Adult attention-deficit hyperactivity disorder: assessment guidelines based on clinical presentation to a specialty clinic

Diagnosing Attention-Deficit/Hyperactivity Disorder (ADHD) in young adults: A qualitative review of the utility of assessment measures and recommendations for improving the diagnostic process

Objective: Identify assessment measures that augment the clinical interview and improve the diagnostic accuracy of adult ADHD assessment.Method: The sometimes limited research literatures concerning the diagnostic efficacies of the clinical interview, standard and novel ADHD behavior rating scales, performance and symptom validity testing, and cognitive tests are critically reviewed.Results: Based on this qualitative review, both clinical interviews alone and ADHD behavior rating scales alone have adequate sensitivity but poor specificity in diagnosing ADHD. Response validity and symptom validity tests have reasonably good sensitivity and very good specificity in detecting invalid symptom presentation. Cognitive test batteries have inadequate sensitivity and specificity in identifying ADHD. Using cognitive tests in conjunction with behavior rating scales significantly improves the specificity of an assessment battery. Executive function behavior rating scales and functional impairment rating scales are unlikely to improve the diagnostic accuracy of ADHD assessment.Conclusions: Based on this review, key clinical interview questions, behavior rating scales, symptom validity tests, and cognitive tests that have promise to enhance current assessment practices are recommended. These are the authors' personal opinions, not consensus standards, or guidelines promulgated by any organization. These measures are incorporated in a practical, somewhat abbreviated, battery that has the potential to improve clinicians' ability to diagnose adult ADHD.

Co-Occurrence of ASD and ADHD Traits in an Adult Population

Objective: ADHD and autism spectrum disorder (ASD) can be viewed as the extreme end of traits found in the general population. Clinical and genetic studies suggest that ADHD and ASD often co-occur and share genetic susceptibility. The aim of this study was to examine co-occurrence of ADHD and ASD traits in the general population. Method: In total, 334 participants were recruited from a population-based sample. Four questionnaires assessing current and retrospective ADHD and ASD traits were administered online: the Adult ADHD Self-Report Scale (ASRS) Symptom Checklist, the Wender Utah Rating Scale (WURS-25), the Broad Autism Phenotype Questionnaire (BAPQ), and the Autism Spectrum Quotient (AQ). Results: A significant correlation was found between ADHD and autistic traits. In particular, higher inattention and overall ADHD scores were associated with self-reported deficits in communication and social skills. Conclusion: Our findings are similar to results from studies on clinical populations, suggesting that ADHD and ASD might share common etiology.

[Attention deficit-hyperactivity disorder (ADHD) and comorbid mental disorders : ADHD-specific self-rating scales in differential diagnostics]

BACKGROUND

It is still unclear how well the established attention deficit-hyperactive disorder (ADHD)-specific rating scales can differentiate between ADHD symptoms and symptoms of other mental disorders.

METHODS

A total of 274 patients with suspected adult ADHD were extensively examined clinically and guideline-conform in an ADHD outpatient clinic. In 190 patients the diagnosis of ADHD could be made with certainty. The patients were also subsequently assessed according to the DSM IV criteria by self-rating scales on current (ADHS-SB, ASRS, CAARS) and retrospective (WURS-K) complaints. A binary logistic regression analysis was performed in order to extract from the questionnaires, which could best distinguish the diagnosis of ADHD from other mental disorders.

RESULTS

The results showed that two self-rating scales (WURS-K and ADHS-SB) were sufficient to correctly diagnose ADHD in 83% of the patients examined with a sensitivity of 94% and specificity of 56%.

CONCLUSION

The ADHD-specific self-rating scales are additionally useful for the diagnostic differentiation between ADHD-specific and other psychiatric symptoms in the clinical practice and can improve the safety of the diagnosis.

Detecting Symptom Exaggeration in College Students Seeking ADHD Treatment: Performance Validity Assessment Using the NV-MSVT and IVA-Plus

The symptoms of ADHD are highly subjective, and there is ample empirical evidence that demonstrates the ease with which impairments in attention can be feigned on many commonly used subjective and objective measures of attention. We examined the combination of two assessment measures, NV-MSVT and IVA+, to screen for performance validity and ADHD symptoms in college students. Results indicated that the NV-MSVT was effective in differentiating between students with potential high impairment, such as ADHD, and possible malingerers. In addition, in vivo clinical data (N = 350) resulted in lower validity cut-off scores on the IVA+ than had been previously suggested. Clinical implications and future research are also discussed.

Treatment-refractory anxiety; definition, risk factors, and treatment challenges

A sizable proportion of psychiatric patients will seek clinical evaluation and treatment for anxiety symptoms reportedly refractory to treatment. This apparent lack of response is either due to “pseudo-resistance” (a failure to have received and adhered to a recognized and effective treatment or treatments for their condition) or to true “treatment resistance.” Pseudo-resistance can be due to clinician errors in selecting and delivering an appropriate treatment effectively, or to patient nonadherence to a course of treatment. True treatment resistance can be due to unrecognized exogenous anxiogenic factors (eg, caffeine overuse, sleep deprivation, use of alcohol or marijuana) or an incorrect diagnosis (eg, atypical bipolar illness, occult substance abuse, attention deficit-hyperactivity disorder). Once the above factors are eliminated, treatment should focus on combining effective medications and cognitive behavioral therapy, combining several medications (augmentation), or employing novel medications or psychotherapies not typically indicated as first-line evidence-based anxiety treatments.

