The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

Greater Frontoparietal Connectivity During Task Engagement Among Toddlers With Parent-Reported Inattention

Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with lifelong impairments. ADHD-related behaviors have been observed as early as toddlerhood for children who later develop ADHD. Children with ADHD have disrupted connectivity in neural circuitry involved in executive control of attention, including the prefrontal cortex (PFC) and dorsal attention network (DAN). It is not known if these alterations in connectivity can be identified before the onset of ADHD. Children (N = 51) 1.5-3 years old were assessed using functional near-infrared spectroscopy while engaging with a book. The relation between mother-reported ADHD-related behaviors and neural connectivity, computed using robust innovation-based correlation, was examined. Task engagement was high across the sample and unrelated to ADHD-related behaviors. Observed attention was associated with greater connectivity between the right lateral PFC and the right temporal parietal junction (TPJ). Children with greater ADHD-related behaviors had greater frontoparietal connectivity, particularly between the PFC bilaterally and the right TPJ. Toddlers at risk for developing ADHD may require increased frontoparietal connectivity to sustain attention. Future work is needed to examine early interventions that enhance developing attention and their effect on neural connectivity between the PFC and attention networks.

Parental illness work across the attention deficit hyperactivity disorder diagnostic journey

The process of referral, assessment, and diagnosis of attention deficit hyperactivity disorder (ADHD) within the UK is often protracted. Given that parents are frequently the instigators of the diagnostic process, understanding the experience of parents is important. Drawing on findings from a longitudinal study, this article explores how the parental experience of the ADHD diagnostic journey includes three significant and distinct forms of 'illness work'. Twenty-one semi-structured serial interviews were conducted over a 2-year period with seven parents of children on the ADHD diagnostic journey in North East England. We present three significant forms of parental illness work: (1) The 'diagnostic quest', parental work recognising and fighting for their children's needs and selfhood, seeking diagnosis and engaging with systems, (2) 'self-biographical illness work', the personal parental biographical response to the diagnostic journey and (3) 'child biographical illness work and recontextualizing the child', parental biographical adjustment and recontextualisation of their children. We advance Rasmussen et al.'s (2021) model by demonstrating its usefulness in understanding how parents with a personal ADHD diagnosis experience biographical disruption or cohesion in response to their children's diagnosis. That a child's diagnosis leads parents with ADHD to experience a self-biographical cohesive or disruptive response is a unique and significant finding.

A Remedy for Crime? A Systematic Review on the Effects of Pharmacological ADHD Treatment on Criminal Recidivism and Rehabilitation in Inmates With ADHD

INTRODUCTION

There is a high prevalence of attention-deficit/hyperactivity disorder (ADHD) in prison populations compared to the general population, and ADHD has also been shown to be associated with criminality and antisocial behavior. This systematic review examines the effect of pharmacological ADHD treatment on criminal recidivism, ADHD symptoms, and rehabilitation in inmates with ADHD.

METHODS

Adhering to PRISMA 2020 and AMSTAR guidelines, we conducted a structured search on September 6, 2023 using PubMed. We focused on original research published in peer-reviewed scientific journals, following the IMRaD format, written in English, containing the established search terms, based on participants who met the criteria for ADHD diagnosis (any edition of DSM), and who were incarcerated at the start of pharmacological treatment for ADHD. The primary outcome was criminal recidivism, the secondary outcomes were ADHD symptoms, and rehabilitation-related factors such as global function, norm-breaking/antisocial behavior, adaptation to society/institutional behavior, cognitive function, and well-being.

RESULTS

Five studies, based on three patient cohorts, were included in this systematic review. Surprisingly, only one study investigated criminal recidivism. That study indicated that self-reported criminal recidivism was lower than expected among inmates who had received pharmacological ADHD treatment. The five studies showed varying results in the effectiveness of pharmacological ADHD treatment on ADHD symptoms and other rehabilitation-related factors. The included studies also varied regarding participant characteristics, study design, dosage, adherence to treatment, treatment regimes, and measured outcomes. All studies reported using osmotic-release oral system (OROS) methylphenidate as their drug of choice.

CONCLUSION

We conclude that there is limited empirical evidence to support the efficacy of pharmacological ADHD treatment on criminal recidivism in inmates diagnosed with ADHD. Still, evidence suggests that these treatments can reduce ADHD symptoms and enhance rehabilitation outcomes, which may, in turn, lower the rate of reoffending. We point to the need for more targeted research in this area.

Positive Childhood Experiences and the Indirect Relationship With Improved Emotion Regulation in Adults With ADHD Through Social Support

OBJECTIVE

To identify direct and indirect associations between PCEs and social support to emotion regulation outcomes in adults with ADHD.

METHOD

Adults with ADHD (n = 81) reported PCEs, current social support, and emotion regulation. Conditional effects modeling examined the direct and indirect relationships between PCEs and emotion dysregulation through social support.

RESULTS

Higher PCEs were indirectly related to improved emotion regulation through increased social support generally (β = -.70, 95% CI [-1.32, -0.17], and specifically through belonging (β = -.43, 95% CI [ -0.87, -0.05], self-esteem (β = -.61, 95% CI [-1.08, -0.27], and tangible social support (β = -.50, 95% CI [-1.07, -0.02].

CONCLUSIONS

PCEs may protect emotion regulation in adults with ADHD through social support, possibly through facilitating social connections, increasing access to social support, and sustaining emotion regulation strategies.

Effects of active breaks on educational achievement in children with and without ADHD: study protocol and rationale of the Break4Brain project

The Break4Brain project aims to elucidate the effects of both acute and chronic physical activity (PA) on educational achievement in children with and without Attention Deficit Hyperactivity Disorder (ADHD). This study will be conducted in two phases: a cross-over design followed by a hybrid type 1 implementation-effectiveness trial, which includes both a cluster randomized controlled trial (RCT) and a qualitative study. In phase I, 60 children aged 10-12, with 30 each from ADHD and non-ADHD groups, will participate in a laboratory-based study over 4 days within 1 month. They will participate in three counterbalanced experimental conditions: (i) PA with cognitive engagement, (ii) PA without cognitive engagement, and (iii) a cognitively engaging control. This phase will assess acute changes in brain function, academic performance, working memory, inhibitory control, and sustained attention. Phase II will involve 600 children aged 10-12, randomly assigned to either a video-based PA program or a control group (300 children per group) in an 8-week cluster RCT. This phase will also incorporate a qualitative approach to explore the implementation context through pre- and post-intervention semi-structured interviews with teachers and school staff, and questionnaires for students. The outcomes of interest in this phase will include working memory, cognitive flexibility, selective attention, and academic performance. For the cross-over study, we hypothesize that PA conditions will enhance the studied outcomes compared to the control condition. In the RCT, we anticipate that the 8-week active breaks program will result in significant improvements in the selected outcomes compared to the control group. This study is expected to make pioneering contributions by including novel variables and focusing on the ADHD population. Furthermore, if the cluster RCT proves effective, it could offer a practical and cost-effective resource for integrating active breaks into daily school routines.

Links Between Attention-Deficit/Hyperactivity Disorder Symptoms, Peer Relationships and Mental Health Outcomes in Western Australian Youth

Peer relationships are critical in the development of positive mental health during childhood and adolescence. Attention-deficit/hyperactivity disorder (ADHD) symptoms can adversely affect the development of positive peer relationships, and thus, have significant long-term implications for mental health. This study explored the long-term relationships between ADHD symptoms, peer relationships and mental health in Western Australian adolescents. Participants were drawn from a sample of 1489 young people: n = 623 males with a mean age of 13.79 years (SD = 1.61) and n = 866 females, with a mean age of 14.29 years (SD = 1.51). Data were collected at three timepoints across three successive years, with different numbers of participants contributing data at each timepoint. Participants completed measures of ADHD symptoms and existing peer problems in the first year; five measures of peer relationships in the second year; and four measures of mental health in the third year. Multiple regression and path analyses were used to determine whether ADHD symptoms predicted scores on the peer relationship and mental health measures and whether peer relationships mediated links observed between ADHD symptoms and mental health. ADHD symptoms significantly predicted both long-term problematic peer relationships and long-term adverse mental health outcomes. Three peer relationship variables were significant mediators of relationships between ADHD symptoms and mental health: sense of belonging, friendships and perceived isolation. ADHD symptoms significantly predict poor peer relationships and adverse mental health outcomes in Western Australian youth, regardless of whether a formal diagnosis has been assigned. Early interventions for young people with ADHD symptoms are needed for such individuals to enjoy positive mental health in their adult years.

Validity of the Strengths and Difficulties Questionnaire for Screening and Diagnosis in Western Australian Adolescents

BACKGROUND/OBJECTIVES

The Strengths and Difficulties Questionnaire (SDQ) is a widely used 25-item screening and diagnostic tool for behavioral and emotional problems in young people. Despite its popularity, evaluations of the SDQ's factor structure in adolescent populations have produced disparate results, and its relationships with theoretically related variables are rarely evaluated. In the present study, these two elements of validity were evaluated based on a large sample of Western Australian adolescents.

