Attention-deficit/hyperactivity disorder in adults: an overview

Common and distinct cortical thickness alterations in youth with autism spectrum disorder and attention-deficit/hyperactivity disorder

BACKGROUND

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are neurodevelopmental disorders with overlapping behavioral features and genetic etiology. While brain cortical thickness (CTh) alterations have been reported in ASD and ADHD separately, the degree to which ASD and ADHD are associated with common and distinct patterns of CTh changes is unclear.

METHODS

We searched PubMed, Web of Science, Embase, and Science Direct from inception to 8 December 2023 and included studies of cortical thickness comparing youth (age less than 18) with ASD or ADHD with typically developing controls (TDC). We conducted a comparative meta-analysis of vertex-based studies to identify common and distinct CTh alterations in ASD and ADHD.

RESULTS

Twelve ASD datasets involving 458 individuals with ASD and 10 ADHD datasets involving 383 individuals with ADHD were included in the analysis. Compared to TDC, ASD showed increased CTh in bilateral superior frontal gyrus, left middle temporal gyrus, and right superior parietal lobule (SPL) and decreased CTh in right temporoparietal junction (TPJ). ADHD showed decreased CTh in bilateral precentral gyri, right postcentral gyrus, and right TPJ relative to TDC. Conjunction analysis showed both disorders shared reduced TPJ CTh located in default mode network (DMN). Comparative analyses indicated ASD had greater CTh in right SPL and TPJ located in dorsal attention network and thinner CTh in right TPJ located in ventral attention network than ADHD.

CONCLUSIONS

These results suggest shared thinner TPJ located in DMN is an overlapping neurobiological feature of ASD and ADHD. This alteration together with SPL alterations might be related to altered biological motion processing in ASD, while abnormalities in sensorimotor systems may contribute to behavioral control problems in ADHD. The disorder-specific thinner TPJ located in disparate attention networks provides novel insight into distinct symptoms of attentional deficits associated with the two neurodevelopmental disorders.

TRIAL REGISTRATION

PROSPERO CRD42022370620. Registered on November 9, 2022.

Exercise Dependency and Overuse Injuries in Attention Deficit Hyperactivity Disorder

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is a common condition, but current medications have limitations, pushing a drive for alternative approaches. Different exercise-focused approaches have shown promise, but concern has also been raised about individuals with ADHD showing greater risk of addiction, including exercise dependency. Using an online survey, we examined current exercise practices, including exercise dependency and the presence of overuse injury, which could result from overexercising, in 114 adults with ADHD. We found that most were regularly exercising. None were classified as exercise dependent, but 38.9% were deemed symptomatic nondependent. Hyperactive-impulsive symptoms were a predictor of the level of exercise withdrawal experienced, and the co-occurrence of autism spectrum disorder was associated with greater risk of overuse injuries. The data indicate that ADHD may confer some greater risk of exercise dependency, aligning with previous studies investigating other addictions and suggesting further research is critical.

A meta-analysis on the effect of telemedicine on the management of attention deficit and hyperactivity disorder in children and adolescents

INTRODUCTION

This study aims to report the effect sizes of telemedicine treatments on the symptom domains of paediatric ADHD.

METHODS

In this systematic review and meta-analysis, electronic databases, i.e. PubMed, Scopus, Web of Science and Embase, were searched for articles published up to December 2020. The inclusion criteria were as follows: children or adolescents diagnosed for ADHD or other hyperkinetic disorders; randomized controlled trials (RCTs); efficacy established with parents and teachers or self-rating scales at least for one of the following domains: inattention, cognitive function, hyperactivity, hyperactivity/impulsivity or oppositional behaviours. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs.

RESULTS

From 310 records reduced to 228 after removing duplicates, overall 12 studies were fulfilled our inclusion criteria. They consisted of 708 participants (358 with telemedicine intervention and 350 controls). The telemedicine interventions varied from computerized training programmes with phone calls to videoconferencing programmes, virtual reality classrooms or games. The most applicable method consisted of computerized training programmes with phone calls. Pooling results of all studies with available data on each subscale showed a significant effect of telemedicine on inattention/cognitive function (standardized mean difference (SMD) = 0.26, 95% CI: 0.16, 0.36), hyperactivity/impulsivity (SMD = 0.29, 95% CI: 0.06, 0.52), and oppositional behaviours (SMD = 0.72, 95% CI: 0.24, 1.20) subscales in ADHD. Almost all studies had an overall unclear risk of bias. The source of outcome assessment (parents, teachers or self-report questionnaire) was addressed as a potential confounding factor. In almost all symptom domains, the satisfaction from the treatment was higher in parents than in teachers.

CONCLUSIONS

The clinical effects of telemedicine on the treatment of ADHD showed a small effect size for inattention/cognitive function, hyperactivity/impulsivity and oppositional behaviours.

Adverse Childhood Experiences and ADHD Symptoms Among French College Students

To examine the relationship between adverse childhood experiences (ACEs) and Attention-deficit Hyperactivity Disorder (ADHD) among college students. We investigated the association between ACEs and ADHD symptoms among French college students enrolled in the i-Share cohort using multivariate logistic regression models. The sample comprised of 1062 participants with a mean age of 20.3 (SD = 2.3) of which 30.6% had no ACEs exposure, 29.6% had 1 ACE, 19.2% had 2 ACEs, and 20.6% had ≥ 3 ACEs. After controlling for potential confounders, every increase in ACE exposure heightened the risk of ADHD symptoms with the respective adjusted Odds Ratios and 95% confidence intervals: 1 ACE: 2.1 (0.7-6.3) / 2 ACEs: 4.5 (2.6-12.8)/ ≥ 3 ACEs: 5.2 (1.8-14.8). Estimates for ADHD symptoms were higher with sexual abuse, emotional and physical neglect, and bullying. Findings suggest that ACEs heighten the risk for developing ADHD symptoms among college students and bear important implications for prevention and clinical practice.

Effects of one single-dose methylphenidate compared to one single-dose placebo on QbTest performance in adults with untreated ADHD: a randomized controlled trial

BACKGROUND

Treatment of adults with attention-deficit/hyperactivity disorder (ADHD) primary involves methylphenidate (MPH). Earlier studies have identified placebo responders to increase toward the end of the treatment periods. However, little is known about the immediate effects of placebo on the core symptoms of ADHD in adults. The present study aimed to examine the effects of one single-dose MPH compared to one single-dose placebo during clinical assessments with continuous performance tests (CPT).

METHODS

In a randomized study with cross-over design, 40 adults between 19 and 64 years (72.5% women) with untreated ADHD were consecutively enrolled. The study comprised two trial days with four days in between. The QbTest was performed twice on the same day, before and 80 min after intake of one single-dose 20 mg immediate release methylphenidate (IR-MPH) and with one single-dose placebo, in randomized order.

RESULTS

Performance improved in QbInattention, F (3, 117) = 38.25, p < 0.001, after given IR-MPH (mean diff = 1.14) and after placebo (mean diff = 0.60) with the effect sizes 1.17 and 0.63 respectively. IR-MPH improved performance in QbActivity (mean diff = 0.81, p < 0.001) and QbImpulsivity (mean diff = 0.46, p < 0.04). The proportion of improvements (a decrease by ≥ 0.5 Qb-score) in the parameters QbInattention, QbActivity and QbImpulsivity were 90%, 60% and 52.5%, respectively. After given placebo, corresponding proportions were 60%, 30% and 35%, respectively.

CONCLUSIONS

There seems to be an immediate placebo response in the core symptom inattention. The effect of placebo cannot be ruled out and must be taken in consideration during drug trials with continuous performance tests (CPTs).

