Diagnosing ADHD in adolescence

Diversity and representation in ADHD psychosocial treatment research: A comprehensive synthesis with data from over 10,000 participants

Demographic data from nearly 50 years of treatment research for children and adolescents with attention-deficit/hyperactivity disorder (ADHD) are synthesized. Comprehensive search identified ADHD treatment studies that were between-group designs, included a psychosocial, evidence-based treatment, and were conducted in the United States. One hundred and twenty-six studies that included 10,604 youth were examined. Reporting of demographics varied with 48% of studies (k = 61) reporting ethnicity, 73% (k = 92) reporting race, 80% (k = 101) reporting age (M age = 8.81, SD = 2.82), and 88% (k = 111) reporting gender. Most participants identified as non-Hispanic/Latine (15.99% Hispanic/Latine), White (62.54%), and boys (74.39%; 24.47% girls). Since the 1970s, zero youth in ADHD treatment studies identified as Middle Eastern/North African, 0.1% were American Indian/Alaskan Native or Native Hawaiian Pacific Islander, 1.77% were Asian, 15.10% were Black, and 3.14% were Multiracial. Based on publication year, the proportions of girls, racially minoritized youth, and Hispanic/Latine youth included in ADHD treatment research have increased over time. Girls, non-binary and non-cisgender youth, young children, adolescents, Hispanic/Latine youth, and youth from all racial groups other than White are underrepresented in ADHD treatment research. Research gaps are discussed, and recommendations for comprehensive demographic reporting in child and adolescent psychological research are provided.

Non-pharmacological treatment of Attention Deficit Disorder with or without Hyperactivity (ADHD). Overview and report of the first international symposium on the non-pharmacological management of ADHD

Attention Deficit Disorder with or without Hyperactivity (ADHD is a neurodevelopmental disorder which affects the day-to-day functioning of children and adults with this condition. Pharmacological treatment can reduce the symptoms associated with ADHD, but it has some limitations. The objective of this symposium is to determine the effects of non-pharmacological approaches on ADHD symptoms. Results indicate that the following intervention are promising approaches: cognitive behavioral therapy (CBT), mindfulness-based interventions (MBI), yoga, cognitive and metacognitive intervention, neurofeedback and parental training programs. Current research advocates multimodal approaches in conjunction with school or work accommodations integrating innovative technologies.

Momentary Dynamics Implicate Emotional Features in the ADHD Phenotype

Emotional dysregulation is increasingly recognized as important to the attention-deficit/hyperactivity disorder (ADHD) phenotype alongside inattention and hyperactivity-impulsivity. Studies of ADHD have relied primarily on trait-based conceptualizations that emphasize stability of symptoms across moderate developmental timescales (i.e., months to years). Trait-based conceptualizations provide a critical view but fail to account for short-term dynamic variations in the expression of ADHD symptoms and emotion. This leaves a gap in our understanding of the short-term variation in ADHD symptom expression and the dynamic relationships among ADHD symptoms and emotion. Here, we assessed caregiver report of ADHD symptoms and positive and negative emotion using ecological momentary approaches over 2 weeks in a sample of 36 children with and without ADHD between the ages of 7-12 years old. Between-person (RKF) and within-person (RC) reliability were estimated. Multilevel models tested specific covariation hypotheses between ADHD symptoms and emotion. Analyses confirmed that ADHD and emotion ratings were reliable as individual differences (i.e., between-person; RKF range 0.93-1.0) and moment-to-moment change (i.e., within-person; Rc range 0.66-0.88) measures. Multilevel models found little evidence for lagged effects between domains, but consistently identified concurrent expression of ADHD symptoms and emotions; inattention covaried most strongly with negative emotion and hyperactivity-impulsivity covaried most strongly with positive emotion. Results demonstrate the importance of complementing trait-level conceptualizations with assessment of momentary dynamics. Momentary assessment suggests important covariation of ADHD symptoms and emotion as part of the ADHD phenotype.

Change in Adolescents' Perceived ADHD Symptoms Across 17 Days of Ecological Momentary Assessment

OBJECTIVE

To test whether adolescents' perceived ADHD symptoms may improve while monitoring them throughout the day.

METHOD

In a sample of 90 adolescents (Mage = 14.7; 66% boys, 34% girls; 76.7% White, 13.3% Black or African American, 8.9% more than one race, 1.1% "other") treated for ADHD by their pediatricians, this study examined: (1) whether self-rated ADHD symptoms decreased across 17 days of 4 times daily ecological momentary assessment (EMA) of symptoms and (2) whether completing versus missing an EMA survey was associated with lower self-rated ADHD symptoms in the subsequent hours.

RESULTS

Multilevel regression analyses showed that, on average, adolescents' perceived ADHD symptoms (inattention, hyperactivity, impulsivity, and total across domains) decreased across 17 days of EMA. Within person, symptoms were lower following completed versus missed EMA surveys. Significant moderating effects showed that the effect of completing the prior EMA survey weakened across the day and over the course of the 17 days.

CONCLUSIONS

This study is the first to document acute improvements in self-rated ADHD symptoms using EMA in adolescents' naturalistic environments. Symptom monitoring throughout the day may help adolescents improve their day-to-day ADHD, at least acutely, and holds promise as one component of mobile-health ADHD interventions.

For better or for worse? Memories and mental health related to COVID-19 lockdowns in adolescents with Attention Deficit Disorders

PURPOSE

In adolescents with Attention Deficit Hyperactivity Disorders (ADHD, ICD-10 defined) we examined self-reported well-being, depressive symptoms and autobiographical memories from the first COVID-19 lockdown in Denmark in comparison to adolescents without an ADHD diagnosis.

METHODS

Data from 16 adolescents with ADHD and 16 non-ADHD age and gender matched controls were collected between September 2020 and April 2021. Questionnaires included the World Health Organization Well-Being Index (WHO-5), the Short Mood and Feelings Questionnaire (SMFQ), and an autobiographical memory survey assessing a lockdown memory, a memory not related to lockdown and a future projection. Mixed design ANOVAs were used to compare within subject differences in memory types across groups and independent sample t-tests were used to compare group differences.

RESULTS

Three adolescents with ADHD scored below the WHO-5 cut-off (< 50) and above the SMFQ cut-off (> 8) indicating risk of depression, compared to two in the control group. Both groups rated lockdown memories as less positive and more negative and reported feeling more sad and worried when reminiscing about lockdown experiences compared to 'other personal memories' and 'future projections'. Compared to the non-ADHD controls, adolescents with ADHD reported more sadness, t(30) = -0.2.45, p < .05 and worries t(30) = -3.84, p < .001 when reminiscing about the lockdown.

CONCLUSIONS

Even though there were no striking differences between groups in the assessments on risk of depression, the findings suggest that adolescents diagnosed with ADHD were more negatively affected when recalling memories about the lockdown compared to their peers.