METHODS

Participants were 1489 adolescents, n = 623 males with a mean age of 13.79 years (SD = 1.61) and n = 866 females, with a mean age of 14.29 years (SD = 1.51). Participants completed the SDQ alongside measures of loneliness, sense of belonging, depression, bullying, and diagnostic status to evaluate its internal structure and correlations with theoretically related variables.

RESULTS

Confirmatory factor analyses supported the internal structure of the SDQ both for males and for females. Relationships between the SDQ subscale scores and those from theoretically related variables were also aligned with the instrument's underpinning framework.

CONCLUSIONS

Despite the somewhat disparate results of previous studies, overall, this study supported the validity of the SDQ for use in the Western Australian context.

Cognitive profiles and developmental variations in ADHD: A comparative analysis of childhood and adolescent diagnoses

This retrospective study investigates the cognitive profiles of individuals with ADHD, categorized by the age at which they were diagnosed-either during childhood or adolescence. The sample comprised 424 participants aged 6 to 20 years, with a predominance of males. Participants were assessed using a variety of neuropsychological standardized tests. The study found significant differences in cognitive performance between those diagnosed in childhood and those diagnosed in adolescence. Specifically, childhood diagnoses were associated with poorer performance in vigilance, selective attention, and motor control, while adolescent diagnoses were linked to lower scores in the environment's perception of their flexibility, working memory, and planning. Binary logistic regression analyses indicated that the neuropsychological profile for the combined ADHD subtype did not vary by age group, in contrast with the inattentive subtype, in which different cognitive constructs were identified serving as significant predictors. Findings suggest that the cognitive challenges associated with ADHD evolve with development, highlighting the need for age-appropriate diagnostic criteria and interventions.

A novel approach to ADHD classification based on severity and emotional impairment: Findings from artificial intelligence analysis

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized by symptoms of inattention and executive dysfunction, although there is not always agreement on the onset, course and long-term stability of the diagnosis. This study aims to detect differences in the cognitive profile according to the subtype of ADHD following a professional diagnosis and to propose an alternative classification. The scores obtained for each cognitive construct were compared using the Student's t-test. In order to explore different diagnostic categories based on groupings made by Artificial Intelligence (AI) subjects were grouped based on their performance through the K-means clustering technique. The results obtained by Artificial Intelligence (AI) identified groups based on the severity of the cognitive profile and the presence of emotional impairment. Difficulties in perceived planning within family and school environments were highlighted as major risk factors in the severity of ADHD in children. Emotional disturbances perceived by both parents, such as depressive symptoms, anxiety, and somatization, were observed subsequently. In accordance with the results, an alternative way to classify ADHD is possible, involving categorization according to the presence or absence of emotional impairment, along with the severity of impairment in attentional and executive functions.

Increased intra-individual variability among individuals with ADHD: first evidence from numerosity judgment and verbal and quantitative reasoning

BACKGROUND

This article presents the results of two studies investigating increased intra-individual variability (IIV) in the performance of individuals with attention deficit hyperactivity disorder (ADHD), in two cognitive domains: numerosity judgments and quantitative and verbal reasoning.

METHODS

Study 1, a pre-registered experiment, involved approximately 200 participants (42.66% female; mean age: 36.86; standard deviation of age: 10.70) making numerical judgments at two time-points. ADHD-symptom severity was assessed on a continuous scale. In Study 2, we collected the data of approximately 3000 examinees who had taken a high-stakes admissions test for higher education (assessing quantitative and verbal reasoning). The sample comprised only people formally diagnosed with ADHD. The control group consisted of approximately 200 000 examinees, none of whom presented with ADHD.

RESULTS

The results of Study 1 revealed a positive correlation between IIV (distance between judgments at the two time-points) and ADHD symptom severity. The results of Study 2 demonstrated that IIV (distance between the scores on two test chapters assessing the same type of reasoning) was greater among examinees diagnosed with ADHD. In both studies, the findings persisted even after controlling for performance level.

CONCLUSIONS

The results indicate that individuals with ADHD, v. those without, exhibit less consistent numerosity judgments and greater fluctuation in performance on verbal and quantitative reasoning. The measurement of the same psychological constructs appears to be less precise among individuals with ADHD compared to those without. We discuss the theoretical contributions and practical implications of our results for two fields: judgment and decision-making, and assessment.

Organic food consumption during pregnancy and symptoms of neurodevelopmental disorders at 8 years of age in the offspring: the Norwegian Mother, Father and Child Cohort Study (MoBa)

BACKGROUND

Partially driven by public concerns about modern food production practices, organic food has gained popularity among consumers. However, the impact of organic food consumption during pregnancy on offspring health is scarcely studied. We aimed to investigate the association between maternal intake of organic food during pregnancy and symptoms of attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in offspring at 8 years of age.

METHODS

This study was based on the Norwegian Mother, Father and Child Cohort Study (MoBa) and the Medical Birth Registry of Norway (MBRN). The total study sample included 40,707 mother-child pairs (children born 2002-2009). Organic food consumption during pregnancy was assessed by six questions from a food frequency questionnaire in mid-pregnancy (sum score 0-18). Symptoms of ADHD and ASD in the offspring aged 8 years were measured by ADHD (0-54) and ASD (0-39) symptom scores based on the Parent/Teacher Rating Scale for Disruptive Behaviour disorders and the Social Communication Questionnaire. Associations between maternal intake of organic food during pregnancy and symptoms of ADHD and ASD in the offspring were analyzed using regression models with adjustment for covariates such as maternal anxiety and depression, including sibling analysis.

RESULTS

Mean ADHD and ASD symptom scores in the offspring differed only slightly by maternal intake of organic food. The covariate-adjusted unstandardized regression coefficient (adjusted(Adj)beta) with 95% confidence interval for the ADHD symptom score with one unit increase in organic food sum score was 0.03 (0.01, 0.05). Similarly, Adjbeta for autism symptom score was 0.07 (0.04, 0.10). For ADHD, the adjusted estimates weakened when adjusting for maternal symptoms of ADHD. The sibling analyses showed no significant results with Adjbeta - 0.07 (- 0.15, 0.01) and - 0.001 (- 0.12, 0.12) for ADHD and ASD outcomes, respectively.

CONCLUSIONS

We observed weak positive associations between frequent maternal organic food consumption during pregnancy and offspring ADHD and ASD symptom levels at 8 years of age. This trend weakened or disappeared after adjusting for maternal symptoms of ADHD, and in sibling analyses, suggesting that the associations mainly reflect genetic confounding. Our study indicates that consumption of organic food during pregnancy should neither be considered a risk factor nor protective against symptoms of ADHD and ASD in offspring.

Efficacy of pharmacological interventions for ADHD: protocol for an updated systematic review and dose-response network meta-analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 5% of children globally, with symptoms often persisting into adulthood. While pharmacological interventions are commonly employed for management, understanding the optimal dosing for efficacy and tolerability remains crucial. This study aims to conduct a dose-response network meta-analysis to estimate the efficacy of pharmacological treatments across different doses, aiming to inform clinical decision-making and improve treatment outcomes.

METHODS

This updated systematic review will include randomized controlled trials evaluating ADHD medication efficacy in children, adolescents, and adults. An updated search from a 2018 NMA will be conducted across multiple electronic databases with no language restrictions, using specific eligibility criteria focused on randomized controlled trials. The primary outcome will assess the severity of ADHD core symptoms, while secondary outcomes will consider treatment tolerability. A dose-response Bayesian hierarchical model will be used to estimate dose-response curves for each medication, identifying optimal dosing strategies.

DISCUSSION

With this dose-response network meta-analysis, we aim to better understand the dose-response relationship of pharmacological treatment in ADHD, which could help clinician to the identification of optimal doses.

SYSTEMATIC REVIEW REGISTRATION

OSF https://doi.org/10.17605/OSF.IO/3MY4A .