Specificity of the CAARS in Discriminating ADHD Symptoms in Adults From Other Axis I Symptoms

OBJECTIVE

In this study, we examined the sensitivity and specificity of the Conners' Adult ADHD Rating Scale-Self-Report: Long Version (CAARS) in 113 adult clinical archival records.

METHOD

Forty-five clients had requested evaluation for ADHD, suggesting problems with attention, and 68 requested other services. To examine the CAARS' ability to differentiate ADHD symptoms from other Axis I symptoms, it was compared with the Personality Assessment Inventory.

RESULTS

The two groups differed significantly on the weighted linear combination of the eight subscales of the CAARS, Wilks's Lambda = .565, F(7, 105) = 11.56, p < .0001, with higher mean scores found among those requesting evaluation of ADHD. z-tests revealed the eight CAARS subscales were more highly correlated with each other, based on the average intercorrelation, than the nine selected clinical scales of the Personality Assessment Inventory (PAI; Somatic Complaints [SOM], Mania [MAN], Paranoia [PAR], Schizophrenia [SCZ], Anxiety [ANX], Anxiety-Related Disorders [ARD], Depression [DEP], Borderline Features [BOR], and Antisocial Features [ANT]). Some unexpectedly high correlations were found between the CAARS and PAI clinical scales (MAN and SCZ).

CONCLUSION

The results of the present study were mixed, with some analyses yielding positive results with respect to the CAARS' sensitivity and others suggesting poor specificity.

A systematic review of attention deficit hyperactivity disorder (ADHD) and mathematical ability: current findings and future implications

BACKGROUND

Several recent behavioural and behavioural genetic studies have investigated the relationship between attention deficit hyperactivity disorder (ADHD) and mathematical ability. The aim of this systematic review was to provide an overview of these studies to date. An emphasis was placed on reviewing results that explored the association between mathematics and the two ADHD components of attention and hyperactivity-impulsivity separately.

METHODS

A systematic search of quantitative studies investigating the association between mathematics and ADHD was conducted across five databases (PsychINFO, Web of Science, PubMed, EMBASE, and Scopus). A total of 30 cross-sectional and four longitudinal studies were included in this review.

RESULTS

Narrative synthesis of the results was provided using PRISMA guidelines. Taken together, the studies pointed at substantial evidence for a negative association between ADHD symptoms and mathematical ability. This association was particularly marked for the inattentive component of ADHD than for the hyperactive-impulsive component. Evidence from twin studies also showed a significant genetic correlation between mathematics and ADHD, which was greater for the inattentive component of ADHD compared to the hyperactive-impulsive component.

CONCLUSIONS

The differential relationship of the hyperactivity-impulsivity and inattention domains with mathematics emphasises the heterogeneity within the disorder and suggests a partially different aetiology of the two ADHD domains. A better understanding of the aetiology of ADHD could help develop more efficient interventions aimed at the reduction of its symptoms. It could also offer an explanatory framework for shortcomings in achievement and inform the development of non-pharmacological intervention strategies.

Types of adult attention-deficit hyperactivity disorder (ADHD): baseline characteristics, initial response, and long-term response to treatment with methylphenidate

Much recent research describes the importance of emotional symptoms in ADHD. While there is no accepted system for including emotionality in diagnosing ADHD, the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) provides a tool to facilitate this. It assesses a range of adult ADHD symptoms which load on two factors: inattentive and emotional dysregulation. The consistently high inattentive factor was used to define significant elevation on the more variable emotional dysregulation factor (which contains four WRAADDS domains: hyperactivity/restlessness, temper, affective lability, and emotional over-reactivity) allowing the definition of two ADHD diagnostic types. We compared these two types on a broad range of adult subject characteristics, including response to methylphenidate (MPH) treatment assessed during two clinical trials. Marked impairment in three of the four emotional domains reflected a symptom severity level equivalent to that of the inattentive factor. 59 % met this threshold, defining them as ADHD emotion dysregulation presentation, as opposed to 41 % with ADHD inattentive presentation. Cluster analysis validated these groups by generating similar clusters with 85 % agreement regarding membership. ADHD emotional dysregulation presentation subjects showed more childhood ADHD symptoms, adult symptoms of oppositional defiant disorder, and evidence of personality disorder. Both types showed similar improvement during the double-blind MPH arm of the trials and during a 6-month open-label phase. Based on the presence of symptoms of emotional dysregulation, ADHD in adults can be conceptualized as two types. Impairment and comorbidity in adults with ADHD are largely concentrated in ADHD emotional dysregulation presentation patients.

Functioning Assessment Short Test (FAST): validity and reliability in adults with attention-deficit/hyperactivity disorder

Studies highlight that the functional deficits in different areas of a subject's life are an important characteristic that define adult attention-deficit/hyperactivity disorder (ADHD). On the other hand, in the scientific literature, there are no evaluation instruments with psychometric studies concerning their reliability and validity for this variable in adults with ADHD. The aim of the present study is to evaluate the psychometric properties of the Functioning Assessment Short Test (FAST), regarding its reliability and validity, as a measure of adult ADHD functioning. A case-control study was carried out in a sample of 152 adult subjects (88 with ADHD diagnosis and 64 healthy controls). The psychometric properties of the instrument were analyzed regarding feasibility, internal consistency, concurrent validity, discriminant validity (ADHD vs. controls) and factor analysis. For the total scale, Cronbach's alpha was of 0.83, and strong values in the measures of its discriminant capacity were obtained, AUC ROC = 0.98, IC (0.96-0.99). The test is reliable as the internal consistency was high. Significant differences are observed in the correlation between domains, between healthy subjects and subjects with ADHD. ADHD subjects showed impairments in all areas of their life, especially in the cognitive functioning domain, followed by the autonomy, occupational functioning and interpersonal relationships domains. The FAST is an easily administered short interview and has good psychometric properties, in terms of reliability and validity, as a measure of the functional level in adults with ADHD. The study also showed that subjects with adult ADHD may be functionally impaired.

