Annual Research Review: Attention-deficit/hyperactivity disorder in girls and women: underrepresentation, longitudinal processes, and key directions

Reciprocal relations between dimensions of attention-deficit/hyperactivity and anxiety disorders from preschool age to adolescence: sex differences in a birth cohort sample

BACKGROUND

Symptoms of anxiety and attention-deficit/hyperactivity disorder (ADHD) are prospectively related from childhood to adolescence. However, whether the two dimensions of ADHD-inattention and hyperactivity-impulsivity-are differentially related to anxiety and whether there are developmental and sex/gender differences in these relations are unknown.

METHODS

Two birth cohorts of Norwegian children were assessed biennially from ages 4 to 16 (N = 1,077; 49% girls) with diagnostic parent interviews used to assess symptoms of anxiety and ADHD. Data were analyzed using a random intercept cross-lagged panel model, adjusting for all unobserved time-invariant confounding effects.

RESULTS

In girls, increased inattention, but not hyperactivity-impulsivity, predicted increased anxiety 2 years later across all time-points and increased anxiety at ages 12 and 14 predicted increased inattention but not hyperactivity-impulsivity. In boys, increased hyperactivity-impulsivity at ages 6 and 8, but not increased inattention, predicted increased anxiety 2 years later, whereas increased anxiety did not predict increased inattention or hyperactivity-impulsivity.

CONCLUSIONS

The two ADHD dimensions were differentially related to anxiety, and the relations were sex-specific. In girls, inattention may be involved in the development of anxiety throughout childhood and adolescence and anxiety may contribute to girls developing more inattention beginning in early adolescence. In boys, hyperactivity-impulsivity may be involved in the development of anxiety during the early school years. Effective treatment of inattention symptoms in girls may reduce anxiety risk at all time-points, while addressing anxiety may decrease inattention during adolescence. Similarly, treating hyperactivity-impulsivity may reduce anxiety risk in boys during late childhood (at ages 8-10).

A Qualitative Analysis of Perspectives on Self-directed Violence in a Prospective Longitudinal Study of Young Women With and Without Childhood ADHD

OBJECTIVE

Non-suicidal self-directed violence (NSSDV) is a significant and growing youth public health crisis. Girls with ADHD are at increased risk of engaging in NSSDV, yet qualitative studies with this population-to better understand manifestations, motivations, and developmental course-are lacking.

METHOD

We conducted semi-structured, qualitative interviews with a sub-sample of 57 young women (32 with childhood ADHD, 25 neurotypical comparisons; mean age of 27 years, part of a larger prospective longitudinal study) regarding histories and manifestations of NSSDV.

RESULTS

Inductive and deductive analysis revealed several key themes, including self-perceived reasons for engaging in NSSDV (affect regulation, attention seeking, self-punishment, asserting control), impulsivity, secretiveness, and in some cases motivations for desistance.

CONCLUSION

Findings underscore the importance of early education and screening, especially among high-risk clinical populations. Increased resources and supports for professionals, parents, and peers are indicated, along with countering the persistent stigma associated with ADHD and NSSDV.

The Development and Content Validation of a Clinical Screening Scale to Identify Attention-Deficit Hyperactivity Disorder Cases Based on the Gender Perspective: An e-Delphi Study

BACKGROUND

Although many studies analyse gender differences in the clinical expression of Attention-Deficit Hyperactivity Disorder (ADHD) and prevalence studies show that girls with ADHD are underdiagnosed, there are no instruments that are sensitive to the detection of girls with ADHD.

OBJECTIVE

The objective of this study is to develop a self-report early detection instrument for boys and girls with ADHD aged 7 to 16, which includes the gender perspective and is sensitive to the detection of girls with ADHD.

METHODS

The scale was developed and the items that comprised it were created from the thematic analysis of ADHD and its evaluation in children based on the diagnostic criteria of the DSM-5-TR. A modified e-Delphi method involving a three-round web survey was used to establish a consensus on the content of the scale. Ten experts were recruited to form a professional panel. The panel members were asked to assess the differential symptomatology of ADHD in boys and girls, the dimensions to be evaluated, and the importance of scale items to evaluate the content.

RESULTS

A consensus was reached regarding 13 total items distributed in three dimensions: inattention; hyperactivity/impulsivity; and, a third dimension, internalisation, which includes symptoms most present in the expression of ADHD in girls.

CONCLUSIONS

To the best of our knowledge, the development of this scale using the Delphi method is the first specific scale used for identifying ADHD that also addresses the gender perspective and the differential symptomatology between boys and girls. However, we must proceed to the analysis of psychometric properties, as the scale requires an exhaustive study of its reliability and validity. We can anticipate that this scale will provide relevant and reliable information that can be used for the identification of ADHD in both boys and girls.

Longitudinal study on all-cause and suicide mortality among individuals with attention deficit hyperactivity disorder

BACKGROUND

Previous research has linked attention deficit hyperactivity disorder (ADHD) with an increased risk of all-cause mortality, primarily owing to unnatural causes such as accidents and suicides. This increase may be attributable to the co-occurrence of major psychiatric disorders, including schizophrenia (SCZ), bipolar disorder (BD), major depressive disorder (MDD), autism spectrum disorder (ASD), anxiety disorders, substance use disorders (SUDs), and personality disorders (PDs). This study examined the all-cause and specific-cause mortality rates in individuals with ADHD and the influence of psychiatric comorbidities.

METHODS

Between 2003 and 2017, 1.17 million individuals were enrolled in the study, of which 233,886 received a diagnosis of ADHD from the Taiwan's National Health Insurance Research Database. A 1:4 sex- and birth year-matched control group without ADHD was also included. Hazard ratios (HRs) for mortality rates were estimated between groups after adjusting for demographic data.

