Thomas E. Brown

Introduction/Objective: Executive function (EF) impairment in attention-deficit/hyperactivity disorder (ADHD) may account for behavioral symptoms such as poor concentration, impaired working memory, problems in shifting among tasks, and prioritizing and planning complex sets of tasks or completing long-term projects at work or school. Poor self-regulation and control of emotional behaviors frequently are seen in patients with ADHD. This study assessed EF behaviors in adults with ADHD at baseline and after 4 weeks of treatment with lisdexamfetamine dimesylate (LDX). Methods: Executive function behavior was assessed using the Brown Attention-Deficit Disorder Scale (BADDS) during the 4-week open-label dose-optimization phase prior to a 2-period, randomized, double-blind, placebo-controlled crossover study of LDX (30–70 mg/day). The ADHD Rating Scale IV (ADHD-RS-IV) with adult prompts assessed ADHD symptoms. Change in EF behavioral symptoms was evaluated based on week 4 BADDS total and cluster scores;...

Objective: To assess whether improvement in executive function correlates with perceived improvement in health-related quality of life (HRQOL) in adults with attention-deficit/hyperactivity disorder (ADHD) who are treated with stimulant medication. Methods: We collected data on executive function and HRQOL using the Brown Attention-Deficit Disorder Scale (BADDS) and the ADHD Impact Module–Adult (AIM-A) during 2 large, randomized, double-blind, placebo-controlled trials evaluating the use of the triple-bead mixed amphetamine salt (MAS) SPD465 as stimulant pharmacotherapy for ADHD. BADDS and AIM-A data were collected at baseline and at study endpoint, and changes from baseline were assessed. Correlation coefficients for BADDS and AIM-A were calculated at baseline and endpoint for each study. Results: The change from baseline in BADDS total score was –14.8 ± 24.49 in Study 1 (dose optimization strategy) and –26.1 ± 28.54 in Study 2 (forced-dose titration strategy), demonstrating substantial reported ...

Objective: Guanfacine extended release (GXR) is a selective α_2A-adrenoceptor agonist that is shown to be an effective nonstimulant treatment for the symptoms of attention-deficit/hyperactivity disorder. This report documents the time course and predictors of symptom efficacy and sedation-related adverse events (AEs) that emerge during GXR treatment throughout 3 randomized, placebo-controlled, double-blind trials of the drug. Method: Analysis of data from 3 GXR clinical trials. Results: Few variables related to the study participants or their treatment regimen affects the emergence or magnitude of sedation-related AEs. The best predictor of sedation is treatment duration, with the likelihood of sedation-related AEs decreasing with increasing time on medication. Sedation-related AEs are not predicted by the actual dose a participant receives, the magnitude of any dose changes, or the relationship between dose received and the magnitude of dose changes. Rates of discontinuation because of sedation-related side effects average 6.3% for GXR-treated participants and 0.5% for placebo-treated participants across the three trials. Conclusion: These results suggest that acclimation to GXR may minimize the risk for, and magnitude of, sedation-related AEs. (J. of Att. Dis. 2010; 13(5) 532-538)

The disorder currently known as attention-deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD) is now recognized by most clinicians as a legitimate and widely prevalent disorder among children and adults. Yet there is still widespread misunderstanding as to the disorder’s nature. Many clinicians mistakenly continue to think of this as a behavior disorder characterized by hyperactivity in children and excessive restlessness or impulsivity in adults. In fact, ADD/ADHD is essentially a cognitive disorder, a developmental impairment of executive functions (EFs), the self-management system of the brain. Although EFs are complex, their impairment constitutes a syndrome that can be recognized readily in clinical practice; impaired EF involves a pattern of chronic difficulties in executing a wide variety of daily tasks. Once recognized, this disorder can be effectively treated in most cases. In this article, I describe the nature of EF impairments in ADD/ADHD and how the syndrome can be recognized and effectively treated in clinical practice. (Note: The term ADHD is used in the balance of this article to refer to both inattentive and combined subtypes.)

While increasing numbers of articles and books refer to Attention Deficit Hyperactivity Disorder (ADHD) as a disorder of “executive function” of the mind, two conflicting views have emerged about how ADHD and executive function are related. In one view it is argued that some, but not all, who meet the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for ADHD suffer from significant impairments of executive function. The alternative view holds that all individuals with ADHD suffer from significant impairment of executive function, and that ADHD essentially is a developmental impairment of executive function. These conflicting viewpoints rest upon divergent understandings of the nature of executive functions and how these functions should be assessed. Each leads to a very different conclusion about the essential nature of ADHD and its relationship to other learning and psychiatric disorders. This article describes and evaluates those two views and their implications.

Atomoxetine and stimulants have both been demonstrated effective as single agents for treatment of attention deficit hyperactivity disorder in children, adolescents, and adults. However, attention deficit hyperactivity disorder symptoms in some patients do not respond adequately to single-agent treatment with these medications, each of which is presumed to impact dopaminergic and noradrenergic networks by alternative mechanisms in different ratios. Four cases are presented to illustrate how atomoxetine and stimulants can be utilized effectively in combination to extend duration of symptom relief without intolerable side effects or to alleviate a wider range of impairing symptoms than either agent alone. This combined pharmacotherapy appears effective for some patients who do not respond adequately to monotherapy, but because there is virtually no research to establish safety and effectiveness of such strategies, careful monitoring is needed.

Abstract: Many children, adolescents, and adults with Attention Deficit Disorders report chronic difficulties with falling asleep, awakening and/or maintaining adequate daytime alertness. These problems may be due to a variety of factors, including environment, lifestyle, and psychiatric comorbidities. Impairments in sleep/arousal may also be related more directly to the underlying pathophysiology of ADD. This chapter describes clinical manifestations of sleep/arousal problems often associated with ADD and reviews behavioral and medication options for treatment.