. Persistent ADHD was associated with
presence of oppositional defiant disorder (ODD), conduct disorder (CD), multiple
(higher or equal to two) anxiety disorders and maternal psychopathology. Family
conflict associated slightly with the higher persistence of ADHD. Other reports
suggest that parental mood or anxiety disorders may increase risk of persistence.
There is little work to date addressing predictive factors into later adulthood.
Recent genetic findings suggest that genes in the dopamine system (DR4 and
DAT1) may influence the persistence of ADHD, but more studies are necessary in
this area of genetics to be able to elaborate a hypothesis on the prognostic value of
genetic studies [37].
Individuals with severe impairment, adversity (mood and affective disorders in
the parents and family dysfunction) and comorbidity are likely to require greater
intervention, and family evaluation and family therapy may be very useful.
9 Managing ADHD in Adolescence and Young Adulthood... 165

Treatment

In adolescents, reducing symptoms of ADHD is particularly important to prevent


development of other psychiatric illnesses or syndromes, and favor the normal pro-
cess of maturity. As is true across the lifespan, multidisciplinary treatment may
help. Fostering capacity to treat and accommodate ADHD self-sufficiently is an
important goal in individuals transitioning to adult independence.

Developmental of a Therapeutic Plan

Understanding the individuals’ strengths and weaknesses facilitates psychoeducation


and accommodation: Identifying learning disabilities and environmental obstacles to
academic and occupational success. Accommodations may be available in school, at
work, or for standardized testing. Specialized tutoring in subjects or organizational
skills may be indicated so individuals can make the most of opportunities.
Guide patients to the right environment: Patients often become independent at the
end of adolescence, leave their family’s home, may live independently, and study or
otherwise work more independently. This period of change can be very stressful for
ADHD patients, in particular those with executive function challenges such as trou-
ble maintaining routines, managing time, or otherwise organizing themselves. It is
very important that key adult figures in their lives help them anticipate the unique
challenges they may face, and prioritize applying skills or using resources that will
help them compensate for these challenges.
A general principal that may help is to think with the young adult about how to
replicate what has helped them function well in the past. For many, having other
people involved in their living environment, studies, assignments, and other work
may be a source of accountability. Such individuals should seek out professors,
advisors, supervisors, coworkers, or other students to work with. There should be
other people involve in monitoring progress, or by whom the individual can pace
themselves. Young adults should be coached on the importance of spending time
with people who meet their own needs in healthy ways—who eat regularly, work
effectively, sleep well, and get exercise. A defined schedule that helps them to keep
routines and healthy habits, may help, and places to study or work without distrac-
tion can help. For some, having all classes in the morning or in the afternoon allows
medication to cover learning hours best.
Educate about personal risks: Patients should be educated about their potentially
higher risk for driving accidents and consequences of impulsivity as that pertains
to them.
Review individual and familial medical history: As highlighted elsewhere, it is neces-
sary to evaluate risk for cardiovascular complications and neuropsychiatric complica-
tions (particularly psychosis, mania, or epilepsy), before starting medication treatment.
166 I. Escamilla

Facilitate adherence to treatment: Establish treatment goals that are shared by the
patient—not just their parents—and establish an experimental, collaborative
approach with the patient to maintain alliance with treatment trials. Adolescents and
young adults may require longer duration of coverage, which may require use of a
short acting agent to cover the end of the day. At the same time, medication can cre-
ate side effects that should be discussed ahead of time and monitored—such as
emotional or physical, or insomnia side effects.
Recommend complementary non-medication interventions: Psychoeducation is cru-
cial for the patient and the family members or partner that lives with them. The
patient may benefit from learning specific strategies to control their symptoms,
increase their effectiveness at daily activities and reduce stress not only personally
but in their environment. As explored elsewhere in this volume, cognitive behavior
therapy can be effective to improve compensatory abilities and address comorbid
conditions. Where conflict arises, strategies from collaborative problem solving
may be a useful resource [38].
Problem solving and social skills training should be considered in the treatment of
ADHD associated with severe behavior problems or conduct disorder. Dialectical
behavior therapy should be considered in adolescents with traits of BPD. Motivational
interviewing or other SUD intervention approaches should be utilized where relevant.
Paraprofessionals such as tutors, trained coaches, or organizational specialists
can be recruited to facilitate accommodation of work, home and school environ-
ments, self-organization, and for practice of relevant skills. Their purpose is to iden-
tify maladaptive approaches, explain better ones, and monitor or supervise their
practice. Such professionals may also help bypass parental involvement in such
tasks and increased conflict at home.

Following the Adolescent with ADHD into Adulthood

Adolescence and young adulthood is a time of change, and the need for treatment,
treatment goals, and type of treatment should be reevaluated regularly. It is impor-
tant to have realistic expectations and propose and celebrate progressive changes to
avoid frustration. As discussed elsewhere in this volume, it is helpful to use rating
scales such as those based on DSM symptom criteria to follow target symptoms—
but it is perhaps even more important to follow related functional challenges.
The primary goal in supporting individuals with ADHD transitioning to adult-
hood is adoption of optimal self-management of ADHD. Helping young adults
determine what opportunities best match their personal strengths and challenges will
increase their chances of thriving. Clinicians should regularly screen for and respond
to predictable exacerbates of distress during the transition to adulthood such as
emergence of comorbidity, freedom to take risks, loss of compensating structure,
new roles/obligations, and changes in stressors or supports. ADHD is often a chronic
9 Managing ADHD in Adolescence and Young Adulthood... 167

illness, requiring long-term management, and thus, this medical saying applies: The
patient needs to take treatment for the time that they need to take it.

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Chapter 10
ADHD in Families

Thomas Jans and Christian Jacob

Abstract Adult ADHD is associated with significant psychosocial impairment


comprising problems at work, financial troubles, interpersonal conflicts, delin-
quency, and family dysfunction. Family impact of ADHD contributes to marital
problems and conflicts with children. Skills to cope with these interpersonal prob-
lems are often limited, including impaired parental skills. Conflicts might be cata-
lyzed by comorbid psychiatric disorders. Moreover, the hereditability of ADHD is
associated with problems involved with raising affected children. All in all, in adult
ADHD patients multiple stressors are interlinked leading to vicious circles widely
affecting family life. Multimodal assessment of adult ADHD has to be broad enough
to cover these personal and environmental factors. The patient’s partner and
child(ren) should also be screened for psychiatric disorders. The need to stabilize
family function does not imply that family-focused interventions are the first line of
therapy. ADHD and comorbid conditions have to be treated first. Medication and
psychoeducational advice to the patient and his or her partner can lead to significant
improvements in family function. Applying skills acquired during individual psy-
chotherapy to family problems could also reduce family conflict. In addition,
strengthening parenting skills by the implementation of parent training is often use-
ful. In the case of psychiatric disorders in children the implementation of treatment
is crucial. However, treatment of the ADHD parent seems to be an important pre-
condition of a successful psychosocial intervention to target the child’s externaliz-
ing symptoms. Reduction of ADHD symptoms in children may also reduce family
conflict more effectively than specific family interventions. This points to the need

T. Jans, Ph.D. (*)


Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy,
University of Wuerzburg, Fuechsleinstr. 15, Wuerzburg, Germany D97080
e-mail: jans@kjp.uni-wuerzburg.de
C. Jacob, P.D., M.D.
Department of Psychiatry, Psychosomatics and Psychotherapy, University of Wuerzburg,
Fuechsleinstr. 15, Wuerzburg, Germany

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 169
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_10,
© Springer Science+Business Media New York 2013
170 T. Jans and C. Jacob

for close cooperation between child and adult mental health services. More specific
couples therapy or family therapy may be indicated if the therapeutic strategies
stated above do not lead to a significant reduction of family conflict.

Introduction

Adult ADHD is associated with significant psychosocial impairment comprising prob-


lems at work, financial troubles, interpersonal conflicts, delinquency, and family dys-
function. Family impact of ADHD is evident in marital problems and conflicts with
children. Skills to cope with these interpersonal problems may be limited, including
impaired parental skills. Conflicts may be catalyzed by comorbid psychiatric disorders.
Moreover, because ADHD is highly inherited, ADHD adults often face challenges
coping with affected children. All in all, in adult ADHD patients multiple stressors
are interlinked leading to vicious circles widely affecting family life. A descriptive
model of these interdependencies is depicted in Fig. 10.1. This chapter focuses on
factors affecting family functioning in adult ADHD. Important empirical findings
are summarized. Recommendations on assessment and treatment will be given.

Fig. 10.1 ADHD and family functioning. Note: This is a descriptive model summarizing important
interdependencies with regard to the impact of adult ADHD on family functioning. Arrows show
unidirectional and bidirectional influences supported by empirical findings. The model is for
didactic purposes and remains heuristic. It does not reflect results of multivariate analyses
10 ADHD in Families 171

Family Impact of Adult ADHD—Empirical Findings

ADHD is a highly heritable disorder. However, a deterministic view is not appropriate


and gene–environment interactions have to be taken into account for the under-
standing of symptom development. Although family and twin studies explicitly
demonstrate a substantial contribution of inherited genetic variation to the risk for
ADHD with heritability estimates of 70–80 %, traditional linkage mapping and can-
didate gene studies have failed to reliably identify ADHD-associated genes that
increase disease risk [1, 2]. The gene–environment approach assumes that gene–
gene interactions influence susceptibility and that environmental factors such as life
events are important for the pathogenesis of ADHD. The behavioral and interper-
sonal consequences of symptoms (inattention, impulsivity, and hyperactivity as
well as accessorial symptoms such as disorganization and mood instability) might
be among those risk factors for children of affected adults. There is thus a danger of
vicious circles in families with more than one affected member. On the other hand,
affected parents might be more capable of understanding ADHD-related behavior
and of enhancing coping strategies.
Adult ADHD symptoms interfere with social and occupational life. Inattentiveness,
hyperactivity, and impulsivity are core symptoms of ADHD. As additional symptom
clusters in adults, mood lability, irritability, and hot temper, impaired stress tolerance
and disorganization have been described [3]. In general, the diagnosis of a psychiat-
ric disorder is bound to symptoms causing significant distress or impairment in social,
occupational, or other important areas of functioning [4]. Impairments described for
adult ADHD include failure to graduate, low job performance and elevated risk of
being fired, financial troubles, low socioeconomic status, interpersonal conflicts, and
delinquency [5–9]. As a consequence, in a significant number of ADHD patients
daily life is characterized by multiple stressors paired with reduced coping skills.
Comorbid disorders might further catalyze psychosocial maladjustment. The
majority of adult ADHD patients suffer from at least one additional psychiatric
disorder. Anxiety disorders, depressive disorders, substance-related disorders, and
personality disorders are the most common conditions [5, 10]. Low self-esteem and
feelings of insecurity might develop as a consequence of academic failure, under-
achievement, and interpersonal difficulties. Each of these comorbid factors can
have its own impact on interpersonal adaptive function.
Having a closer look at family functioning, ADHD adults tend to take up rela-
tionships more quickly and their partnerships are less stable. This is reflected by
studies reporting more frequent treatment for sexually transmitted disease, earlier
sexual intercourse, unplanned pregnancy, and multiple marriages [6, 7, 11]. Early
parenthood might be a consequence of unreliable contraception. Furthermore, ado-
lescents and young adults affected by ADHD might start a family more impulsively
without investing in the prerequisites needed to build up a stable family environ-
ment. For example, in a study of ADHD parents, family and marital functions were
impaired in comparison to controls [12]. Controlling for other parental psycho-
pathological conditions, parental ADHD was associated with high family conflict
172 T. Jans and C. Jacob

and low cohesion [13]. In another report, ADHD spouses saw their family and
marriage more negatively in comparison with their non-ADHD partners [14].
However, their non-ADHD partners noted feeling responsible to compensate for
ADHD-related disorganization.
Reduced parental skills are frequently observed in ADHD parents. Studies on
parents of ADHD children found that parental ADHD symptoms were related to lax
parenting, poor monitoring of child behavior, over-reactivity, more arguing during
parent–child interactions, less effective and less consistent discipline, and less effec-
tive problem solving for child-rearing issues [15–17]. Associations between paren-
tal practices and paternal ADHD remained significant when controlling for comorbid
psychiatric disorders in parents or conduct disorder in children. Dysfunctional par-
enting found in studies investigating parents of ADHD children might be a conse-
quence of parental strain associated with rearing-up a child with externalizing
problem behavior. However, an association between maternal ADHD symptoms
and less effective parenting was also found in a non-clinical sample [18]. ADHD
symptoms were associated with lower parenting self-esteem and a more external
parenting locus of control. Even in first-time expectant women, ADHD symptoms
were correlated with negative parenting self-efficacy expectations [11]. In another
study paternal ADHD was associated with lower academic achievement of their
non-ADHD children [13]. Thus, impairment of educational skills and self-esteem in
ADHD parents cannot be understood as a mere reaction to overwhelming demands
posed by the child’s externalizing problem behavior. ADHD parents seem to be
aware of their reduced parenting skills and express feelings of insufficiency, which
in turn might lead to even poorer parenting strategies. Actually, in non-clinical sam-
ples maladaptive cognitions on child-rearing issues were found to be associated
with parent–child conflicts as well as internalizing and externalizing symptoms of
the child [19].
In the context of heritability, ADHD parents are prone to have children affected
by ADHD and vice versa. Studies suggest that about one-quarter of children present-
ing with ADHD will have an ADHD parent and more than half of all parents with
ADHD will have a child with ADHD [20]. ADHD in parents was associated with
ADHD in offspring, but there were no differences between children of remitted ver-
sus persistent ADHD parents [13]. Accordingly, the mere exposure to parental ADHD
seems not to play a major role in the development of children’s ADHD pointing to
the significance of genetic transmission. However, gene–environment interactions
are present. For example, children’s ADHD diagnosis was associated with dopamine
receptor D2 genotype dependent of factors reflecting mother’s marital stability [21].
Thus, there is an impact of both genetic and psychosocial risk factors.
Children with ADHD have parents at risk for psychiatric disorders. This is in
line with the heritability of ADHD and the known patterns of comorbidity in adult
ADHD. Besides ADHD, higher rates of anxiety, depression, personality disorders,
and substance-related disorders have been described [22–24]. Comorbid disruptive
behavior disorders in children are associated with even higher rates of parental psy-
chiatric morbidity. It can be concluded that more extensive externalizing child
behavior problems seem to go hand in hand with lower parental resources.
10 ADHD in Families 173

