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Skoglund C, Sundström Poromaa I, Leksell D, Ekholm Selling K, Cars T, Giacobini M, Young S, Kopp Kallner H. Time after time: failure to identify and support females with ADHD - a Swedish population register study. J Child Psychol Psychiatry 2024; 65:832-844. [PMID: 38016697 DOI: 10.1111/jcpp.13920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) is associated with risk taking and negative health-related outcomes across the lifespan. Due to delay in referral and diagnostics, young females with ADHD may not be identified, nor appropriately supported by adequate interventions. METHODS A total of 85,330 individuals with ADHD, all of whom were residents in Stockholm County between January 01, 2011, and December 31, 2021, were included as participants in this population-based, cross-sectional cohort study. Population controls (n = 426,626) were matched by age, sex, and socioeconomic status (SES). Data was obtained from Regional Healthcare Data Warehouse of Region Stockholm (VAL) in Stockholm County. Exposure was ADHD-index, defined as the first record of either ICD-10 F90 diagnosis and/or ATC-code for stimulant or non-stimulant ADHD-medication during the study period. Primary outcome was age at ADHD-index. Secondary outcome measures were psychiatric comorbidity, pharmacological treatment, and health care utilization, prior to and after ADHD-index. RESULTS Females were older at ADHD-index (23.5 years, SD 13.8) compared to males (19.6 years, SD 13.9, 95% CI of difference 3.74-4.11). Overall, females with ADHD showed higher rates of psychiatric comorbidity, pharmacological treatment, and health care utilization, compared to males with ADHD and female controls. CONCLUSIONS Females with ADHD receive diagnosis and treatment for ADHD approximately 4 years later than males. They have a higher burden of comorbid psychiatric conditions and health care utilization, compared to males with ADHD and female controls, both prior to and after ADHD-index. To prevent long-term adverse consequences for females with ADHD, methods, and tools for early diagnosis and treatments that mitigate personal suffering and societal burden are warranted.
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Affiliation(s)
| | | | | | - Katarina Ekholm Selling
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Sence Research AB, Uppsala, Sweden
| | | | - Maibritt Giacobini
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- PRIMA Child and Adult Psychiatry, Stockholm, Sweden
| | - Susan Young
- Psychology Services Limited, London, UK
- Department of Psychology, University of Reykjavik, Reykjavik, Iceland
| | - Helena Kopp Kallner
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
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2
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Garcia-Argibay M, Brikell I, Thapar A, Lichtenstein P, Lundström S, Demontis D, Larsson H. Attention-Deficit/Hyperactivity Disorder and Major Depressive Disorder: Evidence From Multiple Genetically Informed Designs. Biol Psychiatry 2024; 95:444-452. [PMID: 37562520 DOI: 10.1016/j.biopsych.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/19/2023] [Accepted: 07/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) are two highly prevalent disorders that frequently co-occur. Prior evidence from genetic and cohort studies supports an association between ADHD and MDD. However, the direction and mechanisms underlying their association remain unclear. As onset of ADHD occurs in early life, it has been hypothesized that ADHD may cause MDD. METHODS We examined the association of ADHD with MDD using 3 different genetically informed methods to disentangle causality from confounding: 1) a nationwide longitudinal register-based full sibling comparison (N = 1,018,489) adjusting for shared familial confounding; 2) a prospective co-twin control study comprising 16,477 twins (5084 monozygotic and 11,393 dizygotic); and 3) a two-sample Mendelian randomization analysis using the largest available ADHD (N = 225,534) and MDD (N = 500,199) genome-wide association study summary statistics, adjusting for correlated and uncorrelated horizontal pleiotropy. RESULTS Sibling and twin comparisons indicated that individuals with ADHD have an increased risk for subsequent development of MDD (hazard ratio = 4.12 [95% CI 3.62-4.69]) after adjusting for shared genetic and familial factors and that ADHD scores endorsed by parents are positively associated with subsequent MDD scores at ages 15 and 18 years (b = 0.07 [95% CI 0.05-0.08] and b = 0.09 [95% CI 0.08-0.11], respectively). Mendelian randomization analyses showed that genetic liability for ADHD is causally related to MDD (odds ratio = 1.15 [95% CI 1.08-1.23]). CONCLUSIONS Our study provides consistent results across 3 different genetically informative approaches, strengthening the hypothesis that ADHD is causally related to MDD.
