Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

The Chinese Version of the Compensatory ADHD Behaviors Scale (CABS): A Study on Reliability, Validity, and Clinical Utility

Purpose

With the further development of attention-deficit/hyperactivity disorder (ADHD) research, more and more assessment tools related to ADHD have been used. However, there is still no measurement instrument to evaluate the compensatory behavior of ADHD in China. This study aimed to examine the reliability and validity of the Compensatory ADHD Behaviors Scale (CABS) adapted in Chinese and explore ecological characteristics in adults with ADHD using the CABS.

Patients and Methods

Data were collected from a sample of 306 adults (Mage = 26.43 years, SD = 5.32; 46.08% male). The original version CABS was translated into Chinese using the forward and backward translation procedures. Participants completed the CABS and questionnaires assessing ADHD symptoms and executive function. We utilized content validity, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and criterion validity to test the validity. Internal consistency and test-retest reliability were employed to test the reliability. Analysis of variance (ANOVA) was employed to compare ADHD subgroups based on gender, ADHD subtype, comorbidities, and medication status, while controlling for demographic variables as covariates.

Results

CABS exhibited good construct validity (two factors: present-oriented and future-oriented), content validity (content validity index: 0.98), internal consistency reliability (Cronbach's alpha coefficient: 0.85 to 0.87) and test-retest reliability (intraclass correlation coefficient: 0.59 to 0.88). The results of CFA showed acceptable fitness for each subscale. CABS demonstrated significant associations with inattention symptoms and plan/organizational abilities. Medicated ADHD individuals scored higher on future-oriented effectiveness subscale of CABS than non-medicated (F = 6.106, p = 0.014).

Conclusion

The results indicate that the Chinese CABS exhibited good validity and reliability. It can be considered a valid tool for assessing compensatory behaviors in Chinese adults with ADHD. Further research is needed to explore the connection between medication and compensatory behavior.

Patterns of filled prescriptions and the association with risk of drug-induced death. A population-based nested case-control register study

PURPOSE

Opioid analgesics (OA) and other pharmaceuticals have been associated with drug-induced deaths. However, there is a lack of knowledge regarding patterns of use of these pharmaceuticals in the population and regarding such associations. We identify and describe subgroups of people with different patterns of filled prescriptions of OA and other relevant pharmaceuticals and examine associations with drug-induced deaths. In addition, we estimate the proportion of drug-induced deaths with a filled OA prescription and OA as cause of death.

METHODS

A Norwegian population-based nested case-control register study with cases (drug-induced deaths 2010-2018, N = 2388) and population controls matched for age, gender and year of inclusion (N = 21 465). Patterns of filled prescriptions for opioid analgesics (OA), benzodiazepines and benzodiazepine-related drugs, gabapentinoids, ADHD medication and antidepressants/antipsychotics were explored by k-means cluster analysis. Associations with drug-induced deaths were estimated by conditional logistic regression adjusted for sociodemographic characteristics. Overlap of filled OA prescriptions and OA as cause of death was estimated.

RESULTS

Five clusters were identified: 'few prescriptions', 'weak OA', 'ADHD medication', 'sedative/psychiatric morbidity' and 'strong OA'. The 'strong OA' cluster had higher socioeconomic status compared to the other groupings. The risk of drug-induced death was also highest in this cluster (OR = 35.5; CI 25.6-49.3) and, for 68% (CI 64-73) of cases, filled prescriptions for OA was indicated as the underlying cause of death.

CONCLUSIONS

The cluster analysis identified a subgroup with filled prescriptions of OA and other pharmaceuticals and a higher socioeconomic status than other subgroups. This subgroup had a high risk of drug-induced death that needs to be addressed.

Predictors of Physician Follow-Up Care Among Patients Affected by an Incident Mental Disorder Episode in Quebec (Canada)

OBJECTIVES

This study identified predictors of prompt (1+ outpatient physician consultations/within 30 days), adequate (3+/90 days) and continuous (5+/365 days) follow-up care from general practitioners (GPs) or psychiatrists among patients with an incident mental disorder (MD) episode.

METHODS

Study data were extracted from the Quebec Integrated Chronic Disease Surveillance System (QICDSS), which covers 98% of the population eligible for health-care services under the Quebec (Canada) Health Insurance Plan. This observational epidemiological study investigating the QICDSS from 1 April 1997 to 31 March 2020, is based on a 23-year patient cohort including 12+ years old patients with an incident MD episode (n = 2,670,133). Risk ratios were calculated using Robust Poisson regressions to measure patient sociodemographic and clinical characteristics, and prior service use, which predicted patients being more or less likely to receive prompt, adequate, or continuous follow-up care after their last incident MD episode, controlling for previous MD episodes, co-occurring disorders, and years of entry into the cohort.

RESULTS

A minority of patients, and fewer over time, received physician follow-up care after an incident MD episode. Women; patients aged 18-64; with depressive or bipolar disorders, co-occurring MDs-substance-related disorders (SRDs) or physical illnesses; those receiving previous GP follow-up care, especially in family medicine groups; patients with higher prior continuity of GP care; and previous high users of emergency departments were more likely to receive follow-up care. Patients living outside the Montreal metropolitan area; those without prior MDs; patients with anxiety, attention deficit hyperactivity, personality, schizophrenia and other psychotic disorders, or SRDs were less likely to receive follow-up care.

