compiled by Karen Sampson Hoffman, MA
In March 2104, the NRC’s Ask the Expert Series hosted two special webinars. Thomas A. Brown, PhD, and Russell J. Barkley, PhD, served as the guest experts.
Emotions and Motivation in ADHD
Thomas E. Brown, PhD, assistant clinical professor of psychiatry at Yale University School of Medicine, associate director of the Yale Clinic for Attention and Related Disorders. His books include Smart But Stuck: Emotions in Teens and Adults with ADHD (Wiley, 2014) and Attention Deficit Disorder: The Unfocused Mind in Children and Adults(Yale University Press, 2005).
What is the relative importance of medication versus therapy when helping individuals with emotional regulation?
ADHD is basically a developmental impairment of the brain’s management system. The underlying factor is the dynamics of the chemistry of the brain. That doesn’t mean medicine works for everybody, but we have pretty good evidence that it works for a lot of people with ADHD if it’s individually tailored for their body’s chemistry and needs. For some people, if you can get the medication right, they pretty much know what they need to do. For them, the medicine alone might be quite helpful in the same way that if you put a pair of glasses on somebody who can’t see very well it helps to solve a lot of problems.
A lot has to be done to fine-tune medication, however, and there are many people who have problems that the medicine is not going to fix. We need to acknowledge that medicine doesn’t work for everybody. Stimulants work for about eight out of ten people. For some people, it’s huge how much it helps them; others it helps substantially, but not hugely; and still others it helps a little but not that much. In two out of ten it doesn’t do anything. The nonstimulant medications sometimes work when nothing else will.
Not every problem comes with a solution, and so it’s not as though medication is magic. The medications we have for ADHD cure nothing. ADHD medication isn’t like an antibiotic that knocks out the infection. It’s more like putting on glasses. They help when they’re in place, but when you take off the glasses off, your eyes aren’t fixed. When the medication wears off, you still have to deal with the same things you had to deal with before you took it.
Medicine plays an important role for most people with ADHD, but it’s not effective for everybody. It requires fine-tuning and monitoring in order to optimize its benefits. In the book I just published, none of the people profiled were helped by medication alone. They all needed conversation with somebody to help them sort out the way they were looking at things and to recognize the complexity of some other feelings they had about situations and some of the assumptions they were making that didn’t make an awful lot of sense. Other people need some remedial help of one kind or another. There isn’t one treatment package that works for everybody. Medication is often but not always effective. It’s very important that clinicians take a look at the whole picture and consider what other things might be useful for a particular person in a particular context.
Should difficulty with emotional modulation be used as a criterion for ADHD? Should this be incorporated into the definition used by the Diagnostic and Statistical Manual of Mental Disorders?
It probably should be incorporated into the DSM, but it’s also important to recognize that problems with regulating emotion are characteristic of a lot of different kinds of problems. We do need an agreed-upon set of criteria for making a diagnosis, a convention or way to carry on conversations about these things. I would think about emotional dysregulation as one part of a syndrome. ADHD is not one syndrome, it’s a collection of symptoms that tend to show up with people who have some underlying difficulties with impairment in the management system in the brain. The model, about which I’ve written quite a bit, includes difficulties with modulating emotion or modulating affect. Russell Barkley has also written on the importance of taking this into account. I certainly think it’s a good idea for us to start incorporating this into the definition, and to eventually work toward developing some criteria about problems regulating emotion as one aspect of ADHD. But that alone would not be a basis for making or breaking a diagnosis.
We all know that many people with ADHD have other problems which include difficulties with emotional regulation that rise to the level of diagnosis, and one needs to sort this out. Is this part of the syndrome with ADHD, which it is for many people? Many people I’ve treated have difficulty with regulating emotions, but it doesn’t warrant a second diagnosis, it is just one aspect of the ADHD. Then there are some for whom it rises to the level where I have to say, “Well, you know, this really does look like it’s a bipolar disorder,” or, “This is an intensity of depression that looks like it wants a diagnosis at this point,” rather than a diagnosis of ADHD.
Impairment in Major Life Activities in Adults with ADHD
Russell A. Barkley, PhD, clinical professor of psychiatry at the Medical University of South Carolina and research professor of psychiatry at the State University of New York Upstate Medical University. His books include Executive Functions: What They Are, How They Work, and Why They Evolved(Guilford, 2012) and Taking Charge of Adult ADHD(Guilford, 2010).
How can someone affected by ADHD tell the difference between the impulsivity associated with ADHD and intuition?
I don’t think there’s any researcher making that distinction; it’s a rather interesting question. Usually, when we think of intuition we think of creativity, and here we have seen some research on this issue. We do know that being a little bit disinhibited or impulsive does help to contribute to the ability to come up with a wide range of possible solutions to various difficulties. But that doesn’t mean that having a lot of impulsiveness is likely to make one even more creative. This is a situation where we see a bell-shaped relationship: A little bit of disinhibition is good because it breaks down barriers that help the individual be less anxious about ideas they have, more likely to explore tangential ideas, and that can certainly contribute to creativity. But as the impulsiveness begins to increase, particularly as it approaches the level of impulsiveness we see in ADHD, which is quite serious, we begin the see it goes the opposite way. It actually can begin to interfere with creativity, because the individual becomes so distractible and so impulsive that he or she can’t stay the course. The person can’t continue to focus on a particular problem to overcome obstacles and reach goals.