Increased Prevalence of Attention Deficit Hyperactivity Disorder in Individuals with Selective Immunoglobulin A Deficiency: A Nationwide Case-Control Study

Background: Selective Immunoglobulin A Deficiency (SIgAD) is one of the most prevalent immunodeficiencies, characterized by an increased risk of mucosal infections. Attention deficit hyperactivity disorder (ADHD) is among the most common neurodevelopmental disorders and is associated with significantly higher rates of various infectious diseases, white blood cell abnormalities, and considerable morbidity. This study aimed to evaluate the prevalence of ADHD among patients with SIgAD. Methods: We conducted a retrospective, observational, population-based case-control study, within Leumit Health Services, by comparing individuals diagnosed with SIgAD to a matched control group. Data were extracted from electronic health records. Results: Of the >700,000 registered individuals, 772 aged ≥4 years with SIgAD were identified (mean age 22.0 ± 17.5 years; male/female ratio 1:1). The 5:1 matched control group consisted of 3860 subjects without SIgAD, with no significant differences between the groups regarding age, gender, ethnicity, and socioeconomic status. ADHD prevalence was significantly higher in the SIgAD group (16.2%) than in the control group (12.9%), with an odds ratio of 1.30 (95% confidence interval 1.05-1.61, p = 0.017), as was the use of methylphenidate (6.6% vs. 4%). Additionally, respiratory and intestinal infections were significantly more common in the SIgAD group (p < 0.001). Conclusion: A significantly higher prevalence of ADHD was observed in patients with SIgAD compared to strictly matched controls without SIgAD. These findings enhance our understanding of the pathophysiology of ADHD and its associated health complications.

Causal effects of pediatric asthma on psychiatric disorders: a bidirectional Mendelian randomization study

BACKGROUND

Previous studies have suggested a potential link between pediatric asthma and psychiatric disorders. However, the causal relationship between pediatric asthma and psychiatric disorders is unclear. Therefore, we used Mendelian randomization to explore causal relationships between pediatric asthma and depression, anxiety disorders, and attention deficit and hyperactivity disorder (ADHD).

METHODS

Genome-wide association studies (GWAS) meta-analyses with the largest possible sample size and independent individuals from European ancestry were selected. The genetic data for depression and anxiety are from FinnGen consortium, while the genetic data for ADHD is from the Psychiatric Genomics Consortium. Inverse variance weighted (IVW) was the main analysis method. The heterogeneity of the instrumental variables (IVs) was assessed using IVW, and the horizontal pleiotropy of the IVs was assessed using MR-Egger.

RESULT

The IVW results showed a significant causal relationship between pediatric asthma and depression (OR = 1.08, 95% CI = 1.02-1.15; p = 0.013). However, there is no evidence to suggest a causal relationship between pediatric asthma, anxiety, and ADHD. Reverse MR suggests a significant causal relationship (OR = 1.27, 95% CI [1.14-1.41], p = 9.64E - 06) between ADHD and pediatric asthma using the IVW method.

CONCLUSIONS

Our findings suggest a causal relationship between pediatric asthma and an increased risk of depression. Additionally, we found that ADHD is significantly associated with a higher risk of pediatric asthma.

Time and ADHD in Danish Families: Mutual Affect Through Rhythm

Based on fieldwork in Danish families living with ADHD, we expand on Nielsen's insight that ADHD is experienced as a state of desynchronization by showing how family members' rhythms mutually affect each other. We argue that ADHD is not only a biological and psychiatric condition, but also a temporal and socially responsive phenomenon. The intensity of ADHD is influenced by mutual affect in families and by general life circumstances. Families constitute bodily networks through which sensations, moods, rhythms, and practices spread and are passed down through generations. Yet, families use various time work strategies to manage rhythm affect.

Association Between Single-Dose and Longer Term Clinical Response to Stimulants in Attention-Deficit/Hyperactivity Disorder: A Systematic Review of Randomized Controlled Trials

Objectives: Stimulants, such as methylphenidate (MPH) and amphetamines, represent the first-line pharmacological option for attention-deficit/hyperactivity disorder (ADHD). Randomized controlled trials (RCTs) have demonstrated beneficial effects at a group level but could not identify characteristics consistently associated with varying individual response. Thus, more individualized approaches are needed. Experimental studies have suggested that the neurobiological response to a single dose is indicative of longer term response. It is unclear whether this also applies to clinical measures. Methods: We carried out a systematic review of RCTs testing the association between the clinical response to a single dose of stimulants and longer term improvement. Potentially suitable single-dose RCTs were identified from the MED-ADHD data set, the European ADHD Guidelines Group RCT Data set (https://med-adhd.org/), as updated on February 1, 2024. Quality assessment was carried out using the Cochrane Risk of Bias (RoB) 2.0 tool. Results: A total of 63 single-dose RCTs (94% testing MPH, 85% in children) were identified. Among these, only a secondary analysis of an RCT tested the association between acute and longer term clinical response. This showed that the clinical improvement after a single dose of MPH was significantly associated with symptom improvement after a 4-week MPH treatment in 46 children (89% males) with ADHD. The risk of bias was rated as moderate. A further RCT used near-infrared spectroscopy, thus did not meet the inclusion criteria, and reported an association between brain changes under a single-dose and longer term clinical response in 22 children (82% males) with ADHD. The remaining RCTs only reported single-dose effects on neuropsychological, neuroimaging, or neurophysiological measures. Conclusion: This systematic review highlighted an important gap in the current knowledge. Investigating how acute and long-term response may be related can foster our understanding of stimulant mechanism of action and help develop stratification approaches for more tailored treatment strategies. Future studies need to investigate potential age- and sex-related differences.

Absent or Hidden? Hyperactivity in Females With ADHD

OBJECTIVE

This study aimed to objectively assess signs of hyperactivity in adults suspected of having ADHD, addressing potential sex bias in diagnosis.

METHODS

About 13,179 (49% female) adults with an average age of 33 years with ADHD and 1,910 (41% female) adults with an average age of 36 years without ADHD were included. Motor activity was measured using the Quantified Behavioral Test, analyzing "provoked," and "basal" activity. Sex by group differences were analyzed using analysis of variance.

RESULTS

Results showed significant ADHD effects on the basal and provoked activity measures, while sex effects were only notable for provoked activity. Males, irrespective of diagnosis, exhibited higher provoked activity than females, while both sexes with ADHD displayed approximately twice the basal activity and about three times the provoked activity compared to their respective sex controls.

CONCLUSION

These findings suggest that females with ADHD suffer equally from hyperactivity compared to males, challenging the notion of a sex-dependent presentation of hyperactivity. This may lead to more accurate and timely diagnoses, reducing ADHD-related burdens and comorbidities in females.

Feasibility study of a telehealth school-based behavioral parent training group program for attention-deficit/hyperactivity disorder

OBJECTIVE

To evaluate the feasibility and preliminary efficacy of Telehealth Behavioral Parent Training (T-BPT), a school telehealth group intervention for attention-deficit/hyperactivity disorder (ADHD) with a companion training program for school clinicians.

METHODS

T-BPT was developed in an iterative three-phase design in partnership with community stakeholders during the COVID-19 pandemic. School clinicians (N = 4) delivered T-BPT over 8 weeks to parents (N = 21, groups of 5-6 per school) of children (Grades 2-5) with ADHD while simultaneously receiving training and consultation from PhD-level study trainers. A single-arm open trial was used to assess feasibility, engagement, and preliminary efficacy.

RESULTS

Parents and school clinicians endorsed high feasibility, acceptability, and usability of T-BPT. Parent attendance was high (M = 94.6%) and a majority of parents (66.7%) attended all eight sessions. Preliminary outcomes indicate moderate to large reductions in parent-reported ADHD symptoms (ω2 = .36), functional and clinical global impairment (ω2s= .21 and .19, respectively), and distance learning challenges (ω2 = .22).

CONCLUSIONS

Results were in line with in-person delivery, indicating promising feasibility of school telehealth BPT groups. This study also provided further support for the feasibility of the remote training model for school clinicians. Implications of the commonly endorsed barriers and benefits beyond COVID-19 and relevance to under resourced communities are also discussed.

The Utility of Neuromuscular Assessment to Identify ADHD Among Patients with a Complex Symptom Picture

OBJECTIVE

Diagnostic assessment of ADHD is challenging due to comorbid psychopathologies and symptoms overlapping with other psychiatric disorders. In this study, we investigate if a distinct pattern of neuromuscular dysregulation previously reported in ADHD, can help identifying ADHD in psychiatric patients with diverse and complex symptoms.

METHOD

We explored the impact of neuromuscular dysregulation, as measured by The Motor Function Neurologic Assessment (MFNU), on the likelihood of being diagnosed with ADHD, affective disorder, anxiety disorder, or personality disorder among adults (n = 115) referred to a psychiatric outpatient clinic.

RESULTS

Logistic regression revealed that neuromuscular dysregulation was significantly associated with ADHD diagnosis only (OR 1.15, p < .01), and not with affective-, anxiety-, or personality disorders. Sensitivity and specificity for ADHD at different MFNU scores is provided.

CONCLUSIONS

A test of neuromuscular dysregulation may promote diagnostic accuracy in differentiating ADHD from other psychiatric disorders in patients with an overlapping symptom picture. This may have important implications for clinical practice. More studies are needed.

