ACA Blog

David Diana
Jun 03, 2010

ADHD, the Latest from a Top Expert

David Diana Interviews Dr. Russell A. Barkeley an internationally recognized authority on attention deficit hyperactivity disorder (ADHD) in children and adults.

Would you offer us some insights/advice about the disorder as it manifests itself in adults? Many clinicians tell me there is a challenge and problem with the potential of undiagnosed/unrecognized ADHD in adults.

Symptoms change with age, as hyperactivity is more significant of an issue in
younger children. We know that impulsive symptoms start earlier than attention
deficits and processing issues. But as you get older, the issue of inattention and
processing begins to take center stage.

In elementary school both symptoms may be prevalent but hyperactivity tends
to decline while inattention remains. These older children and then adults tend
to develop broader executive functioning deficits pertaining to memory, poor
time management, and processing.

By adulthood clinicians need to know these transitions or else they run the risk
of missing these symptoms and understanding what they mean.

For example, emotional impulsiveness and poor emotional self-regulation
load on the impulsive dimension of ADHD but they need to be explicitly noted in
the criteria or clinicians misattribute it to some other disorder.

Problems with regulating emotions, especially in older children and adults are
just as significant and should never have been separated out. They are just as
problematic as the attention piece. (e.g., anger, frustration, impatience)
Emotional regulation is significantly disruptive on a social level. It causes
disruptions with friendships, dating and marriage. In addition, studies also show
problems with parenting appropriately for adults with ADHD.

So we know that ADHD in adults can bring about significant problems with peer
relationships, raising children and occupational functioning. Unfortunately,
these symptoms are sometimes misunderstood and misdiagnosed leading to
treatment interventions that are unproductive.

We have also known since the 1960’s that when you reduce ADHD symptoms
with Stimulants you get a reduction of ODD because of the strong correlation
between the two and the overarching inability to reduce emotional
impulsiveness.

If emotional regulation problems continue to persist even after stimulants are introduced then one might consider adding a second medication. Why?
Because Stimulants increase dopamine and essentially control emotions
through inhibiting them. However, with ADHD the limbic system is not
overactive rather it is having problems moderating things.

Therefore, the use of Stimulants may be suppressing the wrong parts of the
brain. At present, we aren’t sure what other medications might be better at
managing the emotional piece of ADHD. Stimulants do help with its
management but as I just mentioned, perhaps by the wrong mechanism (limbic
inhibition).

It’s likely that Strattera might be better for managing emotional regulation as it’s
not a stimulant and does not affect limbic functioning like stimulants. However,
it’s important to note that we have no actual controlled studies as of yet.

The new drug, Intuniv (guanfacine XR) due out later this year might also be
better for this piece, again for much the same reasons.

Dr. Barkley, would you elaborate on the idea of the Slow Cognitive Tempo form of ADHD that you propose?
Well as a starting point, it should be noted that the subtypes in the DSM IV have
not proven all that useful (e.g., Hyperactive/Impulsive Type; Inattentive Type;
Combined Type). Their validity still remains in question and will most likely be
disbanded altogether when the DMS V comes out in 2011/2012.

We now believe ADHD to be a single disorder. By this I mean one disorder that
ranges in severity versus a disorder with three subtypes.

In the midst of the effort to get rid of subtypes we also know that approximately
30% -50% of people currently classified under the Inattentive Type have what is
now known as Slow Cognitive Tempo. Several senior researchers, including
myself, believe that Slow Cognitive Tempo is actually a separate disorder from
ADHD altogether.

Many of the symptoms for Slow Cognitive Tempo include daydreaming, feeling
“spacey” or “foggy”, lethargic, and hypoactive. In many ways it is the antithesis
of ADHD. People experiencing these symptoms have very slow processing
abilities and are prone to errors. The impairment of executive functioning is one
of the main factors with this group.

There is also a significant social component to consider with Slow Cognitive
Tempo children. Typical ADHD children are often rejected socially in part
because they tend to be aggressive, emotional and viewed as difficult by their
peers. Slow Cognitive Tempo children don’t have these problems. Their main
social challenges pertain to shyness, apprehension and reticence. However, it
is important to note that this is not something that would fall under the Autistic
Spectrum Disorder continuum.

Another distinguishing factor has to do with the strong correlation between
ADHD children and Oppositional Defiant Disorder (ODD). These children are at
higher risk to suffer from ODD because of their impulsive behavior. Outcomes
are different with the Slow Cognitive Tempo children in that they don’t have
these similar symptoms that would put them at risk.

Looking at treatment implications with this population we already know that
Slow Cognitive Tempo children don’t do as well on Stimulants because we are
talking about vastly different symptoms. It’s not an issue of impulsiveness and
hyperactivity rather we are looking more at processing and executive functioning
issues. As a result, Methylphenidate medications have not been shown to
produce good results.

Psycho pharmacologically, non-stimulant medications such as Strattera tend to
be more effective with this population.

Behavioral interventions are also found to be effective with Slow Cognitive
Tempo children because most of them are anxious and psychosocial treatments
are known to work well with children who suffer from anxiety.

