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(p. 43) Commentary 

(p. 43) Commentary
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(p. 43) Commentary
Author(s):

Russell A. Barkley

DOI:
10.1093/med:psych/9780199733668.003.0019
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Dr. Antshel describes an interesting and relatively typical case of a young adult referral in which ADHD has been previously diagnosed. Pat’s history of repetitive antisocial behavior and occasional contacts with the legal authorities is, sadly, relatively commonplace in children with ADHD followed to adulthood (Barkley, Murphy, & Fischer, 2008; Satterfield, Faller, Crinella, Schell, Swanson, & Homer, 2007). This is particularly so for driving offenses, where available research shows teens and adults with ADHD to be at high risk for a variety of adverse outcomes (Barkley & Cox, 2007). Consequently, clinicians must take care to advise not only patients with ADHD but parents as well about the driving risks of teens and young adults with ADHD under their care and the need to take appropriate steps to address those risks, including the use of medication while driving.

As in this case, antisocial activities or contacts with legal authorities may be the basis for the referral for evaluation and often are the most impairing and distressing feature of the current presentation, at least to the patient’s loved ones, if not to the patient himself. And while ADHD, conduct disorder (CD; antisocial behavior), and psychopathy are distinct yet interrelated disorders/constructs (Pardini, Obradovic, & Loeber, 2006), and most cases of ADHD do not become adult psychopaths (Fowler, Langley, Rice, Whittinger, Ross et al., 2009), there is a greater likelihood of psychopathy in teens and adults with ADHD than is the case in the general population, especially if they had manifested symptoms of childhood conduct problems (Waschbusch & Willoughby, 2008). Given the strong contribution of psychopathic traits to persistence of antisocial behavior into and through adulthood (Fowler et al., 2009; Lynam, 1998) and the substantial genetic and neurological contributions to psychopathy (Blair, Peschardt, Budhani, Mitchell, & Pine, 2006), clinicians need to be on the alert for its existence in cases such as Pat’s, as it may bode for an even poorer outcome than would ADHD or CD alone. It may also increase the risk of harm to family members and others attempting to intervene with the patient. Thus it might have been useful in this case to screen for such traits using rating scales for this purpose.

Clinicians also need to appreciate the high risk that such cases of ADHD/antisocial behavior have for current and later drug use and abuse. This was clearly the case for Pat, starting in early adolescence. My own longitudinal study of children with ADHD followed to age 21 suggests that while earlier conduct (p. 44) problems/disorders are clearly associated with later risks for predatory forms of antisocial behavior and with running away from home and teen prostitution by age 21, ADHD was associated with later drug-related activities, such as possession, sale, and use of illegal drugs and theft, even after controlling for earlier CD (Barkley, Fischer, Smallish, & Fletcher, 2004). And once drug use was initiated, it interacted over time with antisocial behavior such that each exacerbated the other. That Pat should show some affinity for the use and abuse of marijuana is also not uncommon. We have found that adults who were diagnosed with ADHD as children and adult clinic-referred patients diagnosed with ADHD have higher rates of use of alcohol, tobacco, and marijuana than does the general population or control groups (Barkley et al., 2008). Hence the need for substance use treatment programs is likely to be part of the treatment package recommended for such cases, as it was for Pat. And while not mentioned in Pat’s case history, those using marijuana are likely to be using tobacco and typically started with the latter drug first (Barkley et al., 2008), perhaps because the individual may find some therapeutic benefit from the nicotine and thus may be self-medicating his or her ADHD (Kollins, McClerman, & Fuemmeler, 2005).

