Anthony L. Rostain

ADHD with Comorbid Anxiety: A Review of the Current Literature.

Objective/Method: ADHD is often comorbid with anxiety disorders, with rates approaching 25% in many samples. This current review’s goal is to examine the literature on ADHD with comorbid anxiety from 1998 to the present. Results: Recent studies indicate that anxiety in ADHD may a) partially inhibit the impulsivity and response inhibition deficits, b) make working memory deficits worse, and c) may be qualitatively different from more phobic types of anxiety seen in pure anxiety samples. In examining subtypes of ADHD, measures of sluggish cognitive tempo show strong correlations with anxiety measures. Insights into the nature of the comorbidity between ADHD and anxiety may be gained by examining the possible comorbidity between Obsessive Compulsive Disorder and ADHD, shared risk factors for ADHD and anxiety, and the current pathogenic models of ADHD. Conclusion: The article concludes with a synthesis of the above work, along with directions for future research.

A combined treatment approach for adults with ADHD--results of an open study of 43 patients.

Objective: Increasing numbers of adults are seeking treatment for ADHD. Pharmacotherapy is well established as the first line treatment for adult ADHD, although medications alone may be insufficient treatment for the myriad problems experienced by these patients. Few studies have examined the clinical outcomes of a combination of pharmacotherapy and psychotherapy for this clinical population. The purpose of the present study is to examine the potential effectiveness of the combination of pharmacotherapy and cognitive-behavior therapy modified to treat adult patients diagnosed with ADHD. Method: Forty-three adults who underwent a structured diagnostic assessment for ADHD complete 6 months of combined treatment. Treatment outcome is assessed by comparing pre- and posttreatment measures of ADHD symptoms, comorbid symptoms, and ratings of overall functioning. Results/Conclusion: Results indicate that combined treatment is associated with significant improvements on all clinical measures. Limitations of the study design and directions for future research are discussed.

Relationship of Perceived Competencies, Perceived Social Support, and Gender to Substance Use in Young Adolescents

OBJECTIVE This survey study explores the relationship between area-specific perceived self-competence, perceived social support, gender, and substance use in young adolescents. METHOD Questionnaires were administered to 140 male and 131 female adolescents attending middle school to assess self-perception of competencies, social support, and substance use. Correlations were performed between the predictor variables and the substance use measures. Hierarchical multiple regressions were also used to identify potential interactions between gender, perceived competencies, and perceived social support in the prediction of specific substances. RESULTS Higher perceived scholastic competence was associated with less substance use in both genders. In boys, more perceived support from teachers, and to a lesser degree parents, was associated with less substance use, particularly in those with low scholastic competence. In girls, social support was unrelated to substance use except for support from classmates, which was associated with more cigarette and marijuana use. However, in girls with low scholastic competence, more support from peers was consistently associated with more substance use. CONCLUSIONS The gender differences in risk factors for early substance use identified in this study deserve further investigation, in view of their potential relevance for adolescent substance abuse prevention and early intervention.

Research Forum on Psychological Treatment of Adults With ADHD

Background: A literature search found five empirical studies of psychological treatment for adults with ADHD, out of 1,419 articles on ADHD in adults. Practice guidelines to date all recommend multimodal intervention, given that a significant number of patients cannot tolerate, do not respond to, or fail to reach optimal outcomes with medication alone. Method: This article provides a literature review and the recommendations of a forum of experts in the psychological treatment of adults with ADHD. Results: Empirical studies of brief, structured, and short-term psychological interventions for adults with ADHD to date demonstrate moderate to large effect sizes. Methodological challenges include selection of control groups, broad-based measures of outcome, and the need for larger samples. Conclusion: Psychological treatment may play a critical role in the management of adults with ADHD who are motivated and developmentally ready to acquire new skills as symptoms remit. (J. of Att. Dis. 2008; 11(6) 642-651)

Psychosocial Treatments for Attention-Deficit/Hyperactivity Disorder in Adults: Current Evidence and Future Directions

Summary and Limitations of Psychosocial TreatmentStudies To date, the aforementioned researchers have laid an initialempirical foundation for the benefit of psychosocial treatments foradult ADHD. Most of these studies made an effort to stabilizemedication treatment before introducing therapy to assess thedistinct contribution of psychosocial interventions (apart frommedication effects) to clinical and functional improvements. Therewere no significant differences between the few treatment partic-ipants who were not taking medications for ADHD and those whowere, either before or after treatment.Comparisons across the different studies must be made cau-tiously as there was great variability in the manner in whichADHD was diagnosed, the focus of change in the treatments, andhow therapeutic change was measured. A common outcome vari-able in all studies was a measure of overall ADHD symptoms.When collapsed across the studies reporting posttreatment ratingsof overall ADHD symptom severity, the mean effect size ( d) forADHD symptom improvement was 1.59, which is considered alarge effect size (i.e., d .80; Cohen, 1992).

