New Understandings of ADDADHD

1
New Understandings of ADD/ADHD Its
Complications

• Thomas E. Brown, PhD
• Associate Director,Yale Clinic for Attention and
  Related DisordersDepartment of Psychiatry
• Yale Medical School

2
Shifts in Conceptualizing ADHD

• 1968 Hyperkinetic Disorder of childhood
• 1980 Attention Deficit Disorder
• 1987 ADHD (only combined symptoms)
• 1994 AD/HD3 types
• 2000 AD/HD (impaired executive function)

• With or without hyperactivity
• Residual type recognized

3
Prevalence and Genetics of ADHD

• 7-9 of children 4.4 of adults
• Male-female 61, 31, 11
• All levels of IQ
• All levels of socioeconomic status
• Family genetic transmission 0.75-0.8
• Inheritance not specific to subtype

Barkley RA. Sci Am. 1998279(3)66-71. Gaub M,
Carlson CL. J Am Acad Child Adolesc Psychiatry.
199736(8)1036-1045. Levy F, et al. J Am Acad
Child Adolesc Psychiatry. 199736(6)737-744.
Smalley SL, et al. J Am Acad Child Adolesc
Psychiatry. 200039(9)1135-1143.
4
ADHD Genetics Heritability Coefficient
Height
Asthma
Schizophrenia
Breast cancer
Hudziak, 2000
Nadder, 1998
Levy, 1997
Sherman, 1997
Silberg, 1996
Gjone, 1996
Thapar, 1995
Schmitz, 1995
Edelbrock, 1992
Gillis, 1992
Goodman, 1989
Willerman, 1973
Average genetic contribution of ADHD based on
twin studies
ADHD Mean
Faraone. J Am Acad Child Adolesc Psychiatry.
2000391455-1457. Hemminki. Mutat Res.
20012511-21.Palmer. Eur Resp J.
200117696-702.
5
DSM-IV Hyper-Impulsive Symptoms(Rephrased)

• Restless feelings and actions
• Impulsive actions and speaking out
• Excessive impatience
• Only 2 speeds full or asleep
• Very difficult to relax
• Intrusive
• Impaired ability to inhibit

6
DSM-IV Inattention Symptoms(Rephrased)

• Organizing tasks and stuff
• Attending to work task
• Sustaining mental effort
• Task completion
• Using short-term memory
• Motivated to work
• Focus for tasks

7
ADHD Symptoms involveImpairments of Interacting
Executive Functions

• For example, inattention
• Does not mean
• Unable to focus as in holding the camera still to
  take a photo of an unmoving object
• Does mean
• Unable to focus as in focusing on the task of
  driving a car

This involves continuous, complex interaction of
shifting, refocusing attention and working memory
Brown TE. 2005
8
Executive Functions

• Wide range of central control processes of the
  brain
• Connect, prioritize, and integrate cognitive
  functionsmoment by moment
• Like conductor of a symphony orchestra

9
What is ADHD?(A Controversial Viewpoint)

• ADHD (all subtypes)
• Developmental Impairment of
• Executive Functions
• Developmental Impairment
• (Not emerging and unfolding as expected for age)

Attention Deficit Disorder The Unfocused Mind in
Children and Adults (T.E. Brown, Yale University
Press, Sept, 2005)
10
Browns Model of Executive Functions Impaired in
ADHDSymptom Characteristics

• Dimensional, not all-or-nothing
• Everyone sometimes has some impairments in these
  functions in ADHD, it is a chronic, severe
  impairment
• Situational variability If Im interested
• Most persons with ADHD have a few activities
  where ADHD impairments are absent

ADHD looks like a willpower problem, but it isnt!
11
Browns Model of Executive Functions Impaired in
ADHD
Executive Functions
Brown TE. 2005
12
1. Organize, Prioritize, Activate

• Difficulty organizing tasks and stuff
• Trouble getting started on work
• Misunderstands directions