The limited or nonexistent insight of Pat into his current problems, history of ADHD, and need for current treatment is a common occurrence. For instance, our longitudinal research found that only 4% of cases we previously diagnosed with the disorder in childhood reported sufficient symptoms to meet DSM diagnostic criteria; the majority saw themselves as not having the disorder and grossly underreported their symptoms (Barkley et al., 2008). As evidence of this fact, we found that the correlation between parent and patient report at age 21 was just .21 and at age 27 was just .43. Parental reports of symptoms were found to correlate more highly with impairment and with more domains of impairment than were self-reported symptoms at age 21, and thus parent reports were considered more valid (Barkley, Fischer, Fletcher, & Smallish, 2002). This striking disparity between parental reports and self-reported information in someone not self-referred for an evaluation of ADHD is commonplace, despite the patient having been diagnosed as a child. It supports the commendable practice by Dr. Antshel of interviewing the parent (or other collateral who knows the patient well) in addition to the routine interview of the patient and has led to this practice being considered as important to the evaluation of adults with ADHD (McGough & Barkley, 2004).

The significant level of distress and conflict in the parent-offspring relationship so palpable between Pat and his mother is also typical of teens and young adults with ADHD, particularly when oppositional defiant disorder and conduct problems exist in the patient (Johnston & Mash, 2001; Edwards, Barkley et al., 2001). In such cases, father absence is more common or, if a father is present within the family unit, disengagement from the teen and even from the marriage may be likely, in my experience—this was certainly the case with Pat’s father and removes one source of potential constructive influence from this situation. In such families, as Dr. Antshel ably discusses, the likelihood of ADHD in one or both parents is significant as a consequence of the striking heritability of the (p. 45) ADHD trait(s). Clinicians should follow Dr. Antshel’s lead in screening all parents of patients with ADHD in instances such as this one (and obviously in children and teens) in which the parent continues to play a substantial role in the life of the patient. The parent’s ADHD may well interfere with not only the current adjustment of the patient but also with efforts to implement treatment programs (Sonuga-Barke, Daley, & Thompson, 2002) for which the parent may have some direct or indirect responsibilities. Further evaluation of and treatment for the parent’s ADHD, as was initiated in this case, is likely to prove beneficial not only for Pat’s mother but also for the treatment plan created for Pat as well.

That a mild mood disorder, such as demoralization or dysthymia, was evident in Pat’s case, and clearly noticeable in his irritability with his mother and the examiner, is likewise not surprising. Such disorders occur with greater frequency in both children with ADHD followed to adulthood (age 27) and adults with ADHD who self-refer for clinical evaluations (Barkley et al., 2008). The linkage may arise, in part, from shared genetics between the disorders (Faraone & Biederman, 1997), as well as the common comorbidity between ADHD, CD, and depression (Angold, Costello, & Erkanli, 1999). Should the patient’s demoralization have arisen as a consequence of his repeated failures and impairments in major life activities associated with his ADHD, it may well respond to management with ADHD medications. This is not likely to be the case for more serious mood disorders, such as major depression, for which separate treatments may be necessary.

The limited or nonexistent benefit of earlier treatments during childhood for ADHD on adolescent and young adult outcomes, as evident in Pat’s case, is also relatively typical in the small literature that has examined the issue (Barkley et al., 2008; Molina, Hinson, Swanson, Arnold, Vitiello et al., 2009). This is not because treatments given in childhood do not have beneficial effects on children’s ADHD or domains of impairment—clearly they do. It is more likely due to the termination of these treatments over time, as was seen in Pat’s case, such that by high school only a minority of ADHD cases who were previously treated continued on their medication or in a combined medication/psychosocial treatment program. The lesson here seems to be that for treatment to improve adolescent and young adult outcomes, it must be sustained through adolescence to young adulthood, as would be the case with any chronic medical condition such as diabetes. That is easier said than done with adolescents, as was clear in Pat’s case. His resistance to taking medication as an adolescent and his later begrudging acceptance of it as a young adult are also quite typical, in my own experience. Adolescent noncompliance with ADHD medications thus makes intervening in these crucial adolescent years much more difficult than may be the case for children with ADHD or for the management of adult self-referrals who are diagnosed with the disorder and are more cooperative with such self-sought interventions.

Also noteworthy in Pat’s history and current adjustment is his limited educational attainment, despite above average intelligence and absence of a specific learning disability. Numerous longitudinal studies, including my own, have repeatedly documented the adverse impact of ADHD on eventual educational (p. 46) attainment; 30–40% of childhood cases do not complete high school, and perhaps just 5–10% complete a college degree program (Barkley et al., 2008). This will obviously carry forward to have a detrimental effect on the level of occupation that such individuals can obtain at entry into the workforce, as well as on their upward advancement in their chosen occupation.