What is meant by the term "neuro enhancement? It seems to be a hot topic especially with regards to the issue of malingering.
Stimulants enhance awareness, make you more alert, awake, and less fatigued.
They do this for people with ADHD and for those without. We also know that
Stimulants improve motor coordination, which is appealing to athletes. And with
the rise in sophistication of medications and their overall prevalence we are
seeing more instances where people are seeking out these medications for neuro enhancement and not to specifically treat ADHD.

Studies show that 1 in 5 college kids who ask for accommodations are actually
malingering (20-25%). Therefore, these settings really need clinical sensitivity
around these issues,

However, I must stress that the question of whether this is right or wrong is a
matter of public debate that I wonʼt engage in.

We do know that side effects are the same for ADHD patients and people who
are seeking enhancement. We donʼt have any evidence suggesting that using
Stimulants as a neuro enhancement would increase abuse. In fact, research
shows no significant rise over the last 20 years of abuse of Stimulants.

Below are some high-level facts pertaining to ADHD that are offered by Dr.
Barkley. You can get more detailed information on his website at
www.russellbarkley.org

Basic Etiology

• ADHD arises from multiple causes
• All reliably supported causes fall in the realm of biology (neurology, genetics)
• Causes may interact and compound each other
• Final common pathways for the disorder appear to be the fronto striatalcerebellar brain circuits and anterior cingulate
• Social causes lack-compelling evidence
• 25-35% of cases attributable to acquired brain injuries*
• 65-75% of cases due to genetics-heredity*
*Nigg, J. T. (2006). What Causes ADHD? New York: Guilford Publications

Some Popular Proposed Etiologies

• Excessive TV or video game viewing:
- TV accounts for just 2-5% of variance in symptoms
- ADHD cases watch more TV and play more videogames, but direction of
causality not proven and likely to be a consequence of ADHD and parental use
of visual media for babysitting a difficult child
• Food additives (coloring, preservatives):
– May exacerbate behavioral problems in 5% of ADHD children in preschool
years
– Associated with small increases in hyperactivity in normal children not found in
ADHD children
•Poor child-rearing methods at home:
– More parent-child conflict found in families with ADHD but research shows this
is related to both child and parental ADHD and maternal depression,
- It improves with medication of the child, and numerous twin studies show no
within-family shared effects


What are some new research findings or clinical treatments in the area of
ADHD?

There are drugs currently being researched. Some of which I will list below.

1) Nicotine receptor drugs: These drugs work by splitting the nicotine
receptor molecule away from concentrations. The drugs are in clinical
trials now but are still several years away. It’s also interesting to note that
people with ADHD are prone to nicotine use/abuse because it helps with
their symptoms.

2) Non-Stimulants: Shire is coming out with an FDA approved and
extended release version of Tenex (guanfacine) known as Intuniv (Create
link). This is a hypertensive medication and the angle they will take from
a marketing standpoint is that it has a positive effect addressing the
emotional regulation aspect of the disorder. It also addresses the
hyperactivity piece. The only real news here is that they are close to FDA
approval (physicians have been using it already) and they will have an
extended release form.

3) We will also see more nor epinephrine reuptake inhibitors arise in the
marketplace. These medications are different from the Stimulants in that
they affect Nor epinephrine vs. Dopamine.

4) The real news pertaining to ADHD treatment, however, centers around
psychosocial treatment as a complement to medication.

Howard Askoff PhD at NYU Medical School is working on development of
a psychosocial curriculum focusing on Time Management training
designed to address executive deficits.

There is also much work being done on developing Cognitive Behavioral
Therapy (CBT) for adult ADHD. We know from research that CBT does
not work with children suffering from ADHD but it does show promise as
a supplement for adults. Below is a list of some important work being
done in this area.

- Steve Safren, Ph.D. at Harvard Medical School is creating the first
Cognitive Behavioral Therapy treatment program and training manual for
adult ADHD.
- Russell Ramsay, Ph.D. and Anthony Rostain, M.D. at Univ. of PA (Phila.),
are also working on a cognitive training manual for ADHD that is similar to
Dr. Safren (about 80% overlap). They do not, as of yet, have as much
controlled research as Steve Safren Ph.D.
- Mary Solanto, Ph.D. and Mt Sinai Medical School in New York City also
have their own version of this CBT treatment model.
Russell A. Barkley, Ph.D., is an internationally recognized authority on attention deficit hyperactivity disorder (ADHD) in children and adults. Dr. Barkley has specialized in ADHD for more than 30 years and is currently a Research Professor in the Department of Psychiatry at the SUNY Upstate Medical University in Syracuse, New York and resides in the Charleston, South Carolina region.
He is a clinical scientist, educator, and practitioner who has authored, co-authored, or co-edited 20 books and clinical manuals. These include “Your Defiant Child”, which was the Winner of a 1998 Parents' Choice Approval and ADHD Award, and “The Nature of Self Control” published in 2005.
He has received numerous awards over his career for his work in ADHD most recently in 2005,when he received an award for distinguished service to the profession of psychology from the American Board of Professional Psychology.
You can learn more about his work at www.russellbarkley.org
What follows is information obtained from my interview with Dr. Barkley. I would like to thank him for his generosity and time!



David P. Diana is a counselor, author, and a director for a behavioral healthcare organization. He writes a weekly blog on sales and marketing for counselors (www.davidpdiana.com)

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