Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

The Work and Social Adjustment Scale (WSAS): An investigation of reliability, validity, and associations with clinical characteristics in psychiatric outpatients

OBJECTIVE

This study, the first to assess the reliability and validity of the Work and Social Assessment Scale (WSAS) in Norwegian routine mental health care, examines differences in functional impairment based on sick leave status, psychiatric diagnosis, and sex.

METHOD

Including 3573 individuals from community mental health services (n1 = 1157) and a psychiatric outpatient clinic (n2 = 2416), exploratory factor analysis (EFA) on subsample 1 and confirmatory factor analysis (CFA) on subsample 2 were utilized to replicate the identified factor structure.

RESULTS

EFA supported a one-factor model, replicated by the CFA, with high internal consistency (α = .82, ω = .81). Patients on sick leave reported greater impairments in all aspects of functioning, except for relationships, with the largest effect size observed in the reported ability to work (d = .39). Psychiatric outpatients with major depressive disorder were associated with difficulties in home management, private leisure activities, and forming close relationships. Patients with attention-deficit/hyperactivity disorder reported less impairment than those with other disorders. Patients with personality disorders reported more relationship difficulties than those with PTSD, ADHD, and anxiety. No differences were found in the perceived ability to work between diagnoses. Women had a higher impairment in private leisure activities, whereas men reported more impairment in relationships.

CONCLUSION

The demonstrated reliability and validity suggest that WSAS is a valuable assessment tool in Norwegian routine mental health care. Variations in functional impairment across sick leave status, sex, and psychiatric diagnoses highlight the importance of integrating routine assessments of functional impairment into mental health care practices. Future research should combine WSAS with register data to allow for a broader understanding of treatment effectiveness, emphasizing improvements in functional outcomes alongside symptom alleviation.

Neurocognitive Characteristics of Patients Who Visited a Psychiatric Outpatient Clinic Requesting Treatment for Adult Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

This study investigated the neurocognitive characteristics of patients who visited an outpatient clinic requesting diagnosis and treatment for adult attention-deficit/hyperactivity disorder (ADHD).

METHODS

The patients' electronic medical records were retrospectively reviewed. Neurocognitive test results were compared using Student's t-test according to their chief complaint, depressive symptoms, childhood history, and intelligence quotient (IQ). Neurocognitive characteristics affecting subjective symptoms of ADHD were analyzed by linear regression.

RESULTS

The study included 106 patients. They did not have significant deficits in neurocognitive tests. Patients with depressive symptoms showed more impulsive responses (hit reaction time [p=0.037] and commission error [p=0.024]) and self-reported ADHD symptoms (p=0.001). Verbal (p=0.036) and visual memory (p=0.020) were significantly deficient in patients with a childhood ADHD diagnosis. Patients with a low IQ had significant deficits in various domains. Depressive symptoms and vigilance were significantly related to subjective symptoms of ADHD (adjusted R2=0.430, β=0.457, p=0.002).

CONCLUSION

Our results imply that the neurocognitive function of patients with subjective ADHD symptoms was not abnormal but was affected by depressive symptoms.

Trends in Pediatric Attention-Deficit Hyperactive Disorder Diagnoses and Prescription Utilization: 2016 to 2019

OBJECTIVE

Attention-deficit hyperactive disorder (ADHD) is one of the most common psychiatric disorders among children, with estimated prevalence of 7% to 15% worldwide. The aim of this analysis was to update and summarize trends in diagnosis, demographics, and drug utilization of pediatric patients with ADHD.

METHODS

We used the Agency for Health care Research and Quality Medical Expenditure Panel Survey (MEPS), a survey of US individuals, families, their medical providers, and employers, using datasets from 2016 to 2019. The data sources from the MEPS database included the full-year consolidated files, medical conditions files, prescribed-medicines files, and condition-event link files for each year. We summarized trends in the proportion of children, ages 17 years and younger, with a diagnosis of ADHD, demographic information and a prescription for medication known to treat ADHD. In addition, we further stratified ADHD medication use by stimulant/nonstimulant categories.