CONCLUSION

This study shows that vulnerable patients with complex clinical characteristics and those with better previous GP care were more likely to receive prompt, adequate or continuous follow-up care after an incident MD episode. Overall, physician follow-up care should be greatly improved.

Costs associated with adverse events during treatment episodes for adult attention-deficit/hyperactivity disorder

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) medication is frequently associated with adverse events (AEs), but limited real-world data exist regarding their costs from a payer's perspective. Therefore, this study evaluated the healthcare costs associated with common AEs among adult patients treated for ADHD in the US.

METHODS

Eligible adults treated for ADHD were identified from a large US claims database (1 October 2015-30 September 2021). A retrospective cohort study design was used to assess excess healthcare costs and costs directly related to AE-specific claims per-patient-per-month (PPPM) associated with 10 selected AEs during ADHD treatment. To account for all costs associated with the AE, treatment episodes with a given AE were compared to similar treatment episodes without this AE. Entropy balancing was used to create cohorts with similar characteristics. Studied AEs were selected based on their prevalence in clinical trials for common ADHD medications and were identified from ICD-10-CM diagnosis codes recorded in claims.

RESULTS

Among the 461,464 patients included (mean age: 34.2 years; 45.5% males), 49.4% had ≥1 AE during their treatment episode. Treatment episodes with AEs were associated with statistically significant AE-specific medical costs (erectile dysfunction: $57; fatigue: $82; dry mouth: $90; diarrhea: $162; insomnia: $147; anxiety: $281; nausea: $299; constipation: $356; urinary hesitation: $491; feeling jittery: $723) and excess healthcare costs PPPM (erectile dysfunction: $120, fatigue: $248, insomnia: $265, anxiety: $380, diarrhea: $441, dry mouth: $485, nausea: $709, constipation: $802, urinary hesitation: $1,105, feeling jittery: $1,160; p < .05).

LIMITATIONS

AEs were identified based on recorded diagnosis on medical claims and likely represent more severe AEs. Therefore, costs may not be representative of milder AEs.

CONCLUSIONS

This study found that AEs occurring during ADHD treatment episodes are associated with significant healthcare costs. This highlights the potential of treatments with favorable safety profiles to alleviate the burden experienced by patients and the healthcare system.

Could psychostimulant drug use among university students be related to ADHD symptoms? A preliminary study

We aimed to explore if psychostimulant use among student could be linked to attention deficit-hyperactivity disorder (ADHD) symptoms using a self-administered questionnaire sent by email to French students in 2021. Participants were asked about their psychostimulant use and the presence of ADHD symptoms using the Wender Utah Rating Scale and the Adult Self-Report Scale. Among the 4431 respondents, the prevalence of psychostimulant use was concerning and significantly associated with ADHD symptoms. This association could be related to undiagnosed ADHD or to psychobehavioral impairments induced by psychostimulant use underlining the need of ADHD screening and targeted prevention measures.

An overview of the use of psychoactive substances among students at the University of Lille during the COVID-19 health crisis: Results of the PETRA study

OBJECTIVES

Students represent a population at risk for substance abuse. That risk may have been exacerbated by the COVID-19 pandemic. We aimed to describe substance abuse among students and to compare consumption according to the university field.

METHODS

A self-administered questionnaire was sent by email to all students at the University of Lille, France, between March and July 2021. This anonymous questionnaire included questions about sociodemographic characteristics, university courses and the use of psychoactive substances (frequency, reasons, routes of administration) since the first university year.

RESULTS

Among the 4431 students who responded (response rate 6.1%), eighty percent declared having used alcohol since the first university year, 34% cannabis, 15.4% benzodiazepines, 14.7% opioid drugs, 7.5% cocaine, 6.8% nitrous oxide and 6.5% MDMA. More than 20% of the users of cannabis, benzodiazepines, amphetamines and cocaine reported having already felt dependent. Recreational use was described by more than 10% of benzodiazepine or opioid drug users. Nitrous oxide use was significantly more frequent in the health and sport field (p < 0.001). Tobacco, benzodiazepine, cannabis and MDMA uses were significantly more frequent in the humanities and social sciences/art, language and literature fields (p < 0.001).

CONCLUSION

Prevention measures focusing on alcohol, cannabis, illicit psychostimulants, nitrous oxide and prescription drugs are required in the student population.

A new mechanistic insight into the association between environmental perfluorooctane sulfonic acid (PFOS) exposure and attention deficit and hyperactivity disorder (ADHD)-like behavior

Perfluorooctane sulfonic acid (PFOS) is one of the main residual environmental pollutants that threaten human health. PFOS exposure is positively correlated with the prevalence of attention deficit hyperactivity disorder (ADHD); however, the underlying mechanism is unknown. Given that dopamine (DA) is a crucial target for PFOS and that its dysfunction is a key role in ADHD development, it is speculated that PFOS exposure contributes to the occurrence of ADHD to some extent by disrupting DA homeostasis. To establish the relationship between PFOS exposure, DA dysfunction, and ADHD-like behavior, adult zebrafish were exposed to PFOS for 21 days using PFOS concentrations in the serum of patients with ADHD as the reference exposure dose. Results showed that PFOS caused ADHD-like behaviors, with the presence of the slightly elevated percentage of time spent in movement and prolonged time spent in reaching the target zone in the T-maze. Hyperactivity and cognitive ability impairment were more severe with increasing PFOS concentrations. Further investigation showed that PFOS exposure resulted in a decrease in the DA content, accompanied by a decrease in the number of dopaminergic neurons and a disturbance in the transcription profiles of genes associated with the dopaminergic system. Treatment with Ritalin effectively alleviated PFOS-induced ADHD-like behavior and restored DA levels, number of dopaminergic neurons, and expression of DA metabolism-related genes, suggesting that PFOS exposure induced ADHD-like behavior by triggering DA secretion disorder. This study enriches our understanding of the pathogenic mechanisms underlying ADHD development and emphasizes the importance of focusing on the health risks pertaining to environmental exposure.