TRIAL REGISTRATION

ClinicalTrials.gov; Identifier: NCT02473185.

Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000 to 2021

OBJECTIVES

To investigate the characteristics and trends of out-of-hospital attention-deficit/hyperactivity disorder (ADHD) medication-related therapeutic errors among youth <20 years old reported to US poison centers.

METHODS

National Poison Data System data from 2000 through 2021 were analyzed. Population-based rates were calculated using US census data.

RESULTS

There were 124 383 ADHD medication-related therapeutic errors reported to US poison centers from 2000 through 2021, with the annual frequency increasing by 299.0% during that period. Two-thirds (66.6%) of the 87 691 first-ranked exposures involved children 6 to 12 years old, three-fourths (76.4%) were among males, and half (50.5%) involved amphetamines and related compounds. Most (79.7%) therapeutic errors were single-substance exposures. Although most (82.7%) individuals did not receive treatment in a health care facility (HCF), 2.3% were admitted to a HCF and 4.2% had a serious medical outcome. Children <6 years old were more likely to experience a serious medical outcome (odds ratio = 2.1; 95% confidence interval: 1.9-2.3) or be admitted to a HCF (odds ratio = 3.4; 95% confidence interval: 3.0-3.7) than 6 to 19-year-olds. The most common scenarios were "inadvertently taken or given medication twice" (53.9%), followed by "inadvertently taken or given someone else's medication" (13.4%), and "wrong medication taken or given" (12.9%).

CONCLUSIONS

The frequency of cases reported to poison centers of pediatric out-of-hospital therapeutic errors related to ADHD medications increased by almost 300% during the 22-year study period and is likely attributable to increased prescribing of these medications. Because therapeutic errors are preventable, more attention should be given to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems.

Seed correlation analysis based on brain region activation for ADHD diagnosis in a large-scale resting state data set

Background

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder of multifactorial pathogenesis, which is often accompanied by dysfunction in several brain functional connectivity. Resting-state functional MRI have been used in ADHD, and they have been proposed as a possible biomarker of diagnosis information. This study's primary aim was to offer an effective seed-correlation analysis procedure to investigate the possible biomarker within resting state brain networks as diagnosis information.

Method

Resting-state functional magnetic resonance imaging (rs-fMRI) data of 149 childhood ADHD were analyzed. In this study, we proposed a two-step hierarchical analysis method to extract functional connectivity features and evaluation by linear classifiers and random sampling validation.

Result

The data-driven method-ReHo provides four brain regions (mPFC, temporal pole, motor area, and putamen) with regional homogeneity differences as second-level seeds for analyzing functional connectivity differences between distant brain regions. The procedure reduces the difficulty of seed selection (location, shape, and size) in estimations of brain interconnections, improving the search for an effective seed; The features proposed in our study achieved a success rate of 83.24% in identifying ADHD patients through random sampling (saving 25% as the test set, while the remaining data was the training set) validation (using a simple linear classifier), surpassing the use of traditional seeds.

Conclusion

This preliminary study examines the feasibility of diagnosing ADHD by analyzing the resting-state fMRI data from the ADHD-200 NYU dataset. The data-driven model provides a precise way to find reliable seeds. Data-driven models offer precise methods for finding reliable seeds and are feasible across different datasets. Moreover, this phenomenon may reveal that using a data-driven approach to build a model specific to a single data set may be better than combining several data and creating a general model.

Disentangling racing thoughts from mind wandering in adult attention deficit hyperactivity disorder

Introduction

Mental restlessness reported by adult with Attention Deficit Hyperactivity Disorder (ADHD) has been mainly explained by excessive mind wandering. However, the description of a mind constantly on the go is also akin to racing thoughts, predominantly described in bipolar disorder. This paper aimed at disentangling mind wandering from racing thoughts in adult with ADHD. Associations between those mental phenomena and the ADHD symptomatology were also investigated.

Methods

To this aim, 84 adults with ADHD completed self-reported questionnaires, including the Mind Wandering-Deliberate and Mind Wandering-Spontaneous questionnaires, the Racing and Crowded Thoughts Questionnaire and the Daydreaming Frequency Scale. Factorial analysis and multiple linear regressions were performed.

Results

The factor analysis yielded a two-factor solution. The first factor encompassed the three facets of racing thoughts and was predicted by emotional lability. The second comprised deliberated-MW, spontaneous-MW and daydreaming, but was neither related to the ADHD symptoms, nor functional impairment.

Discussion

These findings suggest that MW and racing thoughts are two distinguishable mental phenomena. Racing thoughts appear to be a relevant hypothesis to explain the mental restlessness in adult ADHD.

Electrophysiological evidence for increased auditory crossmodal activity in adult ADHD

Background

Attention deficit and hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by core symptoms of inattention, and/or impulsivity and hyperactivity. In order to understand the basis for this multifaceted disorder, the investigation of sensory processing aberrancies recently reaches more interest. For example, during the processing of auditory stimuli comparable low sensory thresholds account for symptoms like higher distractibility and auditory hypersensitivity in patients with ADHD. It has further been shown that deficiencies not only exist on an intramodal, but also on a multimodal level. There is evidence that the visual cortex shows more activation during a focused auditory task in adults with ADHD than in healthy controls. This crossmodal activation is interpreted as the reallocation of more attentional resources to the visual domain as well as deficient sensory inhibition. In this study, we used, for the first time, electroencephalography to identify a potential abnormal regulated crossmodal activation in adult ADHD.

Methods

15 adult subjects with clinically diagnosed ADHD and 14 healthy controls comparable in age and gender were included. ERP components P50, P100, N100, P200 and N200 were measured during the performance of a unimodal auditory and visual discrimination task in a block design. Sensory profiles and ADHD symptoms were assessed with inattention as well as childhood ADHD scores. For evaluating intramodal and crossmodal activations, we chose four EEG channels for statistical analysis and group-wise comparison.

Results

At the occipital channel O2 that reflects possible crossmodal activations, a significantly enhanced P200 amplitude was measured in the patient group. At the intramodal channels, a significantly enhanced N200 amplitude was observed in the control group. Statistical analysis of behavioral data showed poorer performance of subjects with ADHD as well as higher discrimination thresholds. Further, the correlation of the assessed sensory profiles with the EEG parameters revealed a negative correlation between the P200 component and sensation seeking behavior.

Conclusion

Our findings show increased auditory crossmodal activity that might reflect an altered stimulus processing resource allocation in ADHD. This might induce consequences for later, higher order attentional deployment. Further, the enhanced P200 amplitude might reflect more sensory registration and therefore deficient inhibition mechanisms in adults with ADHD.

Progress and Pitfalls in the Provision of Quality Care for Adults With Attention Deficit Hyperactivity Disorder in Primary Care

OBJECTIVE

Quality care for attention deficit hyperactivity disorder (ADHD) in adults has lagged behind other psychiatric disorders. We sought to assess how the achievement of quality measures (QMs) for diagnosing and treating ADHD in adults has changed over time.

METHOD

We assessed 10 QMs in electronic health records (EHRs) from primary care and behavioral health clinics from 2010 to 2020 for 71,310 patients diagnosed with ADHD.

RESULTS

The achievement of QMs increased over time (p < .001). Some showed increases to high levels; others remained low throughout the observation period. No patients achieved more than six of 10 QMs in any year. Small but significant effects for sex, race, ethnicity, practice ownership, practice type, and age.

CONCLUSION

Increase in quality care from 2010 to 2020 along with clear evidence that more efforts are needed to improve quality of care for adults with ADHD seen in primary care.