The Relationship Between Emotion Dysregulation and Error Monitoring in Adolescents with ADHD

Attention-deficit/hyperactivity disorder (ADHD) is emblematic of the limitations of existing diagnostic categories. One potential solution, consistent with the Research Domain Criteria (RDoC) initiative, is to interrogate psychological mechanisms at the behavioral and physiological level together to try and identify meaningful subgroups within existing categories. Such approaches provide a way to revise diagnostic boundaries and clarify individual variation in mechanisms. Here, we illustrate this approach to help resolve heterogeneity in ADHD using a combination of behaviorally-rated temperament measures from the Early Adolescent Temperament Questionnaire; cognitive performance on three difference conditions of an emotional go/no-go task; and electroencephalogram (EEG)-measured variation in multiple stages of error processing, including the error-related negativity (ERN) and positivity (Pe). In a large (N = 342), well-characterized sample of adolescents with ADHD, latent profile analysis identified two ADHD temperament subgroups: 1) emotionally regulated and 2) emotionally dysregulated (with high negative affect). Cognitive and EEG assessment in a subset of 272 adolescents (nADHD = 151) found that the emotionally dysregulated group showed distinct patterns of change in early neural response to errors (ERN) across emotional task conditions as compared to emotionally-regulated ADHD adolescents and typically-developing controls. Both ADHD groups showed blunted later response to errors (Pe) that was stable across emotional task conditions. Overall, neural response patterns identified important differences in how trait and state emotion interact to affect cognitive processing. Results highlight important temperament variation within ADHD that helps clarify its relationship to the ERN, one of the most prominent putative neural biomarkers for psychopathology.

Review of Studies on Incremental Validity of Assessment Measures Used in Psychological Assessment of Attention-Deficit Hyperactivity Disorder

Few studies have summarized the literature relevant to the incremental validity of tools and procedures for the assessment of attention-deficit hyperactivity disorder (ADHD). The current project reviewed such studies published in the prior 18 years. Results from studies on the incremental validity of measures used in the assessment of ADHD were reviewed. Measures included symptom reports, clinical interviews, behavioral observation, continuous performance and other psychomotor tasks, intelligence tests, and measures of executive function. Twenty-nine published studies and two reviews were identified from 2004 to 2022. Incremental validity was determined using various statistics including R2, classification metrics, odds ratios, and post-test probabilities. Findings suggest that symptom reports from a collateral source and continuous performance test measures have incremental validity over self-reports and clinical interviews. Measures of intellectual and executive functioning did not show incremental validity in the diagnosis of ADHD. Findings are relevant to the practitioner, as they bear on the optimization of both the cost-effectiveness and the diagnostic accuracy of combined procedures in the assessment of ADHD.

Identifying subgroups of attention-deficit/hyperactivity disorder from the psychopathological and neuropsychological profiles

The Research Domain Criteria (RDoC) advocates the dimensional approach in characterizing mental disorders. We followed RDoC to characterize children with ADHD using profiling based on the cognitive and psychopathological domains. We aimed to identify and validate ADHD subtypes with different clinical characteristics and functional impairments. We recruited 362 drug-naïve children with ADHD and 103 typically developing controls. The cluster analysis was used to identify subgroups based on the Child Behaviour Checklist (CBCL) and the Behaviour Rating Inventory of Executive Function (BRIEF). The subgroups' clinical characteristics and functional impairments were assessed using the WEISS Functional Impairment Rating Scale-Parent Report (WFIRS-P) and the Conners Parent Symptom Questionnaire (PSQ). The cluster analysis yielded four subgroups: (1) ADHD with severe impairment in psychopathology and executive functions (EF), (2) ADHD with mild executive dysfunctions and normal-level psychopathology, (3) ADHD with severe externalizing problems and (4) ADHD with severe executive dysfunctions. These subgroups showed different clinical characteristics and degrees of functional impairment. The EF impairment group displayed more serious learning problems and worse life skills than the externalizing group. The two groups with externalizing problems (i.e. the severe impairment group and the externalizing group) both exhibited higher rates of the combined subtype of ADHD and higher rates of comorbid ODD. Different subtypes of ADHD displayed different profiles of internalizing and externalizing problems and levels of executive dysfunctions. In particular, the subtype with severe impairment in EF exhibited more learning problems and worse life skills, suggesting EF is a critical target for intervention in children with ADHD.

Evidence-Based Assessment for Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects individuals from all life stages, genders, and races/ethnicities. Accurate assessment of ADHD across different populations is essential as undiagnosed ADHD is associated with numerous costly negative public health outcomes and is complicated by high comorbidity and developmental change in symptoms over time. Predictive analysis suggests that best-practice evidence-based assessment of ADHD should include both ADHD-specific and broadband rating scales from multiple informants with consideration of IQ, academic achievement, and executive function when there are concerns about learning. For children under age 12, parent and teacher ratings should be averaged. For adolescents and adults, informant reports should be prioritized when self- and other-report are inconsistent. Future research should provide more stringent evaluation of the sensitivity of measures to treatment response and developmental change over time as well as further validate measures on historically understudied populations (i.e., adults, women, and racial/ethnic minorities).

Design of a Collaborative Knowledge Framework for Personalised Attention Deficit Hyperactivity Disorder (ADHD) Treatments

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder. From the data collected by the Ministry of Public Health, Thailand, it has been reported that more than one million Thai youths (6-12 years) have been diagnosed with ADHD (2012-2018) This disorder is more likely to occur in males (12%) than females (4.2%). If ADHD goes untreated, there might be problems for individuals in the long run. This research aims to design a collaborative knowledge framework for personalised ADHD treatment recommendations. The first objective is to design a framework and develop a screening tool for doctors, parents, and teachers for observing and recording behavioural symptoms in ADHD children. This screening tool is a combination of doctor-verified criteria and the ADHD standardised screening tool (Vanderbilt). The second objective is to introduce practical algorithms for classifying ADHD types and recommending appropriate individual behavioural therapies and activities. We applied and compared four well-known machine-learning methods for classifying ADHD types. The four algorithms include Decision Tree, Naïve Bayes, neural network, and k-nearest neighbour. Based on this experiment, the Decision Tree algorithm yielded the highest average accuracy, which was 99.60%, with F1 scores equal to or greater than 97% for classifying each type of ADHD.

Harmonizing DSM-IV and DSM-5 Versions of ADHD "A Criteria": An Item Response Theory Analysis

The transition from Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) attention deficit/hyperactivity disorder (ADHD) checklists included item wording changes that require psychometric validation. A large sample of 854 adolescents across four randomized trials of psychosocial ADHD treatments was used to evaluate the comparability of the DSM-IV-TR and DSM-5 versions of the ADHD symptom checklist. Item response theory (IRT) was used to evaluate item characteristics and determine differences across versions and studies. Item characteristics varied across items. No consistent differences in item characteristics were found across versions. Some differences emerged between studies. IRT models were used to create continuous, harmonized scores that take item, study, and version differences into account and are therefore comparable. DSM-IV-TR ADHD checklists will generalize to the DSM-5 era. Researchers should consider using modern measurement methods (such as IRT) to better understand items and create continuous variables that better reflect the variability in their samples.

Diagnosis and treatment children and adolescents with autism and ADHD

Attention-deficit/hyperactivity disorder (ADHD) and autism are neurodevelopmental disorders that emerge in childhood. There is increasing recognition that ADHD and autism frequently co-occur. Yet, questions remain among clinicians regarding the best ways to evaluate and treat co-occurring autism and ADHD. This review outlines issues relevant to providing evidence-based practice to individuals and families who may be experiencing difficulties associated with co-occurring autism and ADHD. After describing the complexities of the co-occurrence of autism and ADHD, we present practical considerations for best practice assessment and treatment of co-occurring autism and ADHD. Regarding assessment, this includes considerations for interviewing parents/caregivers and youth, using validated parent and teacher rating scales, conducting cognitive assessments, and conducting behavior observations. Regarding treatment, consideration is given to behavioral management, school-based interventions, social skills development, and the use of medications. Throughout, we note the quality of evidence that supports a particular component of assessment or treatment, highlighting when evidence is most relevant to those with co-occurring autism and ADHD across stages of development. In light of the current evidence for assessment and treatment of co-occurring autism and ADHD, we conclude by outlining practical implications for clinical and educational practice.