So, it’s a mixed blessing—a little bit can help in expressing creativity, but a lot of impulsivity can interfere with creativity, problem-solving, and task accomplishment. It just depends on the severity of the impulsiveness as to how one is going to fare with regard to intuition and creativity.
What evidence-based assessment tools are recommended for adults when there is the possibility of ADHD?
Whole chapters, if not books, have been written on this subject. I have to reduce it to a cursory overview of the structure of the assessment. Let me point out that there is no test for ADHD, either psychological, neuropsychological or laboratory measures such as a CT or EEG, or more recently the neuroimaging devices, but that’s okay, because it puts ADHD in good company. There is no laboratory or psychological test for any mental disorders or developmental disabilities, and indeed, for many of the medical disorders that we treat. Not having an objective, laboratory-type scientific test for a disorder does not invalidate the disorder.
The evaluation for ADHD is always driven by the issues one has to answer. It begins with an open-ended clinical interview, letting the patient have free rein to cover all the areas they are concerned about. While they’re doing that, the clinician is beginning to organize these reports into various possible categories as to what diagnosis might be applicable and what the domains of impairment are.
Following the unstructured interview, the clinician would do a structured interview. Here one would follow the DSM criteria for various disorders that were raised as a possibility during the interview, not just for ADHD. Has the patient described symptoms consistent with other disorders or concerns? Whatever symptoms have been reported of these other disorders would lead the clinician to bring out the structured criteria for that disorder and review them in detail to see if the patient qualified for them.
Apart from these two kinds of interviews, in our practice we would also supplement with rating scales we routinely use for detecting not only ADHD but co-occuring disorders. The first is a broadband scale that measures many of the dimensions of psychological maladjustment. We often use a symptom checklist, which goes over ninety different symptoms that are arrayed across about eight or nine different dimensions of psychological difficulties. There are other rating scales, like the Adult and Child Behavior Checklist, but we have found the Symptom Checklist 90 to be a very quick screen for other forms of psychopathology. If there is a high score on any of these dimensions, we can go back and do a DSM-5 review of the criteria for those disorders to see what they qualify for.
The second rating scale would be an adult ADHD rating scale. One could use scales like that developed by Keith Connors or the World Health Organization’s screener for ADHD to assess how severe are the DSM-5 symptoms. We want to know that to see whether the individual is simply reporting garden-variety inattention that anyone tends to report, or whether the symptoms rise to a level of severity considered extreme, unusual, or rare. Rating scales are very good in helping us to get a handle on how serious symptoms tend to be and, of course, how many symptoms the person has.
The clinician can also do an assessment through rating scales such as my functional impairment scale, which very quickly assesses fifteen domains of impairment in adults with ADHD. Clinicians can also assess impairment by what is called, very conveniently, the “paper trail of impairment”—by getting educational records, by interviewing about occupational history, by getting driving records or criminal records or previous treatment records. All these records are ways of assessing degrees of impairment across these various domains; and, if symptoms are very impairing, in documenting that the person has suffered impairment from their disorder. Keep in mind that, as clinicians, we don’t just assess symptoms, but we have to show that impairment has arisen from those symptoms because diagnosis for the disorder begins where impairment begins—no impairment, no disorder. Just because someone has symptoms doesn’t mean he or she has a mental disorder.
Now at this point some clinicians might want to drag out psychological testing, and certainly a quick screening of intelligence can be done in fifteen minutes. One would also want to do a quick screen for learning dis- abilities. Those can be done through various individual achievement tests because, again, many adults with ADHD have learning disabilities or achievement problems. But notice, I said a quick screen—not a full battery, not a twenty-four-hour test. If there are concerns in the screen, then one would go ahead and do the full battery.
I don’t recommend the neuropsychological testing. If it’s going to be done, it needs to be done with this problem in mind: that only the most severe cases are likely to score poorly on the test. Therefore, if an adult with ADHD gets normal scores on the test battery it doesn’t rule out the disorder; that has to be done through the interview and the rating scales.
Rating scales of executive functioning are much more accurate and much more valid than the six-hour test batteries clinicians are fond of giving. The rating scale—a very cheap and easy way of assessing executive functioning—turns out actually be more valid and predicative of impairment than those test batteries.
In our clinic we wrap up the evaluation with a review of strong points, using those strengths as a means of helping the individual to compensate for areas of weakness, and giving advice about things such as occupations he or she might wish to pursue.
Karen Sampson Hoffman, MA, is the coordinator of the NRC’s Ask the Expert webinar series and a contributing editor to Attention magazine.