Attention-deficit/hyperactivity disorder in adults: an overview

Transition to adult mental health services for young people with attention deficit/hyperactivity disorder (ADHD): a qualitative analysis of their experiences

BACKGROUND

There is little research on the process of transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). More recently, there is growing recognition that Attention Deficit/Hyperactivity Disorder (ADHD) may persist into adulthood requiring services beyond age 18. However, despite National Institute for Health and Clinical Excellence (NICE) Guidance which recommends specialist services for adults with ADHD, there is currently a lack of such services in the UK. The aim of the current study is to explore the experiences of young people with ADHD during transition from CAMHS to AMHS.

METHOD

Semi-structured qualitative interviews with ADHD patients accessing CAMHS clinics in Nottinghamshire were analysed using thematic analysis.

RESULTS

Ten semi-structured interviews were transcribed and analysed. We found that patients' relationships with their clinician were a key factor in both their reported experience of CAMHS and the transition process. Perceived responsibility of care was also pivotal in how the transition process was viewed. Nature and severity of problems and patients expectations of adult services were also contributing factors in the transition process. The need for continued parental support was openly accepted and thought to be required by the majority of young people with ADHD during transition.

CONCLUSIONS

Timely preparation, joint working, good clinician relationships and parental support serve to facilitate the process of transition for young people with ADHD. Nature and severity of problems are perceived to impede or facilitate transition, with predominantly more 'complex presentations' with associated mental health problems more familiar to AMHS (e.g. self-harm, depression) making for smoother transitions to adult services. Transitions to AMHS were more difficult when ADHD was viewed as the main or sole clinical problem. Further exploration of young people's experiences of transition and their engagement with and experience of adult services is required to provide an overall picture of facilitators to successful transition and integration into adult services.

Diagnostic Profiles among Urban Adolescents with Unmet Treatment Needs: Comorbidity and Perceived Need for Treatment

The goal of this study was to document comorbidity profiles of psychiatric disorder and perceived need for treatment among urban adolescents with unmet behavioral health needs. Participants were 303 community-referred adolescents and their primary caregivers. Adolescents included both boys (54%) and girls and were primarily Hispanic (58%), African American (23%), and multiracial (13%). Home-based interviews with both adolescents and caregivers were used to assess DSM-IV diagnoses and perceived treatment needs. Most adolescents (80%) were diagnosed with multiple disorders and most families (66%) reported a need to treat more than one disorder. Latent class analysis of endorsed DSM-IV disorders identified five distinct diagnostic profiles: Parental Concern, Adolescent Distress, Basic Externalizers, Severely Distressed, and Comorbid Externalizers. Diagnostic profiles were compared on perceived treatment need and related psychosocial risk characteristics. Implications for behavioral health care policy and practice for youth with unmet treatment needs are discussed.

Management of adult attention deficit hyperactivity disorder in UK primary care: a survey of general practitioners

BACKGROUND

Compared to existing literature on childhood attention deficit hyperactivity disorder (ADHD), little published adult data are available, particularly outside of the United States. Using General Practitioner (GP) questionnaires from the United Kingdom, this study aimed to examine a number of issues related to ADHD in adults, across three cohorts of patients, adults who received ADHD drug treatment in childhood/adolescence but stopped prior to adulthood; adults who received ADHD drug treatment in childhood/adolescence and continued treatment into adulthood and adults who started ADHD drug treatment in adulthood.

METHODS

Patients with a diagnosis of ADHD and prescribed methylphenidate, dexamfetamine or atomoxetine were identified using data from The Health Improvement Network (THIN). Dates when these drugs started and stopped were used to classify patients into the three cohorts. From each cohort, 50 patients were randomly selected and questionnaires were sent via THIN to their GPs.GPs returned completed questionnaires to THIN who forwarded anonymised copies to the researchers. Datasets were analysed using descriptive statistics.

RESULTS

Overall response rate was 89% (133/150). GPs stated that in 19 cases, the patient did not meet the criteria of that group; the number of valid questionnaires returned was 114 (76%). The following broad trends were observed: 1) GPs were not aware of the reason for treatment cessation in 43% of cases, 2) patient choice was the most common reason for discontinuation (56%), 3) 7% of patients who stopped pharmacological treatment subsequently reported experiencing ADHD symptoms, 4) 58% of patients who started pharmacological treatment for ADHD in adulthood received pharmacological treatment for other mental health conditions prior to the ADHD being diagnosed.

CONCLUSION

This study presents some key findings relating to ADHD; GPs were often not aware of the reason for patients stopping ADHD treatment in childhood or adolescence. Patient choice was identified as the most common reason for treatment cessation. For patients who started pharmacological treatment in adulthood, many patients received pharmacological treatment for comorbidities before a diagnosis of ADHD was made.

Sensory and sensorimotor gating in adult attention-deficit/hyperactivity disorder (ADHD)

Even though there is an impaired perceptual capacity in attention-deficit/hyperactivity disorder (ADHD) patients, psychophysiological alterations, such as impaired gating as indexed by prepulse inhibition (PPI) or suppression of P50 auditory event-related potentials, have not been found in patients with ADHD. Hence, potential relationships of psychophysiological measures of gating to psychopathology and cognitive performance remain unclear. The present study investigates two distinct operational measures of gating as well as cognitive performance within adult ADHD patients in order to assess the relationship of these measures to psychopathology. PPI, P50 suppression, cognitive performance, and psychopathologic symptoms were assessed in 26 ADHD patients and 26 healthy control subjects. ADHD patients compared to healthy control subjects exhibited impaired P50 suppression, performed worse in cognitive tasks, and reported more psychopathological symptoms, but were normal in the test of PPI. Thus, P50 gating deficits are not specific to schizophrenia-spectrum disorders. These findings highlight the differences between P50 gating and PPI as measures of the gating construct. In keeping with the lack of correlations between these two putative operational measures of gating seen in both humans and animals, adult ADHD patients exhibit deficient P50 suppression and poor cognitive performance, despite exhibiting normal levels of PPI.

Associations between attention deficit hyperactivity disorder symptom domains and DSM-IV lifetime substance dependence

BACKGROUND AND OBJECTIVES

Most studies of attention deficit hyperactivity disorder (ADHD) in the substance dependence literature have assessed ADHD as a single, categorical entity. This approach limits characterization across the spectrum of ADHD symptomatology and may mask differences across the two core domains of ADHD symptoms-hyperactive-impulsive (HI) and inattention (IN). Further, it is unclear whether relations of HI and IN symptoms to substance dependence extend across drug classes and to the general population.

METHODS

This cross-sectional study investigated associations of lifetime ADHD HI and IN symptom levels to individual classes of lifetime substance dependence (alcohol, nicotine, depressants, opioids, stimulants, cannabis, hallucinogens, polysubstance) in a population-based sample of 34,653 American adults.