Distinct structural brain network properties in children with familial versus non-familial attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent, inheritable, and heterogeneous childhood-onset neurodevelopmental disorders. Children with a hereditary background of ADHD have heightened risk of having ADHD and persistent impairment symptoms into adulthood. These facts suggest distinct familial-specific neuropathological substrates in ADHD that may exist in anatomical components subserving attention and cognitive control processing pathways during development. The objective of this study is to investigate the topological properties of the gray matter (GM) structural brain networks in children with familial ADHD (ADHD-F), non-familial ADHD (ADHD-NF), as well as matched controls. A total of 452 participants were involved, including 132, 165 and 155 in groups of ADHD-F, ADHD-NF and typically developed children, respectively. The GM structural brain network was constructed for each group using graph theoretical techniques with cortical and subcortical structures as nodes and correlations between volume of each pair of the nodes within each group as edges, while controlled for confounding factors using regression analysis. Relative to controls, children in both ADHD-F and ADHD-NF groups showed significantly higher nodal global and nodal local efficiencies in the left caudal middle frontal gyrus. Compared to controls and ADHD-NF, children with ADHD-F showed distinct structural network topological patterns associated with right precuneus (significantly higher nodal global efficiency and significantly higher nodal strength), left paracentral gyrus (significantly higher nodal strength and trend toward significantly higher nodal local efficiency) and left putamen (significantly higher nodal global efficiency and trend toward significantly higher nodal local efficiency). Our results for the first time in the field provide evidence of familial-specific structural brain network alterations in ADHD, that may contribute to distinct clinical/behavioral symptomology and developmental trajectories in children with ADHD-F.

Where do neurodevelopmental conditions fit in transdiagnostic psychiatric frameworks? Incorporating a new neurodevelopmental spectrum

Features of autism spectrum disorder, attention-deficit/hyperactivity disorder, learning disorders, intellectual disabilities, and communication and motor disorders usually emerge early in life and are associated with atypical neurodevelopment. These "neurodevelopmental conditions" are grouped together in the DSM-5 and ICD-11 to reflect their shared characteristics. Yet, reliance on categorical diagnoses poses significant challenges in both research and clinical settings (e.g., high co-occurrence, arbitrary diagnostic boundaries, high within-disorder heterogeneity). Taking a transdiagnostic dimensional approach provides a useful alternative for addressing these limitations, accounting for shared underpinnings across neurodevelopmental conditions, and characterizing their common co-occurrence and developmental continuity with other psychiatric conditions. Neurodevelopmental features have not been adequately considered in transdiagnostic psychiatric frameworks, although this would have fundamental implications for research and clinical practices. Growing evidence from studies on the structure of neurodevelopmental and other psychiatric conditions indicates that features of neurodevelopmental conditions cluster together, delineating a "neurodevelopmental spectrum" ranging from normative to impairing profiles. Studies on shared genetic underpinnings, overlapping cognitive and neural profiles, and similar developmental course and efficacy of support/treatment strategies indicate the validity of this neurodevelopmental spectrum. Further, characterizing this spectrum alongside other psychiatric dimensions has clinical utility, as it provides a fuller view of an individual's needs and strengths, and greater prognostic utility than diagnostic categories. Based on this compelling body of evidence, we argue that incorporating a new neurodevelopmental spectrum into transdiagnostic frameworks has considerable potential for transforming our understanding, classification, assessment, and clinical practices around neurodevelopmental and other psychiatric conditions.

Cumulative ADHD medication use and risk of type 2 diabetes in adults: a Swedish Register study

BACKGROUND

Little is known about the impact of cumulative attention-deficit/hyperactivity disorder (ADHD) medication use on the risk of type 2 diabetes (T2D).

OBJECTIVE

The objective is to examine the association between cumulative use of ADHD medication and risk of incident T2D.

METHODS

A nested case-control study was conducted in a national cohort of individuals aged 18-70 years with incident ADHD (n=138 778) between 2007 and 2020 through Swedish registers. Individuals with incident T2D after ADHD were selected as cases (n=2355) and matched with up to five controls (n=11 681) on age at baseline, sex and birth year. Conditional logistic regression models examined the association between cumulative duration of ADHD medication use and T2D.

FINDINGS

Compared with no use, a decreased risk of T2D was observed for those on cumulative use of ADHD medications up to 3 years (ORs: 03 years, 0.97 (95% CI, 0.84 to 1.12)). When investigating medication types separately, methylphenidate showed results similar to main analyses, lisdexamfetamine showed no association with T2D, whereas long-term (>3 years) use of atomoxetine was associated with an increased risk of T2D (OR: 1.44 (95% CI, 1.01 to 2.04)).

CONCLUSION

Cumulative use of ADHD medication does not increase the risk for T2D, with the exception of long-term use of atomoxetine.

CLINICAL IMPLICATIONS

Findings suggest that clinicians should be aware of the potential risk of T2D associated with the cumulative use of atomoxetine among patients with ADHD; however, further replication is strongly needed.

Scheduling of methylphenidate: Preventing misuse or impeding ADHD treatment adherence?

Background

Attention-deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, with a chronic, and potentially debilitating course if untreated. Medication adherence is poor - negatively affecting emotional, social, educational and employment outcomes. The current Schedule 6 status of methylphenidate (MPH) drives healthcare resource utilisation and costs - a potential barrier to care.

Aim

This study explored stakeholders' understanding and perceptions of the potential impact of a regulatory shift in the scheduling of MPH on treatment accessibility and adherence for ADHD.

Setting

Participants from multiple stakeholder groups, involved in ADHD management in South Africa, were recruited via professional networks.

Methods

A qualitative analysis of semi-structured interviews with 23 stakeholders was conducted to explore their views on the utility, benefits and risks associated with rescheduling MPH.

Results

Six key themes emerged from the interviews: 'adherence', 'accessibility', 'affordability', 'stigma', 'rescheduling of MPH' and 'risk mitigation'. Core to these themes is the role of the scheduling of MPH - which can have a protective societal role, but also acts as a barrier to care for individuals with ADHD.

Conclusion

The current Schedule 6 status of MPH is not an effective strategy to prevent misuse and diversion but negatively impacts on treatment adherence. The positive outlook from stakeholders on rescheduling MPH holds significant implications for the ADHD landscape in South Africa.

Contribution

It is crucial to address stigma, facilitate fundamental change in service delivery and remove structural and practical barriers to care to improve outcomes for individuals with ADHD. A framework for ADHD treatment adherence is provided.

The effect of feedback in attention training on Attention Bias to Threat in individuals with Sluggish Cognitive Tempo

BACKGROUND AND OBJECTIVES

This study was conducted to identify the characteristics of attentional bias of individuals with Sluggish Cognitive Tempo (SCT) and how Attention Bias to Threat (ABT) changes when feedback was provided in attention training.

METHODS

First, a dot probe task was conducted to confirm the ABT of the SCT feedback group (N = 27) and SCT no feedback group (N = 25), and healthy control group (N = 30) before intervention. Thereafter, a VR-based attention training was conducted three times with feedback or no feedback. Finally, a dot probe task was executed again.

RESULTS

The SCT groups showed a higher ABT than the healthy control group. A result of the attention training, the reaction time of disengage was significantly reduced when provided feedback. In addition, it was confirmed that the ABT of the SCT group that received feedback, was significantly reduced.

LIMITATIONS

First, the only stimulus used to examine the ABT was the angry face, and the reaction time to other threatening facial expressions was not confirmed. Second, attention training was conducted three times, but further studies are needed on the effect of the duration of training on the magnitude of effect.

CONCLUSIONS

This study identified ABT associated with internalizing symptoms of SCT and suggests that attention training with immediate and continuous feedback is needed to reduce ABT.

Selective attention and sensitivity to auditory disturbances in a virtually-real Classroom: Comparison of adults with and without AD(H)D

Many people, and particularly individuals with Attention Deficit (Hyperactivity) Disorder (AD(H)D), find it difficult to maintain attention during classroom learning. However, traditional paradigms used to evaluate attention do not capture the complexity and dynamic nature of real-life classrooms. Using a novel Virtual Reality platform, coupled with measurement of neural activity, eye-gaze and skin conductance, here we studied the neurophysiological manifestations of attention and distractibility, under realistic learning conditions. Individuals with AD(H)D exhibited higher neural responses to irrelevant sounds and reduced speech tracking of the teacher, relative to controls. Additional neurophysiological measures, such the power of alpha-oscillations and frequency of gaze-shifts away from the teacher, contributed to explaining variance in self-reported AD(H)D symptoms across the sample. These ecologically-valid findings provide critical insight into the neurophysiological mechanisms underlying individual differences in the capacity for sustained attention and the proneness to distraction and mind-wandering, experienced in real-life situations.

Association between methylphenidate use and long-term cardiovascular risk in paediatric patients with attention deficit and hyperactivity disorder

BACKGROUND

There have been concerns about the potential cardiovascular (CV) adverse effects associated with methylphenidate (MTH) use. However, only limited evidence exists on the long-term safety of MTH.

OBJECTIVE

To evaluate whether MTH use is associated with long-term CV risk.