RESULTS

During the follow-up period, 781 individuals with ADHD died. The HR for all-cause mortality was 1.45 (95% confidence interval [CI]: 1.30-1.61), largely owing to unnatural causes, particularly suicide. Suicide rates were particularly high in individuals with ADHD and psychiatric comorbidities: the HRs for suicide were 47.06 in ADHD with SUDs (95% CI: 6.12-361.99), 32.02 in ADHD with SCZ (7.99-128.29), 23.60 in ADHD with PDs (7.27-76.66), 10.11 in ADHD with anxiety disorders (5.74-17.82), 9.30 in ADHD with BD (4.48-19.33), 8.36 in ADHD with MDD (5.66-12.35), and 6.42 in ADHD with ASD (1.83-22.53) relative to ADHD only.

DISCUSSION

ADHD was associated with increased mortality rates, primarily owing to suicide. The presence of major psychiatric comorbidities was associated with a further increase in suicide mortality risk.

Sex and intelligence quotient differences in age of diagnosis among youth with attention-deficit hyperactivity disorder

OBJECTIVES

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental condition and is characterized by inattention, hyperactivity, and impulsivity. Research suggests that some populations, such as females and individuals with high intelligence quotients may be a risk for late ADHD diagnosis and subsequent treatment. Our goal is to advance our understanding of ADHD diagnosis, by examining (1) how child sex and cognitive abilities together are related to the age of diagnosis and (2) whether symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis.

METHODS

Our analyses contained children who completed the required tests (N = 568) from a pre-existing dataset of 1380 children with ADHD from the Province of Ontario Neurodevelopmental Disorders (POND) Network (pond-network.ca). First, we conducted a moderation analysis with sex as the predictor, cognitive abilities as the moderator, and age of diagnosis as the outcome. Second, we conducted correlation analyses examining how symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis.

RESULTS

Higher IQ was related to a later age of diagnosis. Higher hyperactive-impulsive symptoms and externalizing symptoms were related to an earlier age of diagnosis. Internalizing symptoms were trend associated with a later age of diagnosis in girls. Higher socioeconomic status and non-White maternal ethnicity were related to later age of diagnosis.

CONCLUSIONS

IQ, sex, ADHD symptomology, internalizing symptoms, externalizing symptoms, and socio-demographic factors affect the age of diagnosis.

Associations between Computationally Derived Parent Emotional Sentiment Scores and Child ADHD and ODD Over Time

Family emotional climate is often assessed as expressed emotion (EE) using the five-minute speech sample (FMSS). Parent EE is related to child externalizing behavior, but the relationship with ADHD apart from externalizing is unclear. We report the largest ADHD-non-ADHD study of EE to date, introduce computational scoring of the FMSS to assay parent negative sentiment, and use this to evaluate reciprocal parent-child effects over time in ADHD while considering comorbid ODD. Parents of 810 children (nADHD = 509), aged 7-13 years old, completed the FMSS at three points. The FMSS was expert-coded for EE-Criticism at Time 1 and Time 2, negative sentiment was scored at all three time points. Sentiment and EE-Criticism were moderately correlated (r =.39, p <.001, 95% CI [0.32, 0.46]), and each was similarly correlated with baseline ADHD symptoms (r's range 0.31-0.33, p <.001) and ODD symptoms (r(ODD-EE) = 0.35, p <.001; r(ODD-sentiment = 0.28, p <.001). A longitudinal, cross-lagged panel model revealed that increases over time in parental negative sentiment scores led to increased ODD symptoms. Parent sex (namely fathers, but not mothers) showed an interaction effect of sentiment with ADHD. ADHD and ODD are independently and jointly associated with parental EE-Criticism and negative sentiment assessed by the FMSS cross-sectionally. A recursive effects model is supported for ODD, but for ADHD effects depend on which parent is assessed. For fathers, ADHD was related to negative sentiment in complex manners but for mothers, negative sentiment was related primarily to ODD.

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.

A transdiagnostic examination of cognitive heterogeneity in children and adolescents with neurodevelopmental disorders

Children and adolescents with neurodevelopmental disorders demonstrate extensive cognitive heterogeneity that is not adequately captured by traditional diagnostic systems, emphasizing the need for alternative assessment and classification techniques. Using a transdiagnostic approach, a retrospective cohort study of cognitive functioning was conducted using a large heterogenous sample (n = 1529) of children and adolescents 7 to 18 years of age with neurodevelopmental disorders. Measures of short-term memory, verbal ability, and reasoning were administered to participants with attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), comorbid ADHD/ASD, and participants without neurodevelopmental disorders (non-NDD) using a 12-task, web-based neurocognitive testing battery. Unsupervised machine learning techniques were used to create a self-organizing map, an artificial neural network, in conjunction with k-means clustering to identify data-driven subgroups. The study aims were to: 1) identify cognitive profiles in the sample using a data-driven approach, and 2) determine their correspondence with traditional diagnostic statuses. Six clusters representing different cognitive profiles were identified, including participants with varying forms of cognitive impairment. Diagnostic status did not correspond with cluster-membership, providing evidence for the application of transdiagnostic approaches to understanding cognitive heterogeneity in children and adolescents with neurodevelopmental disorders. Additionally, the findings suggest that many typically developing participants may have undiagnosed learning difficulties, emphasizing the need for accessible cognitive assessment tools in school-based settings.

Highly Involved Parenting of Adolescents With ADHD: Examination of the Psychometric Properties of a Measure of "Helicopter Parenting"

OBJECTIVE

The concept of the "helicopter parent" was popularized in the 2000s and 2010s by Western culture, and it has recently begun to be examined by researchers to describe parental over-involvement and intrusive behavior that impedes transition into adulthood. Research has yet to investigate the viability of this construct for adolescents when parenting is needed to facilitate the development of autonomy. The present study examined the psychometric structure of a modified "helicopter parenting" measure adapted for use in a sample with increased likelihood of highly involved parenting: adolescents with ADHD.