The association between psychostimulant use in pregnancy and adverse maternal and neonatal outcomes: results from a distributed analysis in two similar jurisdictions

BACKGROUND

Conflicting evidence suggests a possible association between use of prescribed psychostimulants during pregnancy and adverse perinatal outcomes.

METHODS

We conducted population-based cohort studies including pregnancies conceived between April 2002 and March 2017 (Ontario, Canada; N = 554 272) and January 2003 to April 2011 [New South Wales (NSW), Australia; N = 139 229]. We evaluated the association between exposure to prescription amphetamine, methylphenidate, dextroamphetamine or lisdexamfetamine during pregnancy and pre-eclampsia, placental abruption, preterm birth, low birthweight, small for gestational age and neonatal intensive care unit admission. We used inverse probability of treatment weighting based on propensity scores to balance measured confounders between exposed and unexposed pregnancies. Additionally, we restricted the Ontario cohort to social security beneficiaries where supplementary confounder information was available.

RESULTS

In Ontario and NSW respectively, 1360 (0.25%) and 146 (0.10%) pregnancies were exposed to psychostimulants. Crude analyses indicated associations between exposure and nearly all outcomes [OR range 1.15-2.16 (Ontario); 0.97-2.20 (NSW)]. Nearly all associations were attenuated after weighting. Pre-eclampsia was the exception: odds remained elevated in the weighted analysis of the Ontario cohort (OR 2.02, 95% CI 1.42-2.88), although some attenuation occurred in NSW (weighted OR 1.50, 95% CI 0.77-2.94) and upon restriction to social security beneficiaries (weighted OR 1.24, 95% CI 0.64-2.40), and confidence intervals were wide.

CONCLUSIONS

We observed higher rates of outcomes among exposed pregnancies, but the attenuation of associations after adjustment and likelihood of residual confounding suggests psychostimulant exposure is not a major causal factor for most measured outcomes. Our findings for pre-eclampsia were inconclusive; exposed pregnancies may benefit from closer monitoring.

The translational genetics of ADHD and related phenotypes in model organisms

Attention-deficit/hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder resulting from the interaction between genetic and environmental risk factors. It is well known that ADHD co-occurs frequently with other psychiatric disorders due, in part, to shared genetics factors. Although many studies have contributed to delineate the genetic landscape of psychiatric disorders, their specific molecular underpinnings are still not fully understood. The use of animal models can help us to understand the role of specific genes and environmental stimuli-induced epigenetic modifications in the pathogenesis of ADHD and its comorbidities. The aim of this review is to provide an overview on the functional work performed in rodents, zebrafish and fruit fly and highlight the generated insights into the biology of ADHD, with a special focus on genetics and epigenetics. We also describe the behavioral tests that are available to study ADHD-relevant phenotypes and comorbid traits in these models. Furthermore, we have searched for new models to study ADHD and its comorbidities, which can be useful to test potential pharmacological treatments.

Altered neural flexibility in children with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood, and is often characterized by altered executive functioning. Executive function has been found to be supported by flexibility in dynamic brain reconfiguration. Thus, we applied multilayer community detection to resting-state fMRI data in 180 children with ADHD and 180 typically developing children (TDC) to identify alterations in dynamic brain reconfiguration in children with ADHD. We specifically evaluated MR derived neural flexibility, which is thought to underlie cognitive flexibility, or the ability to selectively switch between mental processes. Significantly decreased neural flexibility was observed in the ADHD group at both the whole brain (raw p = 0.0005) and sub-network levels (p < 0.05, FDR corrected), particularly for the default mode network, attention-related networks, executive function-related networks, and primary networks. Furthermore, the subjects with ADHD who received medication exhibited significantly increased neural flexibility (p = 0.025, FDR corrected) when compared to subjects with ADHD who were medication naïve, and their neural flexibility was not statistically different from the TDC group (p = 0.74, FDR corrected). Finally, regional neural flexibility was capable of differentiating ADHD from TDC (Accuracy: 77% for tenfold cross-validation, 74.46% for independent test) and of predicting ADHD severity using clinical measures of symptom severity (R2: 0.2794 for tenfold cross-validation, 0.156 for independent test). In conclusion, the present study found that neural flexibility is altered in children with ADHD and demonstrated the potential clinical utility of neural flexibility to identify children with ADHD, as well as to monitor treatment responses and disease severity.

Association between MTHFR (677C>T and 1298A>C) polymorphisms and psychiatric disorder: A meta-analysis

Recent studies showed that genetic polymorphism of 5,10-methylenetetrahydrofolate reductase (MTHFR) is related to attention-deficit hyperactivity disorder (ADHD), bipolar disorder (BD) and schizophrenia (SCZ). However, no consistent conclusion has been determined. This meta-analysis aims to interrogate the relationship between MTHFR gene polymorphisms (677C>T and 1298A>C) and the occurrence of ADHD, BD and SCZ. We retrieved case-control studies that met the inclusion criteria from the PubMed database. Associations between MTHFR polymorphisms (677C>T and 1298A>C) and ADHD, BD and SCZ were measured by means of odds ratios (ORs) using a random effects model and 95% confidence intervals (CIs). Additionally, sensitivity analysis and publication bias were performed. After inclusion criteria were met, a total of five studies with ADHD including 434 cases and 670 controls, 18 studies with BD including 4167 cases and 5901 controls and 44 studies with SCZ including 16,098 cases and 19913 controls were finally included in our meta-analysis. Overall, our meta-analytical results provided evidence that the MTHFR 677C>T was associated with occurrence of BD and SCZ, while the 1298A>C polymorphism was related to ADHD and BD, and additionally the sensitivity analysis indicated these results were stable and reliable. This may provide useful information for relevant studies on the etiology of psychiatric disorders.

Questionnaire-based computational screening of adult ADHD

BACKGROUND

ADHD is classically seen as a childhood disease, although it persists in one out of two cases in adults. The diagnosis is based on a long and multidisciplinary process, involving different health professionals, leading to an under-diagnosis of adult ADHD individuals. We therefore present a psychometric screening scale for the identification of adult ADHD which could be used both in clinical and experimental settings.

METHOD

We designed the scale from the DSM-5 and administered it to n = 110 control individuals and n = 110 ADHD individuals. The number of items was reduced using multiple regression procedures. We then performed factorial analyses and a machine learning assessment of the predictive power of the scale in comparison with other clinical scales measuring common ADHD comorbidities.

RESULTS

Internal consistency coefficients were calculated satisfactorily for TRAQ10, with Cronbach's alpha measured at .9. The 2-factor model tested was confirmed, a high correlation between the items and their belonging factor. Finally, a machine-learning analysis showed that classification algorithms could identify subjects' group membership with high accuracy, statistically superior to the performances obtained using comorbidity scales.

CONCLUSIONS

The scale showed sufficient performance for its use in clinical and experimental settings for hypothesis testing or screening purpose, although its generalizability is limited by the age and gender biases present in the data analyzed.

Reduced Glx and GABA Inductions in the Anterior Cingulate Cortex and Caudate Nucleus Are Related to Impaired Control of Attention in Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that impairs the control of attention and behavioral inhibition in affected individuals. Recent genome-wide association findings have revealed an association between glutamate and GABA gene sets and ADHD symptoms. Consistently, people with ADHD show altered glutamate and GABA content in the brain circuitry that is important for attention control function. Yet, it remains unknown how glutamate and GABA content in the attention control circuitry change when people are controlling their attention, and whether these changes can predict impaired attention control in people with ADHD. To study these questions, we recruited 18 adults with ADHD (31-51 years) and 16 adults without ADHD (28-54 years). We studied glutamate + glutamine (Glx) and GABA content in the fronto-striatal circuitry while participants performed attention control tasks. We found that Glx and GABA concentrations at rest did not differ between participants with ADHD or without ADHD. However, while participants were performing the attention control tasks, participants with ADHD showed smaller Glx and GABA increases than participants without ADHD. Notably, smaller GABA increases in participants with ADHD significantly predicted their poor task performance. Together, these findings provide the first demonstration showing that attention control deficits in people with ADHD may be related to insufficient responses of the GABAergic system in the fronto-striatal circuitry.