A Cognitive Therapy Approach for Adult Attention Deficit/Hyperactivity Disorder

While attention deficit/hyperactivity disorder (ADHD) is the most prevalent behavioral disorder of childhood, the past decade has seen a rise in the number of adults presenting for treatment with difficulties related to ADHD. Few treatments (particularly psychosocial treatments) offered to adult patients with ADHD, however, have been empirically tested, much less been grounded in an overarching treatment model that captures the complexity of the various neurobiological, developmental, and psychological issues germane to this clinical population. The purpose of this article is to introduce a cognitive therapy approach for treating adults with ADHD. To do so we will describe the nature of ADHD, discuss some of the clinical issues unique to this diagnosis, and outline a cognitive therapy approach for conceptualizing and treating adult ADHD, integrating a number of case examples.

Attention-deficit/hyperactivity disorder in adults: evidence-based recommendations for management.

Abstract Attention-deficit/hyperactivity disorder (ADHD) is associated with impairments in educational, occupational, neuropsychological, and social functioning in adults. Successful diagnosis and treatment of the disorder in adults can be a challenge because recent and integrative clinical guidelines are lacking and diagnostic criteria are based on making a retrospective diagnosis of childhood-onset ADHD. To develop evidence-based recommendations for the treatment of ADHD in adults, the scientific literature was reviewed, including primary clinical studies, meta-analyses, and available clinical guidelines. Studies show that stimulant therapy is highly effective and safe in the management of ADHD in adults, with similar response rates to those reported in children at doses that are equivalent on a mg/kg basis. Long-acting stimulants, such as OROS® methylphenidate (OROS® MPH, Concerta®), dexmethylphenidate (d-MPH, Focalin®), and mixed amphetamine salts extended release (MAS XR, Adderall XR®), have durations of action of up to 10 to 12 hours, which permit once-daily dosing. For adults with ADHD who do not respond to stimulant therapy or who have a comorbid condition in which a stimulant is contraindicated, the nonstimulant atomoxetine (Strattera®) may be an appropriate alternative. For many adults, cognitive-behavioral therapy in addition to pharmacotherapy may improve treatment response. Attention-deficit/hyperactivity disorder medications may increase blood pressure and heart rate in adults, so patients should be monitored.

Adult ADHD Research Current Status and Future Directions

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Attention deficit disorders in children and adolescents

Children and adolescents who present with inattention, impulsivity, and hyperactivity constitute a large portion of the behavior problems seen in pediatric patients. Attention deficit disorders are associated with various other childhood conditions that need to be investigated systematically. Multimodality treatment includes psychoeducational counseling, pharmacotherapy, behavior management, school interventions, family therapy, and social skills training. This article summarizes recent scientific and clinical research into this complex biopsychosocial disorder and presents a comprehensive guide to its evaluation and management.

Professionalism and the Internet in Psychiatry: What to Teach and How to Teach It

The digital revolution has had a profound impact on medicine and patient care. Patients have a growing expectation that they can find medical information on the web and discuss it with their physician by e-mail (1). Physicians, including psychiatrists, are increasingly using blogs and Twitter to promote their practices (2, 3). The internet itself is used as a vehicle for therapeutic modalities, even psychotherapy (4). Social networking among patients, physicians, and other “friends” are blurring boundaries as never before (5, 6). The potential clinical, legal, ethical, and professionalism issues in using the internet and digital media in psychiatry have been outlined elsewhere, including explicit recommendations for resident education in this area (7). This article focuses on how to teach residents about appropriate use of the internet. The evidence of unprofessional online behavior among physicians and the complexity of the potential issues raised with internet use in psychiatry suggest that psychiatric residents, educators, and administrators need explicit teaching about potential clinical, ethical, and legal pitfalls of internet use. In 2010, the President of the American Association of Directors of Psychiatric Residency Training (AADPRT) established a Taskforce on Professionalism and the Internet, charged with reviewing the literature and creating a curriculum to teach psychiatric trainees about online professionalism. Participants in a Taskforce-run workshop on this subject were asked for examples from their own experience of online professionalism concerns (8), and an outpouring of vignettes ensued. TheTaskforce undertook to create a curriculum based on vignettes designed to promote similar discussion. The principles elicited in these vignettes might be seen as extensions of well-established principles of professionalism (9, 10). Trainees accustomed to continual use of interactive technologies, however, may overlook boundary and other professionalism issues if they are not made explicit in training. The curriculum strives to address principles, rather than specific technologies, since the latter are expected to continue to evolve rapidly. The vignettes in this curriculum (available online at aadprt.org (11)) are designed for either group discussion or individual study; they are accompanied by relevant references and a teacher’s guide. The vignettes are organized around nine issues that may be relevant to various teaching venues: liability, confidentiality, and privacy; psychotherapy and boundaries; safety issues; mandated reporting; libel; conflicts of interest; academic honesty; “netiquette;” and professionalism remediation. We discuss the first eight of these topics, using vignettes from the curriculum for illustration. Where vignettes are based on actual cases, all identifying details are disguised.