METHODS

Adolescents (n = 333; age 13-18 years; 25% female) and their parents (n = 341, 91% female) completed a survey for a study on provider training in stimulant diversion prevention in 2016 and 2017. We modified a previously validated measure of "helicopter parenting" for young adults. Other previously established parenting measures were included. We conducted principal component analysis for both informants' reports of the modified measure. We examined associations between the components and informants' demographic characteristics and parenting measures to begin to examine convergent and discriminant validity.

RESULTS

Two components were identified for adolescent and parent reports and labeled parental Intervention and Day-to-day Monitoring and Planning. These components were differentially associated with demographic characteristics and other measures of parenting. For example, across reporters, parents exhibited less Day-to-Day Monitoring and Planning for older adolescents. Racially/ethnically minoritized parents and male adolescents reported more Intervention parenting. Modest-sized statistically significant associations were found between these indicators of highly involved parenting and the other measures of parenting.

CONCLUSION

Findings provide initial evidence of construct validity. Future work with more heterogeneous samples should examine if this measure captures adaptive parenting, or behaviors that interfere with developing independence, for adolescents with ADHD and neurotypically developing adolescents.

Assessing adherence and clinical utility of modified goal management training for adolescents with ADHD: A pilot study

Many adolescents with attention-deficit hyperactivity disorder (ADHD) have executive functioning (EF) difficulties that contribute to academic and social-emotional challenges. This pilot explored adherence to and effectiveness of modified Goal Management Training (GMT), an EF intervention, with ADHD youth. Six adolescents with ADHD (14-17 years, 2 female) participated in a 6-session online group. Adherence was tracked via attendance and homework. Reliable change scores gaged pre-post differences on measures before and after training (primary: everyday EF and goal attainment; secondary: EF task performance, functional impairment, emotional adjustment, and self-concept). All youth attended at least 4 sessions, though homework completion was mixed. Four youth achieved their goal, some demonstrated reliable change on outcome measures, and all evidenced a reduction in impairment. Results support the feasibility of modified GMT in adolescents with ADHD and suggest that youth may benefit from this more personalized and holistic approach to EF intervention.

Comorbid Attention Deficit Hyperactivity Disorder in Women with Premenstrual Dysphoric Disorder

Background: This study evaluated the associations between inattention, impulsivity, and attention deficit hyperactivity disorder (ADHD) in women with premenstrual dysphoric disorder (PMDD) across the menstrual cycle. Methods: This study enrolled 58 women with PMDD and 50 controls. Symptoms were assessed using the Attention and Performance Self-Assessment Scale and the Dickman Impulsivity Inventory during the pre-ovulatory (PO), mid-luteal (ML), and late luteal (LL) phases of the menstrual cycle. Results: The chi-square analysis revealed a significant association between ADHD and PMDD. Women with PMDD experienced a greater increase in scores of prospective everyday memory problems and difficulties maintaining focused attention from the PO phase to LL phase than the controls; in addition, they had higher scores in dysfunctional impulsivity during the LL phase than the controls. Among women in the PMDD group, those with ADHD had higher scores in prospective everyday memory problems and dysfunctional impulsivity during the PO and ML phases than those without ADHD. Women in the PMDD group without ADHD had a greater increase in scores of prospective everyday memory problems, difficulties maintaining focused attention, and dysfunctional impulsivity from the PO phase to the LL phase than the controls. Conclusion: Our study demonstrated that women with PMDD were more likely to have comorbid ADHD and higher levels of inattention across the menstrual cycle. PMDD was associated with increased impulsivity during the LL phase, independent of ADHD, but it was not associated with a persistent elevation of impulsivity. Furthermore, PMDD women with comorbid ADHD experienced higher inattention and impulsivity during the PO and ML phases than those without it. Thus, ADHD comorbidity should be assessed when assessing or intervening in the symptoms of inattention and impulsivity in women with PMDD.

Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021

OBJECTIVE

To characterize provider types delivering outpatient care overall and through telehealth to U.S. adults with ADHD.

METHOD

Using employer-sponsored insurance (ESI) and Medicaid claims, we identified enrollees aged 18 to 64 years who received outpatient care for ADHD in 2021. Billing provider codes were used to tabulate the percentage of enrollees receiving ADHD care from 10 provider types overall and through telehealth.

RESULTS

Family practice physicians, psychiatrists, and nurse practitioners/psychiatric nurses were the most common providers for adults with ESI, although the distribution of provider types varied across states. Lower percentages of adults with Medicaid received ADHD care from physicians. Approximately half of adults receiving outpatient ADHD care received ADHD care by telehealth.

CONCLUSION

Results may inform the development of clinical guidelines for adult ADHD and identify audiences for guideline dissemination and education planning.

The distribution of parent-reported attention-deficit/hyperactivity disorder and subclinical autistic traits in children with and without an ADHD diagnosis

Background

Autistic traits are often reported to be elevated in children diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, the distribution of subclinical autistic traits in children with ADHD has not yet been established; knowing this may have important implications for diagnostic and intervention processes. The present study proposes a preliminary model of the distribution of parent-reported ADHD and subclinical autistic traits in two independent samples of Australian children with and without an ADHD diagnosis.

Methods

Factor mixture modelling was applied to Autism Quotient and Conners' Parent Rating Scale - Revised responses from parents of Australian children aged 6-15 years who participated in one of two independent studies.

Results

A 2-factor, 2-class factor mixture model with class varying factor variances and intercepts demonstrated the best fit to the data in both discovery and replication samples. The factors corresponded to the latent constructs of 'autism' and 'ADHD', respectively. Class 1 was characterised by low levels of both ADHD and autistic traits. Class 2 was characterised by high levels of ADHD traits and low-to-moderate levels of autistic traits. The classes were largely separated along diagnostic boundaries. The largest effect size for differences between classes on the Autism Quotient was on the Social Communication subscale.