Risk factors associated with newly diagnosed attention-deficit/hyperactivity disorder in adults: a retrospective case-control study

BACKGROUND

Knowledge of risk factors for attention-deficit/hyperactivity disorder (ADHD) may facilitate early diagnosis; however, studies examining a broad range of potential risk factors for ADHD in adults are limited. This study aimed to identify risk factors associated with newly diagnosed ADHD among adults in the United States (US).

METHODS

Eligible adults from the IQVIA PharMetrics® Plus database (10/01/2015-09/30/2021) were classified into the ADHD cohort if they had ≥ 2 ADHD diagnoses (index date: first ADHD diagnosis) and into the non-ADHD cohort if they had no observed ADHD diagnosis (index date: random date) with a 1:3 case-to-control ratio. Risk factors for newly diagnosed ADHD were assessed during the 12-month baseline period; logistic regression with stepwise variable selection was used to assess statistically significant association. The combined impact of selected risk factors was explored using common patient profiles.

RESULTS

A total of 337,034 patients were included in the ADHD cohort (mean age 35.2 years; 54.5% female) and 1,011,102 in the non-ADHD cohort (mean age 44.0 years; 52.4% female). During the baseline period, the most frequent mental health comorbidities in the ADHD and non-ADHD cohorts were anxiety disorders (34.4% and 11.1%) and depressive disorders (27.9% and 7.8%). Accordingly, a higher proportion of patients in the ADHD cohort received antianxiety agents (20.6% and 8.3%) and antidepressants (40.9% and 15.8%). Key risk factors associated with a significantly increased probability of ADHD included the number of mental health comorbidities (odds ratio [OR] for 1 comorbidity: 1.41; ≥2 comorbidities: 1.45), along with certain mental health comorbidities (e.g., feeding and eating disorders [OR: 1.88], bipolar disorders [OR: 1.50], depressive disorders [OR: 1.37], trauma- and stressor-related disorders [OR: 1.27], anxiety disorders [OR: 1.24]), use of antidepressants (OR: 1.87) and antianxiety agents (OR: 1.40), and having ≥ 1 psychotherapy visit (OR: 1.70), ≥ 1 specialist visit (OR: 1.30), and ≥ 10 outpatient visits (OR: 1.51) (all p < 0.05). The predicted risk of ADHD for patients with treated anxiety and depressive disorders was 81.9%.

CONCLUSIONS

Mental health comorbidities and related treatments are significantly associated with newly diagnosed ADHD in US adults. Screening for patients with risk factors for ADHD may allow early diagnosis and appropriate management.

Differential Effects of ADHD Polygenic Risk on Cognitive Performance in Later Life

OBJECTIVE

Understanding the association between polygenic risk for ADHD and cognition throughout aging has not been widely studied. This study aimed to determine whether ADHD risk influences cognitive performance among individuals at both young-old and middle-old age.

METHOD

Participants from the Health and Retirement Study, a biennial survey of 20,000 Americans, were compared on executive function and delayed recall measures using regression analyses.

RESULTS

There was no significant effect of ADHD risk on memory at both age waves for African-ancestry (AA; n = 403) and European-ancestry (EA; n = 2,286). There was, however, a significant association between ADHD risk and performance on executive function for EA at middle-old age (p = .028), but not young-old age; no such association was observed for AA adults.

CONCLUSION

This finding suggests that ADHD risk may differentially influence cognition among older adults throughout the aging process, with important implications for future research.

Effectiveness of cognitive behavioural-based interventions for adults with attention-deficit/hyperactivity disorder extends beyond core symptoms: A meta-analysis of randomized controlled trials

OBJECTIVES

To provide an updated systematic review of randomized controlled studies for the efficacy of cognitive behavioural therapy (CBT) in treating adults with attention-deficit/hyperactivity disorder (ADHD).

DESIGN

Meta-analysis.

METHODS

PROSPERO registration: CRD42021273633. The methods used aligned with the PRISMA guidelines. Database searches identified CBT treatment outcome studies eligible for conducted meta-analysis. Treatment response was summarized by calculating the standardized mean differences for changes in outcome measures for adults with ADHD. Measures included core and internalizing symptoms and were assessed on the basis of self-reporting and investigator evaluation.

RESULTS

Twenty-eight studies met the inclusion criteria. This meta-analysis indicates that CBT for adults with ADHD was effective in reducing both core and emotional symptoms. Decreases in depression and anxiety were predicted by the reduction of core ADHD symptoms. An increase in self-esteem and quality of life were also observed for adults with ADHD who were received CBT. Adults who received either individual or group therapy significantly exhibited a greater reduction of symptoms than those who received active control intervention, received treatment as usual, or were on the treatment waitlist. Traditional CBT was equally effective in reducing core ADHD symptoms but outperformed other CBT approaches in reducing emotional symptoms among adults with ADHD.

