Fatigue in an adult attention deficit hyperactivity disorder population: A trans-diagnostic approach

Childhood neurodivergent traits, inflammation and chronic disabling fatigue in adolescence: a longitudinal case-control study

OBJECTIVES

To test whether inflammatory processes link the expression of childhood neurodivergent traits to chronic disabling fatigue in adolescence.

DESIGN

Longitudinal case-control study.

SETTING

We analysed data from The Avon Longitudinal Study of Parents and Children (ALSPAC).

PARTICIPANTS

8115 and 8036 children of the ALSPAC cohort at ages 7 and 9 years, respectively, 4563 of whom also completed self-report measures at age 18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

We assessed if children scoring above screening threshold for autism/attention deficit hyperactivity disorder (ADHD) at ages 7 and 9 years had increased risk of chronic disabling fatigue at age 18 years, computing ORs and CIs for effects using binary logistic regression. Mediation analyses were conducted to test if an inflammatory marker (interleukin 6 (IL-6)) at age 9 years linked neurodivergent traits to chronic disabling fatigue at age 18 years.

RESULTS

Children with neurodivergent traits at ages 7 and 9 years were two times as likely to experience chronic disabling fatigue at age 18 years (likely ADHD OR=2.18 (95% CI=1.33 to 3.56); p=0.002; likely autism OR=1.78 (95% CI=1.17 to 2.72); p=0.004). Levels of IL-6 at age 9 were associated with chronic disabling fatigue at age 18 (OR=1.54 (95% CI=1.13 to 2.11); p=0.006). Inflammation at age 9 years mediated effects of neurodivergent traits on chronic disabling fatigue (indirect effect via IL-6: ADHD b=1.08 (95% CI=1.01 to 1.15); autism b=1.06; (95% CI=1.03 to 1.10)). All effects remained significant when controlling for the presence of depressive symptoms.

CONCLUSIONS

Our results indicate higher risk of chronic disabling fatigue for children with neurodivergent traits, likely linked to higher levels of inflammation. The implementation of transdiagnostic screening criteria to inform support strategies to counteract risk early in life is recommended.

Development and validation of the ADHD Symptom and Side Effect Tracking - Baseline Scale (ASSET-BS): a novel short screening measure for ADHD in clinical populations

OBJECTIVE

The aim was to develop and test a novel screen of adult ADHD, with a specific focus on clinical use. We designed a series of three studies to accomplish this aim.

METHOD

Study One (n = 155) and Study Two (n = 591) collected data via surveys to conduct exploratory and confirmatory factor analyses, respectively. Study Three analyzed the scale's psychometrics in a clinical sample (n = 151).

RESULTS

Study One and Study Two identified a 10-item scale with a two-factor structure. Study Three found good discriminant validity, sensitivity = 80.0%, specificity = 80.2%, and convergent validity with both the Brown Executive Function/Attention Scales, r (131) = .76, p < .001, and the Conner's Adult ADHD Rating Scales r (131) = .71, p < .001.

CONCLUSION

The scale demonstrated effectiveness in screening for ADHD in a psychiatric outpatient population. Its results may be used to identify patients that may benefit from thorough ADHD diagnostic procedures.

Child Developmental MRI (CDM) project: protocol for a multi-centre, cross-sectional study on elucidating the pathophysiology of attention-deficit/hyperactivity disorder and autism spectrum disorder through a multi-dimensional approach

INTRODUCTION

Neuroimaging studies on attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) have demonstrated differences in extensive brain structure, activity and network. However, there remains heterogeneity and inconsistency across these findings, presumably because of the diversity of the disorders themselves, small sample sizes, and site and parameter differences in MRI scanners, and their overall pathogenesis remains unclear. To address these gaps in the literature, we will apply the travelling-subject approach to correct site differences in MRI scanners and clarify brain structure and network characteristics of children with ADHD and ASD using large samples collected in a multi-centre collaboration. In addition, we will investigate the relationship between these characteristics and genetic, epigenetic, biochemical markers, and behavioural and psychological measures.