Conclusions

Our findings support the conceptualisation of ADHD as a continuum, whilst confirming the utility of current categorical diagnostic criteria. Results suggest that subclinical autistic traits, particularly in the social communication domain, are unevenly distributed across children with clinically significant levels of ADHD traits. These traits might be profitably screened for in assessments of children with high ADHD symptoms and may also represent useful targets for intervention.

Early childhood exposures to phthalates in association with attention-deficit/hyperactivity disorder behaviors in middle childhood and adolescence in the ReCHARGE study

BACKGROUND

Early-life exposure to phthalates alters behaviors in animals. However, epidemiological evidence on childhood phthalate exposure and attention-deficit/hyperactivity disorder (ADHD) behaviors is limited.

METHODS

This study included 243 children from the ReCHARGE (Revisiting Childhood Autism Risks from Genetics and Environment) study, who were previously classified as having autism spectrum disorder (ASD), developmental delay, other early concerns, and typical development in the CHARGE case-control study. Twenty phthalate metabolites were measured in spot urine samples collected from children aged 2-5 years. Parents reported on children's ADHD symptoms at ages 8-18 years using Conners-3 Parent Rating Scale. Covariate-adjusted negative binomial generalized linear models were used to investigate associations between individual phthalate metabolite concentrations and raw scores. Weighted quantile sum (WQS) regression with repeated holdout validation was used to examine mixture effects of phthalate metabolites on behavioral scores. Effect modification by child sex was evaluated.

RESULTS

Among 12 phthalate metabolites detected in >75% of the samples, higher mono-2-heptyl phthalate (MHPP) was associated with higher scores on Inattentive (β per doubling = 0.05, 95% confidence interval [CI]: 0.02, 0.08) and Hyperactive/Impulsive scales (β = 0.04, 95% CI: 0.00, 0.07), especially among children with ASD. Higher mono-carboxy isooctyl phthalate (MCiOP) was associated with higher Hyperactivity/Impulsivity scores (β = 0.07, 95% CI: -0.01, 0.15), especially among typically developing children. The associations of the molar sum of high molecular weight (HMW) phthalate metabolites and a phthalate metabolite mixture with Hyperactivity/Impulsivity scores were modified by sex, showing more pronounced adverse associations among females.

CONCLUSION

Exposure to phthalates during early childhood may impact ADHD behaviors in middle childhood and adolescence, particularly among females. Although our findings may not be broadly generalizable due to the diverse diagnostic profiles within our study population, our robust findings on sex-specific associations warrant further investigations.

ADHD Symptoms in Childhood and Big Five Personality Traits in Adolescence: A Five-Year Longitudinal Study in Girls

Attention-deficit/hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental condition characterized by developmentally extreme and impairing symptoms of inattention and/or hyperactivity/impulsivity. Great interest has emerged in the ways ADHD and its underlying symptom dimensions relate to the development of personality traits. Much extant research on this topic is cross-sectional, relying on self-report measures and male samples. Herein, we present data from a prospective, longitudinal study of a socioeconomically and racially diverse sample of girls, including those with ADHD and a matched neurotypical comparison sample. We examined how parent- and teacher-reported ADHD in middle childhood relate to self-reported Big Five personality traits in adolescence. As expected, childhood ADHD diagnosis prospectively predicted lower self-reported Conscientiousness, lower Agreeableness, and higher Neuroticism in adolescence. With ADHD diagnosis covaried, Inattention (IA) predicted only low Conscientiousness, Hyperactivity/Impulsivity (HI) predicted only low Agreeableness, and neither predicted adolescent Neuroticism. An exploratory moderator analysis showed that family income moderated the effects of IA and HI on the negativity of adolescent self-descriptions of their own personalities, with more pronounced negative effects for girls in families with higher (rather than lower) income. Familial pressures to achieve in higher-income families may be linked to more pronounced negative ramifications of ADHD on personality development.

Relations Between Social Camouflaging, Life Satisfaction, and Depression Among Polish Women with ADHD

BACKGROUND

This study investigated the relationship between social camouflaging, life satisfaction, and depression symptoms in Polish women with ADHD. It aimed to fill a research gap in understanding ADHD manifestations in women, particularly focusing on social camouflaging-a concept known in autism, referring to strategies used to mask symptoms in social interactions.

METHODS

A total of 329 women with ADHD took part in an online survey. The survey measured ADHD symptoms using the ADHD Self Report Scale (ASRS-vI.I), life satisfaction with the Satisfaction With Life Scale (SWLS), and depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9). Additionally, a novel set of questions, inspired by the Camouflaging Autistic Traits Questionnaire (CAT-Q) but tailored for ADHD, was utilized to assess social camouflaging.

RESULTS

Results indicated a significant negative association between social camouflaging and life satisfaction and a positive correlation with depressive symptoms, even after controlling for demographic variables. Additionally, factors like being in a relationship and having a positive subjective financial situation correlated with higher well-being.

LIMITATIONS

Reliance on self-report measures, the cross-sectional design, and participants' self-reported ADHD diagnosis are the main limitations of the study.

CONCLUSION

The research underscores the importance of social camouflaging in understanding ADHD in women, suggesting that efforts to mask symptoms and meet societal expectations may link to lower life satisfaction and increased depressive symptoms. These findings advocate for continued research into these dynamics to develop more effective support for women with ADHD.

Sex Differences in Children with Uncomplicated Attention Deficit/Hyperactivity Disorder and Sleep Problems

BACKGROUND

Approximately 7.6% of children are diagnosed with attention deficit/hyperactivity disorder (ADHD), and sleep impairments affect 25-85%. There is a noticeable lack of research on girls and sex differences. The aim of this study was to examine sex differences in children with uncomplicated ADHD and sleep problems.