RESULTS

HI and IN were associated with the majority of dependence diagnoses in a linear pattern, such that each additional symptom was associated with a proportional increase in odds of dependence. After adjusting for the overlap between symptom domains, both HI and IN uniquely associated with alcohol, nicotine, and polysubstance dependence, but only HI uniquely associated with dependence on illicit substances.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

These findings suggest that individuals in the general population with elevated levels of ADHD (particularly HI) symptoms are at risk for various forms of substance dependence and could benefit from preventive interventions.

An inventory of European data sources for the long-term safety evaluation of methylphenidate

To compile an inventory of European healthcare databases with potential to study long-term effects of methylphenidate (MPH) in patients with attention deficit hyperactivity disorder (ADHD). Potential databases were identified through expert opinion, the website of the European Network of Centres for Pharmacoepidemiology and Pharmacovigilance, and literature search. An online survey was conducted among database providers/coordinators to ascertain the databases' appropriateness for inclusion into the inventory. It included questions about database characteristics, sample size, availability of information on drug exposure, clinical data and accessibility. Forty-two databases from 11 countries were identified and their coordinators invited to participate; responses were obtained for 22 (52.4 %) databases of which 15 record ADHD diagnoses. Eleven had sufficient data on ADHD diagnosis, drug exposure, and at least one type of outcome information (symptoms/clinical events, weight, height, blood pressure, heart rate) to assess MPH safety. These were Aarhus University Prescription Database, Danish National Birth Cohort (Denmark); German Health Interview and Examination Survey for Children and Adolescents; Health Search Database Thales, Italian ADHD Register, Lombardy Region ADHD Database (Italy); Avon Longitudinal Study of Parents and Children, General Practice Research Database, The Health Improvement Network, QResearch (UK) and IMS Disease Analyzer (UK, Germany, France). Of the 20 databases with no responses, information on seven from publications and/or websites was obtained; Pedianet and the Integrated Primary Care Information database were considered suitable. Many European healthcare databases can be used for multinational long-term safety studies of MPH. Methodological research is underway to investigate the feasibility of their pooling and analysis.

Persistence of pharmacological treatment into adulthood, in UK primary care, for ADHD patients who started treatment in childhood or adolescence

BACKGROUND

ADHD guidelines in the UK suggest that children and adults who respond to pharmacological treatment should continue for as long as remains clinically effective, subject to regular review. To what extent patients persist with treatment from childhood and adolescence into adulthood is not clear. This study aims to describe, in UK primary care, the persistence of pharmacological treatment for patients with ADHD who started treatment aged 6-17 years and to estimate the percentage of patients who continued treatment from childhood and adolescence into adulthood.

METHODS

The Health Improvement Network (THIN) database was used to identify patients with ADHD who received their first prescription for methylphenidate/ dexamfetamine/atomoxetine, aged 6-17 years. Patients were monitored until their 'censored date' (the earliest of the following dates: date the last prescription coded in the database ended, end of the study period (31st December 2008), date at which they transferred out of their practice, date of death, the last date the practice contributed data to the database). Persistence of treatment into adulthood was estimated using Kaplan Meier analysis.

RESULTS

610 patients had follow-up data into adulthood. 213 patients (93.4% male) started treatment between 6-12 years; median treatment duration 5.9 years. 131 (61.5%) stopped before 18 years, 82 (38.5%) were still on treatment age ≥18 years. 397 patients (86.4% male) started treatment between 13-17 years; median treatment duration was 1.6 years. 227 (57.2%) stopped before 18 years, 170 (42.8%) were still on treatment age ≥18 years. The number of females in both age categories was too small to formally test for differences between genders in persistence of treatment.

CONCLUSION

Persistence of treatment into adulthood is lower (~40%) compared with published rates of persistence of the condition (~65% when symptomatic definition of remission used). Due to the limited number of patients with data past 18 years, it is important that ongoing monitoring of prescribing into later adulthood is undertaken, particularly to observe the effects of recommendations in new guidelines.

The utility of attention-deficit/hyperactivity disorder screening instruments in individuals seeking treatment for substance use disorders

OBJECTIVE

Several screening tools for attention-deficit/hyperactivity disorder (ADHD) have been validated in non-substance-abusing populations, but limited data are available regarding their utility in adults with current substance use disorders. The aim of this study was to determine the sensitivity, specificity, and positive and negative predictive values of 3 commonly used ADHD screening instruments in cocaine-dependent individuals.

METHOD

Adults seeking treatment for cocaine dependence (N = 102) were administered 3 self-report instruments between May 2009 and April 2011: the Conners Adult ADHD Rating Scale (CAARS), the Wender Utah Rating Scale (WURS), and the Adult ADHD Self-Report Scale-Version 1.1 (ASRS-V1.1). They then met with master's-level clinicians who administered the Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID). With the CAADID serving as the gold standard, the validity of the screening instruments was determined, both singly and in combination.

RESULTS

Twenty-five (25%) of the 102 patients met DSM-IV criteria for ADHD or ADHD not otherwise specified (NOS) based on the CAADID. Kappa scores determining agreement between the screening tools and the CAADID (with ADHD NOS labeled as ADHD or labeled as not ADHD) ranged from 0.37 to 0.69. Sensitivity scores for the broadest range of ADHD cases were 80.0%, 87.5%, and 60.9% for the CAARS, WURS, and ASRS-V1.1, respectively. Positive predictive value was highest for the CAARS, at 74.1%, and negative predictive value was highest for the WURS, at 95.1%. The highest sensitivity (96.0%) was found with coadministration of the WURS and CAARS.

CONCLUSION

While all of the screening instruments were found to have adequate sensitivity and specificity, the CAARS outperformed the other instruments in regard to agreement with the CAADID and positive predictive values. However, the WURS, with the highest sensitivity in regard to the broadest range of ADHD cases, may be the single best instrument for preliminary screening purposes. Further, because the ASRS-V1.1 is the simplest and shortest instrument to administer, it may have advantages when a large number of patients need to be screened.

Analysis of patients' preferences: direct assessment and discrete-choice experiment in therapy of adults with attention-deficit hyperactivity disorder

BACKGROUND

: Attention-deficit hyperactivity disorder (ADHD) is a complex neuropsychiatric disorder that affects children and young people, as well as adults. Since ADHD does not produce specific organic characteristics, behavior and preferences are crucial to diagnosis and treatment. Comprehensive therapy concepts should take full account of the needs of the patients.

OBJECTIVE

: To document therapy attributes that are important from the adults' perspective and to analyze findings from two different valuation approaches used in the same survey.

METHODS

: A self-administered survey measuring attitudes and preferences was conducted in Germany in 2009 (n = 329). Adult patients (aged ≥18 years) were recruited from all over Germany, with the help of patient advocacy organizations. Attitudes were measured and analyzed using a classic rating scale in 5-point Likert format. Discrete-choice experiment (DCE) scenarios were developed using a fractional factorial design and results were analyzed using random effects logit models.

RESULTS

: The aspect of highest importance for the respondents was that social function (job, studies, friendships) was not impaired (coefficient 2.115; standard error 0.111). The next most important in the view of the respondents was achievement of behavioral changes through treatment (coefficient 1.755; standard error 0.110). The 'drug intake' aspect was not important in the attitude component rating and not significant in the DCE.

