Uncategorized Category

ADHD Medications May Be Helpful for Cognitive Impairments in Menopause

Friday, March 31st, 2017

Some women with no previous history of ADHD symptoms report experiencing unprecedented problems with organization, attention, alertness, and working memory as they enter menopause. I have been working with Neill Epperson, MD and other researchers at Perelman School of Medicine of the University of Pennsylvania to test whether medications used for ADHD might be helpful for menopausal women who experience such difficulties. We have now published 3 scientific papers reporting our positive results. Click this link to read our 2015 paper on this research.

Growing Up With ADHD: Clinical Care Issues

Friday, February 12th, 2016

“Growing Up With ADHD: Clinical Care Issues,” was published in the January 2016 issue of Psychiatric Times, a  publication distributed to all psychiatrists in the U.S. It describes why young adults with ADHD often do not get the help they need  when they are no longer being cared for by their pediatrician. It includes some suggestions for how they can be provided more adequate care. Read PDF article >

ADHD: From Stereotype to Science

Tuesday, February 2nd, 2016

Read this article offering updates in understanding ADHD. It was recently published in a national magazine for educators. Click this link to read the article.

The Marshmallow Test, “Willpower” and ADHD

Friday, December 5th, 2014

Check out my recent 2-part blog The Marshmallow Test, “Willpower” and ADHD. It’s posted on the website for Psychology Today.

Find it with this LINK.

JUST RELEASED – “Smart but Stuck: Emotions in Teens and Adults with ADHD.”

Wednesday, February 12th, 2014

class="alignleft" smart but stuck cover photo

 

 

(GET MORE INFORMATION AND READ AN EXCERPT OF THIS NEW BOOK )

 

“Smart but Stuck” offers a series of true stories about intelligent teens and adults who had gotten “stuck” in failures at school, work, or in getting along with friends and family because of their ADHD. It shows how they got “unstuck” by dealing with ups and downs of emotions they didn’t know they had. 

 

In this book you will meet:

• Sue, who earned high grades until middle school, then lost motivation for schoolwork and became disorganized and provocative in 9th grade, frustrating teachers and family while losing hope for herself. 
• Mike, a college student who just got put on academic probation. His dad always told him he’s smart but just lazy, and now he’s starting to believe it.
• Steve, a computer programmer whose ADHD struggles have led to him losing his job—and his wife. He’s good at programming computers, but not at programming himself.
• Sarah, who’s had trouble keeping track of things and getting work done since she hit menopause. She’s puzzled, since she never had such a hard time when she was younger.

Another Open Letter to the Editor of the New York Times

Friday, January 3rd, 2014

Sent January 2, 2014. 

On December 29, 2013, the New York Times published another in its series of articles by Alan Schwarz arguing that medication is used excessively for treatment of ADHD. He cited a large research project sponsored by the U.S. National Institute of Mental Health twenty years ago which  compared medication treatment vs behavioral and vs combined medication/behavioral treatment of 7 to 9 year old children with ADHD over a 14 month period. Results of the study indicated that carefully managed medication was the most effective treatment for ADHD symptoms of those children over that time frame

Schwarz argued that this scientifically-controlled study oversold the benefits of medication treatment, distorted the debate over the most effective treatment, and failed to demonstrate adequately the longer term benefits of behavioral treatments for “teaching children, parents and teachers to create less distracting and more organized learning environments.”  He claimed that more recent studies have cast doubt on whether results of medication treatment last as long as those from behavioral therapy and offered brief quotes from several researchers involved in the NIMH study who shared thoughts about limitations of that research.

Unfortunately, this Schwarz article is seriously flawed in 3 important ways:

1)   The article seems to be based on an outdated understanding of ADHD. Current scientific understanding recognizes ADHD as a complex disorder involving developmental impairments of the brain’s cognitive management system, its executive functions.  These include chronic problems with activation and motivation, organizing and prioritizing tasks, sustaining effort for tasks, managing emotions, and utilizing working memory. Most of these problems, especially when experienced by older children or adults, are not improved adequately by behavioral treatments and are often, though not always, improved by carefully tailored medication treatment.