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Affiliation(s)
- Miguel Garcia-Argibay
- School of Medical Sciences, Örebro University, Faculty of Medicine and Health, Örebro, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Isabell Brikell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Anita Thapar
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, Cardiff University, Cardiff, United Kingdom
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Sebastian Lundström
- Gillberg Neuropsychiatry Centre, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Ditte Demontis
- Department of Biomedicine-Human Genetics, Aarhus University, Aarhus, Denmark; iPSYCH, Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus, Denmark; Center for Genomics and Personalized Medicine, Aarhus, Denmark
| | - Henrik Larsson
- School of Medical Sciences, Örebro University, Faculty of Medicine and Health, Örebro, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Garcia-Argibay M, Zhang-James Y, Cortese S, Lichtenstein P, Larsson H, Faraone SV. Predicting childhood and adolescent attention-deficit/hyperactivity disorder onset: a nationwide deep learning approach. Mol Psychiatry 2023; 28:1232-1239. [PMID: 36536075 PMCID: PMC10005952 DOI: 10.1038/s41380-022-01918-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/05/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
Attention-deficit/hyperactivity disorder (ADHD) is a heterogeneous disorder with a high degree of psychiatric and physical comorbidity, which complicates its diagnosis in childhood and adolescence. We analyzed registry data from 238,696 persons born and living in Sweden between 1995 and 1999. Several machine learning techniques were used to assess the ability of registry data to inform the diagnosis of ADHD in childhood and adolescence: logistic regression, random Forest, gradient boosting, XGBoost, penalized logistic regression, deep neural network (DNN), and ensemble models. The best fitting model was the DNN, achieving an area under the receiver operating characteristic curve of 0.75, 95% CI (0.74-0.76) and balanced accuracy of 0.69. At the 0.45 probability threshold, sensitivity was 71.66% and specificity was 65.0%. There was an overall agreement in the feature importance among all models (τ > .5). The top 5 features contributing to classification were having a parent with criminal convictions, male sex, having a relative with ADHD, number of academic subjects failed, and speech/learning disabilities. A DNN model predicting childhood and adolescent ADHD trained exclusively on Swedish register data achieved good discrimination. If replicated and validated in an external sample, and proven to be cost-effective, this model could be used to alert clinicians to individuals who ought to be screened for ADHD and to aid clinicians' decision-making with the goal of decreasing misdiagnoses. Further research is needed to validate results in different populations and to incorporate new predictors.
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Affiliation(s)
- Miguel Garcia-Argibay
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden. .,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | - Yanli Zhang-James
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samuele Cortese
- School of Psychology, University of Southampton, Southampton, UK.,Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK.,Solent NHS Trust, Southampton, UK.,Hassenfeld Children's Hospital at NYU Langone, New York University Child Study Center, New York City, New York, NY, USA.,Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Larsson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Stephen V Faraone
- Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA
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Halmøy A, Ring AE, Gjestad R, Møller M, Ubostad B, Lien T, Munkhaugen EK, Fredriksen M. Dialectical behavioral therapy-based group treatment versus treatment as usual for adults with attention-deficit hyperactivity disorder: a multicenter randomized controlled trial. BMC Psychiatry 2022; 22:738. [PMID: 36443712 PMCID: PMC9706966 DOI: 10.1186/s12888-022-04356-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/31/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Studies on structured skills training groups have indicated beneficial, although still inconclusive, effects on core symptoms of ADHD in adults. This trial examined effects of Dialectical Behavioral Therapy-based group treatment (DBT-bGT) on the broader and clinically relevant executive functioning and emotional regulation in adults with ADHD. METHODS In a multicenter randomized controlled trial, adult patients with ADHD were randomly assigned to receive either weekly DBT-bGT or treatment as usual (TAU) during 14 weeks. Subsequently, participants receiving TAU were offered DBT-bGT. All were reassessed six months after ended DBT-bGT. Primary outcomes were the Behavior Rating Inventory of Executive Function (BRIEF-A) and the Difficulties in Emotion Regulation Scale (DERS). Secondary outcomes included self-reported ADHD-symptoms, depressive and anxiety symptoms, and quality of life. We used independent samples t- tests to compare the mean difference of change from pre- to post-treatment between the two treatment groups, and univariate linear models adjusting for differences between sites. RESULTS In total, 121 participants (68 females), mean age 37 years, from seven outpatient clinics were included, of whom 104 (86%) completed the 14-week trial. Entering the study, 63% used medication for ADHD. Compared to TAU (n = 54), patients initially completing DBT-bGT (n = 50) had a significantly larger mean reduction on the BRIEF-A (-12.8 versus -0.37, P = 0.005, effect size 0.64), and all secondary outcomes, except for symptoms of anxiety. All significant improvements persisted at 6 months follow-up. Change on DERS did not differ significantly between the groups after 14 weeks, but scores continued to decrease between end of group-treatment and follow-up. CONCLUSIONS This DBT-bGT was superior to TAU in reducing executive dysfunction, core symptoms of ADHD and in improving quality of life in adults with ADHD. Improvements sustained six months after ended treatment. The feasibility and results of this study provide evidence for this group treatment as a suitable non-pharmacological treatment option for adults with ADHD in ordinary clinical settings. TRIAL REGISTRATIONS The study was pre-registered in the ISRCTN registry (identification number ISRCTN30469893, date February 19th 2016) and at the ClinicalTrials.gov (ID: NCT02685254, date February 18th 2016).
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Affiliation(s)
- Anne Halmøy
- Division of Psychiatry, Kronstad District Psychiatric Center, Haukeland University Hospital, 5021, Bergen, Norway. .,Department of Clinical Medicine, University of Bergen, 5020, Bergen, Norway.
| | - Anna Edith Ring
- grid.412008.f0000 0000 9753 1393Division of Psychiatry, Research Department, Haukeland University Hospital, 5021 Bergen, Norway
| | - Rolf Gjestad
- grid.412008.f0000 0000 9753 1393Division of Psychiatry, Research Department, Haukeland University Hospital, 5021 Bergen, Norway ,grid.412008.f0000 0000 9753 1393Center for Research and Education in Forensic Psychiatry, Haukeland University Hospital, 5021 Bergen, Norway
| | - Merete Møller
- grid.412938.50000 0004 0627 3923District Psychiatric Center, Østfold Hospital Trust, 1714 Grålum (Sarpsborg), Norway
| | - Bente Ubostad
- grid.412008.f0000 0000 9753 1393Regional Resource Center for Autism, AD/HD, and Tourettes Syndrome, Western Norway Regional Health Authority, Haukeland University Hospital, 5021 Bergen, Norway ,grid.417292.b0000 0004 0627 3659Division of Mental Health & Addiction, Vestfold Hospital Trust, 3101 Tønsberg, Norway
| | - Tage Lien
- grid.55325.340000 0004 0389 8485Regional Resource Center for Autism, AD/HD, and Tourettes Syndrome, South-Eastern Norway Regional Health Authority, Oslo University Hospital, 0424 Oslo, Norway
| | - Ellen Kathrine Munkhaugen
- grid.55325.340000 0004 0389 8485Regional Resource Center for Autism, AD/HD, and Tourettes Syndrome, South-Eastern Norway Regional Health Authority, Oslo University Hospital, 0424 Oslo, Norway ,grid.55325.340000 0004 0389 8485Norwegian National Advisory Unit On Mental Health in Intellectual Disabilities, Oslo University Hospital, 0424 Oslo, Norway
| | - Mats Fredriksen
- grid.417292.b0000 0004 0627 3659Division of Mental Health & Addiction, Vestfold Hospital Trust, 3101 Tønsberg, Norway