Brown, 1995, 2000, 2001.
13
2. Focus, Shift, Sustain Attention

• Loses focus when trying to listen or plan
• Forgets what was read, needs to re-read
• Easily distracted-internal/external

Brown, 1995, 2000, 2001.
14
3. Regulating Alertness, Effort, Processing
Speed

• Difficulty regulating sleep alertness
• Quickly loses interest in task, especially longer
  projects doesnt sustain effort
• Difficult to complete task on time, especially in
  writing-- slow modem

Brown, 1995, 2000, 2001.
15
4. Manage Frustration, Modulate Emotion

• (not included in DSM-IV criteria)
• Emotions impact thoughts, actions too much
• Cant put it to the back of my mind
• Overreacts to frustration, hurts or worries

Brown, 1995, 2000, 2001.
16
5. Utilize Working MemoryAccess Recall

• Forgets intended tasks or comments
• Difficulty recalling learned material
• Loses track of papers, belongings

Brown, 1995, 2000, 2001.
17
6. Monitor and Self-regulate Action

• Too fast on tasks, not careful enough
• Interrupts, acts too impulsively
• Inadequate self-monitoring

Brown, 1999, 2000, 2001.
18
Development of Brain Structures that Support
Executive Functions

• Structures and functions that support EF are not
  fully developed at birth
• Neural networks underlying executive functions
  begin development at 2-4 years old, but dont
  fully develop until ones 20s
• Development of EF capacities continues into early
  adulthood

Rothbart MK, Posner MI. Mechanism and variation
in the development of attentional networks.In
Nelson CA, Luciana M, eds. Handbook of
Developmental Cognitive Neuroscience 2001.
19
Prepubescent Growth Spurt in Cortex(thickens
just before puberty, then thins)
Aggregate of 52 MRI scans of normal kids scanned
X4 _at_ 2 yr intervals Cortex thickness peaks at 11
yo in females 12.5 in males Then prunes for More
efficient circuits
View of right orbital lateral cortex blue is
thinner
J. Giedd (2003) NIMH
20
Cortex Maturation in ADHD vs NC

• MRI studies of 40K cortex sites in 223 youths
  with ADHD vs matched controls
• Brain maturation was delayed 3yrs in specific
  regions in ADHD youths vs NC
• Frontal areas of cortex slower in ADHD
• Medial PFC developed lagged 5 yrs

(Shaw, et al, PNAS, Nov, 2007)
21
Continuing Brain Development in Late Childhood
and Adolescence

• Between 6-15 years, extreme growth (to 80)
  occurs at the collosal isthmus that supports
  associative relay, while considerable synaptic
  pruning occurs
• Brain myelination increases 100 during the
  teenage years
• Dopamine (DA), norepinephrine (NE), and serotonin
  (5-HT) transmitter systems in the brain continue
  to develop into ones 20s

Thompson PM, et al. Nature. 2000404(6774)190-193
. Benes FM, et al. Arch Gen Psychiatry.
199451(6)477-484.
22
Executive FunctionsDevelopment and Demands

• EF capacity develops through childhood, into
  adolescence, and beyond it is not fully present
  in early childhood
• Environmental demands for EF increase with age,
  from preschool through adulthood
• EF impairments often are not noticeableby age 7!

Brown TE. Emerging understandings of attention
deficit disorders and comorbidities. In Brown
TE, ed. Attention-Deficit Disorders and
Comorbidities in Children, Adolescents, and
Adults 20003-55.
23
What Requires Executive Functions?

