ADHD in adults: a review of the literature

Impact of the impairment criterion in the diagnosis of adult ADHD: 33-year follow-up study of boys with ADHD

OBJECTIVE

To investigate the relationship between ADHD symptoms and impairment among adults diagnosed as having ADHD in childhood (ages 6-12).

METHOD

Clinicians blindly interviewed 121 White males; the mean age was 41 years across the sample. DSM-IV adult ADHD behaviors were systematically rated, and impairment resulting from symptoms was scored on a 5-point Likert-type scale.

RESULTS

Correlations between degree of impairment and number of behaviors were high (r's = .83 to .85, p < .001). The impairment criterion had no effect on classifying any participants as having, or not having, adult ADHD. All participants who reported experiencing 5 or more inattention or hyperactive-impulsive behaviors as "often" or "very often" in adulthood were significantly impaired by their symptoms.

CONCLUSIONS

Contrary to results reported in children, there was a strong relationship between number of ADHD symptoms and degree of impairment. However, for several reasons (discussed in the article), it should not be concluded that the impairment criterion is superfluous.

Long-term safety of OROS methylphenidate in adults with attention-deficit/hyperactivity disorder: an open-label, dose-titration, 1-year study

OBJECTIVE

To evaluate the long-term safety of OROS methylphenidate in the management of attention-deficit/hyperactivity disorder (ADHD) in adults.

METHODS

This multicenter, open-label, dose-titration, flexible dose study enrolled adults with ADHD for 6 or 12 months of treatment with OROS methylphenidate. Dosing began at 36 mg/d, with titration in 18-mg increments every 7 days until a predefined outcome (efficacy threshold, maximum dosage of 108 mg/d, or limiting adverse event). Dose reduction occurred for prespecified reasons, and the subjects discontinued if unable to tolerate 36 mg/d. Assessments included ADHD symptoms, adverse events, vital signs, and laboratory results.

RESULTS

A total of 550 subjects received treatment (52% were men; mean age, 39 years; range, 18-65 years), and 57% (146/258) and 44% (129/292) completed their 6 or 12 months of treatment with mean durations of 128 and 213 days, respectively. The final prescribed dosages were 36 mg/d (22.4%), 54 mg/d (25.1%), 72 mg/d (22.0%), 90 mg/d (17.1%), and 108 mg/d (13.5%). Modest increases from baseline to final visit were observed in mean systolic (2.6 mm Hg) and diastolic (1.9 mm Hg) blood pressure and pulse (4.1 beats per minute). The mean weight decreased by 2.3 kg. No clinically meaningful changes in laboratory values or electrocardiogram parameters were observed other than increased heart rate. Most common adverse events included decreased appetite (26.7%), headache (24.0%), and insomnia (20.7%). No serious adverse event was considered related to study medication. Several measures of efficacy indicated improvement during the study.

CONCLUSIONS

OROS methylphenidate, in the flexible dosage range from 36 to 108 mg/d, was well tolerated for up to 1 year in adults with ADHD.

Preferences related to attention-deficit/hyperactivity disorder and its treatment

OBJECTIVES

A growing body of literature has highlighted the importance of considering patient preferences as part of the medical decision-making process. The purpose of the current review was to identify and summarize published research on preferences related to attention-deficit/hyperactivity disorder (ADHD) and its treatment, while suggesting directions for future research.

METHODS

A literature search identified 15 articles that included a choice-based assessment of preferences related to ADHD.

RESULTS

The 15 studies were grouped into four categories based on preference content: preference for a treatment directly experienced by the respondent or the respondent's child; preference for general treatment approaches; preference for a specific treatment attribute or outcome; and preference for aspects of ADHD-related treatment. Preference assessment methods ranged from global single items to detailed choice-based procedures, with few studies using rigorously developed assessment methods. Respondents included patients with ADHD, clinicians, parents, teachers, and survey respondents from the general population. Factors influencing preference include treatment characteristics, effectiveness for specific symptoms, side effects, and respondent demographics. Minimal research has examined treatment preferences of adults with ADHD.

DISCUSSION

Because there is no dominant treatment known to be the first choice for all patients, ADHD is a condition for which individual preferences can play an important role when making treatment decisions for individual patients. Given the potential role of preferences in clinical decision-making, more research is needed to better understand the preferences of patients with ADHD and other individuals who are directly affected by the disorder, such as parents and teachers.