METHODS AND ANALYSIS

We will collect resting-state functional MRI (fMRI) and T1-weighted and diffusion-weighted MRI data from 15 healthy adults as travelling subjects and 300 children (ADHD, n=100; ASD, n=100; and typical development, n=100) with multi-dimensional assessments. We will also apply data from more than 1000 samples acquired in our previous neuroimaging studies on ADHD and ASD.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Research Ethics Committee of the University of Fukui Hospital (approval no: 20220601). Our study findings will be submitted to scientific peer-reviewed journals and conferences.

Stress and work-related mental illness among working adults with ADHD: a qualitative study

BACKGROUND

Though many adults with ADHD underperform professionally, are more stressed, and have more days of sickness absence compared to adults without ADHD, few studies have explored the experience of working as an adult with ADHD. This study explores the general experience of working with ADHD, including stress and work-related mental illness.

METHODS

Semi-structured telephone interviews were conducted with 20 working adults with ADHD. Interview topics included how the ADHD diagnosis and/or symptoms of ADHD may have affected participants on the job, how work may have affected participants' well-being, and the need for support and accommodation. Qualitative content analysis was used to explore verbatim transcripts from the interviews.

RESULTS

The analysis yielded three themes that describe some of the challenges of working with ADHD: Working and living with ADHD, Needs, and Special abilities, with a total of eight subcategories. Subcategories were Specific challenges; Relationships and cooperation; Negative consequences; Planning, prioritization, organization, and structure; Support, interventions, accommodations, and aids; Openness, understanding, and acceptance; Strategies; Strengths and qualities.

CONCLUSION

Further knowledge about the challenges of working with ADHD is needed in workplaces; where organizational support is lacking, much in terms of accommodations and aids is up to the employee, and the disclosure of diagnoses may be associated with great dilemma.

The relationship between central fatigue and Attention Deficit/Hyperactivity Disorder of the inattentive type

Chronic fatigue and central fatigue with malaise significantly impair quality of life. Inattention caused by central fatigue is closely related to attention deficit/hyperactivity disorder (ADHD) symptoms, but the neurochemical mechanism of central fatigue remains hypothetical. The serotonin hypothesis of central fatigue was proposed first, serving as the central dogma for the molecular and neural mechanisms of central fatigue, and underpinning many studies. The tryptophan hypothesis was proposed because tryptophan released into the synaptic cleft of neurons in the brain coincides with and responds sensitively to development of fatigue. Tryptophan is highly bioactive, with brain concentrations of 50 to 200 times that of serotonin. The tryptophan-kynurenic acid-synergy hypothesis posits that central fatigue is not monocausal but a synergistic effect between tryptophan itself and its catabolite kynurenic acid. Central fatigue is associated with mental health problems and is a cause of inattention, thereby warranting scrutiny for its relationship with ADHD. Fatigability in ADHD is mediated by tryptophan, in which abnormal enhancement of the tryptophan-kynurenine-kynurenic acid pathway causes an imbalance in monoamine nervous system function. Notably, noradrenergic neuronal dysfunction is associated with the characteristic inattention of ADHD. Neutral amino acids such as branched-chain amino acids (BCAAs) can assist recovery from attentional and cognitive decline caused by central fatigue. Since they are transported by the same L-amino acid transporter as tryptophan, BCAAs compete with tryptophan to inhibit its brain uptake. Controlling central fatigue this way may improve attentional cognitive performance.

Work participation, sensory processing and sleep quality in adults with attention deficit hyperactive disorder

BACKGROUND: Although studies have indicated significant effects of attention-deficit hyperactive disorder (ADHD) on work participation, the mechanism underlying work participation of adults with ADHD is still unclear. OBJECTIVE: Following the World Health Organization’s international classification of functioning, disability, and health concepts, this study compares sensory processing and sleep quality (body functions) with work participation among adults with and without ADHD and examines predictive relationships among adults with ADHD. METHODS: Sixty-nine adults with ADHD and 52 matched controls completed a sociodemographic questionnaire, the Adult/Adolescent Sensory Profile, the Mini Sleep Questionnaire, and the Occupational Questionnaire. RESULTS: The ADHD group had significantly poorer body functions, sensory processing (i.e., low-registration, sensory-sensitivity, and sensation-avoiding patterns), sleep quality, and work performance compared to the control group (p <  .001). For adults with ADHD, sensory sensitivity accounted for 10.9%, and sleep quality accounted for 22.0%, of the variance in their work performance. CONCLUSIONS: The deficient body functions of adults with ADHD may affect their work performance and therefore should be considered in further research, as well as in clinical applications.

