Comments on Adult ADHD and its Familial Associations: Neuropsychological Profiles and Psychiatric Comorbidities

In 2008 NICE guidance recommended the identification and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults. Previously, diagnosis and treatment of this condition had mainly been confined to children and young people. Dr Tamsin Newlove-Delgado and Professor Ken Stein from University of Exeter explain why adult ADHD is important and what the implications are for health improvement, commissioning and providing evidence based services Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder, with symptoms of inattention, hyperactivity and impulsivity causing significant impairment in functioning. The diagnostic criteria for ADHD currently require that symptoms must have been present before the age of seven years, and be apparent in more than one setting. There is no single cause; instead the condition appears to result from a complex interaction of genetic and environmental factors.1 ADHD is estimated to affect 3-5% of children of school age in the UK.1,2 Does ADHD exist in adults? Few studies have followed up young people with ADHD beyond the age of 25. A meta-analysis of data from follow-up studies suggested that although the rate of persistence of ADHD meeting the full diagnostic criteria at age 25 was only 15%, the persistence of symptoms was much higher at around 40-60%.3 Therefore, although the prevalence of ADHD certainly declines with age, a significant proportion of adults have still been found to be affected. ADHD in adults remains the subject of some debate, given the high rate of co-morbidities and the difficulty in distinguishing normal symptoms from pathological ones. However, in 2008 the National Institute for Health and Clinical Excellence (NICE) reviewed the evidence on adult ADHD, recommending recognition of the condition and establishment of services for assessment and management, with stimulant medication as the first-line treatment for adults with either moderate or severe levels of impairment.2 How many adults might suffer with ADHD? A meta-analysis of world literature produced a pooled prevalence estimate of 2.5%.4 The UK 2007 Adult Psychiatric Morbidity Survey5 used the six item Adult ADHD Self Report Scale (ASRS) to screen the sample for ADHD symptoms. Using this scale 8.2% of adults scored four or more, which was considered to warrant clinical assessment, and 0.6% scored all six, indicating a high likelihood of a positive diagnosis. NICE have estimated the number of men with ADHD at over 300,000 in England, and the number of women at over 80,000,6 indicating that there is a considerable population likely to be affected. Impact of adult ADHD Higher risk of other psychiatric disorders Adults with ADHD are at increased risk for other psychiatric disorders. Over a lifetime, it is estimated that over threequarters of those with ADHD will have a psychiatric co-morbidity;7 with depression and anxiety being most common. Substance misuse and smoking Substance misuse affects up to half of adults with ADHD.7 A significant proportion of those in contact with substance misuse services also have ADHD symptoms. High rates of smoking (up to 40%) in ADHD8 may be explained by genetic influences or self-medication with nicotine: the condition is also linked with earlier initiation of smoking and difficulty in quitting.9 Accidents Studies have reported that adolescents and adults with ADHD are more likely to be involved in road traffic collisions, to be stopped for speeding, and to report losses of concentration and control whilst driving.10 Similarly, both children and adults with ADHD appear to have more accidents and injuries in general, possibly due to impulsivity and risktaking behaviours.11 Educational and occupational underachievement Adults with ADHD experience higher job turnover and more periods of unemployment. A recent European study found they were twice as likely to be unemployed. …

Introduction: Several investigations have been performed on insomnia symptoms in adult attention-deficit/hyperactivity disorder (ADHD). However, the relationship between insomnia disorder and adult ADHD has been neglected in research. The main objective of the current study is to analyze the differences between adult ADHD patients with and without insomnia disorder, in terms of ADHD clinical severity, medical and psychiatric comorbidity, psychopharmacological treatment, and quality of life.Material and Methods: Two hundred and fifty-two adult patients with ADHD (mean age 37.60 ± 13.22 years; ADHD presentations—combined: 56.7%, inattentive: 39.7%, hyperactive/impulsive: 3.6%) were evaluated with an exhaustive clinical and psychological evaluation protocol including semistructured interviews (for comorbidities and ADHD assessment) and symptom rating scales for ADHD. The diagnosis of ADHD and insomnia disorder was made according to DSM-5 criteria. Furthermore, the Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Epworth Sleepiness Scale were administered.Results: Insomnia disorder was found in 44.4% of adult ADHD patients and was more common in combined presentation (64.3%) and in patients with more ADHD severity. Comorbidities (both medical and psychiatric), especially mood disorders (42%), anxiety disorder (26.8%), personality disorder (39.3%), and any substance use disorder (11.6%), were associated with a higher insomnia disorder prevalence. ADHD stimulant treatment was related to lower insomnia disorder compared to patients without medication, as well as ADHD stable treatment. Additionally, worse health-related quality of life was associated with insomnia disorder.Conclusion: Insomnia disorder is highly prevalent in adult ADHD and is related to higher ADHD severity and more psychiatric and medical comorbidities. Some stimulants and stable pharmacological ADHD treatment are associated with better outcomes of insomnia disorder.