Childhood ADHD challenges parental resources. Elevated levels of parental


stress and marital disagreement are commonly involved. Parents of ADHD children
are confronted with a wide range of challenging behaviors and problem areas, e.g.,
risk-taking behavior, low frustration tolerance and difficulties in accepting delayed
reward, frequent arguing and temper tantrums, restlessness, forgetfulness, academic
failure and homework problems, disorderly and disorganized behavior as well as
conflicts with peers and teachers. High levels of parental stress are common in par-
ents of ADHD children [25] and parental psychological strain has been found to be
correlated with externalizing symptom severity of the child [26, 27]. In an experi-
mental study simulated externalizing problem behavior of confederate children
induced higher parental distress, lower self-competence scores (less successful, less
effective, more hostile, depressed, and anxious), and higher urges to alcohol con-
sumption [28]. Most of the studies investigating parents of ADHD children found
elevated levels of marital conflict and disagreement. Study findings failing to show
this association might partly be due to a selection bias because highly disagreeing
separated parents could not be investigated [29]. Yet it has been shown that impaired
family functioning is correlated rather with the child’s disruptive symptoms than with
ADHD symptoms alone [30]. Moreover, interactions with gender have been described:
the impact of hyperactivity on family life might be more pronounced in ADHD boys
than in girls [31]. In sum, symptoms in parents and family conflicts can partly be
understood as consequences of the stress associated with rearing-up a child with
externalizing problem behavior.
ADHD children benefit from clear, consistent, structured, and rewarding parental
support. However, a lack of functional parental discipline practices is frequent in par-
ents of ADHD children. It has been observed that parents rearing up ADHD children
are more likely to be lax and inconsistent, less responsive, coercive—punishing, criti-
cizing, disapproving, controlling, and overreactive—as well as less supporting, less
rewarding, and more likely to ignore positive behavior. Family life is characterized by
parent–child conflicts while positive interactions are relatively sparse. However,
symptoms of oppositional-defiant disorder and conduct disorder seem to correlate
higher with negative parenting than ADHD symptoms alone [30, 32–34] (see for
review [29, 35]). The child’s authority-challenging, rule-breaking, and unregulated
behavior makes it difficult to their parents to react responsively and supporting.
Dysfunctional child-rearing practices of parents of ADHD children might rather
be a response to the children’s behavior than a cause of it. Engaging in a vicious
circle of coercive parenting can be viewed as a sign of parental helplessness. This is
supported by the fact that parents showed more adequate, consistent, and positive
parenting towards unaffected siblings or unrelated children than towards their ADHD
child [36, 37]. Negative and critical statements of the mothers towards their child
were found to be higher associated with the child’s symptoms than with maternal
psychopathology [38]. The impact of the child’s symptoms on parental practices is
also indicated by more adequate parenting after pharmacological treatment of the
child’s ADHD [39]. Moreover, longitudinal analyses taking environmental and
genetic factors into account point to an impact of boys’ ADHD symptoms on mother–
son hostility, while no effects in the opposite direction were found [40].
174 T. Jans and C. Jacob

Dysfunctional parental practices are associated with a more serious clinical


course of children’s externalizing disorders. Negative parenting does not seem to be
a cause of childhood ADHD. Yet it may have significant impact on the stabilization
of externalizing disorders as described in the social context model [41]. For exam-
ple, one study demonstrated that family conflict predicted adolescent-onset conduct
disorder in ADHD girls (in that study childhood-onset conduct disorder was pre-
dicted by paternal antisocial personality disorder) [42]. Dysfunctional discipline
practices, low parental self-esteem, and external attributions seeing the child as
responsible for poor compliance predicted a less favorable child treatment outcome
in the MTA study [43].
Taken together, in families of ADHD children poor parental skills and parent–
child conflicts may be more pronounced in the presence of paternal ADHD.
Bidirectional influences between externalizing symptoms of the child and coercive
parenting lead to a vicious circle of escalation [41, 44]. Dysfunctional parenting is
augmented by paternal ADHD and parental stress. In turn, parental stress is
influenced by parental psychopathology and health status as well as by the child’s
externalizing symptoms including severity of ADHD [45]. In sum, multiple transac-
tions can be found affecting the stability of ADHD families.
ADHD families of affected parents and affected children have a special need for
support. However, ADHD in parents might constitute a significant barrier to a suc-
cessful treatment of the child. Changing maladaptive parent–child interactions is the
major focus of behavioral parent training. Parent training is an evidence-based treat-
ment for childhood ADHD [46, 47]. Effects have been demonstrated on a wide range
of outcome variables, including externalizing child behavior and parental styles [39,
48, 49]. Reductions in negative and ineffective parenting practices at home did
mediate school-related outcomes [50]. Common treatment modules of parent
training—exemplified by Barkley’s manual [51]—are depicted in Table 10.1.
Weiss and colleagues point out that parents with ADHD taking part in psycho-
therapeutic interventions may have difficulty following instructions or complying
with a treatment regime [20]. They might tend to switch impulsively to alternative
treatment options, act disorganized, be argumentative, or have problems with the
implementation of strategies such as token economies and other consistent rewards.
Thus, treatment effects might be limited in the case of ADHD in parents. This has
been demonstrated in a study on preschoolers [52]. In high ADHD mothers, their
children’s ADHD symptoms were not improved after parent training, whereas in
low ADHD mothers, a substantial and stable decline was found.
The treatment of parental ADHD might be a prerequisite for the success of psy-
chosocial interventions for childhood ADHD. There are encouraging preliminary
study results on the treatment effects of parental ADHD on parenting, parent–child
interaction, and children’s mental health. In a single case study a mother with a his-
tory of ADHD was unable to profit from a parent training for her son’s ADHD [53].
After psychostimulant treatment of the mother, parenting strategies became more
adequate and the mother reported improvements of her son’s behavior as well. In
another case vignette a baby suffered a feeding disorder that led to two admissions
to a pediatric hospital [54]. ADHD was diagnosed in the mother. After stimulant
10 ADHD in Families 175

Table 10.1 Behavioral parent training for defiant children—main treatment steps
• Psychoeducation on symptoms, consequences, and treatment
• Attending to appropriate child behavior (attention, praise)
• Giving effective commands and responding immediately when the child complies
• Establishing a token economy
• Using fair consequences for noncompliant /inappropriate behavior (e.g., ignore, lose
privilege)
• Using a time-out procedure
• Managing noncompliant and inappropriate behavior in public places
• Improving the child’s school behavior (daily report cards)
• Summarizing the interventions and discussing future problems
• Booster sessions
Based on data from Barkley RA. Defiant children: A clinician’s manual for assessment and parent
training. 2nd. New York: Guilford Press; 1997

treatment of the mother the baby constantly gained weight. In a study on 23 mother–
child dyads after stimulant treatment of the mothers, a decline of maternal ADHD
symptoms and improved parenting skills assessed by maternal self-ratings were
found (effects on maternal involvement, poor monitoring/supervision, inconsistent
discipline, and corporal punishment) [55]. However, observing mother–child inter-
actions there were no substantial effects on parenting practices [56]. The authors
suggested that additional behavioral interventions might be necessary to address
impairments in parenting among adults with ADHD. The enhancement of parent
training efficacy by the treatment of maternal ADHD actually is under investigation
in an ongoing randomized controlled multicentre trial on 144 mother–child dyads
combining psychopharmacological treatment, cognitive-behavioral group psycho-
therapy, and parent training [57].
Besides the treatment of ADHD in parents, interventions targeting other parental
symptoms have utility for family health. Study of maternal depression treatment
offers encouraging results. Cognitive behavior therapy for mothers of ADHD chil-
dren was followed by improvements in maternal depressive symptoms, maternal
self-esteem, child-related cognitions, and family impairment [58]. In the Multimodal
Treatment Study maternal depression was interlinked to poor parental practices
leading the authors to conclude that targeting cognitive and affective factors in par-
ents might constitute an important additive treatment in some families with ADHD
children [59]. This surely also holds for the treatment of substance-related disorders
and other parental psychopathology.
Summing up, adult ADHD has a major impact on family functioning. Referring
to Fig. 10.1, the following interdependencies can be seen:
• Path 1: associations between adult ADHD, comorbid disorders, and psychoso-
cial impairment.
• Path 2: associations between parental ADHD, family maladjustment, and poor
child-rearing practices.
• Path 3: associations between parental ADHD and ADHD in the offspring.
176 T. Jans and C. Jacob

• Path 4: associations between ADHD in the child, parental disagreement, parental


stress, and poor parental skills.
• Path 5: elevated rates of psychiatric disorders in parents of children with exter-
nalizing disorders.
• Path 6: associations between family dysfunction, comorbid disorders, and addi-
tional psychosocial impairment.
Many of these associations are bidirectional and interlinked, leading to feedback-
loops with potential to worsen symptoms and psychosocial functions [29, 44]. On
the other hand, the interdependencies depicted in Fig. 10.1 also offer multiple
opportunities to break these vicious interactions. Moreover, there are chances that
improvements might generalize across other domains of function.
The impact on family health of the ADHD-impacted pathways summarized
above offers possible targets for intervention. However, they highlight negative
aspects of the overall picture and neglect positive resources that adults with
ADHD may contribute. ADHD is a dimensional disorder which can be more or
less pronounced in an individual. Symptoms might change over time. A decrease
of symptom severity from childhood to adulthood is frequently observed. Adults
included in studies on ADHD are often included on the basis of diagnostic crite-
ria requiring significant distress or psychosocial impairment, whereas subjects
with only subclinical symptoms are excluded. A significant part of these subjects
might have learned to manage ADHD and to cope with psychosocial conse-
quences. Focusing only on patients with symptom severity exceeding critical
cutoff scores will lead to an overestimation of the psychosocial burden associ-
ated with adult ADHD symptoms.1 Furthermore, results of studies on ADHD
patients mostly refer to group statistics comparing patients with controls. This
means that minor psychosocial difficulties can be highlighted by the compara-
tive analyses.
However, our discussion of how ADHD impacts family functioning summarized
above is valid, given the common presence of psychosocial problems worthy of
therapeutic support. A thoughtful clinical evaluation of a parent with ADHD would
also include a close look at the subjects’ capacities and resources. For example, with
respect to child-rearing practices, data suggests that mothers with ADHD may have
a better understanding of ADHD-related problems in their children [38]. A study on
Korean mothers with ADHD children identified three patterns of parenting (praise-
fairness, strict-control, sensitive response-balanced), emphasizing that a coercive
child-rearing style is not exclusively present. A therapeutic alliance may be gener-
ated in many cases by noting the foundation for further skill development that
existent productive parenting abilities provide.

1
However, it has to be stated that in clinical studies a selection bias in the opposite directions is
frequently present implying an exclusion of severely affected patients with major comorbidities
and severe psychosocial burden [60]. Thus, the representativeness of study samples may be affected
by the exclusion of both highly functioning ADHD patients and severely impaired patients.
10 ADHD in Families 177

Assessment of the Impact of Adult ADHD on Family


Functioning

Figure 10.1 might also serve as a map to illustrate the areas to be covered in the
assessment of family functioning in adult ADHD. First of all, a thorough assessment
of adult ADHD is needed according to current guidelines as outlined in chapter 2. The
diagnostic strategy comprises a screening for comorbid disorders and the assessment
of the level of psychosocial adaptation in important areas of daily life, including occu-
pational functioning and social relationships.
Particular attention should be given to collecting adequate information to evalu-
ate the impact of ADHD on family life. This may come from partners, spouses,
parents, and older children. In addition, global rating scales covering psychosocial
adaptation or quality of life can be used. Scales focusing more specifically on psy-
chosocial consequences frequently present in ADHD patients may be helpful. For
example, the Weiss Functional Impairment Rating Scale—Self Report (WFIRS-S)
can be recommended (part of the CADDRA ADHD Assessment Toolkit). The scale
includes items referring to family relations and other social relationships, work and
school, life skills, self-concept, and risk-taking behavior. A summary of the scale is
presented in Table 10.2. We show each of the domains covered by the WFIRS-S
here, both to indicate the multiple domains to be addressed in assessing an individ-
ual with ADHD and to allow the reader to contemplate how these domains may
impact family options and functioning.
A selection of rating scales covering patterns of parenting, partnership, and fam-
ily functioning is presented in Table 10.3. For most of these scales norms are not
available. However, the inspection of response patterns provides clinically valuable
information. Scores of the patient and his or her partner can be compared.
Reassessments allow evaluation of treatment impact.
For the assessment of parent–child relationship, child-rearing practices, and mar-
ital function, information should be gathered from the patient, his or her partner, and
the child(ren) to take into account the needs and wishes of each family member. The
observation of family interaction is also an important source of information.
Observation should be directed to the way conflicts are discussed within the family
as well as to the atmosphere during conjoint activities, such as family games.
As a consequence of ADHD treatment family functioning might improve with-
out the implementation of specific family interventions. Thus over treatment it
might become clearer if more specific interventions are needed to stabilize family
functioning. Therefore, family assessment can be limited to a screening in order to
obtain an overview on family functioning. A more sophisticated view on family
function might or might not be indicated later in the course of treatment.
The assessment of family functioning should always include a screening of the
patient’s child(ren) for psychiatric disorders and for academic and social impair-
ment in order to implement treatment and support, if necessary. If there are signs of
psychiatric symptoms or impairment in the patient’s partner and the therapeutic
contact is stable enough to raise this question, the partner should either be evaluated
or referred for diagnostic evaluation.
178 T. Jans and C. Jacob

