Wender-Reimherr Adult Attention Deficit Disorder Scale Research Articles

Eating disorders and emotional dysregulation are associated with insufficient weight loss after bariatric surgery: a 1-year observational follow-up study

PurposeSubjects with obesity, especially those seeking bariatric surgery, exhibit high rates of mental disorders and marked psychopathological traits. The primary objective of this prospective, non-interventional study was to investigate whether the presence of different psychiatric disorders, attention deficit/hyperactivity disorder (ADHD) symptomatology and emotional dysregulation influenced weight loss at 1-year follow-up after surgery.MethodsSubjects consecutively referred for pre-surgical evaluation at the Obesity Center of Pisa University Hospital were recruited. Psychiatric diagnoses were made through the Mini-International Neuropsychiatric Interview (MINI) and ADHD symptomatology was assessed with the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). Emotional dysregulation was investigated through the WRAADDS and self-report questionnaires. After surgery, weight and obesity-related comorbidities were monitored during follow-up.ResultsOf the 99 participants recruited, 76 underwent surgery and 65 could be reevaluated 1 year after surgery. Subjects with insufficient weight loss (excess body mass index loss ≤ 53%, n = 15) had more frequent lifetime binge eating disorder (BED) and BED-mood disorders comorbidity than subjects with favorable post-surgical outcome. Additionally, they scored higher on both physician-administered and self-report scales assessing emotional dysregulation, which represents a nuclear symptom of ADHD in adults. At the logistic regression analysis, older age, higher preoperative excess body mass index and greater affective instability were predictors of reduced weight loss at 1-year follow-up.ConclusionEmotional dysregulation seems to be associated with a worse outcome after bariatric surgery. Further studies with larger samples and longer follow-up are needed to confirm the influence of different psychiatric disorders and psychopathological traits on post-surgical outcome.Level of evidenceV, prospective descriptive study.

The Use of Brexpiprazole Combined With a Stimulant in Adults With Treatment-Resistant Attention-Deficit/Hyperactivity Disorder.

This is the first controlled pharmacologic study in either adults or children with uncomplicated, treatment-resistant attention-deficit/hyperactivity disorder (ADHD). This study augmented stimulant therapy with the atypical antipsychotic brexpiprazole. The Food and Drug Administration preapproved primary outcome measure (Conners' Adult ADHD Rating Scale [CAARS]) showed no drug-placebo differences. Often studies showing no efficacy on the prestudy, defined primary outcome variable go unpublished. While this is decried, publishing studies with equivocal results remains rare. This reanalysis highlights trends in secondary measures having implications for treatment and research regarding treatment resistant ADHD. Initially, 559 stimulant-naive and 174 prior stimulant nonresponders received methylphenidate osmotic-release oral system, dexmethylphenidate hydrochloride, lisdexamfetamine, or mixed amphetamine salts. After 5 weeks, 168 stimulant-naive patients and 68 prior stimulant nonresponders who failed treatment were randomized to brexpiprazole or placebo in a 2:1 ratio while the remaining were on the stimulant. Outcome was measured with the CAARS, Montgomery-Asberg Depression Rating Scale, Beck Depression Inventory, Clinical Global Impression, and the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). The WRAADDS contains 2 factors: attention and emotional dysregulation. Stimulant-naive patients showed no improvement with adjunctive brexpiprazole. Prior stimulant nonresponders displayed no brexpiprazole effect on the CAARS, Montgomery-Asberg Depression Rating Scale, or Beck Depression Inventory. In contrast, the WRAADDS detected a trend in treatment benefit, primarily through emotional dysregulation symptoms. Adverse effects on brexpiprazole and placebo were equivalent. Brexpiprazole might be effective in ADHD adults who are nonresponders to 2 or more stimulants. Future trials in treatment-resistant ADHD should use a 1:1 randomization and use a measure of ADHD symptoms that includes emotional dysregulation.