CONCLUSIONS

: The primary goal of ADHD treatment is by no means the alleviation of core symptoms. Instead, therapy should help enable patients to set and achieve their own objectives. Treatment should enable patients to organize their social participation in everyday life.

Improving visual memory, attention, and school function with atomoxetine in boys with attention-deficit/hyperactivity disorder

OBJECTIVE

Atomoxetine is efficacious in reducing symptoms of attention- deficit/hyperactivity disorder (ADHD), but its effect on visual memory and attention needs more investigation. This study aimed to assess the effect of atomoxetine on visual memory, attention, and school function in boys with ADHD in Taiwan.

METHOD

This was an open-label 12 week atomoxetine treatment trial among 30 drug-naíve boys with ADHD, aged 8-16 years. Before administration of atomoxetine, the participants were assessed using psychiatric interviews, the Wechsler Intelligence Scale for Children, 3rd edition (WISC-III), the school function of the Chinese version of the Social Adjustment Inventory for Children and Adolescents (SAICA), the Conners' Continuous Performance Test (CPT), and the tasks of the Cambridge Neuropsychological Test Automated Battery (CANTAB) involving visual memory and attention: Pattern Recognition Memory, Spatial Recognition Memory, and Reaction Time, which were reassessed at weeks 4 and 12.

RESULTS

Our results showed there was significant improvement in pattern recognition memory and spatial recognition memory as measured by the CANTAB tasks, sustained attention and response inhibition as measured by the CPT, and reaction time as measured by the CANTAB after treatment with atomoxetine for 4 weeks or 12 weeks. In addition, atomoxetine significantly enhanced school functioning in children with ADHD.

CONCLUSION

Our findings suggested that atomoxetine was associated with significant improvement in visual memory, attention, and school functioning in boys with ADHD.

Are language production problems apparent in adults who no longer meet diagnostic criteria for attention-deficit/hyperactivity disorder?

In this study, we examined sentence production in a sample of adults (N = 21) who had had attention-deficit/hyperactivity disorder (ADHD) as children, but as adults no longer met DSM-IV diagnostic criteria (APA, 2000). This "remitted" group was assessed on a sentence production task. On each trial, participants saw two objects and a verb. Their task was to construct a sentence using the objects as arguments of the verb. Results showed more ungrammatical and disfluent utterances with one particular type of verb (i.e., participle). In a second set of analyses, we compared the remitted group to both control participants and a "persistent" group, who had ADHD as children and as adults. Results showed that remitters were more likely to produce ungrammatical utterances and to make repair disfluencies compared to controls, and they patterned more similarly to ADHD participants. Conclusions focus on language output in remitted ADHD, and the role of executive functions in language production.

Pharmacotherapy for parents with attention-deficit hyperactivity disorder (ADHD): impact on maternal ADHD and parenting

Given the high heritability of the disorder, attention-deficit hyperactivity disorder (ADHD) is common among parents of children with ADHD. Parental ADHD is associated with maladaptive parenting, negative parent-child interaction patterns and a diminished response to behavioural parent training. We describe our previous research demonstrating that stimulant medications for mothers with ADHD are associated with reductions in maternal ADHD symptoms. Although limited beneficial effects on self-reported parenting were also found in our study, the impact of ADHD medications on functional outcomes related to parenting and family interactions may not be sufficient for many families. Many questions remain with regard to how best to treat multiplex ADHD families in which a parent and child have ADHD. In particular, future studies are needed: (1) to evaluate how best to sequence pharmacotherapy, psychosocial treatment for adult ADHD and behavioural parenting interventions; (2) to determine the best approach to maintaining treatment effects over the long term for both parents and children; and (3) to identify individual predictors of treatment response.

Assessment of physician practices in adult attention-deficit/hyperactivity disorder

OBJECTIVE

Adult attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric disorder, yet only 1 in 10 affected adults receives treatment. The study objective was to assess gaps in knowledge and describe current practice patterns of primary care physicians and psychiatrists in the United States in the management of adult patients with ADHD.

METHOD

Primary care physicians and psychiatrists completed an Internet survey as a needs assessment of customary care related to management of adults with ADHD. Adult clinical case vignettes were followed by practice, confidence, and barrier questions. Survey data were collected from April 15, 2010, to August 22, 2010, and were deidentified and analyzed in aggregate to maintain confidentiality. χ(2) and t tests were used to compare responses of primary care physicians with those of psychiatrists.

RESULTS

The survey was completed by 1,924 physicians: 1,216 primary care physicians and 708 psychiatrists. Fewer primary care physicians than psychiatrists were "extremely confident" in diagnosis (8% vs 28%, respectively, P < .001) and treatment (8% vs 27%, respectively, P < .001). Limited experience with ADHD diagnosis was more of a barrier in primary care than in psychiatry (44% vs 19%, respectively, P < .001). Mean scores on 12 evidence-based questions were lower for primary care physicians than for psychiatrists (6.1 vs 6.8 correct, respectively, P < .001). Awareness of adult ADHD prevalence was lower among primary care physicians than among psychiatrists (32% vs 47% correct, respectively, P < .001). Fewer primary care physicians than psychiatrists recognized comorbid substance use disorder (76% vs 82%, respectively, P = .002), but more primary care physicians than psychiatrists recognized eating disorders (35% vs 21%, respectively, P < .001).

CONCLUSIONS

The self-assessment survey results indicate physician practices in primary care and psychiatry differ and show areas in which further education will be useful to improve care for adults with ADHD.

Under diagnosis of adult ADHD: cultural influences and societal burden

OBJECTIVE

To explore the literature focusing on cultural influences in the diagnosis of adult ADHD and respective societal burden.

METHOD

A review of the literature over the past 10 years was performed using OVID.

RESULTS

Although numerous articles focused on diagnosis and burden of adult ADHD, few focused on cultural factors influencing diagnosis. Like other mental health disorders, cultural and social perspectives contribute to our understanding of adult ADHD and may play a significant role in the diagnosis and varying acceptance of the condition. Moreover, adults with ADHD may underestimate the impact of ADHD symptoms, and in many cases have learned to compensate for ADHD related impairments by choosing lifestyles that help compensate for symptoms. Some adults with ADHD may appear to function well, however they may expend excessive amounts of energy to overcome impairments; and they may be distressed by ongoing symptoms such as restlessness, mood instability and low self-esteem. Research shows that ADHD can be detrimental to many areas of life including work, daily activities, social and family relationships and psychological and physical well-being. Patient-reported impairments in productivity due to poor time management, procrastination, and distractibility can translate into significant indirect costs and decreased quality of life. ADHD in adults is also associated with increased accidents, medical resource utilization, antisocial behaviour and drug alcohol abuse.

CONCLUSION

The substantial societal burden of adult ADHD highlights the importance of providing a better understanding of the factors that contribute to accurate diagnosis and of improving the low recognition of the disorder in many world regions.