Table 10.2 Functional deficits covered by the Weiss Functional Impairment Rating Scale—Self
Report (WFIRS-S)
Family conflict Work
• Overall problems with family Problems with
• Problems with spouse/partner • Performing duties
• Excessive relying on others • Getting work done efficiently
• Causing fights in the family • Supervisors
• Restricting fun in family activities • Keeping a job
• Problems taking care of family members • Getting fired
• Problems balancing own needs against • Working in a team
those of the family • Attendance
• Losing control over family • Being on time
• Taking on new tasks
• Working to own potential
• Poor performance evaluations
School Life skills
Problems with Problems with
• Taking notes • Excessively or inappropriately using
• Completing assignments internet, video games, or TV
• Getting work done efficiently • Keeping an acceptable appearance
• Teachers • Getting ready to leave the house
• School administrators • Getting to bed
• Meeting minimum requirements to stay in • Nutrition
school • Sex
• Attendance • Sleeping
• Being on time • Getting hurt or injured
• Working to own potential • Avoiding exercise
• Inconsistent grades • Keeping regular appointments with doctor/
dentist
• Keeping up with household chores
• Managing money
Self-concept Social relationships
• Feeling bad about oneself Problems with
• Feeling frustrated with oneself • Arguing
• Feeling discouraged • Cooperating
• Not feeling happy with own life • Getting along with people
• Feeling incompetent • Having fun with others
• Participating in hobbies
• Making friends
• Keeping friends
• Saying inappropriate things
• Complaints from neighbors
Risk-taking behavior • Being involved with the police
Problems with • Substance abuse (cigarettes, marijuana,
• Aggressive driving alcohol, illegal drugs)
• Doing other things while driving • Sex without protection
• Road rage • Sexually inappropriate behavior
• Breaking or damaging things • Physical aggression
• Illegal behavior • Verbal aggression
Note. This is a summary of items covered by the WFIRS-S. Items are modified in order to present
a general view and must not be used in this abbreviated form for diagnostic purposes. The original
form is available in the public domain (www.caddra.ca) and a version appears in the Appenix.
The WFIRS is copyrighted by the University of British Columbia (2011)
10 ADHD in Families 179

Table 10.3 Rating scales covering patterns of parenting, partnership, and family functioning
Rating scale Assessment of Subscales
Parenting stress index Child characteristics, Child characteristics:
(PSI) [73] parent personality, • Distractibility/hyperactivity
and situational • Adaptability
variables as • Reinforces parent
possible sources • Demandingness
of parental stress • Mood
• Acceptability
Parent/situational characteristics:
• Competence
• Isolation
• Attachment
• Health
• Role restriction
• Depression
• Spouse
Parenting sense of Negative and positive • Dissatisfaction (manipulation,
competence scale aspects in the frustration, low motivation)
(PSOC) [74] parenting role • Efficacy (skills, problem-solving
ability, familiarity with parenting)
Parental locus of control Parental attributions • Parental efficacy
scale (PLOC) [75] or influences on • Parental responsibility
child behavior • Child control
• Belief in fate or chance
• Parental control
Parenting scale (PS) [76] Dysfunctional • Lax discipline
discipline • Overreactive discipline
• Verbose discipline
Dyadic adjustment scale Relationship • Dyadic satisfaction
(DAS) [77] adjustment • Dyadic consensus
• Expression of affection
• Dyadic cohesion
• Overall adjustment
Family assessment Structural and • Behavior control
device (FAD) [78] organizational • Affective involvement
properties of the • Roles
family, group, and • Communication
interactions • Problem solving
between family • Affective responsiveness
members • General functioning
Family impact Impact of • Negative feelings and attitudes
questionnaire externalizing child about the child
(FIQ-R) [79] behavior on • Positive feelings and attitudes
family functioning about the child
• Impact of the child on parents’
social life
• Financial impact of the child
• Impact of the child on marital
relationship
• Impact of the child on siblings
180 T. Jans and C. Jacob

Assessment strategies must not be understood as a mere description of problems


and impaired functions. An assessment restricted to unfolding the patient’s failure in
important domains of his life will clearly be discouraging. Such a dampening of self-
esteem is commonly seen in patients with ADHD reflecting the former course of their
life. However, ADHD adults have developed strategies to cope with ADHD symp-
toms and consequences. Some of these coping mechanisms might be dysfunctional,
others might be highly effective. Moreover, it is worthwhile to uncover examples of
success and personal strengths in the patient’s history. These life skills have to be
emphasized and the patient has to be validated for his efforts and resources.
Strategies and results of assessment should be made as transparent to the patient
as possible. A functional model of the patient’s ADHD including antecedents and
consequences of problem behavior has to be developed in cooperation with the
patient. In addition, the patient’s health beliefs on the causes of ADHD, its role in
family functional challenges, and effective supports for these challenges are impor-
tant to facilitate creation of a treatment plan and establishment of therapeutic tar-
gets. Thus, transparent assessment constitutes an important psychoeducational
function and is essential for building up motivation for change.

Therapeutic Approaches

The need for therapeutic support varies between patients. The severity of symptoms
and impairments varies between subjects with ADHD. Symptom manifestations can
be specific to age or developmental stage manifestations of the symptoms. For some
subjects with ADHD, this seems to be consistent with an underlying delay of the
neurobiological maturation of the brain. Patients and their family members also
often adapt and cope with the symptoms and the resulting family conflict.
Accordingly, there is a varying need for professional help with parenting and mari-
tal function. This emphasizes the need for a detailed assessment yielding to the
definition of individualized targets of treatment.
Even in the case of severe family dysfunction, ADHD and comorbid conditions are
an important target for treatment. Dysfunctional parenting strategies and high rates of
conflict within the family are seen in a substantial portion of ADHD adults. However,
the need to stabilize family relationships does not imply that family issues have to
constitute the primary focus of intervention. Impairments in family life often result
from ADHD. Therefore, ADHD symptoms often have to be treated first. According to
current guidelines, the treatment of choice is a multimodal intervention comprising
pharmacotherapy, psychoeducation, and cognitive-behavioral therapy to enable the
patients to deal with remaining symptoms and impairments [61–63]. By treating
ADHD, family dysfunction might significantly decrease. Pharmacotherapy of adult
ADHD has been shown to have a positive impact not only on ADHD core symptoms
but also on functional impairment including family conflict [63]. In addition, treat-
ment of comorbid disorders can be a prerequisite for stabilization of family relations
and other psychosocial problems (e.g., in the case of substance dependence).
10 ADHD in Families 181

If the patient’s partner or children suffer from a psychiatric disorder, specific


treatment also has to be implemented before engaging in extended family interven-
tions. Parent–child conflicts might significantly decrease with the treatment of the
child’s externalizing disorder. Data suggests that the duration of ADHD pharmacologic
effect can have an impact on child-related parental distress [64]. In the case of family
conflict or parent–child hostility it has been concluded from treatment studies as well
as from community-based surveys that treatment of a child’s externalizing symptoms
should be prioritized over addressing parent–child interaction directly [40, 65].
Treatment modules of cognitive-behavioral therapy programs for adult ADHD
are highly suitable to address family problems. As emphasized in a chapter 7, evi-
dence-based psychotherapeutic approaches for the treatment of adult ADHD share
a cognitive-behavioral background [66, 67]. The following modules have been
incorporated in treatment programs: psychoeducation about ADHD; decreasing
self-blame with respect to ADHD symptoms; time-management, planning, and
organization skills; cognitive restructuring (building up adaptive thoughts to deal
with task avoidance, procrastination, lack of motivation, and negative affect); prob-
lem-solving skills; anger control training; re-training cognitive and executive func-
tions; and situational solutions (modifying the environment). Dialectical-behavioral
approaches have also been applied: mindfulness training; self-application of func-
tional analysis of problem behavior to get insight and to develop strategies to change
antecedents and consequences; skills to cope with impulsivity; and skills to regulate
emotions. In all programs for behavioral change, homework assignments play an
important role. Individual coaches have been used to assist the patient with the
implementation of management strategies in his or her daily life. These strategies
for adult ADHD are highly suitable to address family problems. In short, the main
purpose is to support the patient to be a more reliable and more self-controlled part-
ner and parent. In Table 10.4 examples are given of interventions appropriate to
adult ADHD that can be applied to family issues. This is far from a comprehensive
list of strategies. Nevertheless, examples might demonstrate that techniques appro-
priate to intervention with individuals with ADHD are often appropriate to apply to
family problems. In fact, successful family interventions will depend on generaliza-
tion of skills acquired by individual members of the family.
It is important to get the patient’s partner involved in treatment. This requires
that they have information on ADHD symptoms, consequences, and planned treat-
ment steps. The partner might be motivated to take the role of a coach, assisting the
patient to implement self-management skills in his daily life. Actually, partners are
usually already involved in compensating for the patient’s dysfunctional manage-
ment of household organization, time management, child-rearing, work, school, or
financial issues [14]. However, these activities might clearly be annoying for some
of the partners. A mutual agreement between the patient and his or her partner, bal-
ancing the partner’s support and the patient’s responsibilities, is a valuable target of
treatment.
Engaging the partner in the planning of therapeutic targets might be introduced
by the following questions [68]: Which symptoms of ADHD do you think are most
problematic for family members? What are the most important ways in which these
182 T. Jans and C. Jacob

Table 10.4 Applying psychotherapeutic strategies appropriate to adult ADHD to family


problems
General aim of the intervention: Application to family problems—examples:
Mindfulness training: to become more Mindfulness might help an individual:
aware of the current (social) • Reflect on their feelings and behavior as an
situation, internal states (including important precondition to engaging in self-man-
perceptions, emotions, cognitions, agement skills
motives), and behavior in an • Get to a more accepting mindset with respect to
accepting and non-evaluating manner difficult traits or conduct of family members
to be able to act more effectively • Be more empathic, to see the situation from the
view of family members
• Be more present during the interaction with
family members instead of thinking of many
other things
• Do only one activity at the same time (e.g., when
assisting the child to complete his homework
assignments)
Emotion regulation/anger control Skills for emotion regulation might help:
training: to able to lower the • Prevent angry, impulsive reaction in conflict
intensity of emotional states with family members
• Prevent harsh punishment or other inappropriate
negative consequences in case of noncompliance
of the child
Problem-solving training: fosters a Problem solving might allow thoughtful approaches
stepwise approach towards goals, to family problems instead of impulsive
using brainstorming, evaluating pros switching from one strategy to another, e.g.:
and cons of each strategy, deciding • How to manage work, household, child
on a strategy, and planning its supervision, and leisure time activities
implementation • How to help a child to build relationships with
children in the neighborhood
• How to deal with a financial problem
• How to allocate family duties to family members
Impulse control training: to align Impulsive behavior often fulfills immediate wants at
behavior with personal goals taking into the expense of other goals, which can neglect the
account consequences for others needs of other family members. Patterns of
impulsive behavior may be identifiable, allowing
pre-emptive effort to balance personal and
family needs
Cognitive restructuring—adaptive Examples of negative thoughts to be reframed:
thinking: to identify negative • Why should I praise my child for complying one
automatic thoughts and thinking time while they frequently disobey?
errors and to develop rational • I’ve been trying to help my child to meet
responses in order to cope with academic demands for years now: there’s no
negative emotions and motivational chance—it won’t work!
barriers • My child is lazy—his lack of motivation is not
my problem!
• Teachers will always be as unfair to my child as
they were towards me during my school days!
• He’s right to criticize my poor housekeeping—
its all my fault, and all my responsibility to do a
better job!
(continued)
10 ADHD in Families 183

Table 10.4 (continued)


General aim of the intervention: Application to family problems—examples:
Organization skills (time-management, Organization skills might help reliability as a
using calendars and time tables, partner and parent, e.g.:
prioritizing tasks using to-do-lists, • Being on time to pick the child up after school
dividing overwhelming tasks into or sports
manageable steps, keeping order • Establishing a time-table for the week with time
using folder systems, managing periods to, for example, get homework done,
distractibility and procrastination, complete parent-training homework, have fun.
using memory aids) • Establishing a plan for how to assist the child
step by step to improve his vocabulary in a
foreign language
• Using a time table to accomplish therapeutic
homework assigned during parent training
• Using folders to keep track of the child’s
documents (report cards, pediatric examinations,
immunization schedules, identification cards,
etc.)
Functional analysis of problem behavior: Self-administration of functional analysis might
to train the patient to analyze help the patient get insight about family conflicts
problem behavior in the framework and develop strategies to cope with recurrent
of functional analysis (describing the patterns. Applying functional analysis estab-
situational context and problem lishes a focus on the factors contributing to an
behavior together with cognitions, adult or child’s behavior so they can be
sensations and emotional reactions; addressed. Use of reinforcement and extinction
analyzing the behavior in the (to change antecedents and consequences) is
framework of antecedents and preferable to coercion and punishment
consequences)

symptoms have affected the relationship with particular family members? General
advice to enhance the partnership includes recommendations such as [69]: Establish
clearly for yourself the significance your partnership holds for you—and say it to
your partner! Take time for your partnership, make clear appointments to talk about
your relationship—and keep the appointment! Approach management of ADHD as
a team—discuss problems, wishes, and possible solutions! Write down possible
solutions and keep track of the implementation! Regularly praise your progress!
Keep your sense of humor dealing with your ADHD!
Training in communication skills might reduce arguing between partners. It has
been noted that enhancing communication and mutual understanding is an impor-
tant goal in ADHD couples [70]. Controlled dialogue is a well-known intervention
in behavioral family therapy, although controlled studies on this approach for
ADHD patients are not available.
In the case of ADHD in the child, parent training should be offered to the ADHD
parent in order to strengthen his parental skills. However, the indication of parent
training is not restricted to children affected by ADHD or oppositional-defiant disor-
der. With only minor variations the strategies covered by behavioral parent training
programs are also used for preventive purposes. Relevant treatment steps are outlined
184 T. Jans and C. Jacob

