Subtype differences in adults with attention-deficit/hyperactivity disorder (ADHD) with regard to ADHD-symptoms, psychiatric comorbidity and psychosocial adjustment

Adult attention-deficit/hyperactivity disorder and nicotine use: a qualitative study of patient perceptions

BACKGROUND

Adult Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with high rates of comorbid substance use disorders, and cigarette smoking has a particularly high prevalence in this population. However, there is an ongoing debate as to whether this tobacco use is an attempt at "self-medication" or due to behavioral disinhibition. There is a surprising lack of qualitative studies that investigate the subjective perceptions of adults with ADHD regarding cigarette smoking. The present study was designed to fill this gap in the literature.

METHODS

We recruited twelve adult patients with ADHD and comorbid tobacco use from our ADHD consultation service, an outpatient facility of the Zurich University Psychiatric Hospital. Subjects were interviewed using qualitative methodology, and Mayring's qualitative content analysis was used to evaluate findings.

RESULTS

We identified two explanatory models linking ADHD and tobacco use: smoking as an attempt at self-medication and "smoking as a social behavior". On one hand, subjects considered tobacco a therapeutic aid, reporting positive effects on "inner tension" and cognitive function, and noted possible antidepressant properties as well. On the other hand, subjects considered smoking to enhance social functioning and to have a positive impact on interpersonal relationships. The majority believed that stimulant medications offered only a transient decrease in patterns of tobacco use because their ability to reduce nicotine cravings wore off quickly. Others believed that stimulants had no effect or even reinforced cigarette use.

CONCLUSIONS

Participants had different views about the link between cigarette smoking and ADHD. While the majority thought of nicotine as a sort of therapy, viewing smoking as a way to self-medicate symptoms of ADHD, motivations for nicotine use were also related to self-image, desire to belong to a peer-group, and a drive to undermine perceived social norms. Ultimately, these findings can be used by clinicians to improve treatment alliance and collaboration.

Early-age clinical and developmental features associated to Substance Use Disorders in Attention-Deficit/Hyperactivity Disorder in Adults

OBJECTIVE

The main objective was to explore early-age conditions associated to Substance Use Disorders (SUD) in adults with Attention Deficit/Hyperactivity Disorder (ADHD); secondly, to determine which of those conditions are specific to ADHD subjects; and finally, to compare ADHD and non-ADHD subjects in terms of SUD lifetime prevalence and professional, social and personal adjustment.

METHOD

Comparison between ADHD adults with (n=236) and without lifetime SUD (n=309) regarding clinical characteristics of ADHD, externalization disorders, temperamental traits, environmental factors, academic history and family psychiatric history; secondly, ADHD subjects were compared to a non-ADHD group (n=177) concerning those variables.

RESULTS

The following variables were found to be positively associated to SUD in ADHD subjects: ADHD severity, CD and ODD comorbidities, temperamental characteristics ("fearful", "accident prone" and "frequent temper tantrums"), "sexual abuse", "be suspended from school", family history of SUD and ADHD, and male gender; ADHD inattentive subtype and "fearful" were inversely associated to SUD. From those variables, "frequent temper tantrums" was also associated to SUD in non-ADHD subjects. ADHD subjects had higher prevalence of lifetime SUD and greater professional, social and personal impairment than non-ADHD subjects.

CONCLUSION

Findings suggest a significant association between ADHD, SUD and early-age conditions, such as CD and ODD comorbidity; other variables from childhood, namely, ADHD subtype, temper characteristics ("fearful", "accident prone"), "sexual abuse", "be suspended from school" and family history of ADHD are associated to SUD in ADHD subjects, but not in non-ADHD subjects. Moreover, this study confirms both the higher prevalence of lifetime SUD and greater professional, social and personal impairment in ADHD subjects than in non-ADHD subjects.

Childhood and persistent ADHD symptoms associated with educational failure and long-term occupational disability in adult ADHD

Few studies have examined the impact of childhood attention deficit hyperactivity disorder (ADHD) symptoms on adult ADHD functional outcomes. To address this issue dimensionally, ADHD symptoms in childhood and adulthood and their relation to educational deficits and work disability are studied in a clinical sample of adult patients with previously untreated ADHD. About 250 adults diagnosed systematically with ADHD according to DSM-IV were prospectively recruited. Primary outcomes were high school dropout and being out of the work last year. Childhood ADHD symptoms, sex differences, comorbidities of other mental disorders, and adult ADHD symptoms were examined by historical data, clinician interviews, and questionnaires. High levels of ADHD symptom severity in childhood were related to dropping out of high school [odds ratio (OR) = 3.0], as were higher numbers of hyperactive-impulsive symptoms in childhood. Significantly, more women than men were long-term work disabled (OR = 2.0). After adjusting for age and gender, persisting high levels of ADHD inattention symptoms in adulthood (OR = 2.5), number of comorbid disorders, and particularly anxiety disorders were significantly related to long-term work disability. Childhood hyperactive-impulsive symptoms and overall severity of childhood ADHD symptoms were associated with high school dropout rates; however, persisting ADHD inattention symptoms and comorbid mental disorders in adulthood were more correlated to occupational impairment. These findings underline proposals for studies on early recognition and interventions for ADHD and psychiatric comorbidity. They further suggest that inattentive symptoms be a focus of adult ADHD treatment and that workplace interventions be considered to prevent long-term work disability.