The Impact of ADHD on Maternal Quality of Life

Childhood attention-deficit/hyperactivity disorder (ADHD) is associated with substantial burden to caregiver quality of life (QoL). However, a paucity of work has focused on quantifying QoL among caregivers of adolescents with a history of ADHD. The purpose of the current study was (1) to quantify maternal QoL in a sample of mothers of adolescents with and without childhood ADHD; and (2) to examine predictors (i.e., parent and child characteristics and behavior) associated with maternal QoL. Participants included mothers of adolescents with (N = 110) and without ADHD (N = 90) ranging in age from 13 to 18 (M = 16.09, 92% male). The Quality Adjusted Life-Year (QALY) was used to calculate maternal QoL using two health domains (i.e., anxiety/depression and disruption in daily activities) commonly impacted by raising youth with ADHD. QALYs are valued monetarily to estimate disease burden. Mothers of adolescents with childhood ADHD experienced significantly worse QoL relative to mothers in the comparison group. Maternal depression, as well as adolescent age, ADHD status, and discipline problems significantly predicted lower levels of maternal QALY health status index, with ADHD being the strongest predictor. This is equal to a reduction in 1.96 QALYs when summed over the course of a child's lifetime and is associated with a loss of $98,000 to $196,000. Results of the investigation help to further elucidate the health impacts incurred by families of adolescents with ADHD and have important public health implications. Further, parental QoL should be considered when conceptualizing the financial and negative health impact of ADHD.

Attention-Deficit/Hyperactivity Disorder: Restricted Phenotypes Prevalence, Comorbidity, and Polygenic Risk Sensitivity in the ABCD Baseline Cohort

OBJECTIVE

To evaluate the prevalence and major comorbidities of ADHD using different operational definitions in a newly available national dataset and to test the utility of operational definitions against genetic and cognitive correlates.

METHOD

The US Adolescent Brain Cognitive Development (ABCD) Study enrolled 11,878 children aged 9-10 years at baseline. ADHD prevalence, comorbidity, and association with polygenic risk score and laboratory-assessed executive functions were calculated at 4 thresholds of ADHD phenotype restrictiveness. Bias from missingness, sampling, and nesting were addressed statistically.

RESULTS

Prevalence of current ADHD for 9- to 10-year old children was 3.53% (95% CI 3.14%-3.92%) when Computerized Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS-COMP) score and parent and teacher ratings were required to converge. Of ADHD cases so defined, 70% had a comorbid psychiatric disorder. After control for overlapping comorbidity and ruling out for psychosis or low IQ, 30.9% (95% CI 25.7%-36.7%) had a comorbid disruptive behavior disorder, 27.4% (95% CI 22.3%-33.1%) had an anxiety or fear disorder, and 2.1% (95% CI 1.2%-3.8%) had a mood disorder. Children in the top decile of polygenic load incurred a 63% increased chance of having ADHD vs the bottom half of polygenic load (p < .01)-an effect detected only with a stringent phenotype definition. Dimensional latent variables for irritability, externalizing, and ADHD yielded convergent results for cognitive correlates.

CONCLUSION

This fresh estimate of national prevalence of ADHD in the United States suggests that the DSM-5 definition requiring multiple informants yields a prevalence of about 3.5%. Results may inform further ADHD studies in the ABCD sample.

An Observational Study of the Morning and Evening Behavior of Individuals With and Without Attention-Deficit/Hyperactivity Disorder

Evidence of ADHD symptoms and impairments were documented in the morning and evening hours for individuals diagnosed with ADHD. These results illustrate additional areas in need of attention in the refinement of treatments for adults with ADHD.

Parent training in non-violent resistance for children with attention deficit hyperactivity disorder: a controlled outcome study

Current forms of parent training for childhood attention deficit hyperactivity disorder (ADHD) are often insufficient. Many families drop out of the training, and treatment gains are often not maintained. Nonviolent resistance parent training (NVR) focuses on helping parents resist the child's negative behaviors without escalating the problem. NVR helps parents to fulfill an anchoring function, supporting the child through presence, self-regulation, structure, and support network. This study is a randomized controlled trial designed to assess the efficacy of NVR in the treatment of childhood ADHD. Participants were Israeli parents of children with primary ADHD diagnosis (N = 101; 5-13 years old; 79% male participants) randomly assigned to either 12-session NVR (N = 50) or waiting list (N = 51). Measures were administered before and after treatment and at a 4-month follow-up. ADHD outcomes included the Conners and Child Behavior Checklist. Parenting outcomes included parental helplessness, emotional regulation, anchoring function, and family chaos. Participants in the NVR condition reported significant improvements in the child's internalizing, externalizing, and ADHD symptoms, as well as improvement in paternal and maternal helplessness and anchoring. Participants in the control condition did not report changes in the child's symptoms or the parents' condition. The results at follow-up revealed maintenance of change in the child's externalizing and internalizing symptoms, but failure to maintain gains in ADHD core symptoms. Maternal helplessness and anchoring, as well as family chaos continued to improve at follow-up. Dropout rates in the treatment group were low (5%), and fathers' engagement was close to 100%. NVR is an efficient treatment for childhood ADHD, with benefits extending beyond the child's symptoms to the entire family. NVR's special focus on parental distress may have contributed to low dropout, high paternal engagement, and maintenance of change.

Longitudinal Association of Sluggish Cognitive Tempo with Depression in Adolescents and the Possible Role of Peer Victimization

It is unknown whether sluggish cognitive tempo (SCT) is prospectively associated with depression in adolescence, and possible processes linking SCT to depression remain unexamined. Using a longitudinal study with three timepoints over a two-year period, the current study tested the indirect effects of SCT on depression via peer victimization, specifically physical, relational, and verbal victimization. Participants were 302 adolescents (M_age = 13.17 years; 44.7% female participants; 81.8% White; 52% with ADHD). In the fall of 8th grade, adolescents and parents completed measures of adolescents' SCT and ADHD symptoms. Adolescents completed a measure of peer victimization in spring of 8th grade and a measure of depressive symptoms in 10th grade. Models examining indirect effects were conducted with and without control of baseline ADHD and/or depressive symptoms. Across analyses, adolescent and parent ratings of SCT symptoms uniquely predicted greater depressive symptoms two years later when controlling for adolescent sex, study site, and either 8th grade depressive or ADHD symptoms. Further, adolescents' self-reported 8th grade SCT symptoms predicted 10th grade depressive symptoms via verbal victimization when controlling for 8th grade ADHD symptoms, but not in analyses incorporating 8th grade depressive symptoms. Findings underscore the predictive association of SCT on depressive symptoms, the possible role of adverse peer relationships as a mechanism linking SCT to depression, and the importance of considering ADHD and depressive symptoms in research on longitudinal correlates of SCT.

