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Lenard A. Adler, MD
Departments of Psychiatry and Child and Adolescent Psychiatry
New York University School of Medicine
VA Harbor Healthcare System
New York, New York
Andrew Alan Nierenberg, MD
Professor of Psychiatry at Harvard Medical School
Co-Director, Bipolar Clinic and Research Program
Associate Director, Depression Clinical and Research Program
Massachusetts General Hospital
Anthony Rostain, MD
Director of Education, Department of Psychiatry University of Pennsylvania Health System Philadelphia, PA
Richard L. Rubin, MD
Adjunct Associate Professor at Dartmouth Medical College
Ron Gasbarro, PharmD, MS Journ
New Milford, Pennsylvania
Estimated Time To Complete CME Activity:
Welcome to the second issue of the APSARD ADHD and Comorbidity Newsletter developed by the American Professional Society for Attention and Related Disorders (APSARD). This newsletter series is designed to present the latest evidenced-based findings on attention deficit hyperactivity disorder and comorbid mental health disorders. A new issue will be published every two months. In each newsletter, we will review recent and relevant literature, discuss several pertinent topics in detail and present the evaluation and treatment of a pertinent case.
In this issue, we focus on ADHD and concomitant impairments in executive functioning (EF), measurement of EF via neuropsychological testing, the effects of stimulants in the treatment of EF deficits, and a case study about a child with ADHD and dyslexia as well as EF deficits is presented and discussed. Recent journal articles are also reviewed and discussed.
We look forward to continuing to presenting you the latest findings in ADHD and comorbid mental health disorders. Please visit the APSARD site for more information and membership.
Andrew A. Nierenberg, MD
Director, Bipolar Research Program
Associate Director, Depression Clinical and Research Program
Massachusetts General Hospital, Boston, Massachusetts
Professor of Psychiatry, Harvard Medical School, Cambridge, Massachusetts
Lenard A. Adler, MD
Professor of Psychiatry and Child and Adolescent Psychiatry
Director, Adult ADHD Program
NYU School of Medicine, New York, New York
Statement of Need
Longitudinal studies following children with attention deficit hyperactivity disorder (ADHD) into adulthood reveal impairments in various major life activities, particularly in executive functioning. . When children with ADHD progress to adulthood, they tend to have lower occupational status and annual salaries than control groups followed to adulthood; worse employer-rated job performance; more job dismissals; rapidly changing jobs; less adequate in fulfilling work demands, less likely to be working independently and to complete tasks, and less likely to be getting along well with supervisors as rated by employers; and with poorer performances at job interviews and certain tasks at work too difficult for them. 
While the literature has defined executive functioning (EF) in a variety of ways, 2 descriptions stand out. Pennington stated that EF “is defined as the ability to maintain an appropriate problem-solving set for attainment of a future goal."  They include the components of: "a) an intention to inhibit a response or to defer it to a later more appropriate time; b) a strategic plan of action sequences; and c) a mental representation of the task, including the relevant stimulus information encoded in memory and the desired future goal-state." A different approach was described by Lezar who said EFs “consist of those capacities that enable a person to engage successfully in independent, purposive, self-serving behavior.  They differ from cognitive functions in a number of ways. Questions about executive functions ask how and whether a person goes about doing something (e.g., Will you do it and if so, how?); questions about cognitive functions are generally phrased in terms of what or how much (e.g., How much do you know? What can you do?)."
On the neurobiological level, recent advances have improved our understanding of ADHD and how it related to EF. The higher-order association cortices in the temporal and parietal lobes and prefrontal cortex (PFC) interconnect to mediate aspects of attention . The parietal association cortices are important for orienting attentional resources in time and space, while the temporal association cortices analyze visual features critical for identifying objects/places. These posterior cortices are engaged by the physical characteristics of a stimulus, such as movement and color. Conversely, the PFC is critical for regulating attention. The PFC is important for screening distractions, sustaining attention and shifting/dividing attention in a task-appropriate manner. The PFC is significant in regulating behavior/emotion, especially for inhibiting inappropriate emotions, impulses and habits. Significantly, the PFC is needed for allocating and planning to achieve goals and organizing behavior and thought, the regulatory abilities referred to as executive functions. The intent of this issue is to explore the interconnection between executive functioning and ADHD, and to approach their relationship more accurately from a therapeutic standpoint.
- Barkley RA. Executive Functioning and Self-Regulation: Integration, Extended Phenotype, and Clinical Implications. New York: Guilford Press; 2011.