in Table 10.1. Important goals of parent trainings are: to escape the vicious circle of
coercive or lax parenting, to build up positive parent–child interactions, to supervise
the child age-appropriately, and to balance strategies of reinforcement, extinction,
and setting negative consequences. The principles of parent training are not that com-
plicated, but regular implementation and habit formation in daily life can be straining
for any parent. Treatment must focus on tangible goals. Repetition is needed. Training
should be interactive, including role playing and video analysis, and must not be
restricted to mere advice. Parental involvement might be enhanced by applying train-
ing to family activities preferred by the parent—such as a sports activity. It is impor-
tant to build agreement and corresponding strategies between parents in response to
their child’s behavior because parents might disagree about medication and other
treatment strategies and thus provide mixed messages to the child.
The older the ADHD child, the more he or she has to be involved in the elabora-
tion of the treatment plan. A family council might be held to decide behavior rules
appropriate for particular family members and to keep track of their implementa-
tion. This cooperation is especially important for adolescents for which there is a
fine line in the balance of age-appropriate responsibility and self-determination on
the one hand and the need for parental support and supervision on the other hand.
Management of ADHD in the transition to adulthood is a main focus of chapter 9.
However, we note here that problem-solving and communication training as an age-
appropriate intervention to change parent–adolescent conflict in addition to age-
adapted parent training.
The main steps of parent–teen treatment involve problem-solving, communica-
tion training, and cognitive restructuring to enhance more adaptive beliefs about
each other’s behavior. However, families might feel overwhelmed with such train-
ing at the very start of treatment and teens’ commitment might be rather low.
Moreover, if significant parent–teen conflicts are present, we feel that the family
might be ineffective as an instrument of change, pointing to the need for additional
or alternative interventions, e.g., medication treatment. In adolescents, clinic-based
interventions may offer more limited success than real-life, home-based
intervention.
In general, psychosocial interventions for teens with ADHD should involve the
following principles [71]: strong involvement of the teen in the planning of inter-
ventions; prioritization of organization, time-management and self-management
skills; age-adapted contingency management by the parents; and more intensive
school-based interventions. Although cognitive strategies such as problem-solving
and concentration training may have limited efficacy due to problems in generaliza-
tion [72], self-management skills seem to work in ADHD adults. It thus may be
valuable to offer these interventions to ADHD adolescents. The parent may have a
role in coaching teenagers in the implementation of self-management skills.
However, responsibility for additional structure can burden an ADHD parent, under-
scoring the need to activate additional resources.
The activation of additional resources is often needed to support parents and
children. Behavior change is most effectively achieved by immediate consequences
when the behavior occurs. For school behavior, contingency management can be
10 ADHD in Families 185

implemented in cooperation with school officials and therapists. The use of daily
report cards in combination with token economies has proven to be supportive.
Daily contact, such as through written communication, between parents and teach-
ers can allow parents to offer rewards or consequences. School psychologists and
social workers should assist whenever possible. Environmental changes relieving
overburdened parents might be necessary: full-time school, after school care, attend-
ing a school for therapeutic pedagogy, and private lessons should be considered. In
the case of low parental resources or severely conduct disordered children, social-
work assistance is important. The method of implementation depends on the struc-
ture of the social system of the particular state or country the family is living in.
Municipal social services, the youth welfare office, social-work assistance for the
family and for the ADHD teen or parent or legal guardians might be important
resources to assist the family. Educational counseling and home treatment may in
some cases be delivered by regular home visits by social workers or other
therapists.
Regional ADHD support groups and self-help groups, as well as online support
communities, might offer important additional support for adult ADHD and for par-
ents of ADHD children.
Couples therapy or family therapy might be indicated if there is insufficient
change in family functioning after the implementation of interventions directed to
treat parent’s ADHD and comorbid disorders as well as disorders and impairments
in family members representing sources of family maladjustment.

Key Points

• In ADHD families an accumulation of psychosocial risks and impairments is


frequently seen. Multimodal assessment of adult ADHD has to be broad enough
to address possible personal and environmental factors. The patient’s partner and
child(ren) should also be screened for psychiatric disorders. Elevated rates of
ADHD are present in the offspring of ADHD parents.
• Resources and solutions should be offered as part of any clinical consultation on
ADHD-related family challenges to support motivation for change.
• Family conflict including marital disagreement, parental stress, and poor educa-
tional practices is frequent in ADHD adults. Stabilization of family functioning
is often needed. However, this does not imply that family-focused interventions
are the first choice of therapy.
• ADHD and comorbid conditions have to be treated first. Multimodal support for
mental health conditions should be applied for any family member impacted, and
this may lead to significant improvement in family functioning.
• There are several cognitive-behavioral and training approaches that can help
families cope with ADHD. Skills acquired during individual psychotherapy or
training can reduce family conflict. Awareness and skills gained in the family
186 T. Jans and C. Jacob

setting might also apply to other close social roles (e.g., relationship with boss or
coworker, in church or other social groups).
• Avoid overburdening the ADHD patient by addressing too many therapeutic tar-
gets at the same time. “Going step by step” and “doing one thing at a time” will
be important slogans for the therapist.
• Partner involvement is important. In drawing on the partner’s resources to assist
the ADHD patient, it is important to find a balance between the partner’s support
and the patient’s personal responsibility.
• The treatment of an ADHD parent seems to be an important precondition for
psychosocial intervention in a child’s externalizing symptoms. This points to the
need for a close cooperation between child, adolescent, and adult mental health
services.
• More specific couples therapy or family therapy might be indicated if the thera-
peutic strategies stated above do not lead to a significant reduction of family
conflict.
• A portion of ADHD families also have severe psychosocial impairment or other-
wise lack parental resources that a disorder-specific treatment should not to be
expected to change. Additional support by social services should be utilized for
these families.

Acknowledgements Our research on the treatment of ADHD is supported in part by the German
Federal Ministry of Education and Research (BMBF; 01GV0605, 01GV0606) within the frame-
work “research networks on psychotherapy.”

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Chapter 11
Clinical Dilemmas in the Assessment
and Management of ADHD in Adults:
A Psychiatrist’s View from an Urban
Hospital Clinic

Anton Pesok

Abstract This chapter discusses common considerations that arise in the evaluation
and treatment of patients with attentional difficulties in an urban hospital clinic.
While some cases are straightforward to address, others are more complex and
require thoughtful decisions by the clinician regarding diagnostic strategies, prac-
tice management, and treatment planning. There is little clinical research to inform
best practices in such complex scenarios, so this chapter offers insights from experi-
ence in an outpatient psychiatric clinic of a general hospital.

Introduction

In prior chapters, this text has detailed expert approaches to the assessment and
treatment of ADHD in adulthood. However, in daily clinical practice, there are par-
ticular dilemmas that emerge in working with this population that are worthy of
careful thought. Although in many cases treatment for ADHD is transformative,
who should receive such treatment and what kind of treatment they should receive
can be complicated to figure out.
We do see many (mostly young) men and women who come into an outpatient
psychiatry clinic of an urban hospital wanting to be “evaluated for ADHD.” There
are several clusters of complicating factors that we have been able to identify and
perhaps found some ways to address with this patient population. It is frequently
hard to see clear paths out of the woods, but we would like to point out certain paths
that may lead deeper into them.

A. Pesok, M.D. (*)


Department of Psychiatry, Beth Israel Deaconess Medical Center,
330 Brookline Avenue, Boston, MA 02215, USA
e-mail: apesok@bidmc.harvard.edu

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 191
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3_11,
© Springer Science+Business Media New York 2013
192 A. Pesok

• “My new patient requests an emergency evaluation for ADHD.” You would think
that ADHD has a seasonal pattern! These young college students come in around
November when the sky starts to fall as the end of semester is nearing. If they do
have prior history of good diagnostic workup and successful treatment, perhaps
it is appropriate to resume their stimulant medication. If this is their first evalua-
tion, however, it would be very important to resist getting rushed. You might
need to tell them that you require time to get to know them and their situation.
Patients might perceive their predicament as a true emergency, therefore it might
be quite appropriate to focus on their specific difficulties and on reasonable dam-
age control, rather than to speculate whether or not they have a chronic condi-
tion. They should ask for a medically based extension or take a leave if they
must.
• “Can I trust what my patient is telling me?” You cannot have a therapeutic rela-
tionship if you do not trust your patient. It can be easier to seek corroborative
information early in a treatment—such as reports from prior treatment, records
from school or work, perspectives from significant others, collection of neurop-
sychological data, or referral for second opinion by a colleague. However, there
are some patients where one will still have questions about what the person’s life
and challenges are really like. Experience suggests that such intuition can be
very valuable, and it is a recipe for problems to pursue interventions without
confidence about what the real issues are.
• “Should I refer patients for neuropsychological evaluation?” It depends. As is
emphasized in this text, ADHD diagnosis cannot be made based on tests. Reasons
for neuropsychological testing are outlined in the chapter 4 on that topic in this
volume, but in clinical practice these are the most common:
(a) You are not sure if ADHD is present and you would like another set of eyes
to take a look.
(b) You are deciding where to start with addressing a spectrum of confusing
comorbid conditions, but the presence of robust cognitive impairment may
help you choose a treatment.
(c) You suspect presence of learning disability or other cognitive impairment
that may be a reason for academic distress and may be accommodated.
Learning disabilities do not respond to stimulants, although improved atten-
tion may help these patients to compensate better.
(d) To gather evidence for or against thought disorganization (psychosis).
(e) To establish metrically the severity of their forms of distress or functional
impairment.
(f) To rule out a dementia process or establish a baseline for comparison later.
(g) To provide documented need for disability accommodation by an institution
or agency.
• “I have concerns that my patient with ADHD might be abusing substances.” As
previously discussed in this text, stimulant treatment is inappropriate for most
patients who are actively abusing a substance. But we do not always know
whether we can trust the patients who say they are not. Moreover, presence of
11 Clinical Dilemmas in the Assessment and Management of ADHD in Adults… 193

ADHD does not protect patients from misuse of prescription medication


themselves or from sharing it with others. The core question to address here is
whether or not they are serious about working towards abstinence and can be
straightforward with you about substance abuse.
Many people may now feel it is normal to experiment on their own with other
people’s medications or illicit drugs. One can explain that you can only provide
care to them if they work collaboratively with you—that you need to know what
they are taking and need to agree on the dosing and agents together. You want to
know the “strategies” they have tried to treat themselves and how agents impact
them. Treatment planning should also include an open discussion about possible
impact of psychoactive substances on mental health and cognitive function as
well as potentially risky interference with prescribed medications. Laboratory
toxicology screening for substances of abuse can also be considered, but if this is
being considered it is likely that there is enough clinical concern that abusable
agents should be avoided altogether. Where testing is utilized, the purpose of this
testing should be agreed on between doctor and patient—if the testing is seen as
unwanted monitoring, it may compromise the treatment alliance.
• “How do I understand anxious or preoccupied patients who appear inattentive or
restless?” Anxiety, mood distress, and other preoccupying mind states can be a
source of internal distraction and produce symptoms that look like ADHD.
Sometimes in the course of treatment, these other traits will emerge or persist in
a pattern than indicates their previously unappreciated clinical importance. We
have seen many patients for whom racing thoughts and resulting inability to stay
with feelings, including intolerable ones, appears to be a psychological defense
accumulated during years of failures. Keep it in mind; explain the connection
between other kinds of distress and attention/behavior problems early in working
with such patients.
• “My patient meets criteria for mood disorder, anxiety disorder, and ADHD.”
Welcome to modern psychiatric taxonomy. As discussed in the chapter 8 on com-
mon comorbidities, clinical experience suggests that you are often better off
addressing impairing mood and anxiety symptoms before ADHD. In the absence
of a clear priority among the comorbidities, it is practical and alliance building to
choose the primary target collaboratively with the patient. One can ask them
whether they feel more burdened by mood, anxiety, or control of focus, acknowl-
edging that they are interrelated. After treating the clinical priority, reevaluate.
Do they still have attentional difficulties and hyperactivity? As discussed in
chapters 3, 8, 9 on comorbidity in this text, there is largely anecdotal evidence to
guide choice of treatment in comorbid presentations. It is thus rational to treat a
clinical priority with the agent indicated for it (such as sertraline for comorbid
depression) or to use an agent that may address multiple issues (such as bupro-
pion for depression and ADHD). Sometimes choice of treatment is informed by
the complications a treatment option can cause. For example, if you use benzo-
diazepines, they may end up on two potentially addictive substances. Where
comorbidity is present, there is greater importance of careful differential diagno-
sis, serial re-evaluation of treatment priorities and efficacy, and use of non-med-
ication interventions.
194 A. Pesok