2)   It implies that creating “less distracting, more organized learning environments” would alleviate problems of ADHD. Impairments of this disorder certainly may be helped by environments that are well organized and not excessively distracting, but the essential impairments of ADHD are due to inherited problems in brain connectivity and brain chemistry; they are not caused by environmental distractions.

3)   It mentions that recent research studies “have also cast doubt on whether medication’s benefits last as long as those from (behavioral) therapy.”  Neither medication treatment nor behavioral therapy confers lasting remediation of ADHD symptoms any more than eyeglasses provide continuing remediation of vision problems after they are taken off.

It is unfortunate that this reputable newspaper continues to offer its readers information about ADHD which is so outdated, incomplete, and persistently biased as this series of articles by Alan Schwarz.

Thomas E. Brown, Ph.D.

Clinical Psychologist

Associate Director of Yale Clinic for Attention & Related Disorders

Dept. of Psychiatry

Yale University School of Medicine

www.DrThomasEBrown.com

An Open Letter to the Editor of the New York Times from Thomas E. Brown, Ph.D.

Monday, December 16th, 2013

Sent December 16, 2013

The front page of the New York Times on Sunday, December 15, 2013 featured an article “The Selling of Attention Deficit Disorder” by Alan Schwarz announcing that the number of diagnoses of ADD soared amid a 20-year drug marketing campaign. This lengthy article acknowledged that “classic ADHD, historically estimated to affect 5% of children, is a legitimate disability that impedes success at school, work and personal life.” It also acknowledged that “medication often assuages the severe impulsiveness and inability to concentrate, allowing a person’s underlying drive and intelligence to emerge.”

In his piece, Schwarz describes in detail how several pharmaceutical companies have waged extensive campaigns to educate physicians and parents about ADHD and to promote their medications used to treat ADHD. He also provides a number of examples where pharma advertising or physicians have made excessive claims for the potential benefits of these medications, have minimized potential risks of treatment, and have made inadequately supported statements about the disorder. Many of these examples warrant criticism.

Yet, this Schwarz article is seriously flawed in 4 important ways:

1)     It seems to assume that the substantial increase in ADHD diagnoses over the past 20 years is due simply to pharma companies seducing doctors and parents into medicating many children needlessly for problems that are trivial or non-existent. It shows no real grasp of how science-based understanding of ADHD has substantially changed over the past 20 years from the “classical”  focus on young children with disruptive behavior. Schwarz does not recognize that this disorder is now understood as developmental impairment of the brain’s management system, its executive functions. And he sees efforts to address these problems in adolescents and adults as just a search for more people to medicate rather than as recognition that many, though not all, who have ADHD in their childhood continue to suffer from these impairments throughout adolescence and, in some cases, much of their life.

2)     Schwarz claims that ADHD now is understood as including “relatively normal behavior like carelessness and impatience.” While it is true that all of the characteristics of ADHD occur for most people some of the time, legitimate diagnosis of ADHD requires that these problems significantly impair the functioning of the individual in ways that are inconsistent with usual expectations for the person’s age and negatively impact the person’s functioning, not just occasionally, but persistently for more than half a year.

3)     The article begins with an alarmist quote from Keith Conners, a retired researcher in ADHD, who recently lamented that the rising rates of diagnosis are “a national disaster of dangerous proportions…a concoction to justify giving out of medications at unprecedented and unjustifiable levels.”  Both Conners and Schwarz apparently assume that the incidence rate for ADHD should remain forever set at that earlier level. They do not allow for the possibility that the earlier estimate may have been incorrect or that the more recent science-based understanding of ADHD may describe a problem that actually impairs a larger number of children and adults.