Variable Patterns of Remission From ADHD in the Multimodal Treatment Study of ADHD

OBJECTIVE

It is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood.

METHODS

Children with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing.

RESULTS

Approximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time.

CONCLUSIONS

The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.

Longitudinal network model of the co-development of temperament, executive functioning, and psychopathology symptoms in youth with and without ADHD

Attention-deficit hyperactivity disorder (ADHD) is a common, chronic, and impairing disorder, yet presentations of ADHD and clinical course are highly heterogeneous. Despite substantial research efforts, both (a) the secondary co-occurrence of ADHD and complicating additional clinical problems and (b) the developmental pathways leading toward or away from recovery through adolescence remain poorly understood. Resolving these requires accounting for transactional influences of a large number of features across development. Here, we applied a longitudinal cross-lagged panel network model to a multimodal, multilevel dataset in a well-characterized sample of 488 children (nADHD = 296) to test Research Domain Criteria initiative-inspired hypotheses about transdiagnostic risk. Network features included Diagnostic and Statistical Manual of Mental Disorders symptoms, trait-based ratings of emotional functioning (temperament), and performance-based measures of cognition. Results confirmed that ADHD symptom domains, temperamental irritability, and working memory are independent transdiagnostic risk factors for psychopathology based on their direct associations with other features across time. ADHD symptoms and working memory each had direct, independent associations with depression. Results also demonstrated tightly linked co-development of ADHD symptoms and temperamental irritability, consistent with the possibility that this type of anger dysregulation is a core feature that is co-expressed as part of the ADHD phenotype for some children.

Too Connected to Being Connected? Adolescents' Social Media Emotional Investment Moderates the Association between Cybervictimization and Internalizing Symptoms

This study examined whether the association between cybervictimization and internalizing symptoms was moderated by adolescents' emotional connectedness to their social media. Participants were 288 adolescents (54.9% male participants) with (n = 151) and without (n = 137) attention-deficit/hyperactivity disorder (ADHD) between the ages of 13 and 15 years (M = 14.09, SD = 0.36). Adolescents reported on social integration and emotional connection (SIEC) to social media and parents reported on their impression of their adolescent's SIEC to social media. Adolescents also reported on cybervictimization experiences and internalizing symptoms. Adolescents with ADHD had higher cybervictimization scores than adolescents without ADHD and were also more likely to report multiple experiences of cybervictimization over the past month. Emotional investment in social media moderated the relations between cybervictimization and internalizing symptoms such that cybervictimization was associated with higher anxiety and depression symptoms at higher levels of emotional investment in social media. Results were consistent across both parent and adolescent report of social integration and emotional connection to social media. These findings indicate that cybervictimization may be associated with negative outcomes specifically among adolescents with a strong emotional connection to their social media use.

Impulsive and Omission Errors: Potential Temporal Processing Endophenotypes in ADHD

Temporal processing (TP) is associated with functions such as perception, verbal skills, temporal perspective, and future planning, and is intercorrelated with working memory, attention, and inhibitory control, which are highly impaired in individuals with attention deficit hyperactivity disorder (ADHD). Here we evaluate TP measures as potential endophenotypes in Caribbean families ascertained from probands affected by ADHD. A total of 232 individuals were recruited and clinically evaluated using an extensive battery of neuropsychological tasks and reaction time (RT)-based task paradigms. Further, the heritability (genetic variance underpinning phenotype) was estimated as a measure of the genetics apportionment. A predictive framework for ADHD diagnosis was derived using these tasks. We found that individuals with ADHD differed from controls in neuropsychological tasks assessing mental control, visual-verbal memory, verbal fluency, verbal, and semantic fluency. In addition, TP measures such as RT, errors, and variability were also affected in individuals with ADHD. Moreover, we determined that only omission and commission errors had significant heritability. In conclusion, we have disentangled omission and commission errors as possible TP endophenotypes in ADHD, which can be suitable to assess the neurobiological and genetic basis of ADHD. A predictive model using these endophenotypes led to remarkable sensitivity, specificity, precision and classification rate for ADHD diagnosis, and may be a useful tool for patients' diagnosis, follow-up, and longitudinal assessment in the clinical setting.

Attention-Deficit/Hyperactivity Disorder Symptoms and Community Violence Exposure in Russian Adolescents

A large body of research has shown that exposure to community violence is common for many children across the world. However, less is known about exposure in particular subgroups such as those children with developmental disorders. To address this research gap, the aim of this study was to examine community violence exposure (CVE) in adolescents with attention-deficit/hyperactivity disorder (ADHD) symptoms and the role of gender in this association. Data were analyzed from 2,782 adolescents aged 13 to 17 years from Arkhangelsk, Russia that were collected during the Social and Health Assessment (SAHA). ADHD status was assessed with the hyperactivity/inattention scale of the Strengths and Difficulties Questionnaire (SDQ). Information was obtained on past-year witnessing and violence victimization in the community. Results showed that CVE was more prevalent in children with ADHD symptoms. Specifically, 75.1% of children with ADHD symptoms had been exposed to any violence versus 62.3% in the non-ADHD group (χ² = 18.65, p < .001). Multivariate analyses of covariance (MANCOVAs) revealed that CVE was significantly higher for adolescents with ADHD symptoms for both witnessing and victimization, while exposure was significantly higher for ADHD boys compared with girls. The findings of this study suggest that CVE may be elevated in adolescents with higher ADHD symptoms. Given that CVE has been associated with a variety of negative social and psychological outcomes in typically developing children, an important task for future research is to determine what factors are associated with CVE in adolescents with ADHD symptoms including those relating to such phenomena as comorbid psychopathology, the family, and peer relations, so that interventions can be designed and implemented to reduce CVE and its detrimental effects in this population.

Leveraging Machine Learning to Identify Predictors of Receiving Psychosocial Treatment for Attention Deficit/Hyperactivity Disorder

This study aimed to identify factors associated with receiving psychosocial treatment for ADHD in a nationally representative sample. Participants were 6630 youth with a parent-reported diagnosis of ADHD from the 2016-2017 National Survey of Children's Health. Machine learning analyses were performed to identify factors associated with receipt of psychosocial treatment for ADHD. We examined potentially associated factors in the broad categories of variables hypothesized to affect problem recognition (e.g., severity, mental health comorbidities); the decision to seek treatment; service selection (e.g., insurance coverage) and service use. We found that three machine learning models unanimously identified parent-reported ADHD severity (mild vs. moderate/severe) as the factor that best distinguishes between children who receive psychosocial treatment for ADHD and those who do not. Receive operating characteristic curve analysis revealed the following model performance: classification and regression tree analysis (area under the curve; AUC = .68); an ensemble model (AUC = .71); and a deep, multi-layer neural network (AUC = .72), as well as comparison to a logistic regression model (AUC = .69). Further, insurance coverage of mental/behavioral health needs emerged as a salient factor associated with the receipt of psychosocial treatment. Machine learning models identified risk and protective factors that predicted the receipt of psychosocial treatment for ADHD, such as ADHD severity and health insurance coverage.