• “Patient is late and/or misses appointments.” Try to supportively confront and


explore tardiness. This discussion may be very important, as it likely happens
with your patients outside of your office too. Individuals with poor time manage-
ment often have other organizational challenges—as this guide has highlighted,
they deserve specialized and personalized support. Some patients run late and
some do not show up no matter how much time you have spent in thoughtful
discussions about the subject. Have a strategy before you start getting resentful.
Some clinicians would not see a patient if they are more than “x” minutes late.
Some would have a strict missed appointment policy which they discuss with
patient in the very beginning of treatment—i.e., “If you miss appointments or
make last minute cancellations, I may recommend that you seek care elsewhere
due to your difficulty using our services.” Decide if you want to have your office
staff call with appointment reminders. Fees for missed appointments are a pos-
sible incentive as well—but one has to be mindful of the regulations of insurers
and of your institution.
• “What about non-medication therapy for ADHD?” This subject has been dis-
cussed in detail previously in this text. Successful clinicians seem to blend meth-
ods of cognitive behavioral therapy (CBT) with organizational skills, life
coaching, and motivational interviewing. As the Treatment Planning chapter 3 in
this text emphasizes, interventions should be offered that the individual is likely
to be able to adopt. Organizational impairments, as the Treatment Planning chap-
ter emphasizes, will get in the way of adherence to interventions unless they are
supported.
Despite the fact that ADHD has become a widely recognized condition, exper-
tise in applying supports for the condition is still relatively rare. Many individuals
may provide the forms of non-medication supports discussed in this guide. Any
individual who has professional training in supporting emotional, learning, or
other functional challenges could be a resource. Coaching professionals, speech-
language pathologists, occupational therapists, rehabilitation specialists, voca-
tional counselors, educational tutors, psychologists, social workers, or psychiatrists
may all have applicable experience. Although it is critical to avoid overburdening
family members, they are often able to achieve mutually beneficial accommoda-
tion to a patient’s challenges. Don’t underestimate also the usefulness of commu-
nity groups or consumer organizations. A clinician can do a great service to steer
patients towards the right resources that will enable them to grow.
• “Should I be concerned about other developmental disorders in my patients with
ADHD?” Autism spectrum and low IQ patients may present with ADHD-like
symptoms, and it can help to evaluate whether ADHD is a comorbidity by carefully
considering whether their impairments are confounded by these symptoms. Patients
with developmental disorders often do not respond to psychotropic medications in
predictable ways. They also have high rates of other psychiatric disorders (also
frequently expressed in atypical ways) so watch carefully for the need to manage
contraindications such as bipolar and psychotic disorders. Learning disabilities
may accompany ADHD and impede both treatment and patient’s ability to develop
compensatory coping strategies.
11 Clinical Dilemmas in the Assessment and Management of ADHD in Adults… 195

• “Would this be cognitive enhancement or treatment of ADHD?” Threatened job


security, lack of flexibility in the job market, and increasing push for longer
hours and accelerated productivity would make cognitive enhancers more attrac-
tive to working adults. Poor studying habits and attempts to master material
beyond one’s cognitive abilities would make them more attractive to college stu-
dents. Instead of providing more structured and personalized environment, strug-
gling public schools might get pushed to outsource the problem to an already
stretched mental health care system.
The medications are also sought because they are there! One of every five
respondents to a poll conducted among readers of a major science journal
reported using stimulant medications for non-medical reasons to stimulate their
focus, concentration, or memory [1] while studies place chance of having ADHD
to about 1 in 20. A recent analysis of stimulant prescription pattern data from
school-age children suggests that 30% of stimulants may be diverted to non-
medical use [2]. The demand for prescription stimulants significantly exceeds
the needs of patients with ADHD.
Symptoms of inattention, hyperactivity, and impulsivity can be present in
many normal and pathological states. They can be fabricated, deliberately or
unconsciously amplified. They can be situational and transient. They do not nec-
essarily represent ADHD.
There is an emerging debate over whether stimulant medications should be
available to general public as cognitive enhancers or be restricted for medical
use—as reflected in the article by Margaret Talbot [3], physicians should be mind-
ful of established criteria for diagnosis of ADHD, existing guidelines, and laws
pertaining to prescribing practices. Assessment of impairment should be made
relative to what is reasonably expected of a person given their capacities—relative
to who they “are”—not relative to who they think they “should be.” The Clinical
Assessment chapter 2 discusses factors that can mask or mimic impairment and
offers perspective on the difference between “enhancement” and “accommoda-
tion.” This kind of determination is based on clinical experience and a deep under-
standing of a person’s potential and pattern of personal growth.
If a reasonable change in environment would eliminate impairment, it is pref-
erable to help the patient work towards that than to change their pattern of brain
function. Ongoing conversation about whether treatment is necessary or envi-
ronmental change would be sufficient, emphasis on formulation of longer-term
goals (such as future career, living a life where work and personal time are bal-
anced) can help patients move away from struggle with frustrating daily stres-
sors to making more adaptive, strategic decisions about life.
• “History is suggestive of ADHD, but there is so much chaos in patient’s life that
the issue of ADHD seems to be relatively minor.” ADHD and executive function
deficits that often accompany it often cause more suffering where support and
structure are lacking. Even where there are services available to address stressors
like unemployment, lack of supportive relationships, lack of sustainable housing,
or lack of health care, these assistance services may be hard to access. It can
demand excellent focus and executive functioning to complete paperwork, visit
196 A. Pesok

offices dispersed across town, and fit appointments in. Patients struggling with
such stressors and organizational problems like ADHD may not be considered
severe enough to merit support from government agencies serving the mentally
ill. Social workers and other community resource specialists familiar with sup-
porting chronically ill patients are very helpful to treat this subpopulation. Try to
set realistic and practical goals for treatment and discuss these steps with your
patients. Unfortunately, you also may be wise to proceed with caution in pre-
scribing substances that have high abuse potential and may be sold on the street
where mental health care may be a low priority in an individual’s effort to
survive.
• “I am still uncomfortable treating this patient”
“First do no harm”—for the treatment to proceed, the risks of treating (physi-
cal, mental, and psychological) should be considered and should be outweighed
by the mental and psychological risks of not treating. If you can’t in good con-
science prioritize treatment for an “ADHD” complaint (such as during severe
unstable mood, during substance addiction, or where you aren’t sure if it really
is “ADHD”), you should offer hope that there can be more clarity around the
issue in the future. In such cases, explain that the chronic issue with focus or
behavior may be better addressed once it is better understood or if the more
severe condition is managed.
Engage the patient in gathering more information, if that will help you make
a diagnosis and recommendation. This can be done by referral to other colleagues
who can meet more frequently with the patient or offer a different perspective.
The ASRI inventories in the Appendix can be administered serially to monitor
the stability of the concerns. In the absence of clear diagnosis of clinical priority,
it may still be appropriate to suggest low-risk supportive interventions, such as
environmental accommodations or non-medication therapies. There are thus
ways to offer what you can, including hope, and keep a patient engaged in
healthy work.
As in all medical care, it may be helpful to remember that “Naura sanat, medicus
curat morbos”—“nature heals, the doctor only administers the cure.” We should
always be aware of our limitations and be attentive to the patient’s reality and
goals.

References

1. Maher B. Poll results: look who’s doping. Nature. 2008;452(7188):674–5.


2. Swanson JM, Wigal TL, Volkow ND. Contrast of medical and nonmedical use of stimulant
drugs, basis for the distinction, and risk of addiction: comment on Smith and Farah (2011).
Psychol Bull. 2011;137(5):742–8.
3. Talbot M. Brain gain: the underground world of “neuroenhancing” drugs. The New Yorker. April
27, 2009.
Appendix

Guide to Use of Appendix Items in Clinical Practice ......................................................... 197


Items for Clinicians
Adult ADHD Diagnosis Checklist ........................................................................................... 198
ADHD Differential Diagnosis and Cognitive Comorbidity Inventory .................................... 199
Adult Symptoms and Role Impairment Inventory (ASRI) ...................................................... 200
Instructions ......................................................................................................................... 200
Self and Third-Party Inventories ........................................................................................ 200
The Clinician Inventory ...................................................................................................... 200
Items to Give Clients
Clinician Adult Symptom and Role Impairment Inventory Guide .......................................... 202
Clinician Adult ADHD Symptoms and Role Impact Inventory Rating Sheet ......................... 205
Treatment Planning Form for ADHD + Organizational Impairment........................................ 206
Instructions ......................................................................................................................... 206
Treatment Targets ............................................................................................................... 206
Treatment Plan ................................................................................................................... 207
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist ........................................ 208
Self-Report Adult Symptoms and Role Impairment Inventory ............................................... 209
Third-Party Adult ADHD Symptoms and Role Impairment Inventory ................................... 211
WFIRS Self-Report.................................................................................................................. 213
Weiss Functional Impairment Rating Scale – Self-Report (WFIRS-S) ................................... 214
Record of Past Treatments ....................................................................................................... 215
ADHD Treatment Tracking ..................................................................................................... 216

Guide to Use of Appendix Items in Clinical Practice

The tools in this Appendix facilitate evaluation of ADHD and treatment planning
for ADHD, in adults. Please see Chapters 2 and 3 in this guide for related detailed
guidance. Please also see instructions for each instrument. This Appendix includes
novel instruments developed by Dr. Craig Surman for clinical use based on experi-
ence applying the Diagnostic and Statistical Manual criteria for ADHD for patient
care and clinical research purposes.

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 197
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3,
© Springer Science+Business Media New York 2013
198 Appendix

Adult ADHD Diagnosis Checklist: This checklist ensures completion of a compre-


hensive evaluation of whether an individual meets criteria for ADHD.
Differential Diagnosis and Cognitive Comorbidity Inventory: Prompts system-
atic identification of conditions that could alternately explain ADHD symptoms or
could exacerbate ADHD symptoms.
Adult ADHD Symptoms and Role Impairment Guide and Inventories
(Clinician, Self-Report, and Third-Party Versions): The Clinician Guide and
Rating Sheet help clinicians document current ADHD symptoms, their historical
onset, and examples of how they impair major life roles. The Self-Report and Third-
Party rating sheets can also be given to clients to help gather this information.
Adult ADHD Self-Report Scale Symptom Checklist: This scale screens for
ADHD in adults.
Weiss Functional Impairment Rating Scale–Self-Report (WFIRS-S): This self-
report scale facilitates capture of current impairment in major areas of functioning.
Previous Treatment Record: Can be completed by patients or clinicians to capture
experience with past medication or therapies.
Treatment Planning Form for ADHD + Organizational Impairment: Prompts
identification of treatment goals and personalized approaches to treatment goals.

Adult ADHD Diagnosis Checklist

Instructions:
This checklist can be used to ensure that a thorough diagnostic evaluation is
conducted, as discussed in Chapter 2 of this guide.

MEETS Criteria (Yes or No)


CURRENT SYMPTOM CRITERIA THRESHOLD
# of moderate or severe symptoms from ASRI:
Inattentive: ________
Impulsive/Hyperactive: ________
Are at least four* symptoms present in either category? Yes _____ No _____
ONSET OF SYMPTOMS IN CHILDHOOD:
Have some symptoms persisted ever since childhood? Yes _____ No _____
IMPAIRMENT DUE TO SYMPTOMS
Do symptoms cause impairment in two or more roles Yes _____ No _____
(personal, school/work, social)
SYMPTOMS NOT EXPLAINED BY ANOTHER CONDITION:
Is ADHD the primary cause of the impairing symptoms? Yes _____ No _____
Diagnosis of ADHD in an adult requires Yes to all four of the criteria above.
*Four current symptoms is a recent research-based threshold of current symptoms for diagnosis of
adults, but six or more symptoms has been conventional for DSM-based diagnoses.
Developed by Craig B.H. Surman, MD
Appendix 199

ADHD Differential Diagnosis and Cognitive


Comorbidity Inventory

The following list can be used to identify two categories of conditions during initial
evaluation: those that present like ADHD and should be differentiated from ADHD
and those that could compound functional impairment and should be targeted in
treatment of an ault with ADHD. See Chapter 2 for detailed guidance. This is not a
comprehensive list. A comprehensive review of any condition impacting well-being
should be conducted.

Note if suspected/known;
Category of condition and whether past/current
Mental health conditions (affective, anxious, substance,
psychosis, eating, posttraumatic disorders, etc.)
Learning or processing disorders
Tourette’s or tic disorder
Chronic systemic medical conditions
Developmental disorder/autism
Asperger’s/Social skill deficits
Medication, substance, poison effects (e.g., lead)
Nutritional deficiency (e.g., iron, B12)
Brain trauma (e.g., post-concussive syndrome)
Delirium
Degenerative neurologic condition (e.g., dementia)
Endocrine disorder (e.g., thyroid disorder)
Seizure disorder
Sleep disorder (e.g., insomnia, phase delay, apnea)
Dietary allergy or sensitivity
Major life stress (loss, trauma)
Familial/genetic disorders
Other Encephalopathies (e.g., fetal alcohol)
Developed by Craig B.H. Surman, MD
200 Appendix

Adult Symptoms and Role Impairment Inventory (ASRI)

Instructions

The ASRI explores three of the four criteria for ADHD: current symptom burden,
current impairment, and childhood onset, and should be used as part of a comprehen-
sive interview. Diagnosis also requires clarification that impairing symptoms are not
due to another condition and have been persistent throughout a person’s life. Please
see Chapter 2 for guidance on comprehensive clinical evaluation of adults with pos-
sible ADHD. The ASRI guide, inventories, and prompts were developed by Dr. Craig
Surman out of experience applying the Diagnostic and Statistical Manual criteria for
ADHD. These are not normed scales, but scoring is provided for tracking purposes.

Self and Third-Party Inventories

These inventories are meant to facilitate completion of the Clinician Inventory


(described below). It is useful to ask patients and, if possible and comfortable, a third
party, to complete these inventories. They are an efficient way to gather information
on ADHD symptoms, the life roles they impact, and age of symptom onset. If admin-
istered over time, they also help track symptoms and their impact. Responses should
be reviewed during a clinical interview (e.g., through the prompts of the Clinical
Inventory) to clarify how questions were understood and to identify their severity.

The Clinician Inventory

This Interview Guide facilitates completion of the Rating Sheet, to identify significant
symptoms, age of their onset, and current impairment from symptoms. Clinicians
are encouraged to work from the Guide to tailor questions and examples to the
individuals they work with.
Rating symptoms:
Asking individuals to think about a recent, typical week is useful.
Each prompt is a set of questions: (1) a question designed to identify compensa-
tory effort related to a trait and (2) a question capturing the frequency of problems
related to the symptom.
Appendix 201

A symptom should be considered present where there is either burdensome com-


pensatory effort or symptom-related impairment.
Try to identify different kinds of challenges or problems with each symptom.
It is useful to consider both frequency and impact of symptoms to determine
their severity. Typically, a symptom rated as moderate or more severe by the terms
noted below would be considered towards fulfillment of the current symptom
criteria:
Mild: minimal effort to avoid consequences/occasional consequences (e.g.,
weekly)
Moderate: takes regular effort to avoid consequences/frequent consequences (e.g.,
daily)
Severe: cannot avoid consequences through effort/very frequent consequences (e.g.,
multiple times a day)

Rating impairment:
The symptom interview should determine whether there is impairment in two or
more settings, as required for the diagnosis. For each symptom, one can ask for
examples of personal, work, school, and/or social function. The ASRI Interview
Guide includes examples of typical ADHD-related problems in these role areas.
Clinicians may find it helpful to refer to these examples as they looking for similar
problems or to directly ask patients if they have similar problems.