Adult ADHD: a controversial diagnosis?

Attention deficit hyperactivity disorder (ADHD) is characterised by inattention, hyperactivity and impulsivity with onset in children before the age of seven years. ADHD is the most common disorder presenting to child guidance clinics and has been shown to be a well-validated diagnosis. Current estimates of prevalence range from 1%5%. The concept of adult ADHD as a clinical entity is an emerging but controversial area in psychiatry. While childhood ADHD is accepted as a reliable and valid diagnosis, the validity of adult ADHD as a disorder is unclear. This paper reviews the likely presenting features of adult ADHD and common comorbid disorders. Guidelines for assessment and management are discussed and the evidence for validity of the diagnosis is critically examined.

Retrospective assessment of ADHD symptoms in childhood: discriminatory validity of Finnish translation of the Wender Utah Rating Scale

OBJECTIVE

To examine the discriminatory validity of the Wender Utah Rating Scale (WURS) and its five suggested subscales (Conduct Problems, Impulsivity Problems, Mood Difficulties, Inattention/Anxiety, Academic Concerns) in a Finnish sample.

METHOD

WURS was administered to 114 adults, aged 18 to 55 years. Participants with ADHD (n = 37) and dyslexia (n = 36) were compared with healthy controls (n = 41).

RESULTS

The ADHD group scored significantly higher than the control group on all subscales. Compared with the dyslexia group, the ADHD group did not differ in Mood Difficulties or Academic Concerns. Using the total score, the positive predictive value was .53 in this sample and only .21 when the prevalence of ADHD was taken into account.

CONCLUSION

Three out of five domains of WURS are reliable indicators of ADHD. Domains with low discriminatory power, low general prevalence of ADHD, and other developmental disorders within the population decrease the accuracy.

Systematic review of national and international guidelines on attention-deficit hyperactivity disorder

During the last few years several clinical guidelines on attention-deficit hyperactivity disorder (ADHD) have been published by national and international medical societies. To systematically review and compare recommendations of selected ADHD guidelines, we performed a systematic search in online guideline databases and PubMed in order to retrieve guideline texts. Guidelines meeting inclusion criteria were reviewed and recommendations on assessment and treatment extracted. The AGREE instrument was used to assess methodological quality. Of the 26 guidelines identified, 13 were selected for further analysis: 11 guidelines deal with ADHD in childhood and adolescence and 5 guidelines cover transitional patients and/or ADHD in adults. The methodological quality of ADHD guidelines is moderate to good. They reflect similarities and differences of healthcare systems. Diagnosis throughout the lifespan is based on a detailed clinical history. There is greater agreement on evidence-based pharmacological treatment than on psychosocial interventions, reflecting the strength of evidence.

The positive illusory bias: does it explain self-evaluations in college students with ADHD?

OBJECTIVE

To evaluate whether the positive illusory bias explains the self-evaluations of driving and work behaviors in college students with ADHD.

METHOD

A total of 103 students with ADHD were compared to a sample of 94 students without ADHD. Both groups completed self-reports of their specific driving and work behaviors and then rated their overall, global performance in each area. Three specific-to-global change scores were obtained (one measuring work and two measuring driving) that were thought to be measures of the positive illusory bias. These specific-to-global change scores were analyzed using chi-square to evaluate differences between participants with and without ADHD.

RESULTS

The participants with ADHD were significantly more likely than the participants without ADHD to engage in the positive illusory bias on two of the three work and driving ratings.

CONCLUSION

College students with ADHD demonstrate self-evaluations that appear to reflect the positive illusory bias and that may be related to their academic functioning in the college setting and willingness to receive treatment.

Processing speed and working memory performance in those with both ADHD and a reading disorder compared with those with ADHD alone

In previous studies, children with both Attention-Deficit Hyperactivity Disorder (ADHD) and a Reading Disorder were found to have more difficulties with processing speed, working memory, and timed as opposed to non-timed executive functioning (EF) measures when compared with those with either disorder alone. The current study found that older adolescents and adults with both disorders also had more difficulties on processing speed and working memory measures than individuals who only had ADHD. There were no differences among non-timed EF scores. These results add support to the premise that common underlying features may be contributing to the high co-morbidity between these disorders and associated cognitive weaknesses.

Very early predictors of adolescent depression and suicide attempts in children with attention-deficit/hyperactivity disorder

CONTEXT

Major depression and dysthymia in adolescence are associated with substantial disability, need for mental health services, and risk for recurrence. Concrete suicidal ideation and attempts during adolescence are particularly associated with significant distress, morbidity, and risk for completed suicide.

OBJECTIVES

To test the hypothesis that young children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for depression and suicidal ideation and attempts during adolescence and to identify early predictors of which young children with ADHD are at greatest risk.

DESIGN

Prospective follow-up study.