Developmental differences in structure of attention-deficit/hyperactivity disorder (ADHD) between childhood and adulthood

The current paper utilizes a bifactor modeling approach to evaluate the structure of attention-deficit/hyperactivity disorder (ADHD) in adulthood and assess developmental continuity of ADHD structure between childhood and adulthood. The study compared traditional one-factor, two-factor, three-factor, and second-order factor models of ADHD with a bifactor model of ADHD. Developmental differences in ADHD structure were examined using an extension of the bifactor model: a two-group model comparing children and adults. Participants were 406 adults (49% male; 145 of 406 with ADHD), (18 to 37) years old, and 548 children (58% male; 302 of 548 with ADHD), 6 to 18 years old. A bifactor model of ADHD exhibited the best fit in adults and children compared to traditional models, suggesting continuity in the ADHD latent construct across development. However, significant differences in the factor loadings were evident between children and adults in the two-group bifactor model, suggesting changes in the relative importance of particular symptoms over time. Namely, hyperactivity symptoms appear to decline in importance relative to the ADHD phenotype between childhood and adulthood.

ADHD matures: time for practitioners to do the same?

Attention deficit and hyperactivity disorder (ADHD) is not restricted to children. Abundant evidence from follow-up studies accumulated since the 1970s supports the concept of ADHD in adulthood. Genetic research points to a heritability of 76%, and neuroimaging studies have reported structural and functional brain abnormalities in patients with ADHD. Contrary to popular belief, ADHD is not a culturally bound disorder and has been described worldwide. ADHD has a cost for society, as adults with this disorder suffer from increased rates of unemployment and psychiatric comorbidity, including substance use disorders. Studies undertaken in forensic populations describe high rates of ADHD in these groups, particularly amongst young offenders. One of the main issues in the diagnosis of ADHD in the adult is the fact that most clinicians have not been educated to diagnose and treat ADHD. Effective pharmacological treatments for ADHD are available and should be prescribed for these patients. The National Institute for Health and Clinical Excellence (NICE) and the British Association for Psychopharmacology (BAP) guidelines established a benchmark for service development required to treat ADHD adequately in the adult population. However, the implementation of new services has been slow. More resources are needed to effectively assess and treat ADHD in the adult.

White matter abnormalities and their impact on attentional performance in adult attention-deficit/hyperactivity disorder

Inattention is the most important behavioral feature of adult patients with attention-deficit/hyperactivity disorder (ADHD). Neuroimaging studies in ADHD have demonstrated abnormalities primarily in the frontostriatal circuitry and were mostly conducted in children. We investigated white matter (WM) integrity in adult ADHD patients and the correlation of WM microstructure and neuropsychological parameters in 37 (21 men) never-medicated adult ADHD patients and 34 age- and gender-matched healthy controls. All subjects underwent clinical interviews, rating scales, and neuropsychological tests of attentional performance. Diffusion tensor imaging (DTI) was acquired, and 12 WM regions-of-interest (ROIs) within the attentional network were chosen. Group differences of mean fractional anisotropy (FA) and mean diffusivity (MD) values were calculated for each ROI, and patients' DTI measures were then correlated with measures of attentional performance. FA values in ADHD patients were significantly reduced in the left inferior longitudinal fasciculus (ILF), while MD values were significantly increased in ADHD patients in the frontal portion of the left frontooccipital fasciculus (IFO). In ADHD patients, MD values were negatively correlated with attentional performance in the left ILF. Our findings provide further support for disturbed frontostriatal structural connectivity and also point to an involvement of the left temporal white matter with an impact on attentional performance.

Comparison of the burden of illness for adults with ADHD across seven countries: a qualitative study

Background

The purpose of this study was to expand the understanding of the burden of illness experienced by adults with Attention Deficit-Hyperactivity Disorder (ADHD) living in different countries and treated through different health care systems.

Methods

Fourteen focus groups and five telephone interviews were conducted in seven countries in North America and Europe, comprised of adults who had received a diagnosis of ADHD. The countries included Canada, France, Germany, Italy, The Netherlands, United Kingdom, and United States (two focus groups in each country). There were 108 participants. The focus groups were designed to elicit narratives of the experience of ADHD in key domains of symptoms, daily life, and social relationships. Consonant with grounded theory, the transcripts were analyzed using descriptive coding and then themed into larger domains.

Results

Participants’ statements regarding the presentation of symptoms, childhood experience, impact of ADHD across the life course, addictive and risk-taking behavior, work and productivity, finances, relationships and psychological health impacts were similarly themed across all seven countries. These similarities were expressed through the domains of symptom presentation, childhood experience, medication treatment issues, impacts in adult life and across the life cycle, addictive and risk-taking behavior, work and productivity, finances, psychological and social impacts.

Conclusions

These data suggest that symptoms associated with adult ADHD affect individuals similarly in different countries and that the relevance of the diagnostic category for adults is not necessarily limited to certain countries and sociocultural milieus.

Factors associated with attention deficit/hyperactivity disorder among US children: results from a national survey

Background

The purpose of this study was to investigate the association between Attention Deficit/Hyperactivity Disorder (ADHD) and various factors using a representative sample of US children in a comprehensive manner. This includes variables that have not been previously studied such as watching TV/playing video games, computer usage, family member’s smoking, and participation in sports.

Methods

This was a cross-sectional study of 68,634 children, 5–17 years old, from the National Survey of Children’s Health (NSCH, 2007–2008). We performed bivariate and multivariate logistic regression analyses with ADHD classification as the response variable and the following explanatory variables: sex, race, depression, anxiety, body mass index, healthcare coverage, family structure, socio-economic status, family members’ smoking status, education, computer usage, watching television (TV)/playing video games, participation in sports, and participation in clubs/organizations.

Results

Approximately 10% of the sample was classified as having ADHD. We found depression, anxiety, healthcare coverage, and male sex of child to have increased odds of being diagnosed with ADHD. One of the salient features of this study was observing a significant association between ADHD and variables such as TV usage, participation in sports, two-parent family structure, and family members’ smoking status. Obesity was not found to be significantly associated with ADHD, contrary to some previous studies.

Conclusions

The current study uncovered several factors associated with ADHD at the national level, including some that have not been studied earlier in such a setting. However, we caution that due to the cross-sectional and observational nature of the data, a cause and effect relationship between ADHD and the associated factors can not be deduced from this study. Future research on ADHD should take into consideration these factors, preferably through a longitudinal study design.