Differences in alcohol and cannabis use amongst substance use disorder patients with and without comorbid attention-deficit/hyperactivity disorder

Background

Substance use disorders (SUDs) continue to be a public health problem. Attention-deficit/hyperactivity disorder (ADHD) is seen as a risk factor for SUD. Prevalence of alcohol and cannabis use amongst adults with SUD and comorbid ADHD impacts both disorders cognitively and behaviourally.

Aim

Our study aimed to compare alcohol and cannabis use between treatment-seeking SUD patients with ADHD and SUD patients without ADHD symptomatology.

Setting

Various rehabilitation centres, including the South African National Council on Alcoholism and Drug Dependence (SANCA) Centres, and Private and Provincial Government Substance Abuse Treatment Centres.

Methods

A cross-sectional study of adults on drug rehabilitation was conducted. Data on socio-demographic information and alcohol and cannabis use from 185 post-detox inpatients were collected. Diagnoses were based on DSM-IV criteria. Attention-deficit/hyperactivity disorder diagnosis was confirmed by the Diagnostic-Interview for ADHD in Adults (DIVA 2.0). SUD+ADHD (n = 52) and SUD-ADHD (n = 128) groups were compared on alcohol and cannabis use as a function of gender.

Results

No significant differences in the use of alcohol between the SUD+ADHD and SUD-ADHD groups were found. However, the SUD+ADHD group showed increased cannabis consumption. Especially, the SUD+ADHD females showed an earlier age of onset of cannabis use than the SUD-ADHD females and revealed that they use cannabis for a longer period compared with the SUD-ADHD females and SUD+ADHD and SUD-ADHD males.

Conclusion

The results revealed the relationship between ADHD and cannabis use, especially amongst females with ADHD and reinforce the need to consider ADHD in cannabis use SUD in clinical interventions.

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

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

Tryptophan modulation in individuals with attention deficit hyperactivity disorder: a systematic review

The serotonergic system is implicated in ADHD, but the impact of serotonin’s precursor molecule, tryptophan, on ADHD symptomology remains unclear. Systematic searches of randomised controlled trials with an experimental tryptophan intervention in children and adults with ADHD identified 14 studies measuring core and related symptoms of the condition. Risk of bias was assessed using the Cochrane Risk of Bias tool. The 14 studies all used acute tryptophan depletion procedures, and most did not investigate core ADHD symptoms (inattention, impulsivity, hyperactivity) as primary outcome measures. Only two studies examined attention and revealed mixed effects of tryptophan. Similar effects were found for impulsivity in a small number of studies. No studies investigated hyperactivity. Most studies focused on reactive aggression, but samples were heterogenous and small, rendering potential meta-analyses inconclusive or misleading. However, the narrative analysis indicates tryptophan interventions may impact reactive aggression. More research is needed on the effect of tryptophan modulation on core ADHD symptoms, especially in adults, using more diverse samples to determine potential as an intervention. From current data, tryptophan modulation appears to alter aggressive behaviour in ADHD; however, the available studies were insufficient for the planned meta-analysis.

Investigating the Clinical Utility of the Combined Use of Objective and Subjective Measures of ADHD During Treatment Optimization

BACKGROUND

This study investigated the clinical utility of the combined use of objective and subjective measures of attention-deficit/hyperactivity disorder (ADHD) prepharmacological and postpharmacological treatment.

METHODS

Adults with ADHD (N = 77) completed the Quantified Behavioral Test, self-ratings of ADHD-related symptoms, and quality of life measures pretreatment and posttreatment.

RESULTS

The use of objective and subjective measures of ADHD-related symptoms during initiation and follow-up of pharmacological treatment resulted in significant improvements in quality of life after 6 months. Both objective and subjective measures captured changes in ADHD-related symptoms, with more patients showing clinically relevant treatment effects on objective measures. Convergence rates between objective and subjective measures were low to moderate, and improvements on these measures correlated with increased quality of life.

CONCLUSIONS

Objective and subjective measures of ADHD capture important components of the condition. The findings from this study have important implications for clinical practice.

The Effects of Drug Treatments for ADHD in Measures of Cognitive Performance

Based on core symptoms of inattention and deficient impulse control, and the identification of effective pharmacotherapies such as amphetamine (AMP; Adderall^®), methylphenidate (MPH; Ritalin^®), and atomoxetine (ATX; Strattera^®), ADHD is a clinical condition which provides opportunity for translational research. Neuropsychological tests such as the 5-Choice and Continuous Performance Tasks, which measure aspects of attention and impulse control in animals and humans, provide scope for both forward (animal to human) and reverse (human to animal) translation. Rodent studies support pro-attentive effects of AMP and MPH and effectiveness in controlling some forms of impulsive behavior. In contrast, any pro-attentive effects of ATX appear to be less consistent, the most reliable effects of ATX are recorded in tests of impulsivity. These differences may account for AMP and MPH being recognized as first-line treatments for ADHD with a higher efficacy relative to ATX. DSM-5 classifies three "presentations" of ADHD: predominantly inattentive type (ADHD-I), predominantly hyperactive/impulsive type (ADHD-HI), or combined (ADHD-C). Presently, it is unclear whether AMP, MPH, or ATX has differential levels of efficacy across these presentation types. Nonetheless, these studies encourage confidence for the forward translation of NCEs in efforts to identify newer pharmacotherapies for ADHD.

[Adult attention deficit hyperactivity disorder (ADHD) in the clinical descriptions and classificatory reflections of Gustav Specht (1905) and Hermann Paul Nitsche (1910)]

Es verstetigt sich die Ansicht, dass die adulte Form der Aufmerksamkeitsdefizit‑/Hyperaktivitätsstörung (ADHS) kein Konstrukt der modernen Psychiatrie ist. Die Geschichte der Psychiatrie kann hier einen aufklärenden Beitrag leisten. Diesem Anspruch und konkret Literaturverweisen Emil Kraepelins (1856–1926) folgend, wird hier jeweils eine Studie von Gustav Specht (1860–1940) und dem späteren NS-Psychiater Hermann Paul Nitsche (1876–1948) aus den Jahren 1905 bzw. 1910 zum Themenfeld chronische Manie inhaltlich analysiert. Wir gelangen zu dem Schluss, dass beide Autoren in mehreren Kasuistiken Kranke schildern und in ihre klinischen Erörterungen Aspekte einfließen lassen, die die heute so definierten Kernsymptome der adulten ADHS berühren oder in denen sich aktuell diskutierte Forschungsfragen wiederfinden. Beide Autoren drücken ihre Unzufriedenheit mit der klassifikatorischen Situation dieser Kranken in ihrer Zeit aus. Specht postuliert die „chronische Manie“, unter der er die adulten ADHS-Patienten einfasst, sogar als eine „völlig selbständige Geisteskrankheit“, die von den Psychiatern aber kaum als vollwertige Krankheitsform anerkannt, sondern eher als Verlegenheitsdiagnose verwendet werde. Nitsche sieht die von ihm sog. „chronisch-manischen Zustände“ zwar als „klinische Eigenart“, rechnet sie aber der großen Gruppe des „manisch-depressiven Irreseins“ zu. In Zukunft erst werde diese feiner aufzuteilen sein.