METHODS

Cross-sectional baseline data were retrieved from a randomized controlled trial with weighted blankets (55 boys and 41 girls, 6-14 years) on a cohort recently diagnosed with uncomplicated ADHD and sleep problems. Differences between boys and girls in ADHD symptoms, objectively and subjectively measured sleep, anxiety, and functioning were examined via parent- or self-reported validated instruments.

RESULTS

Girls reported significantly lower (worse) satisfaction with well-being, life overall, and school, but not for family. Parents reported more sleep anxiety and night-time wakings among boys, but no sex differences in other measures and also not in self-reported measures or objective sleep measures. Children who reported worry, sadness, or unhappiness had more sleep problems.

CONCLUSIONS

Boys with ADHD and sleep problems may need support with sleep-related anxiety and night-time wakings, while girls may require support with overall functioning. Additionally, children who express feelings of worry, sadness, or unhappiness alongside their ADHD symptoms should have attention given to their sleep.

Sex Differences in Diagnosis and Treatment Timing of Comorbid Depression/Anxiety and Disease Subtypes in Patients With ADHD: A Database Study

OBJECTIVE

Our study examined the impact of sex, ADHD subtype, and comorbid illnesses (depression/anxiety) on the timing of diagnosis and treatment for ADHD.

METHOD

To analyze ADHD patients, four health databases were used to assess subtype, comorbid mood, and antidepressant or anxiolytic drug exposure. Analyses were stratified by sex and age. Standardized mean differences measured intergroup differences.

RESULTS

Females with ADHD were identified at older ages and had higher rates of depression and anxiety diagnoses and treatments before and after their initial ADHD diagnosis. Predominantly inattentive ADHD patients were diagnosed later and more likely to receive mood disorder diagnosis and treatment than hyperactive impulsive ADHD patients.

CONCLUSIONS

Results suggest a more complex ADHD presentation in females, potentially causing late diagnosis and delayed treatment.

The Chinese Version of the Compensatory ADHD Behaviors Scale (CABS): A Study on Reliability, Validity, and Clinical Utility

Purpose

With the further development of attention-deficit/hyperactivity disorder (ADHD) research, more and more assessment tools related to ADHD have been used. However, there is still no measurement instrument to evaluate the compensatory behavior of ADHD in China. This study aimed to examine the reliability and validity of the Compensatory ADHD Behaviors Scale (CABS) adapted in Chinese and explore ecological characteristics in adults with ADHD using the CABS.

Patients and Methods

Data were collected from a sample of 306 adults (Mage = 26.43 years, SD = 5.32; 46.08% male). The original version CABS was translated into Chinese using the forward and backward translation procedures. Participants completed the CABS and questionnaires assessing ADHD symptoms and executive function. We utilized content validity, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and criterion validity to test the validity. Internal consistency and test-retest reliability were employed to test the reliability. Analysis of variance (ANOVA) was employed to compare ADHD subgroups based on gender, ADHD subtype, comorbidities, and medication status, while controlling for demographic variables as covariates.

Results

CABS exhibited good construct validity (two factors: present-oriented and future-oriented), content validity (content validity index: 0.98), internal consistency reliability (Cronbach's alpha coefficient: 0.85 to 0.87) and test-retest reliability (intraclass correlation coefficient: 0.59 to 0.88). The results of CFA showed acceptable fitness for each subscale. CABS demonstrated significant associations with inattention symptoms and plan/organizational abilities. Medicated ADHD individuals scored higher on future-oriented effectiveness subscale of CABS than non-medicated (F = 6.106, p = 0.014).

Conclusion

The results indicate that the Chinese CABS exhibited good validity and reliability. It can be considered a valid tool for assessing compensatory behaviors in Chinese adults with ADHD. Further research is needed to explore the connection between medication and compensatory behavior.

Self-Esteem in Adults With ADHD Using the Rosenberg Self-Esteem Scale: A Systematic Review

OBJECTIVE

To summarize and analyze recent articles investigating self-esteem in adults with ADHD, focusing on the impact of demographic and clinical characteristics, and methodological issues.

METHOD

Following PRISMA guidelines, a systematic search for literature published between 2010 and 2022 was conducted in the Web of Science, Ovid, Pubmed, and EBSCO databases.

RESULTS

Eleven studies met inclusion criteria. Five of the six studies including healthy controls reported lower self-esteem in participants with ADHD. ADHD symptoms correlated negatively with self-esteem. Gender differences were not observed. Self-esteem mediated several outcomes associated with ADHD. There was a lack of studies that examined potential mechanisms behind the reduced self-esteem, and studies controlling for confounding variables.

CONCLUSION

A robust association between ADHD and low self-esteem in adults emerged, but the lack of control of confounding variables is critical to consider when interpreting the findings. Longitudinal studies addressing the limitations of the current studies are needed.

ADHD Prevalence Rose, Yet Disparities Remain: Commentary on the 2022 National Survey of Children's Health

This is a commentary on Danielson and colleagues' report entitled "ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment," which provides updated prevalence rates related to ADHD diagnosis and treatment utilization using data from the 2022 National Survey of Children's Health (NSCH). This timely article is among the first to report on ADHD prevalence rates since the COVID-19 pandemic, and highlights important patterns related to ADHD diagnosis and treatment utilization. In this commentary, we contextualize these findings with consideration to the COVID-19 pandemic and within the existing literature on health disparities among youth with ADHD and their families. We end with recommendations for future work involving researchers, clinicians, and policymakers with the intention of reducing disparities in ADHD diagnosis and treatment in the U.S.

"Tell Me More About Your Child's Sleep": A Qualitative Investigation Of Sleep Problems In Children With ADHD

OBJECTIVE

To investigate parental experiences and perceptions of sleep problems in their children with Attention Deficit Hyperactivity Disorder (ADHD), the perceived impacts of sleep problems and coping strategies deployed by parents.

METHODS

Semi-structured interviews with twenty-six parents of pre-adolescent children with a diagnosis of ADHD, followed by thematic analysis of the interview transcripts.