Adult attention-deficit hyperactivity disorder (ADHD) is increasingly recognized; however, evidence describing diagnostic pathways, comorbidity burden, and prescribing practices in adult care remains limited. To characterize diagnostic patterns, psychiatric comorbidities, and prescribing ‎practices for adult ADHD across outpatient specialties in a tertiary care setting in the United ‎Arab Emirates.‎. A retrospective chart review was conducted for adults aged ≥18 years diagnosed with attention-deficit hyperactivity disorder (ADHD) at a tertiary care hospital in Dubai, United Arab Emirates, between May 2023 and August 2024. Cases were identified using the ICD-10 code F90.x. Demographic characteristics, diagnosing specialty, ADHD diagnostic hierarchy and subtype, psychiatric comorbidities, and prescription data were extracted from electronic health records. Prescription data included ADHD-specific pharmacotherapy and medications for associated psychiatric or medical comorbidities. Descriptive statistics summarized diagnostic and prescribing patterns. One-way analysis of variance and chi-square tests examined differences in diagnostic yield across outpatient specialties and associations between diagnosis type, comorbidity presence, and prescribing patterns, with statistical significance set at P < 0.05. A total of 157 adult ADHD cases were identified. Psychiatry accounted for most diagnoses (60.5%), followed by family medicine (28.0%), neurology (10.2%), and internal medicine (1.3%). Diagnostic yield differed significantly across specialties (F = 32.96, P < 0.001). ADHD was documented as a secondary diagnosis in 60.5% of cases, most commonly with anxiety and depressive disorders, with comorbidity presence significantly associated with diagnosis type (χ2 = 157.00, P < 0.001). Inattentive and unspecified subtypes predominated (χ2 = 85.82, P < 0.001). Among 509 prescribed medications, methylphenidate accounted for 46% and was prescribed significantly more frequently than other agents (χ2 = 314.21, P < 0.001). Adult ADHD was often diagnosed with psychiatric comorbidity, mainly in psychiatric services, with marked variation across specialties, highlighting the need for standardized diagnostic pathways and UAE-specific clinical guidance.

To determine comorbidity patterns in treatment-seeking substance use disorder (SUD) patients with and without adult attention deficit hyperactivity disorder (ADHD), with an emphasis on subgroups defined by ADHD subtype, taking into account differences related to gender and primary substance of abuse. Data were obtained from the cross-sectional International ADHD in Substance use disorder Prevalence (IASP) study. Forty-seven centres of SUD treatment in 10 countries. A total of 1205 treatment-seeking SUD patients. Structured diagnostic assessments were used for all disorders: presence of ADHD was assessed with the Conners' Adult ADHD Diagnostic Interview for DSM-IV (CAADID), the presence of antisocial personality disorder (ASPD), major depression (MD) and (hypo)manic episode (HME) was assessed with the Mini International Neuropsychiatric Interview-Plus (MINI Plus), and the presence of borderline personality disorder (BPD) was assessed with the Structured Clinical Interview for DSM-IV Axis II (SCID II). The prevalence of DSM-IV adult ADHD in this SUD sample was 13.9%. ASPD [odds ratio (OR) = 2.8, 95% confidence interval (CI) = 1.8-4.2], BPD (OR = 7.0, 95% CI = 3.1-15.6 for alcohol; OR = 3.4, 95% CI = 1.8-6.4 for drugs), MD in patients with alcohol as primary substance of abuse (OR = 4.1, 95% CI = 2.1-7.8) and HME (OR = 4.3, 95% CI = 2.1-8.7) were all more prevalent in ADHD(+) compared with ADHD(-) patients (P < 0.001). These results also indicate increased levels of BPD and MD for alcohol compared with drugs as primary substance of abuse. Comorbidity patterns differed between ADHD subtypes with increased MD in the inattentive and combined subtype (P < 0.01), increased HME and ASPD in the hyperactive/impulsive (P < 0.01) and combined subtypes (P < 0.001) and increased BPD in all subtypes (P < 0.001) compared with SUD patients without ADHD. Seventy-five per cent of ADHD patients had at least one additional comorbid disorder compared with 37% of SUD patients without ADHD. Treatment-seeking substance use disorder patients with attention deficit hyperactivity disorder are at a very high risk for additional externalizing disorders.