RESULTS

There was a 1.6% and 4.7% absolute increase in children with an ADHD diagnosis and those prescribed ADHD medications, respectively, from 2016 to 2019. Most of these children were male, non-Hispanic, and on public insurance. Of the children prescribed an ADHD medication and concomitant behavioral medications, stimulants-only use was the highest (60%-67%), followed by stimulants/nonstimulants (13%-15%), stimulant/antidepressants (6%-9%), and nonstimulants only (5%-9%). The proportion of patients with ADHD in the high-income and near-poor categories increased by 4% from 2016 to 2019.

CONCLUSION

Diagnosis of ADHD among children is trending upward in the United States. Central nervous system stimulants, especially methylphenidate formulations, are the most prescribed ADHD medications for children 17 years and younger.

Reduced thalamic activity in ADHD under ABR forward masking conditions

Attention-deficit hyperactivity disorder (ADHD) is a common chronic neurodevelopmental disorder characterized by symptoms of inattention, overactivity, and/or impulsiveness. The prevalence of ADHD varies in different settings and there have been voices raised to call for more objective measures in order to avoid over- and underdiagnosing of ADHD. Auditory Brainstem Response (ABR) is a method where click shaped sounds evoke potentials that are recorder from electrodes on the skull of a patient. The aim of this study was to explore possible alterations in the ABR of 29 patients with ADHD compared to 39 healthy controls. We used a forward masked sound. We found differences in ABR that correspond to the thalamic area. The thalamus seems to play an active role in regulation of activity level in ADHD. More research is needed to draw any further conclusions on using ABR as an objective measurement to detect ADHD.

Language and reading in attention-deficit/hyperactivity disorder and comorbid attention-deficit/hyperactivity disorder + developmental language disorder

Background

The current study sought to examine whether psycholinguistic assessments could discriminate children and adolescents with developmental language disorder (DLD) from those with attention-deficit/hyperactivity disorder (ADHD; combined or inattentive subtype) and comorbid DLD + ADHD.

Methods

The Clinical Evaluation of Language Fundamentals-Screening Test (CELFST; Wiig et al., 2013), the Comprehensive Test of Phonological Processing (nonword repetition subtest; Wagner et al., 2013), and the Test of Word Reading Efficiency (sight word and phonemic decoding subtests; Torgesen et al., 2012) were examined in 441 children and adolescents between 6 and 16 years of age.

Results

The presence of a language disorder (with or without ADHD) predicted poor performance across tasks. Children and adolescents with ADHD (combined vs. inattentive) only significantly differed in sight word reading, in favor of those with combined type. Measures of reading efficiency could distinguish between the two types of ADHD, but not between other groups. Interestingly, scores on the standard language screener were no worse for children with ADHD + DLD than children with DLD only.

Conclusions

The combination of comorbid ADHD + DLD did not appear to be associated with lower language abilities, sight word reading, or phonemic decoding relative to DLD alone. Reading efficiency was effective in discriminating between ADHD subtypes. These findings offer valuable insights into differential diagnosis and the identification of comorbidity.

Adult ADHD: it is old and new at the same time - what is it?

Even though the number of studies aiming to improve comprehension of ADHD pathology has increased in recent years, there still is an urgent need for more effective studies, particularly in understanding adult ADHD, both at preclinical and clinical levels, due to the increasing evidence that adult ADHD is highly distinct and a different entity from childhood ADHD. This review paper outlines the symptoms, diagnostics, and neurobiological mechanisms of ADHD, with emphasis on how adult ADHD could be different from childhood-onset. Data show a difference in the environmental, genetic, epigenetic, and brain structural changes, when combined, could greatly impact the behavioral presentations and the severity of ADHD in adults. Furthermore, a crucial aspect in the quest to fully understand this disorder could be through longitudinal analysis. In this way, we will determine if and how the pathology and pharmacology of ADHD change with age. This goal could revolutionize our understanding of the disorder and address the weaknesses in the current clinical classification systems, improving the characterization and validity of ADHD diagnosis, specifically those in adults.

