Adult AbstractAttention-deficit/hyperactivity Disorder Research Articles

On the screening, diagnosis, and treatment of adolescent and adult ADHD patients with comorbid substance use: international guidelines

Abstract Attention deficit/hyperactivity disorder (ADHD) often co-occurs with substance use disorders (SUD). Together, these disorders are associated with significantly more burden for patients and society, than each alone. Patients with SUD and underlying ADHD have more complex SUD and have more poly-substance use compared with SUD patients without ADHD. A correct identification of ADHD in adult and adolescent individuals with SUD remains important regarding treatment, treatment effectiveness, and treatment retention. Several screening tools are available and have been validated in individuals with ADHD and comorbid SUD. It is highly recommended that these are used routinely, followed by an ADHD diagnostic process initiated as soon as possible. While several treatment options are accessible, randomized controlled trials show only limited effect sizes of standard pharmacotherapy in adult and adolescent ADHD patients with comorbid SUD. Simultaneous and integrated treatment, with a combination of pharmacotherapy and psychotherapy and for both ADHD and SUD, should preferably be initiated. We present an overview of the current international guidelines on screening, diagnosis and treatment of ADHD adults and adolescents with comorbid substance use disorders. Disclosure of Interest None Declared

A randomized-controlled neurofeedback trial in adult attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a childhood onset disorder persisting into adulthood for a large proportion of cases. Neurofeedback (NF) has shown promising results in children with ADHD, but randomized controlled trials in adults with ADHD are scarce. We aimed to compare slow cortical potential (SCP)- and functional near-infrared spectroscopy (fNIRS) NF to a semi-active electromyography biofeedback (EMG-BF) control condition regarding changes in symptoms and the impact of learning success, as well as changes in neurophysiological parameters in an adult ADHD population. Patients were randomly assigned to SCP-NF (n = 26), fNIRS-NF (n = 21) or EMG-BF (n = 20). Outcome parameters were assessed over 30 training sessions (pre, intermediate, post) and at 6-months follow-up (FU) including 3 booster sessions. EEG was recorded during two auditory Go/NoGo paradigms assessing the P300 and contingent negative variation (CNV). fNIRS measurements were conducted during an n-back- as well as a Go/NoGo task. All three groups showed equally significant symptom improvements suggesting placebo- or non-specific effects on the primary outcome measure. Only when differentiating between learners and non-learners, fNIRS learners displayed stronger reduction of ADHD global scores compared to SCP non-learners at FU, and fNIRS learners showed specifically low impulsivity ratings. 30.8% in the SCP-NF and 61.9% of participants in the fNIRS-NF learned to regulate the respective NF target parameter. We conclude that some adults with ADHD learn to regulate SCP amplitudes and especially prefrontal hemodynamic activity during NF. We did not find any significant differences in outcome between groups when looking at the whole sample. When evaluating learners only, they demonstrate superior effects as compared to non-learners, which suggests specific effects in addition to non-specific effects of NF when learning occurs.

Long-term improvement of quality of life in adult ADHD – results of the randomized multimodal COMPAS trial

Attention Deficit Hyperactivity Disorder (ADHD) negatively impacts Quality of Life (QoL) in adults. Earlier studies on pharmacological treatment have shown short-term beneficial effects on QoL. No data are available on long-term effects on multimodal psychosocial and/or pharmacological interventions. The Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (Plac) (2 × 2 factorial design over a period of 52 weeks). Change of QoL was measured after three months of intensive treatment, after 26 weeks, and after one year of maintenance treatment, using the Quality of life enjoyment and satisfaction questionnaire (Q-LES-Q, eight subscales). A follow-up was performed 1.5 years after treatment completion. Q-LES-Q scores were analyzed descriptively (means and confidence intervals). A linear regression model was used to test for significant differences between the four treatment arms. The full analysis set comprised 419 patients. Q-LES-Q scores increased between baseline and the end of treatment across all Q-LES-Q subscales (with exception of stable scores in the physical health/activities subscale in the CM + Plac group) and remained stable improved at follow-up. Regression analyses did not show any significant differences between the four treatment conditions. COMPAS is the first study to demonstrate stable and long-term improvements of QoL after multimodal treatment regardless of medication with MPH or Placebo, and regardless of structured GPT or individual CM. Trial registration: ISRCTN54096201

Methylphenidate treatment of adult ADHD patients improves the degree of ADHD severity under routine conditions