Sleep Instability Correlates with Attentional Impairment in Boys with Attention Deficit Hyperactivity Disorder

Theoretical models of sleep and attention deficit hyperactivity disorder (ADHD) suggest that symptoms of ADHD are associated with daytime sleepiness, but it has received little support. The present study aimed at testing an alternative model involving the association of attentional instability with sleep instability, i.e., sleep stage transitions and arousals. Twelve ADHD and 15 healthy control (HC) boys aged between 8 and 12 years old underwent polysomnography recording and attentional testing. The microarousal index, the number of awakenings, and the number of stage shifts between stages 1, 2, 3, 4 and REM sleep throughout the night were computed as sleep stability parameters. Attentional functioning was assessed using the Continuous Performance Test-II. We found significantly higher sleep instability in ADHD compared to HC. Sleep arousals and stage transitions (micro arousal index, stage 4/3 and 2/4 transitions) in ADHD significantly correlated with lower attentional scores. No association whatsoever was found between sleep instability and attentional functioning in HC. The results show that sleep instability is associated with lower attentional performance in boys with ADHD, but not in HC. This could be compatible with a model according to which attention and sleep stability share a common neural substrate in ADHD.

Neuropsychological functioning of individuals at clinical evaluation of adult ADHD

OBJECTIVES

Numerous studies showed that adults with attention deficit hyperactivity disorder (ADHD) suffer from impairments in a range of cognitive functions when compared to healthy controls. However, only little is known about the neuropsychological functions when compared to various clinical control groups and whether a distinct neuropsychological profile can be identified for adult ADHD.

METHOD

This retrospective study examined data of 199 outpatients referred for clinical evaluation of adult ADHD, allocated either to an ADHD group (n = 78) or to one of two clinical comparison groups, depending on whether they show indications (n = 71) or no indications (n = 50) for the presence of psychiatric disorders other than ADHD. All individuals performed a comprehensive neuropsychological test battery.

RESULTS

Data analysis revealed impairments in a range of cognitive functions in a substantial number of patients of all three groups. However, profiles of neuropsychological impairments were similar between groups. Furthermore, significant small- to medium-sized correlations between basic and higher-order cognitive functions were revealed in the ADHD group and the clinical comparison group with indications for psychiatric disorders other than ADHD.

CONCLUSION

Neuropsychological impairments are prominent in psychiatric outpatients seeking a clinical evaluation of adult ADHD but are not specific for ADHD. It is concluded that neuropsychological test performance may have limited incremental value to support the psychiatric differential diagnosis. Furthermore, a clinical trajectory may need to take into account that deficits in a range of higher-order cognitive functions can be substantially explained by deficits in basic cognitive functions.

ADHD in University Settings: Predictive Validity of Quantitative EEG Coherence

PURPOSE

Research has demonstrated distinct patterns of electroencephalography (EEG) coherence with attention-deficit/hyperactivity disorder (ADHD) in children; however, few studies have examined coherence measures in adults with ADHD. Further, specific research examining EEG coherence within the subgroup of young adults in post-secondary education is absent from the literature.

METHODS

The current study investigated the utility of quantitative EEG in predicting ADHD behavioral symptoms in 35 college students with a documented ADHD diagnosis and 35 control students.

RESULTS

Increased interhemispheric frontal beta-wave coherence was found in individuals with ADHD. Logistic regression of principle components of quantitative EEG coherence metrics predicted ADHD group membership.

CONCLUSIONS

Suggestions for improving ADHD identification in college populations using quantitative EEG are discussed.

Smartphone addiction and associated factors among postgraduate students in an Arabic sample: a cross-sectional study

BACKGROUND

Smartphone addiction, as with other behavioral addictions, is associated with social, physical, and mental health issues. In this article, we investigated the prevalence of smartphone addiction among postgraduate students and evaluated its correlation with social demographics, depression, attention-deficit/hyperactivity disorder (ADHD), and nicotine dependence.

OBJECTIVES

The objective of this study was to investigate the prevalence of smartphone addiction among Middle Eastern postgraduate students, determine the factors associated with smartphone addiction, and estimate the incidence rate of major depressive disorder (MDD), ADHD, insomnia, and nicotine addiction among postgraduate students with smartphone addiction.

METHODS

As part of a cross-sectional online survey, participants were given a self-questionnaire divided into six sections: Socio-demographics, Smartphone Addiction Scale (SAS), Patient Health Questionnaire (PHQ9) for Depression, Athens Insomnia Scale (AIS), the Fagerström Test for Cigarette Dependence Questionnaire (FTCd), and the adult ADHD Self-Report Scale (ASRS-v1.1).

RESULTS

Of the 506 patients, 51.0% of the participants demonstrated smartphone addiction. A significant association was also observed between extensive smartphone use and MDD (P = 0.001). Of the smokers in this study, 41.5% were addicted to smartphones (P = 0.039). Smartphone addicts had approximately two times the chance of having insomnia (OR = 2.113) (P = 0.013). In addition, they showcased more ADHD symptoms (OR = 2.712) (P < 0.001).

CONCLUSIONS

We found a positive association among insomnia, depression, adult ADHD, and smartphone addiction, which confirms the findings reported in the previous studies. Therefore, we encourage the scientific community to further study the impacts of smartphone addiction on the mental health of postgraduate students.

Prevalence and determinants of attention deficit/hyperactivity disorder (ADHD) medication use during pregnancy: Results from the Quebec Pregnancy/Children Cohort

AIMS

The use of attention deficit/hyperactivity disorder (ADHD) medications has grown over the past decade among pregnant women, but these treatments are not without risk. Updated prevalence of ADHD medication use and whether prescribed dosages follow guidelines are needed. The aim of this study is to describe the prevalence of ADHD medication use among pregnant women-dosages and switches-and identify determinants of ADHD medication use.

METHOD

A population-based longitudinal cohort study within the Quebec Pregnancy/Children Cohort (QPC). Women aged 15-45 years old covered by the RAMQ prescription drug plan for at least 12 months before and during pregnancy from 1998 to 2015. ADHD medication exposure was assessed before and during pregnancy. We estimated odds ratios (ORs) for determinants of ADHD medication use during pregnancy with generalized estimating equations.

RESULTS

Among 428,505 included pregnant women, 1,130 (0.26%) used ADHD medication. A 14-fold increase in the prevalence of ADHD medication use in pregnant women was observed, from 1998 (0.08%) to 2015 (1.2%). Methylphenidate was the most prevalent medication at 70.1%. ADHD medication fillings were at optimal dosage 91.8% of the time based on guidelines and 18.1% of women switched to another ADHD medication class during gestation. Main determinants of ADHD medication use during pregnancy were psychiatric disorders (aOR 2.19; 95% confidence interval [CI] 1.57, 2.96), mood and anxiety disorders (aOR 1.74; 95% CI 1.32, 2.24), and calendar year.

CONCLUSIONS

The number of pregnancies exposed to ADHD medications has increased similarly to the increase reported in other countries between 1998 and 2015. In addition to the current literature, the use of ADHD medications during pregnancy is consistent with Canadian guidelines recommendations on dosage.