The Risk of Methylphenidate Pharmacotherapy for Adults with ADHD

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders. It was once thought to be a disorder affecting only children, but in those undiagnosed in childhood, symptoms do not disappear with age. There is now a growing recognition of the late diagnosis and treatment of adults with ADHD. The first-line drug in pharmacotherapy is methylphenidate, and information about its adverse effects, when used by adults, has not been as extensively described as in children. The aim of this article was to review the literature describing the risks of methylphenidate therapy for adults with ADHD. A total of 19 articles-15 clinical trials and 4 case reports presenting rare side effects resulting from methylphenidate therapy, such as reversible ischemic stroke, myocardial infarction, and psychotic episodes, were analyzed. The analysis from clinical trials included 3458 adult patients with ADHD and described the most common side effects, psychiatric adverse events, effects of methylphenidate treatment on sleep, laboratory results, body mass, and cardiovascular symptoms. Methylphenidate treatment is well tolerated, with side effects described, according to severity, as mild to moderate. We conclude that pharmacotherapy is not risk-free and methylphenidate, due to its side effects, may not be the first drug of choice for every patient.

Medical Expenditures Associated with Attention-Deficit/Hyperactivity Disorder Among Adults in the United States by Age, 2015-2019

BACKGROUND

Attention-deficit hyperactivity disorder is a common disorder that affects both children and adults. However, for adults, little is known about ADHD-attributable medical expenditures.

OBJECTIVE

To estimate the medical expenditures associated with ADHD, stratified by age, in the US adult population.

DESIGN

Using a two-part model, we analyzed data from Medical Expenditure Panel Survey for 2015 to 2019. The first part of the model predicts the probability that individuals incurred any medical costs during the calendar year using a logit model. The second part of the model estimates the medical expenditures for individuals who incurred any medical expenses in the calendar year using a generalized linear model. Covariates included age, sex, race/ethnicity, geographic region, Charlson comorbidity index, insurance, asthma, anxiety, and mood disorders.

PARTICIPANTS

Adults (18 +) who participated in the Medical Expenditure Panel Survey from 2015 to 2019 (N = 83,776).

MAIN MEASURES

Overall and service specific direct ADHD-attributable medical expenditures.

KEY RESULTS

A total of 1206 participants (1.44%) were classified as having ADHD. The estimated incremental costs of ADHD in adults were $2591.06 per person, amounting to $8.29 billion nationally. Significant adjusted incremental costs were prescription medication ($1347.06; 95% CI: $990.69-$1625.93), which accounted for the largest portion of total costs, and office-based visits ($724.86; 95% CI: $177.75-$1528.62). The adjusted incremental costs for outpatient visits, inpatient visits, emergency room visits, and home health visits were not significantly different. Among older adults (31 +), the incremental cost of ADHD was $2623.48, while in young adults (18-30), the incremental cost was $1856.66.

CONCLUSIONS

The average medical expenditures for adults with ADHD in the US were substantially higher than those without ADHD and the incremental costs were higher in older adults (31 +) than younger adults (18-30). Future research is needed to understand the increasing trend in ADHD attributable cost.

A Class Activation Map-Based Interpretable Transfer Learning Model for Automated Detection of ADHD from fMRI Data

Automatic detection of Attention Deficit Hyperactivity Disorder (ADHD) based on the functional Magnetic Resonance Imaging (fMRI) through Deep Learning (DL) is becoming a quite useful methodology due to the curse of-dimensionality problem of the data is solved. Also, this method proposes an invasive and robust solution to the variances in data acquisition and class distribution imbalances. In this paper, a transfer learning approach, specifically ResNet-50 type pre-trained 2D-Convolutional Neural Network (CNN) was used to automatically classify ADHD and healthy children. The results demonstrated that ResNet-50 architecture with 10-k cross-validation (CV) achieves an overall classification accuracy of 93.45%. The interpretation of the results was done via the Class Activation Map (CAM) analysis which showed that children with ADHD differed from controls in a wide range of brain areas including frontal, parietal and temporal lobes.