The history of attention deficit hyperactivity disorder

The contemporary concept of attention deficit hyperactivity disorder (ADHD) as defined in the DSM-IV-TR (American Psychiatric Association 2000) is relatively new. Excessive hyperactive, inattentive, and impulsive children have been described in the literature since the nineteenth century. Some of the early depictions and etiological theories of hyperactivity were similar to current descriptions of ADHD. Detailed studies of the behavior of hyperactive children and increasing knowledge of brain function have changed the concepts of the fundamental behavioral and neuropathological deficits underlying the disorder. This article presents an overview of the conceptual history of modern-day ADHD.

Efficacy of reboxetine in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled clinical trial

OBJECTIVE

The main aim of this study is to evaluate the efficacy of reboxetine, a specific noradrenergic reuptake inhibitor, in adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

In a double blind placebo-controlled clinical trial, the efficacy of 8 mg/day of reboxetine (twice daily) was compared with placebo in 40 adults diagnosed with ADHD during 6 weeks. The measures were Conners' Adult ADHD Rating Scale-Self-Report, Screening Version (CAARS-S, SV), Hamilton Anxiety and Depression Rating Scales, Clinical Global Impression - Severity Scale (CGI-S), and Global Assessment of Functioning Scale (GAF).

RESULTS

There was a main effect of time and significant time X treatment (reboxetine vs. placebo) interaction on CAARS subscales and CGI scores which decreased along the study (p < 0.01). There was also a main effect of time and time X treatment interaction on GAF score which increased at the end point of the study (p < 0.01). In terms of Hamilton Anxiety and Depression Rating Scales there was just a main effect of time on Hamilton Depression Scale (p < 0.01). Irritability, anxiety, sleep disturbance, and dry mouth were the common side effects of reboxetine.

CONCLUSION

Reboxetine could be used and tolerated as an effective treatment for adults with ADHD.

Correlating family nurse practitioners' perspectives of adult ADD/ADHD with employed pharmacotherapy: a pilot study

PURPOSE

This study explores how family nurse practitioners (FNPs) in the state of Washington view adulthood attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) and how these views affect the pharmacotherapy FNPs employ.

DATA SOURCES

A confidential survey containing 30 questions was mailed to self-selected FNPs who practice in the state of Washington (N= 126). Descriptive and Kendall's rank correlations coefficient statistical methods were used for data analysis.

CONCLUSIONS

The majority of respondents do not hold negative views toward adults with ADD/ADHD and are aware that their personal views may affect how they treat the disorder. Most of the respondents agreed that given the likelihood of co-morbidity of adult ADD/ADHD, it can be a challenge to diagnose the disorder. The predominant prescribed medications for adult ADD/ADHD are consistent with current pediatric guidelines, with the exception of buproprion, which was identified by 40% of the respondents as either their primary or secondary drug of choice for treating adult ADD/ADHD.

IMPLICATIONS FOR PRACTICE

Research effort needs to focus on the efficacy of buproprion for treating ADD/ADHD in adults. Moreover, exploration of the effectiveness of current pediatric guidelines to treat ADD/ADHD in adults must be assessed.

German validation of the Conners Adult ADHD Rating Scales-self-report (CAARS-S) I: factor structure and normative data

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood. Instruments for diagnosing ADHD in childhood are well validated and reliable, but diagnosis of ADHD in adults remains problematic. Attempts have been made to develop criteria specific for adult ADHD, resulting in the development of self-report and observer-rated questionnaires. To date, the Conners Adult ADHD Rating Scales (CAARS) are the international standard for questionnaire assessment of ADHD. The current study evaluates a German version of the CAARS self-report (CAARS-S).

METHODS

Eight hundred and fifty healthy German control subjects were recruited to fill out the CAARS-S and to answer questions on sociodemographic variables. Explorative and confirmative factor analyses were conducted to obtain the factor structure for the German model and to replicate the factor structure of the original American model. Analyses on gender, age, and education level were calculated for normative data.

RESULTS

The explorative factor analysis of the German sample results in a six-factor solution that explained 52% of the variance. A confirmative analysis that was based on the 42 items of the original American model showed a high model-fit. Analyses of normative data showed significant influences of age, gender, and education level on the emerging subscales.

CONCLUSION

Even though the explorative factor analysis yields a solution different from the American original, the confirmative factor analysis results in such a high model-fit that use of the American version is justified with respect to international multicenter studies, for which this instrument will be highly valuable.