Types of Adult Attention-Deficit/Hyperactivity Disorder: A Replication Analysis.

Research supports the importance of emotional symptoms in adults with attention-deficit/hyperactivity disorder (ADHD), which are not reflected in the DSM-5 or ICD-10 criteria. The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) assesses these symptoms, plus inattention, hyperactivity, and impulsivity. This scale allowed us to divide adult ADHD into 2 subtypes in a 2015 publication: ADHD inattentive presentation and ADHD emotional dysregulation presentation. The present study refines this observation using a larger, more diverse sample. Eight double-blind adult ADHD clinical trials (encompassing 1,490 subjects) were selected because they included assessment with the WRAADDS; a second, alternative ADHD measure; and the Clinical Global Impressions-Severity of Illness scale (CGI-S). These data were subjected to confirmatory factor analyses, and ADHD presentations were compared, including treatment response. The original factor structure fit poorly with these new data. However, an alternative 2-factor solution fit both the original and the new subjects. ADHD inattentive presentation (n = 774) was defined by the inattention factor, and ADHD emotional dysregulation presentation (n = 620) was defined by additional elevation of the emotional dysregulation factor. The proportion of ADHD emotional dysregulation presentation ranged from 25% to 73% across the 8 studies. The emotional dysregulation presentation was associated with both a greater severity as measured by the CGI-S (P < .001) and more manifestations of childhood ADHD as measured by the Wender Utah Rating Scale (P < .001). Factor analytic results supported the validity of 2 adult ADHD presentations based on levels of emotional dysregulation. This system offers a more clinically relevant approach to the diagnosis of ADHD in adults than does the DSM system.

Types of Adult Attention-Deficit Hyperactivity Disorder (ADHD): A Replication Analysis

Background: Research supports the importance of emotional symptoms in ADHD adults, symptoms not reflected in the DSM-5 or IDC-10 criteria. The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) assesses these symptoms, plus inattention, hyperactivity and impulsivity. This range of ADHD symptoms allowed us to divide adult ADHD into two subtypes in a 2015 publication: ADHD Inattentive presentation and ADHD Emotional dysregulation presentation. In the present study, we refine this observation using a larger, more diverse sample. Methods: WRAADDS data from additional clinical trials (1,493 subjects) were subjected to confirmatory factor analyses and ADHD presentations were compared, including treatment response. Outcome: Our original factor structure fit poorly with these new data. However, an alternative 2 factor solution fit both the original and the new subjects. ADHD Inattentive presentation was defined by the Inattention factor. ADHD Emotional dysregulation presentation was defined by additional elevation of the Emotional Dysregulation factor. The proportion of ADHD Emotional Dysregulation Presentation ranged from 30 to 70% across the 8 studies and it was associated with both a greater severity as measured by the Clinical Global Impression-Severity scale and more manifestations of childhood ADHD as measured by the Wender Utah Rating Scale. Interpretation: Factor analytic results supported the validity of two adult ADHD presentations based on levels of emotional dysregulation. This system offers a more clinically relevant approach to the diagnosis of ADHD in adults than does the DSM system. Funding Statement: Data came from clinical trials supported by Eli Lilly, Glaxo-Welcome, NIMH, Shire, McNeil PPPC, and Medice. This reanalysis was funded by the authors. Declaration of Interests: None of the authors have a financial interest that will be affected by the results of this article. Ethical Approval Statement: The authors selected published clinical trials of psychotropic medications used to treat ADHD in adults conducted using similar protocols. All met Declaration of Helsinki ethical criteria and were approved by relevant research review boards.

Revising the diagnostic criteria for Attention-Deficit Hyperactivity Disorder (ADHD): an adulthood perspective.