• Tasks that involve managing oneself
• To prioritize, start, sustain, shift, stop, and
  integrate cognitive functions
• Using memory without moment-by-moment guidance
  from others

Brown TE. In press.
24
Executive Functions and Scaffolding

• In early childhood, others perform all executive
  functions for the child (parents, teachers, sibs
  and other caretakers)
• Scaffolding is provided by showing, directing,
  helping, reminding, coaching, critiquing
• (Examples walking, getting dressed, crossing
  street, riding bike, driving car)
• Scaffolding is gradually withdrawn, as child
  becomes able to (or is forced to) perform these
  functions for self
• In adolescence adulthood scaffolding may be
  provided by friends, teachers, coaches, spouses,
  supervisors

25
How Can Executive FunctionsBecome Impaired?

• Developmentally, eg, ADHD
• Trauma, eg, traumatic brain injury
• Disease, eg, Alzheimers disease
• In trauma and disease, the patient usually has
  had adequate EF, then loses it
• In ADHD, EF has not developed adequately

26
When Are ADHDImpairments Noticeable?

• Some are obvious very early andare noticeable in
  preschool years
• Some are not noticeable untilmiddle elementary
  or junior high
• Some are not apparent until child leaves home to
  go to university or later

27
Challenges May Reveal Weaknesses

• Cardiac weaknesses may not be noticeable in EKG
  taken while lying quiet on a table, but may be
  very noticeable while playing basketball,
  shoveling snow
• EF weaknesses may not be noticeable until ones
  self-management is challenged by increased
  demands of adult life

28
How Can ADHD Be Assessed?

• When ADHD was seen as just a disruptive behavior
  disorder in childhood, dx was based on observing
  overt behavior
• EF impairments of ADHD are largely cognitive,
  covert, not easily observed
• EF are complex interactive, not easily isolated
  for capture in laboratory measures
• Comprehensive clinical interview is best measure

29
WISC-IV WAIS-IIIIndex Scores Discrepancies to
Assess ADHD

• Index Scores VCI, POI less sensitive to
• problems in
• attention, memory, processing speed
• vs
• Index Scores WMI, PSI
• more sensitive to these problems
• (Brown, 2005)

30
Verbal Working Memoryassessment

• Digit Span test (esp. backward) picks up some
  impairments of working memory
• another important aspect can be tested with story
  memory test of WMS-III (Logical Memory Subtest)
• compare individual score to verbal IQ
• many with ADHD 1 SD or more below VIQ

(Quinlan and Brown, 2003)
31
Sean18 years old- (dx Predom Inattentive)

• On meds for ADHD 8th grade thru 12th
• Honor student in competitive high school
• Varsity athlete, shy in social activities
• No meds in college fell behind early
• Excessive alcohol, marijuana, computer
• Missed many classes and assignments
• Just their being around

32
117 High IQ Children and Adolescents 8 Measures
of EF Impairment

• Working Memory Index /or Processing Speed Index
  1 SD below VCI or POI
• Story Memory Test Score (CMS/WMS)
• 1 SD below Verbal Comp Index
• T-score on any of the 5 cluster scores on Brown
  ADD Scale 65
• Overall impairment of EF 5 or more of 8

33
Youths with ADHD IQ 120n 117

• Gender 75 male.
• ADHD diagnoses
• 62 Predominantly Inattentive Type and 38
  Combined Type.
• Ages
• 26 6-11 yrs.
• 24 12-15
• 50 16-17

(Brown, Reichel Quinlan, 2007)
34
117 High-IQ Youths with ADHD
100
90
80
74.4
70
60
1 SD
50
40.2
40
2 SD
30
22.9
20
10
4.9
0
ADHD
STD. Sample
Figure 1.
(Brown, Reichel Quinlan, 2007)
35
117 High-IQ Youths with ADHD
Processing Speed Index (PSI) Percent of Ss with
PSI 1 and 2 SD below VCI or POI
100
90
80.3
80
70
60
1 SD
50
42.0
40
2 SD
26.8
30
20
10
4.4
0
ADHD
STD. Sample
Figure 2.
(Brown, Reichel Quinlan, 2007)
36
117 High-IQ Youths with ADHD
Story Memory Index (SMI) Percent of Ss with SMI 1
and 2 SD below VCI
100
88.0
90
80
70
1 SD
60
50
37.6
40
30
25.0
2 SD
20
10
2.3
0
ADHD
STD. Sample
Figure 3.
(Brown, Reichel Quinlan, 2007)
37
117 High-IQ Youths with ADHD
Clusters of Executive Function Impairments Parent/
Self-Report on Brown ADD Scales Percent Scoring
T 65
100
ADHD
90
STD. Sample
80
75.2
70
65.8
65.8
64.1
60
50
40
35.9
30
20
10
8.2
8.2
6.2
6.1
5.8
0
Activation
Emotion
Focus
Effort
Memory
Figure 4.
(Brown, Reichel Quinlan, 2007)
38
Adults with ADHD IQ 120n 157