A few comments on the approach to assessment used by Dr. Antshel seem in order. The use of adult ADHD rating scales for the initial screening for risk for disorder and especially to document the developmental inappropriateness of the symptoms, as was done here, is essential for establishing that the patient has met these aspects of diagnostic criteria for ADHD (McGough & Barkley, 2004; Murphy & Gordon, 2006). Several rating scales, besides the Adler scale used here, have acceptable norms and are available for documenting DSM-IV symptoms of ADHD in adults (Barkley, 2011a; Conners, Erhardt, & Sparrow, 1998). Also noteworthy was the attempt by Dr. Antshel to broadly screen for potential impairment in major domains of life activities, in this case adapting the child impairment scale initially developed by Fabiano. Symtom severity does not equate directly to related levels of impairment, requiring that impairment be assessed separately and specifically in such cases, rather than just inferring such from the severity of the ADHD symptoms (Gordon, Antshel, Faraone, Barkley, Lewandowski et al., 2006; Lewandowski, Lovett, & Gordon, 2009). Problematic with the Children’s Impairment Scale, however, is the lack of validity and other psychometric information about the scale when used with adults and the lack of norms for an adult general population sample. These problems have been addressed in a more recently published rating scale of impairment in adults that captures 15 major domains of life activities (Barkley, 2011b) that now would be a more appropriate alternative.

Given that adults with ADHD often have associated deficits in various domains of executive functioning (EF; Barkley et al., 2008; Hervey, Epstein, & Curry, 2004), I also encourage clinicians to incorporate some assessment of these functions in the evaluation of adults with ADHD. While this has been traditionally done using psychometric EF test batteries, such tests often fail to detect the difficulties in EF associated with ADHD, with just 25–50% falling in the impaired range on these tests (Barkley & Murphy, 2011; Biederman, Petty, Fried, Black, Doyle et al., 2008; Biederman, Petty, Fried, Fontanella, Doyle et al., 2006). Moreover, such tests have low or no ecological validity. This is to say that they correlate poorly, if at all, with either ratings of EF in daily life activities or with measures of impairment in a variety of important domains of adult major life activities (Barkley, 2011c; Barkley & Fischer, 2011; Barkley & Murphy, 2011; Barkley & Murphy, 2010). As a result, I do not recommend that clinicians waste their time with such a time-consuming psychometric test battery approach in cases of adult ADHD. More useful, economical, convenient, and ecologically valid is the use of rating scales of EF in daily life activities, such as the Deficits in Executive Functioning Scale (Barkley, 2011d) or Behavior Rating Inventory of Executive Functioning, Adult Version (Roth, Isquith, & Gioia, 2005). Note, however, that the latter scale may have the potential to over-identify EF deficits (p. 47) in view of its relatively super-normal and technologically, psychiatrically, and medically filtered normative sample. Rating scales have greater utility than tests in predicting impairment (Barkley & Fischer, 2011; Barkley & Murphy, 2010), which makes them more pertinent to assessing issues of EF deficits in clinical settings where understanding and predicting such impairments is a major purpose of such evaluations. Such scales indicate that 86–98% of adults with ADHD are impaired in one or more domains of EF in daily life, such as self-organization and problem-solving, self-management to time, self-motivation, self-discipline, and self-regulation of emotions (Barkley, 2011c). Another advantage to such EF rating scales and those noted earlier for adult ADHD and impairment is their convenience for monitoring response to interventions, as was done in Pat’s case, using the ADHD and impairment ratings.