CONCLUSIONS

This meta-analysis offers cautiously optimistic support for the efficacy of CBT in treating adults with ADHD. The additional reduction of emotional symptoms demonstrates the potential of CBT in adults with ADHD who are at higher risk for depression and anxiety comorbidities.

Where Do Neurodevelopmental Disorders Go? Casting the Eye Away from Childhood towards Adulthood

Neurodevelopmental disorders (NDDs) encompass a group of complex conditions with onset during the early developmental period. Such disorders are frequently associated with a number of neuropsychiatric features, the most prevalent ones being autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disability, communication and specific learning disorders, and motor disorders. These conditions are characterized by wide genetic and clinical variability, and although they were previously conceptualized as childhood-limited disorders, NDDs are progressively being recognized as persistent conditions with a potentially relevant impact on the quality of life and overall functioning during adult life. In addition, emerging evidence seems to point towards the hypothesis of a neurodevelopmental continuum, according to which NNDs could portray different time-dependent outcomes, depending on the severity of the altered brain development. Despite representing lifelong phenotypes, they are often not promptly identified and/or managed in adulthood. In this regard, specific guidelines on clinical and therapeutic approaches for these conditions have not yet been delineated. In this view, future research investigations should be encouraged to broaden available knowledge, characterize the clinical course of NDDs across an individual’s lifespan, and better understand the patterns of aging-related concerns in adults with an NDD diagnosis. Additionally, considering the difficulties many young adults encounter while transitioning from childhood to adult mental health services, new, specific programs should be developed and existing programs should be implemented to improve the transition process and for the management of NDDs in adulthood.

[The mediating role of emotion regulation strategies between symptoms and anxiety problems in children with attention deficit hyperactivity disorder]

OBJECTIVES

To study the mediating role of emotion regulation strategies between symptoms and anxiety problems in children with attention deficit hyperactivity disorder (ADHD).

METHODS

Convenience cluster sampling was performed to select 435 eligible children with ADHD from 10 211 students in 10 elementary schools in Kashgar of Xinjiang Uygur Autonomous Region. SNAP-IV Assessment Scale, Emotion Regulation Questionnaire for Children and Adolescents, and Conners Parent Symptoms Questionnaire were used to obtain relevant information. The Spearman correlation analysis and the moderated mediation method were used for data analysis.

RESULTS

For the children with ADHD, the score of cognitive reappraisal was negatively correlated with the scores of symptoms and anxiety problems (rs=-0.254 and -0.270 respectively, P<0.001), and the score of symptoms was positively correlated with the score of anxiety problems (rs=0.329, P<0.001). The analysis of mediating effect showed that cognitive reappraisal played a partial mediating role between symptoms and anxiety problems, with a 95% confidence interval of 0.008-0.027, and the mediating effect accounted for 16.10% of the total effect. In addition, sex played a regulatory role in this mediation model (P<0.001).

CONCLUSIONS

Cognitive reappraisal plays a mediating role between symptoms and anxiety problems in children with ADHD, while sex regulates the relationship of symptoms with cognitive reappraisal and anxiety problems in these children.

Prevalence of ADHD Symptomatology in Adult Population in the Czech Republic: A National Study

BACKGROUND

ADHD is a common neurodevelopmental disorder frequently diagnosed between the ages 7 and 10 years. We measured ADHD symptomatology in a representative sample of the Czech population.

MATERIAL AND METHODS

Data collection was performed in January 2019 through the European National Panel. The respondents completed a demographic questionnaire focusing on ADHD history and a standardized questionnaire, the Adult ADHD Self-Report Scale (ASRS) screener for ADHD symptomatology in adulthood.

RESULTS

From the sample of 1,518 respondents, 3% of the respondents reported having been diagnosed with ADHD/hyperkinetic disorder in their lifetime. According to ASRS scoring, 119 respondents were classified as suspected ADHD. Overall, more males than females reported ADHD symptomatology. Age was also significantly associated with ASRS. Education status yielded no significant results.

CONCLUSION

Our study documents that the prevalence of ADHD symptomatology in adults is comparable with that in Western countries despite the different historical and health care backgrounds.

A Critical View on Motor-based Interventions to Improve Motor Skill Performance in Children With ADHD: A Systematic Review and Meta-analysis

OBJECTIVE

To map the effect of motor-based interventions on motor skills in children with ADHD.

METHOD

A systematic literature search was performed in Pubmed, Web of Science, and the SCOPUS database (last search: October 30th 2022). Methodological quality was assessed using the PEDro-scale and the quality of evidence was determined with the GRADE-method. Meta-analysis was performed when at least five studies were available.

RESULTS

Thirteen studies (7 RCTs) satisfied the inclusion criteria, five of which were eligible for meta-analysis. Only one of the included studies reached the low risk of bias threshold. Comparing different motor-based interventions to any non-motor control intervention showed large motor skill improvements (SMD = 1.46; 95% CI = [1.00;1.93]; I² = 47.07%). The most effective type of motor-based intervention and the optimal treatment parameters could not be determined yet.

CONCLUSION

Motor-based interventions in general seem to improve motor skills in children with ADHD. Additional RCTs are needed to increase current low GRADE confidence.

