Adult ADHD

A recent story by Melinda Beck in the Wall Street Journal was important for disseminating information about Adult ADHD, but disappointing for the absence of any mention of EEG brainwave biofeedback. I wrote to Ms. Beck, “Good article BUT…why no mention of neurofeedback (EEG biofeedback)? By now the professional literature is replete with studies demonstrating that neurofeedback is comparably helpful for ADHD as stimulant medication–and that upon discontinuation the effects tend to hold much more than with medication. I’ve attached a current bibliography.

“Perhaps you didn’t mention it because of the paucity of studies with adult ADHD. To that, I can only assert (weakly) that my clinical experience bears out the studies with childhood ADHD.

“Another interesting question to be studied is the ways in which neurofeedback and medication help different aspects of the condition. (I just reviewed an article for a journal which found that while the overall results were statistically significant and positive for neurofeedback and methylphenidate (Ritalin), methylphenidate was superior on behavioral measures of inattention and hyperactivity, but neurofeedback was superior for control of impulsivity). All such questions are confounded by the problem that what we call ADHD is an undifferentiated cluster of conditions as suggested by the genotype studies.”

A current article in the Journal of Attention Disorders, 5, 524-531 studied the functioning of adults who were medicated.  Residual impairments were significant even after stimulant medication–almost all those studied were functioning half as well at work as non-ADHD adults.  To my thinking, this is a powerful argument for the addition of neurofeedback in the treatment program of adults with ADHD.

The article was nicely summarized in a recent post by David Rabiner PhD, in his newsletter, Attention Research Update, as follows.

How effective is medication treatment for adults with ADHD?

One way to answer this question is by looking at the reduction in core ADHD symptoms, i.e., difficulties with attention and hyperactivity-impulsivity, that medication treatment yields. When examined in this manner, it appears that a reduction in core symptoms of about 50% or less is what is generally obtained, although this can vary considerably from one individual to the next. This is a sufficient reduction to have a meaningful impact on daily functioning for many adults with ADHD, although it would also seem likely that significant residual difficulties related to ADHD remain for many.

A good way to get at these residual difficulties – and how impairing adults with ADHD find them to be – would be to examine adults’ perception of their functioning in important life areas following ADHD medication treatment. This was done in an article published recently in the Journal of Attention Disorders [Safren et. al., (2010). Life impairments in adults with medication-treated ADHD. Journal of Attention Disorders, 5, 524-531.

Participants were 105 adults diagnosed with ADHD (55 men and 55 women) with an average age of 42, all of whom were being treated with ADHD medication. Participants completed a rating of ADHD symptom severity and were administered a semi-structured interview to assess their quality of life impairments in 4 areas: work life, interpersonal relationships, recreation, and overall life satisfaction. (Note: For adults who were in school rather than working, the work domain focused on their functioning at school.) This interview was administered to participants by a trained clinician who rated the extent to which the adults’ functioning in different areas had been impaired during the past week as a result of ADHD symptoms.

– Results –

Impairment was judged to be greatest in the work domain, where the average score across the 105 participants indicated ‘moderate impairment’. Overall, 73% of the sample was judged to have moderate impairment at work because of ADHD symptoms (remember, these were symptoms that were evident even though all adults were receiving medication treatment) and 98% were judged to have at least ‘mild impairment’.

Interpersonal relations was the domain that received the second highest impairment ratings. Here, 50% of participants were judged to have at least some impairment because of ADHD symptoms. However, on a positive note, that means that half the adults were not felt to be impaired in their interpersonal functioning because of residual ADHD symptoms and only 17% were judged to be significantly impaired because of such symptoms.

Ratings of overall life satisfaction were similar to those found for the interpersonal domain. Fifty-nine percent were judged to have residual ADHD symptoms that compromised their overall life satisfaction but only 5% were judged to have poor overall life satisfaction because of ADHD symptoms.

Impairment from ADHD symptoms was lowest in the recreational domain where only 29% of participants were judged to have at least a moderate level of impairment.

– Summary and Implications –

Results from this study highlight that many adults with ADHD who receive medication treatment continue to experience important functional difficulties, particularly in the work domain. In fact, nearly all experienced at least some impairment at work related to their ADHD symptoms as judged by the assessor. Residual symptoms also compromised interpersonal functioning for many participants, although the impairment in this domain was generally less problematic than in the work domain. While this is discouraging news, it is also important to recognize that a substantial percentage of medication treated adults were not experiencing impairment in these areas from ADHD symptoms.

The implications of these findings are self-evident: for many adults with ADHD, medication treatment alone will not eliminate the difficulties created by their ADHD symptoms and additional interventions to address these difficulties are required. Helping adults with ADHD develop compensatory strategies at work are especially important, as is the need to address relationship difficulties to which ADHD symptoms also contribute.

There are limitations to this study that the authors acknowledge. Most importantly, there was no control group on non-treated adults with ADHD so that impairment rates could be compared for those receiving vs. not receiving medication. The authors also did not control for other psychiatric symptoms in participants, e.g., depression, anxiety, so that the unique contribution of ADHD symptoms to life impairments after controlling for these other factors could be evaluated. Finally, it would have been helpful if the authors provided more specific information about the types of impairments that adults were experiencing at work and in relationships as a result of their ADHD symptoms.

In conclusion, while these findings do not indicate that ADHD medication is not important in the treatment of ADHD – far from it – they do highlight the limitations of such treatment. For these reasons, careful attention should be given to the development of psychosocial treatments for ADHD in adults. Unfortunately, however, research in this area is quite limited, although promising findings have been reported in several studies. In the months ahead, I will try to include reviews of such studies in Attention Research Update.

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