The impact of insomnia disorder on adult attention-deficit/hyperactivity disorder severity: A six-month follow-up study

Background: Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder, traditionally seen as a childhood disorder; recent studies show that it persists into adulthood, affecting 2.58% of adults globally. ADHD often runs in families, with genetic and environmental factors contributing to its persistence across generations. The aim of the study was to assess the prevalence of ADHD, neuropsychological functioning, and psychiatric comorbidities in the family members of adults diagnosed with ADHD in childhood. Methods: This cross-sectional, analytical study was conducted at a tertiary care hospital. Family members of adult males who were diagnosed with ADHD, including parents and siblings, were assessed for ADHD symptoms and psychiatric comorbidities. Neuropsychological testing for cognitive impairments in attention, memory, and executive functions was done. Statistical analysis was conducted using IBM SPSS, with chi-square and t -tests applied for group comparisons. Results: Thirty male adults were the reference group diagnosed with childhood ADHD. Family history of ADHD was positive in 36.7% of the reference group, with 11 members screening positive for ADHD (7 siblings and 4 parents) out of 82. Neuropsychological testing in these family members revealed deficits across multiple cognitive domains, particularly in sustained attention (81.8%), working memory (81.8%), and planning (100%). Psychiatric morbidity was found in 40% of family members, with substance use disorder being the most common (16.7%). Conclusion: A significant proportion of family members of adults with ADHD also exhibit symptoms of ADHD, reinforcing the genetic link. Neuropsychological deficits in attention, memory, and executive function were prominent in affected family members.

Obstetric complications have been associated with a number of mental disorders. In this study, we investigate how obstetric complications relate with clinically significant determinants of adult attention deficit hyperactivity disorder (ADHD), such as gender, age of diagnosis, psychiatric co morbidity, severity of symptomatology and general functioning. Presence of obstetric complications as reported in the psychiatric history of 64 patients in transition from adolescence to adulthood referred to the Yorkshire service for adults with ADHD between June 2009 and October 2010 were recorded. The presence or not of these complications was examined as a factor determining a number of clinically significant variables, such as gender, age at first diagnosis, psychiatric comorbidity, severity of symptomatology (measured with Conners Adult ADHD Rating Scale (CAARS)) and general functioning (measured using the DSM-IV General Assessment of Functioning (GAF) index). Obstetric complications were not associated with any of the variables examined. Adults with ADHD in transition to adult services were highly symptomatic and disabled with a mean Conner’s score (n = 56) of 30.5 (SD = 12.8) and the most common frequency of the GAF score (n = 55) on the 60–51 range. Although it has been reported that environmental factors are associated with ADHD, the presence or absence of obstetric complications in an adult ADHD population was not associated with a number of proxy measures clinically associated with organic aetiology in mental health conditions. Future research on etiology and etiopathology should focus on prenatal and genetic factors instead.