Infant malnutrition is associated with persisting attention deficits in middle adulthood

Infantile malnutrition is known to be associated with cognitive and behavioral impairment during childhood and adolescence. Data pertaining to longer-term effects on behavioral outcomes in adulthood are limited. In this study, we report associations between infantile malnutrition and attention problems in adults at midlife. Attention problems were assessed by the Conners Adult ADHD Rating Scales (CAARS) and the Conners Continuous Performance Test (CPT) in 145 Barbadian adults (aged 37-43 y) who had been followed longitudinally since childhood. Previously malnourished participants (n = 80) had experienced moderate to severe protein-energy malnutrition in the first year of life and were successfully rehabilitated thereafter. They were compared with healthy adults (n = 65) who were former classmates of the index cases and who had been matched for age, sex, and handedness in childhood. Multiple regression analyses showed persisting effects of childhood malnutrition on both the CAARS and the CPT, independent of effects of household standard of living assessed in childhood. The malnutrition effect on the CAARS ratings was independent of IQ, whereas this effect was attenuated for the CPT after adjustment for IQ. Teacher-reported attention problems in childhood predicted attention problems in adulthood, indicating continuity over the life span. Infantile malnutrition may have long-term effects on attentional processes nearly 40 y after the episode, even with excellent long-term nutritional rehabilitation and independent of socioeconomic conditions in childhood and adolescence. This finding has major public health implications for populations exposed to early childhood malnutrition.

Candidate system analysis in ADHD: evaluation of nine genes involved in dopaminergic neurotransmission identifies association with DRD1

OBJECTIVES

Several pharmacological and genetic studies support the involvement of the dopamine neurotransmitter system in the aetiology of attention-deficit hyperactivity disorder (ADHD). Based on this information we evaluated the contribution to ADHD of nine genes involved in dopaminergic neurotransmission (DRD1, DRD2, DRD3, DRD4, DRD5, DAT1, TH, DBH and COMT).

METHODS

We genotyped a total of 61 tagging single nucleotide polymorphisms (SNPs) in a sample of 533 ADHD patients (322 children and 211 adults), 533 sex-matched unrelated controls and additional 196 nuclear ADHD families from Spain.

RESULTS

The single- and multiple-marker analysis in both population and family-based approaches provided preliminary evidence for the contribution of DRD1 to combined-type ADHD in children (P=8.8e-04; OR=1.50 (1.18-1.90) and P=0.0061; OR=1.73 (1.23-2.45)) but not in adults. Subsequently, we tested positive results for replication in an independent sample of 353 German families with combined-type ADHD children and replicated the initial association between DRD1 and childhood ADHD (P=8.4e-05; OR=3.67 (2.04-6.63)).

CONCLUSIONS

The replication of the association between DRD1 and ADHD in two European cohorts highlights the validity of our finding and supports the involvement of DRD1 in childhood ADHD.

Evaluation of total oxidative status in adult attention deficit hyperactivity disorder and its diagnostic implications

Adult Attention Deficit Hyperactivity Disorder (A-ADHD) is one of the psychiatric disorders which awareness is growing. The exact causes of A-ADHD are still unknown. In addition to neurochemical and neuroanatomic disorders, genetic and environmental factors are discussed in its etiology. In our study, we aimed to evaluate the oxidative status of A-ADHD patients and investigate whether oxidative metabolites can be used as diagnostic tools or not in A-ADHD. Blood samples were taken from enrolled 50 A-ADHD patients and 31 controls in appropriate way and Total Antioxidative Status (TAS), Total Oxidative Status (TOS), and Oxidative Stress Index (OSI) were studied in Harran University Biochemistry Labs. Results were compared between groups and ROC curve was drawn in order to evaluate diagnostic performances. Patients' TAS, TOS and OSI were significantly higher than controls. There was not a significant difference between comorbid cases and only A-ADHD patients in terms of measured values. A-ADHD can be predicted for TOS over 9.8575 μmol H(2)O(2) Eqv./L level with 86% positive predictive value and %100 negative predictive value. In A-ADHD, oxidative balance is impaired. High antioxidant levels may be compensatory against the oxidant increase. Oxidative parameters may be used in A-ADHD diagnosis.

The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

The aim of the study was to present nationally representative data on the lifetime independent association between attention deficit hyperactivity disorder (ADHD) and psychiatric co-morbidity, correlates, quality of life and treatment seeking in the USA.

METHOD

Data were derived from a large national sample of the US population. Face-to-face surveys of more than 34 000 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of ADHD, Axis I and II disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version.

RESULTS

ADHD was associated independently of the effects of other psychiatric co-morbidity with increased risk of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, specific phobia, and narcissistic, histrionic, borderline, antisocial and schizotypal personality disorders. A lifetime history of ADHD was also associated with increased risk of engaging in behaviors reflecting lack of planning and deficient inhibitory control, with high rates of adverse events, lower perceived health, social support and higher perceived stress. Fewer than half of individuals with ADHD had ever sought treatment, and about one-quarter had ever received medication. The average age of first treatment contact was 18.40 years.

CONCLUSIONS

ADHD is common and associated with a broad range of psychiatric disorders, impulsive behaviors, greater number of traumas, lower quality of life, perceived social support and social functioning, even after adjusting for additional co-morbidity. When treatment is sought, it is often in late adolescence or early adulthood, suggesting the need to improve diagnosis and treatment of ADHD.

Abnormal functional connectivity between the anterior cingulate and the default mode network in drug-naïve boys with attention deficit hyperactivity disorder

A previous study indicated that adults with attention deficit hyperactivity disorder (ADHD) had a decreased anti-correlation between the dorsal anterior cingulate cortex (dACC) and the default mode network (DMN). In this study, we investigated whether children with ADHD also show a decreased anti-correlation between the dACC and the DMN. We also explored the developmental characteristics of the resting-state functional connectivity (RSFC) of the dACC with the DMN in children with ADHD. Resting-state functional magnetic resonance imaging scans were obtained from a 3T scanner in 19 drug-naïve boys with ADHD and 23 controls. Compared with normal controls, the dACC in boys with ADHD showed a significantly decreased negative RSFC with the DMN, including the dorsomedial prefrontal cortex and the posterior cingulate cortex. The RSFC strength between the dACC and the posterior cingulate cortex showed a significantly negative correlation with age in normal controls, but not in boys with ADHD. This decreased anti-correlation may suggest an abnormal balance or interaction between attentional and intrinsic thoughts. Our age-related analysis suggested an abnormal development pattern of the dACC-DMN interaction in ADHD.

ADHD and female specific concerns: a review of the literature and clinical implications

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD.

Challenges in identifying and managing attention-deficit/hyperactivity disorder in adults in the primary care setting: a review of the literature

OBJECTIVE

To examine how to screen for and establish a correct diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults and to identify the outcomes associated with untreated ADHD.

DATA SOURCES

PubMed was searched using the key words ADHD, adult, diagnosis, and primary care from the years 1999 to 2009.

STUDY SELECTION

This search produced 50 publications.

DATA EXTRACTION

Publications were screened for data specific to the diagnosis or management of adult patients with ADHD in the primary care setting.

DATA SYNTHESIS

The estimated prevalence of ADHD in adults throughout the United States is 4.4% or approximately 10 million adults. Adults with ADHD by definition must experience impairment from the symptoms of ADHD in at least 2 areas of their life. Despite significant impairment, only 1 in 10 adults with ADHD have received ADHD treatment within the past year. Given the high rates of undertreatment, primary care physicians, who provide much of the general adult mental health care in the United States, are increasingly charged with making the diagnosis of ADHD in adults. ADHD symptoms are often masked by comorbid psychiatric conditions or patient adaptations such as choice of occupation. One of the ADHD assessment tools, a short 6-item screener, can simplify identification and management of ADHD in adults and help identify which patients may require further evaluation.