Over the several decades since the publication of the DSMIII (American Psychiatric Association 1980), the diagnosis of ADHD in adults has been imbued with uncertainty. At that time, it was thought to be a disorder confined to childhood and consequently the criteria focused on children between the ages of 6–12. These criteria, involving both observable behaviors and reported symptoms, fit this age group quite well, but are not easily applied to either older adolescents or adults. Most other adult DSM diagnoses are based on symptom areas, not specific behaviors, making the application of the DSM ADHD criteria to adults an oddity. In the late 1970s and 1980s at the University of Utah in the United States (Wender et al. 1981; Wood et al. 1976), we started to publish studies of adults with ADHD and noted that many of these patients had problems beyond the accepted inattention, hyperactivity and impulsivity symptoms seen in children. With the publication of the Utah Criteria for the diagnosis of ADHD in 1985 (Wender et al. 1985), we tried to clarify and specify the kinds of problems with emotionality encountered in adults. We then began to develop the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) to help define more precisely the mood lability, temper control and emotional over-reactivity that we found in our adults with ADHD. Both the criteria and the corresponding scale included a variety of emotional symptoms. In addition, both presented ADHD criteria as problem areas, not narrowly defined behaviors. In the 1990s, we published the widely accepted Wender Utah Rating Scale (Ward et al. 1993), which was devised to retrospectively identify childhood characteristics associated with ADHD. It encompasses symptoms, including emotionality, which have been associated with the persistence of ADHD into adulthood. In the early 2000s, publications from the Multimodal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study, which dealt with children exclusively, helped define more severe ADHD, which frequently included emotional and oppositional symptoms (Jensen et al. 2001). In fact, 70 % of these patients, all with Combined Type ADHD, had emotional and/or oppositional symptoms. Analyzing data in 2005 from a large multicenter study, we used the WRAADDS to define a subset of adult ADHD patients with high levels of emotional symptoms, which we labeled as ‘‘ADHD related emotional dysregulation’’ (Reimherr et al. 2005). These patients were more impaired than others in the sample and were highly responsive to treatment. Since then multiple well-respected researchers from Europe, the United States and more globally have documented the ongoing emotional symptoms in both pediatric and adult ADHD, and numerous reports support the position that emotional symptoms are integral to ADHD. F. W. Reimherr Department of Psychiatry, University of Utah School of Medicine and Psychiatric and Behavioral Solutions, 1522 South 1100 East, Salt Lake City, UT 84105, USA

The Effect of Personality Disorder Symptoms on Response to Treatment With Methylphenidate Transdermal System in Adults With Attention-Deficit/Hyperactivity Disorder

This trial was designed to prospectively explore the relationship among personality disorder (PD) symptoms, attention-deficit/hyperactivity disorder (ADHD), and treatment response in a randomized, double-blind, crossover clinical trial of methylphenidate transdermal system (MTS) and to confirm results of a prior exploratory study. 67 adults who met the Utah and/or DSM-IV-TR criteria for ADHD were recruited with no attempt to include or exclude patients with PD. Responders were defined by a 50% improvement on the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), the primary outcome measure. Personality disorder was diagnosed by the clinicians using the Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders Questionnaire, several self-report scales, and clinical observations. Subjects were categorized as: no PD (PD-negative), 1 PD (PD-positive), and 2 or more PDs (PD-plus). The study was conducted from February 2007 to December 2009 at the Mood Disorders Clinic at the University of Utah School of Medicine, Salt Lake City. 37% (n = 25) were PD-positive, and another 27% (n = 18) were PD-plus. In those with a PD, 65% (n = 28) had a cluster C diagnosis, 44% (n = 19) cluster B, and 5% (n = 12) cluster A. PD-plus subjects had significantly higher levels of oppositional defiant disorder (ODD) symptoms (P = .007) and emotional dysregulation (P = .004). 71% (15/21) of the PD-positive and PD-negative subjects were responders in the MTS arm (P < .001) as opposed to 38% (6/16) of the PD-plus subjects (P = .24). Conversely, the interaction between treatment (placebo versus MTS) and the 3 PD groups was not statistically significant (P = .46) when the total WRAADDS was used as the outcome measure. Personality disorder status was associated with more complex ADHD, especially high levels of emotional dysregulation and ODD symptoms. There was a significant treatment effect for PD-positive and PD-negative, but not PD-plus subjects. ClinicalTrials.gov identifier: NCT00506285.