Symptom prevalence of ADHD in a community residential substance abuse treatment program

OBJECTIVE

ADHD is a common comorbid condition with substance use disorder. This study seeks to examine the discrepancy in the prevalence rate between those previously diagnosed with ADHD and those diagnosed while in treatment. It is hypothesized that clients with ADHD would have earlier unsuccessful terminations from treatment than non-ADHD clients and that the ADHD Self-Report Scale (ASRS Version 1.1) would be a reliable predictor.

METHOD

Participants (N = 87) are admitted to a publicly funded 28-day residential treatment program. All participants are screened with the ASRS and participate in a clinical assessment evaluation.

RESULTS

A significant difference is found between the clinical record rate of 3.44% and the 43.68% rate found during treatment. The ASRS significantly predicts ADHD.

CONCLUSIONS

The use of the ASRS is recommended and should be incorporated into standard intake assessment protocols. Careful diagnostic interviews are urged to determine if clients in residential treatment have ADHD.

ADHD-related symptoms among adults in out-patient psychiatry and female prison inmates as compared with the general population

OBJECTIVE

To compare the prevalence of symptoms consistent with attention deficit hyperactivity disorder (ADHD) and related problems in adults in the general population, out-patient psychiatry (where females are in majority), and female convicts.

METHOD

A questionnaire based on the DSM-IV criteria of ADHD, reported childhood symptoms, reading and spelling problems, difficulties and suffering, and general assessment of functioning (GAF) was distributed to samples of the general population, open care psychiatry, and female prison inmates. Completed questionnaires were received from 517/1000, 349/400, and 50/65 of the three samples, respectively.

RESULTS

Symptoms consistent with ADHD were more than three times higher in out-patient psychiatry than in the general population (6.6% versus 2.1%), with a male-to-female ratio of 1.6-1.7. The severity of symptoms and frequencies of associated disabilities were similar in men and women. ADHD symptoms and related problems occurred in 50% of the female prisoners, which is similar to male prisoners according to the literature.

CONCLUSION

The high prevalence of symptoms and disabilities of ADHD in women should lead to awareness of the disorder in both sexes and be addressed in terms of diagnostic work-up, treatment, and rehabilitation.

Self-reported adult attention-deficit/hyperactivity disorder symptoms among college students

OBJECTIVE

Report the distribution of scores from the Adult ADHD Self-Report Scale (ASRS) and estimate the prevalence of self-reported attention-deficit/hyperactivity disorder (ADHD) symptoms as compared to clinical diagnoses.

PARTICIPANTS

Participants were 1,080 college students, divided into 3 groups: (1) no ADHD diagnosis (n = 972), (2) diagnosed with ADHD but no current pharmacologic treatment (n = 54), and (3) diagnosed with ADHD with current pharmacologic treatment (n = 54).

METHODS

The ASRS was administered during the fourth annual interview of an ongoing longitudinal cohort study.

RESULTS

As expected, individuals who were never clinically diagnosed with ADHD had lower ASRS scores (M = 4.0, SD = 3.3) than individuals diagnosed with ADHD who were either under current pharmacologic treatment (M = 7.9, SD = 4.0) or not under treatment (M = 6.3, SD = 3.7). Overall, 10.3%wt of individuals without an existing clinical diagnosis of ADHD had high levels of ADHD symptoms.

CONCLUSIONS

A substantial minority of undiagnosed individuals may benefit from a clinical assessment for ADHD.

Unveiling the mystery about adult ADHD: one woman's journey

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

Nearpoint phorias after nearwork predict ADHD symptoms in college students

PURPOSE

Phorometric findings have been observed to change with stress. We test the hypothesis that postnearwork phorias predict symptoms that have been theorized to result from nearwork-induced visual stress.

METHODS

We measured nearpoint and farpoint dissociated phorias in 37 unselected college students with an alternate cover test both before and after a challenging reading comprehension test. We also assessed a broad range of putative attention deficit hyperactivity disorder (ADHD)-related symptoms with the Nadeau College-level ADHD Questionnaire.