SETTING

Chicago, Illinois, and Pittsburgh, Pennsylvania. Patients  A cohort of 125 children who met DSM-IV criteria for ADHD at 4 to 6 years of age and 123 demographically matched comparison children without ADHD were prospectively followed up in 7 structured diagnostic assessments of depression and suicidal behavior in assessment years 6 through 14, spanning 9 through 18 years of age.

MAIN OUTCOME MEASURES

DSM-IV criteria for depressive disorders and suicidal behavior.

RESULTS

Children with ADHD at 4 to 6 years of age were at greatly increased risk for meeting DSM-IV criteria for major depression or dysthymia (hazard ratio, 4.32) and for attempting suicide (hazard ratio, 3.60) through the age of 18 years relative to comparison children. There were marked variations in risk for these outcomes among children with ADHD, however. Within the ADHD group, children with each subtype of ADHD were at risk but for different adverse outcomes. Girls were at greater risk for depression and suicide attempts. Maternal depression and concurrent child emotional and behavior problems at 4 to 6 years of age predicted depression and suicidal behavior.

CONCLUSIONS

All subtypes of ADHD in young children robustly predict adolescent depression and/or suicide attempts 5 to 13 years later. Furthermore, female sex, maternal depression, and concurrent symptoms at 4 to 6 years of age predict which children with ADHD are at greatest risk for these adverse outcomes. Identifying high-risk young children with ADHD sets the stage for early prevention trials to reduce risk for later depression and suicidal behavior.

Development of an Infrequency Index for the CAARS

There is a clinical need for measurement of noncredible self-reporting of symptoms of attention deficit hyperactivity disorder (ADHD) in adults presenting for ADHD evaluation. The present study describes the development of initial validity data for an Infrequency Index for the Conner’s Adult Attention Deficit/Hyperactivity Rating Scale (CII). Items for the CII were obtained from a large sample of nontreatment seeking university students, including individuals with a self-reported history of ADHD diagnosis. Items endorsed infrequently in the sample, including those with ADHD diagnoses, were identified and summed to create the CII. Initial validation data were gathered from a sample of individuals seeking clinical evaluation for ADHD. The CII was strongly related to noncredibly high symptom report and was also related to noncredible performance on cognitive measures. Results provide initial support for the CII’s use in assessing noncredible overreporting on the Conner’s Adult Attention-Deficit/Hyperactivity Rating Scale.

An examination of shared variance in self-report and objective measures of attention in the incarcerated adult population

OBJECTIVE

The present study was designed to test some assumptions about screening procedures for ADHD in adults.

METHOD

Twenty-eight incarcerated male adults completed a self report scale of attention deficits as a part of an examination of attention and reading skills. Further assessment of attention included a battery of tests that assessed vigilance, attention shifts, and other aspects of cognitive control.

RESULTS

Fifty seven percent of the sample showed test performance indicating a high probability of ADHD. Correlation analyses yielded significant effects for self report scales and objective tests of attention.

CONCLUSION

The results support the assumption that the self report measures share a significant part of the variance with tests of attention commonly used in clinical assessment. However, the risk of making both false positive and false negative inferences about ADHD is present, as the specificity and the sensitivity of the rating scale needs to be further explored.

Correlating family nurse practitioners' perspectives of adult ADD/ADHD with employed pharmacotherapy: a pilot study

PURPOSE

This study explores how family nurse practitioners (FNPs) in the state of Washington view adulthood attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD) and how these views affect the pharmacotherapy FNPs employ.

DATA SOURCES

A confidential survey containing 30 questions was mailed to self-selected FNPs who practice in the state of Washington (N= 126). Descriptive and Kendall's rank correlations coefficient statistical methods were used for data analysis.

CONCLUSIONS

The majority of respondents do not hold negative views toward adults with ADD/ADHD and are aware that their personal views may affect how they treat the disorder. Most of the respondents agreed that given the likelihood of co-morbidity of adult ADD/ADHD, it can be a challenge to diagnose the disorder. The predominant prescribed medications for adult ADD/ADHD are consistent with current pediatric guidelines, with the exception of buproprion, which was identified by 40% of the respondents as either their primary or secondary drug of choice for treating adult ADD/ADHD.

IMPLICATIONS FOR PRACTICE

Research effort needs to focus on the efficacy of buproprion for treating ADD/ADHD in adults. Moreover, exploration of the effectiveness of current pediatric guidelines to treat ADD/ADHD in adults must be assessed.

Self-reported childhood attention-deficit/hyperactivity disorder symptoms are not specific to the disorder

OBJECTIVE

The present study examined the specificity of self-reported childhood attention-deficit/hyperactivity disorder (ADHD) symptoms using the Wender Utah Rating Scale (WURS) in young adults with (1) a previous diagnosis of ADHD, (2) comorbid ADHD and psychological symptoms or diagnoses, (3) psychological diagnoses or symptoms without comorbid ADHD, and (4) controls.

METHOD

One thousand four hundred thirty-one non-treatment-seeking individuals (508 males), aged 18 to 25 years, were assigned to 1 of 4 groups (psychological controls, controls, ADHD, ADHD comorbid), based on responses to psychological, demographic, and health history questionnaires completed as part of a larger study. Responses to the WURS were analyzed at the individual item and subtest levels for their specificity to ADHD using area under the curve analyses.

