Childhood Adult Attention-deficit/hyperactivity Disorder Research Articles

A Systematic Review of Rates and Diagnostic Validity of Comorbid Adult Attention-Deficit/Hyperactivity Disorder and Bipolar Disorder

Adult attention-deficit/hyperactivity disorder (ADHD) is increasingly recognized and reported to frequently coexist with bipolar disorder. Concurrent diagnosis of adult ADHD and bipolar disorder remains controversial. In this study, we conducted a systematic review to examine the rates and diagnostic validity of the concept of comorbid adult ADHD and bipolar disorder. MEDLINE, Embase, PsycInfo, and Cochrane databases were searched for articles published before March 30, 2007, using the keywords manic, bipolar, attention deficit hyperactivity, and adult. The computer search was supplemented with bibliographic cross-referencing. Exclusion criteria were studies with only pediatric subjects, childhood ADHD only but not adult ADHD, and either bipolar disorder or ADHD only, but not both; review articles, case reports; letters to the editor; and book chapters. Of the 262 citations found, 12 studies met our inclusion criteria. Specific diagnostic validating criteria examined were phenomenology, course of illness, heredity, biological markers, and treatment response. There were 6 studies on comorbid rates, 4 on phenomenology, 3 on course of illness, 2 on heredity, none on biological markers, and 1 on treatment response. The proposed comorbid syndrome is fairly common (present in up to 47% of adult ADHD and 21% of bipolar disorder populations), with a more severe course of illness compared with that of bipolar disorder alone, and high rates of comorbidity with other psychiatric disorders. Its treatment appears to require initial mood stabilization. Comorbid adult ADHD and bipolar disorder has been insufficiently studied, with more emphasis on comorbidity rates and few data on course, neurobiology, heredity, and treatment. The diagnostic validity of adult ADHD/ bipolar disorder as a true comorbidity is not well-established on the basis of this equivocal and insufficient literature. More studies are greatly needed to further clarify its diagnostic validity and treatment approach.

Comorbidity of adult attention deficit hyperactivity disorder in adult patients with bipolar disorder: prevalence and clinical correlates

Aims:The objective of this study is to assess the frequency of adult Attention Deficit Hyperactivity Disorder (ADHD) comorbidity and the effect of ADHD comorbidity on various demographic and clinical variables in patients diagnosed with bipolar disorder (BD).Methods:103 patients with BD (51 female, 52 male) presenting at outpatient clinic of the BD Unit of the Department of Psychiatry of Cukurova University Faculty of Medicine were included in this study. All patients were evaluated for the presence of adult ADHD diagnosis and comorbidity using the entire SCID-I and the childhood ADHD sections of K-SADS-PL. Furthermore, the patients have also completed the Wender Utah Rating Scale (WURS-25) and Present Symptoms Scales.Results:13 of the 103 patients diagnosed with bipolar disorder (12.6%) were diagnosed with adult ADHD. BD patients with ADHD comorbidity had mood episodes at an earlier age and had higher numbers of previous total episodes, depressive and hypomanic episodes and higher numbers of hospital admittances than those without comorbidity. Overall, a larger portion of the patients with comorbidity had axis I comorbidities and panic disorder and alcohol abuse disorders were found at higher rates.Discussion:Adult ADHD is a common comorbidity in BD patients, which adversely affects the course of the disease and disrupts the social adjustment of the patients. Regular monitoring and scanning that keeps in mind the diagnosis of ADHD, will help prevent the problems and complications in the disease process, particularly in patients with early onset BD.

Anatomical and functional brain imaging in adult attention-deficit/hyperactivity disorder (ADHD)—A neurological view

In this review, we discuss current structural and functional imaging data on ADHD in a neurological and neuroanatomical framework. At present, the literature on adult ADHD is somewhat sparse, and so results from imaging have to therefore be considered mainly from the childhood or adolescence perspective. Most work has considered the impairment of executive functions (motor execution, inhibition, working memory), and as such a number of attention networks and their anatomical correlates are discussed in this review (e.g. the cerebello-(thalamo-)-striato-cortical network seems to play a pivotal role in ADHD pathology from childhood to adulthood). The core findings in ADHD imaging are alterations in the architecture and function of prefrontal cortex and cerebellum. The dorsal part of anterior cingulated cortex (dACC) is an important region for decision making, and executive control is impaired in adult ADHD. Finally, dysfunction of basal ganglia is a consistent finding in childhood and adulthood ADHD, reflecting dysregulation of fronto-striatal circuitry. The cerebellum, and its role in affect and cognition, is also persistently implicated in the pathology of ADHD.