The aim of this study was to determine the frequency of adult attention deficit hyperactivity disorder (ADHD) comorbidity with lifetime bipolar disorder, and the influence of this comorbidity on various demographic and clinical variables in patients. Patients (n=159) with a previous diagnosis of bipolar disorder (79 female, 80 male) were included in this study. All patients were interviewed for the presence of current adult and childhood ADHD diagnosis and other axis I psychiatric disorder comorbidities using the structured clinical interview for DSM-IV (SCID) and the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL). The subjects also completed a Wender Utah rating scale (WURS-25) and a Current Symptoms Scale for ADHD symptoms. In particular, patients' clinical characteristics, the age of onset of bipolar disorder, and the number of episodes were noted. Twenty-six of the 159 bipolar patients (16.3%) were diagnosed with adult ADHD, while another subgroup of patients (n=17, 10.7%) received a diagnosis of childhood ADHD but did not fulfill criteria for adult ADHD. Both of these two subgroups (patients with adult ADHD, and patients with only childhood ADHD) had an earlier age of onset of the disease and a higher number of previous total affective or depressive episodes than those without any lifetime ADHD comorbidity. However only bipolar patients with adult ADHD comorbidity had higher lifetime comorbidity rates for axis I psychiatric disorders, such as panic disorder and alcohol abuse/dependence, compared to patients without lifetime ADHD. Bipolar patients with comorbid adult ADHD did not differ from bipolar patients with comorbid childhood ADHD in terms of any demographic or clinical variables except for adult ADHD scale scores. In conclusion, ADHD is a common comorbidity in bipolar patients, and it adversely affects the course of the disease and disrupts the social adjustment of the patients. Regular monitoring of ADHD will help to prevent problems and complications that could arise in the course of the disease, particularly in patients with early onset bipolar disorder.

P.2.017 - ADHD and related aspects in a standardised investigation in Austrian prisons – incarcerated patients with substance use disorders

ABSTRACTObjective: Neurocognitive evaluations are commonly integrated with clinical assessment to evaluate adult Attention Deficit Hyperactivity Disorder (ADHD). Study goal is to identify measures most strongly related to ADHD diagnosis and to determine their utility in screening processes. Participants: 230 students who were evaluated at the Vanderbilt University Psychological and Counseling Center between July 2013 and October 2015. Methods: We retrospectively examined charts, including clinical diagnosis, family history, childhood parental reported and current self-reported ADHD symptoms, psychiatric comorbidities, and continuous performance test (CPT). Result: Positive report of childhood and current ADHD symptoms, and lack of comorbid psychiatric symptoms were strongly associated with clinical diagnosis. CPT results were not associated with an ADHD diagnosis. The absence of reported childhood and current ADHD symptoms may serve as a contradictory marker for ADHD diagnosis. Conclusion: Clinical assessment of ADHD symptoms and ADHD childhood history, but not CPT, contributes to an accurate diagnosis of ADHD in college-aged adults.

Patients with adult attention-deficit/ hyperactivity disorder (ADHD) and bipolar disorder can present with similar symptoms, including increased energy, distractibility, disorganization, impulsivity, hyperactivity, and rapid speech. Determining whether the patient has either, or possibly both, of these syndromes can be a complex task. This review attempts to clarify where these disorders overlap, both symptomatically and epidemiologically, and where they diverge, to help clinicians increase the accuracy of their diagnoses. Changes to diagnostic criteria from the fourth to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (from DSM-IV-TR to DSM-5) are discussed, as is the evidence base for pharmacological treatments. Studies and sources were identified using computerized searches. Adult ADHD and bipolar disorder have multiple overlapping symptoms, but there are differences in prevalence (ADHD affects 4.4% of adults in the United States versus 1.4% for bipolar disorder), onset of symptoms (usually before age 7 years in ADHD versus after age 12 years in bipolar disorder), disease course (chronic in ADHD versus cyclical in bipolar disorder), mood symptoms (absent in ADHD but always present in bipolar disorder), and psychotic symptoms (absent in ADHD but sometimes present in bipolar disorder). Approximately 20% of adult patients with ADHD also have bipolar disorder, while 10%-20% of patients with bipolar disorder have adult ADHD. Comorbidity of bipolar disorder and ADHD is associated with an earlier age of onset and a more chronic and disabling course of bipolar disorder, as well as more psychiatric comorbidity. Distinguishing between adult ADHD and bipolar disorder requires careful attention to phenomenology and awareness of epidemiology, with a focus on childhood history, lifetime course of symptoms, and the possibility of comorbidity.

Adult attention deficit/hyperactivity disorder (ADHD) is a valid and impairing psychiatric disorder. In this article, we review the diagnosis of ADHD in adults, focusing on symptom presentation differences between pediatric and adult ADHD as well as the importance of assessing functional impairments. Differentiating ADHD from other clinical disorders is often the most difficult part of making an ADHD diagnosis in adults. Psychiatric comorbidities are also described and discussed as potential impact factors upon not only diagnosing ADHD but also treatment of adult ADHD. Especially in those adults with psychiatric comorbidities, treatments need to be multimodal and include both pharmacotherapy and psychosocial interventions.