RESULTS

Three themes were generated from the data: Children's Sleep Difficulties; Impacts of Children's Sleep; and Improving Children's Sleep. Sleep initiation problems in children with ADHD were commonly reported by parents, were perceived to be linked in a bidirectional manner with executive and emotional problems, and were reported as being disruptive to parental sleep. Some parents reported that their children's sleep problems were the initial prompt that lead to a diagnosis of ADHD. Parents reported utilizing a range of coping strategies to mitigate sleep problems, such as controlling the bedroom sensory environment and using emotional "wind down" as part of the bedtime routine. Some parents endorsed a beneficial effect of melatonin on their children's sleep.

CONCLUSIONS

Sleep problems in children with ADHD were perceived as important issues by parents. Equipping parents with evidence-based strategies for the management of their children's sleep may lead to benefits for the children, parents and wider household.

Prevalence and Incidence Trends of Attention Deficit/Hyperactivity Disorder in Children and Youth Aged 1-24 Years in Ontario, Canada: A Validation Study of Health Administrative Data Algorithms: Tendances de la prévalence et de l'incidence du trouble de déficit de l'attention/hyperactivité chez les enfants et les jeunes âgés de 1 à 24 ans, en Ontario, Canada: une étude de validation des algorithmes de données administratives de santé

OBJECTIVE

To estimate prevalence and incidence rates over time in children and youth with attention deficit/hyperactivity disorder from the validation of population-based administrative data algorithms using family physicians' electronic medical records as a reference standard.

METHODS

A retrospective cohort study was conducted in Ontario, Canada to identify attention deficit/hyperactivity disorder among children and youth aged 1-24 years in health administrative data derived from case-finding algorithms using family physicians' electronic medical records. Multiple administrative data algorithms identifying attention deficit/hyperactivity disorder cases were developed and tested from physician-diagnosis of attention deficit/hyperactivity disorder in the electronic medical record to determine their diagnostic accuracy. We calculated algorithm performance using sensitivity, specificity, and predictive values. The most optimal algorithm was used to estimate prevalence and incidence rates of attention deficit/hyperactivity disorder from 2014 to 2021 in Ontario.

RESULTS

The optimal performing algorithm was "2 physician visits for attention deficit/hyperactivity disorder in 1 year or 1 attention deficit/hyperactivity disorder-specific prescription" with sensitivity: 83.2% (95% confidence interval [CI], 81.8% to 84.5%), specificity: 98.6% (95% CI, 98.5% to 98.7%), positive predictive value: 78.6% (95% CI, 77.1% to 80.0%) and negative predictive value: 98.9% (95% CI, 98.8% to 99.0%). From 2014, prevalence rates for attention deficit/hyperactivity disorder increased from 5.29 to 7.48 per 100 population in 2021 (N = 281,785). Males had higher prevalence rates (7.49 to 9.59 per 100 population, 1.3-fold increase) than females (2.96-5.26 per 100 population, 1.8-fold increase) from 2014 to 2021. Incidence rates increased from 2014 (0.53 per 100 population) until 2018, decreased in 2020 then rose steeply in 2021 (0.89 per 100 population, N = 34,013). Males also had higher incidence rates than females from 2014 to 2020 with females surpassing males in 2021 (0.70-0.81 per 100 male population,1.2-fold increase versus 0.36-0.97 per 100 female population, 2.7-fold increase).

CONCLUSIONS

Attention deficit/hyperactivity disorder is increasing in prevalence. We developed an administrative data algorithm that can reliably identify children and youth with attention deficit/hyperactivity disorder with good diagnostic accuracy.

Secondary analyses of sex differences in attention improvements across three clinical trials of a digital therapeutic in children, adolescents, and adults with ADHD

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) remains underdiagnosed and undertreated in girls. Inattentive symptoms, often predominant in girls with ADHD, represent a key driver of impairment and often persist into adulthood. AKL-T01 is a regulated digital therapeutic targeting inattention. We examined potential sex differences in the efficacy of AKL-T01 in three separate trials for 1) children, 2) adolescents, and 3) adults.

METHODS

We conducted secondary analyses of clinical outcomes by sex in three AKL-T01 randomized clinical trials in ADHD (n1 = 180 children 30.6% female, M(SD) age = 9.71 (1.32); n2 = 146 adolescents; 41.1% female, M(SD) age = 14.34 (1.26); n3 = 153 adults; 69.9% female, M(SD) age = 39.86 (12.84)). Active treatment participants used AKL-T01 for 25 min/day over 4-6 weeks. Primary outcomes included change in attention on the Test of Variables of Attention (TOVA) and symptom change on the clinician-rated ADHD Rating Scale (ADHD-RS). To evaluate study hypotheses, we conducted a series of robust linear regressions of TOVA and ADHD-RS change scores by sex, adjusting for baseline scores.

RESULTS

In children, girls demonstrated greater improvement in objective attention relative to boys following AKL-T01 (TOVA Attentional Composite Score; Cohen's d = .36 and Reaction Time Mean Half; Cohen's d = .54), but no significant sex differences in ADHD rating scale change. We did not observe significant sex differences in outcomes in the adolescent or adult trials. Limitations include binary sex categorization and slight study design variation across the three samples.

CONCLUSION

AKL-T01 might notably improve attentional functioning in girls with ADHD relative to boys. Objective attention measures may be particularly important in the assessment of attentional improvement in childhood, given known gender biases in ADHD symptom reporting. We emphasize the importance of considering sex and gender-specific factors in ADHD treatment evaluation.

TRIAL REGISTRATIONS

STARS ADHD CHILD: ClinicalTrials.gov ID NCT03649074; STARS ADHD ADOLESCENT: ClinicalTrials.gov ID NCT04897074; STARS ADHD ADULT: ClinicalTrials.gov ID NCT05183919.