Association between ADHD drug use and injuries among children and adolescents

To study the association between attention deficit hyperactivity disorder (ADHD) drug use and the incidence of hospitalization due to injuries. A random sample of 150,000 persons (0-18 years) was obtained from the Dutch PHARMO record linkage system. An ADHD medication cohort as well as an up to six age/sex/index date sampled control cohort with no history of ADHD drug use was formed. Differences in incidence of hospitalization due to injuries were stratified for age and sex and compared prior, during and after exposure on ADHD drugs. The overall incidence of hospital admissions for injuries was two times higher in the ADHD medication cohort [incidence rate ratios (IRR) 2.2 (95 % CI 1.6-2.9)]. The incidence rate for injuries during exposure to ADHD drugs was lower in the exposed period compared to the period prior to ADHD drug use, although the difference was not statistically significant [IRR 0.68 (95 % CI 0.29-1.60)]. The relative risk for injuries was almost five times higher in the ADHD medication cohort among those who concomitantly used other psychotropics [IRR 4.8 (95 % CI 1.4-16.9)]. Risk for injuries was highest in 12-18 years olds. Children and adolescents using ADHD medication showed a twofold risk for hospital admissions for injuries. ADHD drug use might diminish the increased injury risk, but still overall risk is higher than in age/sex sampled children and adolescents without treatment with ADHD drugs. Use of ADHD and concomitant psychotropics increases the risk for injuries compared to only ADHD drug use.

Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study

AIMS

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.

DESIGN

Data were obtained from the cross-sectional International ADHD in Substance use disorder Prevalence (IASP) study.

SETTING

Forty-seven centres of SUD treatment in 10 countries.

PARTICIPANTS

A total of 1205 treatment-seeking SUD patients.

MEASUREMENTS

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).

FINDINGS

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.

CONCLUSIONS

Treatment-seeking substance use disorder patients with attention deficit hyperactivity disorder are at a very high risk for additional externalizing disorders.

Analysis of individual items on the attention-deficit/hyperactivity disorder symptom rating scale in children and adults: the effects of age and sex in pivotal trials of lisdexamfetamine dimesylate

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) symptom presentation across age and sex has not been fully elucidated. The present post hoc analyses qualitatively explored the baseline levels of ADHD symptomatology across subgroups in two clinical trials of children and adults with ADHD to elucidate differences in participant presentation. The response to treatment was examined to determine patterns of response among items of the ADHD Rating Scale IV.

METHODS

Exploratory post hoc analyses of ADHD Rating Scale IV item scores were conducted on data from two 4-week placebo-controlled trials in children (6-12 years) and in adults (18-55 years) with ADHD. Baseline and endpoint mean item scores were determined for subgroups defined by age (6-9, 10-12, 18-39, and 40-55 years) and sex.

RESULTS

The baseline mean item scores were generally numerically similar for all age-by-sex subgroups. The inattention (IA) items were numerically higher than hyperactivity/impulsivity (H/I) items among older children and adults. The endpoint mean item scores were numerically lower after lisdexamfetamine dimesylate treatment for IA and H/I items in all subgroups.

CONCLUSION

These results suggest that regardless of age or sex, baseline IA and H/I symptom profiles were comparable; however, IA vs H/I symptoms were more severe in older participants. In all age-by-sex subgroups, IA and H/I symptoms appeared to decrease after active treatment.

Attention deficit/hyperactivity disorders with co-existing substance use disorder is characterized by early antisocial behaviour and poor cognitive skills

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD) is associated with an increased risk of co-existing substance abuse. The Swedish legislation on compulsory healthcare can be applied to persons with severe substance abuse who can be treated involuntarily during a period of six months. This context enables a reliable clinical assessment of ADHD in individuals with severe substance use disorder (SUD).

METHODS

In the context of compulsory care for individuals with severe SUD, male patients were assessed for ADHD, co-morbid psychiatric symptoms, psychosocial background, treatment history, and cognition. The data from the ADHD/SUD group (n = 60) was compared with data from (1) a group of individuals with severe substance abuse without known ADHD (SUD group, n = 120), as well as (2) a group with ADHD from an outpatient psychiatric clinic (ADHD/Psych group, n = 107).

RESULTS

Compared to the general SUD group in compulsory care, the ADHD/SUD group had already been significantly more often in compulsory care during childhood or adolescence, as well as imprisoned more often as adults. The most common preferred abused substance in the ADHD/SUD group was stimulant drugs, while alcohol and benzodiazepine abuse was more usual in the general SUD group. Compared to the ADHD/Psych group, the ADHD/SUD group reported more ADHD symptoms during childhood and performed poorer on all tests of general intellectual ability and executive functions.

CONCLUSIONS

The clinical characteristics of the ADHD/SUD group differed from those of both the SUD group and the ADHD/Psych group in several respects, indicating that ADHD in combination with SUD is a particularly disabling condition. The combination of severe substance abuse, poor general cognitive ability, severe psychosocial problems, including indications of antisocial behaviour, and other co-existing psychiatric conditions should be considered in treatment planning for adults with ADHD and SUD.

A randomized controlled multicenter trial on the multimodal treatment of adult attention-deficit hyperactivity disorder: enrollment and characteristics of the study sample

Adult ADHD is a frequent psychiatric disorder affecting relevant aspects of an individual's life. The aim of our study group was to carry out the first randomized controlled multicenter study to evaluate the effects of psychotherapy compared to clinical management in combination with psychopharmacological treatment with methylphenidate (MPH) or placebo (Plac) in a factorial four-arm design. Here, we present the enrollment procedure and description of adult ADHD patients recruited for the trial. Four hundred and thirty-three adult patients with ADHD were randomized at seven study sites in Germany to four treatment conditions: manualized dialectical-behavioral-therapy-based group psychotherapy (GPT) plus MPH or Plac, or clinical management (CM) including supportive counseling plus MPH or Plac with weekly sessions in the first 12 weeks and monthly sessions thereafter. Assessment for eligibility included standardized scales and instruments. After prescreening of 1,480 patients, 518 were evaluated for trial participation and 433 were randomized. The main reasons for prescreening failure were lack of interest in participating (n = 205), difficulties in meeting the time and effort requirements for participation (n = 186), and contraindications for psychopharmacological treatment with MPH (n = 194). The full analysis set (FAS) comprised 419 adult ADHD patients (mean age 35.2 years, males/females 1:1). Fifty-seven percent of the patients suffered from the combined ADHD subtype. Prevalence of at least one current or lifetime axis-I comorbidity was 66 %. Axis-II comorbidity rates was 18 % (patients with comorbid borderline and antisocial personality disorders were excluded). Our network was able to recruit an adult ADHD sample essentially comparable to community samples. A selection bias was created by excluding patients unable or unwilling to participate, or who had somatic and psychiatric contraindications for stimulant treatment (Current Controlled Trials ISRCTN54096201, FUNDING: Federal Ministry of Education and Research 01GV0606).