4)     In this article and several earlier articles in the Times, Schwarz correctly emphasizes that medications used to treat ADHD can have serious adverse effects. This is true of any medication, including such common over-the-counter medications as Tylenol. Yet he tends to exaggerate the risk of severe adverse effects, e.g. “cannot sleep for days, lose their appetite or hallucinate” by not mentioning that hallucinations due to these medications are quite transient and extremely rare; nor does he note that problems with sleep or appetite can almost always be alleviated without any significant or lasting harm. If prescribed medications are not effective or cause any significant adverse effects, any responsible prescriber will correct it with dose adjustments, medication change, or discontinuation.

It is quite reasonable for the Times for make readers aware of problems such as Alan Schwarz described in his article, but it seems irresponsible for such a reputable newspaper to present such information without more careful attention to underlying assumptions of the piece that may be inaccurate, outdated, and, for many readers who may be struggling with this disorder, unnecessarily frightening.

 

Thomas E. Brown, Ph.D.
Clinical Psychologist
Associate Director of Yale Clinic for Attention & Related Disorders
Dept. of Psychiatry
Yale University School of Medicine
www.DrThomasEBrown.com

Dr. Brown Presents “How Our Understanding of ADHD is Changing” at the Help Group Summit 2013

Tuesday, October 15th, 2013

Summit 2013

Recent neuroscience and psychological research has brought major changes in how ADHD is understood. This disorder is now seen not as a behavior disorder, but as developmental impairment of the brain’s management system, its executive functions. Dr. Brown will address questions like: Why can those with ADHD focus very well on some tasks while having great difficulty focusing on other tasks they recognize as important? How do impairments of ADHD change from childhood through adolescence and in adulthood? What treatments help to improve ADHD change from childhood through adolescence and in adulthood? What treatments help improve ADHD impairments? How do they work? Are they safe? Why do children and adults with ADHD have additional emotional, cognitive, and learning disorders more often than most others? Learning Objectives: Understand how brain development in persons with ADHD differs from others of the same age. Recognize the role of emotions and motivation in ADHD. Identify which treatments tend to be helpful and safe for ADHD. Consider reasons for overlaps between ADHD and learning disorders, substance abuse, anxiety and autism spectrum disorder. Friday, October 25th from 11:15 a.m.-12:30 p.m.

An Open Letter from Dr. Brown Expressing Concern about a Recent FDA Action Related to ADHD

Monday, July 22nd, 2013

An open letter from Dr. Brown expressing concern about recent FDA approval of a diagnostic device for ADHD that is not adequately supported by research and may become a barrier to diagnosis for some.

July 22, 2013

An Open Letter to Margaret A. Hamburg, M.D. 

Commissioner of Food & Drug Administration of the U.S.

Dear Commissioner Hamburg:

On July 15, 2013, your agency issued a press release reporting that the “FDA permits marketing of the first brain wave test to help assess children and teens for ADHD.” In this action your agency, apparently on the basis of a single unpublished study of 275 children, has created significant risks for those affected with ADHD.

Although your press release said “allows marketing” of this device, radio, TV and print coverage of the news over the past week has trumpeted the message as “FDA has approved a brain wave test for ADHD.” For many, this is likely to be interpreted as meaning that the FDA has approved this device to be “safe and effective” for making a diagnosis of ADHD, just as medications approved by the FDA are taken to be safe and effective for treating a specific disorder. 

That press release reported “results showed that the use of NEBA” this newly approved device, “aided clinicians in making a more accurate diagnosis of ADHD when used in conjunction with a clinical assessment for ADHD.” This creates the false impression that within 15 or 20 minutes this device has the capacity to provide objective data which can make a more valid diagnosis than a clinician using the usual clinical measures for assessment. This creates a serious risk that a number of clinicians, parents, and others will give undue weight to that brief data sample and, on that basis, deny an ADHD diagnosis to a patient who warrants it or, perhaps, to diagnose someone with ADHD who does not, in fact, have it.  