Long-term open-label response to atomoxetine in adult ADHD: influence of sex, emotional dysregulation, and double-blind response to atomoxetine

A three-year open-label study of atomoxetine in adults with ADHD followed two multicenter, double-blind trials. In the double-blind trials, female gender and higher levels of emotional symptoms were associated with better outcome. Following a 4-week placebo washout period, 384 (of 536) subjects continued into the open-label study. 61% of subjects entering this open-label study remained after 6months at an average dose of 100mg/day. Subjects who had previously responded to double-blind atomoxetine achieved maximum response after 8weeks of open-label medication, but others continued to improve for 36weeks. Women improved more (7.7±6.4) than men (6.1±6.4) on the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) (P=.007) and the Conners' Adult ADHD Rating Scale (P=.03). Subjects with emotional dysregulation improved more than others on the WRAADDS (P=.001). Responders ultimately improved approximately 60% in attentional, hyperactive/impulsive, and emotional symptoms. Thirty-nine percent of atomoxetine double-blind non-responders became responders during open-label treatment.

Multiscale assessment of treatment efficacy in adults with ADHD: A randomized placebo-controlled, multi-centre study with extended-release methylphenidate

Objectives. This trial was performed to test the efficacy and safety of an extended-release formulation of methylphenidate (MPH ER). Methods. A total of 162 adults with ADHD according to DSM-IV were treated for 8 weeks with either two daily individually body weight-adjusted doses of MPH ER up to 1 mg/kg per day (N = 84) or placebo (N = 78). The primary efficacy outcome was the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) 8 weeks after randomization. Secondary efficacy measures were the ADHD Diagnostic Checklist (ADHD-DC), the Conners Adult Attention Deficit Disorder Scale (CAARS-S:L), the Clinical Global Impression (CGI) and the Sheehan Disability Scale (SDS). Results. At week 8 a significantly higher decline of the total WRAADDS score was found in the MPH ER group as compared to the placebo group (P = 0.0003). The rates of responders were 50% in the MPH ER and 18% in the placebo group (P < 0.0001). Furthermore, similar effects were observed for the secondary efficacy variable: ADHD-DC score (P = 0.004), CAARS-S:L score (P = 0.008) and the SDS score (P = 0.017). 50% of the MPH ER group and 24.4% of the placebo group were improved “much” or “very much” according to the CGI rating (P = 0.0001). MPH ER treatment was well tolerated. At week 2 also the mean heart rate was significantly higher in the MPH ER group as compared to the placebo group (P = 0.01). No differences between the study groups were observed regarding mean blood pressure at any visit. Conclusions. This clinical trial demonstrated statistically significant and clinical relevant effects of MPH ER in adults with ADHD for several self- and investigator-rated ADHD psychopathology and also functional efficacy measures.

Twenty-four-week treatment with extended release methylphenidate improves emotional symptoms in adult ADHD