Objective Adult Attention Deficit Hyperactivity Disorder (ADHD) is internationally well described but little clinical information has emerged from Australia. We explored the demographic and psychiatric characteristics of adults consecutively referred to an Australian private psychiatric clinic. Methods Medical records of 473 adults aged 18–70 with ADHD were reviewed with the Adult Self-Report Scale (ASRS) 1.1, Depression Anxiety and Stress Scale-21 (DASS-21) and Behaviour and Symptom Identification Scale (BASIS-32). Results The sex ratio was lower in the ADHD adulthood versus childhood diagnosed group (1.4:1 versus 4.9:1). Women were likely to be diagnosed 5 years later than men, had lower socioeconomic status, and experienced more ADHD symptoms and trauma. Conclusion Women are at risk of delayed diagnosis despite more ADHD symptoms and related problems. There is a need for increased adult ADHD services and health professional education in Australia to identify and support adult ADHD. Key points What is already known about this topic: (1) Attention deficit hyperactivity disorder (ADHD) persists into adulthood and affects around 2-3% of adults. (2) Adult ADHD is associated with high levels of psychiatric comorbidity. (3) There is very little research on the presentation of Australian adults with ADHD. What this topic adds: (1) This research describes the clinical presentation of 473 Australian adults with ADHD who were consecutively referred to a private psychiatric clinic. (2) Women were likely to be diagnosed with ADHD later than men. (3) There were high rates of comorbidities and minimal differences between those diagnosed with ADHD in adult versus childhood.

To determine the prevalence of adult attention deficit hyperactivity disorder (ADHD) and comorbid mental disorders in a Malaysian forensic mental hospital. All adult patients admitted to the forensic wards who were able to understand Malay or English language and give written informed consent were included. Participants were assessed using the Conners Adult Attention-Deficit Diagnostic Interview for DSM-IV (for presence of adult ADHD and a history of childhood ADHD) and the Mini International Neuropsychiatric Interview (for psychiatric comorbidities). Sociodemographic and offence-related data were also collected. Of 199 patients admitted, 120 were included for analysis. The mean age of participants was 36.3 years. 94.2% were men. 81.7% were single, divorced, or separated. 25% had a history of childhood ADHD. The prevalence of adult ADHD was 15.8%. The persistence rate was 63%. Among the 19 participants with adult ADHD, the most common psychiatric comorbidities were substance dependence (68.4%), lifetime depression (63.2%), and generalised anxiety disorder (47.4%). Compared with participants without ADHD, participants with adult ADHD were less likely to be married (0% vs 21.8%, p = 0.022) and more likely to have alcohol abuse (15.8% vs 2%, p = 0.028), lifetime manic/hypomanic episodes (42.1% vs 7.9%, p = 0.001), and generalised anxiety disorder (47.4% vs 19.8%, p = 0.017), and were of younger age at first offence (21.8 years vs 26.9 years, p = 0.021). Adult ADHD is common in a Malaysian forensic mental hospital and is associated with unmarried status, alcohol abuse, lifetime manic/hypomanic episodes, generalised anxiety disorder, and younger age at first offence.

ABSTRACTIntroduction: ADHD is characterized by a developmentally inappropriate level of inattentiveness, impulsivity and/or hyperactivity. In adults, the disorder is frequently accompanied by Emotional Dysregulation (ED), associated to a variety of related psychiatric comorbidities, complicating its recognition and treatment management.Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in adults with ADHD and ED, other neurodevelopmental disorders, Bipolar Disorder (BD) and Anxiety Disorders (ADs). When controlled data are unavailable, the authors have included open-label and observational studies.Expert opinion: ED in adult patients with ADHD is a very common and impairing problem that can be treated with stimulants or atomoxetine. ADHD studies in adults with other neurodevelopment disorders are scarce; stimulants seem to be the most effective and safe drugs in treating ADHD symptoms, without worsening the core features of other neurodevelopmental disorders. In patients with ADHD and comorbid BD, the treatment of BD alone may result in residual symptoms of ADHD. Patients should be treated hierarchically: BD should be treated first, while ADHD should be treated combining ADHD medications and mood stabilizers after mood stabilization. The available evidence for treating patients with ADHD and comorbid ADs in adults supports the idea of an anti-anxiety/ADHD-specific treatment association.