Psychiatric Comorbidity and Addiction Severity Differences in Patients With ADHD Seeking Treatment for Cannabis or Cocaine Use Disorders

Objective: The objective of this study was to compare psychiatric comorbidity and consumption-related variables in ADHD patients seeking treatment for cocaine, cannabis, or both. Method: Assessment was conducted using European Addiction Severity Index (EuropASI), Conners' Adult ADHD Diagnostic Interview (CAADID), Structured Clinical Interview for DSM Disorders (SCID), Adult Self-Report Scale (ASRS), Wender Utah Rating Scale (WURS), Barratt Impulsiveness Scale-11 (BIS-11), and FIDI, with statistical analyses of analysis of variance (ANOVA), Student's t test, chi-square test, and multinomial regression model. Results: In total, 1,538 patients with substance use disorder (SUD) were evaluated for ADHD; 239 (15.5%) had ADHD, with cannabis 41, cannabis/cocaine 36, and cocaine 74. Men represented 80%, with mean age of 32.9 ± 10 years. Significant variables were-in bivariate analysis-more years of cannabis use in cannabis group and younger age for cocaine use disorder in cannabis/cocaine group, and-in multivariate analysis-lifetime anxiety disorder and younger age at onset of any SUD in cannabis group and working affected scale in cannabis and polysubstance use in cannabis/cocaine group. Conclusion: Groups with cannabis use had higher severity. ADHD features were similar in all groups. The assessment of ADHD and comorbid disorders is important.

Optimising medication management in children and young people with ADHD using a computerised test (QbTest): a feasibility randomised controlled trial

BACKGROUND

Medication for attention deficit hyperactivity disorder (ADHD) should be closely monitored to ensure optimisation. There is growing interest in using computerised assessments of ADHD symptoms to support medication monitoring. The aim of this study was to assess the feasibility and acceptability of a randomised controlled trial (RCT) to evaluate the efficacy of one such computerised assessment, the Quantified Behavior (Qb) Test, as part of medication management for ADHD.

METHODS

This feasibility multi-site RCT conducted in child and adolescent mental health and community paediatric settings recruited participants aged 6-15 years diagnosed with ADHD starting stimulant medication. Participants were randomised into one of two arms: experimental (QbTest protocol) where participants completed a QbTest at baseline and two follow-up QbTests on medication (2-4 weeks and 8-10 weeks later) and control where participants received treatment as usual, including at least two follow-up consultations. Measures of parent, teacher, and clinician-rated symptoms and global functioning were completed at each time point. Clinicians recorded treatment decision-making and health economic measures were obtained. Data were analysed using multi-level modelling and participants (children and parents) and clinicians were interviewed about their experiences, resulting data were thematically analysed.

RESULTS

Forty-four children and young people were randomised. Completion of study outcome measures by care-givers and teachers ranged from 52 to 78% at baseline to 47-65% at follow-up. Participants reported the questionnaires to be useful to complete. SNAP-IV inattention scores showed greater reduction in the intervention than the control group (- 5.85, 95% CI - 10.33, - 1.36,). Engagement with the intervention ranged from 100% at baseline, to 78% follow-up 1 and 57% follow-up 2. However, only 37% of QbTests were conducted in the correct time period. Interview data highlighted that the objectivity of the QbTest was appreciated by clinicians and parents. Clinicians commented that the additional time and resources required meant that it is not feasible to use QbTest for all cases.

CONCLUSION

The trial design and protocol appear to be feasible and acceptable but could be improved by modifying QbTest time periods and the method of data collection. With these changes, the protocol may be appropriate for a full trial. Adding QbTest may improve symptom outcome as measured by SNAP-IV.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03368573 , prospectively registered, 11th December 2017, and ISRCTN, ISRCTN69461593 , retrospectively registered, 10th April 2018.

Association of Wender Utah Rating Scale (WURS)-61 items with clinical psychiatric diagnosis in adulthood

BACKGROUND

The Wender Utah Rating Scale (WURS) is a widely used retrospective scale in adults presenting for ADHD evaluations which features items relating to childhood symptoms.

AIMS

The aim of this study is to establish if certain childhood symptoms (including ADHD) as identified by the WURS-61 are associated with specific mental health disorders in adulthood.

METHODS

Case-control study of N=630 attending Adult Mental Health Services (AMHS) and a control group without mental disorders (N=96).

RESULTS

The mean age of the participants was 39.81 (SD 12.94) of which 387 (53.3%) were females. There were no significant differences between cases and controls in terms of age (t= 1.829, df 724, p=.068) and gender (x²=1.123, df 1, p=.289). Exploratory factor analysis of WURS-61 reveals 5 factors. Using factor scores and after cross-tabulation, we found that: The presence of childhood impulsivity, emotional lability and distress in addition to inattention/disorganisation were significantly associated with adult ADHD diagnosis (F90). WURS items which suggests childhood conduct problems were associated with a number of adult diagnoses, when present either on its own (psychoactive substance use, or when present in combination with childhood impulsivity, emotional lability and distress (personality disorders).

CONCLUSION

There is an association between certain childhood behaviours and risk for later development of personality disorders, and psychoactive substance use. There is overlap of childhood symptoms to those who later diagnosed in adulthood with ADHD, personality disorders, and substance abuse.

The role of neuropsychological assessment in adults with attention deficit/hyperactivity disorders

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and/or impulsivity. While ADHD was initially recognized as a childhood syndrome, scientific evidence accumulated to indicate that a significant proportion of ADHD children continue to experience symptoms of ADHD in adulthood. Moreover, the question of ADHD diagnosis can arise in adult patients who were not diagnosed in childhood. Currently, the diagnosis of ADHD in adulthood is based on the revised criteria described for children. However, their application for adults may be difficult for many reasons including compensation and comorbid disorders. To date, no clinical, neuropsychological, biological or imaging marker is available for the diagnosis of ADHD. Considering that ADHD is based on a neuropsychological model, in this article we will examine the usefulness of neuropsychological testing in the diagnosis in adults. We will first present diagnostic criteria of ADHD and the limits of their application in adults. We will then detail the neuropsychological data available in adult ADHD and the French and international clinical recommendations for neuropsychological assessment. Finally, we will explore the predictive value of neuropsychological scores in the diagnosis of ADHD and discuss key methodological points and perspectives for clinical research.

Applied Machine Learning Method to Predict Children With ADHD Using Prefrontal Cortex Activity: A Multicenter Study in Japan

Objective: To establish valid, objective biomarkers for ADHD using machine learning. Method: Machine learning was used to predict disorder severity from new brain function data, using a support vector machine (SVM). A multicenter approach was used to collect data for machine learning training, including behavioral and physiological indicators, age, and reverse Stroop task (RST) data from 108 children with ADHD and 108 typically developing (TD) children. Near-infrared spectroscopy (NIRS) was used to quantify change in prefrontal cortex oxygenated hemoglobin during RST. Verification data were from 62 children with ADHD and 37 TD children from six facilities in Japan. Results: The SVM general performance results showed sensitivity of 88.71%, specificity of 83.78%, and an overall discrimination rate of 86.25%. Conclusion: A SVM using an objective index from RST may be useful as an auxiliary biomarker for diagnosis for children with ADHD.

A novel quantitative electroencephalography subtype with high alpha power in ADHD: ADHD or misdiagnosed ADHD?