METHODS

This was a retrospective cohort study using 2003-2017 data from the Health and Welfare Database in Taiwan. Patients newly diagnosed with attention deficit and hyperactivity disorder (ADHD) and between 3 and 18 years of age were included. Two treatment statuses were assessed: initial treatment ≥7 days and ≥180 days. Patients treated with MTH were compared with those receiving non-medication therapy. One-to-one propensity score matching was used to balance between-group differences. Study outcomes included major CV events, chronic CV disease, cardiogenic shock and all-cause mortality. Cox proportional hazard models were used to estimate HRs between the two groups.

RESULTS

We began with 307 459 patients with ADHD. After exclusion, 224 732 patients were included in the final cohort. The results showed that compared with non-ADHD medication users, patients who were treated with MTH for more than 7 days had a similar risk of major CV events (HR 0.85, 95% CI 0.72 to 0.99; p=0.040). Identical trends were found in groups who were treated for more than 180 days (HR 0.83, 95% CI 0.69 to 1.00; p=0.050). The results of the sensitivity analyses were consistent with the main analyses across all groups and individual outcomes.

CONCLUSION

Short-term MTH use did not increase CV risk among patients with ADHD. More evidence on long-term MTH use and risk of cardiogenic shock and death is warranted.

Trends in Body Mass Index Among Individuals With Neurodevelopmental Disorders

Importance

Neurodevelopmental disorders (NDDs) such as autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are increasingly common. Individuals with NDDs have heightened obesity risks, but long-term data on body mass index (BMI) trends over time in this population are lacking.

Objective

To assess secular BMI changes from 2004 to 2020 among children with NDDs compared with those without NDDs.

Design, Setting, and Participants

This repeated cross-sectional study used data from the Child and Adolescent Twin Study in Sweden. Children born between January 1, 1992, and December 31, 2010, were screened for neurodevelopmental symptoms using the Autism-Tics, ADHD, and Other Comorbidities inventory between July 2004 and April 2020 when they were 9 or 12 years of age. Data analysis was conducted between September 27, 2023, and January 30, 2024.

Main Outcomes and Measures

BMI percentiles (15th, 50th, and 85th) were modeled using quantile regression and compared between youths with and without NDDs. Secular changes in BMI percentiles over time spanning 2004 to 2020 were evaluated and stratified by NDD subtype.

Results

The cohort included 24 969 Swedish twins (12 681 [51%] boys) born between 1992 and 2010, with mean (SD) age of 9 (0.6) years. Of these, 1103 (4%) screened positive for 1 or more NDDs, including ADHD, ASD, and/or learning disability. Results indicated that at the 85th BMI percentile, there was a greater increase in BMI from 2004 to 2020 among youths with NDDs compared with those without NDDs (β for interaction [βint] between NDD status and time, 1.67; 95% CI, 0.39-2.90). The greatest divergence was seen for ASD (βint, 2.12; 95% CI, 1.26-3.70) and learning disability (βint, 1.92; 95% CI, 0.65-3.82). Within the latest cohort (2016-2020), the 85th BMI percentile was 1.99 (95% CI, 1.08-2.89) points higher among children with NDDs compared with those without NDDs.

Conclusions and Relevance

In this repeated cross-sectional study, at the higher end of the BMI distribution, children with NDDs had significantly greater increases in BMI compared with peers without NDDs over a 16-year period, highlighting an increasing risk of overweight over time in youths with NDDs compared with those without NDDs. Targeted obesity prevention efforts for this high-risk population are needed.

From neurons to brain networks, pharmacodynamics of stimulant medication for ADHD

Stimulants represent the first line pharmacological treatment for attention-deficit/hyperactivity disorder (ADHD) and are among the most prescribed psychopharmacological treatments. Their mechanism of action at synaptic level has been extensively studied. However, it is less clear how their mechanism of action determines clinically observed benefits. To help bridge this gap, we provide a comprehensive review of stimulant effects, with an emphasis on nuclear medicine and magnetic resonance imaging (MRI) findings. There is evidence that stimulant-induced modulation of dopamine and norepinephrine neurotransmission optimizes engagement of task-related brain networks, increases perceived saliency, and reduces interference from the default mode network. An acute administration of stimulants may reduce brain alterations observed in untreated individuals in fronto-striato-parieto-cerebellar networks during tasks or at rest. Potential effects of prolonged treatment remain controversial. Overall, neuroimaging has fostered understanding on stimulant mechanism of action. However, studies are often limited by small samples, short or no follow-up, and methodological heterogeneity. Future studies should address age-related and longer-term effects, potential differences among stimulants, and predictors of treatment response.

Drug survival and risk factors for ADHD medication discontinuation in adults: A Danish Nationwide Registry-based cohort study

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) medication has proven effective for treating ADHD in adults, nonetheless previous studies have shown high rates of medication discontinuation.

OBJECTIVE

To assess drug survival and identify risk factors associated with discontinuation of ADHD medication.

METHODS

A nationwide registry-based cohort study in Danish adults who redeemed a prescription for ADHD medication for the first time between 2010 and 2015. All patients were followed for 5 years from the first redeemed prescription. Discontinuation was defined as a gap of 12 months between redemptions. Logistic regression analysis with odds ratio (OR) and Kaplan Meier analysis were used to examine risk factors (sex, age, socioeconomic status, substance use disorders, and comorbidities) associated with discontinuation.

RESULTS

Twenty three thousand nine-hundred and sixteen patients with ADHD were identified. The 5-year overall drug survival was 29% in women vs. 23.5% in men. The risk of medication discontinuation was significantly higher in men compared to women, OR 1.26 (95% CI 1.19-1.34, p < 0.001). Adults aged 31-50 years had a significantly decreased risk of medication discontinuation compared to adults aged 18-30 years, OR 0.57 (95% CI 0.53-0.61, p < 0.001). Switching ADHD medication two times or three times or more significantly decreased the risk of discontinuation; OR 0.53 (95% CI 0.49-0.56, p < 0.001) and OR 0.26 (95% CI 0.23-0.30, p < 0.001), respectively. Substance use disorders and certain comorbidities were associated with medication discontinuation. Eating disorders, OR 0.71 (95% CI 0.64-0.78, p < 0.001), intellectual disabilities, OR 0.65 (95% CI 0.59-0.73, p < 0.001) and sleep disorders, OR 0.42 (95% CI 0.37-0.49, p < 0.001) were associated with continuation of ADHD medication.

CONCLUSIONS

The 5-year overall drug survival was longer in women compared to men. Women with ADHD; adults aged 31-50; and patients with comorbid eating disorder; intellectual disability; sleep disorder and medication switching were individually associated with continuation of ADHD medication. Various factors were associated with medication discontinuation. Discontinuation should be acknowledged as a common phenomenon in patients with ADHD and calls for increased attention from the treatment responsible prescriber or team. Moreover, our findings suggest that timely, frequent medication switching, or temporary regimens may indeed represent optimal management strategies for a significant proportion of the ADHD population.

Adult Attention Deficit-Hyperactivity Disorder is associated with Lewy Body Disease and Cognitive Impairment: A prospective cohort Study With 15-year Follow-Up

OBJECTIVES

Past reports have suggested that attention-deficit/hyperactivity disorder (ADHD) may be a risk factor for Lewy body disease (LBD). To confirm this relationship, we conducted the present study.

DESIGN

A prospective observational cohort study with a follow-up to 15 years.

SETTING

The subjects were recruited from cognitive neurology clinics, where they attended for a cognitive complaint or health check-up.

PARTICIPANTS

Two groups of subjects: ADHD adults and healthy subjects.

MEASUREMENTS

The risk of dementia and LBD was estimated with Kaplan-Meier analysis comparing for the presence or absence of ADHD with the log-rank test. Predictors of conversion were assessed through separate univariate and multivariate Cox regression analyses, adjusting for several variables.

RESULTS

The baseline sample consisted of 161 subjects with ADHD and 109 without ADHD. At the end of the follow-up, 31 subjects developed dementia, 27 cases in the ADHD group and 4 in comparison group. Dementia with Lewy bodies (DLB) was the most frequent type (N:20) of which 19 corresponded to the ADHD group. The incidence of non-amnestic-MCI in the ADHD group was higher representing 67.1 % of these subjects (N:108), and 17.4% (N:19) of healthy cases. The hazard ratios for dementia and LBD in the multivariate adjusted model were 3.33 (95% CI 1.0915 to 10.1699) and 54.54 (95% CI 7.4849 to 397.5028), respectively in the ADHD group.

CONCLUSIONS

This study showed that adult ADHD is independently associated with an increased risk of LBD, dementia, and na-MCI. Future studies should clarify this relationship to develop preventive measures for these patients.

[Cannabinoid Drugs in the Treatment of Psychiatric Disorders - Data from the German Federal Institute for Drugs and Medical Devices]

BACKGROUND

Since 2017 physicians in Germany can prescribe cannabis based medicines or medical cannabis with subsequent funding by the statutory health insurance system.