Polymorphisms in the FKBP5 gene are associated with attention deficit and hyperactivity disorder in Korean children

Attention deficit hyperactivity disorder (ADHD) is a common and heritable childhood psychiatric disorder. Recently, many studies reported a down-regulated hypothalamus-pituitary-adrenal axis (HPA-axis) with low cortisol levels in children with ADHD. The FK506 binding protein 5 or FKBP5 gene regulates the negative feedback of the HPA-axis, and genetic variants in this gene showed an association with ADHD. We investigated the genetic association between FKBP5 gene polymorphisms and susceptibility to ADHD in Korean children. We conducted a case-control study with 150 ADHD children and 322 controls. Genotyping of FKBP5 rs9394309 and rs7748266 was performed by using polymerase chain reaction - restriction fragment length polymorphism (PCR-RFLP). Our results showed that rs7748266 polymorphism has significant genotype (p = 0.021) and allele (p = 0.009) frequency differences between children with ADHD and the control group. CT genotype [odds ratio (OR) 1.70, 95 % confidence interval (CI) 1.134-2.540, p = 0.010] and T allele (OR 1.54, 95 % CI 1.114-2.117, p = 0.009) were associated with increased risk of ADHD. In addition, dominant (p = 0.006) and over-dominant genetic (p = 0.016) models showed significant associations with ADHD. In the stratified analysis, a significant result was obtained from the girl samples (p = 0.048). The OR of the girls with ADHD with CT genotype was 2.29 (95 % CI 1.170-4.469, p = 0.014). In contrast to rs7748266 polymorphism, rs9394309 polymorphism did not show any significant result (p > 0.05). Haplotype analysis also revealed a significant difference of the TG haplotype for rs7748266 - rs9394309 (p = 0.028, global haplotype association p-value of 0.0091). Conclusively, we confirmed that FKBP5 gene polymorphisms were associated with ADHD in Korean children. These results suggested that FKBP5 may factor in the development of ADHD.

Can the MMPI Predict Adult ADHD? An Approach Using Machine Learning Methods

(1) Background: Adult attention-deficit/hyperactivity disorder (ADHD) symptoms cause various social difficulties due to attention deficit and impulsivity. In addition, in contrast to ADHD in childhood, ADHD in adulthood is difficult to diagnose due to mixed psychopathologies. This study aimed to determine whether it is possible to predict ADHD symptoms in adults using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) with machine learning (ML) techniques; (2) Methods: Data collected from 5726 college students were analyzed. The MMPI-2-Restructured Form (MMPI-2-RF) was used, and ADHD symptoms in adults were evaluated using the Attention-Deficit/Hyperactivity Disorder Self-Report Scale (ASRS). For statistical analysis, three ML algorithms were used, i.e., K-nearest neighbors (KNN), linear discriminant analysis (LDA), and random forest, with the ASRS evaluation result as the dependent variable and the 50 MMPI-2-RF scales as predictors; (3) Results: When the KNN, LDA, and random forest techniques were applied, the accuracy was 93.1%, 91.2%, and 93.6%, respectively, and the area under the curve (AUC) was 0.722, 0.806, and 0.790, respectively. The AUC of the LDA method was the largest, with an excellent level of diagnostic accuracy; (4) Conclusions: ML using the MMPI-2 in a large group could provide reliable accuracy in screening for adult ADHD.

Empirically-informed guidelines for first-time adult ADHD diagnosis

INTRODUCTION

Adult Attention Deficit/Hyperactivity Disorder (ADHD) is prone to misdiagnosis because its symptoms are subjective, share features with a broad range of mental, behavioral and physical disorders, and express themselves heterogeneously. Furthermore, Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for adult ADHD diagnosis remain underdeveloped, prompting a need for systematic and empirically-informed guidelines.

METHOD

This article presents a brief history of research on adult ADHD and reviews common sources of false positive and false negative diagnoses. A systematic, stepped diagnostic procedure is described that adheres to DSM guidelines and integrates the latest science on adult ADHD assessment and diagnosis.

RESULTS

Seven steps are recommended: a structured diagnostic interview with the patient, collection of informant ratings, casting a wide net on symptoms using "or rule" to integrate informant reports, providing checks and balances on the "or rule" by enforcing the impairment criterion, chronicling a symptom timeline, ruling out alternative explanations for symptoms, and finalizing the diagnosis.

CONCLUSIONS

Based on the extant research, it is expected that the stepped diagnostic procedure will increase detection of malingering, improve diagnostic accuracy, and detect non-ADHD cases with subclinical difficulties or non-ADHD pathologies.

ADHD Endophenotypes in Caribbean Families

Objective: The aim of this study is to contrast the genetics of neuropsychological tasks in individuals from nuclear families clustering ADHD in a Caribbean community. Method: We recruited and clinically characterized 408 individuals using an extensive battery of neuropsychological tasks. The genetic variance underpinning these tasks was estimated by heritability. A predictive framework for ADHD diagnosis was derived using these tasks. Results: We found that individuals with ADHD differed from controls in tasks of mental control, visuospatial ability, visuoverbal memory, phonological and verbal fluency, verbal and semantic fluency, cognitive flexibility, and cognitive ability. Among them, tasks of mental control, visuoverbal memory, phonological fluency, semantic verbal fluency, and intelligence had a significant heritability. A predictive model of ADHD diagnosis using these endophenotypes yields remarkable classification rate, sensitivity, specificity, and precision values (above 80%). Conclusion: We have dissected new cognitive endophenotypes in ADHD that can be suitable to assess the neurobiological and genetic basis of ADHD.

Development of ADHD: Etiology, Heterogeneity, and Early Life Course

ADHD represents a powerful entry point for developmental approaches to psychopathology due to its major role in early emergence of major life problems. One key issue concerns the role of early environmental risks in etiology and maintenance in the context of genetic liability. Here, psychosocial aspects of development need more attention. A second key issue is that phenotypic heterogeneity requires better resolution if actionable causal mechanisms are to be effectively identified. Here, the interplay of cognition and emotion in the context of a temperament lens is one helpful way forward. A third key issue is the poorly understood yet somewhat striking bifurcation of developmental course in adolescence, when a subgroup seem to have largely benign outcomes, while a larger group continue on a problematic path. A final integrative question concerns the most effective conceptualization of the disorder in relation to broader dysregulation. Key scientific priorities are noted.

Incremental Clinical Utility of ADHD Assessment Measures With Latino Families

Objective: This study examined the incremental clinical utility of parent and teacher reports of ADHD symptomatology and functional impairment in Latino youth, as well as parent and teacher agreement with the final clinical judgment on a diagnostic structured interview. Method: Participants included 70 Latino youth (47 males, 23 females; M age = 8.13 years, SD = 2.51 years) and their parents and teachers; 60 participants were diagnosed with ADHD. Correlations, percent agreement, kappas, and regressions were utilized. Results: Results demonstrated that teachers agreed with the final clinical judgment more often than did parents. Results additionally demonstrated that functional impairment did not statistically significantly improve diagnostic models already including ADHD symptoms; follow-up analyses were run and are discussed. Finally, results demonstrated that teacher reports statistically significantly improved diagnostic models already including parent reports. Conclusion: The current findings suggest the importance of including both parent and teacher reports of both ADHD symptomatology and functional impairment when assessing ADHD in Latino youth.