RESULTS

The standard WURS cutoff score of 46 was neither sensitive nor specific to ADHD, with a high rate of false positives in psychological controls. Factor analyses supported a 5-factor model (conduct problems, impulsivity problems, mood difficulties, inattention/anxiety symptoms, poor academic functioning) that accounted for 62% of the total variance; these factors were used to generate factor-based WURS subscales. Three subscales (impulsivity, poor academic functioning, and inattention/anxiety symptoms) showed potential for discriminating ADHD from controls among females. No subscales showed adequate sensitivity or specificity for discriminating ADHD from psychological controls among the males.

CONCLUSIONS

Results provide further evidence that retrospective self-report of childhood ADHD symptoms is not specific to ADHD and highlight concerns about the reliance on self-report of childhood ADHD symptoms for diagnostic purposes. Results suggest consideration of specific types of symptoms, and sex differences might increase diagnostic use of self-reported childhood symptoms.

Management of attention-deficit hyperactivity disorder in adults: focus on methylphenidate hydrochloride

Attention-deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in young adults and causes significant psychosocial impairment and economic burden to society. Because of the paucity of long-term evidence and lack of national guidelines for diagnosis and management of adult ADHD, most of the data are based on experience derived from management of childhood ADHD. This article reviews the current evidence for the diagnosis and management of adult ADHD with special emphasis on the role of methylphenidate hydrochloride preparations in its treatment. Methylphenidate hydrochloride, a stimulant that acts through the dopaminergic and adrenergic pathways, has shown more than 75% efficacy in controlling the symptoms of adult ADHD. Although concern for diversion of the drug exists, recent data have shown benefits in preventing substance use disorders in patients with adult ADHD.

A Comparison of Methamphetamine-Dependent Inpatients With and Without Childhood Attention Deficit Hyperactivity Disorder Symptomatology

Methamphetamine-dependent inpatients (N = 51) were screened for childhood attention deficit hyperactivity disorder (ADHD) using the Wender Utah Rating Scale upon admission to 30-day inpatient treatment. Baseline assessments included neuropsychological tests of executive function, memory, information processing, verbal fluency, attention, motor skills, and the Brief Symptom Inventory (BSI), a measure of psychiatric symptomatology. The thirty-six participants (70.6%) screening positive for ADHD reported significantly more frequent methamphetamine use prior to baseline. Baseline cognitive functioning was similar between groups, but the presumptive ADHD participants exhibited significantly worse psychiatric symptomatology. At three-week follow- up, 41 participants (80.4%) repeated the neuropsychological battery and BSI. All 10 non-completers screened positive for ADHD. The entire sample improved with abstinence in most neuropsychological domains except memory. The presumptive ADHD group failed to improve on tests of attention. All participants demonstrated significant reductions in psychiatric symptoms with abstinence. Methamphetamine-dependent individuals with ADHD symptoms are common and pose a significant treatment challenge.

Adult ADHD and depressive disorders: prevalence, significance, and clinical presentation

Adult attention-deficit/hyperactivity disorder (ADHD) and the spectrum of depressive disorders have high overlapping prevalence rates. Rates of depression in adults with ADHD and rates of ADHD in depressed adults provide an important epidemiologic background for clinicians treating either or both of these populations. There is a distinctive phenomenology of ADHD and depression, and distinctive diagnostic issues that present with the coexistence of these two disorders.

Psychometric properties of the Chinese version of the adult ADHD Self-report Scale

Although attention deficit/hyperactivity disorder (ADHD) in adulthood has become a topic of considerable interest to psychiatrists over the past decade, little is known about the prevalence or correlates of adult ADHD in the Chinese population. As a first step in addressing this problem, this study presents data on the psychometric properties of the Chinese version of the World Health Organization's Adult ADHD Self-report Scale (ASRS) in a sample of 1031 young males from an army base and 3298 young adults from two colleges. All participants completed the Chinese ASRS. Participants from an army base also completed a clinical assessment including the Wender Utah Rating Scale (WURS) for assessing childhood ADHD, the Impulsiveness Scale for measuring the severity of current impulsive behaviors, and information about substance use. Results showed good concordance (intraclass correlations = 0.80 approximately 0.85) and internal consistency (Cronbach's alpha = 0.83 approximately 0.91) among the ASRS subscales and moderate to high correlations between these subscales and the WURS (Pearson's correlations = 0.37 approximately 0.66). The Chinese ASRS also demonstrated the ability to predict childhood disruptive problems and habitual use of substances. Our findings suggest that the Chinese ASRS is a reliable and valid instrument to assist in screening for adult ADHD.

Attention Deficit/Hyperactivity Disorder in Adults

Attention deficit/hyperactivity disorder (ADHD), characterized by inattention, hyperactivity/impulsivity, or a combination of these, is being increasingly recognized in adults. Adult ADHD prevalence rates range from 1% to 4%. The pathophysiology of adult ADHD is likely multifactorial, including genetic, environmental, and neurobiological influences. Though ADHD diagnostic criteria per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) were developed based on child samples, the symptoms are believed to be similar in adults, with some developmental differences in symptom presentation. This article identifies common presenting complaints of adults who have ADHD and provides information useful for differential diagnosis of these patients. Specific strategies for pharmacological and nonpharmacological intervention are also presented.

Exploring the performance differences on the flicker task and the conners' continuous performance test in adults with ADHD

OBJECTIVE

To examine the ability of the flicker task to demonstrate greater utility in discriminating performance in young adults with and without ADHD compared to the Conners' CPT (CCPT).