Attention-deficit hyperactivity disorder (ADHD) is associated with substantial personal and social impairments. Besides psychosocial interventions, current guidelines recommend a therapy with methylphenidate (MPH). This prospective, non-interventional study aims to investigate the efficacy and tolerability of MPH treatment of adult ADHD patients in a real-world setting. 468 adult patients with newly diagnosed ADHD were observed for 12–14 weeks. Primary efficacy endpoint was the clinical global impression (CGI) by the physician. Secondary endpoints comprise patient evaluation (Wender–Reimherr self-report, WR-SR), safety, tolerability, and dosage of MPH. With a mean daily dose of 35.8 (±17.0) mg MPH, the population of patients being severely/most extremely ill or markedly ill decreased by 64% and 61%, respectively. According to physicians’ assessment (CGI), 74.5% of patients were identified as treatment responders. The total score of patient-based assessment (WR-SR) improved by 23.5% (50.1 ± 40.3 points) with the most profound improvement in attention deficit (−30.0%), disorganization (−26.6%), and hyperactivity / unrest (−23.3%). Self-evaluation revealed a responder rate of 35.4%. In summary, MPH treatment improves the degree of ADHD severity under routine conditions. In addition, activities of daily living were facilitated when taking MPH. The rather poor responder rates determined by patient assessment as well as the comparatively low applied mean daily dose of 35.8 mg (median 40 mg) indicate sub-optimal dosing under routine conditions, not exploiting the full beneficial therapeutic potential of MPH.

A Place for Psychological Testing in the Assessment of Adult ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, impulsivity, and hyperactivity that interfere with social, occupational, or academic functioning. Clinical communities differ regarding whether or not formal psychological or neuropsychological assessment is necessary for diagnosing ADHD. A comprehensive assessment model that emphasizes differential clinical diagnosis is recommended. This model provides practice guidelines that ensure accurate diagnosis when faced with potential complicating factors, such as symptom overlap, substance abuse, and symptom feigning.

Translation of the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale into an African Language: An Exploratory Study.

Attention-Deficit/Hyperactivity Disorder (ADHD) is commonly perceived as a cultural construct due to its disproportionate global representation, however limited data is available from Africa. Standardisation of screening tools in epidemiological studies is essential for global prevalence comparison, but tools such as the Adult ADHD Self-Report Scale (ASRS) have not been translated into African languages. To assess the translation process followed in attempting to adapt the ASRS into an indigenous African language widely spoken within South Africa for cross-cultural research. Xhosa was selected as an appropriate target language for translation. An exploratory approach was used to assess linguistic considerations for adaptation of the ASRS. Blind translation was applied by two independent bilingual translators. A translational studies expert translated the ASRS into Xhosa. The translated document was back-translated into English by a bilingual pharmacist. Side-by-side comparison of the original and back-translated English versions revealed 13 content queries. Each query was discussed with the back translator, revealing common themes which complicated the effective Xhosa ASRS translation. Appropriate contextualisation of questions and removal or explanation of idiomatic terms were identified as key requirements to improve properties for Xhosa translation. Suitability of the original instrument for Xhosa translation was problematic and further investigation into appropriate cross-cultural translation techniques is needed to improve ASRS translation properties and assess its Xhosa translation. Development of a suitable Xhosa version of the ASRS is considered to be an important step towards broadening the scope of ADHD research in South Africa.

Consumption of Synthetic Cannabinoids in Adult Attention-Deficit/Hyperactivity Disorder: a Pilot Study

Attention-deficit/hyperactivity disorder (ADHD) is associated with an increased risk for substance abuse and addiction. Synthetic cannabinoids (SC) have gained rising importance as their consumption increased rapidly in the last few years. However, SC consumption in patients with adult ADHD has not been investigated yet. A prospective clinical pilot study was conducted, including 60 adults with ADHD, assessing the prevalence of SC consumption and its associations with psychiatric comorbidities and patient characteristics. A drug consumption survey was utilized to investigate the use of SC and other drugs. Current ADHD symptoms were evaluated via ADHD Self-Rating Scale (ADHD-SR) and retrospective childhood ADHD symptom severity via Wender Utah Rating Scale (WURS-k) questionnaire. A positive lifetime prevalence of SC consumption was found in 15.0% of the analyzed sample. SC consumption was significantly associated with current smoking, lifetime use of natural cannabis (NC), cocaine, amphetamines, and benzodiazepines. Lifetime NC consumption was indicated by 65.0% and found to antecede SC use in adult ADHD patients. Logistic regression analysis identified substance use disorder and male sex as predictive for SC consumption. Patients with history of SC use scored significantly higher in both WURS-k and ADHD-SR questionnaire compared with nonusers and suffered significantly more frequently from psychiatric comorbidities. Main side-effects of SC included gastrointestinal, cardiovascular, and neuropsychiatric symptoms. SC consumption in adults with ADHD is frequent and associated with stronger ADHD symptom severity. Given the underestimated dangerous effects and related comorbidities, SC use should be subject to scrutiny by clinicians treating ADHD patients. More studies are needed to further elucidate the impact of SC use in ADHD.