- Barkley RA, Murphy KR, Fischer M. ADHD in adults: What the science says. New York: Guilford Press; 2008.
- Pennington BF, Bennetto L, McAleer O, Roberts RF. Executive functions and working memory: Theoretical and measurement issues. In: Lyon, GR, Krasnegor N, eds. Attention, Memory, and Executive Function. (pp. 327-348). Baltimore, MD: Paul H. Brookes; 1996:327-348.
- Lezak MD. Neuropsychological Assessment; 3rd ed.; New York: Oxford University Press; 1995.
- Arnsten AF. Toward a new understanding of attention-deficit hyperactivity disorder pathophysiology: an important role for prefrontal cortex dysfunction. CNS Drugs. 2009;23(Suppl 1):33-41.
After completing this activity, the reader should be better able to:
How To Obtain Your CME Certificate
- Discuss the problems associated with the tests used in the clinical assessment of EF.
- Discern whether stimulants are effective in the treatment of executive function deficits.
- Explain how childhood adversity, psychiatric comorbidities can predict ADHD persistence into adulthood.
- Describe a case study in which a patient with ADHD, dyslexia, and executive function disorder was successfully assessed and treated.
Register for the course at www.naceonline.com.
- View the content.
- Complete and submit the post-test and evaluation.
- A minimum passing score of 60% must be earned on the post-test in order to complete the CME
- Print your CME certificate.
National Association for Continuing Education
|Accreditation Designation Statement
The National Association for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The National Association for Continuing Education designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Policy on Faculty and Provider Disclosure: It is the policy of the National Association for Continuing Education to ensure fair balance, independence, objectivity and scientific rigor in all activities. All faculty participating in CME activities sponsored by the National Association for Continuing Education are required to present evidence-based data, identify and reference off-label product use and disclose all relevant financial relationships with those supporting the activity or others whose products or services are discussed. Faculty disclosure is provided below.
Lenard Adler, MD has the following relationships to disclose: consultant for Shire Pharmaceuticals, Alcobra, Astra-Zeneca, Major League Baseball Players Association and an inventor and receives royalties for NYU School of Medicine. Conducts sponsored research for Shire Pharmaceuticals and is on the advisory board for Astra-Zeneca.
Andrew Nierenberg, MD has the following relationships to disclose: Consultant to the Appliance Computing Inc., Brandeis University, Astra Zeneca, Brain Cells, Inc, Dianippon Sumitomo/Sepracor, Johnson and Johnson, Labopharm, Merck, Methylation Science, Novartis, PGx Health, Shire, Schering-Plough, Targacept, and Takeda/Lundbeck Pharmaceuticals. He received grant/research support through MGH from NIMH, PamLabs, Pfizer Pharmaceuticals, and Shire. He received honoraria from Belvior Publishing, Hillside Hospital, APSARD, American Society for Clinical Psychopharmacology, Columbia University, IMEDEX, ISBD, MJ Consulting, New York State, MBL Publishing, Physicians Postgraduate Press, SciMed, SUNY Buffalo, University of Wisconsin, and the University of Pisa. He is on the advisory boards of Appliance Computing, Inc., Brain Cells, Inc., Eli Lilly and Company, Johnson and Johnson, and Takeda/Lundbeck and Targacept. Dr. Nierenberg owns stock options in Appliance Computing, Inc. and Brain Cells, Inc. Through MGH, he is named for copyrights to the Clinical Positive Affect Scale and the MGH Structured Clinical Interview for the Montgomery Asberg Depression Scale exclusively licensed to the CTNI.
Anthony Rostain, MD has the following relationships to disclose: Advisory Board-Shire, Ortho-McNeill-Janssen.
Richard L. Rubin, MD has the following relationships to disclose: Research/Consultant/Speaker’s Bureau—Abbott, Cephalon, Eli Lilly, Johnson & Johnson, Novartis, Shionogi, and Shire
Ron Gasbarro, PharmD, MS Journ has no relationships to disclose.
Harvey C. Parker, Ph.D., Activity Planning Committee, has the following relationship to disclose: co-owner of Specialty Press, Inc. and Health Link Systems, Inc.
Michelle Frisch, MPH, Activity Planning Committee, has no relationships to disclose.
Alan Goodstat, LCSW, Activity Planning Committee, has no relationships to disclose.
This activity is supported by an educational grant from Lilly USA, LLC. For further information concerning Lilly grant funding, visit www.lillygrantoffice.com