AD/HD, Co-morbidities, and Issues for Assessment and Treatment

Dr. Thomas B. Brown, a clinical psychologist and assistant Clinical Professor of Psychiatry at Yale Medical School gave a talk on ADD/ADHD (and on the conditions which often co-exist with it) on 8th April at the First International Conference on AD/HD in Oxford, England. Dr. Brown spoke at two sessions to the more than 400 delegates. (Dr. Brown is also the Associate Director of the Yale Clinic for Attention and elated Disorders in Adults and has a special interest in treating children, adolescents and adults with ADD and high I.Q.s).

In talking about attention deficit disorders Dr. Brown focused on the following important points:

• that there is a wide spectrum of inattention
• that AD/HD) is not a unitary disorder
• it is developmental and heritable
• it is dimensional, not categorical
• it is not especially linked with hyperactivity or impulsiveness
• it is often responsive to stimulant medication
• when assessing AD/HD it is very important to take a look at possible cognitive impairments.

In making an assessment for Attention Deficit Disorder, there were a number of essentials to remember:

• there is no single measure of ADD
• this should be a data based approach, not an adversarial one
• ADD indicates impairment since childhood
• you are looking for parallel issues as well as collecting anecdotal information
• the weight of data is balanced with clinical judgement
• the task of assessors is to do this in a way that has empathy. A sensitive clinician can listen to the stories and tell a great deal.

During an assessment for AD/HD a number of different kinds of information will be helpful

• It is important to hear the chief complaints
• Look at the symptoms and areas or domains of impairment. Have they been chronic since childhood? Do they involve school, job, family, social activities, relationships?
• How is the person currently functioning - including the demands on them and their performance? How do they function at school, work, within the family, social settings, leisure? What do they do for fun?
• Have any blood relatives been diagnosed or experienced attention or learning problems or related disorders?
• What is their current living situation, its supports and stressors?
• What are their relations like with other people and what is their image of themselves?
• Important factors of health and medication.
• Information about alcohol and other drug use.
• Sleep and appetite.
• Any previous evaluations.

Added to this may be other self reports and parallel reports (eg. ADD ratings/scales produced by Brown, Barkley or Conners), and evaluation against the DSM-IV criteria by the person, someone who knows the person well, the clinician.

It is important to explain ADD thoroughly to the patient and any relatives or friends with them Then it is important to look any ways the model fits or does not fit.

Dr Brown stated that research has shown that for 4 to 17 year olds a diagnosis of AD/HD) requires that 6 out of 9 of the DSM IV criteria be satisfied, and the cut-off for this is at about 93% of the totalpopulation. In adult samples only 1% of adults satisfy the 6 out of 9 criteria --93% of a total population will fall out of the 4 out of 9 criteria. Thus adults will have less symptoms and still have ADHD! It is very important to talk to adults about what ADD looks like and how it fits.

Often testing is usetul *eg. WISC intelligence tests) where verbal or spatial functioning is compared to concentration/processing speed and verbal memory is compared to verbal IQ - not against others but self to self. Measures that are usually sensitive to possible AD/HD include digit span *recall), arithmetic and digit symbols. Not so sensitive areas include vocabulary, similarities, comprehension, block design, object assembly, and picture completion. If you look for an individual at the two strongest scores on subtests and the 2 lowest then 66% of ADD adolescents had a difference of at least 1 standard deviation vs 22% of non-ADD adolescents in an important study. 25% of ADD adolescents had a difference of 2 standard deviations in these scores, where in the general population the rate was 2%. In adults, the rates for 1 standard deviation was 87% of ADD patients vs. 20% in the ordinary population. One area which is important to test carefully, and which is often a problem, is that of working memory. Some people can remember numbers and not words. Working memory involves different parts of the brain and individuals may be affected differently.

Similar results occur when comparing verbal IQ with verbal memory - 64% of ADD people have a difference of 1 standard deviation as against 19% of the general population and 30% will have a 2 standard deviation difference vs 3.6% of the general population.