Impulsive choice in two different rat models of ADHD-Spontaneously hypertensive and Lphn3 knockout rats

Introduction

Impulsivity is a symptom of attention-deficit/hyperactivity disorder (ADHD) and variants in the Lphn3 (Adgrl3) gene (OMIM 616417) have been linked to ADHD. This project utilized a delay-discounting (DD) task to examine the impact of Lphn3 deletion in rats on impulsive choice. "Positive control" measures were also collected in spontaneously hypertensive rats (SHRs), another animal model of ADHD.

Methods

For Experiment I, rats were given the option to press one lever for a delayed reward of 3 food pellets or the other lever for an immediate reward of 1 pellet. Impulsive choice was measured as the tendency to discount the larger, delayed reward. We hypothesized that impulsive choice would be greater in the SHR and Lphn3 knockout (KO) rats relative to their control strains - Wistar-Kyoto (WKY) and Lphn3 wildtype (WT) rats, respectively.

Results

The results did not completely support the hypothesis, as only the SHRs (but not the Lphn3 KO rats) demonstrated a decrease in the percent choice for the larger reward. Because subsequent trials did not begin until the end of the delay period regardless of which lever was selected, rats were required to wait for the next trial to start even if they picked the immediate lever. Experiment II examined whether the rate of reinforcement influenced impulsive choice by using a DD task that incorporated a 1 s inter-trial interval (ITI) immediately after delivery of either the immediate (1 pellet) or delayed (3 pellet) reinforcer. The results of Experiment II found no difference in the percent choice for the larger reward between Lphn3 KO and WT rats, demonstrating reinforcement rate did not influence impulsive choice in Lphn3 KO rats.

Discussion

Overall, there were impulsivity differences among the ADHD models, as SHRs exhibited deficits in impulsive choice, while the Lphn3 KO rats did not.

Convergence mechanism of mindfulness intervention in treating attention deficit hyperactivity disorder: Clues from current evidence

This paper reviews the underlying evidence for various aspects of the convergence mechanism of mindfulness intervention in attention deficit hyperactivity disorder (ADHD). There may be compatibility among various ADHD remission models and the therapeutic mechanism of mindfulness intervention in ADHD may be mainly via the convergence mechanism. However, neuroimaging-based analysis of the mechanisms of mindfulness intervention in treating ADHD is lacking. Differences in the efficacy of various subtypes of mindfulness intervention, and corresponding specific imaging changes need further investigation. Future research may focus on the neuroimaging features of specific mindfulness intervention subtypes.

Comorbidity of adult ADHD and substance use disorder in a sample of inpatients bipolar disorder in Iran

BACKGROUNDS

The study of the relationship between adult Attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received more attention in recent years and there is limited information in this area. On the other hand, there is a significant comorbidity between ADHD and bipolar disorder with substance use disorder. In this study, we investigated the prevalence of comorbidity of adult ADHD and substance use disorder among a group of bipolar patients admitted to a psychiatric hospital.

METHODS

One hundred fifty patients from a total of 200 consecutive patients who were referred to the emergency department of Roozbeh Psychiatric Hospital in Tehran, diagnosed with bipolar disorder based on the initial psychiatric interview and needed hospitalization, were evaluated again by an experienced faculty member psychiatrist by using a subsequent interview based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5). They were evaluated using the Structured Clinical Interview for DSM-5 (SCID-5) questionnaire to confirm the diagnosis of bipolar disorder and the comorbidity of adult ADHD and substance use disorder.

RESULTS

From 150 patients diagnosed with bipolar disorder, 106 patients (70.7%) had adult ADHD. 89 patients (59.3%) had substance use disorder and 58 patients (38.7%) had both of these comorbidities with bipolar disorder. Comorbidity of adult ADHD was associated with the earlier onset of the first mood episode in bipolar disorder (p value = 0.025). There was no statistically significant relationship between substance use disorder and age of onset of the first episode. (P value = 0.57).

CONCLUSIONS

Due to the limitations of studies on adult ADHD comorbidity with bipolar disorder, especially in hospital settings, as well as the increased risk of association with substance use disorder, further multicenter studies in this area with larger sample sizes can increase awareness in this regard.

Reasons for treatment changes in adults with attention-deficit/hyperactivity disorder: a chart review study

BACKGROUND

Adults with attention-deficit hyperactivity disorder (ADHD) often cycle through multiple treatments for reasons that are not well documented. This study analyzed the reasons underlying treatment changes among adults treated for ADHD in a real-world setting.

METHODS

Data were collected via an online reporting form completed by eligible physicians between October and November 2020. Data for adult patients in the United States who were diagnosed with ADHD and initiated a treatment regimen within 1 to 5 years of chart abstraction were obtained. Reason for a treatment change was described for a randomly selected regimen episode, which spanned from treatment initiation until the earliest among treatment add-on/switch or discontinuation, death, or date of chart abstraction. The overall rate of ADHD/treatment-related complications were also described. Physician satisfaction with current treatment options for adult ADHD and opinions on areas for improvement were assessed.