Development of ADHD: Etiology, Heterogeneity, and Early Life Course

ADHD represents a powerful entry point for developmental approaches to psychopathology due to its major role in early emergence of major life problems. One key issue concerns the role of early environmental risks in etiology and maintenance in the context of genetic liability. Here, psychosocial aspects of development need more attention. A second key issue is that phenotypic heterogeneity requires better resolution if actionable causal mechanisms are to be effectively identified. Here, the interplay of cognition and emotion in the context of a temperament lens is one helpful way forward. A third key issue is the poorly understood yet somewhat striking bifurcation of developmental course in adolescence, when a subgroup seem to have largely benign outcomes, while a larger group continue on a problematic path. A final integrative question concerns the most effective conceptualization of the disorder in relation to broader dysregulation. Key scientific priorities are noted.

Developmental trajectory of subtle motor signs in attention-deficit/hyperactivity disorder: A longitudinal study from childhood to adolescence

This study examined the developmental trajectory of neurodevelopmental motor signs among boys and girls with attention-deficit/hyperactivity disorder (ADHD) and typically-developing (TD) children. Seventy children with ADHD and 48 TD children, aged 8-17 years, were evaluated on at least two time-points using the Physical and Neurological Assessment of Subtle Signs (PANESS). Age-related changes in subtle motor signs (overflow, dysrhythmia, speed) were modeled using linear mixed-effects models to compare the developmental trajectories among four subgroups (ADHD girls and boys and TD girls and boys). Across visits, both boys and girls with ADHD showed greater overflow, dysrhythmia, and slower speed on repetitive motor tasks compared to TD peers; whereas, only girls with ADHD were slower on sequential motor tasks than TD girls. Developmental trajectory analyses revealed a greater reduction in overflow with age among boys with ADHD than TD boys; whereas, trajectories did not differ among girls with and without ADHD, or among boys and girls with ADHD. For dysrhythmia and speed, there were no trajectory differences between the subgroups, with all groups showing similar reductions with age. Children with ADHD show developmental trajectories of subtle motor signs that are consistent with those of TD children, with one clear exception: Boys with ADHD show more significant reductions in overflow from childhood to adolescence than do their TD peers. Our findings affirm the presence of subtle motor signs in children with ADHD and suggest that some of these signs, particularly motor overflow in boys, resolve through adolescence while dysrhythmia and slow speed, may persist.

Four-Year Follow-Up of High versus Low Intensity Summer Treatment for Adolescents with ADHD

OBJECTIVE

Despite an emergence of psychosocial treatments for adolescent ADHD, their long-term effects are unknown.

METHOD

We examine four-year outcomes of a randomized controlled trial (N = 218) comparing high-intensity (HI; 412 h, $4,373 per participant) versus low-intensity (LI; 24 h, $97 per participant) skills-based summer intervention delivered to adolescents with ADHD at two secondary school transitions (6th/9th grade). Quantitative and qualitative analyses evaluated group×time and group×grade×time effects on 4-year outcomes.

RESULTS

Relative to LI, a single dose of HI had modest but lasting effects on teen organization skills (d =.40) and ADHD symptoms (9th grade only: d =.27 to.31) at 4-year follow-up. There was no long-term incremental effect of HI (vs. LI) for parent-teen conflict, GPA, or parent use of contingency management. Treatment appeared most effective when delivered to older adolescents (i.e., 9th versus 6th grade), suggesting the long-term impact of ADHD treatment may increase with age. Qualitative data corroborated that the primary long-term benefit of HI (vs. LI) treatment was to organization skills; many of the remaining perceived benefits were to parent and teen psychological variables (i.e., increased self-esteem, self-awareness, parental optimism). HI offered no incremental benefit to long-term educational or clinical service utilization or costs.

CONCLUSIONS

Modest therapeutic benefits of adolescent ADHD treatment are maintained long term. However, HI treatment did not impact outcomes that could defray the intervention's high costs ($4,373) compared to LI treatment ($97).

Psychometric Properties of the Weiss Functional Impairment Rating Scale: Evidence for Utility in Research, Assessment, and Treatment of ADHD in Emerging Adults

Objective: The current study examines psychometric properties of the Weiss Functional Impairment Rating Scale (WFIRS), a measure of adult ADHD-related impairment. It is a self-report questionnaire that provides a metric of overall life impairment and domain-specific dysfunction. Method: Using data from a large (N = 2,093), multi-institution sample of college students and including a subsample of collateral informants (n = 262), a series of analyses were conducted. Results: The WFIRS demonstrated robust internal reliability, cross-informant agreement on par or superior to other measures of ADHD symptomatology and impairment, and concurrent validity. The WFIRS was not shown to be uniquely associated with ADHD, as internalizing symptoms also associated with the total and domain scores. Conclusion: The use of the WFIRS in identifying ADHD-related impairment in emerging adults appears to be psychometrically supported, and will prove useful to clinicians and researchers.

ADHD in Adolescents: Commentary on the Special Issue of Ripple Effects in Self-Perceptions and Social Relationships

Adolescence is a developmental period that affords both risk as well as enormous opportunity. Ripple effects can extend far and wide and speak to the nuance and complexity in understanding and treating ADHD during the adolescent period. The studies in this special issue provide novel and important insights into the lives of adolescents with ADHD, and they collectively point to important areas for both research and clinical attention. Further, each of the studies underscore the importance of soliciting the perspective of adolescents with ADHD. In this commentary, I consider the value of self-report when working with adolescents with ADHD, the possibility of a self-perception bias in youth with ADHD, challenges in assessing social functioning in adolescence, and implications for school-based assessments and interventions. For treatment specifically, I raise the possibility of a modular intervention approach for adolescents with ADHD and shared decision making that solicits and incorporates the adolescent perspective. The voices of adolescents with ADHD may be crucial for understanding how to lower risk, promote resilience, reduce stigma, and improve our assessments and interventions.

Real-World Changes in Adolescents' ADHD Symptoms within the Day and across School and Non-school Days

Research on attention-deficit/hyperactivity disorder (ADHD) points to the possibility that contextual factors (e.g., time of day, school vs. home) may be related to symptoms and impairment. This prior research has relied on laboratory-based or retrospective, global approaches which has limited ecological validity. The present study substantively contributes to the extant literature by examining adolescents' ADHD symptoms in the real world across the day on both school and non-school days to test whether symptoms worsened throughout the day and were higher on school days relative to non-school days. As part of a larger study, 83 adolescents taking stimulant medication for ADHD (M_age = 14.7, 66% identified as boys/men, 78% White) completed a 17-day ecological momentary assessment protocol that included wake-up and bedtime reports and two reports in the afternoon and evening. These assessments asked about ADHD symptoms and stimulant medication usage since the last report. Hypotheses were tested using multilevel modeling. Accounting for demographic covariates and medication usage, ADHD symptoms worsened quadratically, peaking by the afternoon report and subsequently declining, across school days but not non-school days. Mean-level ADHD symptoms were also worse on school days relative to non-school days. Results did not differ across gender. In conclusion, our study is the first to examine important environmental factors (school, time of day) in real time in relation to level of naturalistically occurring ADHD symptoms. Our findings highlight the importance of advancing treatments to support adolescents with ADHD on school days and in the afternoon.