Dr. Antshel commendably elected to use the most evidence-based interventions for Pat’s ADHD, these being medication and cognitive behavioral treatment (CBT). Medications remain a mainstay, empirically based treatment for child and especially adult ADHD (see Prince, Wilens, Spencer, & Biederman, 2006) and so returning Pat to medication was a wise choice in this case, even if the patient complied grudgingly. Medications will likely be required for the management of 70–80% or more of adult cases, in my opinion, whether to treat the ADHD or, as often is the case in over 80% of adults with ADHD (Barkley et al., 2008), to treat their comorbid disorders. While annoying side effects certainly exist with these medications, and their side effect profile clearly depends on whether stimulants (methlphenidate, amphetamine), nonstimulants (atomoxetine), or anti-hypertensives (guafacine XR, clonidine XR [FDA approved only for children to date]) are utilized, the safety profile of these medications is unsurpassed in any other area of psychopharmacology for psychiatric disorders despite sensationalized media accounts to the contrary. The most common side effects (30–50% or more of cases) for the stimulants are typically loss of appetite for midday meals primarily, along with insomnia, both of which tend to be more problematic for child than adult cases of ADHD. Some modest temporary cessation of gains in growth in children may occur, but these have not been documented to continue into late adolescence or adulthood. Perhaps 25% or fewer cases complain of stomachaches or headaches in conjunction with stimulant use. From 10–25% of cases do not respond to the starting medication type or delivery system (pills, OROS pump, time release pellets, skin patch, or pro-drug) and may require switching to alternative delivery systems or medications before a good therapeutic effect is obtained. About 3–5% of cases may not be able to tolerate any dose of these medications.

The CBT program by Safren and colleagues (Safren, Perlman, Sprich, & Otto, 2005) implemented with Pat is a fine intervention for adult ADHD with an increasing evidence base (Knouse & Safren, 2010). Several similar programs that also have an evidence base are available for conducting CBT with adults with ADHD (Ramsay & Rostain, 2007; Solanto, 2010). All CBT programs focus on training adults in strategies to compensate for their deficits in executive functioning in daily life, such as difficulties with time management, organization, (p. 48) problem-solving, emotional self-control, and so on, as noted above. There is no consensus yet in the field as to the sequence in which the medication and CBT treatments ought to be instituted for an adult with ADHD. Safren and colleagues require their patients to be on medication before enrolling in CBT as they believe that it makes them more likely to attend to, and follow through on, the treatment procedures than if they are off medication—a point with which I agree. Ramsay and Rostain strongly encourage a combined intervention as well. The Solanto program has been studied with patients being off medication and has had some success as well, but it is not clear whether more improvement might have been evident had patients also been on an ADHD medication. Given the initial findings of the MTA study (and others) with children that combined treatment was typically more beneficial than either medications or psychosocial treatments alone, this would seem to be the best approach for now, with both children and adults with ADHD, when both are available—something not usually the case in rural areas of the United States.

Besides such feedback counseling about the disorder following the evaluation, ADHD medications, and the manual-based CBT interventions, some counseling of the teen or young adult with ADHD, along with his or her parents or guardians, is in order concerning other major domains of increased risk in major life activities associated with ADHD at these ages, as well as possible means to address the risks (Barkley & Benton, 2010; Ramsay, 2010). While little or no research exists on the best treatments for various impairments, some commonsense advice can still be offered. These impairments include not only the driving problems noted above, but also the penchant for risky sexual behavior and adolescent pregnancy (Barkley, Fischer, et al., 2006; Flory, Molina, Pelham, Gnagy, & Smith, 2006), occupational difficulties, money management problems, and increased health risks such as excess use of legal substances, psychosomatic symptoms, obesity, bulimia (in ADHD females), and cardiovascular disease (Barkley et al., 2008). It is also important to direct such patients and families to trusted sources of information on adult ADHD and its management in the trade media and on the Internet (see Adler, 2006; Barkley & Benton, 2010; Pera, 2009; Sarkis & Klein, 2010; Tuckman, 2007), given the plethora of such information in these sources, much of which may not be science-based.

My remarks and caveats notwithstanding, Dr. Antshel has selected a fine case, representative of the typical referral that one is likely to encounter in seeing young adults for evaluation and management of ADHD. His approach to the evaluation, counseling, and management of the case is commendable, empirically based, and an exemplar to other clinicians.

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