Current research on ADHD has demonstrated that symptoms of this disorder tend to be situationally variable. DSM-5 states “Typically, symptoms (of ADHD) vary depending on context within a given setting. Signs of the disorder may be minimal or absent when the individual is… in a novel setting…or is interacting in one-to-one situations (e.g. the clinician’s office).”  Just as a brief structural brain image, e.g. SPECT scan, cannot determine a diagnosis of ADHD, so a sample of EEG data cannot provide clinically useful information about how the individual functions in meeting the multiple demands of daily life. Diagnosis of ADHD is essentially based upon careful assessment of the individual’s current history in multiple aspects of cognitive and behavioral functioning in school, work, family life and social relationships. 

As a clinician and researcher confronted daily with the frustrations and suffering of children and adults with ADHD, I urge your agency to reconsider its approval of this device so it does not become a barrier to those who need access to diagnosis and treatment for this complex and often persistent disorder.

Thomas E. Brown, Ph.D.

Associate Director

Yale Clinic for Attention & Related Disorders

Dept. of Psychiatry

Yale University School of Medicine

DSM-5 Changes in ADHD Diagnostic Criteria

Friday, July 5th, 2013

In May, 2013 the American Psychiatric Assn. published a new edition of their Diagnostic & Statistical Manual of Mental Disorders, the reference widely used for diagnosing ADHD and other psychiatric disorders. In this 5th edition there were some useful changes in the diagnostic criteria for ADHD, but there were also some unfortunate omissions.

Useful changes:

  • Age of onset: previously, diagnosis of ADHD required that at least some symptoms of ADHD had been present in the individual by age 7 years. DSM-5 raised the age criterion to having several ADHD symptoms present by age 12 years or earlier.
  • Fewer symptoms required for adults: previously the diagnosis of ADHD required at least 6 of the 9 listed symptoms of inattention and/or 6 of the 9 symptoms of hyperactivity/ impulsivity. Now just  5 symptoms from either set are required for diagnosis of persons 17 years or over.
  • Examples of adult symptoms: previously most of the listed examples of symptoms were childhood behaviors not common in adolescents or adults with ADHD; some examples of common adult ADHD symptoms have been added.
  • Comorbidity with autistic spectrum disorders:  previously the diagnosis of ADHD was not supposed to be made for individuals diagnosed with a disorder on the autistic spectrum.  DSM-5 allows diagnosis of both disorders when criteria for both are met.

Importantly, the DSM-5 does note more explicitly than did its predecessor that “Typically, symptoms vary depending on context within a given setting. Signs of the disorder may  be minimal or absent when the individual is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e.g. via electronic screens), or is interacting in one-on-one situations (e.g. the clinician’s office).”

Although these changes are useful, this version of the DSM does not very adequately reflect scientific advances in understanding ADHD that have emerged over the 13 years since the last revision or the 19 years since the edition which introduced research-based changes in the diagnostic criteria for ADHD.

  • DSM-5 retains the behaviorally-focused emphasis of previous versions of the manual and does not adequately reflect the underlying cognitive difficulties, the syndrome of executive function impairments, which have been found to be the core of ADHD. 
  • DSM-5 does not adequately address the important role of emotions in ADHD. It does not pick up the impaired motivational aspect of emotions which makes it so difficult for many with ADHD to get started on or sustain effort for tasks not intrinsically interesting to them. And it does not include any symptoms that reflect characteristic problems of persons with ADHD in modulating their experience and expression of emotions.
  • DSM-5 does not recognize the importance of problems in regulating sleep and alertness which have been identified in research on ADHD in children and adults. 

One of the researchers who contributed to the difficult work of revising ADHD diagnostic criteria for DSM-5 once gave an early report on the proposed changes for a group of clinicians and researchers. After being peppered with many queries about “Why haven’t you included this or that in your changes?” the presenter reminded the group, “The DSM follows the field; it does not lead it!”  There is good reason for us to be grateful to those who worked hard to update DSM-5. There is also good reason for us to look to other sources to continue to update and increase our understanding of this complex disorder.