This study investigated quantitative electroencephalography (QEEG) subtypes as auxiliary tools to assess Attention Deficit Hyperactivity Disorder (ADHD). A total of 74 subjects (58 male and 16 female) were assessed using the Korean version of the Diagnostic Interview Schedule for Children Version IV and were assigned to one of three groups: ADHD, ADHD-Not Otherwise specified (NOS), and Neurotypical (NT). We measured absolute and relative EEG power in 19 channels and conducted an auditory continuous performance test. We analyzed QEEG according to the frequency range: delta (1–4 Hz), theta (4–8 Hz), slow alpha (8–10 Hz), fast alpha (10–13.5 Hz), and beta (13.5–30 Hz). The subjects were then grouped by Ward’s method of cluster analysis using the squared Euclidian distance to measure dissimilarities. We discovered four QEEG clusters, which were characterized by: (a) elevated delta power with less theta activity, (b) elevated slow alpha relative power, (c) elevated theta with deficiencies of alpha and beta relative power, and (d) elevated fast alpha and beta absolute power. The largest proportion of participants in clusters (a) and (c) were from the ADHD group (48% and 47%, respectively). Conversely, group (b) mostly consisted of the participants from the NOS group (59%), while group (d) had the largest proportion of participants from the NT group (62%). These results indicate that children with ADHD does not neurophysiologically constitute a homogenous group. We also identified a new subtype with increased alpha power in addition to those commonly reported in ADHD. Given the QEEG characteristics with increased alpha power, we should consider the possibility that this subtype may be caused by childhood depression. In conclusion, we believe that these QEEG subtypes of ADHD are expected to provide valuable information for accurately diagnosing ADHD.

Creativity in ADHD: Goal-Directed Motivation and Domain Specificity

Objective: This research aimed to provide explanations for the inconsistent findings regarding creativity in ADHD. Method: In Study 1, we assessed real-world creative achievements and intrinsic motivation during idea generation in adults with ADHD and compared these with controls. In Study 2, we manipulated competition during idea generation to investigate effects on idea originality in adults with ADHD versus controls, and assessed creativity in specific domains. Results: Adults with ADHD reported more real-world creative achievements. We did not observe differences in intrinsic motivation during idea generation between groups, but adults with ADHD generated more original ideas when competing for a bonus. Moreover, adults with ADHD rated themselves as more creative in specific creative domains. Conclusion: Our findings suggest that goal-directed motivation may drive the enhanced real-world creative achievements of people with ADHD. Moreover, people with ADHD may selectively engage and excel in creative domains that fit their skills and preferences.

Objective Level of Alertness and Inhibitory Control Predict Highway Driving Impairment in Adults With ADHD

Objective: It remains unclear whether daytime impairments in ADHD patients are better explained by an altered level of alertness and/or by cognitive deficits. The aim of this study was to determine the respective contribution of these factors on driving performance in ADHD adults. Method: ADHD adults (n = 39) and healthy controls (n = 18) underwent a nocturnal polysomnography (PSG) followed by a Maintenance of Wakefulness Test (MWT), a simulated driving task, and a neuropsychological evaluation. Results: ADHD patients had shorter mean sleep latency on the MWT and worse driving performance than controls. They also made more errors on attention and executive functioning tests. Logistic regression analyses showed that inhibition deficits and objective daytime sleepiness predicted highway driving performance in ADHD. Conclusion: Our study shows that not only inhibitory control deficits but also pathological level of alertness independently contribute to highway driving impairment in ADHD patients, providing a better understanding of the pathophysiological mechanisms involved in ADHD.

ADHD Is Highly Prevalent in Patients Seeking Treatment for Cannabis Use Disorders

Objective: To estimate the prevalence of ADHD and determine an effective screening test for ADHD in a population-seeking treatment for cannabis use disorders. Method: The Conners Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; CAADID) was used to generate sensitivity and specificity data for ADHD screening tests, which were then administered to 99 participants seeking treatment for cannabis use disorders to estimate ADHD prevalence. Results: The prevalence estimated from the Wender Utah Rating Scale (WURS) was 45% (sensitivity = 0.88, sensitivity of 0.75), from the Conners Adult ADHD Rating Scale (CAARS) 34% (sensitivity = 0.80, specificity = 0.91), from the WURS + CAARS 36% (sensitivity = 0.71, specificity = 0.95), and from the Adult ADHD Self-Report Scale (ASRS) 46% (sensitivity = 0.61, specificity = 0.86). Conclusion: The prevalence of ADHD in adults seeking treatment for cannabis use disorders is estimated to be between 34% and 46%. The WURS paired with the CAARS provides excellent sensitivity and specificity for the diagnosis of ADHD in this population.

A novel digital health intervention to improve patient engagement to stimulants in adult ADHD in the primary care setting: Preliminary findings from an open label study

AIMS

We piloted the effectiveness and acceptability of a novel text messaging-based (SMS) digital health intervention aimed at addressing the previously documented poor rate of patient engagement in stimulant treatment in the primary care setting.

METHODS

117 adults ages 18-55 from primary care and psychiatric practices who were prescribed a stimulant medication for ADHD treatment received the SMS intervention. Comparators were age-, race-, and sex-matched patients from the same health care organization's electronic medical record who had been prescribed stimulant medications over a similar time period. Using documented prescription records, we determined whether patients had timely prescription refills.

RESULTS

Ninety-six percent (N = 112) of participants completed our a priori metric of patient engagement consisting of 37 days of the SMS program. Eighty-one percent of participants refilled their index prescriptions in a timely manner compared to only 36% of patients receiving treatment as usual (OR=7.54, 95% CI: 4.46, 12.77; p<0.001). We found no significant interaction between prescribing source (non-psychiatry vs. psychiatry) and intervention group (SMS vs. treatment as usual).

CONCLUSIONS

These data suggest that an ADHD-centric, digital health intervention using text messaging significantly improves patient engagement in stimulant treatment in adults with ADHD.

Examining the Role of Genetic Risk and Longitudinal Transmission Processes Underlying Maternal Parenting and Psychopathology and Children's ADHD Symptoms and Aggression: Utilizing the Advantages of a Prospective Adoption Design

Although genetic factors may contribute to initial liability for ADHD onset, there is growing evidence of the potential importance of the rearing environment on the developmental course of ADHD symptomatology. However, associations between family-level variables (maternal hostility, maternal depressive symptoms) and child behaviors (developmental course of ADHD and aggression) may be explained by genes that are shared by biologically related parents and children. Furthermore, ADHD symptoms and aggression commonly co-occur: it is important to consider both simultaneously to have a better understanding of processes underlying the developmental course of ADHD and aggression. To addresses these issues, we employed a longitudinal genetically sensitive parent-offspring adoption design. Analyses were conducted using Cohort I (n = 340) of the Early Growth and Development Study with cross-validation analyses conducted with Cohort II (n = 178). Adoptive mother hostility, but not depression, was associated with later child ADHD symptoms and aggression. Mothers and their adopted children were genetically unrelated, removing passive rGE as a possible explanation. Early child impulsivity/activation was associated with later ADHD symptoms and aggression. Child impulsivity/activation was also associated with maternal hostility, with some evidence for evocative gene-environment correlation processes on adoptive mother depressive symptoms. This study provides novel insights into family-based environmental influences on child ADHD and aggression symptoms, independent of shared parental genetic factors, implications of which are further explicated in the discussion.

The burdened life of adults with ADHD: Impairment beyond comorbidity

Since approximately 70% of adult patients with attention-deficit/hyperactivity disorder (ADHD) have at least one comorbid disorder, rating of impairment specifically attributable to ADHD is a hard task. Despite the evidence linking environmental adversities with negative outcomes in ADHD, life events measures have not been used to rate the disorder impairment. The present study tested for the first time the hypothesis that increased ADHD severity is associated with an increase in negative recent life events, independently of comorbidity status. The psychiatric diagnoses of 211 adult ADHD outpatients were based on DSM-IV criteria assessed through structured interviews (K-SADS-E for ADHD and ODD, MINI for ASPD and SCID-IV-R for other comorbidities). ADHD severity was evaluated with the Swanson, Nolan and Pelham rating scale (SNAP-IV) and recent life events with the Life Experience Survey. Higher SNAP-IV inattention and hyperactivity scores, female gender, lower socioeconomic status and the presence of comorbid mood disorders were associated with negative life events. Poisson regression models with adjustment for possible confounders confirmed the effect of inattention and hyperactivity severity on negative life events. Our results suggest that the negative life events experienced by these patients are associated to the severity of ADHD independently from comorbid psychiatric disorders.