Atypical procedural learning in children with developmental coordination disorder: A combined behavioral and neuroimaging study

While procedural learning (PL) has been implicated in delayed motor skill observed in developmental coordination disorder (DCD), few studies have considered the impact of co-occurring attentional problems. Furthermore, the neurostructural basis of PL in children remains unclear. We investigated PL in children with DCD while controlling for inattention symptoms, and examined the role of fronto-basal ganglia-cerebellar morphology in PL. Fifty-nine children (6-14 years; nDCD = 19, ncontrol = 40) completed the serial reaction time (SRT) task to measure PL. The Attention-Deficit Hyperactivity Disorder Rating Scale-IV was administered to measure inattention symptoms. Structural T1 images were acquired for a subset of participants (nDCD = 10, ncontrol = 28), and processed using FreeSurfer. Volume was extracted for the cerebellum, basal ganglia, and frontal regions. After controlling for inattention symptoms, the reaction time profile of controls was consistent with learning on the SRT task. This was not the case for those with DCD. SRT task performance was positively correlated with cerebellar cortical volume, and children with DCD trended towards lower cerebellar volume compared to controls. Children with DCD may not engage in PL during the SRT task in the same manner as controls, with this differential performance being associated with atypical cerebellar morphology.

Perceived associations between the menstrual cycle and Attention Deficit Hyperactivity Disorder (ADHD): A qualitative interview study exploring lived experiences

BACKGROUND

The research gap regarding Attention Deficit Hyperactivity Disorder (ADHD) in people who were assigned female at birth has led to a lack of knowledge and adequate approaches in clinical practice, as well as diagnosis processes. Recent studies report potential associations between reproductive hormones and ADHD, but existing research remains scarce.

AIM

This study aims to explore the experiences of people who perceive an association between their menstrual cycle and their ADHD symptoms.

METHODOLOGY

Design and Method. A qualitative research design with an inductive approach was used. Ten participants were interviewed, using semi-structured, in-depth interviews. The data was transcribed, coded, and analyzed using reflexive thematic analysis according to Braun and Clarke.

RESULTS

Findings show participant's perceived associations between their ADHD and their menstrual cycle: participants reported experiencing ADHD symptom mor severe during the mid-luteal phase of the menstrual cycle. Other results showed uncertainty around ADHD medication in relation to the cycle and varied experiences with health care encounters as well as heightened challenged around menstrual health management.

CONCLUSIONS

This study provides insights to how perceived associations between ADHD and the menstrual cycle might be experienced. This report highlights the need for further research and theory about the potential associations between ADHD and reproductive hormones. The researchers strongly suggested that forthcoming ADHD studies consider times of key hormonal changes, such as puberty and menarche, menopause, hormonal birth control, pregnancy, hormone treatment, and more.

A Female-Specific Treatment Group for ADHD-Description of the Programme and Qualitative Analysis of First Experiences

Background: The diagnostics and treatment of attention-deficit/hyperactivity disorder (ADHD) in women remain insufficient. Fluctuations of reproductive hormones during the premenstrual period, postpartum period, and (peri)menopause are neglected, even though they impact ADHD symptoms and associated mood disorders. Therefore, we created a female-specific treatment group for women with ADHD and premenstrual worsening of ADHD and/or mood symptoms. Methods: We describe the group programme and underlying rationale, offering a qualitative analysis of the participants' evaluation. Results: The seven bi-weekly sessions foreground the menstrual cycle and address several ADHD-specific topics in relation to this cyclical pattern. Concurrently, women track their menstrual cycle and (fluctuating) ADHD and mood symptoms with an adjusted premenstrual calendar. In total, 18 women (25-47 years) participated in three consecutive groups. We analysed the evaluation of the last group. Participants experienced the group as a safe and welcoming space. Recognition was valued by all. The topics discussed were deemed valuable, and the structure suited them well. Completing the premenstrual calendar augmented the awareness and recognition of individual cyclical symptoms. A lifespan approach increased self-understanding. Participants took their menstrual cycle more seriously, prioritising self-acceptance and self-care. Conclusions: Exploring a cyclical approach in a group setting seems to be a positive addition to treatment for female ADHD.

Tools for the Diagnosis of ADHD in Children and Adolescents: A Systematic Review

CONTEXT

Correct diagnosis is essential for the appropriate clinical management of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

OBJECTIVE

This systematic review provides an overview of the available diagnostic tools.

DATA SOURCES

We identified diagnostic accuracy studies in 12 databases published from 1980 through June 2023.

STUDY SELECTION

Any ADHD tool evaluation for the diagnosis of ADHD, requiring a reference standard of a clinical diagnosis by a mental health specialist.

DATA EXTRACTION

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

RESULTS

In total, 231 studies met eligibility criteria. Studies evaluated parental ratings, teacher ratings, youth self-reports, clinician tools, neuropsychological tests, biospecimen, EEG, and neuroimaging. Multiple tools showed promising diagnostic performance, but estimates varied considerably across studies, with a generally low strength of evidence. Performance depended on whether ADHD youth were being differentiated from neurotypically developing children or from clinically referred children.

LIMITATIONS

Studies used different components of available tools and did not report sufficient data for meta-analytic models.

CONCLUSIONS

A valid and reliable diagnosis of ADHD requires the judgment of a clinician who is experienced in the evaluation of youth with and without ADHD, along with the aid of standardized rating scales and input from multiple informants across multiple settings, including parents, teachers, and youth themselves.

Sex Differences in ADHD: Review and Priorities for Future Research

PURPOSE OF REVIEW

In childhood, attention-deficit/hyperactivity disorder (ADHD) is diagnosed three to 16 times more frequently in males compared to females, yet in adulthood, nearly equivalent numbers of males and females are diagnosed with ADHD. Relatively few studies have prioritized examination of sex differences in ADHD even though sex differences may have critical implications for the identification and treatment of ADHD in females and males. This review highlights current research on sex differences in ADHD across the lifespan that has emerged from cross-sectional and prospective longitudinal studies of youth, adult-ascertained samples, and registry studies.