RESULTS

Data on 320 patients were reported by 152 physicians specializing in psychiatry (40.1%), pediatrics (25.0%), family medicine (21.7%), and internal medicine (13.2%). Patients had a mean age of 29.3 years; most were diagnosed with ADHD as adults (57.5%) and within the previous 5 years (56.5%). Selected treatment regimens included stimulants (79.1%), nonstimulants (14.7%), and combination therapy (5.6%) for an average duration of 1.9 years. Among patients with treatment discontinuation (N = 59), the most common reasons for discontinuation were suboptimal symptom management (55.9%), occurrence of ADHD/treatment-related complications (25.4%), and patient attitude/dislike of medication (25.4%). The main reasons for other key treatment changes were inadequate/suboptimal management of symptoms and cost considerations. Over 40% of patients had ≥ 1 documented ADHD/treatment-related complication, irrespective of whether they led to a treatment change. One in 5 physicians (19.8%) were very dissatisfied, moderately dissatisfied, or neither satisfied nor dissatisfied with current treatment options for ADHD in adults; the top 3 suggested improvements were lower risk of abuse (71.7%), longer effect duration (65.1%), and fewer ADHD/treatment-related complications (61.2%).

CONCLUSIONS

The top reasons for treatment changes among adults with ADHD are lack of efficacy and ADHD/treatment-related complications, highlighting the importance of developing more effective and safer treatments to alleviate the burden of ADHD.

Validity of the Czech Translation of the Adult Attention-Deficit/Hyperactivity Disorder (ADHD) Self-Report Scale (ASRS)

Objective

The study aim was to assess the psychometric properties of the ASRS in the Czech Republic. Although this screening tool is now frequently used, its validity has not been assessed among the general Czech population.

Methods

The ASRS and WURS were administered online to the general Czech population (N = 1,518). We performed confirmatory and exploratory factor analyses.

Results

For the ASRS, confirmatory factor analysis showed good fit for the screening part (SRMR = 0.03, RMSEA = 0.06, CFI = 0.98). For the symptom list, the fit was good according to the SRMR, acceptable according to the RMSEA, and slightly below acceptable according to the CFI. For the WURS, the results showed SRMR = 0.06, RMSEA = 0.07, and CFI = 0.92.

Conclusion

The Czech translation of the ASRS is appropriate and has acceptable psychometric properties. However, we strongly recommend only using this tool together with clinical judgment.

Feasibility of an Extensive Strategy for Adult Diagnosis of Attention Deficit Hyperactivity Disorder Among Patients Suffering From Substance Use Disorders

INTRODUCTION

Attention Deficit Hyperactivity Disorder (ADHD) is found in up to 20% adults with Substance Use Disorder (SUD). ADHD + SUD is associated with a more complex clinical presentation and poorer outcomes than each disorder alone. In the presence of SUD, adult ADHD is particularly difficult to diagnose as both disorders can mimic or hide the symptoms of each other. Our university hospital in Paris recently started an extensive outpatient diagnostic procedure for adult patients with SUD to ascertain or refute ADHD diagnosis and to provide therapeutic guidance. Here, we report the acceptability of the assessment procedure for patients and the preliminary description of the current and lifetime clinical profiles as a function of the final diagnosis "ADHD vs. no ADHD."

METHOD

Adult SUD patients with suspected ADHD were included in the current pilot study after stating they had no objection that their de-identified data were used for research purposes, according to French ethical procedures. Patients were evaluated for ADHD, comorbid mental disorders, cognitive state and dimensional psychological variables. They were assessed by trained psychologists and psychiatrists using standardized tools over a day. ADHD diagnosis was mainly based on the Diagnostisch Interview Voor ADHD for DSM-5 (DIVA-5).

RESULTS

Out of 18 eligible patients, 17 were included in the cohort (1 excluded) and none was opposed to using their data. Thirteen (76%) participants were diagnosed with ADHD. All patients appointed for the ADHD diagnostic procedure came, respected schedules and finished the evaluation. All patients were impaired on cognitive functioning and were highly comorbid, but ADHD patients seems to suffer even more from those conditions, especially for cannabis and stimulant use disorders.

DISCUSSION

Preliminary results show high acceptability of the procedure by ADHD-SUD patients. This result could be explained by all the organization adapted to the psychopathology. Patients' baseline motivation to participate also represents an uncontrolled variable that could promote the ability to follow the procedure. Acceptance results of the protocol are promising and represent a starting point to identify the best procedures to design patient-centered pharmacological and non-pharmacological therapies.

Gaming Disorder Seen Through the Prism of Dual Diagnosis: Prevalence and Associated Factors

INTRODUCTION

Dual diagnosis (DD) is defined as the co-occurrence of at least a psychiatric disorder and at least an addictive disorder. Most studies about DD considered substance use disorders. In 2018, gaming disorder (GD) was recognized as a formal disorder and integrated into the category of addictive disorders in the 11th version of the International Classification of Diseases. Our objectives were to measure DD prevalence among GD patients and to assess factors associated with the presence of DD.

METHODS

As part of the EVALuation of behavioral ADDictions (EVALADD) cohort, 92 patients with GD were included in the present study. Psychiatric disorders, including anxiety, mood, and psychotic disorders, were explored with the Mini International Neuropsychiatric Interview (MINI 5.0.0). Probable adult attention-deficit/hyperactivity disorder (ADHD) was screened with the Wender Utah Rating Scale (WURS) in childhood and with the ADHD Self-Report Scale-V1.1 (ASRS) in adulthood. Finally, personality was assessed using the 125-item version of the Temperament and Character Inventory (TCI-125), motives for gaming with the Videogame Motives Questionnaire (VMQ) and attachment styles with the Relationship Scales Questionnaire (RSQ). To measure the prevalence of DD among GD patients, we considered the occurrence of current GD with current anxiety, mood, or psychotic disorders, or with probable current ADHD. We also performed a multivariate analysis to identify independent factors associated with DD.

