LAS VEGAS – Despite the strides that clinicians like Anthony L. Rostain, MD, have made in better understanding and treating patients with ADHD, it remains virtually impossible to predict how a child with the disorder will fare in adulthood.
Dr. Anthony L. Rostain
“We cannot predict the trajectory of the disorder,” Dr. Rostain said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “We’re still learning about the variables that affect clinical course. There are many determinants to the trajectory.”
Dr. Rostain, professor of psychiatry and pediatrics at the University of Pennsylvania, Philadelphia, said ADHD commonly presents with numerous other neurodevelopmental disorders and with comorbid psychiatric conditions like bipolar disorder and anxiety.
“In psychiatry, we tend to see the more complicated patients, the ones with multiple comorbidities,” he said. “The most important change in the way we think about people with ADHD has to do with the growing emphasis on how it affects executive functions, in particular the cognitive, affective, and behavioral consequences of executive dysfunction. In this growingly complex world, with what some describe as ‘distracted minds’ emerging from being immersed in all our technology, it’s sometimes hard to tell: Is this person distracted because they’re always looking at their cell phone, or do they have intrinsic difficulty with managing attention?
“That’s going to become a greater challenge as children grow up in this world filled with shiny screens and devices that make [it] easier to connect with others but also harder to set a goal and follow it to its conclusion.”
ADHD changes over time, Dr. Rostain continued, but there is no single theory or biological explanation to explain its heterogeneity. “There is no cookie-cutter approach; you have to individualize when you are treating the individual in your office,” he said.
It is widely accepted that ADHD arises from biological factors, but social factors likely influence the degree of impairment, risk for comorbid disorders, and access to resources, said Dr. Rostain, who is also codirector of the developmental neuropsychiatry program at The Children’s Hospital of Philadelphia and medical director of the Adult ADHD Treatment and Research Program at Penn Medicine.
he said. “If there were one thing we could do to prevent ADHD, it might be to prevent pregnant women from drinking or to reduce poverty and violence, but that’s beyond the scope of this talk.”
He also noted that, because of epigenetics, ADHD risk factors express themselves early in some individuals and later in others. “We’re convinced that developmental disorders unfold in a nonlinear fashion,” he said. “Life [with ADHD] is curvy, not a straight line.”
Numerous studies of ADHD neurobiology have demonstrated frontal subcortical and cerebellar dysfunction – smaller striatal structures in particular. “In MRI studies, we also see difficulties with the differential maturation of important neural circuits, along with the persistence of cortical thickening where it should be thinning,” Dr. Rostain said. He went on to note that the normal brain consists of three main networks: the salience network, “which tells us whether to pay attention or to relax,” the attention and control network, and the default mode network, “which is where our mind goes when we’re daydreaming,” he said. “All of us are constantly switching between attention and daydreaming. That’s normal. In ADHD, the balance and synchrony between the default mode and the attention network is disrupted. Individuals with ADHD either remain too long in the default mode, or their attentional system isn’t powered up enough to keep them paying attention and following through during nonrewarding tasks.”
The presentation of ADHD symptoms tends to differ in children, compared with adults. For example, children with the disorder tend to be squirmy, can’t sit still, are restless, and can’t play or work quietly. On the other hand, adults tend to complain about inefficiencies at work, not being able to finish projects, not being able to sit through meetings. They tend to drive too quickly, and they often talk excessively, and make inappropriate comments. “The symptoms of ADHD emerge from disruptions or inefficiencies in basic functions, whether those are executive functions or motivational processes,” he said. “All of this is thought to be the result of genetic unfolding throughout the lifespan.”
The goal of ADHD medical therapy is to alter catecholamine tone in the prefrontal cortex, an area of the brain “designed to help us guide our thinking toward distal goals and navigate the world around us,” Dr. Rostain said. “It allows us also to inhibit actions that are task-irrelevant or are not serving our purposes. It also enable us to regulate emotions.” In his opinion, the medical treatment of ADHD should focus on helping the prefrontal cortex function optimally. “How much we can do – that remains to be seen – but that’s really where the action is,” he said. “From a functional standpoint, that’s what are we trying to achieve. When we have guided attention and when our responses to the world are appropriate, we can say that we’re ‘in the zone.’ That means we can listen, understand, make sense of the world, and deviate or shift direction if something gets in the way of our goals. Our responses should be flexible. We should be able to say, ‘That doesn’t work? Let me try something else.’ This indicates that the norepinephrine and dopamine circuits of the frontal cortex are optimally operating.”
On the other hand, individuals with ADHD find themselves in what Dr. Rostain described as an “unguided attention state” characterized by distraction and poor impulse control. “We also see it in people who are sleep deprived,” he said. “This could be untreated ADHD. If we treat ADHD properly, we move individuals into the optimal zone. But if we overdo it, if our medications are prescribed at doses that are higher than optimal, what you then see is excessive stimulation of the norepinephrine and dopamine systems. This leads to misguided attention, overfocusing, and mental inflexibility. People in this state report extreme amounts of stress and distress.”
Dr. Rostain recommends that medication plans be embedded in a comprehensive treatment approach that starts with psychoeducation. “When treating ADHD, we’re not going to turn a lion into a lamb, and we’re not going to make someone want to study if they don’t like school,” he said. “One of my patients, a college student, told me that, with the medication I prescribed for him, he was able to sit down and read for the first time for 3 hours straight. I said, ‘Great. Did you read your physics book? He said, No. I read Wired magazine.’ So while he was very focused, he didn’t concentrate on what he needed to focus on.”
Dr. Rostain supports the notion of a triad model of care with psychosocial interventions, medical interventions, and educational/workplace interventions “to improve the performance of demanded tasks, and to achieve a sense of being supported by that environment rather than being criticized,” he said. “If you ask most adults with ADHD what school was like, what will they tell you? They usually say it was bad or terrible, like a prison. If you ask them to describe it, they may have trouble remembering a lot of it, because it was so difficult for them.”
Dr. Rostain reported having received scientific advisory board honoraria from Shire, Ironshore, and Arbor. He also has received consultant honoraria from Major League Baseball, the National Football League, and from SUNY/Upstate.