Objectives. Treatment investigations with methylphenidate in adults with ADHD focus preferentially on the classical psychopathology: inattention, hyperactivity and impulsivity. ADHD-associated emotional symptoms, which are frequently present at least in ADHD subpopulations, were studied rarely. The vast majority of the placebo-controlled trials had observation periods between 4 and 8 weeks. To assess the medium- to long-term effects of extended release methylphenidate (MPH-ER) on emotional symptoms and other psychopathology frequently seen in ADHD patients, we conducted a large-scale, multicenter treatment study. Methods. We performed a randomised, 24-week, double-blind, placebo-controlled study in adults with ADHD. The diagnosis was made on the basis of the DSM-IV criteria, which were confirmed by clinical history and a structured psychopathological interview and the use of rating instruments. 363 patients were randomized to MPH-ER or placebo at a ratio of 2:1. The duration of the titration period was 5 weeks followed by a maintainance phase of 19 weeks. The efficacy measures were the observer rated 10-item Emotional Dysregulation Scale (EDS) derived from the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) and a self-report, six-item Emotional Lability Scale (ELS) extracted from the long version of the Conners Adult ADHD Self Report Scale (CAARS:S:L). In addition we used the SCL-90-R for the assessment of ADHD associated and comorbid psychopathology. Results. MPH-ER was statistically superior to placebo in reducing emotional symptoms as assessed by the EDS and the ELS. Obsessive-compulsive symptoms and those of problems with self-concept declined until the end of the observation period. The decline was more pronounced in MPH-ER treated individuals. The effects remained robust during the entire maintenance period until week 24. Symptoms of anxiety, depression, anger and hostility, phobia, paranoid ideations and psychoticism were not improved. Conclusions. MPH-ER appears to be an efficacious treatment for emotional symptoms with ADHD. Also obsessive-compulsive symptoms and problems with self-concept were affected positively.

S15-04 - Do symptoms of emotional dysregulation respond to pharmacological treatment of adult ADHD?

The core psychopathology of ADHD comprises attentional deficits, hyperactivity and impulsivity. At least in subpopulations the majority of individuals suffering from ADHD present with emotional symptoms additonally. There is an ongoing and controversial debatte whether emotional symptoms belong to the disorder as further intrinsic ADHD psychopathology or may have their origin in comorbid affective disorders. There is growing evidence that emotional symptoms of ADHD as measured by the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) respond to treatment with Methylphenidate (MPH), while the classical symptoms of depression or anxiety disorder show no significant improvement.We report on a 24-week, placebo controlled treatment study with MPH-extended release in 359 adults with ADHD. Emotional symptoms were assessed with the WRAADDS. Symptoms of depression and anxiety were endorsed by use of the Symptom Checklist-90-Revised (SCL-90-R).As compared with placebo we found a significant treatment response in favour of MPH-ER regarding emotional symptoms like affective lability, emotional overreactivity and temper control. The psychopathology of depression and anxiety did not display a significant treatment response.

S15-02 - Is emotional dysregulation part of the psychopathology of adult ADHD?

The dimensions of ADHD symptoms in adults have been discussed controversially. Beside the classical symptom domains as unattention, hyperactivity, and impulsivity, other symptom clusters as emotional dysregulation are in debate. The aim of this presentation is to update the recent discussions on this topic by reviewing current positions and empirical data as well as presenting own data. The relationship between the scales with emotional contents in the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) compared to other established ADHD rating scales was explored in a sample of 600 ADHD patients. The aim is to clarify whether the symptoms are independent of other ADHD domains.

A randomised, placebo-controlled, 24-week, study of low-dose extended-release methylphenidate in adults with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) affects many adults who had ADHD in childhood. Although stimulants and methylphenidate in particular are a common off-label treatment for adult patients with ADHD in European countries, little is known about their long-term efficacy and safety. A randomized, 24-week double-blind, placebo-controlled, parallel-design study of extended-release methylphenidate (MPH ER) in 359 adult individuals with ADHD according to DSM-IV. Standardized instruments were used for diagnosis. Treatment was started with MPH ER doses of 10 mg/day and titrated up to 60 mg/day, depending on individual efficacy and tolerability. Mean daily MPH SR dose was 0.55 mg/kg. Treatment with MPH ER resulted in clinical and statistically significant reductions of ADHD symptoms rated with the Wender-Reimherr adult attention deficit disorder scale (WRAADDS) and symptoms of inattention and hyperactivity/impulsivity according to DSM-IV, respectively. Improvements were maintained significant versus placebo up to week 24 of treatment. At endpoint, 61% of the subjects receiving MPH ER were rated as responders according to the a priori definition of response of more than 30% reduction of the WRAADDS score, compared to 42% in the placebo group. The second defined response criterion of much or very much improved on the clinical global impression scale (CGI) was fulfilled by 55% of subjects receiving MPH ER and 37% of subjects receiving placebo. MPH ER treatment was associated with a statistically significant increase of pulse at week 4 (72 bpm at baseline, 77 bpm at week 4). There were no significant differences of heart rate or blood pressure between treatment and placebo groups at any time point. MPH ER treatment in low to moderate doses was effective and safe in the treatment of ADHD in adults. Efficacy measures were clinical and statistically significant and robustly sustained during the 24-week observation period. In this study, no clinical significant effects on blood pressure but a transient increase of the heart rate were found. The interpretation of the results is limited by the low dose-range used in this study, the high drop-out rate and placebo-response which might have affected the therapeutic effect size.