Recording Ratings
The Rating Sheet is organized in two sections, presenting inattentive and impulsive/
hyperactive symptoms of ADHD. The number of moderate or severe symptoms and
age of onset of these symptoms can be recorded in each section. The roles impaired
by symptoms can also be recorded both to facilitate diagnosis and to establish treat-
ment targets.
Developed by Craig B.H. Surman, MD
202 Appendix

Clinician Adult Symptom and Role


Impairment Inventory Guide
Brief Instructions (see Chapter 2 and ASRI Instructions in Appendix):
This Guide facilitates completon of the ASRI Clinician Inventory.
Interview to determine compensatory effort and symptom frequency using Prompts.
Ask what age symptoms began to persist.
Record role impairment similar to Self/Home, School/Work, Relationship examples.
Inattentive Traits
Difficulty being accurate with details
Prompt: How much effort does it take to be accurate or catch mistakes in your work? How often
do you make errors that matter?
Self/Home: Filling out forms School/Work: “Careless Relationships: Missing
incorrectly. mistakes,” missed important details in
instructions. emails.
Difficulty sustaining attention
Prompt: How much effort does it take to pay attention when you should? How often do you
miss presented information because of mind wandering?
Self/Home: Mind wandering School/Work: Gaps in class or Relationships: Trouble
while reading. meeting notes. following the theme
in group
conversations.
Difficulty listening in conversation
Prompt: How hard is it to listen to someone who is speaking directly to you? How often do you
miss what people say to you?
Self/Home: Not hearing School/Work: Not hearing Relationships: Other
requests from others at home. instructions. people have to repeat
themselves.
Difficulty sticking to and finishing actions
Prompt: How much effort does it take to stick with a task and not start a new one? How often
do things go unfinished?
Self/Home: Frequently School/Work: Partially Relationships: Difficulty
sidetracked from everyday completed tasks pile up. staying on topic in
tasks. conversations.
Difficulty organizing
Prompt: How much effort does it take to stay organized? How often do you wish things your
space or activities were more organized?
Self/Home: Mess makes it hard School/Work: Overwhelmed Relationships: Less
to use personal spaces due to poor planning and likely to organize
(desk, closet) prioritizing. social activities.
Putting off tasks requiring mental effort
Prompt: How often are you scrambling to meet a deadline or miss one? How hard is it to get
around to work that you need to complete?
Self/Home: Mail left unopened, School/Work: Staying up Relationships: Lack of
paying bills late. late to prepare work preparation for
for the next day. shared activities
upsets others.
(continued)
Appendix 203

(continued)
Often losing important items
Prompt: Do you have to be careful not to misplace things? How often do you spend more than
10 min a day looking for things?
Self/Home: Personal time School/Work: Takes longer Relationships:
consumed by looking for to complete work Overreliance on
items like keys or phone. because of looking others to keep track
for needed items. of personal items.
Forgetfulness
Prompt: Does it take special effort to remember things you need to do? How often are you upset
that you forgot something?
Self/Home: Having to return School/Work: Forgetting Relationships: Forgetting
to get things left behind. assignments or to call or meet with
instructions. others.
Often distracted by things in environment
Prompt: Is it hard to tune out distractions around you? How often does distraction keep you
from accomplishing tasks?
Self/Home: Need to isolate from School/Work: Inefficient Relationships: Difficulty
reminders of other tasks at working around listening with
to get personal tasks done. others. conversations
or activity nearby.
Hyperactive/Impulsive Traits
Fidgeting
Prompt: How much effort does it take to be still when sitting? How often is your fidgeting
upsetting to you or others?
Self/Home: Self-conscious School/Work: Disrupting classes Relationships: Physical
of own fidgeting. or meetings by tapping movements
on a desk, bouncing legs. misinterpreted as
anxiety, lack of
interest.
Restless
Prompt: How much effort does it take for you to sit as long as you should? How often do you
interrupt activities to get up?
Self/Home: Hard to sit long School/Work: Frequently Relationships: Difficulty
enough to sort through mail, disengaging from tasks sitting through
manage bills. and meetings to get up. activities, conversa-
tions upsets others.
Excessively in motion
Prompt: Is it hard to stop yourself from moving too much? How often are you more in motion
than other people?
Self/Home: Requires exercise School/Work: Poor Relationships: Hard to
to feel physically calm. performance at tasks enjoy low-action
requiring sitting. activities with others.
(continued)
204 Appendix

(continued)
Excessively loud
Prompt: Does it take effort for you to control the “volume” of your voice or presence? How
often do you wish you had controlled it better?
Self/Home: Excitability detracts School/Work: Excessive, Relationships: Volume or
from quality of communication distracting presence intensity makes other
with others. in class or meetings. people
uncomfortable.
Excessive internal drive
Prompt: Is it hard to linger at activities? How often does the urge to stay busy cause problems?
Self/Home: Rarely taking time to School/Work: Taking on too Relationships: Others
relax. many new activities or find the person to be
responsibilities. rarely “present”
because of urge to
move on.
Talking excessively
Prompt: Does it take effort not to talk longer than you need to? How often do you wish you had
stopped talking sooner?
Self/Home: Talking too School/Work: Lose other’s Relationships: Talking
much creates inefficient interest in classes or more than other
communication with service meetings. people limits depth of
providers like doctors. relationships.
Speaking at the wrong time in conversation
Prompt: How hard is it not to speak before your turn? How often do other people ask you to let
them finish?
Self/Home: Interrupting School/Work: Missing Relationships: Annoying
limits information gathering, e.g., important information other people, limiting
with a service provider. because are consciously chance to build
trying to “hold the relationships.
thought” and not interrupt?
Difficulty waiting
Prompt: How hard is it to wait, such as in a line at a supermarket, or in light traffic? How often
do you avoid lines or leave them?
Self/Home: Leaving or avoiding School/Work: Acting without Relationships: Upsetting
necessary lines (shopping, finding waiting form input from others with
food). others. impatience.
Intruding on others
Prompt: Is it hard not to interrupt others people when they are already in a conversation? How
often do you intrude on other people?
Self/Home: Others are less willing to School/Work: “Taking Relationships: Offending
assist because of impolite, charge” of a meeting others with impolite,
intrusive behavior. or project out of place. intrusive style.
Developed by Craig B.H. Surman, MD
Appendix 205

Clinician Adult ADHD Symptoms and Role


Impact Inventory Rating Sheet
Inattentive Symptoms None Mild Moderate Severe Age started
Difficulty being accurate with details
Difficulty sustaining attention
Difficulty listening in conversation
Difficulty sticking to and finishing actions
Difficulty organizing
Putting off tasks requiring mental effort
Often losing important items
Forgetfulness
Often distracted by things in environment
# of moderate or severe inattentive symptoms: ____
Impulsive/Hyperactive Symptoms
Fidgeting:
Restless:
Excessively in motion:
Excessively loud:
Excessive internal drive:
Talking excessively:
Speaking at the wrong time in
conversation:
Difficulty waiting:
Intruding on others:
# of moderate or severe impulsive/hyperactive symptoms: ____
List examples of how Inattentive symptoms impair role functioning
for personal daily tasks: work or school function: in relationships:

List examples of how Impulsive/Hyperactive symptoms impair role functioning


for personal daily tasks: work or school function: in relationships:

Developed by Craig B.H. Surman, MD


206 Appendix

Treatment Planning Form for ADHD + Organizational


Impairment

Instructions

This form can be used to decide on treatment targets and methods of reaching those
targets, when starting or revising treatment. It may be given to a client as a reminder
of treatment plans between sessions.

Treatment Targets

Core ADHD Symptoms


List important role daily challenges that are a direct result of ADHD traits.
Self/Home:

Work/School:

Relationships:

Other Organizational Problems


List other important daily patterns of disorganization in major life roles.
(e.g., poor sleep pattern, overwhelmed by work, last-minute social planning)
Self/Home:

Work/School:

Relationships:

Developed by Craig B.H. Surman, MD


Appendix 207

Treatment Plan

For Core ADHD Symptoms: list medication options that could improve core
ADHD symptoms (new agent, dose change, cover longer duration)

For Improved Organization: List critical situations where better habits (deci-
sions or actions) can be practiced (e.g., taking time to prioritize/plan; more reliance
on others or electronic devices; using reminders; isolating from lower priority
distractions).

For Adherence: List what will ensure practice of the treatment plan. Consider fac-
tors in past success (e.g., deadlines, reminders, tracking, involving others, other
accountability).

For Environmental Accommodation: List accommodations, e.g.: for weaknesses


(e.g., extra time to check work, recording meetings/class); to make tasks more
engageable (e.g., clearer steps/goals, better match to interests); for accountability
(e.g., involving others, deadlines); for work space (lower distraction).

For other challenges: (e.g., other medication changes; therapeutic homework or


habits)

Developed by Craig B.H. Surman, MD


208 Appendix

Adult ADHD Self-Report Scale (ASRS-v1.1)


Symptom Checklist

Instructions: If four or more marks appear in the darkly shaded boxes within Part A
then the patient has symptoms highly consistent with ADHD in adults and further
investigation is warranted. A full diagnostic evaluation is needed to determine if the
diagnosis is present.
Please answer the questions below, rating Never Rarely Sometimes Often Very
yourself on each of the criteria shown Often
using the scale on the right side of the
page. As you answer each question,
place an X in the box that best describes
how you have felt and conducted
yourself over the past 6 months.
Please give this completed checklist
to your healthcare professional to
discuss during today’s appointment.
1. How often do you have trouble wrapping
up the final details of a project, once the
challenging parts have been done?
2. How often do you have difficulty
getting things in order when you have
to do a task that requires organization?
3. How often do you have problems
remembering appointments or
obligations?
4. When you have a task that requires
a lot of thought, how often do you
avoid or delay getting started?
5. How often do you fidget or squirm
with your hands or feet when you
have to sit down for a long time?
6. How often do you feel overly active
and compelled to do things, like
you were driven by a motor?

Reprinted from Kessler RC, Adler L, Ames M, et al. The World Health Organization
Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the gen-
eral population. Psychol Med. Feb 2005;35(2):245–256. With permission from
Cambridge University Press.
Appendix 209

Self-Report Adult Symptoms and Role Impairment Inventory


Name: ______ Date: _______
Time period considered ________________ Medication and dose (if applies) _____________

Instructions: This inventory can be used to measure ADHD symptoms. Think of a


“typical,” recent week, and complete the lines above. For each item there are ques-
tions about effort and consequences. Note on the right how often either of these
occur. Use space at the bottom of each page to describe examples of how these
symptoms keep you from functioning well in major life roles. If using this form for
diagnosis, write down the earliest age each active symptom began to persist.
Very Age
Inattentive Traits Rarely Sometimes Often Often started
Difficulty being accurate with details
How often does it take effort to avoid errors? Or: 0 1 2 3
How often do you make “careless” mistakes?
Difficulty sustaining attention
How often does it take effort to pay attention when 0 1 2 3
in meetings, classes, or while reading? Or:
How often does your mind wander in meetings,
class, or while reading?
Difficulty listening in conversation
How often is it hard to listen in conversation? Or: 0 1 2 3
How often do you miss what people say to you?
Difficulty sticking to and finishing actions
How often does it take effort to stick with a task? Or: 0 1 2 3
How often do you leave things unfinished?
Difficulty organizing
How often is it a struggle to stay organized? Or: 0 1 2 3
How often is there a problem because of poor
organization?
Putting off tasks requiring mental effort
How often is it hard to get around to tasks? Or: 0 1 2 3
How often do you miss a deadline?
Often losing important items
How often do you take care not to misplace things? Or: 0 1 2 3
How often are you looking for things you misplaced?
Forgetfulness
How often do you depend on lists or reminders? Or: 0 1 2 3
How often are you upset that you forgot something?
Often distracted by things in environment
How often do you avoid or tune out distractions? Or: 0 1 2 3
How often are you distracted from tasks?
Total inattentive symptom score: ______
Note here examples of how these, or similar difficulties, impact your life roles:
Your own daily activities:

Work or school activities:

Relationships with others:

(continued)
210 Appendix

(continued)
Very Age
Hyperactive/Impulsive Traits Rarely Sometimes Often Often started
Fidgeting
How often does it take effort to be still? Or: 0 1 2 3
How often is your fidgeting upsetting to
you or others?
Restless
How often do you stop yourself from standing 0 1 2 3
up in the middle of an activity? Or:
How often do you get up in the middle of an
activity?
Excessively in motion
How often do you stop yourself from walking 0 1 2 3
or running too much? Or:
How often are you walking or running when
others are not?
Excessively loud
How often do you keep yourself from being 0 1 2 3
too loud? Or:
How often do you wish you had kept
yourself from being too loud?
Excessive internal drive
How often do you stop yourself from moving 0 1 2 3
on to another activity? Or:
How often is it hard to stick with or enjoy
quiet activities?
Talking excessively
How often do you stop yourself from 0 1 2 3
talking too much? Or:
How often do you wish you had stopped
talking sooner?
Speaking at the wrong time in conversation
How often do you stop yourself from 0 1 2 3
interrupting in a conversation? Or:
How often do wish you had waited to speak
in turn?
Difficulty waiting
How often do you struggle to wait in a line? Or: 0 1 2 3
How often do you avoid lines or leave them?
Intruding on others
How often is it hard to stop yourself from 0 1 2 3
interrupting others when they are busy? Or:
How often do you intrude on other people?
Total impulsive/hyperactive Score: _______
Note here examples of how these, or similar difficulties, impact your life roles:
Your own daily activities:

Work or school activities:

Relationships with others:

Developed by Craig B.H. Surman, MD


Appendix 211

Third-Party Adult ADHD Symptoms and Role


Impairment Inventory

Instructions: This inventory can be completed by a third party (e.g., significant


other, family, friend) to help track ADHD symptoms. Ask them to think of a “typi-
cal,” recent week. For each item note on the right how often they occur, and the
earliest age they began to persist. Note impact on major life roles at bottom.