Heterogeneity and Subtyping in Attention-Deficit/Hyperactivity Disorder-Considerations for Emerging Research Using Person-Centered Computational Approaches

Few if any experts believe that existing psychiatric diagnostic categories included in DSM and ICD are actually discrete disease entities. Attention-deficit/hyperactivity disorder (ADHD) is emblematic of the problems in the existing psychiatric classification system. ADHD symptoms reliably cluster into two correlated dimensions in factor analysis. However, children with ADHD vary considerably in their symptom profiles, symptom trajectories, clinical outcomes, and biological and psychological correlates. Thus, the field has sought alternative approaches that harness the dimensions of emotional, cognitive, and behavioral functioning that underlie ADHD and other existing psychiatric categories to create informative phenotypes that improve clinical prediction and clarify etiology. Within ADHD, cognitive (neuropsychological) and temperament/personality features have received considerable attention. In some cases, subphenotypes based on these features appear to improve on existing classifications and could eventually be translated into clinical practice. This review summarizes findings from subphenotyping efforts in ADHD that use cognitive, emotion-related, and other features to highlight major considerations for research applying person-oriented approaches to inform an improved psychiatric nosology. Considerations related to feature selection, validation of newly proposed divisions, defining populations of interest, and incorporating a developmental perspective are discussed.

Metacognitive and motivation deficits, exposure to trauma, and high parental demands characterize adolescents with late-onset ADHD

The objective of this study is to evaluate support for three hypotheses about the etiology of adolescent-onset ADHD symptoms: (1) a "cool" cognitive load hypothesis, (2) a "hot" rewards processing hypothesis, and (3) a trauma exposure hypothesis. Participants (N = 50) were drawn from two public high schools in a culturally diverse metropolitan area. A detailed procedure for identifying and confirming late-onset ADHD cases is described. Adolescents with late-onset ADHD (n = 15) were identified and compared to childhood-onset (n = 17) and non-ADHD classmates (n = 18). Adolescents and parents completed measures of neurocognition, rewards' processing, clinical profile, and environmental demands. Late-onset cases were clinically and neurocognitively indistinguishable from childhood-onset cases; however, they experienced higher demands from parents (d = 1.09). Compared to the non-ADHD group, late-onset cases showed significant deficits in metacognition (d = 1.25) and academic motivation (d = 0.80), as well as a pronounced history of multiple trauma exposure (OR 11.82). At 1-year follow-up, ADHD persisted in 67.7% of late-onset cases. Late-onset cases (26.7%) were more likely than childhood-onset cases (0.0%) to transfer to alternative schools by 1-year follow-up. Multiple factors may contribute to adolescent-onset ADHD. Adolescents with metacognition and motivation deficits may be at greatest risk for the late-onset ADHD phenotype, particularly in highly demanding environments. Exposure to traumatic stress may play a key role in the exacerbation of existing deficits or onset of new symptoms. Late-onset ADHD was persistent in most cases and associated with higher risk for school disengagement than childhood-onset ADHD. Further work is needed to better understand the etiologies of late-onset ADHD symptoms.

Revisiting ADHD age-of-onset in adults: to what extent should we rely on the recall of childhood symptoms?

BACKGROUND

ADHD diagnosis requires the presence of symptoms before the age of twelve. In clinical assessment of adults, the most frequent strategy to check this criterion is investigating self-report recall of symptoms, despite little evidence on the validity of this approach. We aim to evaluate the recall accuracy and factors associated with its reliability in a large population-based sample of adults.

METHODS

Individuals from the 1993 Pelotas Birth Cohort were followed-up from childhood to adulthood. At the age of 22, 3810 individuals were assessed through structured interviews by trained psychologists regarding mental health outcomes, including ADHD diagnosis and ADHD symptoms in childhood. The retrospective recall was compared with available information on ADHD childhood symptoms at the age of eleven. We also assessed factors related to recall accuracy through multiple regression analyses.

RESULTS

Self-reported recall of childhood symptoms at 22 years of age had an accuracy of only 55.4%, with sensitivity of 32.8% and positive predictive value of 40.7%. Current inattention symptoms were associated with lower risk and social phobia with higher risk for false-positive endorsement, while higher levels of schooling correlated with lower risk and male gender with higher risk for false-negative endorsement.

CONCLUSIONS

Clinicians treating male patients with social phobia and ADHD symptoms should assess even more carefully retrospective recall of ADHD childhood symptoms. Moreover, characteristics associated with recall improvement do not impact accuracy robustly. In this context, the recall of childhood ADHD symptoms seems an unreliable method to characterize the neurodevelopmental trajectory in adults with currently-impairing ADHD symptomatology.

Cigarette Smoking Progression Among Young Adults Diagnosed With ADHD in Childhood: A 16-year Longitudinal Study of Children With and Without ADHD

INTRODUCTION

Children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for smoking cigarettes, but there is little longitudinal research on the array of smoking characteristics known to be prognostic of long-term smoking outcomes into adulthood. These variables were studied into early adulthood in a multisite sample diagnosed with ADHD combined type at ages 7-9.9 and followed prospectively alongside an age- and sex-matched local normative comparison group (LNCG).

METHODS

Cigarette smoking quantity, quit attempts, dependence, and other characteristics were assessed in the longitudinal Multimodal Treatment Study of Children with ADHD (MTA) eight times to a mean age of 24.9 years: ADHD n = 469; LNCG n = 240.

RESULTS

In adulthood, the ADHD group had higher rates of daily cigarette smoking, one or more quit attempts, shorter time to first cigarette of the day, and more severe withdrawal than the LNCG. The ADHD group did not appear to have better smoking cessation rates despite a higher proportion quitting at least once. Smoking quantity and nicotine dependence did not differ between groups. The ADHD group reported younger daily smoking onset and faster progression from smoking initiation to daily smoking across assessments. Finally, ADHD symptom severity in later adolescence and adulthood was associated with higher risk for daily smoking across assessments in the ADHD sample.

CONCLUSIONS

This study shows that ADHD-related smoking risk begins at a young age, progresses rapidly, and becomes resistant to cessation attempts by adulthood. Prevention efforts should acknowledge the speed of uptake; treatments should target the higher relapse risk in this vulnerable population.

IMPLICATIONS

Although childhood ADHD predicts later smoking, longitudinal studies of this population have yet to fully characterize smoking behaviors into adulthood that are known to be prognostic of long-term smoking outcome. The current study demonstrates earlier and faster progression to daily smoking among those with a childhood ADHD diagnosis, as well as greater risk for failed quit attempts. Prevention efforts should address speed of smoking uptake, while treatments are needed that address smoking relapse risk. The current study also demonstrates ADHD symptom severity over development increases daily smoking risk, implicating the need for continuous ADHD symptom management.

Implementing Parent-Teen Motivational Interviewing + Behavior Therapy for ADHD in Community Mental Health

Despite the promise of psychosocial interventions for adolescent Attention Deficit Hyperactivity Disorder (ADHD), there are no studies that examine their implementation in community mental health contexts. In this study, we evaluate the implementation of community-based Supporting Teens' Autonomy Daily (STAND), a parent-teen Motivational Interviewing + Behavior Therapy intervention for adolescents with ADHD. Adolescents with ADHD (N = 225), who were clients at four community mental health agencies, received treatment from 82 therapists. There was double randomization of adolescents and therapists to STAND or Usual Care (UC). Nearly all therapists randomized to STAND completed the training and regularly attended supervision, rating STAND as acceptable and lower burden than UC practices. In the STAND group, MI competence and implementation were lower than in university trials (benchmark range, 19.5% for reflection to question ratio to 83.1% for technical globals). MI integrity in the STAND group was significantly higher than UC across most MITI indices. Content fidelity was adequate in STAND's engagement and skills phases (76.4-85.0%), but not its planning phase (24.4%). Therapists commonly neglected weekly review of goals and home practice and deviated from manualized pace and sequencing of therapy tasks. Learning MI was more challenging for bilingual therapists and therapists with more years of experience. STAND was delivered with higher integrity in earlier sessions and office-based sessions. Discussion identifies future directions for exporting adolescent ADHD interventions to community settings. Patient outcome data for this trial is presented elsewhere. Trial Registration: NCT02694939 www.clinicaltrials.gov .