Comorbid Psychiatric Illness Often Found in Adults With ADHD

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessComorbid Psychiatric Illness Often Found in Adults With ADHDJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:5 May 2006https://doi.org/10.1176/pn.41.9.0022Between 2001 and 2003, Ronald Kessler, Ph.D., a professor of health care policy at Harvard Medical School, and colleagues undertook a formidable challenge—determining the status of Americans' mental health.Their assessment—called the National Comorbidity Survey Replication—was based on detailed interviews with more than 9,000 Americans, representative of the American population. The major results from the survey were published in the June 2005 Archives of General Psychiatry (Psychiatric News, July 15, 2005).Now in the April American Journal of Psychiatry, Kessler and his team reported what they have learned from their survey about adult attention-deficit/hyperactivity disorder (ADHD). This illness was not addressed by the last two major American psychiatric epidemiology surveys—the Epidemiologic Catchment Area Study and the National Comorbidity Survey.Because of concern about recall failure among older adults, Kessler and his coworkers decided to assess only 3,199 of their survey participants, all between 18 and 44 years of age, for the presence of adult ADHD. The assessments were conducted by lay interviewers using the Diagnostic Interview Schedule for DSM-IV. Respondents who indicated that they had had ADHD in childhood were then asked an additional question—whether they continued to have any ADHD symptoms. Of the 3,199 participants, 3 percent were found to have had childhood ADHD as well as current ADHD symptoms.Then 154 of the 3,199 participants—representing an oversampling of those with adult ADHD symptoms—were assessed in reappraisal interviews for adult ADHD. These interviews were conducted by clinical psychologists who used the Adult ADHD Clinical Diagnostic Scale. Although there is no standard method for diagnosing adult ADHD, this scale has been used in adult-ADHD clinical trials.Kessler and his team then used both the initial interview results and the reappraisal-interview results to derive an estimated prevalence of adult ADHD for the entire sample of 3,199 participants. The estimate prevalence they obtained was 4 percent.Few Get TreatmentMoreover, Kessler and his colleagues learned, survey participants who had adult ADHD were more often male than female; were often unemployed, no longer married, and impaired in such areas as thinking, taking care of themselves, and getting about; and often had other mental illnesses, notably anxiety, depression, a substance use disorder, or intermittent explosive disorder.Only 10 percent of those diagnosed with adult ADHD were receiving treatment for it. This is a much lower percentage than the number of Americans being treated for anxiety, mood, and substance use disorders.Their results, Kessler and his coworkers noted, make one wonder whether treatment of adult ADHD might mitigate the mental illnesses that often accompany the condition. After all, they explained, a diagnosis of adult ADHD requires that at least some of the symptoms of ADHD began before the age of 7, so the mental conditions that often accompany it probably occurred at a later age and perhaps in response to the ADHD.Indeed, the researchers pointed out, successful treatment of ADHD in children often reduces the symptoms of mental disorders that frequently occur along with ADHD.Taken together, Kessler and his team concluded, their results regarding adult ADHD were mostly what they had expected. However, one finding did surprise them—a lower prevalence of adult ADHD among blacks and Hispanics than among whites. This outcome, they reasoned, could reflect true racial or ethnic differences or perhaps a greater acceptance of ADHD symptoms by blacks and Hispanics.More Screening Needed“This is a well-designed, cross-sectional study of the prevalence of adult ADHD,” Tony Rostain, M.D., director of education in the University of Pennsylvania Department of Psychiatry and an adult ADHD authority, told Psychiatric News. “The authors used rigorous methods to screen and interview 154 respondents in order to determine the rate of ADHD diagnosis, as well as demographic correlates and comorbid disorders seen in subjects with ADHD.“Their finding that 4.4 percent of the adult population meets criteria for ADHD is credible, as are the findings of significantly increased rates of depression, anxiety, substance abuse, and intermittent explosive disorder in this group. Finally, the low rates of treatment for ADHD that these patients are receiving underscores the importance of careful screening for the disorder, especially in adult patients being treated for depression, anxiety, and substance abuse.”The National Comorbidity Survey Replication was funded by the National Institute of Mental Health, the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the John W. Alden Trust. Additional support for the adult ADHD assessments came from a grant from Eli Lilly and Co.“The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/4/716>.▪ ISSUES NewArchived

Patterns and Predictors of Attention-Deficit/Hyperactivity Disorder Persistence into Adulthood: Results from the National Comorbidity Survey Replication

Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood. A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders). Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD. No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.