Among a sample of Iranian students, adult attention deficit hyperactivity disorder is related to childhood ADHD, but not to age, gender, socioeconomic status, or birth order--an exploratory study

OBJECTIVE

The aim of the present study was to explore the prevalence of adult attention deficit hyperactivity disorder (ADHD) in young adult Iranian students and to examine gender, birth order, socioeconomic status (SES), and history of ADHD as potential predictors of adult ADHD.

METHODS

A total of 387 young adult students (mean age: 19.6 years; 66.3% females) completed the Adult ADHD Self-Report Scale-V1.1 symptom checklist to assess current symptoms of ADHD and the Wender Utah Rating Scale to assess symptoms of ADHD in childhood and adolescence. Experts' ratings were based on Wender-Reimherr Interview.

RESULTS

Self-rated and expert-rated prevalence rates were 16.5% and 13.4%, respectively. Past symptoms of ADHD were correlated with current symptoms. Childhood ADHD, current hyperactivity, and disorganization predicted current ADHD.

CONCLUSIONS

Among a sample of Iranian students, the prevalence rates of ADHD were higher than estimated rates worldwide. Data also show child ADHD to be associated with adult ADHD; gender, age, birth order, and SES did not seem to influence current symptomatology.

Symptoms of attention-deficit/hyperactivity disorder (ADHD) moderate suicidal behaviors in college students with depressed mood

OBJECTIVE

College students with attention-deficit/hyperactivity disorder-related hyperactive/impulsive (HI) and/or inattentive (IA) symptoms may be at greater risk for suicidal behavior due to core and secondary symptoms that increase their potential to engage in behaviors that put them at risk for suicidal behavior. Consequently, the current study examined the moderating effect of combined HI/IA symptoms, in addition to independent HI and IA symptoms on the relationship between depressed mood and suicidal thoughts and behavior.

METHOD

A sample of 1,056 undergraduate students (61.5% female, 96.4% aged 18-24 years) provided self-report ratings of mood, suicidal behavior (thoughts, self-harm, attempts, and need for medical attention), and current HI/IA symptoms.

RESULTS

Significant moderation effects were detected, such that greater HI/IA symptoms were associated with a stronger relationship between depressed mood and suicidal ideation and attempts, but not self-harm. Current HI and IA symptoms significantly moderated the relationship between depressed mood and suicidal thoughts and suicide attempts, but did not moderate the relationship between depressed mood and self-harm and need for medical attention.

CONCLUSIONS

The current findings suggest that the presence of combined HI/IA symptoms conveys increased suicide risk for depressed college students. Additionally, results suggest a complex relationship between independent HI and IA symptoms and severe suicidal outcomes.

Sleep and daytime function in adults with attention-deficit/hyperactivity disorder: subtype differences

OBJECTIVES

Although sleep disorders have been reported to affect more than half of adults with attention-deficit/hyperactivity disorder (ADHD), the association between sleep and ADHD is poorly understood. The aims of our study were to investigate sleep-related variables in adults with ADHD and to assess if any differences exist between ADHD of the predominantly inattentive (ADHD-I) and combined (ADHD-C) subtypes.

METHODS

We used the Epworth sleepiness scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), and the fatigue severity scale (FSS) to collect data on daytime sleepiness, sleep quality, and fatigue in 126 subjects (45 ADHD-I and 81 ADHD-C subjects).

RESULTS

Approximately 85% of subjects reported excessive daytime sleepiness or poor sleep quality. The most common sleep concerns were initial insomnia, interrupted sleep, and feeling too hot. When examining ADHD subtype differences, ADHD-I subtypes reported poorer sleep quality and more fatigue than ADHD-C subtypes. Partial correlation analyses revealed that interrelationships between sleep quality, daytime sleepiness, and fatigue differ between ADHD subtypes; in ADHD-I subtypes fatigue was associated with sleep quality, while in the ADHD-C subtypes fatigue was associated with both sleep quality and daytime sleepiness. There also appears to be a subtype×gender interaction that affects the perception of fatigue, as subjective fatigue was markedly higher in ADHD-I women than in ADHD-C women.

CONCLUSION

Altogether our data indicate that the interplay of variables associated with daytime function and sleep varies between ADHD subtypes. This finding may have considerable relevance in the management and pathophysiologic understanding of ADHD, and thus lead to tailored treatments for ADHD subtypes.

Psychiatric comorbidity distribution and diversities in children and adolescents with attention deficit/hyperactivity disorder: a study from Turkey

OBJECTIVE

We aimed to determine distribution and diversities of psychiatric comorbidities in children and adolescents with attention deficit/hyperactivity disorder (ADHD) in terms of age groups, sex, and ADHD subtype.

MATERIALS AND METHODS

The sample included 6-18 year old children and adolescents from Turkey (N=108; 83 boys, 25 girls) diagnosed with ADHD. All comorbid diagnoses were determined based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version assessment.

RESULTS

96.3% of the cases were found to have at least one psychiatric comorbid diagnosis. The most frequent psychiatric comorbid disorder was oppositional defiant disorder (69.4%) followed by anxiety disorders (49%) and elimination disorders (27.8%). Disruptive behavior disorders were more common in ADHD-combined type. Depression and anxiety disorders were more common in girls. Separation anxiety disorder and elimination disorder were more common in children, whereas depression, bipolar disorder, obsessive-compulsive disorder, and social phobia were more common in the adolescents.

CONCLUSION

According to our results, when a diagnostic tool was used to assess the presence of comorbid psychiatric disorders in children and adolescents diagnosed with ADHD, almost all cases had at least one comorbid diagnosis. Therefore, especially in the clinical sample, ADHD cases should not be solely interpreted with ADHD symptom domains, instead they should be investigated properly in terms of accompanying psychiatric disorders.