Survey on centres and procedures for the diagnosis and treatment of adult ADHD in public services in Italy.

Attention deficit/hyperactivity disorder (ADHD) often persists into adulthood. Although its persistence and relative high prevalence, ADHD in adults is often underdiagnosed and undertreated in Italy, leading to poor clinical and functional outcomes, and higher costs of illness. The aims of the study were to identify the Italian mental health services for ADHD in adults, describe the diagnostic and treatment procedures they follow, and compare this offer with the recommendations of the German and English guidelines. The centres, that adopt a clinical and assessment protocol for adult ADHD diagnosis (carried out by specifically trained personnel) and prescribe pharmacological treatment for adult ADHD, were selected from the list of accredited services provided by the Appendix B.2 of the ISTISAN 16/37 Reports of the ISS. An ad-hoc survey including open-ended and close-ended questions was sent to each selected centre in February 2020. The overall picture resulting from the data analysis was compared with the recommendations of the German and English guidelines. The present survey shows that only a few centres are specialised in the diagnosis and treatment of ADHD in adults in Italy. Furthermore, there are no national guidelines for adult ADHD in Italy. The collected data also suggest that there is no a unified practice shared by the Centres both for the patient's transition from child and adolescent to adult mental health services and for the diagnostic-therapeutic process. It is therefore crucial to create specific protocols and develop national guidelines to better identify and diagnose ADHD in adults and provide targeted and more efficient multimodal treatments.

Neurobiological marker for child and adult ADHD diagnoses

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorder. It is a chronic disease where 50–60% of ADHD cases persist into adult life. ADHD is associated with a range of clinical and psychosocial impairments. In children hyperactivity, impulsivity and inattention are the core symptoms of ADHD. In adults these core symptom are also present but inattention is more prominent. Correct diagnosis of ADHD remains challenging, especially as several other psychiatric and medical disorders show the similar symptomology.ObjectivesThe diagnosis of ADHD is clinical based upon a cluster of symptoms and criteria established by guidelines such as the DSM-5. Yet, objective markers are needed to support the clinical ADHD diagnosis in children and adults. Studies suggest that a neurobiological marker (eye vergence i.e. where the eyes move in opposite directions) can detect ADHD in children and adults. The eyes converge during orienting attention, as evidenced by visual event related potentials at parietal locations. This attention related vergence is impaired in ADHD patients.MethodsWe review the neurobiology and findings of eye vergence and the relevance of its measurement for the clinical diagnosis of ADHD.ResultsNeural circuits underlying eye vergence and attention largely overlap. Using machine learning, eye vergence measurements can classify ADHD in children and adults with high (> 90%) accuracy.ConclusionsEye vergence is a promising candidate for an objective clinical diagnosis of ADHD.Disclosure of interestPart of this research was paid by Braingaze. HS is co-founder and shareholder of Braingaze.

Disordered gamblers with and without ADHD: the role of coping in elevated psychological distress

Attention-deficit/hyperactivity disorder (ADHD) is significantly more prevalent among disordered gamblers than in the general adult population. Despite this, it remains unclear whether co-occurring ADHD is associated with clinically significant differences that call for specialized assessments and treatment planning. The purpose of this article was to explore differences in psychological distress and coping strategies among individuals presenting to an outpatient gambling treatment centre with and without co-occurring adult ADHD. Participants (n = 99) were primarily female (69%) and Caucasian (86%) outpatient treatment-seeking disordered gamblers. At intake, individuals completed self-report measures of coping (Coping Inventory for Stressful Situations – Adult Form), psychological distress (Beck Depression Inventory II) and ADHD (Brown Attention-Deficit Disorder Scales – Adult Form). Results indicated that individuals with ADHD (n = 42) reported significantly more psychological distress and less adaptive coping strategies than those without co-occurring ADHD (n = 57). Mediation analyses showed that an ADHD diagnosis had an indirect effect on psychological distress via the mediator of maladaptive coping. Assessment and treatment should be tailored to address the variety of presentations of gambling disorder. Screening for ADHD at intake may be helpful in creating an individualized treatment plan for disordered gamblers.