RESULTS

More than half (55.4%) of GD patients suffered from DD. We found a high prevalence of probable ADHD (38%) and anxiety disorders (29% suffering from generalized anxiety disorder, social, agoraphobia or panic disorder). Four variables were significantly associated with DD: suicidal thoughts [odds ratio (OR) = 6.83, 95% confidence interval (95%CI) (1.66-28.09)], VMQ "coping" scores [OR = 1.18, 95%CI (1.01-1.38)], TCI-125 "harm avoidance" scores [OR = 1.04, 95%CI (1.01-1.07)] and "novelty seeking" scores [OR = 1.03, 95%CI (1.00-1.06)].

DISCUSSION

The prevalence of certain psychiatric disorders among GD patients far exceeded that observed in the general population. Both ADHD and suicidal ideations should particularly be screened among GD patients. Specific interventions targeting personality dimensions associated with DD but also on the management of negative affect should represent new treatment opportunities.

Review of barriers and interventions to promote treatment engagement for pediatric attention deficit hyperactivity disorder care

Attention deficit hyperactivity disorder (ADHD) is a common and impairing behavioral health disorder, impacting over 5% of children worldwide. There are multiple evidence-based pharmacological and psychosocial treatments for ADHD, and greater service utilization is associated with improved acute and long-term outcomes. However, long-term outcomes are suboptimal as multimodal treatments are often not accessed and most care ends prematurely. This narrative review discusses barriers to engagement for children and adolescents with ADHD and their families as well as interventions to overcome these barriers. Families face a variety of structural and attitudinal barriers, ranging from cost and access to stigma and low self-efficacy to successfully implement change. There are multiple interventions that may enhance engagement with ADHD care including psychoeducation, integration of behavioral services in general medical settings, telehealth as well as specific adaptations to existing ADHD treatments, such as the use of motivational interviewing or shared decision making. Integration of behavioral health into general medical settings and telehealth have been found in controlled studies to increase access by reducing both structural and attitudinal barriers. Adding motivational interviewing, shared decision making and other engagement interventions to evidence-based ADHD treatments has been found to reduce attitudinal barriers that translates into improved participation and satisfaction while enhancing outcomes. However, little is known about how to promote extended engagement with ADHD services even though a chronic care model for ADHD is recommended.

Economic burden of attention-deficit/hyperactivity disorder among adults in the United States: a societal perspective

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with substantial clinical burden as individuals transition to adulthood, including higher rates of comorbidities, mortality, incarceration, and psychiatric hospitalizations than in individuals without ADHD. These higher rates likely contribute to substantial economic burden as well. OBJECTIVE: To provide a comprehensive evaluation of the economic burden associated with ADHD in the US adult population. METHODS: Direct health care costs were obtained by using claims data from the IBM MarketScan Research Databases (January 1, 2017, through December 31, 2018). Direct non-health care costs and indirect costs were estimated on the basis of the literature and government publications. Excess costs incurred by adults with ADHD during 2018 were evaluated from a societal perspective; per-patient costs were extrapolated to the national level. RESULTS: An estimated 8.7 million adults live with ADHD in the United States, resulting in a total societal excess cost attributable to ADHD of $122.8 billion ($14,092 per adult). Excess costs of unemployment ($66.8 billion; 54.4%) comprised the largest proportion of the total, followed by productivity loss ($28.8 billion; 23.4%) and health care services ($14.3 billion; 11.6%). CONCLUSIONS: ADHD in adults is associated with substantial economic burden. DISCLOSURES: This study was funded by Otsuka Pharmaceutical Development & Commercialization, Inc. (Otsuka). The study sponsor contributed to and approved the study design, participated in the interpretation of data, and reviewed and approved the manuscript. Schein is an employee of Otsuka. Gagnon-Sanschagrin, Davidson, Kinkead, Cloutier, Guérin, and Lefebvre are employees of Analysis Group, Inc., a consulting company that provided paid consulting services to Otsuka to develop and conduct this study and write the manuscript. Adler has received research support from Shire/Takeda, Sunovion, and Otsuka; consulting fees from Bracket, Shire/Takeda, Sunovion, Otsuka, the State University of New York (SUNY), the National Football League (NFL), and Major League Baseball (MLB); and royalty payments (as inventor) from New York University (NYU) for license of adult ADHD scales and training materials. Childress has received research support from Allergan, Takeda/Shire, Emalex, Akili, Ironshore, Arbor, Aevi Genomic Medicine, Neos Therapeutics, Otsuka, Pfizer, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, and the US Food and Drug Administration; was on the advisory board of Takeda/Shire, Akili, Arbor, Cingulate, Ironshore, Neos Therapeutics, Otsuka, Pfizer, Purdue, Adlon, Rhodes, Sunovion, Tris, Supernus, and Corium; received consulting fees from Arbor, Ironshore, Neos Therapeutics, Purdue, Rhodes, Sunovion, Tris, KemPharm, Supernus, Corium, Jazz, and Tulex Pharma; received speaker fees from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Tris, and Supernus; and received writing support from Takeda/Shire, Arbor, Ironshore, Neos Therapeutics, Pfizer, Purdue, Rhodes, Sunovion, and Tris. Part of the material in this study was presented as a poster at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 2021 Virtual Meeting; May 17-20, 2021.