Eye Tracking During a Continuous Performance Test: Utility for Assessing ADHD Patients

OBJECTIVE

The use of continuous performance tests (CPTs) for assessing ADHD related cognitive impairment is ubiquitous. Novel psychophysiological measures may enhance the data that is derived from CPTs and thereby improve clinical decision-making regarding diagnosis and treatment. As part of the current study, we integrated an eye tracker with the MOXO-dCPT and assessed the utility of eye movement measures to differentiate ADHD patients and healthy controls.

METHOD

Adult ADHD patients and gender/age-matched healthy controls performed the MOXO-dCPT while their eye movements were monitored (n = 33 per group).

RESULTS

ADHD patients spent significantly more time gazing at irrelevant regions, both on the screen and outside of it, than healthy controls. The eye movement measures showed adequate ability to classify ADHD patients. Moreover, a scale that combined eye movement measures enhanced group prediction, compared to the sole use of conventional MOXO-dCPT indices.

CONCLUSIONS

Integrating an eye tracker with CPTs is a feasible way of enhancing diagnostic precision and shows initial promise for clarifying the cognitive profile of ADHD patients. Pending replication, these findings point toward a promising path for the evolution of existing CPTs.

The influence of nocebo information on fatigue and urge to stop: An experimental investigation

BACKGROUND AND OBJECTIVES

Fatigue is an adaptive state after prolonged effort and often goes hand in hand with changes in behavior and motivation, such as the urge to stop exerting further effort. However, fatigue may become chronic in nature, as seen in multiple psychiatric disorders and chronic diseases, thereby losing its adaptive function. The etiology of fatigue symptoms remains poorly understood. We aimed to investigate whether nocebo information about the fatigue inducing nature of a cognitive task may contribute to the experience of fatigue and the motivational urge to stop.

METHODS

Participants (N = 46) repeatedly rated currently experienced fatigue while engaging in cognitive effort (working memory task). Crucially, half of participants received nocebo instructions prior to this task, whereas the other half only received neutral information.

RESULTS

Over the entire sample, results showed an increase in fatigue and urge to stop as the task progressed. Crucially, participants in the nocebo condition reported a higher urge to stop throughout the task relative to participants in the neutral condition. No significant effects were found for fatigue. Interestingly however, after controlling for baseline differences between conditions in negative affect, there was a significant Condition*Task block interaction effect on fatigue.

LIMITATIONS

Limitations include the relatively short experimental protocol and the underrepresentation of male relative to female participants.

CONCLUSIONS

These findings suggest that heightened awareness among clinicians and therapists about potential nocebo effects in their communication is warranted.

Occupational experiences of college students with ADHD: A qualitative study

BACKGROUND

College students with attention deficit hyperactivity disorder (ADHD) face difficulties with occupational performance in many functional domains. Despite the broad literature on academic and psychosocial functions, there is a gap in knowledge regarding how these students experience participation in their various daily functions.

OBJECTIVE

Gaining a deeper understanding of the occupational experiences of college students with ADHD and exploring factors that facilitate or impede their occupational performance.

METHOD

Twenty college students with ADHD were interviewed using the Occupational Performance History Interview (OPHI-II). Qualitative content analysis was employed.

RESULTS

Six themes were found in relation to varied occupational domains: (1) Eating and meal preparation: Too little or too much; (2) Sleep: Not enough to 'recharge batteries'; (3) Medication management: Intense ambivalence; (4) Studying: Too hard, too effortful (5) Work: Need it and love it; and (6) Leisure: Desired yet absent. Each theme contained categories related to factors that influenced performance. Impeding factors included occupational demands, ADHD biological attributes, and personal beliefs. Facilitating factors included self-awareness, executive strategies, adaptive routines, and enabling social context.

CONCLUSIONS

College students with ADHD experience profound difficulties in occupational performance, yet variation occurs across domains, attributable to occupational, biological, psychological, and social factors. Results can inform tailored interventions supporting occupational performance in this population.