Randomized Trial of Academic Training and Medication Decision-Making for Adolescents with ADHD in Usual Care

Objective: This study tested two family-based interventions designed for delivery in usual care: Changing Academic Support in the Home for Adolescents with ADHD (CASH-AA), containing motivational interventions, homework management and schoolwork organization training, and family-school partnership building; and Medication Integration Protocol (MIP), containing ADHD psychoeducation, medication decision-making, and integrated medication management.Method: This study used a cluster randomized design to test CASH-AA + MIP versus CASH-AA Only for adolescents with ADHD in five sites. Therapists (N = 49) were site clinicians randomized to condition. Clients (N = 145) included 72% males; 42% White Non-Hispanic, 37% Hispanic American, 15% African American, and 6% more than one race; average age was 14.8 years. Fidelity data confirmed protocol adherence and between-condition differentiation.Results: One-year improvements were observed across conditions in several outcomes. Overall, CASH-AA + MIP produced greater declines in adolescent-report inattentive symptoms and delinquent acts. Similarly, among non-substance users, CASH-AA + MIP clients attended more treatment sessions. In contrast, among substance users, CASH-AA Only clients showed greater declines in caregiver-report hyperactive symptoms and externalizing.Conclusions: This study provides initial experimental support for family-based ADHD medication decision-making when coupled with academic training in usual care. The treatment protocols, CASH-AA and MIP, showed positive effects in addressing not only ADHD symptoms but also common co-occurring problems, and youth with substance use problems benefitted along with non-using peers.

Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in childhood with persistence into adulthood. It has a multifactorial etiology. Its chronicity, if diagnosis is missed or delayed, will result in significant negative impact on the individual's overall functioning and development. With the revised diagnostic criteria released in 2013 by the American Psychiatric Association, established standards of clinical practice continue to be applicable and valuable in the diagnosis and management of ADHD. In older children and adolescents, it is important to differentiate what is developmentally appropriate from problematic as ADHD has high correlation with poor outcomes, comorbidities, and low quality of life.

Chronic Care for Attention-Deficit/Hyperactivity Disorder: Clinical Management from Childhood Through Adolescence

OBJECTIVE

Impairments generally persist when children diagnosed with attention-deficit/hyperactivity disorder (ADHD) mature into adolescence. To examine changes in ADHD care during the transition from childhood to adolescence, we conducted a retrospective, longitudinal cohort study of patients diagnosed with ADHD before the age of 10 years to assess changes from preadolescence through adolescence in (1) frequency by which primary care providers offer ADHD care to patients, (2) range of concerns assessed during patient encounters, and (3) treatments implemented or recommended.

METHODS

We identified patients from 3 practices included in a large primary care network who (1) were born between 1996 and 1997, (2) were diagnosed with ADHD before the age of 10 years, and (3) received primary care continuously from age 9 through late adolescence. Clinical care was compared among patients in preadolescence (age 9-11), early adolescence (age 12-14), and late adolescence (age 15-18).

RESULTS

Children diagnosed with ADHD before the age of 10 years were less likely to have a documented visit for ADHD during late adolescence (41% of patients) compared with preadolescence (63%, p < 0.001). Evidence of monitoring for depression, suicide, and substance abuse increased from preadolescence to adolescence (p < 0.001) and occurred in about 90% of adolescent patients. However, monitoring for risky sexual activity occurred in only about 50% of adolescents. Discussions of medication diversion and driver readiness were essentially not documented.

CONCLUSION

The findings raise concerns about how primary care providers manage adolescents with a history of ADHD. Improving monitoring of risky sexual behavior and driver readiness and providing patient education about medication diversion are needed.

Associations between sleep problems and ADHD symptoms among adolescents: findings from the Shandong Adolescent Behavior and Health Cohort (SABHC)

Study Objectives

Sleep problems and symptoms of attention-deficit hyperactivity disorder (ADHD) in adolescence are common. Little is known about the prospective the prospective associations between sleep and subsequent ADHD symptoms in adolescents. This study examined the prospective associations between sleep problems and subsequent ADHD symptoms in a large sample of adolescents.

Methods

Participants included 7072 adolescents from the Shandong Adolescent Behavior and Health Cohort (SABHC) study in Shandong, China. Participants were initially assessed in November–December of 2015 and were reassessed 1-year later in 2016. Sleep duration, sleep problems, and psychosocial information were collected using a structured questionnaire. ADHD symptoms were measured by the Achenbach Child Behavior Checklist-Youth Self-Report.

Results

At baseline, 7.6% participants had clinically relevant ADHD symptoms, which were highly comorbid with sleep problems including insomnia symptoms, poor sleep quality, symptoms of restless legs syndrome (RLS), frequent snoring, and short sleep duration. Of the 6531 participants without clinically relevant ADHD symptoms at baseline, 4.5% reported clinically relevant ADHD symptoms at 1-year follow-up. After adolescent and family covariates were adjusted for, insomnia (OR = 2.09, 95% CI = 1.45–3.02), RLS (OR = 1.47, 95% CI = 1.02–2.11), and frequent snoring (OR = 2.30, 95% CI = 1.36–3.90) were all significantly associated with subsequent ADHD symptoms.

Conclusion

ADHD symptoms and sleep problems are highly comorbid. Insomnia, RLS and frequent snoring appear to be significant predictors of subsequent ADHD symptoms. Our study highlights the importance of assessing and managing sleep problems for prevention and clinical treatment of ADHD symptoms in adolescence.

Academic impairment among high school students with ADHD: The role of motivation and goal-directed executive functions

Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with academic failure in high school; however the underpinnings of these difficulties are insufficiently understood. This study examined deficits in self-regulated learning in a sample of high school students with ADHD (n = 32) compared to demographically similar classmates without ADHD (n = 18). A multimethod battery of self and parent rating scales and cognitive tasks measured aspects of intrinsic motivation, extrinsic motivation, and goal-directed executive functions. A multiple regression modeled predictors of current Grade Point Average (GPA). Results indicated that high school students with ADHD placed lower value on academics (d = .99), were less likely to use goal-setting strategies (d = .95), possessed lower levels of metacognition (d = 1.86), and showed significant deficits in task-based cognitive flexibility (d = .80). After controlling for covariates, the set of self-regulated learning variables explained 23% of the variance in GPA, with metacognition (6% of variance explained) and cognitive flexibility (7% of variance explained) serving as significant predictors of outcome. Findings suggest that higher-order executive function deficits play a critical role in the academic functioning of high school students and students with ADHD show large deficits in these areas. Thus, interventions that target metacognition and cognitive flexibility (i.e., the ability to think through decisions before acting, inhibit automatic responses, and make effective decisions for a desired goal) may be particularly promising to remediate ADHD-related academic problems in high school.