Attention deficit hyperactivity disorder and gaming disorder: Frequency and associated factors in a clinical sample of patients with Gaming Disorder

BACKGROUND AND AIMS

Since June 2018, gaming disorder (GD) has been recognized as a disease. It is frequently associated with attention deficit hyperactivity disorder (ADHD), as there are common vulnerability factors and bidirectional interactions between the two disorders. This study aims to evaluate the presence of ADHD symptoms and predictive factors of ADHD among patients with GD.

METHODS

Ninety-seven patients ≥16 years old referred to the University Hospital of Nantes between 2012 and 2020 for GD were included. The diagnosis of GD was given a posteriori in accordance with the new ICD-11 GD definition. ADHD was screened using the Adult-ADHD Self-Report Scale and the Wender-Utah Rating Scale. A multivariate logistic regression model was used to identify explanatory factors for ADHD-GD comorbidity.

RESULTS

The rate of GD patients who screened positive for ADHD was 39%. Predictive factors of ADHD-GD comorbidity were impulsivity (higher score on the negative urgency dimension) and low self-esteem.

DISCUSSION

The rate of ADHD found among patients with GD is consistent with that from the literature on internet GD but higher than that found for other behavioural addictions. The identification of a higher negative urgency score and low self-esteem as predictive factors of AHDH-GD comorbidity indicates that gaming could be considered a dysfunctional way to cope with emotional dysregulation in ADHD or to virtually escape.

CONCLUSIONS

Comorbid ADHD must be taken into consideration to minimize its functional impact on GD patients and gaming-related damage. In contrast, the evaluation of gaming habits in patients with ADHD could be useful for both prevention and care.

Off-Label Medication: From a Simple Concept to Complex Practical Aspects

Off-label use of drugs is widely known as unapproved use of approved drugs, and it can be perceived as a relatively simple concept. Even though it has been in existence for many years, prescribing and dispensing of drugs in an off-label regimen is still a current issue, triggered especially by unmet clinical needs. Several therapeutic areas require off-label approaches; therefore, this practice is challenging for prescribing physicians. Meanwhile, the regulatory agencies are making efforts in order to ensure a safe practice. The present paper defines the off-label concept, and it describes its regulation, together with several complex aspects associated with clinical practices regarding rare diseases, oncology, pediatrics, psychiatry therapeutic areas, and the safety issues that arise. A systematic research of the literature was performed, using terms, such as “off-label”, ”prevalence”, ”rare diseases”, ”oncology”, ”psychiatry”, ”pediatrics”, and ”drug repurposing”. There are several reasons for which off-label practice remains indispensable in the present; therefore, efforts are made worldwide, by the regulatory agencies and governmental bodies, to raise awareness and to ensure safe practice, while also encouraging further research.

ADHD: Reviewing the Causes and Evaluating Solutions

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which patients present inattention, hyperactivity, and impulsivity. The etiology of this condition is diverse, including environmental factors and the presence of variants of some genes. However, a great diversity exists among patients regarding the presence of these ADHD-associated factors. Moreover, there are variations in the reported neurophysiological correlates of ADHD. ADHD is often treated pharmacologically, producing an improvement in symptomatology, albeit there are patients who are refractory to the main pharmacological treatments or present side effects to these drugs, highlighting the importance of developing other therapeutic options. Different non-pharmacological treatments are in this review addressed, finding diverse results regarding efficacy. Altogether, ADHD is associated with different etiologies, all of them producing changes in brain development, leading to the characteristic symptomatology of this condition. Given the heterogeneous etiology of ADHD, discussion is presented about the convenience of personalizing ADHD treatment, whether pharmacological or non-pharmacological, to reach an optimum effect in the majority of patients. Approaches to personalizing both pharmacological therapy and neurofeedback are presented.

Attention Networks in ADHD Adults after Working Memory Training with a Dual n-Back Task

Patients affected by Attention-Deficit/Hyperactivity Disorder (ADHD) are characterized by impaired executive functioning and/or attention deficits. Our study aim is to determine whether the outcomes measured by the Attention Network Task (ANT), i.e., the reaction times (RTs) to specific target and cue conditions and alerting, orienting, and conflict (or executive control) effects are affected by cognitive training with a Dual n-back task. We considered three groups of young adult participants: ADHD patients without medication (ADHD), ADHD with medication (MADHD), and age/education-matched controls. Working memory training consisted of a daily practice of 20 blocks of Dual n-back task (approximately 30 min per day) for 20 days within one month. Participants of each group were randomly assigned into two subgroups, the first one with an adaptive mode of difficulty (adaptive training), while the second was blocked at the level 1 during the whole training phase (1-back task, baseline training). Alerting and orienting effects were not modified by working memory training. The dimensional analysis showed that after baseline training, the lesser the severity of the hyperactive-impulsive symptoms, the larger the improvement of reaction times on trials with high executive control/conflict demand (i.e., what is called Conflict Effect), irrespective of the participants’ group. In the categorical analysis, we observed the improvement in such Conflict Effect after the adaptive training in adult ADHD patients irrespective of their medication, but not in controls. The ex-Gaussian analysis of RT and RT variability showed that the improvement in the Conflict Effect correlated with a decrease in the proportion of extreme slow responses. The Dual n-back task in the adaptive mode offers as a promising candidate for a cognitive remediation of adult ADHD patients without pharmaceutical medication.