METHODS

Physicians prescribing cannabinoid drugs were legally required to take part in a survey conducted by the Federal Institute for Drugs and Medical Devices. This study analyses data from 16.809 case reports that were collected from 30.3.2017 to 31.12.2021.

RESULTS

There were 5582 cases documenting the use of cannabinoid drugs in psychiatric disorders. More than half of the prescriptions were Dronabinol. 80% of the treatments concerned somatoform disorders. Most of the treatments for other psychiatric disorders also targeted pain. Doctors reported a positive effect on symptoms in at least 75% of the cases.

DISCUSSION

Most patients with psychiatric disorders received cannabinoid drugs for pain. The evidence from randomized controlled clinical trials for the use of cannabinoid drugs in psychiatric indications is weak.

Assessment of functioning in ADHD according to World Health Organization standards: First revision of the International Classification of Functioning, Disability and Health Core Sets

AIM

To conduct the first revision of the World Health Organization International Classification of Functioning, Disability and Health (ICF) Core Sets for attention-deficit/hyperactivity disorder (ADHD).

METHOD

A Delphi-like method was used, integrating evidence from stakeholder feedback and developing and piloting the ADHD ICF Core Set platform to inform revisions to the ADHD Core Sets.

RESULTS

A total of 27 second-level ICF codes were added to the comprehensive ADHD Core Set: body functions of temperament and personality, and basic sensory functions; activities and participation in terms of learning to read and write, spoken communication, community life, religion and spirituality, education, economy, and human rights; environmental factors for domestic animals; and several societal services. The revised comprehensive Core Set contains 98 ICF codes: 18 body function codes; 47 activities and participation codes; and 33 environmental factor codes. Extensive changes were also made to the age-appropriate brief Core Sets to allow their independent use in research and clinical practice.

INTERPRETATION

Although substantially expanded, the revised ICF Core Sets better reflect the lived experience of individuals with ADHD and clinical implementation preferences than the initial sets. We recommend further feasibility and validation studies of these Core Sets with the goal of optimizing their acceptance and practicability, and strengthening their evidence base.

Changes in parental attitudes toward attention-deficit/hyperactivity disorder impairment over time

Background

Over the last decades, the prevalence of Attention-deficit/hyperactivity disorder (ADHD) has increased. However, the underlying explanation for this increase remains unclear. We aimed to assess whether there has been a secular change in how parents perceive the impairment conferred by ADHD symptomatology.

Methods

Data for this study were obtained from the Child and Adolescent Twin Study in Sweden, involving 27,240 individuals whose parents answered a questionnaire when the children were 9 years old. We assessed the relationship between parentally perceived impairment caused by ADHD symptoms scores over time. The analysis was performed separately for five different birth cohorts, spanning three-year periods from 1995 to 2009 and for ADHD inattention and hyperactivity/impulsivity dimensions.

Results

We found a consistent upward trend of parents reporting impairment in relation to ADHD symptomatology across birth cohorts. Over a 12-year period, comparing those born 2007-2009 (assessed 2016-2018) with those born 1995-1997 (assessed 2004-2006), impairment scores increased by 27% at clinically relevant levels of ADHD symptomatology. Notably, when specifically evaluating the hyperactivity/impulsivity dimension, the disparity was even more striking, with an increase of up to 77%.

Conclusions

This study revealed a significant secular change in parental perception of impairment attributed to ADHD symptomatology over recent decades, providing new insights into the increased prevalence of ADHD. It underscores the need to better understand the factors that have contributed to the increased perception of impairment related to ADHD symptoms.

Assessment of the Quality of Life and Family Function in Attention Deficit Hyperactivity Disorder Caregivers in Al-Ahsa, Saudi Arabia

Background Attention deficit hyperactivity disorder (ADHD) is the most prevalent neurobehavioral disorder in children and teenagers. The condition is debilitating, affecting numerous cognitive and behavioral processes and leading to substantial long-term consequences. Affected individuals, their families, and society as a whole bear a heavy functional, psychological, and financial cost. Aim The objective of this study was to evaluate the quality of life (QOL) among parents of children with ADHD diagnoses, as well as the burden and level of dysfunction in the family. Additionally, to ascertain the sociodemographic factors that influence these issues. Methods This cross-sectional study used an online survey to collect data from caregivers of children with a confirmed diagnosis of any type of ADHD who were exhibiting symptoms before the age of seven, speaking Arabic fluently and consented to take part in the study. The Arabic version questionnaire of the World Health Organization Quality of Life instrument (WHOQOL-BREF) was used to assess the QOL, and the Zarit Burden Interview questionnaire was employed to assess the degree of the experienced burden. Participants were recruited by a systematic random sampling method. Results A total of 103 ADHD caregivers were included in the study. A total of 89 out of 103 (86.4%) participants reported having various degrees of burden. There was a significant relation between the marital status of the caregiver and the degree of burden (p=0.024). Divorced caregivers were (4, 57.1%) severely burdened. Ninety out of 103 participants (87.4%) reported having dysfunctional families, and the majority of them (60, 60.1%) reported moderate family dysfunction. All quality-of-life domains were negatively impacted, with the environmental domain experiencing the most disruption. The overall four subdomains of QOL did not differ significantly with various sociodemographic characteristics. Conclusion There was a high prevalence of burden and family dysfunction among caregivers of ADHD children. Marital status was associated with a significant impact on the level of burden. In addition, there was a detrimental influence on every aspect of quality of life, with the environmental domain suffering the most. It is important to take into account family therapy and other interventions that strengthen caregivers' and families' relationships.

Effect of ginseng and ginsenosides on attention deficit hyperactivity disorder: A systematic review

Attention deficit hyperactivity disorder (ADHD) is a rapidly increasing neurodevelopmental disorder but currently available treatments are associated with abuse risk, side effects, and incomplete symptom relief. There is growing interest in exploring complementary options, and ginseng has gained attention for its therapeutic potential. This systematic review aimed to assess current evidence on the efficacy of ginseng and its active components, ginsenosides, for ADHD. Eligible studies were identified through searches of PubMed, Embase, Cochrane Library, and Web of Science, up to June 2023. The inclusion criteria included both human and animal studies that investigated the effects of ginseng or ginsenosides on ADHD. The risk of bias was assessed according to study type. Six human studies and three animal studies met the inclusion criteria. The results suggest that ginseng and ginsenosides may have beneficial effects on ADHD symptoms, particularly inattention, through dopaminergic/norepinephrinergicmodulation and BDNF/TrkB signaling. Ginseng and ginsenosides have promising potential for ADHD treatment. Due to limitations in evidence quality, such as the risk of bias and variability in study designs, larger controlled studies are essential. Integrating ginseng into ADHD management may have valuable implications for individuals seeking well-tolerated alternatives or adjunctive therapies.

Attention-deficit/hyperactivity disorder and dopamine receptor D4 (DRD4) exon 3 variable number of tandem repeats (VNTR) 2-repeat allele

To investigate the association of attention-deficit/hyperactivity disorder (ADHD) with the 48-base pair (bp) variable number of tandem repeats (VNTR) in exon 3 of the dopamine receptor D4 (DRD4) gene, we genotyped 240 ADHD patients and their parents from Hong Kong. The 4R allele was most common, followed by 2R. We examined association between the 2R allele (relative to 4R) and ADHD by Transmission Disequilibrium Test (TDT). The odds ratio (OR) (95% confidence interval) was 0.90 (0.64-1.3). The p-value was 0.6. Examining subgroups revealed nominally significant association of 2R with inattentive ADHD: OR = 0.33 (0.12-0.92) and p = 0.03. Because our study used TDT analysis, we meta-analyzed the association of 2R with ADHD in Asians (1329 patient alleles), revealing results similar to ours: OR = 0.97 (0.80-1.2) and p = 0.8. To examine the association of 2R with inattentive ADHD, we meta-analyzed all studies (regardless of analysis type or ethnicity, in order to increase statistical power): 702 patient alleles, 1420 control alleles, OR = 0.81 (0.57-1.1) and p = 0.2. Overall, there is no evidence of association between ADHD and the 2R allele, but the suggestive association with the inattentive type warrants further investigation.

Assessing Brain Iron and Its Relationship to Cognition and Comorbidity in Children With Attention-Deficit/Hyperactivity Disorder With Quantitative Susceptibility Mapping

BACKGROUND

Quantitative susceptibility mapping is a neuroimaging technique that detects local changes in magnetic susceptibility induced by brain iron. Brain iron and the dopaminergic system are linked because iron is an important cofactor for dopamine synthesis. Attention-deficit/hyperactivity disorder (ADHD) is associated with dysregulation of dopaminergic transmission. Therefore, we applied quantitative susceptibility mapping on subcortical structures to study potential alterations in brain iron and its impact on cognition and mental health in children with ADHD.