Differences at brain SPECT between depressed females with and without adult ADHD and healthy controls: etiological considerations

BackgroundComorbidity between Attention Deficit Hyperactivity Disorder (ADHD) and mood disorders is common. Alterations of the cerebellum and frontal regions have been reported in neuro-imaging studies of ADHD and major depression.MethodsThirty chronically depressed adult females of whom 16 had scores below, and 14 scores above, cut-offs on the 25-items Wender Utah Retrospective Scale (WURS-25) and the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) were divided into subgroups designated "Depression" and "Depression + ADHD", respectively. Twenty-one of the patients had some audiological symptom, tinnitus and/or hearing impairment. The patients were investigated with other rating scales and 99mTc-HMPAO SPECT. Controls for 99mTc-HMPAO SPECT were 16 healthy females. SPECT was analyzed by both statistical parametric mapping (SPM2) and the computerized brain atlas (CBA). Discriminant analysis was performed on the volumes of interest generated by the CBA, and on the scores from rating scales with the highest group differences.ResultsThe mean score of a depression rating scale (MADRS-S) was significantly lower in the "Depression" subgroup compared to in the "Depression + ADHD" subgroup. There was significantly decreased tracer uptake within the bilateral cerebellum at both SPM and CBA in the "Depression + ADHD" subgroup compared to in the controls. No decrease of cerebellar tracer uptake was observed in "Depression". Significantly increased tracer uptake was found at SPM within some bilateral frontal regions (Brodmann areas 8, 9, 10, 32) in the "Depression + ADHD" subgroup compared to in "Depression". An accuracy of 100% was obtained for the discrimination between the patient groups when thalamic uptake was used in the analysis along with scores from Socialization and Impulsivity scales.ConclusionThe findings confirm the previous observation of a cerebellar involvement in ADHD. Higher bilateral frontal 99mTc-HMPAO uptake in "Depression + ADHD" compared to in "Depression" indicate a difference between these subgroups. 99mTc-HMPAO uptake mechanisms are discussed.

Gender Differences in 2 Clinical Trials of Adults With Attention-Deficit/Hyperactivity Disorder

Studies show that, in childhood attention-deficit/hyperactivity disorder (ADHD), boys have the combined type with externalizing behaviors more frequently, and girls have the inattentive type with increased internalizing disorders more frequently. This study explored gender differences in adults with ADHD in 2 large, placebo-controlled, multicenter studies conducted from 2000 to 2001. Information collected included 2 measures of ADHD, multiple psychological measures, general physical symptoms, and treatment response. Thirty-four percent of the subjects were female. Women were rated as more impaired on every measure of ADHD symptoms including total Conners' Adult ADHD Rating Scale-Investigator Format (CAARS-INV), total Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), and most subscales of both measures. More women (75%) had combined type compared with men (62%). Women showed a more complex presentation, with higher scores on the Hamilton Rating Scale for Anxiety (HAM-A) and the Hamilton Rating Scale for Depression, 17-item version (HAM-D(17)), more sleep problems, and more past DSM-IV Axis I diagnoses. Both sexes displayed substantial impairment on 3 Psychological General Well-Being Schedule factors: tension-anxiety, life satisfaction, and vitality-drive. Women experienced significantly (p = .003) greater rates of emotional dysregulation (37%) versus men (29%) as defined by a cluster of symptoms on the WRAADDS. The emotional dysregulation factor is derived by combining 3 symptoms--temper control, mood lability, and emotional overreactivity--from the Utah Criteria for ADHD in adults. These symptoms are considered associated symptoms in the DSM-IV description of ADHD. Women also experienced greater improvement (p = .011) on this symptom factor. In contrast to the results from childhood studies, women were more impaired than men on ADHD scales in our study. The higher level of emotional symptoms and more complicated presentation in women may obscure the diagnosis of ADHD. Thus, the assessments of adults with ADHD should include an exploration of the emotional dimensions of the illness.