Correlates for academic performance and school functioning among youths with and without persistent attention-deficit/hyperactivity disorder

Childhood attention-deficit hyperactivity disorder (ADHD) is associated with academic underachievement and school dysfunction. Little is known whether such association varies with the persistence of ADHD symptoms. The authors investigated school functioning among youths with and without persistent ADHD and identified the clinical correlates for school functioning in a large sample of 333 youths with persistent ADHD, 166 with non-persistent ADHD, and 266 without ADHD. The participants and their mothers received structured interviews for diagnosis of ADHD and other psychiatric conditions according to the DSM-IV diagnostic criteria by using the Kiddie epidemiologic version of the Schedule for Affective Disorders and Schizophrenia, and for school functioning by using the Chinese Social Adjustment Inventory for Children and Adolescents. The results showed that both ADHD groups had more impairment in all domains of school functioning than youths without ADHD with a gradient relationship in the order of persistent ADHD, non-persistent ADHD, and non-ADHD. The most consistent correlates for all domains of impaired school functioning were youth- and mother-reported inattention symptoms and increased age. Childhood hyperactivity-impulsivity symptoms also predicted more severe problems in social interactions and school behaviors. Psychiatric comorbid conditions also predicted poorer attitudes toward school works and interactions at school. Our findings indicate that lifetime diagnosis of ADHD, regardless of persistence of ADHD, associate with the impairment of overall school functioning sustaining from childhood into adolescence, and imply that early intervention of childhood inattention may offset school dysfunction at late childhood and adolescence.

Efficacy of guanfacine extended release in the treatment of combined and inattentive only subtypes of attention-deficit/hyperactivity disorder

BACKGROUND

Extended-release guanfacine (GXR) is approved for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents aged 6-17 years. This post-hoc analysis further examines the effects of GXR on hyperactivity-impulsivity and inattentiveness.

METHOD

Data from two large double-blind placebo-controlled pivotal trials of GXR in the treatment of ADHD were analyzed. Using the pooled population to provide sufficient sample size and associated statistical power, the impact of GXR treatment on core ADHD symptoms was examined by comparing ADHD Rating Scale IV (ADHD-RS-IV) total scores in the overall GXR and placebo groups in subjects with each of the three ADHD subtypes. ADHD-RS-IV Hyperactivity-Impulsivity and Inattentiveness subscale scores in the overall study population by randomized dose group (vs. placebo) were also examined.

RESULTS

The full analysis set included 631 subjects aged 6-17 years (GXR: n=490; placebo: n=141). Among subjects with the predominantly inattentive subtype of ADHD, differences in least squares (LS) mean reductions from baseline in ADHD-RS-IV total scores were significantly greater in GXR-treated subjects (n=127) than in placebo-treated subjects (n=38) at treatment weeks 3 through 5 and end point (p≤0.020). Among subjects with combined type ADHD, differences in LS mean ADHD-RS-IV total score reductions from baseline were significantly greater in the GXR group (n=354) than in the placebo group (n=100) at treatment weeks 1 through 5 and end point (p≤0.011). The dearth of predominantly hyperactive-impulsive type subjects (n=12) precluded analysis of this subgroup. Each randomized GXR dose group in each trial demonstrated significantly greater reductions from baseline in ADHD-RS-IV Hyperactivity-Impulsivity and Inattentiveness subscale scores than did the respective placebo group at end point (p≤0.05 for all).

CONCLUSIONS

The results support the use of GXR in the treatment of core ADHD symptoms as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision, including hyperactivity, impulsivity, and inattention.

Time course of the development of depressive mood and oppositional defiant behavior among boys with attention deficit hyperactivity disorder: differences between subtypes

AIM

The aim of this research was to clarify the development of depression among boys with attention deficit hyperactivity disorder (ADHD) by examining the correlation between depressive mood, oppositional defiant behavior, and age for each ADHD subtype.

METHODS

The Birleson Depression Self-Rating Scale (DSRS) was used to evaluate depressive mood while the Oppositional Defiant Behavior Inventory (ODBI) was used to evaluate oppositional defiant behavior. The 90 subjects were divided into three groups: 22 boys (mean age, 12.4 ± 1.9 years) were placed in the ADHD predominantly inattentive type (ADHD-I) group; 45 boys (mean age, 10.4 ± 2.0 years) were placed in the ADHD combined type (ADHD-C) group; and 23 boys (mean age, 12.7 ± 2.4 years) were placed in the depressive disorder (DD) group. The DD group was included to highlight characteristics of depressive mood among boys with ADHD.

RESULTS

The DSRS score was significantly higher in the DD group compared to the ADHD-I and ADHD-C groups. The ODBI score was significantly higher in the ADHD-C group compared to the ADHD-I (P = 0.043) and DD (P = 0.013) groups. In the DD group, ODBI was seen to decrease with increasing age. A certain degree of oppositional defiant behavior was seen in each ADHD subtype. The DSRS score correlated with the ODBI score in the ADHD-C group, while the DSRS score correlated with age in the ADHD-I group.

CONCLUSION

The characteristics of developing depressive mood in childhood ADHD appeared to differ between subtypes and also differed from depression without ADHD.

Community Knowledge and Beliefs About ADHD

Accurate knowledge and positive attitudes within the community are important for the effective diagnosis, treatment and support of people with ADHD. Most previous research about knowledge and attitudes has focused only on professional groups and parents of children with ADHD. The aim of this study was to explore knowledge about ADHD characteristics and causes, and attitudes towards issues such as medication in the general population. Six hundred and forty-five members of the Australian community, all of whom were parents, completed a questionnaire. The findings showed that the core features of ADHD were well-known, but there were misconceptions and considerable uncertainty about many aspects. Most respondents failed to recognise the genetic basis of the disorder and its potentially lifelong nature. Fathers were less knowledgeable than mothers. Although most participants believed that ADHD is a genuine disorder and recognised the benefits of medication, the majority believed that it is diagnosed too frequently and that medication is prescribed too readily. The study concluded that, in many respects, the public is not well-informed about ADHD and suggested that the media may have an important role in enhancing community awareness of the disorder through responsible, sensitive and accurate reporting.