Treating adult ADHD and comorbid substance-related disorders

Attention-deficit/hyperactivity disorder (ADHD) is a complex, and multifactorial and chronic neurodevelopmental disorder. Comorbid psychiatric disorders are highly prevalent in individuals with a diagnosis of ADHD. There is a solid overlap between ADHD and substance use disorders (SUD). Prevalence of SUD is high among patients with ADHD, so that SUD are approximately double as common among individuals with ADHD than in general population, and individuals with SUD have much higher rates than expected of a comorbid ADHD. Studies shown that treatment during childhood of attention-deficit/hyperactivity disorder with stimulant medication neither protects nor increases the risk of later substance use disorders. Nevertheless, recent studies found that patients with ADHD and SUD can reduce ADHD symptoms and SUD with stimulants and cognitive-behavioral therapy. Treatment of ADHD in patients with SUD requires a comprehensive diagnostic assessment. It is recommendable to stabilize the addiction prior to treating the ADHD. In this talk, the recent literature for the treatment of adults with co-occurring ADHD and SUD will be reviewed.Disclosure of interestThe author has not supplied his declaration of competing interest.

Adult ADHD: an area lacking in clinical research?

Attention-deficit/hyperactivity disorder (ADHD) is characterized by damage of neurodevelopment, manifested in the form of excessive inattention and/or hyperactivity and impulsivity, as well as a lack of emotional self-control and motivation [1]. It is a chronic disorder of childhood onset and one of the most common psychiatric disorders worldwide within this stage of life (5–6%) [2]. During the last 40 years we have seen that a significant proportion of the affected children continue displaying symptoms throughout adulthood. Several inter national epidemiological studies, carried out in different cultures and socioeconomic environments, have shown that ADHD is one of the most common disorders in adults and is estimated to affect between 2–5% of the general adult population [1]. Studies on adults with ADHD have shown that its presence is associated with a significant impairment on academic achievement, work adjustment, interpersonal relationships, drug use, greater frequency of traffic accidents and crime problems [1,3]. Nowadays, evolutionary studies are available with over 30 years of monitoring [4,5]. Moreover, many genetic and neuroimaging studies have been performed that show differences between adults diagnosed with ADHD and those without. Regarding genetic research, differences have been found in the serotonergic and dopaminergic system, neurotrophic factors, the SNARE complex and the gene latrophilin-3, among others [6]. Similarly, neuroimaging studies have shown brain abnormalities at the structural, functional and connectivity level [7]. These findings have been mainly observed in the inferior frontal cortex and dorsolateral prefrontal, as well as striatal regions, anterior cingulate and cerebellar parietotemporales [7,8]. The diagnosis of ADHD in adults has been reflected in international diagnostic classifications since DSM-III, in 1980, which reported that the disorder can persist into adulthood for some of the affected children. The new version, DSM-V, makes even more explicit references to the progression of ADHD into adulthood, adapting the current criteria to the disorder’s evolutionary reality [3]. At present, there are reliable psychometric instruments for diagnostic assessment of ADHD in adults, as in other psychiatric disorders for this population, such as bipolar disorder or schizophrenia [1,3]. Therefore, from the current research, ADHD in adults has good evidence based on epidemiological, genetic, neuroimaging, clinical characteristics, psychosocial impairments and diagnostic instruments. Despite the data presented above, ADHD remains an underdiagnosed disorder in adults worldwide [1,3,9,10]. This situation is common to other psychiatric disorders beginning in childhood, such as autism. As a result, there is an undertreatment of ADHD in adulthood, which has major societal and personal costs [11]. “...attention-deficit/hyperactivity disorder is one of the most common disorders in adults and is estimated to affect between 2–5% of the general adult population.”

Psychotherapy in adult attention deficit hyperactivity disorder: implications for treatment and research

Attention deficit hyperactivity disorder (ADHD) is a risk factor for co-occurring psychiatric disorders and negative psychosocial consequences in adulthood. Previous trials of psychotherapeutic programs for adult ADHD were based on cognitive behavioral psychotherapeutic approaches and showed significant effects. Targets of psychotherapeutic interventions include not only coping with the core symptoms and associated problems such as depression and anxiety, but also probable consequences such as low self-esteem. Improvements in ADHD symptomatology and associated symptoms have been reported after psychotherapeutic treatment. The support of other participants is strongly regarded as helpful by patients in group therapy. This manuscript provides an overview of psychotherapy approaches and results of studies evaluating programs developed to treat adults with ADHD. Finally, the specific requirements of psychotherapy for adult ADHD as well as further research questions will be discussed.