METHODS

Quantitative susceptibility mapping data (3T) of 111 participants (nADHD = 58, mean [SD] age = 13.2 [0.63] years; nControl = 53, mean [SD] age = 13.2 [0.51] years) were analyzed. Subcortical regional brain iron values were extracted. Analysis of variance was used to examine group differences for each region of interest. For dimensional approaches, Pearson correlation analysis was performed across the cohort to examine the association of brain iron with symptoms, mental health, and cognition.

RESULTS

No significant differences were found in iron susceptibility between children with ADHD and control children, between children with persistent ADHD and those with remitted ADHD, or between medicated and medication-naïve children. An unexpected finding was that children with an internalizing disorder had significantly higher iron susceptibility, but the result did not survive multiple comparison correction. Higher brain iron was associated with sustained attention, but not inhibition, IQ, or working memory.

CONCLUSIONS

This is the first study to address brain iron susceptibility and its association with comorbidities and cognition in ADHD. Alterations in brain iron may not fully account for a diagnosis of ADHD but may be an indicator of internalizing problems in children. Alterations in brain iron content in children were linked to detrimental sustained attention and may represent developmental variation in cognition.

Serotonergic Drugs for the Treatment of Attention-Deficit/Hyperactivity Disorder: A Review of Past Development, Pitfalls and Failures, and a Look to the Future

Serotonin has been implicated in the neurobiology of attention-deficit/hyperactivity disorder (ADHD) due to its association with impulsivity, attention, and emotional regulation. Many compounds with serotonergic properties have been evaluated in ADHD, but few have been approved by regulatory authorities. Utilizing a search of public databases, we identified interventions studied in ADHD. Prescribing information and peer-reviewed and gray literature helped us to determine which compounds had an underlying mechanism of action associated with changing serotonin levels. Of the 24 compounds that met the search criteria, 16 had either failed clinical studies in an ADHD population or had been discontinued from future development. The available evidence was assessed to identify the developmental history of drugs with serotonergic activity and the outlook for new ADHD drug candidates targeting serotonin. Several treatment candidates floundered due to an inability to balance effectiveness with safety, underscoring the potential importance of potency, and selectivity. Ongoing drug development includes compounds with multimodal mechanisms of action targeting neurotransmission across serotonin, norepinephrine, and dopamine pathways; it appears likely that treatment which balances competing and complementary monoamine effects may provide improved outcomes for patients. It is hoped that continuing research into ADHD treatment will produce new therapeutic options targeting the serotonergic system, which can positively impact a wide range of symptoms, including mood, anxiety, and sleep as well as attention and hyperactivity.

Coping strategies and symptoms of Adjustment Disorder among adults with Attention Deficit Hyperactivity Disorder (ADHD) during the Covid-19 pandemic

BACKGROUND

The current study examined whether coping strategies and symptoms of Adjustment Disorder in adults with ADHD differed from what was observed in the general adult population during the Covid-19 pandemic, and compared the extent to which coping strategies and symptom levels of Adjustment Disorder were related to ADHD.

METHOD

This cross-sectional study was based on survey data collected during the spring of 2021 from 231 adult ADHD patients in specialist care and 1148 volunteers without ADHD in Sweden. The survey included questions about sociodemographic and clinical characteristics, along with the Brief-COPE and Adjustment Disorder-New Module 8 questionnaires. Regression models adjusting for sociodemographic and clinical characteristics were used for between-group comparisons of coping strategies and symptoms of Adjustment Disorder.

RESULTS

There were some notable differences in the use of coping strategies between persons with and without ADHD; however, many of these differences were not observed in the adjusted models. The use of behavioral disengagement was more frequently observed among individuals with ADHD, whereas planning was more common among individuals without ADHD. Individuals with ADHD appeared to show higher symptom levels of Adjustment Disorder during the pandemic. Passive coping strategies, such as denial, self-blame, and behavioral disengagement, were associated with higher symptom levels of adjustment disorder in both individuals with and without ADHD.

CONCLUSION

In conclusion, the results highlight that persons with ADHD may need more support to adjust to large societal changes than the general public. Potential targets for intervention towards members of this group include reducing resignation and maladaptive coping strategies.

Wider health needs in attention deficit hyperactivity disorder from lived and professional experience: a qualitative framework analysis

OBJECTIVES

This study aimed to explore the perspectives of people with attention deficit hyperactivity disorder (ADHD), their supporters and primary care professionals (PCPs), on the wider physical and mental health needs of people with ADHD and the support currently available.

DESIGN

Qualitative semi-structured interviews, analysed using reflexive thematic analysis.

SETTING

Five general practice surgeries across England.

PARTICIPANTS

Participants with lived experience (people with ADHD and their supporters (n=11)) and PCPs (n=9) (eg, general practitioners and practice managers), recruited via clinical academic networks and previous work packages of this study.

RESULTS

We generated three major themes in relation to ADHD, using reflexive thematic analysis: understanding health, barriers to health and addressing health. Within these, participants reflected on mental and physical health challenges, as well as wider social difficulties and variability in support offered/accessed.

CONCLUSIONS

This study highlights that health problems in ADHD are complex and rooted both in individual factors (eg, mental health) and social factors (eg, support). This study also highlights the differences in expectations and fulfilment of healthcare.

Effects of Auditory and Visual White Noise on Oculomotor Inhibition in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Crossover Study

BACKGROUND

In attention-deficit/hyperactivity disorder (ADHD), poor inhibitory control is one of the main characteristics, with oculomotor inhibition impairments being considered a potential biomarker of the disorder. While auditory white noise has demonstrated the ability to enhance working memory in this group, visual white noise is still unexplored and so are the effects of both types of white noise stimulation on oculomotor inhibition.

OBJECTIVE

This crossover study aims to explore the impact of auditory and visual white noise on oculomotor inhibition in children with ADHD and typically developing (TD) children. The study will investigate the impact of different noise levels (25% and 50% visual, 78 dB auditory), and performance will be evaluated both with and without noise stimulation. We hypothesize that exposure to white noise will improve performance in children with ADHD and impair the performance for TD children.

METHODS

Memory-guided saccades and prolonged fixations, known for their sensitivity in detecting oculomotor disinhibition in ADHD, will be used to assess performance. Children diagnosed with ADHD, withdrawing from medication for 24 hours, and TD children without psychiatric disorders were recruited for the study.

RESULTS

Data collection was initiated in October 2023 and ended in February 2024. A total of 97 participants were enrolled, and the first results are expected between September and November 2024.

CONCLUSIONS

This study will examine whether cross-modal sensory stimulation can enhance executive function, specifically eye movement control, in children with ADHD. In addition, the study will explore potential differences between auditory and visual noise effects in both groups. Our goal is to identify implications for understanding how noise can be used to improve cognitive performance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06057441; https://clinicaltrials.gov/study/NCT06057441.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56388.

Enhancing Ecological Validity: Virtual Reality Assessment of Executive Functioning in Children and Adolescents with ADHD

BACKGROUND

SmartAction-VR uses virtual reality to simulate daily life tasks and assess cognitive performance based on the multi-errand paradigm. This study explored whether this new task could provide insights into the executive functioning of children and adolescents with ADHD in their everyday activities.

METHODS

A cross-sectional study was conducted between November 2021 and December 2022. It consisted of one session and was divided into two parts (cognitive tests; and SmartAction-VR). The sample comprised 76 children and adolescents with a median age (IQR) of 13 (11-14) years and an age range of 9-17 years. Of these participants, 60.50% (n = 46) were males. Out of this sample, 40 participants were in the ADHD group and 36 were in the neurotypical group. The following instruments were used: Waisman Activities of Daily Living Scale, Assessment of Sensory Processing and Executive Functioning, Pediatric Simulator Disease Questionnaire, Digit span subtest, Stroop test, NEPSY-II Subtest of Auditory Attention and Cognitive Flexibility, Trail Making Test, Zoo Map Test, and SmartAction-VR.

RESULTS

The ADHD group demonstrated lower accuracy (U = 406, p = 0.010), higher values for total errors (U = 292, p = 0.001), more commissions (U = 417, p = 0.003), new actions (U = 470, p = 0.014), and forgetting actions (U = 406, p = 0.010), as well as fewer perseverations compared to the neurotypical group (U = 540.5, p = 0.029). Additionally, participants who forgot more actions were found to have lower independence in daily life (r = -0.281, p = 0.024).

CONCLUSIONS

The correlations between the results of SmartAction-VR and activities of daily living, as well as cognitive tests, suggest that this new task could be useful for evaluating executive functioning in daily life.