A systematic review of global publication trends regarding long-term outcomes of ADHD

There is increased global recognition of attention deficit hyperactivity disorder (ADHD) as a serious medical condition with long-term consequences. Although originally conceived of as a childhood disorder, ADHD is being increasingly recognized in adults. Individual geographic regions may have specific interests and objectives for the study of ADHD. A systematic review of long-term outcomes (LTOs) in ADHD was conducted to evaluate research on ADHD LTOs on a global scale. Studies that were at least 2 years in duration were examined. A total of 351 studies were identified in the final analysis. We identified nine outcomes of interest and classified studies by specific geographical regions, age groups studied and study design by region and over time. Published studies of LTOs in ADHD have increased in all geographical regions over the past three decades, with a peak number of 42 publications in 2008. This rise in publications on ADHD LTOs may reflect a rise in global interest and recognition of consequences and impairment associated with ADHD. Although many world regions have published on ADHD LTOs, the majority of studies have emerged from the US and Canada, followed by Europe. While investigators in the US and Canada were predominantly interested in drug addiction as a LTO, European researchers were more interested in antisocial behavior, and Eastern Asian investigators focused on both of these LTOs as well as self-esteem. Geographical differences in the focus of ADHD LTO studies may reflect regional variations in cultural values. Proportionally fewer prospective longitudinal studies and proportionally more retrospective and cross-sectional studies have been published in more recent decades. Finally, more studies focusing on ADHD in adolescents and adults have been conducted in recent years, and particularly adolescents in Eastern Asia. These changes in basic study design may reflect an increase in the recognition that ADHD is a lifetime chronic disorder. This systematic review analysis of publication trends in ADHD LTOs reflects geographically based interests that change over time.

Coexisting psychiatric problems and stressful life events in adults with symptoms of ADHD--a large Swedish population-based study of twins

OBJECTIVE

To explore the associations of subtypes of adult ADHD with other psychiatric problems, stressful life events, and sex differences.

METHOD

Odds ratios were calculated using information from 17,899 participants from a population-based survey of adult twins born in Sweden between 1959 and 1985.

RESULTS

Symptoms of attention deficit hyperactivity disorder (ADHD) were associated with an increased risk for symptoms of (odds ratio [95% confidence interval]): generalized anxiety disorder (5.6 [4.3; 6.5]), major depression (2.8 [2.4; 3.2]), bipolar disorder (8.0 [5.1; 12.6]), obsessive-compulsive disorder (3.9 [3.1; 4.9]), and alcohol dependence (2.6 [2.2; 3.1]). Symptoms of ADHD were found to be associated with an increased risk for stressful life events (1.8 [1.3; 2.4]). No significant difference in comorbidity was observed between the two sexes.

CONCLUSION

Both women and men with ADHD are at increased risk for symptoms of other psychiatric disorders. They are also at increased risk for stressful life events.

Sleep in attention-deficit/hyperactivity disorder in children and adults: past, present, and future

The understanding that sleep can give rise to, or exacerbate symptoms of attention-deficit/hyperactivity disorder (ADHD), and that good sleep hygiene improves attention and concentration tasks has sparked interest in the investigation of possible etiological relationships between sleep disorders and ADHD. Studies indicate that 30% of children and 60-80% of adults with ADHD have symptoms of sleep disorders such as daytime sleepiness, insomnia, delayed sleep phase syndrome, fractured sleep, restless legs syndrome, and sleep disordered breathing. The range and diversity of findings by different researchers have posed challenges in establishing whether sleep disturbances are intrinsic to ADHD or whether disturbances occur due to co-morbid sleep disorders. As a result, understanding of the nature of the relationship between sleep disturbances/disorders and ADHD remains unclear. In this review, we present a comprehensive and critical account of the research that has been carried out to investigate the association between sleep and ADHD, as well as discuss mechanisms that have been proposed to account for the elusive relationship between sleep disturbances, sleep disorders, and ADHD.

Attention-deficit/hyperactivity disorder subtypes in adolescents with comorbid substance-use disorder

BACKGROUND

Little is known about the relationship between attention-deficit/hyperactivity disorder (ADHD) subtypes and substance-use disorder (SUD). As there is literature suggesting different subtype phenotypes, there may be subtype differences in regard to the risk for developing SUD and substance treatment response.

OBJECTIVES

To characterize the sample in a Clinical Trials Network (CTN) study according to ADHD subtypes and baseline psychosocial and substance-use characteristics and to compare subtypes on response to treatment.

METHODS

Secondary analyses on data collected from adolescents (n = 276) diagnosed with ADHD and SUD (non-nicotine) and treated with stimulant medication or placebo and cognitive behavioral therapy (CBT) for substance use. Participants were characterized as inattentive or combined ADHD subtype and compared on baseline characteristics and treatment outcome.

RESULTS

The combined subtype presented with more severe SUDs and higher rates of conduct disorder. There were a greater proportion of boys with inattentive subtype. The inattentive subtype appeared less ready for treatment (greater University of Rhode Island Change Assessment precontemplation scores) with poorer coping skills (poorer problem-solving and abstinence focused coping) at baseline. However, the two subtypes responded equally to treatment even after controlling for baseline differences.

CONCLUSIONS

Findings from this large community sample indicate that there were no subtype differences in treatment response, although there were differences in terms of substance use, antisocial behavior, readiness for treatment, and gender prior to treatment.

SCIENTIFIC SIGNIFICANCE

This study is the first to report on subtype differences for treatment response for non-nicotine SUD in a comorbid ADHD-SUD population. Despite some baseline differences, both subtypes responded equally to treatment, suggesting limited relevance for subtype designation on treatment planning.