Very Age
Inattentive Traits Rarely Sometimes Often Often started
Difficulty being accurate with details
How often do they make “careless” mistakes? 0 1 2 3
Difficulty sustaining attention
How often does their mind wander in 0 1 2 3
meetings, class, or while reading?
Difficulty listening in conversation
How often do they miss what people say to 0 1 2 3
them?
Difficulty sticking to and finishing actions
How often do they leave a task before it is 0 1 2 3
finished?
Difficulty organizing
How often do they have problems because of 0 1 2 3
poor organization?
Putting off tasks requiring mental effort
How often do they do things at the last minute? 0 1 2 3
Often losing important items
How often do they have to look for misplaced 0 1 2 3
things?
Forgetfulness
How often do they forget things that matter? 0 1 2 3
Often distracted by things in environment
How often do they seem distracted by things 0 1 2 3
around them?
Total inattentive symptom score: _________
Do these symptoms impair function in daily activities, at work or school, or relationships
with others? Please note some examples here:

(continued)
212 Appendix

(continued)
Very Age
Impulsive/Hyperactive Traits Rarely Sometimes Often Often started
Fidgeting
How often do they fidget? 0 1 2 3
Restless
How often do they get up in the middle of an 0 1 2 3
activity?
Excessively in motion
How often are they walking or running when 0 1 2 3
others are not?
Excessively loud
How often are they louder than other people 0 1 2 3
around them?
Excessive internal drive
How often do they leave quiet activities 0 1 2 3
before others do?
Talking excessively
How often do they talk longer than 0 1 2 3
necessary?
Speaking at the wrong time in conversation
How often do they interrupt other people 0 1 2 3
in a conversation?
Difficulty waiting
How often are they upset when waiting? 0 1 2 3
Intruding on others
How often do they intrude on people who 0 1 2 3
are busy?
Total Impulsive/Hyperactive Presentation score: ________
Do these symptoms impair function in daily activities, at work or school, or relationships
with others? Please note some examples here:

Developed by Craig B.H. Surman, MD


Appendix 213

WFIRS Self-Report
Appendix 215

Record of Past Treatments

Name: Date:

Please note any past or current treatments you have tried for mental health or better
function (medication or non-medication). Note examples at bottom.
Name of medication Dates tried, Positive effects Negative effects
or kind of therapy frequency,
duration

EXAMPLES
Methylphenidate (generic) 20 mg, twice a day Got schoolwork done Low appetite
for a year, age 20
Organizational skills class Used planner, task list Felt more organized Stuck with skills
for 2 weeks
Developed by Craig B.H. Surman, MD
216 Appendix

ADHD Treatment Tracking

Instructions
1. This form can be personalized to measure impact of treatment on daily
function.
2. Note time period you are thinking of
3. Write in Treatment examples: medication, therapy, coaching; examples of new
habits: new way of planning time, using reminders; accommodation examples:
recording information, lower distraction environment.
4. Write in any improvement in daily function. Consider change in any goals you
have for improvement in your daily activities, at work or school, or in
relationships.
5. Note problems related to treatment. For example, write down any discomfort,
emotions, or problems functioning on medication; or skills that were hard to
adopt.

Time period Treatment, new habit Improved self, home, or Negative effects
or accommodation relationship role function

Developed by Craig B.H. Surman, MD


Author Biographies

Barbara Alm, M.D., M.Psy., holds degrees in psychology and medicine. She is a
senior consultant specializing in psychiatry and psychotherapy and a supervisor in
behavioral psychotherapy. Since 1995, she is the head of the outpatient clinic at the
Central Institute of Mental Health (CIMH) in Mannheim, Germany. In 1998, she
established an outpatient ADHD clinic. She is also co-chair of the adult ADHD
research group at the CIMH. Her research focuses on psychotherapy of adult ADHD
and psychosocial impairment related to adult ADHD.

Philip Asherson, M.B., B.S., M.R.C.Psych., Ph.D., is a senior consultant in the


National Adult ADHD Clinic at the Maudsley Hospital in London and Professor of
Molecular Psychiatry at the Institute of Psychiatry, Kings College London. He
started his medical career training in adult psychiatry and went onto work on molec-
ular genetic studies of schizophrenia at the University of Wales in Cardiff. He started
work on ADHD when he moved to the Institute of Psychiatry in 1996. Initially he
focused efforts on establishing a program of research into the genetics of ADHD in
children, as research at that time had identified ADHD as one of the most heritable
childhood conditions. His strong background as an adult psychiatrist led him to
work in the first UK clinic for adults with ADHD, at the Maudsley Hospital in
London, which was established in 1994. His work since that time has combined
both basic science and clinical approaches to further our understanding of how
ADHD in adults impacts on individuals. He has played a key role in establishing
national and international guidelines for the diagnosis and treatment of ADHD
across the lifespan, adopting a common sense and evidence-based approach, and
emphasizing the important role that ADHD plays in adult psychopathology.

Daniela de Bustamante Carim, M.Psy., holds a Masters degree in Neuroscience


and lectures at Santa Casa da Misericórdia in Rio de Janeiro. She has coordinated a
course on neuropsychology recognized by the Federal Council of Psychology in
Brazil. She completed a 10-month observership in neuropsychological assessment
in 1999 at Massachusetts General Hospital and a private clinic in Boston. She has

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 217
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3,
© Springer Science+Business Media New York 2013
218 Author Biographies

worked as a clinical Neuropsychologist in private and public institutions in Rio de


Janeiro. In addition to neuropsychological assessment, she frequently provides
counseling to parents and teachers of children with ADHD regarding executive dys-
function. She translated and validated into Portuguese the Behavior Rating Inventory
of Executive Function (BRIEF, parent, teacher, and self-report).

David Coghill, M.B., Ch.B., M.D., has drawn on a wide range of academic,
research, and clinical experience in contributing his chapter. As an academic child
and adolescent Psychiatrist with the University of Dundee he is heavily involved in
both teaching and research. He is particularly interested in understanding the mech-
anisms by which medications reduce symptoms and impairment and directs a broad
program of research that includes molecular genetics, pharmacogenomics, neu-
roimaging, and neuropsychopharmacology on the one hand, and clinical trials and
studies of quality of life on the other. He has first-hand experience of leading several
large international clinical trials of ADHD medications in Europe. He is a core
member of the European ADHD Guidelines Group and has been involved in the
development of several influential clinical guidelines. He is very active in teaching
with a particular focus on helping implement research findings and the recommen-
dations of clinical guidelines in routine clinical practice. As a clinical consultant
child and adolescent Psychiatrist with National Health Service Tayside he leads a
large Developmental Psychiatry Service that specializes in delivering care to chil-
dren and young people with a wide range of disorders including ADHD, Autism
Spectrum Disorders, and Tourette’s. The team has developed a range of evidence-
based tools and care pathways that have been used as templates by many services
around the world.

Stephanie Daffner, Ph.D., studied psychology at the University of Heidelberg and


is a member of the Adult ADHD research group at the Central Institute of Mental
Health (CIMH) Mannheim, Department of Psychiatry and Psychotherapy, Medical
Faculty Mannheim, University of Heidelberg, Mannheim, Germany. He contributes
to pharmacological interventions and neuropsychological assessment.

Inmaculada Escamilla, M.D., Ph.D., is a child and adolescent Psychiatrist at the


University of Navarra Clinic, an Associate Professor of Medicine at University of
Navarra (Spain), and an expert in bipolar disorder in children and adolescents.
Through these roles, she frequently works with complex presentations of ADHD in
children and adolescents. She had published several papers and is frequently invited
to present in national and international meetings. She is committed to training clinicians
in child and adolescent psychiatry and she has written many chapters in manuals
and specialized books. She has a special interest in how educational systems can be
adapted to children’s learning abilities and difficulties, applying neuroscientific
features to pedagogy science. She also authored a book about medical reasons that
students drop out of school.
Author Biographies 219

Helenice Charchat Fichman, Sc.D., is a clinical neuropsychologist who also holds a


Masters degree in Neuroscience and Psychology and is a Psychology Professor at
Catholic University of Rio de Janeiro (PUC-RJ). She specializes in neuropsychological
examination, rehabilitation, and cognitive psychotherapy, in both private and public
institutions. During her practice, she developed an interest in comprehensive neurop-
sychological examination of adults with ADHD. Since that, I realize that the disexecu-
tive profile of these patients is a interesting subject for research. In her instruction of
psychology students at Catholic University of Rio de Janeiro, she emphasizes that
theories in neuropsychology emerged through study of psychiatric and neurological
patients and that ADHD in adulthood presents a special model of interface between
cognitive, behavior, and neuroscience approaches in psychology.

Paul Hammerness, M.D., is an Assistant Professor of Psychiatry at Harvard


Medical School and Staff Psychiatrist at the Clinical and Research Program in
Pediatric Psychopharmacology and Adult ADHD of the Massachusetts General
Hospital (MGH). Dr. Hammerness completed his Adult Psychiatry Residency and
Fellowship in Child and Adolescent Psychiatry at the combined program of MGH-
McLean Hospital. Dr. Hammerness has been involved in over 100 research studies
over the past decade in his work with the MGH research program. Dr. Hammerness
has specific interest and expertise in pediatric and adult ADHD and the cardiovas-
cular effects of ADHD pharmacotherapy. Dr. Hammerness supervises MGH-
McLean Child Psychiatry fellows in psychopharmacology and has lectured locally,
nationally, and internationally on the topic of ADHD and pediatric psychopharma-
cology. In addition, Dr. Hammerness is the Director of a part-time outpatient
practice in general Child and Adolescent Psychiatry at Newton Wellesley Hospital,
provides ongoing psychopharmacology consultation to a local pediatric group
practice, and has served on the MGH Institutional Review Board.

Christian Jacob, P.D., M.D., is a Psychiatrist and Psychotherapist as well as a


Supervisor of behavior therapy. Since 1999 he has been a senior Physician of the
Department of Psychiatry, Psychosomatics, and Psychotherapy at Wuerzburg
University Hospital in Germany. He has a particular clinical and research interest in
adult attention deficit hyperactivity disorder and personality disorders. He has been
a project manager within Clinical Research Group (KFO 125) supported by the
German Research Foundation and was involved in a randomized controlled multi-
center trial on the combined treatment of ADHD children and their ADHD mothers,
which was supported by the Federal Ministry of Education and Research.

Thomas Jans, Ph.D., is a Psychologist, Psychotherapist, and Supervisor of behavior


therapy. He has a Masters degree in Psychology. He has been a member of the
Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy
at Wuerzburg University Hospital in Germany since 1995. He is a licensed psycho-
therapist, with experience in both inpatient and outpatient assessment and treatment
of psychiatric disorders in children and adolescents. His primary clinical research
220 Author Biographies

interests are obsessive-compulsive disorder, dissociative disorders, and ADHD.


He has coordinated a randomized controlled multicenter trial on the combined treat-
ment of ADHD children and their ADHD mothers.

Laura Knouse, Ph.D., is an Assistant Professor of Psychology and licensed clinical


psychologist at the University of Richmond. She completed her predoctoral
internship and postdoctoral fellowship at Massachusetts General Hospital and
Harvard Medical School, where she worked with Dr. Steven Safren in his clinical
research program developing cognitive-behavioral treatments for adults and adoles-
cents with medication-treated ADHD and residual symptoms. Her training included
extensive supervised experience in cognitive-behavioral therapy, including specific
treatment of adults with ADHD in the outpatient clinic and in the context of research
studies. She co-authored several manuscripts and chapters with Dr. Safren and com-
pleted a project examining predictors of depression in adults with ADHD. During
graduate school, Dr. Knouse received extensive training in ADHD assessment at the
ADHD Clinic at UNC Greensboro, where she served as assistant director. Current
interests include the adaptation of CBT approaches for college students with
ADHD—particularly, the incorporation of learning and study strategies derived
from cognitive psychology—and the effect of individual differences in executive
functioning on college adjustment. In addition to conducting her own research,
Dr. Knouse teaches courses in introductory psychology, psychopathology, and
behavior therapy, mentors undergraduate honors thesis projects, and sees clients at
the University’s counseling center.

Georgios Paslakis, M.D., is board certified in Psychiatry and Psychotherapy. He is


a senior consultant at the Central Institute of Mental Health (CIMH) Mannheim,
Central Institute of Mental Health (CIMH) Mannheim, Department of Psychiatry
and Psychotherapy, Medical Faculty Mannheim, University of Heidelberg,
Mannheim, Germany. He specializes in addiction medicine with a clinical focus on
Adult ADHD, substance use disorders, and affective disorders in the elderly. His
main research areas are the hypothalamus–pituitary–adrenal axis, stress-related dis-
orders, and ADHD with comorbid substance use disorders.

Anton Pesok, M.D., received his medical training in St. Petersburg, Russia and
his psychiatric training at the Harvard Longwood Psychiatry Residency in Boston.
Dr. Pesok attends to patients at the ambulatory psychiatry clinic of the Beth Israel
Deaconess Medical Center in Boston where he sees many young adults with com-
plaints of difficulties with school performance as well as patients with a large vari-
ety of mood and anxiety problems. He is a faculty member at Harvard Medical
School where he teaches and supervises medical students and resident physicians.