Managing ADHD across the Lifespan in the Primary Care Setting

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral condition that affects most patients throughout their lives and is associated with occupational underachievement, psychiatric comorbidity, and substance abuse. Primary care physicians (PCPs) are at the forefront of helping patients with ADHD manage symptoms and overcome functional impairments. In this article, the problems of recognizing and effectively managing ADHD are explored through the presentation of 2 composite patient cases based on real patients in the authors' practices. Both cases highlight maturational changes in ADHD-related problems as patients develop through childhood, adolescence, and into adulthood. The striking differences between the cases serve to illustrate the highly varied clinical presentation and developmental trajectories of ADHD, moderated by family environment, patient characteristics, and life events. Emphasis is placed on understanding the crucial developmental turning points from early childhood through adulthood at which patients with ADHD are most likely to need increased support and specialized behavioral interventions. Diagnosis of adult ADHD is also reviewed, including an overview of potentially clinically relevant patient characteristics that should alert PCPs to the possible presence of ADHD and use of the World Health Organization's rapid 6-item adult ADHD Self-Report Scale as a screening device. The present discussion challenges PCPs to recognize the varied presentations of what ADHD “looks like,” and describes the need for PCPs to establish and maintain working partnerships with families, patients, and mental health care professionals in their local communities to successfully treat ADHD across the lifespan.

Distinguishing Symptoms of ADHD from Other Psychiatric Disorders in the Adult Primary Care Setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.

Performance Improvement CME: Adult ADHD

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders and is now understood to be a lifelong condition for most individuals. Unfortunately, many adults with ADHD are not being diagnosed, possibly due to insufficient diagnostic criteria, the complex presentation of the disorder, and a reluctance by physicians to diagnose the disorder in adults. Additionally, many of those who have been diagnosed with ADHD do not receive adequate treatment despite the availability of established and effective agents. Performance Improvement CME (PI CME) is an educational activity in which clinicians retrospectively assess their current clinical practice, choose areas for improvement and implement interventions based on treatment guidelines and health care standards, and then re-evaluate their clinical practice to assess the improvements made. This PI CME activity focuses on improving the diagnosis and treatment of adult ADHD.

Structural and functional brain imaging in adult attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a childhood disorder that persists into adulthood. Nevertheless, there are far fewer imaging studies in adult compared with childhood ADHD. Here we review the imaging literature on brain structure, function and structural and functional connectivity in adult ADHD, as well as the effects of psychostimulants on brain dysfunctions. Importantly, we discuss similarities and differences between these deficit findings and those in childhood ADHD to address the key question of continuity of brain abnormalities into adulthood. Findings show strikingly similar but more inconsistent abnormalities in adult ADHD in key childhood ADHD deficit areas of frontostriatal, temporoparietal and cerebellar regions, presumably due to highly prevalent confounding factors in adult ADHD of elevated rates of comorbidity and medication history.

A 2009 update on adult ADHD

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent and highly morbid neurobehavioral disorder afflicting children, adolescents, and adults throughout the world. This article discusses the clinical assessment of adult ADHD, reviews the results of recent adult ADHD treatment studies with an emphasis on medications currently approved by the US Food and Drug Administration, and discusses the clinical management and monitoring of ADHD pharmacotherapy.

Unveiling the Mystery about Adult ADHD: One Woman's Journey

Attention deficit hyperactivity disorder (ADHD), a neurobiological disorder, affects millions of individuals and can significantly impact an individual's life course. Research guidelines used in assessment, diagnosis, and treatment have focused primarily on Caucasian males generating, in part, the need to redress how gender and other contextual factors are considered. Consequently many women and persons from diverse cultural groups can be ignored or misdiagnosed. Undiagnosed and untreated women with ADHD are therefore limited in their potential to flourish socially, academically, interpersonally, and in their family roles. This case example of a 38-year-old African American woman illustrates how her life journey was affected by undiagnosed ADHD.

Update on adult attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent and highly morbid neurobehavioral disorder afflicting children, adolescents, and adults throughout the world. This article discusses the clinical assessment of adult ADHD, reviews the results of recent adult ADHD treatment studies with an emphasis on medications currently approved by the US Food and Drug Administration, and discusses the clinical management and monitoring of ADHD pharmacotherapy.