METHOD

Flicker task and CCPT performance were compared between an ADHD (n = 28) and control (n = 30) group of college students.

RESULTS

This study replicated previous flicker task findings, providing support for using the flicker task to demonstrate the robust nature of change blindness. However, the flicker task did not demonstrate better discriminative utility than the CCPT. Task-dependent measures correlated with ADHD rating scale indices of inattention and hyperactivity/impulsivity, indicating that CPTs lack symptom domain specificity.

CONCLUSION

Results support the growing evidence that CPTs currently provide only modest utility for discriminating performance in adults with and without ADHD. Recommendations are provided regarding the future study of CPTs as a valid measure of ADHD performance and the potential utility of the flicker task.

ADHD and achievement: meta-analysis of the child, adolescent, and adult literatures and a concomitant study with college students

This article presents results from two interrelated studies. The first study conducted a meta-analysis of the published literature since 1990 to determine the magnitude of achievement problems associated with attention-deficit/hyperactivity disorder (ADHD). Effect sizes were significantly different between participants with and without ADHD (sample weighted r = .32, sample weighted d = . 71; p = .001). Effects were also examined according to the moderators of age, gender, achievement domain (reading, math, spelling), measurement method (standardized tests vs. grades, parent/teacher ratings, etc.), sample type (clinical vs. nonclinical), and system used to identify ADHD (DSM-III-R vs. DSM-IV). Significant differences emerged from the moderator comparisons. The second study, using averaged effect sizes from the first study as a baseline for comparison, investigated achievement levels for an understudied age group with ADHD, namely, college students. Unlike previous studies at the college level, the sample incorporated both student and parent ratings (N = 380 dyads). The results were comparable to outcomes from the meta-analysis for college students and adults. Analyses demonstrated modest (R = .21) but meaningful predictive validity across 1 year to end-of-first-year grades. However, unlike earlier studies with children and adolescents, student ratings were as predictive as parent ratings. Findings are discussed in terms of the impact of moderator variables on ADHD and achievement.

Attention deficit hyperactivity disorder (ADHD) in adults: social-demographic profile from a university hospital ADHD outpatient unit in São Paulo, Brazil

PURPOSE: To describe the social-demographic variables, including interpersonal, academic, and professional performance in adult individuals with the diagnoses of attention deficit hyperactivity disorder (ADHD). There are no reports of this kind in the Brazilian population with ADHD. The ADHD is a common disorder, which can reach up to 3% of the general population. METHOD: Descriptive study of adults with ADHD, according to the DSM-IV criteria (American Psychiatric Association). The sample was selected from a specialized outpatient service in São Paulo city. The social-demographic data was obtained by personal interviews. RESULTS: There was a predominance of males in the sample (61.2%) and a high education level (90.2% had at least a high school degree) and 52% of the 102 patients had repeated their class at a least once during their school lives. In addition, 22.5% of the population sample were unemployed at the time of the interview. CONCLUSION: The distribution of the socio-demographic variables in adult ADHD is similar to other ADHD samples reported in other countries, despite the high education level met in our sample. Similarities between child and adult ADHD could also be traced.

Methylphenidate-induced improvements of various measures of attention in adults with attention deficit hyperactivity disorder

The present study examined the effect of the stimulant medication methylphenidate (MPH) on attentional functioning of adults with ADHD. Sixteen adults with a diagnosed ADHD without comorbidity were assessed twice, at baseline off MPH and following MPH treatment. The assessment battery consisted of reaction time tasks of low complexity, including measures of alertness--subdivided into tonic and phasic alertness, vigilance, divided attention, flexibility and such aspects of selective attention as including focused attention, inhibition and integration of sensory information. In addition, 16 healthy participants who were matched to adults with ADHD according to sex, age, education level and intellectual functions were also assessed twice using the same test battery. The results of the present study suggest that adults with ADHD off stimulant medication are seriously impaired in various components of attention including vigilance, divided attention, selective attention and flexibility. These impairments of attention were observed primarily in regard to reaction time and its variability. Treatment of adults with ADHD using individually tailored doses of MPH has a positive effect on measures of alertness, vigilance, selective attention, divided attention and flexibility. However, even on MPH adults with ADHD displayed considerable deficits in vigilance and integration of sensory information. The present findings indicate that adults with ADHD are not differentially impaired in attentional processes but may suffer from a more global deficit of attention. Although MPH treatment has been found to be effective in the treatment of the attention deficit of adults with ADHD, additional treatment appears to be necessary.

Neuropsychological functioning in people with ADHD across the lifespan

ADHD is defined by behavioral characteristics similar to neuropsychological disorders of executive dysfunction. This paper is a literature review of the neurocognitive characteristics of ADHD from early childhood through adulthood. The author addresses the development of the concept of attention and executive function (EF) deficits in ADHD, clinical neuropsychological studies of pre-teenage children, teenagers and adults with ADHD, gender and the role of psychiatric co-morbidity including the relationship of learning disabilities to ADHD, heterogeneity of neuropsychological dysfunctions, experimental neuropsychological studies, the relationship of brain structure to function, psychopharmacology of ADHD, and clinical neuropsychological assessment. The group data clearly supports the hypothesis that executive dysfunctions are correlates of ADHD regardless of gender and age, and these EF deficits are exacerbated by co-morbidity with learning disabilities such as dyslexia. However, there is limited data on children under the age of 5, teenagers from age 13-18, and adults with ADHD over the age of 40. Studies of individual classification of people with ADHD compared to healthy, non-psychiatric controls do not support the use of neuropsychological tests for the clinical diagnosis of ADHD, and indicate that not all persons with ADHD have EF deficits. Some persons with ADHD may have deficits in brain reward systems that are relatively independent of EF impairments. Future research should clarify the multiple sources of ADHD impairments, continue to refine neuropsychological tools optimized for assessment, and incorporate longitudinal, developmental designs to understand ADHD across the lifespan.