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Lindström T, Kierkegaard Suttner A, Forster M, Bölte S, Hirvikoski T. Is Parents' ADHD Symptomatology Associated With the Clinical Feasibility or Effectiveness of a Psychoeducational Program Targeting Their Children's ADHD? J Atten Disord 2022; 26:1653-1667. [PMID: 35491992 PMCID: PMC9373197 DOI: 10.1177/10870547221092120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine if the clinical feasibility and effectiveness of a psychoeducational program targeting children's ADHD differ between parents with varying ADHD symptom severities. METHOD An open trial analyzed data from 549 parents of children with ADHD aged 3 to 17 years, who participated in psychoeducation at an outpatient habilitation/disability clinic. In all analyses, parents were stratified into three symptom severity groups (low/middle/high) based on scores on an ADHD screening scale. RESULTS Parental ADHD symptom severity was not associated with results on any outcome, although the odds of having incomplete data were higher in parents reporting higher symptom severity. Across the entire sample, we observed high program completion rates, positive acceptability ratings and large increases in parental knowledge. CONCLUSIONS Psychoeducation may be beneficial regardless of the participating parent's ADHD symptomatology. Further research is needed to examine whether these results are generalizable to parents diagnosed with ADHD, an underrepresented group in our study.
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Affiliation(s)
- Therese Lindström
- Karolinska Institutet and Stockholm
Health Care Services, Region Stockholm, Stockholm, Sweden,Stockholm Health Care Services, Region
Stockholm, Sweden,Therese Lindström, Child and Adolescent
Psychiatry Research Center, Center of Neurodevelopmental Disorders at Karolinska
Institutet (KIND), Gävlegatan 22B, Stockholm 113 30, Sweden.
| | - Axel Kierkegaard Suttner
- Karolinska Institutet and Stockholm
Health Care Services, Region Stockholm, Stockholm, Sweden,Stockholm Health Care Services, Region
Stockholm, Sweden
| | | | - Sven Bölte
- Karolinska Institutet and Stockholm
Health Care Services, Region Stockholm, Stockholm, Sweden,Stockholm Health Care Services, Region
Stockholm, Sweden,Curtin University, Perth, WA,
Australia
| | - Tatja Hirvikoski
- Karolinska Institutet and Stockholm
Health Care Services, Region Stockholm, Stockholm, Sweden,Stockholm Health Care Services, Region
Stockholm, Sweden
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Becker S, Sharma MJ, Callahan BL. ADHD and Neurodegenerative Disease Risk: A Critical Examination of the Evidence. Front Aging Neurosci 2022; 13:826213. [PMID: 35145394 PMCID: PMC8822599 DOI: 10.3389/fnagi.2021.826213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/28/2021] [Indexed: 11/29/2022] Open
Abstract
In this review, we undertake a critical appraisal of eight published studies providing first evidence that a history of attention-deficit/hyperactivity disorder (ADHD) may increase risk for the later-life development of a neurodegenerative disease, in particular Lewy body diseases (LBD), by up to five-fold. Most of these studies have used data linked to health records in large population registers and include impressive sample sizes and adequate follow-up periods. We identify a number of methodological limitations as well, including potential diagnostic inaccuracies arising from the use of electronic health records, biases in the measurement of ADHD status and symptoms, and concerns surrounding the representativeness of ADHD and LBD cohorts. Consequently, previously reported risk associations may have been underestimated due to the high likelihood of potentially missed ADHD cases in groups used as “controls”, or alternatively previous estimates may be inflated due to the inclusion of confounding comorbidities or non-ADHD cases within “exposed” groups that may have better accounted for dementia risk. Prospective longitudinal studies involving well-characterized cases and controls are recommended to provide some reassurance about the validity of neurodegenerative risk estimates in ADHD.
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Affiliation(s)
- Sara Becker
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Manu J. Sharma
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Brandy L. Callahan
- Department of Psychology, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- *Correspondence: Brandy L. Callahan
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