Fronto-striatal underactivation during interference inhibition and attention allocation in grown up children with attention deficit/hyperactivity disorder and persistent symptoms

Attention deficit hyperactivity disorder (ADHD) in medication-naïve children has been associated with reduced activation in inferior/medial prefrontal, striatal and parieto-temporal cortices during inhibitory control and attention allocation. Functional magnetic resonance imaging (fMRI) studies in adult ADHD, however, have been inconsistent and confounded by medication-history and the need for a retrospective diagnosis of childhood ADHD. We used fMRI combined with a Simon task that measured interference inhibition and controlled for and co-measured attention allocation to compare brain function in 11 medication-naïve adults with persistent inattentive/hyperactive behaviours, followed up from childhood ADHD, and 15 age-matched controls. Despite comparable task performance, patients showed reduced activation compared to controls in left orbital/medial frontal cortex and striatum during interference inhibition and in left lateral inferior/dorsolateral prefrontal cortex during attention allocation. Whole-brain regression analyses within patients showed a negative correlation between symptom severity and fronto-striatal, temporo-parietal and cerebellar brain activation. The findings demonstrate that the typical fronto-striatal dysfunction observed in children with ADHD during interference inhibition and attention allocation is also observed in adults grown up from childhood ADHD with persistent symptoms. Furthermore, they show that functional deficits in adult ADHD are not related to chronic stimulant medication given that this sample was medication-naive.

Exploring DRD4 and its interaction with SLC6A3 as possible risk factors for adult ADHD: a meta-analysis in four European populations

Attention-deficit hyperactivity disorder (ADHD) is a common behavioral disorder affecting about 4-8% of children. ADHD persists into adulthood in around 65% of cases, either as the full condition or in partial remission with persistence of symptoms. Pharmacological, animal and molecular genetic studies support a role for genes of the dopaminergic system in ADHD due to its essential role in motor control, cognition, emotion, and reward. Based on these data, we analyzed two functional polymorphisms within the DRD4 gene (120 bp duplication in the promoter and 48 bp VNTR in exon 3) in a clinical sample of 1,608 adult ADHD patients and 2,352 controls of Caucasian origin from four European countries that had been recruited in the context of the International Multicentre persistent ADHD CollaboraTion (IMpACT). Single-marker analysis of the two polymorphisms did not reveal association with ADHD. In contrast, multiple-marker meta-analysis showed a nominal association (P = 0.02) of the L-4R haplotype (dup120bp-48bpVNTR) with adulthood ADHD, especially with the combined clinical subtype. Since we previously described association between adulthood ADHD and the dopamine transporter SLC6A3 9R-6R haplotype (3'UTR VNTR-intron 8 VNTR) in the same dataset, we further tested for gene × gene interaction between DRD4 and SLC6A3. However, we detected no epistatic effects but our results rather suggest additive effects of the DRD4 risk haplotype and the SLC6A3 gene.

A review of fronto-striatal and fronto-cortical brain abnormalities in children and adults with Attention Deficit Hyperactivity Disorder (ADHD) and new evidence for dysfunction in adults with ADHD during motivation and attention

Attention Deficit Hyperactivity Disorder (ADHD) has long been associated with abnormalities in frontal brain regions. In this paper we review the current structural and functional imaging evidence for abnormalities in children and adults with ADHD in fronto-striatal, fronto-parieto-temporal, fronto-cerebellar and fronto-limbic regions and networks. While the imaging studies in children with ADHD are more numerous and consistent, an increasing number of studies suggests that these structural and functional abnormalities in fronto-cortical and fronto-subcortical networks persist into adulthood, despite a relative symptomatic improvement in the adult form of the disorder. We furthermore present new data that support the notion of a persistence of neurofunctional deficits in adults with ADHD during attention and motivation functions. We show that a group of medication-naïve young adults with ADHD behaviours who were followed up 20 years from a childhood ADHD diagnosis show dysfunctions in lateral fronto-striato-parietal regions relative to controls during sustained attention, as well as in ventromedial orbitofrontal regions during reward, suggesting dysfunctions in cognitive-attentional as well as motivational neural networks. The lateral fronto-striatal deficit findings, furthermore, were strikingly similar to those we have previously observed in children with ADHD during the same task, reinforcing the notion of persistence of fronto-striatal dysfunctions in adult ADHD. The ventromedial orbitofrontal deficits, however, were associated with comorbid conduct disorder (CD), highlighting the potential confound of comorbid antisocial conditions on paralimbic brain deficits in ADHD. Our review supported by the new data therefore suggest that both adult and childhood ADHD are associated with brain abnormalities in fronto-cortical and fronto-subcortical systems that mediate the control of cognition and motivation. The brain deficits in ADHD therefore appear to be multi-systemic and to persist throughout the lifespan.

Less discontinuation of ADHD drug use since the availability of long-acting ADHD medication in children, adolescents and adults under the age of 45 years in the Netherlands

Treatment options for ADHD in the Netherlands have increased with the introduction of the extended-release formulations of methylphenidate (MPH ER, Concerta^®) in 2003 and atomoxetine (ATX, Strattera^®) in 2005, but data on the effect on drug usage patterns are scarce. The objective of the present study was to describe changes in the patterns of ADHD medication use and determinants thereof among children, adolescents and adults (<45 years) starting ADHD medication since the introduction of MPH ER and ATX. Data were obtained from Dutch community pharmacies as collected by the Foundation for Pharmaceutical Statistics, covering 97% of all dispenses for prescription medicines to outpatients in the Netherlands. Usage patterns (continuation, discontinuation, switching and addition) of ADHD drugs were evaluated at 3, 6 and 12 months after initiation for three separate time cohorts (patients starting ADHD medication in Jan-Dec 2002, Jan 2003–June 2004, respectively July 2004–Dec 2005). It was found that between 2002 and 2006, most ADHD drug users were initiated on methylphenidate IR. Discontinuation of any ADHD drug treatment decreased over time partly in favour of switching and addition. Discontinuation at 3 months decreased from around 33% to around 25%, at 6 months from less than 50% to almost 35%, and at 12 months from just fewer than 60% to less than 45%. Discontinuation was higher among females and in adults >18 years. After the introduction of MPH ER and ATX (time cohort III), 16.5% of the incident ADHD drug users switched their medication and almost 9% added an ADHD drug to the prior ADHD drug. In conclusion, discontinuation of incident ADHD drug use is high after 3, 6 and 12 months. During the study period, the incidence of discontinuation decreased because of the availability of extended-release methylphenidate and atomoxetine.