Steven Safren, Ph.D., is a Professor in Psychology in the Department of Psychiatry


at Harvard Medical School and the Director of Behavioral Medicine at Massachusetts
General Hospital. He received his Ph.D. in clinical psychology from the University
Author Biographies 221

at Albany (State University of New York) in 1998 and did his internship and
postdoctoral fellowship at Massachusetts General Hospital/Harvard Medical
School. Dr. Safren is board certified in Cognitive Behavioral Therapy from the
American Board of Professional Psychology (ABPP). Dr. Safren has over 150 pro-
fessional publications inclusive of data-driven papers, reviews, chapters, commen-
taries, and books and has been the PI or protocol chair of nine NIH-funded grants.
Dr. Safren started working with adults with ADHD during his fellowship training at
Massachusetts General Hospital. Through a collaboration with the Pediatric
Psychopharmacology Unit, he started by treating adults with ADHD in his clinical
practice, and, given the lack of evidenced-based treatments for adults with ADHD
at the time, he developed a research interest in this area. His first study was an R03,
for which he developed a treatment manual for adults with ADHD, and tested it in
a sample of adults who were treated with medications but still had significant resid-
ual symptoms. Based on the success, his second study was an R01 comparing the
efficacy of this new treatment to an attention-matched control, relaxation with edu-
cational support. The successful trial was published in JAMA in 2010 and showed
superiority of CBT over the control treatment.

Michael Schredl, Ph.D., has worked in the sleep laboratory of the Central Institute
of Mental Health (CIMH) Mannheim, in Mannheim, Germany since 1990. His pub-
lications cover various topics such as dream recall, dream content analysis, night-
mares, sleep disorders, sleep physiology, and sleep in ADHD. He is editor of the
online journal “International Journal of Dream Research.” He has participated in
several clinical trials for insomnia patients.

Esther Sobanski, M.D., is board certified in child and adolescent psychiatry and
psychotherapy as well as in psychiatry and psychotherapy. She is an Associate
Professor of child and adolescent psychiatry and head of the adult ADHD research
group at the Central Institute of Mental Health (CIMH) Mannheim, Department of
Psychiatry and Psychotherapy, Medical Faculty Mannheim, University of
Heidelberg, Mannheim, Germany. She has extensive clinical experience in the
assessment and treatment of both children and adults with ADHD. She has con-
ducted numerous studies on pharmacological and psychotherapeutic interventions,
neuropsychological issues, as well as clinical and psychosocial features of ADHD.
Esther Sobanski is a member of the steering committee of the German ADHD-Net
and of the European Adult ADHD Network, both networks fostering awareness of
this disorder and improving knowledge and patient care by providing education and
establishing research links.

Craig Surman, M.D., is an Assistant Professor of Psychiatry at Harvard Medical


School. He is the Scientific Coordinator of the Adult ADHD Research Program of
the Clinical and Research Program in Pediatric Psychopharmacology at
Massachusetts General Hospital. He completed a residency in Psychiatry at the
Harvard Longwood Psychiatry Residency Training Program in Boston, as well as a
222 Author Biographies

fellowship in Neuropsychiatry at the Division of Cognitive and Behavioral


Neurology at Brigham and Women’s Hospital, also in Boston. His work has been
published in peer-reviewed journals and presented internationally. Dr. Surman has
directed or facilitated over 40 studies related to ADHD in adults. He directs a course
on ADHD Psychopharmacology for the Massachusetts General Hospital psychiatry
residency. His research strives to improve the assessment and treatment of self-
regulatory disorders, including ADHD, in adulthood.
Index

A symptoms, 27
Adult ADHD diagnosis checklist, 197, 198 traits and comorbidity, 38
Adult ADHD self-report scale symptom trouble paying attention, 27
checklist, 197, 208 clinical impact and challenges
Adult Symptoms and Role Impairment neurodevelopmental disorders, 9
Inventories (ASRI), 200–201 risk factor, 9–10
a2-Agonists, 92, 97–98, 103, 112 symptoms of, 8–9
American Heart Association (AHA), 84 clinical services, 6
Amphetamine (AMP), 76 definition and etiology, 2
Atomoxetine, 90–91, 93–95, 101–102 diagnostic validity
Attention deficit hyperactivity disorder anxiety and depression, 3–4
(ADHD) clinical and psychosocial problems, 4
clinical assessment epidemiological and clinical
clinical symptoms, 27–28 research, 3
compensatory efforts, 26 genetic factors, 4–5
deficient emotional self-regulation, 40–41 hyperactivity-impulsivity, 4
diagnosis, 21–22, 41 medication, 5
diagnostic impression, 42 neurodevelopmental problems, 3
DSM criteria, 24–25 etiological models, 10–13
environmental factors, 29 impairments, 10–12
evaluation, 20 medication and psychological treatment
executive function deficits, 39 programs, 6–7
explore executive and self-regulatory nosological considerations and
skills, 39, 40 comorbidity, 7–8
identify current concerns, 23–24 organizational impairment, treatment
impact, 28 planning, 206–207
impulsive/hyperactive symptoms, 25, 26 societal burden, 5–6
medication treatment, 37 treatment tracking, 215
mental and physical activities, 19–20
mental health distress, 34
neuropsychiatric conditions, 36, 37 B
recent time period, 26 Beck Depression Inventory (BDI), 65
role impairment, 31–33 Bipolar disorder (BD), 159–160
self-regulatory problems, 39 Brown’s Attention Deficit Disorder Scales
stimulant treatment, 38–39 (BADDS), 63
subthreshold, 38 Bupropion, 91, 95–96, 102

C.B.H. Surman (ed.), ADHD in Adults: A Practical Guide to Evaluation and Management, 223
Current Clinical Psychiatry, DOI 10.1007/978-1-62703-248-3,
© Springer Science+Business Media New York 2013
224 Index

C prevalence and clinical characteristics,


Cardiovascular 137–138
blood pressure and heart rate, 83 symptoms, 138–139
ECG screening, 84 treatment, 139
effects, 80 sleep disorders treatment
screening recommendations, 79 pharmacological treatment, 149–150
Catechol-O-methyltransferase (COMT), 9 prevalence and clinical
Clinician adult symptom inventory, 202–205 characteristics, 148
Cognitive behavioral treatments (CBT), 120 sleep diaries, 148
Cognitive comorbidity inventory, 197, 199 symptoms, 149
Combining medications Substance Use Disorder treatment
a2-agonists, 112 genetic polymorphism, 141
guanfacine-stimulant combination, 113 methylphenidate, 143
OROS methylphenidate, 112 molecular genetics, 142
polypharmacy, 111 methylphenidate, 143, 144
Comorbid psychiatric disorders neuroanatomy, 142
adolescence physician–patient relationship,
clinical features, 156 144–145
detection and appropriate therapeutic prevalence and clinical
approach, 156 characteristics, 141
family history, 157 symptoms, 142
medical mimics, 158 therapeutic plan, 165–167
neuropsychological assessment, Conduct disorder (CD), 162–163
157–158 Conners’ Adult Attention-Deficit Rating Scale
adulthood (CAARS), 63
Bipolar disorder, 159–160 Continuous Performance Test (CPT), 63
Conduct and Oppositional Defiant Continuous Positive Airway Pressure
Disorders, 162–163 (CPAP), 150
comorbid psychiatric conditions, 158 CPT. See Continuous Performance Test (CPT)
eating disorders, 160–161
Personality Disorders, 163–164
prognosis, 164 D
Restless Legs Syndrome, 161–162 DAT. See Dopamine transporter (DAT)
sleep disruption, 161 Differential diagnosis, 197, 199
Sleep Onset Insomnia, 162 Dopamine transporter (DAT), 76
Substance Use Disorders, 163
anxiety disorders treatment
prevalence and clinical characteristics, E
145–146 Eating disorders, 160–161
symptoms, 146–147 ECG. See Electrocardiogram (ECG)
treatment, 147–148 EFs. See Executive functions (EFs)
depressive symptoms Electrocardiogram (ECG), 84
antidepressants and stimulants Epworth sleepiness scale, 149
combination, 140 Evoked response potentials (ERP), 12
atomoxetine, 140 Executive function deficits
emotional dysregulation, 140 ADHD and, 195
low self-esteem and demoralization, neuropsychological assessment (see
141 Neuropsychological assessment)
methylphenidate treatment, 139 Executive functions (EFs), 60
Index 225

F N
Family dysfunction Neuropsychological assessment
impact of adult assessment scales, 62–63
child-rearing practices, 173 behavioral traits, 61
children, psychiatric disorders cognitive traits, 61
risk, 172 executive dysfunction model, 60–61
cognitive behavior therapy, 174 history, 62
comorbid disorders, 171 methodology
gene–environment factors, 171 cognitive assessment, 66
heritability, 172 goal-oriented behaviors, 67
interdependencies, 170, 175–176 mood instability, 64
parental practices, 174 neuropsychological rehabilitation
parental resources, 173 program, 67–68
parental skills and parent–child scales and inventories, use of, 65–66
conflicts, 174 Executive function testing, 63–64
parent training, 173–174 Non-stimulant drug treatments
psychosocial interventions, atomoxetine, 107
childhood, 174 cardiovascular implications, 107–108
reduced parental skills, 172 clinical experience, 105
sexually transmitted disease, 171 cognitive behavioural therapy, 106
symptoms, 171 combining medications
impact of adult assessment, 177–180 a2-agonists, 112
impaired parental skills, 170 guanfacine-stimulant
patients multiple stressors, 170 combination, 113
therapeutic approaches OROS methylphenidate, 112
cognitive-behavioral therapy polypharmacy, 111
programs, 181 evidence base
communication skills, 183 a2-agonists, 97–98
couples therapy or family atomoxetine, 93–95
therapy, 185 bupropion, 95–96
educational counseling, 185 modafinil, 99
parent–child conflicts, 181 RCTs, 99
parent–teen treatment, 184 short and long acting stimulants, 100
parent training, 175, 183–184 tricyclic antidepressants, 97
pharmacotherapy, 180 venlafaxine, 99–100
psychosocial interventions, 184 mechanism of action
psychotherapeutic strategies, atomoxetine, 90–91
181–183 bupropion, 91
treatment plan, 184 methylphenidate, 104–105
monitoring nonstimulant treatment, 111
monitoring treatment, 109–110
G motivational interview, 106
Guanfacine, 113 optimal titration and dosing strategies,
109–110
safety and adverse effect
L a2-agonists, 103
Lisdexamfetamine (LDX), 74 atomoxetine, 101–102
Low-energy neurofeedback systems bupropion, 102
(LENS), 133 modafinil, 103–104
TCAs, 102–103
switch medications clinicians, 108, 109
M TCAs
Methylphenidate (MPH), 76, 139 a2-agonists, 92
Mixed amphetamine salts (MAS), 76 modafinil, 92–93
Modafinil, 92–93, 99, 103–104 Number needed to treat (NNT), 100
226 Index

O monitoring effectiveness, 75–76


Oppositonal Defiant Disorder (ODD), 162–163 monitoring stimulant treatment, 80
methylphenidate agents, 77
methylphenidate vs. amphetamine
P formulation, 78
Personality disorders (PD), 163–164 Randomized Clinical Trials, 74
Pittsburgh Sleep Quality Index, 149 short acting vs. long acting stimulant,
Psychosocial treatment 77–78
ADHD coaching, 132 side effect patterns, 81–83
cognitive-behavioral treatment, 119, 120 stimulant medications, 78–79
DBT skills, 131–132 Substance use disorders (SUD)
LENS, 133 adulthood, 163
multimodal treatment, 120 genetic polymorphism, 141
skills-based treatment planning methylphenidate, 143
behavioral strategies, 122–123 molecular genetics, 142
CBT approaches, 127, 130–131 neuroanatomy, 142
clinician skills, 125–126 prevalence and clinical
diagnostic assessment, 121–122 characteristics, 141
longer-term benefits, 124–125 symptoms, 142
patient’s primary goal, 122 treatment, 143–144
psychoeducation, 124
teaching skills, 127–128
treatment targets, 123–124 T
TCAs. See Tricyclic antidepressant (TCAs)
Third-party adult ADHD symptom
R inventory, 211–212
Randomized controlled trials (RCTs), 74 Treatment planning, adults
Restless leg syndrome (RLS), 161–162 accommodations, 53–54
Role impact inventory rating sheet, 205 clinical intervention, 46–47
Role impairment inventory, 202–204, 209–212 cognitive strength, 50–51
external distraction, 53
habits
S improving sleep habits, 55
Self-report adult symptoms, 209–210 organizational struggles, 56
Sleeping disorders self-regulatory problems, 54–55
pharmacological treatment, 149–150 hyperactivity/restlessness, 50
prevalence and clinical characteristics, 148 internal distraction, 52–53
sleep diaries, 148 long-term care, 56
symptoms, 149 non-medication treatment, 48
Sleep-onset insomnia (SOI), 162 salient and natural abilities, 51–52
Stimulant pharmacotherapy targeting role impairment, 46
ADHD symptoms and role impact Tricyclic antidepressant (TCAs)
inventory (ASRI), 73 a2-agonists, 92
AMP agents, 76 modafinil, 92–93
cardiovascular
blood pressure and heart rate, 83
ECG screening, 84 U
monitoring effects, 80 Urban hospital clinic
screening recommendations, 79 abusing substances, 192
clinical trial, 74 emergency evaluation, 192
dosing pattern, 79–80 laboratory toxicology screening, 193
LDX, 77 medical care, 196
medication treatment, 71–72, 81 medications, 195
Index 227

mood and anxiety symptoms, 193 V


neuropsychological evaluation, 192 Venlafaxine, 99–100
non-medication therapy, 194
patient appointment, 194
patient population, 191 W
people’s medications/illicit drugs, 193 Weiss Functional Impairment Rating
psychiatric disorders, 194 Scale–Self-Report (WFIRS-S), 197,
treatment planning, 193 213–214