Sleep in adults with autism spectrum disorder and attention deficit/hyperactivity disorder: A systematic review and meta-analysis

Sleep-related problems have been frequently reported in neurodevelopmental disorders, with special emphasis in Autism Spectrum Disorder (ASD) and Attention Deficit/Hyperactivity Disorder (ADHD). The aim of the present study is to conduct a systematic review and meta-analysis on sleep disturbances in adults with ASD and/or ADHD (PROSPERO's CRD42019132916). PubMed and PsycINFO were searched for studies reporting data on sleep objective/subjective measures, as well as prevalence data of sleep disorders, in adults with ASD and/or ADHD. A manual search was conducted throughout reference lists of eligible studies. A total of 1126 studies and 66 references were identified by electronic and manual searches, respectively. Of these, 42 studies were included in the meta-analysis. Results showed that both disorders share a similar sleep-impaired profile with higher sleep onset latency, poorer sleep efficiency, greater number of awakenings during sleep, and a general lower self-perceived sleep quality compared with healthy controls. A higher proportion of N1 sleep was found in ASD participants, while a greater Periodic Limb Movements in Sleep is specific in ADHD adults. More studies are needed, especially those directly comparing ASD and ADHD participants. Controlling for medication, intellectual disability, and concurrent psychiatric disorders is mandatory.

Potential Role of Neuroactive Tryptophan Metabolites in Central Fatigue: Establishment of the Fatigue Circuit

Central fatigue leads to reduced ability to perform mental tasks, disrupted social life, and impaired brain functions from childhood to old age. Regarding the neurochemical mechanism, neuroactive tryptophan metabolites are thought to play key roles in central fatigue. Previous studies have supported the “tryptophan-serotonin enhancement hypothesis” in which tryptophan uptake into extensive brain regions enhances serotonin production in the rat model of exercise-induced fatigue. However, serotonin was transiently released after 30 minutes of treadmill running to exhaustion, but this did not reflect the duration of fatigue. In addition, as the vast majority of tryptophan is metabolized along the kynurenine pathway, possible involvement of the tryptophan-kynurenine pathway in the mechanism of central fatigue induction has been pointed out. More recently, our study demonstrated that uptake of tryptophan and kynurenine derived from the peripheral circulation into the brain enhances kynurenic acid production in rat brain in sleep deprivation–induced central fatigue, but without change in serotonin activity. In particular, dynamic change in glial-neuronal interactive processes within the hypothalamus-hippocampal circuit causes central fatigue. Furthermore, increased tryptophan-kynurenine pathway activity in this circuit causes reduced memory function. This indicates a major potential role for the endogenous tryptophan-kynurenine pathway in central fatigue, which supports the “tryptophan-kynurenine enhancement hypothesis.” Here, we review research on the basic neuronal mechanism underlying central fatigue induced by neuroactive tryptophan metabolites. Notably, these basic findings could contribute to our understanding of latent mental problems associated with central fatigue.

How do adolescents with ADHD perceive and experience stress? An interview study

Background: Attention-deficit/hyperactivity disorder (ADHD) is linked to high levels of perceived stress in adult populations. Thus, it is not surprising that stress managing techniques are being included in treatment protocols for adults with ADHD. There is, however, a paucity of studies on perceived stress in adolescents with ADHD.Aims: This study aims to explore how adolescents with ADHD perceive and experience stress (and stressors) using a qualitative approach.Methods: Explorative interviews were conducted with 20 adolescents (Mean age: 16.30) diagnosed with ADHD in conjunction with group treatment therapy. Data were analysed using qualitative content analysis.Results: Stress and ADHD, as well as stress, anxiety and ill-health, were described as closely intertwined. The result is presented in four categories: stress is often present, triggers of stress, stress affects daily life, and stress can be handled and prevented. A relation was found between stress and feelings of helplessness, ill-health and anxiety. Stress was viewed as being out of proportion with reality and was driven by such factors as ADHD symptoms, school demands, unpredictable situations and relational problems. Several negative consequences of stress were reported, including postponing schoolwork and the tendency to give up. Some participants also reported performing better when stressed. Accepting help from others, practising acceptance, settling down and controlling oneself, and planning in advance were seen as helpful stress managing techniques.Conclusions: Stress should be considered among other problems related to ADHD. Psychoeducation about stress, stress managing techniques and coaching should be included in the treatment of adolescents with ADHD.