CONCLUSIONS

Primary care physicians should consult with other members of the health care community such as psychiatrists and psychologists when necessary, but should also develop a level of comfort with diagnosing and treating ADHD.

Language production strategies and disfluencies in multi-clause network descriptions: a study of adult attention-deficit/hyperactivity disorder

A prominent behavioral manifestation of impulsivity in children with attention-deficit/hyperactivity disorder (ADHD) is inappropriate language production, such as talking excessively, blurting out answers, and interrupting others.

OBJECTIVE

In this study, we examined language production in ADHD and non-ADHD controls to determine whether these types of language production problems are apparent in adults with ADHD.

METHOD

Participants (18-35 years old, 53.3% male) were asked to describe networks of colored dots that contained two branches that differed in length and complexity. According to the Minimal-Load Principle (Levelt, 1989), participants should prefer to describe a shorter and less complex branch first, in order to minimize planning and memory demands when formulating a description of the network. The dependent measures focused on which branch participants chose to describe first and the fluency of the descriptions. Four types of disfluency were examined: filled pauses, silent pauses, repetitions, and repairs.

RESULTS

There was no difference between ADHD participants and controls in the decisions they made when describing the networks (p > .10, η² = .004). Participants in both groups preferred to describe a short branch before describing a long branch and decisions were unaffected by complexity. However, ADHD participants did produce more words overall, t(73) = -2.33, p < .05, η² = .07, and they also produced more disfluencies, F(4, 70) = 2.98, p < .05, η² = .15, even after adjusting for number of words produced.

CONCLUSIONS

These findings suggest less language efficiency and reduced fluency in ADHD, and that language production issues remain in adults with ADHD, similar to the issues commonly reported in children with ADHD.

DIRAS2 is associated with adult ADHD, related traits, and co-morbid disorders

Several linkage analyses implicated the chromosome 9q22 region in attention deficit/hyperactivity disorder (ADHD), a neurodevelopmental disease with remarkable persistence into adulthood. This locus contains the brain-expressed GTP-binding RAS-like 2 gene (DIRAS2) thought to regulate neurogenesis. As DIRAS2 is a positional and functional ADHD candidate gene, we conducted an association study in 600 patients suffering from adult ADHD (aADHD) and 420 controls. Replication samples consisted of 1035 aADHD patients and 1381 controls, as well as 166 families with a child affected from childhood ADHD. Given the high degree of co-morbidity with ADHD, we also investigated patients suffering from bipolar disorder (BD) (n=336) or personality disorders (PDs) (n=622). Twelve single-nucleotide polymorphisms (SNPs) covering the structural gene and the transcriptional control region of DIRAS2 were analyzed. Four SNPs and two haplotype blocks showed evidence of association with ADHD, with nominal p-values ranging from p=0.006 to p=0.05. In the adult replication samples, we obtained a consistent effect of rs1412005 and of a risk haplotype containing the promoter region (p=0.026). Meta-analysis resulted in a significant common OR of 1.12 (p=0.04) for rs1412005 and confirmed association with the promoter risk haplotype (OR=1.45, p=0.0003). Subsequent analysis in nuclear families with childhood ADHD again showed an association of the promoter haplotype block (p=0.02). rs1412005 also increased risk toward BD (p=0.026) and cluster B PD (p=0.031). Additional SNPs showed association with personality scores (p=0.008-0.048). Converging lines of evidence implicate genetic variance in the promoter region of DIRAS2 in the etiology of ADHD and co-morbid impulsive disorders.

Efficacy and tolerability of pharmacotherapies for attention-deficit hyperactivity disorder in adults

This review examines the evidence regarding the efficacy and tolerability of long- and short-acting stimulant medications, as well as the non-stimulant medications atomoxetine and bupropion in the treatment of adult attention-deficit hyperactivity disorder (ADHD). Effect sizes in adults appear to be of almost the same magnitude as in school-age children when robust doses are used. There are adequate data demonstrating short-term efficacy and safety of medication in ADHD during adulthood but long-term studies are lacking, particularly in view of concerns regarding cardiovascular adverse events. There is some evidence that stimulant medication can improve driving performance in adults with ADHD. The extent to which medication may improve academic, occupational and social functioning in adults with ADHD is unclear, and future research should investigate these outcomes. Medication treatment of adults with ADHD in sports is controversial. Both stimulant and non-stimulant medications seem to be well tolerated. Monitoring of pulse and blood pressure is recommended with these drugs because of their cardiovascular effects. There have been extremely rare case reports of sudden death in adults and children treated with stimulants and atomoxetine, but it is difficult to clearly establish causality. In view of reports of treatment-related suicide-related behaviour with atomoxetine, it is recommended that adults should be observed for agitation, irritability, suicidal thinking, self-harming or unusual behaviour, particularly in the first months of treatment, or after a change of dose. ADHD in adults continues to remain an under-recognized disorder in many parts of the world and there is a lack of specialist clinics for assessment and treatment of adult ADHD. Studies to date have failed to show efficacy of medications in the treatment of ADHD in the substance misuse population. There is little evidence so far to suggest an increased misuse of stimulants or diversion amongst substance misusers; however, data are insufficient to draw firm conclusions. Further work is necessary to evaluate effective treatments in subgroups such as the substance misuse population, those with multiple co-morbidities and different ADHD subtypes.

The role of maternal and child ADHD symptoms in shaping interpersonal relationships

The current study investigated the influence of maternal ADHD symptoms on: (a) mothers' own social functioning; (b) their child's social functioning; and (c) parent-child interactions following a lab-based playgroup involving children and their peers. Participants were 103 biological mothers of children ages 6-10. Approximately half of the children had ADHD, and the remainder were comparison youth. After statistical control of children's ADHD diagnostic status and mothers' educational attainment, mothers' own inattentive ADHD symptoms predicted poorer self-reported social skills. Children with ADHD were reported to have more social problems by parents and teachers, as well as received fewer positive sociometric nominations from playgroup peers relative to children without ADHD. After control of child ADHD status, higher maternal inattention and hyperactivity/impulsivity each predicted children having more parent-reported social problems; maternal inattention predicted children receiving more negative sociometric nominations from playgroup peers. There were interactions between maternal ADHD symptoms and children's ADHD diagnostic status in predicting some child behaviors and parent-child relationship measures. Specifically, maternal inattention was associated with decreased prosocial behavior for children without ADHD, but did not influence the prosocial behavior of children with ADHD. Maternal inattention was associated with mothers' decreased corrective feedback and, at a trend level, decreased irritability toward their children with ADHD, but there was no relationship between maternal inattention and maternal behaviors for children without ADHD. A similar pattern was observed for maternal hyperactivity/impulsivity and mothers' observed irritability towards their children. Treatment implications of findings are discussed.

