Diagnosis and Treatment of Adults With Attention Deficit Hyperactivity Disorder

The impact of psychological theory on the treatment of Attention Deficit Hyperactivity Disorder (ADHD) in adults: A scoping review

Psychological theory and interpretation of research are key elements influencing clinical treatment development and design in Attention Deficit Hyperactivity Disorder (ADHD). Research-based treatment recommendations primarily support Cognitive Behavioural Therapy (CBT), an extension of the cognitive behavioural theory, which promotes a deficit-focused characterisation of ADHD and prioritises symptom reduction and cognitive control of self-regulation as treatment outcomes. A wide variety of approaches have developed to improve ADHD outcomes in adults, and this review aimed to map the theoretical foundations of treatment design to understand their impact. A scoping review and analysis were performed on 221 documents to compare the theoretical influences in research, treatment approach, and theoretical citations. Results showed that despite variation in the application, current treatments characterise ADHD from a single paradigm of cognitive behavioural theory. A single theoretical perspective is limiting research for effective treatments for ADHD to address ongoing issues such as accommodating context variability and heterogeneity. Research into alternative theoretical characterisations of ADHD is recommended to provide treatment design opportunities to better understand and address symptoms.

Using the Personality Assessment Inventory to Identify ADHD-Like Symptoms

OBJECTIVE

The purpose of this study was to investigate the possibility of creating a new scale on the Personality Assessment Inventory (PAI) to assess for ADHD-like symptomatology.

METHOD

Two approaches to scale development were compared: (a) stepwise regression using PAI scales and subscales as predictors and the CAARS-H index as the dependent variable and (b) a MANOVA using discharge diagnosis as the grouping variable and PAI scales and subscales as the dependent variables.

RESULTS

Stepwise regression identified six PAI scales and subscales (PIM, RXR, SOM-S, ARD-T, MAN-A, and SCZ-T) that were responsible for a large proportion of variance (39%) in the CAARS-H index, and the MANOVA also identified six subscales that significantly differed between those clients eventually diagnosed with ADHD and those not diagnosed (ANT-S, SCZ-T, MAN-A, ANX-C, BOR-S, and MAN-G).

CONCLUSION

Although each set produced statistically significant findings, neither produced high correct classification rates in the eventual diagnosis of ADHD.

Prevalence of ADHD in Publicly Insured Adults

OBJECTIVE

To estimate the prevalence of adult ADHD diagnosis and treatment in U.S. Medicaid beneficiaries.

METHOD

Using outpatient, inpatient, and pharmacy billing records for patients eligible for Medicaid fee-for-service benefits within 29 states from 1999 to 2010, we estimated the annual prevalence of ADHD diagnosis and treatment.

RESULTS

The prevalence of ADHD diagnosis increased from 2.20 per 1,000 patients in 1999 to 10.57 in 2010. Likewise, prevalence of ADHD treatment increased from 1.95 per 1,000 patients in 1999 to 13.16 in 2010. Between 40% and 65%, patients had ADHD drug prescription fills 6 months after ADHD diagnosis, whereas 45% to 55% of the beneficiaries with an ADHD drug prescription fill had ADHD diagnoses within 6 months before the prescription.

CONCLUSION

In publicly insured adults, the prevalence of ADHD diagnosis and treatment increased dramatically over the years. Approximately half of the diagnosed patients are not treated, whereas half of the treated adults are not diagnosed.

[Minimal cerebral dysfunctions and ADHD in adulthood]

Attention deficit hyperactivity disorder (ADHD) is of great importance not only in children but also in adults; however, despite extensive research there are still many unsolved questions with respect to the diagnosis. Patients not only suffer from attention deficits and hyperactivity but also a variety of other problems, such as dyspraxia, problems with stimulus discrimination, dysgrammatism, legasthenia, or motor coordination problems. Furthermore, there are also psychopathological disorders, such as problems with memory, formal thinking, emotional modulation, drive and vegetative stability, in the sense of a psycho-organic syndrome. Such syndromes have long been known in psychiatry under terms, such as complex capacity disorders, minimal cerebral dysfunction (MCD), minimal brain dysfunction (MBD), mild psycho-organic syndrome, psycho-organic axis syndrome, mild cognitive impairment, developmental disorder and developmental biological syndrome. Etiological data with respect to genetics and early childhood brain trauma support the notion of a psychobiological disorder for complex cerebral dysfunction in the sense of a psycho-organic syndrome. Depending on the individual life and work situation, these additional symptoms of ADHD are in many cases of greater relevance for life adjustment than the core symptoms, depending on the individual life and work situations. The concept of minimal cerebral dysfunction describes the ADHD problem better and has a direct bearing on the diagnosis, therapy and sociomedical care of the patients.