A Double-Blind, Placebo-Controlled, Crossover Study of Osmotic Release Oral System Methylphenidate in Adults With ADHD With Assessment of Oppositional and Emotional Dimensions of the Disorder

The realization that attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood has led to increased frequency of diagnosis and treatment in adults. Osmotic release oral system (OROS) methylpheni-date is a long-acting stimulant demonstrated to be effective in the treatment of children and adolescents with ADHD. Forty-seven adults entered and 41 completed this double-blind, placebo-controlled, crossover trial of OROS methylphenidate. Each double-blind arm lasted 4 weeks; data were collected from August 2004 through December 2005. Subjects met both DSM-IV-TR and Utah Criteria for ADHD in adults. Outcome measures included the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS), the adult ADHD-Rating Scale (ADHD-RS), and the Clinical Global Impressions-Improvement scale (CGI-I). At baseline, subjects were categorized as having significant emotional symptoms with the WRAADDS and/or significant oppositional-defiant symptoms using a self-report scale assessing the DSM-IV criteria for oppositional defiant disorder. 17% of the sample (N = 8) had ADHD alone, 38% (N = 18) had ADHD plus significant emotional symptoms, and 40% (N = 19) had ADHD with both significant emotional and oppositional symptoms. At a mean +/- SD dose of 64.0 +/- 23.3 (0.75 mg/kg), OROS methylphenidate proved superior to placebo for all clinical measures: total WRAADDS score decrease of 42% versus 13%, respectively, p < .001 and total ADHD-RS score decrease of 41% versus 14%, respectively, p = .003, plus the subscales addressing inattention, hyperactivity/ impulsivity, and emotional dysregulation. OROS methylphenidate proved effective in treating adult ADHD. ADHD alone was relatively uncommon. Over 80% of our patients had ADHD with a combination of emotional and/or oppositional symptoms.

Emotional Dysregulation in Adult ADHD and Response to Atomoxetine

Before 1980, attention-deficit/hyperactivity disorder (ADHD) was called minimal brain dysfunction and included emotional symptoms now listed as "associated features" in DSM-IV. Data from two multicenter, placebo-controlled studies with 536 patients were reexamined to assess: 1) the pervasiveness of these symptoms in samples of adults with ADHD; 2) the response of these symptoms to atomoxetine; and 3) their association with depressive/anxiety symptoms. The Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) was used to assess temper, affective lability, and emotional overreactivity, thus identifying patients exhibiting "emotional dysregulation." Other DSM-IV Axis I diagnoses were exclusionary. Outcome measures were the Conners' Adult ADHD Rating Scale (CAARS) and the WRAADDS. Thirty-two percent of the sample met post hoc criteria for emotional dysregulation and had higher baseline scores on ADHD measures, a lower response to placebo, and greater response to atomoxetine (p = .048). Symptoms of emotional dysregulation had a treatment effect (p < .001) at least as large as the CAARS (p = .002) and the total WRAADDS (p = .001). Emotional dysregulation was present in the absence of anxiety or depressive diagnosis. Symptoms of emotional dysregulation were present in many patients with ADHD and showed a treatment response similar to other ADHD symptoms.