Contribution of LPHN3 to the genetic susceptibility to ADHD in adulthood: a replication study

Attention-deficit/hyperactivity disorder (ADHD) is a common and highly heritable developmental disorder characterized by a persistent impairing pattern of inattention and/or hyperactivity-impulsivity. Using families from a genetic isolate, the Paisa population from Colombia, and five independent datasets from four different populations (United States, Germany, Norway and Spain), a highly consistent association was recently reported between ADHD and the latrophilin 3 (LPHN3) gene, a brain-specific member of the LPHN subfamily of G-protein-coupled receptors that is expressed in ADHD-related regions, such as amygdala, caudate nucleus, cerebellum and cerebral cortex. To replicate the association between LPHN3 and ADHD in adults, we undertook a case-control association study in 334 adult patients with ADHD and 334 controls with 43 single nucleotide polymorphisms (SNPs) covering the LPNH3 gene. Single- and multiple-marker analyses showed additional evidence of association between LPHN3 and combined type ADHD in adulthood [P = 0.0019; df = 1; odds ratio (OR) = 1.82 (1.25-2.70) and P = 5.1e-05; df = 1; OR = 2.25 (1.52-3.34), respectively]. These results further support the LPHN3 contribution to combined type ADHD, and specifically to the persistent form of the disorder, and point at this new neuronal pathway as a common susceptibility factor for ADHD throughout the lifespan.

Objective measurement of motor activity during cognitive performance in adults with attention-deficit/hyperactivity disorder

OBJECTIVE

This study investigates whether hyperactivity, i.e. an increased level of motor activity, can be observed in adults with attention-deficit/hyperactivity disorder (ADHD).

METHOD

An infrared motion-tracking system was used to measure motor activity in 20 unmedicated adults with ADHD and 20 matched healthy controls (HC) during a 1-back working memory task.

RESULTS

Motor activity was higher in ADHD. It increased with the duration of testing and co-varied with cognitive performance in ADHD only. Subjective and objective measurements of motor activity were related in HC, but not in ADHD.

CONCLUSION

Higher levels of motor activity in ADHD are objectively measurable not only in children, but in adults as well. It is linked to cognitive performance arguing against distinguishable diagnostic subtypes. The objective measurement of motor activity seems to extend the description of ADHD symptoms derived from rating scales and might thus help to bridge the gap between psychopathological symptom description and neurobiological alterations.

[The health economics of attention deficit hyperactivity disorder in Germany. Part 1: Health care utilization and cost of illness]

In the German region of Nordbaden, 5% of children (aged 7-12 years) and 1.3% of adolescents (aged 13-19 years) were diagnosed with attention deficit hyperactivity disorder (ADHD) in 2003. About two thirds of these patients were not seen by a physician specialized in psychiatry. Now the National Association of Statutory Health Insurance Physicians in Germany (Kassenaerztliche Bundesvereinigung, KBV) has developed a proposal for the integrated provision of care for these patients, combining a guidelines-oriented multidisciplinary approach with a system of quality assurance. Against this background, currently available ADHD-related data are presented, covering epidemiology, comorbidity and differential diagnosis, health care utilization, and cost of illness. According to administrative data analyses from Nordbaden, direct medical costs for patients with ADHD, from the perspective of statutory health insurance (SHI), exceed those of matched controls by a factor of >2.5. On this basis, ADHD-related expenditures of the German SHI may be estimated at around EUR 260 million in 2003, and almost certainly will have continued to grow further since. In addition to this, a diagnosis of ADHD is associated with substantial indirect cost. Although the literature on the burden of ADHD is incomplete, it seems plausible that the cost of illness might be comparable to that reported for alcohol and addiction disorders. Thus we anticipate an increasing relevance of formal health economic evaluations of health care programs offered to patients with ADHD.

Wie stark sind Erwachsene mit ADHS und komorbiden Störungen in ihrer gesundheitsbezogenen Lebensqualität beeinträchtigt?

Hintergrund: Zur ADHS bei Erwachsenen liegen nur wenige Studien vor, die den Zusammenhang zwischen einer ADHS und komorbiden Störung erheben und mit der gesundheitsbezogenen Lebensqualität in Verbindung bringen. Methode: Die Teilnehmer der Studie wurden per Kreuzklassifikation in Gruppen unterteilt, nachdem sie als auffällig oder unauffällig eingestuft wurden. Neben χ2-Tests und korrelativen Beziehungen wurden prädiktive Werte und das relative Risiko bestimmt, um den Zusammenhang zwischen ADHS, komorbiden Störungen und der gesundheitsbezogenen Lebensqualität zu ermitteln. Ergebnisse: Während bei wenigen und begrenzten ADHS-Symptomen kaum komorbide Störungen festzustellen waren, so treten in der Hälfte aller Fälle von ADHS weitere psychische Belastungsfaktoren auf. Dabei hatten ADHS-Betroffene ein deutlich höheres Risiko für das Vorliegen psychischer Beschwerden als die Nichtbetroffenen. Diskussion: ADHS ist mit erhöhter psychischer Belastung bei gleichzeitiger Abnahme der gesundheitsbezogenen Lebensqualität verbunden. Neben dem generellen Nachweis einer hohen psychischen Belastung bei ADHS hat dies wichtige Konsequenzen für Diagnostik und Therapie. So ist eine umfassende Differenzialdiagnostik nötig, damit eine Therapie auch komorbide Störungen einbeziehen kann und sich somit die gesundheitsbezogene Lebensqualität verbessern lässt.