Language of ADHD in Adults on Social Media

Objective: We computationally analyze the language of social media users diagnosed with ADHD to understand what they talk about, and how their language is correlated with users' characteristics such as personality and temporal orientation. Method: We analyzed approximately 1.3 million tweets written by 1,399 Twitter users with self-reported diagnoses of ADHD, comparing their posts with those used by a control set matched by age, gender, and period of activity. Results: Users with ADHD are found to be less agreeable, more open, to post more often, and to use more negations, hedging, and swear words. Posts are suggestive of themes of emotional dysregulation, self-criticism, substance abuse, and exhaustion. A machine learning model can predict which of these Twitter users has ADHD with an out-of-sample AUC of .836. Conclusion: Based on this emerging technology, conjectures of future uses of social media by researchers and clinicians to better understand the naturalistic manifestations and sequelae of ADHD.

Associations of fatigue and sleep disturbance with nine common mental disorders

OBJECTIVE

To investigate the contribution of nine mental/substance use disorders to fatigue and sleep disturbance.

METHODS

3620 Australians aged 18 years or older recruited from the general community via Facebook during January-February 2016 completed an online survey assessing demographic characteristics, diagnosed medical conditions and nine mental disorders. Outcome measures were Patient Reported Outcomes Measurement Information System (PROMIS®) fatigue and PROMIS sleep disturbance.

RESULTS

Overall, 56% of the sample met criteria for at least one mental disorder. Linear regression models of sleep disturbance revealed all mental disorders except obsessive compulsive disorder (β = 0.038) had independent associations with sleep disturbance, with generalised anxiety disorder (GAD) (β = 0.173), major depressive disorder (MDD) (β = 0.117) and post-traumatic stress disorder (PTSD) (β = 0.111) making the greatest contribution. Inclusion of fatigue in the model attenuated the effects of panic disorder, MDD and attention-deficit hyperactive disorder (ADHD) to non-significance. For the outcome of fatigue, GAD (β = 0.223), MDD (β = 0.176) and PTSD (β = 0.147) made the greatest contributions, although all disorders had significant independent relationships. After adjusting for sleep disturbance, all mental disorders continued to make a significant contribution except for alcohol use disorder and substance use disorder.

CONCLUSION

Sleep disturbance and fatigue have independent associations with many mental disorders after correcting for comorbidity and known confounds. The disorders providing the greatest contribution to sleep disturbance and fatigue were GAD and MDD. Sleep disturbance and fatigue may be appropriate transdiagnostic targets for improving symptoms and global functioning for people with mental disorders.

ADHD and lifestyle habits in Czech adults, a national sample

BACKGROUND

Adult attention-deficit/hyperactivity disorder (ADHD) has been added as a diagnosis to the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM5) in 2013, thus making ADHD, which has been classically known as a childhood disorder, a life-long disorder. Those suffering from the condition show very specific behavioral traits, which manifest as lifestyle habits; they also show comorbidities that can be the symptoms and/or consequences of certain lifestyles.

MATERIALS AND METHODS

The targeted population was adults aged 18-65 years. The total sample was 1,012 (507 males and 505 females). The Adult ADHD Self-Report Scale (ASRS V. 1.1) was administered to evaluate the current symptoms of ADHD and a questionnaire regarding lifestyles that are pertinent to ADHD, exercise, drug use, and diet.

RESULTS

An ASRS score of 4-6 points was found in 11.4% of the male population and 9.7% of the female population (5-6 points indicate very high-intensity symptoms). A score of 6, the highest intensity of symptomatology, was found in 1.18% of males and 0.99% of females. Gender differences in scores were not statistically significant. In terms of self-reported lifestyles, we calculated an ordered logistic regression and the odds ratios of those with ASRS scores >4. Those with higher ASRS scores had higher rates of self-reported unhealthy lifestyles and poor diets with high consumption of sweets. We also ascertained a paradoxical finding that is not in line with the current literature on the disorder - lower rates of cigarette smoking among people with higher ADHD symptomatology.

CONCLUSION

Several specific lifestyles were found to be associated with higher ADHD symptoms such as poor diet and cannabis use. Other factors classically associated with the disorder such as cocaine addiction and nicotinism were either insignificant or surprisingly less prominent among the Czech sample. However, ADHD-prone respondents reported to be more physically active, which fits the clinical picture of hyperactivity but contrasts with literature that reports sedentary ADHD lifestyle.