Adults with Attention Deficit Hyperactivity Disorder

This paper is a discussion of the experience of adult attention deficit hyperactivity disorder (ADHD). While much is known about the diagnosis and treatment of childhood ADHD, therapists may be less familiar with the clinical signs of adult ADHD and fail to detect and address such deficits in patients. Adult ADHD often affects all occupational domains-work/school, family life, social relationships, and self-organization-often without the person's awareness of the condition. When people with ADHD do not receive a formal diagnosis until adulthood, deficits in the above occupational domains may be severe. The first half of this paper describes (a) clinical presentation; (b) classification; prevalence, adult course, and comorbid conditions; (c) biologic factors; and (d) pharmacologic treatment. The latter half discusses occupational therapy intervention and describes a case study involving a college student.

The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population

A self-report screening scale of adult attention-deficit/hyperactivity disorder (ADHD), the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed in conjunction with revision of the WHO Composite International Diagnostic Interview (CIDI). The current report presents data on concordance of the ASRS and of a short-form ASRS screener with blind clinical diagnoses in a community sample. The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions that were selected based on stepwise logistic regression to optimize concordance with the clinical classification. ASRS responses were compared to blind clinical ratings of DSM-IV adult ADHD in a sample of 154 respondents who previously participated in the US National Comorbidity Survey Replication (NCS-R), oversampling those who reported childhood ADHD and adult persistence. Each ASRS symptom measure was significantly related to the comparable clinical symptom rating, but varied substantially in concordance (Cohen's kappa in the range 0.16-0.81). Optimal scoring to predict clinical syndrome classifications was to sum unweighted dichotomous responses across all 18 ASRS questions. However, because of the wide variation in symptom-level concordance, the unweighted six-question ASRS screener outperformed the unweighted 18-question ASRS in sensitivity (68.7% v. 56.3%), specificity (99.5% v. 98.3%), total classification accuracy (97.9% v. 96.2%), and kappa (0.76 v. 0.58). Clinical calibration in larger samples might show that a weighted version of the 18-question ASRS outperforms the six-question ASRS screener. Until that time, however, the unweighted screener should be preferred to the full ASRS, both in community surveys and in clinical outreach and case-finding initiatives.

Accuracy of adult recall of childhood attention deficit hyperactivity disorder.

Although reports of childhood status are necessary for making a diagnosis of adult attention deficit hyperactivity disorder (ADHD), systematic investigation of the accuracy of retrospective self-reports has been limited. This study examined accuracy of adult recall of childhood ADHD. Participants were from a controlled, prospective 16-year follow-up of children with ADHD. At a mean age of 25 years, 176 probands (85% of the 207 subjects in the initial cohort) and 168 non-ADHD comparison subjects were interviewed by clinicians who were unaware of the subjects' childhood status. Subjects were asked about specific childhood ADHD behaviors, and the diagnosis of childhood ADHD was retrospectively established. Seventy-eight percent of the probands and 11% of the comparison subjects were identified as having childhood ADHD. Six symptoms demonstrated high discriminating power in differentiating the subject groups: distractibility, concentration difficulties, complaints of inattention, acting before thinking, being on the go, and fidgeting/squirming. When findings were adjusted for the prevalence of ADHD in the general population, the power of prediction was low. Positive predictive value was 0.27, i.e., of all adults retrospectively given a diagnosis of childhood ADHD, only 27% would be correctly identified. As expected, positive predictive value increased with increases in the estimated prevalence of ADHD. Retrospective diagnoses of childhood ADHD made on the basis of self-reports will in most cases be invalid in settings such as epidemiological surveys and primary care facilities. Greater accuracy can be expected in settings in which childhood ADHD is frequent. The results stress the importance of obtaining contemporaneous information on childhood symptoms in establishing a childhood history of ADHD. Future directions and implications for DSM-V are discussed.

Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment

In this study, 281 cocaine abusers seeking treatment were assessed for adult attention-deficit hyperactivity disorder (ADHD). Structured assessments included the SCID for DSM-IV, a SCID-like module for ADHD, and a pattern of drug use questionnaire. The sample consisted of 82% men, 67% African-Americans, 19% Hispanics, and 14% Caucasians identified at several treatment sites. Average age was 33.7±.4 years. Twelve percent ( n=34) of the sample met DSM-IV criteria for childhood ADHD. Of the entire sample, 10% ( n=27), or 79% of the patients diagnosed with childhood ADHD, had adult ADHD. A history of conduct disorder and antisocial personality disorder were prevalent among those with adult ADHD (63% and 52%, respectively). This subpopulation of cocaine abusers may be one of the most difficult-to-treat cocaine-abusing groups, particularly if the ADHD remains undetected. To provide effective treatment for cocaine abusers, clinicians may need to identify subpopulations of patients, such as those with ADHD, and target both pharmacologic and nonpharmacologic interventions for these groups.