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

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

Distinguishing symptoms of ADHD from other psychiatric disorders in the adult primary care setting

Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.

P300 deficits in adults with attention deficit hyperactivity disorder: a meta-analysis

BACKGROUND

The P300 (P3) event-related potential (ERP) component, a possible endophenotype for attention deficit hyperactivity disorder (ADHD), has been widely examined in children, but received little attention in adults. Our objective was to conduct a meta-analysis of P3 studies in adults with ADHD.

METHOD

We searched the Medline and PsycINFO databases for controlled studies examining both adult ADHD and matched healthy controls. Six relevant publications were identified for the meta-analysis, which had comparable data across studies with regard to the amplitude of ERP components related to target detection (P3, P3b). Pooled effect size (ES) for P3 amplitude as well as the association of the ES with age and gender were investigated using meta-regression.

RESULTS

Comparing the ADHD group versus controls, the pooled effect size for a decrease in P3 amplitude was in the medium range (Cohen's d=-0.55, p=0.0006). Additionally, meta-regression revealed that decrease in P3 amplitude significantly varied with the mean age of ADHD patients (p=0.0087), with a gradual increasing of the difference at higher ages. Results also showed a significant association between the ES and gender, indicating a more pronounced reduction of P3 amplitude in the ADHD group versus controls when females were predominantly represented in the sample.

CONCLUSIONS

To our knowledge, this is the first meta-analysis of P3 characteristics in adults with ADHD. It reveals a significantly decreased P3 amplitude during target detection. Our result that the reduction in P3 amplitude increases with age is interpreted in a neurodevelopmental context.

A context for normalizing impulsiveness at work for adults with attention deficit/hyperactivity disorder (combined type)

Impaired executive function and impulsiveness or intolerance to boredom in adult attention deficit/hyperactivity disorder (ADHD) are thought to compromise performance at work. Several task parameters help people with ADHD to perform better on computerized cognitive tasks, namely reduced response-to-stimulus interval, discriminative feedback, or a format resembling a videogame. However, still very little is known about how these contexts might be helpful in a real work environment. We developed a computerized task resembling a fast-paced videogame with no response-to-stimulus interval and constant and diverse discriminative error feedback. The task included several measurements of high-order executive function (planning, working memory, and prospective memory) formatted as a single multitask simulating occupational activities (SOA). We also administered the Continuous Performance Test-II (CPT-II), a very simple vigilance task without discriminative feedback and with long response-to-stimulus intervals. We tested 30 adults answering to DSM-IV criteria of ADHD (combined type) and 30 IQ-matched adults without ADHD. As has been reported many times, the ADHD participants made significantly more errors of commission than the control participants on the CPT-II, whereas the two groups made the same number of errors of commission on the SOA. The ADHD group also sought discriminative feedback significantly more actively on the SOA than the control group and performed at par with the control group in all respects. There was no speed/accuracy trade-off, nor was there any evidence of other costs of normalization on the SOA. Impulsiveness in adult ADHD is compensable on a task simulating the work environment.

Disturbed brain activation during a working memory task in drug-naive adult patients with ADHD

Neuroimaging studies in attention-deficit/hyperactivity disorder (ADHD) have shown abnormalities in several brain areas including the frontostriatal circuitry and were mostly conducted in children and adolescents. We investigated 30 never-medicated adult ADHD patients (16 males) and 30 matched healthy control individuals. Functional magnetic resonance imaging was acquired during a working memory paradigm (n-back). Group activation maps and group differences of activation were calculated using voxel-based analyses. The generic activation pattern was more extended in the control group. In ADHD patients, significantly decreased activation was found in the right inferior parietal cortex. Disturbed parietal brain function may particularly contribute to inattention and working memory impairment in ADHD patients.

Psychiatric symptomatologies and disorders related to epilepsy and antiepileptic medications

INTRODUCTION

Psychiatric comorbidities (such as depression, anxiety, psychosis, inattention, obsession, personality traits, aggression and suicide) are frequent in patients with epilepsy and have a significant impact on medical management and quality of life.

AREAS COVERED

A literature search was performed in MEDLINE for epidemiological, longitudinal, prospective, double-blind clinical trial studies published between 1990 and 2011 using the following words: epilepsy, antiepileptic drugs (AEDs), behavioral/emotional/psychiatric comorbidities, suicide and aggression. In this review, the author discusses: i) the characterization and prevalence of behavioral disturbances associated with epilepsy, ii) variables correlated with behavioral comorbidities which include: psychosocial-, clinical- and treatment-related variables, iii) the complex mechanisms of behavioral comorbidities associated with epilepsy, which include both psychosocial (functional) and organic; the process of epileptogenesis, neuronal plasticity, abnormalities in hypothalamic-pituitary axis and neurotransmitters and pathways are fundamental determinants, iv) the negative psychotropic effects of AEDs and their mechanisms and v) the suggested biopsychosocial model of management (pharmacological and non-pharmacological).

EXPERT OPINION

The relationship between psychiatric disorders and epilepsy has relevant therapeutic implications which should be directed towards a comprehensive biopsychosocial approach that focuses on the whole person rather than simply on the disease process.

Gray matter alterations in adults with attention-deficit/hyperactivity disorder identified by voxel based morphometry

BACKGROUND

Gray and white matter volume deficits have been reported in many structural magnetic resonance imaging (MRI) studies of children with attention-deficit/hyperactivity disorder (ADHD); however, there is a paucity of structural MRI studies of adults with ADHD. This study used voxel based morphometry and applied an a priori region of interest approach based on our previous work, as well as from well-developed neuroanatomical theories of ADHD.

METHODS

Seventy-four adults with DSM-IV ADHD and 54 healthy control subjects comparable on age, sex, race, handedness, IQ, reading achievement, frequency of learning disabilities, and whole brain volume had an MRI on a 1.5T Siemens scanner. A priori region of interest hypotheses focused on reduced volumes in ADHD in dorsolateral prefrontal cortex, anterior cingulate cortex, caudate, putamen, inferior parietal lobule, and cerebellum. Analyses were carried out by FSL-VBM 1.1.

RESULTS

Relative to control subjects, ADHD adults had significantly smaller gray matter volumes in parts of six of these regions at p ≤ .01, whereas parts of the dorsolateral prefrontal cortex and inferior parietal lobule were significantly larger in ADHD at this threshold. However, a number of other regions were smaller and larger in ADHD (especially fronto-orbital cortex) at this threshold. Only the caudate remained significantly smaller at the family-wise error rate.

CONCLUSIONS

Adults with ADHD have subtle volume reductions in the caudate and possibly other brain regions involved in attention and executive control supporting frontostriatal models of ADHD. Modest group brain volume differences are discussed in the context of the nature of the samples studied and voxel based morphometry methodology.

Lack of association between a 3'UTR VNTR polymorphism of dopamine transporter gene (SLC6A3) and ADHD in a Brazilian sample of adult patients

OBJECTIVE

To investigate a possible association between a 3'UTR VNTR polymorphism of the dopamine transporter gene (SLC6A3) and ADHD in a Brazilian sample of adult patients.