Incidence of ADHD in Adults With Severe Mental Health Problems

The purpose of this study was to determine the prevalence rates of attention deficit hyperactivity disorder (ADHD) and comorbid disorders in an adult inpatient psychiatric setting. Patient charts were reviewed from a state hospital in the western United States. Of the 292 persons served in 2002, only 6 received a diagnosis of ADHD. Of these patients, 2 received additional diagnoses for Major Depression, 1 for General Anxiety and 1 for Bipolar Disorder. Five of the 6 ADHD participants had a history of substance abuse and 4 were diagnosed with Personality Disorders. None of the 6 diagnosed with ADHD received a diagnosis of Learning Disability. A variety of nonstimulant medications were utilized to treat these patients. Characteristics of adult psychiatric populations are reviewed. Prevalence, comorbidity and implications for future research regarding adult ADHD are discussed.

Neuropsychology of adults with attention-deficit/hyperactivity disorder: a meta-analytic review

A comprehensive, empirically based review of the published studies addressing neuropsychological performance in adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) was conducted to identify patterns of performance deficits. Findings from 33 published studies were submitted to a meta-analytic procedure producing sample-size-weighted mean effect sizes across test measures. Results suggest that neuropsychological deficits are expressed in adults with ADHD across multiple domains of functioning, with notable impairments in attention, behavioral inhibition, and memory, whereas normal performance is noted in simple reaction time. Theoretical and developmental considerations are discussed, including the role of behavioral inhibition and working memory impairment. Future directions for research based on these findings are highlighted, including further exploration of specific impairments and an emphasis on particular tests and testing conditions.

Adult Outcome of Child and Adolescent Attention Deficit Hyperactivity Disorder in a Primary Care Setting

OBJECTIVES

To determine the adult status of children and adolescents previously diagnosed with attention deficit hyperactivity disorder (ADHD).

METHODS

From a consecutive sample, a case series from a primary care, private physician, office-based practice was evaluated. Seventy-seven adults were eligible, having been diagnosed with ADHD as children and adolescents by Diagnostic and Statistical Manual of Mental Disorders, Revised Third and Fourth Editions criteria. Seventy-three adults were available for interviews. Parents and/or significant others were also interviewed. The same criteria used originally were employed in the adult follow-up analysis. Main outcome measures included rates of adult ADHD, other psychiatric disorders, and educational attainment.

RESULTS

Of 73 participants, only 4 (5.5%) had retained ADHD into adulthood. Sixty-nine (94.5%) did not have adult ADHD. The majority of the cohort did not exhibit any disabling psychopathology, and most had achieved positive educational attainment.

CONCLUSIONS

Adult follow-up of children and adolescents diagnosed with ADHD shows adult ADHD is rare in primary care. The data suggests that clinicians can have the greatest impact on ADHD by concentrating on the evaluation and management of children and adolescents with the disorder.

The marital and family functioning of adults with ADHD and their spouses

Little is known about the family relationships of adults with Attention-Deficit/Hyperactivity Disorder (ADHD). Thus, the marital adjustment and family functioning of 33 married adults with ADHD and their spouses was compared to 26 non-ADHD control participants and their spouses. Results revealed that married adults with ADHD reported poorer overall marital adjustment on the Dyadic Adjustment Scale (DAS; Spanier, 1989) and more family dysfunction on the Family Assessment Device (FAD; Eptein, Baldwin, & Bishop, 1983) than control adults. The spouses of adults with ADHD did not differ from control spouses in reports of overall marital adjustment and family dysfunction. A greater proportion of their marital adjustment scores, however, fell within the maladjusted range. The ADHD adults' perceptions of the health of their marriages and families were more negative than their spouses' perceptions. The way in which spouses of ADHD adults compensated for their partners' difficulties were explored through clinical interviews. The findings in this study underscore the need for assessments and treatments to address marital and family functioning of adults with ADHD.

Attention-deficit/hyperactivity disorder in adult patients with posttraumatic stress disorder (PTSD): is ADHD a vulnerability factor?

OBJECTIVE

There is limited evidence suggesting a link between posttraumatic stress disorder (PTSD) and Attention-Deficit/ Hyperactivity Disorder (ADHD). This study examined the association between PTSD and ADHD using retrospective and current clinical evaluations.

METHOD

Twenty-five male veterans with PTSD and 22 male veterans with panic disorder were evaluated for ADHD. The data was analyzed using chi-square and student's t-tests.

RESULTS

Thirty-six percent of participants with PTSD and 9% of participants with panic disorder met criteria for childhood ADHD. Twenty-eight percent of participants with PTSD and 5% of participants with panic disorder met criteria for current ADHD.

CONCLUSIONS

There appears to be a significant association of PTSD with ADHD. ADHD or common predisposing factors may increase the vulnerability for developing PTSD.