Temporal patterns in adolescent psychiatric treatment and outcomes: a nationwide register-based cohort follow-up

The rise in mental health problems among adolescents in high-income countries presents a challenge to service systems. For the development of services, there is a need for better insight into temporal psychiatric treatment-trends and outcomes. This study aims to analyze time-trends in both psychiatric treatment patterns and outcomes, utilizing a national sample of all adolescents receiving psychiatric treatment in Finland from 2003 to 2013. For time-trend-analysis, the sample was divided into two cohorts, using the onset year of 2008 as a cutoff. For each case, information on psychiatric treatment was gathered from registers within a five-year follow-up period from the onset of treatment or to death. The association between the inclusion year and outcome variables was studied via weighted generalized linear models. Adolescents in the latter cohort had a greater proportion (p < 0.001) of mood and anxiety diagnoses, a lower likelihood of hospitalization, a higher average of outpatient visits, and greater usage of psychotropics (excluding benzodiazepines). Those whose treatment began after 2008 were more likely to be alive (baseline characteristic adjusted Odds Ratio (aOR): 0.7, 95%CI: 0.6-0.8) and still in treatment contact (aOR: 1.4, 95%CI: 1.3-1.4) after four years from the onset. There was no difference in the long-term disability ratio. The results indicate favorable developments towards outpatient care in mental health services for adolescents with a significant decrease in mortality. Approaches to further developing cost-effective, personalized mental health services are discussed.

Quantification of ADHD medication in biological fluids of pregnant and breastfeeding women with liquid chromatography: a comprehensive review

Attention Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder that has long been considered a concern only in the pediatric population. However, symptoms often sustain into adulthood and may require medication. For women with ADHD, this also means dealing with the disorder during the reproductive period. Medication safety during pregnancy and breastfeeding is a critical concern, and the potential transfer of ADHD medication to infants remains a topic of scientific interest. The quantification of ADHD medications in both maternal blood and breast milk are vital for understanding their pharmacokinetics and potential exposure risks for (nursing) infants. This review aims (1) to compile and critically assess existing research on the transfer of ADHD medications into breast milk and the potential implications for nursing infants and (2) to provide a comprehensive overview and discussion of the literature regarding the quantification of methylphenidate, amphetamine, atomoxetine, viloxazine, guanfacine, clonidine and bupropion in the blood, urine, oral fluid, and breast milk with liquid chromatography. A literature search was conducted using PubMed, Scopus, and Web of Science, to identify relevant articles published from January 2014 up to December 2023. We illustrate the lack of methods to simultaneously monitor multiple ADHD medications as well as the lack of developed methods for breast milk. Finally, we highlight the need for continued research to refine our understanding of medication transfer into breast milk and potential risks, and to develop clinical guidelines to support mothers with ADHD in making informed choices regarding medication use during pregnancy and lactation.

Medication adherence and persistence in children and adolescents with attention deficit hyperactivity disorder (ADHD): a systematic review and qualitative update

Low medication-adherence and persistence may reduce the effectiveness of ADHD-medication. This preregistered systematic review (PROSPERO CRD42020218654) on medication-adherence and persistence in children and adolescents with ADHD focuses on clinically relevant questions and extends previous reviews by including additional studies. We included a total of n = 66 studies. There was a lack of consistency in the measurement of adherence/persistence between studies. Pooling the medication possession ratios (MPR) and using the most common adherence definition (MPR ≥ 80%) indicated that only 22.9% of participants had good adherence at 12-month follow-up. Treatment persistence on medication measured by treatment duration during a 12-month follow-up averaged 170 days (5.6 months). Our findings indicate that medication-adherence and persistence among youth with ADHD are generally poor and have not changed in recent years. Clinicians need to be aware that various factors may contribute to poor adherence/persistence and that long-acting stimulants and psychoeducational programs may help to improve adherence/persistence. However, the evidence to whether better adherence/persistence contributes to better long-term outcomes is limited and requires further research.

Exploring role of prefrontal cortex region of brain in children having ADHD with machine learning: Implications and insights

OBJECTIVE

Attention deficit hyperactivity disorder (ADHD), is a general neurodevelopmental syndrome. This affects both adults and children, causing issues like hyperactivity, inattention, and impulsivity. Diagnosis, typically reliant on patient narratives and questionnaires, can sometimes be inaccurate, leading to distress. We propose utilizing empirical mode decomposition (EMD) for feature extraction and a machine learning (ML) algorithm to categorize ADHD and control.

METHOD

Publicly available Kaggle dataset is used for research. The EMD technique decomposes an electroencephalogram (EEG) waveform to 12 intrinsic mode functions (IMFs). Thirty-one statistical parameters are generated over the first 6 IMFs to create an input feature vector for the deep belief network (DBN) classifier. Principal component analysis (PCA) is utilized to reduce dimension.

FINDINGS

Experimental results are compared on prefrontal cortex channels Fp1 and Fp2. After an in-depth evaluation of all metrics, it is observed that, in patients with ADHD, the prefrontal cortex regulates attention, behavior, and emotion. Our findings align with established neuroscience. The critical functions of the brain, such as organization, planning, attention, and decision making, are performed by the frontal lobe.

NOVELTY

Our work provides a novel approach to understanding the disorder's underlying neurobiological mechanisms. It has the potential to deepen our understanding of the condition, improve diagnostic accuracy, personalize treatment methods, and, ultimately, improve outcomes for those affected.

The adult ADHD assessment quality assurance standard

Background

Attention Deficit Hyperactivity Disorder (ADHD) frequently persists into adulthood. There are practice guidelines that outline the requirements for the assessment and treatment of adults. Nevertheless, guidelines specifying what constitutes a good quality diagnostic assessment and report and the competencies required to be a specialist assessor are lacking. This can lead to variation in the quality and reliability of adult ADHD assessments. Poor quality assessments may not be accepted as valid indicators of the presence of ADHD by other clinicians or services, resulting in wasteful re-assessments and delays in providing treatment. To address this issue the UK Adult ADHD Network (UKAAN) proposes a quality framework for adult ADHD assessments - the Adult ADHD Assessment Quality Assurance Standard (AQAS).

Methods

The co-authors agreed on five questions or themes that then guided the development of a set of consensus statements. An initial draft was reviewed and amended in an iterative process to reach a final consensus.

Results

What constitutes a high-quality diagnostic assessment and report was agreed by consensus of the co-authors. The resulting guideline emphasises the need to evaluate impairment, describes core competencies required by the assessor and highlights the importance of linking the diagnosis to an appropriate post-diagnostic discussion. Assessments should be completed in the context of a full psychiatric and neurodevelopmental review, and need good interview skills, using a semi-structured interview with open questioning and probing to elicit real life examples of symptoms and impairments. It is recommended that 2 hours or more is required for an adequate assessment including both the diagnostic assessment and initial post-assessment discussions.

Conclusion

The AQAS has been developed as a practical resource to support reliable and valid diagnostic assessments of adult ADHD. It is intended to complement formal training. A secondary objective is to empower patients by providing them with evidence-based information on what to expect from an assessment and assessment report.

Attention Deficit/Hyperactivity Disorder in Individuals with Non-Syndromic Craniosynostosis: A Systematic Review and Meta-Analysis

It is not yet understood whether, and to what extent, craniosynostosis impacts the development of Attention Deficit/Hyperactivity Disorder (ADHD). This PRISMA compliant and PROSPERO pre-registered (ID: CRD42023458640) systematic review and meta-analysis examines the association of single-suture, non-syndromic craniosynostosis with ADHD and inattention/hyperactivity symptoms. Data from 17 independent studies (Nparticipants = 2,389; Mage = 7.3 years) were analyzed, taking into consideration suture location, surgical status, age, and measures administered, where feasible. Few differences were found between cases and controls, but some studies reported high symptom levels. Additional research is required utilizing larger sample sizes and more comprehensive assessment of ADHD.

Current nonstimulant medications for adults with attention-deficit/hyperactivity disorder

INTRODUCTION

Stimulants, including methylphenidate and amphetamines, are the first-line pharmacological treatment of ADHD in adults. However, in patients who do not respond or poorly tolerate stimulants, non-stimulant medications are usually recommended.

AREAS COVERED

The authors provide a narrative review of the literature on non-stimulant treatments for adult ADHD, including controlled and observational clinical studies conducted on adult samples. Atomoxetine has been extensively studied and showed significant efficacy in treating adult ADHD. Issues related to dosing, treatment duration, safety, and use in the case of psychiatric comorbidity are summarized. Among other compounds indicated for ADHD in adults, antidepressants sharing at least a noradrenergic or dopaminergic component, including tricyclic compounds, bupropion, and viloxazine, have shown demonstratable efficacy. Evidence is also available for antihypertensives, particularly guanfacine, as well as memantine, metadoxine, and mood stabilizers, while negative findings have emerged for galantamine, antipsychotics, and cannabinoids.

EXPERT OPINION

While according to clinical guidelines, atomoxetine may serve as the only second-line option in adults with ADHD, several other nonstimulant compounds may be effectively used in order to personalize treatment based on comorbid conditions and ADHD features. Nevertheless, further research is needed to identify and test more personalized treatment strategies for adults with ADHD.