Dysregulation of synaptic pruning as a possible link between intestinal microbiota dysbiosis and neuropsychiatric disorders

The prenatal and early postnatal stages represent a critical time window for human brain development. Interestingly, this window partly overlaps with the maturation of the intestinal flora (microbiota) that play a critical role in the bidirectional communication between the central and the enteric nervous systems (microbiota-gut-brain axis). The microbial composition has important influences on general health and the development of several organ systems, such as the gastrointestinal tract, the immune system, and also the brain. Clinical studies have shown that microbiota alterations are associated with a wide range of neuropsychiatric disorders including autism spectrum disorder, attention deficit hyperactivity disorder, schizophrenia, and bipolar disorder. In this review, we dissect the link between these neuropsychiatric disorders and the intestinal microbiota by focusing on their effect on synaptic pruning, a vital process in the maturation and establishing efficient functioning of the brain. We discuss in detail how synaptic pruning is dysregulated differently in the aforementioned neuropsychiatric disorders and how it can be influenced by dysbiosis and/or changes in the intestinal microbiota composition. We also review that the improvement in the intestinal microbiota composition by a change in diet, probiotics, prebiotics, or fecal microbiota transplantation may play a role in improving neuropsychiatric functioning, which can be at least partly explained via the optimization of synaptic pruning and neuronal connections. Altogether, the demonstration of the microbiota's influence on brain function via microglial-induced synaptic pruning addresses the possibility that the manipulation of microbiota-immune crosstalk represents a promising strategy for treating neuropsychiatric disorders.

The Efficacy of Cognitive Behavioral Therapy for Adults With ADHD: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: To systematically review the literature on published randomized controlled trials (RCTs) of cognitive behavioral therapy (CBT) for adult ADHD and to establish the effectiveness of CBT in reducing ADHD symptoms. Method: A systematic review of nine RCTs and two subsequent meta-analyses of eight of the studies were conducted. Results: Just nine studies were identified, of generally good quality but with some limitations. Four trials (total N = 160) compared CBT with waiting list controls, and three trials (total N = 191) compared CBT with appropriate active control groups. Meta-analyses showed that CBT was superior to waiting list with a moderate to large effect size (standardized mean difference [SMD] = 0.76, 95% confidence interval [CI] [0.21, 1.31], p = .006) and superior to active control groups with a small to moderate effect size (SMD = 0.43, 95% CI [0.14, 0.71], p = .004). Conclusion: These results give support to the efficacy of CBT in reducing symptoms of ADHD post-intervention.

A Novel Text Message Intervention to Improve Adherence to Stimulants in Adults With Attention Deficit/Hyperactivity Disorder

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) is a prevalent neurobiological disorder associated with a wide range of adverse outcomes. Although large data sets document that stimulants decrease the risks for many ADHD-associated adverse outcomes, compliance with stimulants remains very poor. The main aim of this study was to assess the effectiveness of a novel text messaging-based intervention aimed at improving the poor rate of adherence to stimulant medications in adults with ADHD.

METHODS

Subjects were adults with ages 18 to 55, prescribed a stimulant medication for ADHD treatment. For comparators, we identified at a 5-to-1 ratio (age and sex matched) adult patients from the Partners HealthCare electronic medical record who had been prescribed stimulant medications over a 1-year period. We determined whether patients had timely prescription refills, defined as refilled within 37 days, using prescriptions documented in their electronic medical record.

RESULTS

Our results showed that 68% of the SMS intervention group refilled their prescriptions in a timely manner. In contrast, only 34% of patients receiving treatment as usual refilled their prescriptions in a timely fashion (odds ratio, 4.04; 95% confidence interval, 2.49-6.56; P < 0.001).

CONCLUSIONS

These data indicate that an innovative ADHD-centric text messaging intervention significantly improved patient engagement to treatment with stimulants in adults with ADHD. Findings provide strong support for the use of a readily accessible, inexpensive, and widely available technology to improve the poor rate of adherence to stimulant treatment in adults with ADHD. To the best of our knowledge, this study is the first digital health intervention aimed at improving adherence to stimulant medication for adults with ADHD.

DRD4 48 bp multiallelic variants as age-population-specific biomarkers in attention-deficit/hyperactivity disorder

The identification of biomarkers to support the diagnosis and prediction of treatment response for attention-deficit/hyperactivity disorder (ADHD) is still a challenge. Our previous works highlighted the DRD4 (dopamine receptor D4) as the best potential genetic marker for childhood diagnosis and methylphenidate (MPH) response. Here, we aimed to provide additional evidence on biomarkers for ADHD diagnosis and treatment response, by using more specific approaches such as meta-analytic and bioinformatics tools. Via meta-analytic approaches including over 3000 cases and 16,000 controls, we demonstrated that, among the different variants studied in DRD4 gene, the 48-base pair, Variable Tandem Repeat Polymorphism, VNTR in exon 3 showed an age/population-specificity and an allelic heterogeneity. In particular, the 7R/"long" allele was identified as an ADHD risk factor in European-Caucasian populations (d = 1.31, 95%CI: 1.17-1.47, Z = 4.70/d = 1.36, 95%CI: 1.20-1.55, Z = 4.78, respectively), also, from the results of last meta-analysis, linked to the poor MPH efficacy. The 4R/"short" allele was a protective factor in European-Caucasian and South American populations (d = 0.83, 95%CI: 0.75-0.92, Z = 3.58), and was also associated to positive MPH response. These results refer to children with ADHD. No evidence of such associations was detected for adults with persistent ADHD (data from the last meta-analysis). Moreover, we found evidence that the 4R allele leads to higher receptor expression and increased sensitivity to dopamine, as compared with the 7R allele (d = 1.20, 95%CI: 0.71-1.69, Z = 4.81), and this is consistent with the ADHD protection/susceptibility effects of the respective alleles. Using bioinformatics tools, based on the latest genome-wide association (GWAS) meta-analysis of the Psychiatry Genomic Consortium (PGC), we demonstrated that the 48 bp VNTR is not in Linkage Disequilibrium with the DRD4 SNPs (Single Nucleotide Polymorphisms), which were not found to be associated with ADHD. Moreover, a DRD4 expression downregulation was found in ADHD specific brain regions (Putamen, Z score = -3.02, P = 0.00252). Overall, our results suggest that DRD4 48 bp VNTR variants should be considered as biomarkers to support the diagnosis of ADHD and to predict MPH response, although the accuracy of such a biomarker remains to be further elucidated.

Comparison of Neuropsychological Functioning Between Adults With Early- and Late-Onset DSM-5 ADHD

Objective: We aimed to compare the visually dependent neuropsychological functioning among adults with Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) ADHD who recalled symptom onset by and after age 7 and non-ADHD controls. Method: We divided the participants, aged 17 to 40 years, into three groups-(a) ADHD, onset <7 years (early-onset, n = 142); (b) ADHD, onset between 7 and <12 years (late-onset, n = 41); (c) non-ADHD controls (n = 148)-and compared their neuropsychological functioning, measured by the Cambridge Neuropsychological Testing Automated Battery. Results: Both ADHD groups had deficits in attention and signal detectability, spatial working memory, and short-term spatial memory, but only the early-onset group showed deficits in alertness, set-shifting, and planning after controlling for age, sex, and psychiatric comorbidities. There was no statistical difference between the two ADHD groups in neuropsychological functioning. Conclusion:DSM-5 criteria for diagnosing adult ADHD are not too lax regarding neuropsychological functioning.