ADHD symptoms and academic adjustment to college: the role of parenting style

OBJECTIVE

The primary aim of this study was to examine relationships among parenting style, symptoms of ADHD, and academic adjustment in college students. Specifically, we investigated whether parenting style may act as a buffer in the negative relationship between ADHD symptoms and academic adjustment.

METHOD

Participants were 200 undergraduate students attending a large public university. Questionnaires measuring their ADHD symptoms, parent's parenting style, and academic adjustment were completed.

RESULTS

Results indicated small but significant moderation effects for authoritarian parenting and authoritative parenting on the relationship between ADHD symptoms and academic adjustment.

CONCLUSION

Although research has revealed that different parenting styles may relate to different outcomes in children with ADHD, for young adults, the effects of parenting on academic adjustment may be diluted. Future research should investigate variables that may be more salient predictors of functional outcomes for this population, such as organizational skills.

Evaluation of a Stress Management Training Program for Adults With ADHD-A Pilot Study

We conducted a pilot study to examine the feasibility, acceptance, and subjective effectiveness of a new stress management training program tailored to the needs of adults with attention deficit hyperactivity disorder (ADHD). After a baseline evaluation of perceived chronic stress and coping strategies, 18 adults with ADHD participated in four sessions of stress management training and completed posttests on chronic stress and additional measures. Participants rated the acceptance and effectiveness of the training as high. Positive effects were found with respect to perceptions of excessive demands at work, chronic worry, and general stress experience. The findings suggest that stress management training is a valuable adjuvant for the treatment of ADHD in adults. Further development and evaluation of the intervention is desirable.

Objective Measures of Behavior Manifestations in Adult ADHD and Differentiation from Participants with Bipolar II Disorder, Borderline Personality Disorder, Participants with Disconfirmed ADHD as Well as Normative Participants

Background:

The present study evaluated two psychometric instruments derived from the objective measurement of adult ADHD using the Quantified Behavior Test Plus. The instruments were examined in ADHD versus a clinical group with overlapping symptoms including borderline personality disorder and bipolar II disorder, and another clinical group with participants assessed for but disconfirmed a diagnosis of ADHD as well as adult normative participants.

Methods:

The Quantified Behavior Test Plus includes Continuous Performance Testing and a Motion Tracking System with parameters related to attention and activity operationalized as the cardinal symptoms of ADHD and then summarized into a Weighed Core Symptoms scale with ten cut-points ranging from 0 to 100. A categorical predictor variable called Prediction of ADHD was used to examine the levels of sensitivity and specificity for the Quantified Behavior Test Plus with regard to ADHD.

Results:

The Weighed Core Symptoms scale separated ADHD and normative participants from each other as well as from the two clinical reference groups. The scale reported highest levels of core symptoms in the ADHD group and the lowest level of core symptoms in the normative group. Analyses with Prediction of ADHD yielded 85 % specificity for the normative group, 87 % sensitivity for the ADHD group, 36 % sensitivity for the bipolar II and borderline group and 41 % sensitivity for the group with a disconfirmed diagnosis of ADHD.

Conclusions:

The Weighed Core Symptoms scale facilitated objective assessment of adult ADHD insofar that the ADHD group presented more core symptoms than the other two clinical groups and the normative group. Sensitivity for the Quantified Behavior Test Plus was lower in complex clinical groups with Bipolar II disorder, Borderline disorder and in patients with a disconfirmed diagnosis of ADHD. The psychometric instruments may be further evaluated with regard to well-documented and effective treatment programs for ADHD core symptoms.

Efficacy of Retrospective Recall of Attention-Deficit Hyperactivity Disorder Symptoms: A Twin Study

Attention-deficit hyperactivity disorder (ADHD) is currently recognized as a neurobiological, genetically based disorder in both children and adults. In this article we examine whether, by using a sample of middle-aged male twin veterans, the phenotypic characterization, prevalence, heritability and the longitudinal course of the illness is comparable to results observed in samples of children and adolescents. We evaluated the utility of adult reports of lifetime ADHD symptoms by examining the heritability of retrospectively reported childhood symptoms, using both symptom-based and discrete classification- based approaches, as well as examining the persistence of ADHD symptoms into adulthood for that subsample of individuals who were judged to possibly have ADHD as children. Our results showed prevalence rates that were approximately similar to those observed in other studies, demonstrable familiality, similar item endorsement patterns, a strong genetic association between hyperactive and inattentive subtypes, and a longitudinal decline in symptom severity. We concluded that while assessing ADHD in adult probands may be less accurate than with children or adolescents, since it demonstrates several characteristics in common with other assessment techniques it remains a viable diagnostic and research strategy, even with population samples.