• Gender 76 male.
• ADHD diagnoses
• 67 Predominantly Inattentive Type and 33
  Combined Type.
• Ages
• 36 18-19 years
• 35 20-25 years
• 29 26 to 53 yrs.

(Brown, Reichel Quinlan, 2007)
39
High IQ with ADHD Impaired on 5 of 8 EF
measures

• Youths 62
• Adults 73

40
Spectrum of impairment of EFin ADHD

• For affected individuals and their family,
• impact may be
• -small/transient
• -medium
• -substantial
• -devastating
• as life brings
• different challenges, more or fewer resources
  

41
How Is ADHD Relatedto Comorbid Disorders?

• ADHD developmental impairment of executive
  functions that organize and regulate many
  specific functions of the mind
• cf impaired orchestra conductor
• Comorbidity ADHD with 1 or more specific mental
  functions also impaired
• cf orchestra player(s) conductor impaired

Brown TE. Attention Deficit Disorder The
Unfocused Mind in Children and Adults (Yale
Press, 2005).
42
Other Psychiatric Disorders Often Accompany ADHD
70 of children with ADHD had at least one
psychiatric disorder in addition to ADHD.
(MTA, 1999)
43
Comorbidity in MTA study

• Did not include learning disorders
• selected only combined type ADHD
• Included only 7-9 yo children
• Cross sectional (6-12 mos)

44
Psychiatric Comorbiditiesin adults with ADHD

• 12 mo.
  Lifetime
• OR OR
• Any mood 25.5 3.5 45.4 3.0
• Any anxiety 47.0 3.4 59.0
  3.2
• Any substance 14.7 2.8 35.8
  2.8
• Any impulse1 35.0 5.6 69.8 5.9
• Any psychiatric 66.9 4.2 88.6
  6.3
• (1impulse antisocial pd, ODD, CD, Intermittent
  explosive disorder, bulimia, gambling
• (from Ntnl Comobidity Survey-Replication data
  presented by R.Kessler at APA, 5/1/04)
• i

45
Comorbidity in NCSR

• Included any disorders at any point in entire
  lifetime
• Included only 18-44 year old adults
• Did not include learning disorders
• Based on self-report of sx

46
PUZZLING QUESTIONS!

• Why are there such high rates of comorbidity
  between ADHD and so many other disorders?
• Why is an adult with ADHD 6 times more likely to
  have at least one additional DSM-IV disorder at
  some point in life?

47
Fruit Salad Theory of Comorbidity

• Each of 200 disorders in DSM-IV is seen as a
  discrete entitylike a separate tree producing
  its own fruit
• Comorbidity is seen as chance convergence of
  genetics
• No recognition of overlap between disorders or
  hybrid variants

Brown, in press
48
An Alternative Theory of Comorbidity

• ADHD developmental impairment of executive
  functions
• ADHD is not just one disorder among many
• ADHD is a foundational disorder that cross-cuts
  other disorders
• ADHD increases risks of other disorders

Brown, in press
49
How does ADHD increase risk?