ADHS im Jugendalter

Ausgehend von der Betrachtung der ADHS als Lebensspannenerkrankung geht die vorliegende Studie der Frage nach, inwieweit Symptome einer adulten Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) bereits im Jugendalter auftreten und Folgen für die klinische Praxis haben. Auf der Basis einer Repräsentativdatenerhebung wurde eine Stichprobe von N = 140 Jungen und Mädchen im Alter zwischen 14 und 19 Jahren erhoben. Mittels der eingesetzten Verfahren ADHS-E, SF-12, SWLS und PHQ-15 und PHQ-9 wurden Zusammenhänge zwischen den ADHS-Symptomen im Erwachsenenalter und Lebenszufriedenheit bzw. Lebensqualität über psychische und körperliche Symptome bei Heranwachsenden untersucht. Dabei konnte die ADHS als ein wesentlicher Faktor für die Beeinträchtigung der Lebenszufriedenheit und Begünstigung von Depressivität in der Adoleszenz ausgemacht werden. Für die klinische Praxis ergibt sich daraus ein veränderter Blickwinkel auf die Lebenszufriedenheit von Jugendlichen im Allgemeinen und auf zusätzliche psychische Belastungen im Rahmen einer adoleszenten Form der ADHS im Besonderen.

Presenting ADHD symptoms, subtypes, and comorbid disorders in clinically referred adults with ADHD

OBJECTIVE

Despite the increasing presentation of attention-deficit/hyperactivity disorder (ADHD) in adults, many practitioners remain reluctant to assess individuals for ADHD, in part related to the relative lack of data on the presenting symptoms of ADHD in adulthood. Comorbidity among adults with ADHD is also of great interest due to the high rates of psychiatric comorbidity, which can lead to a more persistent ADHD among adults.

METHOD

We assessed 107 adults with ADHD of both sexes (51% female; mean +/- SD of 37 +/- 10.4 years) using structured diagnostic interviews. Using DSM-IV symptoms, we determined DSM-IV subtypes. The study was conducted from 1998 to 2003.

RESULTS

Inattentive symptoms were most frequently endorsed (> 90%) in adults with ADHD. Using current symptoms, 62% of adults had the combined subtype, 31% the inattentive only subtype, and 7% the hyperactive/impulsive only subtype. Adults with the combined subtype had relatively more psychiatric comorbidity compared to those with the predominately inattentive subtype. Women were similar to men in the presentation of ADHD.

CONCLUSION

Adults with ADHD have prominent inattentive symptoms of ADHD, necessitating careful questioning of these symptoms when evaluating these individuals.

Adults with Tourette's syndrome with and without attention deficit hyperactivity disorder

OBJECTIVE

Comorbidity between Tourette's syndrome (TS) and attention deficit hyperactivity disorder (ADHD) is high. In children, those with both TS+ADHD fare less well than those with TS-only on measures of both psychopathology and behaviour. The objective of this study was to document such measures in adult patients.

METHOD

Eighty adults with TS-only were compared to 64 with TS+ADHD using a clinical interview and standardised measures of depression, anxiety and obsessionality.

RESULTS

The two groups were no different on measures of TS severity. TS+ADHD patients had significantly more depression, anxiety, obsessive-compulsive behaviour and maladaptive behaviours than patients with TS-only. There were also significant differences in the incidence of copro- and echo-phenomena and family history of ADHD.

CONCLUSION

The finding of increased overall behavioural difficulties and psychopathology in adult patients with TS+ADHD when compared with TS-only is in agreement with previous findings in children with TS. Appropriate treatment of ADHD in TS patients during childhood may prevent many behavioural problems in adulthood.

Developmental psychopathology: Attention Deficit Hyperactivity Disorder (ADHD)

BACKGROUND

Attention Deficit/Hyperactivity Disorder (ADHD), formerly regarded as a typical childhood disorder, is now known as a developmental disorder persisting over the lifespan. Starting in preschool-age, symptoms vary depending on the age group affected.

METHOD

According to the variability of ADHD-symptoms and the heterogeneity of comorbid psychiatric disorders, a broad review of recent studies was performed. These findings were summarized in a developmental psychopathological model, documenting relevant facts on a timeline.

RESULTS

Based on a genetic disposition and a neuropsychological deregulation, there is evidence for factors which persist across the lifespan, change age-dependently, or show validity in a specific developmental phase. Qualitative changes can be found for children in preschool-age and adults.

CONCLUSION

These differences have implications for clinical practice as they can be used for prevention, diagnostic proceedings, and therapeutic intervention as well as for planning future studies. The present article is a translated and modified version of the German article "Entwicklungspsychopathologie der ADHS", published in Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 56, 2008, S. 265-274.

Entwicklungspsychopathologie der ADHS

Galt die ADHS vor einigen Jahren noch als eine Erkrankung des Kindes- und Jugendalters, so versteht man heute darunter ein Störungsbild über die Lebensspanne. Mit Beginn im Vorschulalter divergieren die Symptome in Abhängigkeit des Alters. Daraus lässt sich ein Modell ableiten, welches diese Veränderungen (Komorbiditäten, Alltagsbeeinträchtigungen) auf der Zeitachse dokumentiert und mit den jeweils gültigen diagnostischen Kriterien in Verbindung bringt. Ausgehend von einer genetischen Prädisposition und einer neurobiologischen Dysregulation sind Faktoren festzustellen, die über die Lebensspanne andauern, sich altersspezifisch verändern oder nur für einen bestimmten Entwicklungsabschnitt gültig sind. Es wird deutlich, dass das Vorschulalter und der Übergang in das Erwachsenenalter die Phasen darstellen, in denen sich die meisten qualitativen Veränderungen feststellen lassen. Dies hat Implikationen für die klinische Praxis, indem diese Veränderungen zu Zwecken der Prävention, des diagnostischen Prozesses und der Therapieplanung herangezogen werden können und somit sowohl dem Anwender eine Hilfestellung bieten, aber auch als Ausgangspunkt für weitere Studien herangezogen werden können.