Subclinical ADHD, stress, and coping in romantic relationships of university students

OBJECTIVE

To examine how the subclinical symptoms of adult ADHD and those of oppositional-defiant disorder (ODD) affect relationship satisfaction and stress and to determine whether different patterns of coping strategies emerge when undergraduates have symptoms of one or both disorders.

METHOD

Participants (N = 497) complete self-report surveys assessing ADHD and ODD symptoms, relationship satisfaction, stress, and coping strategies used in their intimate relationships.

RESULTS

ADHD and ODD symptoms are significantly related to a number of stressors and different patterns of coping strategies. University students with symptoms of both ADHD and ODD display a different pattern of stressors and different patterns of coping than those with symptoms of ADHD only.

CONCLUSION

Screenings for both ADHD and ODD and the provision of services that offer students more constructive coping alternatives to deal with stress in their intimate relationships are needed on university campuses.

ADHD in adults: a review of the literature

OBJECTIVE

ADHD presents significant challenges to adults. The current review's goals are (a) to critically examine the current state of knowledge regarding ADHD in adults and (b) to provide clinicians with practice-friendly information regarding assessment, diagnosis, and treatment.

METHOD

Searches of PsycINFO and Medline were conducted, and reference lists from articles and books were searched for additional relevant references.

RESULTS/CONCLUSION

A valid and reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview, neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the combination of cognitive behavioral therapy and medication.

Quality of life of Israeli adults with borderline intelligence quotient and attention-deficit/hyperactivity disorder

The quality of life of 127 Israeli young adults diagnosed as having borderline intelligence quotient and attention-deficit/hyperactivity disorder, and living in community residences, was studied with respect to personal, disability and social ecology data. Overall, quality of life was associated with studying in inclusive education, total attention-deficit disorder symptomatology score, monthly income, participation in leisure activities and having a personal friend. Two significant predictors of quality of life were attention-deficit disorder symptomatology score and monthly income. Additional analysis indicates that among younger residents the two significant predictors were inclusive education and high monthly income, whereas the predictors for older residents were low level of medical disability and low attention-deficit disorder symptomatology score.

Quality of life of men and women with borderline intelligence and attention deficit disorders living in community residences: a comparative study

The research studies the quality of life (QOL) of 127 men and women diagnosed as having a borderline IQ and ADHD living in two major residential programs of the Sharon region in central Israel in respect to their personal, disability, and social ecological variables. Core findings indicate that men and women differ significantly according to their educational background. Among those who studied in a regular educational environment, the main predictor of men's QOL is their monthly income, whereas the main predictor for women is their level of attention deficit symptoms. The only predictor of QOL among men who studied in a special education program is the quality of contact with their mothers, whereas no significant predictor is observed among women.

Beck Depression Inventory-II items associated with self-reported symptoms of ADHD in adult psychiatric outpatients

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and the Conners' Adult ADHD Rating Scale-Self-Report: Screening Version (CAARS-S:SV; Conners, Erhardt, & Sparrow, 1999) were administered to 371 (64%) female and 204 (36%) male adult (> 18 years old) outpatients who were diagnosed with various psychiatric disorders to determine whether any of the 21 items or subsets of items in the BDI-II were related to symptoms of attention deficits and hyperactivity as measured by the CAARS-S:SV DSM-IV Total ADHD Symptoms scale (attention-deficit/hyperactivity disorder [ADHD] Symptoms). Stepwise multiple-regression analyses found that the BDI-II Concentration Difficulty explained 30% of the variance in these total scores. Ratings > 1 for the BDI-II Concentration Difficulty item were discussed as being useful for ruling out possible symptoms of ADHD.

Self-report of ADHD symptoms in university students: cross-gender and cross-national prevalence

Little research has examined the structure and prevalence of attention-deficit/hyperactivity disorder (ADHD) symptoms in university students, including whether symptom structure conforms to the bidimensional (i.e., inattention and hyperactivity-impulsivity) conceptualization of the Diagnostic and Statistical Manual of Mental Disorders (DSMV-IV; American Psychiatric Association, 1994) and whether self-reported symptoms vary across gender and country. A sample of 1,209 university students from three countries (Italy, New Zealand, and the United States) completed a 24-item self-report measure (the Young Adult Rating Scale) tapping ADHD symptomatology. Factor analyses within the U.S. and New Zealand samples supported a bidimensional symptom structure, whereas weaker support for this conceptualization was provided by the Italian sample. Participants did not vary significantly by gender in symptom report; however, Italian students reported significantly more inattention and hyperactivity-impulsivity symptoms than students from the United States, and students from New Zealand reported more inattention symptoms than students from the United States. The prevalence of self-reported ADHD symptoms beyond DSM-IV thresholds for diagnosis ranged from 0% (Italian women) to 8.1% (New Zealand men). The implications of these results for the use of DSM-IV criteria in identifying university students with ADHD are discussed.