• Adaptive impairments of ADHD expose to
  environmental risks, eg. Poor school achievement?
  drop into peer group less motivated for school
  and higher exposure to substance abuse
• Genetic impairments of ADHD may be associated
  with heightened risk for other genetic problems,
  e.g. reading disorder and ADHD have some common
  genetic risk of slow processing speed

(Molina Pelham, 2003 Wilcutt, et al, 2005)
50
General Specific Factors

• Intelligence includes both
• -a general factor (g) core abilities
• -other specific mental abilities
• Emotion includes both
• -generalized arousal level (vector amplitude)
• -specific feeling and object (angle of vector)

D.Pfaff, 2006
51
General and Specific Factors

• Psychiatric Comorbidity involves both
• -some level of general EF impairment
• -specific impairments of
• information processing
• arousal/motivation
• social-emotional regulation
• that differ from EF in quality or degree

Brown, in press
52
Comorbidity Screen

• Screen for possible comorbid disorders
• CBCL, Conners, BASC, CDI, MASC
• What other psychiatric dx
• Current? Lifetime? Sub-syndromal?
• If comorbidity, what are tx priorities?

53
LD in ADHD Children

• Clinical Sample of ADHD Children
• Reading LD 27
• Math LD 31
• Written Expression LD 65
• One or more LD 70
• (Mayes, Calhoun, Crowell,
  2000)
• Epidemiological Sample
• CDC National Health Interview Study
• 50 of children ADHD-diagnosed children are
  also identified as having LD
• (CDC, 2002)

54
Reading Disorder

• core is phonological processing deficit
• knows words when heard, but cant
• recognize them in written form
• normally distributed in population
• boys and girls equally affected
• linked to chromosomes 6 15
• Fluency, processing speed and working memory also
  important

55
Reading Comprehension (3 Items on Brown ADD
Scales)

• Distracted frequently when doing required
  reading keeps thinking of things that have
  nothing to do with what is being read.
• Loses track in required reading of what has just
  been read and needs to read it again understands
  the words, but what was read just doesnt
  stick.
• Remembers some of the details in required reading
  but has difficulty grasping the main idea.

56
Reading ADHD

• Reading is often impaired in children,
  adolescents and adults with ADHD
• 25 of persons with ADHD are dyslexic (vs. 5 of
  general population)
• ADHD impairments of working memory, processing
  speed, attention, etc. often impair reading, even
  if there is no dyslexia

57
Types of Math Disorder

• procedural
• -counting on fingers/finger writing
• -procedural errors (signs/sequencing)
• semantic memory
• -inability to learn math facts/ tables
• -slow retrieval of facts
• visuospatial
• -misaligns number columns
• -misinterprets place values

58
Disorder of Written Expression

• Significant impairment in writing
• grammatically correct sentences
• organized paragraphs often, but
• not always poor spelling
• chronic difficulty in what to write,
• organizing ideas, and elaboration
• oral expression adequate or strong
  while weak in written expression

59
ADHD vs LDSeparate entities?

• Some think
• ADHD chemical problem in brain
• LD hard-wiring problem in brain
• ADHD and LD may not be so separate
• - shared genetic etiology in Reading Disorder
  and ADHD (Willcutt, Pennington DeFries, 2000)
• - ADHD LD both involve EF, esp working memory

60
Other problems dont eliminate possibility of
ADHD or vice-versa

• Specific Learning Disorders
• Substance abuse
• Depression
• Anxiety
• OCD
• Aspergers Disorder (autistic spectrum)
• ADD/ADHD is a foundational disorder that
  increases vulnerability to LD
• other disorders

61
(No Transcript)
62
Key Points

• ADHDdevelopmental impairment of EF
• EF development continues into adulthood
• Some EF impairments are not noticeable until
  challenged by tasks of adolescenceor adult life
• Medication treatments often alleviate a wide
  range of EF impairments of ADHD
• ADHD is a foundational disorder that often
  underlies learning psychiatric disorders

63
My Website

• To see more info
• To download articles
• To sign up for free email newsletter
• www.DrThomasEBrown.com
•