Diagnosis and evaluation of adults with attention-deficit/hyperactivity disorder

Although some areas of adult ADHD knowledge remain unclear, there isa strong sense of how to proceed with diagnosis using current DSM-IV criteria as a guide. Thorough clinical interview, aided by the use of rating scales for current symptoms and collateral information about childhood from parents or siblings, forms the backbone of the assessment. The poor psychosocial outcomes of patients with ADHD. often a consequence of unrecognized,untreated disorder manifestation, also can serve as a diagnostic indicator. Diagnostic and symptom assessment scales also can be a significant helpin diagnosing and establishing the symptoms of ADHD in adults. It is important to remember that according to DSM-IV, the cardinal criteria for making the diagnosis are the presence of sufficient current symptoms and impairment in two realms (home, school/work, and social interactions). Accordingly, adult ADHD remains a clinical diagnosis, and the clinician-administered interview remains the cornerstone of diagnostic evaluation.

Neuropsychological function in adults with attention-deficit/hyperactivity disorder

This article reviews the current state of the literature pertaining to the neuropsychological dysfunctions that are found in children and adults with attention-deficit/hyperactivity disorder (ADHD). Be-cause considerable controversy has existed about the nature and validity of adult ADHD, this article will aid clinicians in develop-ing a better understanding of the empirical literature on neuropsychological function in ADHD throughout the lifespan.

Screening and diagnostic utility of self-report attention deficit hyperactivity disorder scales in adults

Attention deficit hyperactivity disorder (ADHD) in adults is associated with significant social, legal, occupational, and psychiatric difficulties. The estimated prevalence of ADHD in the adult population is between 0.3% and 5%. Recent interest in the condition in adults has been accompanied by the appearance of a number of readily available scales for screening adults and aiding in the diagnosis of ADHD in this age group. However, there are few published data on the validity and reliability of such measures. We examined the diagnostic and screening utility of three ADHD scales (Adult Rating Scale [ARS], Attention-Deficit Scales for Adults [ADSA], and Symptom Inventory for ADHD) in 82 adults presenting for ADHD evaluation. All three instruments were sensitive to the presence of symptoms in adults with ADHD (correctly identifying 78% to 92% of patients with ADHD), but a high proportion of individuals with non-ADHD diagnoses screened positive (incorrectly identifying between 36% and 67% of non-ADHD patients). Our results suggest that the use of such measures for screening and as an aid in diagnosis should be approached with considerable caution.

ADHD and reading disability in male adults: is there a connection?

The present study examined the comorbidity between attention-deficit/hyperactivity disorder (ADHD) and reading disability (RD) in male adults. Participants were 120 men, of whom 24 were classified as having ADHD. The basis for the diagnosis was two self-report scales validated by interviews and background data. An extensive battery was used to assess phonological abilities and various aspects of reading skills. No differences were obtained between adults with and without ADHD on measures of either phonological processing skills or word decoding, indicating a low comorbidity with RD. This finding was valid even when different criteria were used to diagnose RD. However, the two groups differed in reading comprehension, with individuals with ADHD performing poorly in tests of reading comprehension. These results are compatible with the view that reading comprehension involves many of the higher cognitive control functions assumed to be impaired in ADHD. However, these attentional control functions are not critical to word recognition, which is determined by a more encapsulated phonological processing module. The pattern of associations between ADHD and RD observed in the present study is explained with reference to the differential attentional demands of the two aspects of reading.

Atomoxetine

Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor and nonstimulant that has shown greater efficacy than placebo in attention deficit hyperactivity disorder (ADHD) in adults. In two large, well controlled, 10-week trials in adults with ADHD, improvements in ADHD symptoms, as assessed by investigator- and patient-rated scores, were greater with oral atomoxetine (60, 90 or 120 mg/day) than with placebo. Mean reductions in the total ADHD symptom score on the investigator-rated Conners' Adult ADHD Rating Scale (CAARS) in atomoxetine versus placebo recipients were 28.3% versus 18.1% and 30.1% versus 19.6%, respectively. Mean reductions in the scores on the Clinician Global Impression of Severity Scale, patient-rated CAARS and Wender-Reimherr Adult Attention Deficit Disorder Scale were also significantly greater with atomoxetine than with placebo. Continued efficacy was demonstrated in a noncomparative, 34-week extension phase. Atomoxetine was generally well tolerated in clinical trials; withdrawal rates due to adverse events in atomoxetine-treated versus placebo-treated patients participating in the two major trials were 7.8% versus 4.3% and 9.3% versus 2.4% (p<0.05 for the latter trial). Adverse events reported significantly more frequently with atomoxetine than placebo included dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating, dysuria, sexual problems and palpitations. Modest increases in heart rate and blood pressure were well tolerated and gradually decreased on cessation of treatment. Atomoxetine was not associated with QT interval prolongation. Atomoxetine can be administered once or twice daily. Its subjective-effects profile is different to that of methylphenidate and atomoxetine is not associated with abuse or diversion; it is therefore not a controlled substance in the US. This also means repeat prescriptions during long-term treatment can be more conveniently processed.

CONCLUSION

Atomoxetine is an effective and generally well tolerated treatment for adults with ADHD. It is a nonstimulant and is the first ADHD treatment to be approved specifically for adult use based on its efficacy in well controlled adult trials. It can be administered as a single daily dose or split into two evenly divided doses. It carries negligible risk of abuse or diversion and is not a controlled substance. Atomoxetine is a valuable new treatment option for adults with ADHD and is particularly useful in patients who are at risk for substance abuse or who do not wish to take a controlled substance.