RESULTS

For phorias measured at nearpoint after nearwork, greater deviation from the median phoria (three exophoria) predicted higher symptoms (rho (35) = 0.52, p < 0.001), whether that deviation was in a convergent or a divergent direction (both rho's (18) = >0.48, p's < 0.04). An analogous result was obtained for "distance-near" stimulus accommodative convergence to accommodation (AC/A) ratios calculated from phorias, where greater deviation from median postnearwork AC/A ratio predicted higher symptoms (rho (35) = 0.52, p < 0.0001). Symptoms did not correlate with prenearwork phorias, prenearwork AC/A ratios, or postnearwork farpoint phorias (p's > 0.05).

CONCLUSIONS

Phorias postnearwork, but not prenearwork, predicted self-reported ADHD-related symptoms in college students. These results link binocular imbalance immediately after sustained nearwork to symptoms theorized to result from nearwork-induced visual stress.

Efficacy and safety of OROS methylphenidate in adults with attention-deficit/hyperactivity disorder: a randomized, placebo-controlled, double-blind, parallel group, dose-escalation study

OBJECTIVE

To assess the efficacy and safety of OROS methylphenidate (Concerta; McNeil Pediatrics Division of Ortho-McNeil-Janssen Pharmaceuticals, Inc, Titusville, NJ) in the management of attention-deficit/hyperactivity disorder (ADHD) in adults.

METHODS

A randomized, 7-week, double-blind, placebo-controlled, dose-escalation, parallel-group study of OROS methylphenidate 36, 54, 72, 90, or 108 mg/d versus placebo was conducted in adults with ADHD. The primary end point was the Adult ADHD Investigator Symptom Report Scale. Other assessments included the Clinical Global Impressions-Improvement scale, a post hoc responder analysis, adverse events, and vital signs.

RESULTS

Two hundred twenty-six subjects (56.2% male; mean age, 39.0 years; range, 18-65 years) were included in the intention-to-treat population (110 subjects on OROS methylphenidate; 116 subjects on placebo). OROS methylphenidate resulted in greater ADHD symptom improvement than placebo as demonstrated by a statistically significantly lower least squares mean change from baseline in Adult ADHD Investigator Symptom Report Scale total score at the final visit (last observation carried forward [LOCF]; P = 0.012). Subjects on OROS methylphenidate also had a significantly lower least squares mean Clinical Global Impressions-Improvement score at the final visit (LOCF; P = 0.008). A significantly greater proportion of subjects on OROS methylphenidate (36.9%, 38/103 subjects) were responders at the final visit (LOCF) compared with placebo (20.9%, 24/115 subjects; P = 0.009). OROS methylphenidate was well tolerated. Adverse events were reported by 93 (84.5%) of the 110 OROS methylphenidate-treated subjects versus 74 (63.8%) of the 116 placebo-treated subjects. No serious treatment-emergent adverse events and no deaths were reported. Similar mean changes from baseline to final visit (LOCF) for systolic and diastolic blood pressures for the OROS methylphenidate and placebo groups were observed.

CONCLUSIONS

In a dose escalation ranging from 36 to 108 mg/d, OROS methylphenidate is effective and well tolerated in the management of ADHD in adults.

Attention-deficit/hyperactivity disorder in adults: evidence-based recommendations for management

Attention-deficit/hyperactivity disorder (ADHD) is associated with impairments in educational, occupational, neuropsychological, and social functioning in adults. Successful diagnosis and treatment of the disorder in adults can be a challenge because recent and integrative clinical guidelines are lacking and diagnostic criteria are based on making a retrospective diagnosis of childhood-onset ADHD. To develop evidence-based recommendations for the treatment of ADHD in adults, the scientific literature was reviewed, including primary clinical studies, meta-analyses, and available clinical guidelines. Studies show that stimulant therapy is highly effective and safe in the management of ADHD in adults, with similar response rates to those reported in children at doses that are equivalent on a mg/kg basis. Long-acting stimulants, such as OROS methylphenidate (OROS MPH, Concerta), dexmethylphenidate (d-MPH, Focalin), and mixed amphetamine salts extended release (MAS XR, Adderall XR), have durations of action of up to 10 to 12 hours, which permit once-daily dosing. For adults with ADHD who do not respond to stimulant therapy or who have a comorbid condition in which a stimulant is contraindicated, the nonstimulant atomoxetine (Strattera) may be an appropriate alternative. For many adults, cognitive-behavioral therapy in addition to pharmacotherapy may improve treatment response. Attention-deficit/hyperactivity disorder medications may increase blood pressure and heart rate in adults, so patients should be monitored.