Dr. Brown stated that about half of the people with ADD have one other psychiatric diagnosis. It is important to look at other current diagnoses and the history of any relevant symptoms (eg. manic attacks) ADD symptoms will exist prior to the co-morbid symptoms - some ADD symptoms will have been present since childhood. If co-existing conditions are suspected, it is very important to consider diagnosis priorities - which disorders are causing the most trouble?

In tailoring treatment to someone with 2 or more conditions, it is important to base this on a comprehensive assessment for ADD, for the co-morbid disorders and the context in which the person lives. Also vital is educating the patient about ADD and its treatment, fine tuning medication and monitoring it intermittently. Often brief inputs of psychotherapy and intensive or intermittent support of other types is often helpful. For most people a comprehensive and multi-modal approach is the most helpful. But recent research now says that some people only need medication to help them begin to cope successfully! This is a change from what was previously believed.

Complicated cases of ADD may involve additional psychiatric problems - for example with mood, anxiety, behavior, learning and others. These conditions exist at the same time in the same person - A may cause B, B may cause A or C may cause A and B. The mechanisms may be genetic, environmental or reactive.

In the USA of those attending clinics, 6.5% are diagnosed with ADHD, 7.5% with anxiety disorders and 25% of the above with both. Oppositional Defiant Disorder is present in the general population at a rate of about 16% - but 45% of ADD people will satisfy the symptoms at some time. Conduct disorders occur at a rate of 25% among ADD patients vs 10% in the ordinary population, psychoactive substance use disorders will affect 30% of the ADHD population. vs. 14% of the ordinary population. Anxiety disorders affect 25% of the ADHD population vs 1.0% of the ordinary population. Dyslexia and severe mathmatics learning problems affect 25% of the ADHD population, spelling and language disorders affect 30% of ADHD populations, depression may affect up to 70%, bi-polar disorder 20% *vs 1% of the general population), sleep problems 50%, social phobias 31%. All these are at much higher rates than are present in the ordinary population.

Untreated ADD has huge consequences for individuals: underachievement, impaired peer relationships, strained family relationships, and debased self - esteem. If the effects over a number of years are considered, the full consequences become more apparent. Within families, untreated ADD leads to chronic stress and frustration, social isolation, a climate of blaming and guilt, frozen roles and alliances and polarised parenting. Throughout life it has often huge knock-on effects at key periods and transitions.

Some of the common problems for ADD students with associated learning difficulties include persistant and severe difficulties in:

• organising thoughts for oral and written expression.
• understanding written directions for tasks
• learning sequenced material
• recalling learned material
• being readily overwhelmed in unstructured tasks
• slow task completion
• keeping track of assignments, books, papers
• can't find the "right word" to express thoughts
• extreme inconsistencies in performance
• hearing it vs seeing it discrepancies
• difficulties in listening and writing simultaneously
• too much "circling the airport" before starting homework
• poor organization and sequencing of tasks/time
• forgetfulness re: assignments, materials, etc.
• slow processing of information.
• weak retention of studied materials

When working with adolescents with ADHD and parents, it is vital to actively involve the adolescent from the onset - and convey respect for the adolescent as the primary person. Ask them. about school, what they do for fun, what they do well. Build up rapport.

• Explain the symptoms, causes and outcomes.
• Desribe the treatment options, risks, benefits.
• Explore the resistances of the young person and the family.
• Avoid "personalising"!
• Foster a collaborative relationship.

Medication is given in the sense of providing eyeglasses, not antibiotics. The approach should be aggressive, not as a last resort. Help needs to be given to obtain the most effective doses - fine tuning to schedule, side effects and hills and valleys. Taper it carefully to reduce rebound effects, and fit to tasks (eg. sports and lessons) Develop practical plans, and combinations to deal with co-morbidities or cases where there is only a partial response.

Treatment also may involve many other supports. In addition to medication a coach or case manager can help with regular contact. Support groups, advisors, building on skills and islands of competence, and specific skill training are examples of approaches which can play an important part. Educational Interventions and psychotherapy specific to ADD can also be vital.