METHOD

Study Case-control with 102 ADHD adult outpatients ( DSM-IV criteria) and 479 healthy controls. The primers' sequence used were: 3'UTR-Forward: 5' TGT GGT GAT GGG AAC GGC CTG AG 3' and 3'UTR-Reverse: 5' CTT CCT GGA GGT CAC GGC TCA AGG 3'. Alleles of the 3'UTR were coded according to their number of repeats: 6- repeat 320 bp (allele 6), 8- repeat 400 bp (allele 8), 9- repeat 440 bp (allele 9), 10- repeat 480 bp (allele 10), and 11- repeat 520 bp (allele 11).

RESULTS

There were no allelic (χ(2) = 2.67, 5df, p = .75) and genotypic (χ(2) = 7.20, 1 df, p = .61) association between adult ADHD and VNTR 3'UTR polymorphism of SLC6A3.

CONCLUSION

Our findings do not support SLC6A3 as marker genetic susceptibility factor in adult ADHD. More comprehensive polymorphism coverage within the SLC6A3 region should be conducted in larger samples, including comparisons in clinical subgroups, and in samples with different ethnic backgrounds.

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

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

Stimulant use under a prison treatment protocol for attention-deficit/hyperactivity disorder

Although stimulant medications are the mainstay of effective intervention for attention-deficit/ hyperactivity disorder (ADHD), their use presents a daunting scenario for psychiatry, nursing, and custody staff in correctional settings, where reported prevalence rates range from 9% to 45%. The reported rates, however, may overestimate actual prevalence in general and need for treatment in particular. Under a monitored protocol that required documentation of history, diagnosis, lack of response to nonstimulant treatment, and significant functional impairment, less than 1% of male inmates in the Massachusetts state prison system met criteria for treatment with stimulants. Although this protocol did not attempt to determine overall ADHD prevalence rates, the relatively low number of inmates with compelling reasons for stimulant treatment may provide a more realistic idea of the likely consequences of allowing access to this intervention.

An open-label, dose-titration tolerability study of atomoxetine hydrochloride in Japanese adults with attention-deficit/hyperactivity disorder

AIMS

The main purpose of this first atomoxetine study in Japanese adults with attention-deficit/hyperactivity disorder (ADHD) was to investigate the tolerability of an 8-week treatment regimen.

METHODS

This was an open-label, dose escalation study conducted in 45 Japanese patients aged at least 18 years with DSM-IV-defined ADHD. Patients received atomoxetine orally for 8 weeks. Atomoxetine administration was started at 40 mg/day (7 days), and subsequently increased to a maximum dose of 120 mg/day. Tolerability was assessed by discontinuation rate due to adverse events. Adverse events, laboratory tests, vital signs and electrocardiograms were collected. In addition, ADHD symptoms were assessed by using the Japanese version of the Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version (CAARS-Inv:SV) scores.

RESULTS

Thirty-nine patients completed the study period. Atomoxetine was well tolerated with a 6.7% (3/45) discontinuation rate due to nausea, malaise and anorexia. The most commonly reported adverse events were nausea, nasopharyngitis and headache; there were no unexpected safety concerns. No deaths or serious adverse events were reported. Mean CAARS-Inv:SV-J total ADHD symptom scores decreased in a time-dependent manner; the mean change from baseline to endpoint was -15.0 (P<0.001).

CONCLUSIONS

This study showed that atomoxetine was well tolerated in these patients and suggested that atomoxetine at a maximum dose of 120 mg/day would be safe in Japanese ADHD patients.

Differential effects of methylphenidate on problem solving in adults with ADHD

OBJECTIVE

Two studies were performed to assess both divergent and convergent thinking in adults with ADHD.

METHOD

The first study compared the problem-solving abilities of healthy participants (N = 144) and unmedicated adults with ADHD (N = 144). In the second study, problem-solving abilities of adults with diagnosed ADHD (N = 22) were examined twice, that is, on and off methylphenidate (MPH), and compared with the performance of a healthy control group (N = 22). Convergent thinking was measured using a Tower of London task, whereas divergent thinking was assessed using verbal fluency tasks.

RESULTS

Adults with ADHD off MPH displayed marked deficits of both divergent and convergent thinking. MPH treatment resulted in a marked improvement of convergent thinking, while no effect of medication was found regarding divergent thinking.

CONCLUSION

Pharmacological treatment of adults with ADHD revealed a differential effect of MPH on problem solving abilities.

Anterior cingulate cortex gray matter abnormalities in adults with attention deficit hyperactivity disorder: a voxel-based morphometry study

Attention deficit hyperactivity disorder (ADHD) is a psychiatric disease that affects children and persists in 50% of cases into adulthood. Magnetic Resonance Imaging (MRI) studies in children suggest that ADHD is associated with structural abnormalities in the brain. However, very little research has been carried out on adult ADHD. Using high-resolution MRI, we tested the hypothesis that adult ADHD patients exhibit gray and/or white matter volume (GMV, WMV) abnormalities in the prefrontal cortex (PFC), cingulate cortex (CC), hippocampus and amygdala, also evaluating putative associations between volumetric data and symptoms of ADHD. We investigated 20 adult patients with ADHD and 20 age-matched healthy controls. We found significantly smaller GMV in the right and left anterior cingulate cortex (ACC) but no GMV/WMV difference in the PFC, hippocampus and amygdala. No correlation was found between ADHD behavioral measures and MRI data. Our results might suggest that adults with ADHD exhibit smaller GMV in the ACC, as measured by VBM. Volumetric abnormalities in the brain of adult ADHD patients might be less pronounced than those found in children and adolescents, although the role played by chronic stimulant treatment needs further investigation.

An association study between SNAP-25 gene and attention-deficit hyperactivity disorder

Attention-Deficit Hyperactivity Disorder (ADHD) is the most common behavioral disorder in childhood. Genetic associations have been reported between ADHD and polymorphic variants within or near dopamine pathway genes. Synaptosomal-associated protein, 25 kDa (SNAP-25), a presynaptic plasma membrane protein with an integral role in synaptic transmission, has shown association with ADHD in several datasets. We characterized two single-nucleotide polymorphisms (rs362549, rs363006) and one microsatellite [5'-UTR (TAAA)(n)] of SNAP-25. The association of these variants with ADHD was assessed in 102 trios collected from 90 male and 12 female probands. Transmission disequilibrium test (TDT) analysis showed that none of the polymorphic alleles were preferentially transmitted to the probands. Quantitative analysis was also conducted to assess the relationship between these marker alleles and the severity of ADHD symptoms. Analysis of the DSM-IV subtypes indicated that a significant association was identified between SNP rs362549 and ADHD subtypes (P = 0.0047). This is the first report of an association between SNAP-25 and ADHD in Chinese subjects of Han descent. We still support the premise that SNAP-25 is a genetic susceptibility factor for ADHD.