RECENT FINDINGS

Accumulating research suggests that both males and females with ADHD experience widespread impairment across the lifespan. Some evidence of sex differences emerged, although effects have generally been modest in size. Continued research that includes females and males with ADHD is needed to clarify the nature of sex differences in ADHD. Research that focuses on equitable identification of ADHD in males and females, disentangles the effects of sex and gender, probes underlying mechanisms of sex differences, and addresses the clinical impact of sex differences in ADHD must be prioritized.

Pubertal timing in adolescents with ADHD: extension and replication in an all-female sample

Pubertal timing predicts a miscellany of negative mental and physical health outcomes. Prior work examining pubertal timing in youth with attention-deficit hyperactivity disorder (ADHD) has failed to investigate potential sex specificity of results. Therefore, we aim to extend past findings in a sample of female adolescents with ADHD. We compare pubertal timing (1) between females with and without carefully diagnosed ADHD and (2) between females with ADHD who do vs. do not have a history of stimulant medication use during childhood. We examine 127 adolescent females with childhood-diagnosed ADHD and 82 matched neurotypical peers (Mage: 14.2 years, range: 11.3-18.2) from the Berkeley Girls with ADHD Longitudinal Study (Wave 2). We measured pubertal timing using self-reported Tanner staging and age at menarche. Three strategies compared pubertal timing across groups: (1)χ 2 tests of Tanner Stages, (2) t tests of residuals of pubertal status regressed on age, and (3) t tests of age at menarche. Pubertal timing of girls with and without ADHD did not differ significantly across methods and measures. Yet females with ADHD who had received stimulant medication during childhood menstruated later than those without a stimulant history, potentially related to differences in BMI across groups. On the other hand, no significant differences between medicated vs. non-medicated participants emerged for the two Tanner staging indicators. Our findings extend prior work, suggesting that females with ADHD are developing physically at a similar time as their peers, which parallels findings from previous mixed-sex samples that did not examine effects separately by sex.

The ADHD Phenotype in Black and White Girls From Childhood to Adolescence: Results From the Community-Based Pittsburgh Girls Study

OBJECTIVE

The goal of the present study is to describe the ADHD phenotype from childhood to adolescence in Black and White girls in a community sample.

METHOD

Primary caregivers enrolled in the population-based, longitudinal Pittsburgh Girls Study reported on girls' ADHD symptoms and impairment from ages 7 to 17; diagnostic subtypes were estimated based on meeting symptom criteria.

RESULTS

The prevalence of any subtype of ADHD ranged from 6.4 to 9.2% and from 2.3 to 6.4% for Black and White girls respectively; the inattentive subtype was most endorsed. A relatively equal number of new diagnoses at each age was observed. Persistence of ADHD diagnoses was typically 1 to 2 years.

CONCLUSIONS

ADHD in the community is relatively common, with the inattentive subtype as the most common phenotype for Black and White girls. Research on developmentally sensitive periods for symptom exacerbation or new onset of ADHD in girls is needed.

Potential Mechanisms Underlying Suicidality in Autistic People with Attention Deficit/Hyperactivity Disorder: Testing Hypotheses from the Interpersonal Theory of Suicide

Background

Autistic people with co-occurring attention deficit/hyperactivity disorder (ADHD) appear to be at heightened risk of suicide. To understand why, we explored two explanatory mechanisms from the interpersonal theory of suicide: first, that co-occurring ADHD might be associated with greater risk through greater thwarted belongingness and perceived burdensomeness and, secondly, that hyperactive/impulsive features might incur additional risk through their association with painful and provocative events, which are suggested to create "capability" for suicide.

Methods

Autistic adults (n = 314) completed an online survey including measures of thwarted belongingness, perceived burdensomeness, painful and provocative events, acquired capability for suicide, and ADHD features. Creating an overall index of likely ADHD, we examined associations between likely ADHD, suicide ideation, and lifetime suicide attempts through the parallel mediators of thwarted belongingness, perceived burdensomeness, anxiety, and depression. In several models, we then examined hyperactive, impulsive, and inattentive features as predictors of exposure to painful and provocative events and subsequent capability for suicide, and examined whether these two variables, sequentially or individually, mediated an association with lifetime suicide attempts.

Results

Likely ADHD was associated with past-year suicide ideation through greater depression and perceived burdensomeness, which also mediated its association with more suicide attempts. Hyperactive and impulsive features were associated with exposure to painful and provocative events and through this acquired suicide capability. Both features were associated with more numerous suicide attempts through these two mediators sequentially, and through exposure to painful and provocative events alone.

Conclusions

These data suggest that suicidality in autistic people with ADHD may be partially related to perceived burdensomeness and to acquired suicide capability after exposure to painful and provocative events. However, as we observed a pathway to suicidality associated with painful and provocative events alone, it is likely that there are also other explanatory mechanisms for the influence of traumatic events on suicide risk.

Attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD; also known as hyperkinetic disorder) is a common neurodevelopmental condition that affects children and adults worldwide. ADHD has a predominantly genetic aetiology that involves common and rare genetic variants. Some environmental correlates of the disorder have been discovered but causation has been difficult to establish. The heterogeneity of the condition is evident in the diverse presentation of symptoms and levels of impairment, the numerous co-occurring mental and physical conditions, the various domains of neurocognitive impairment, and extensive minor structural and functional brain differences. The diagnosis of ADHD is reliable and valid when evaluated with standard diagnostic criteria. Curative treatments for ADHD do not exist but evidence-based treatments substantially reduce symptoms and/or functional impairment. Medications are effective for core symptoms and are usually well tolerated. Some non-pharmacological treatments are valuable, especially for improving adaptive functioning. Clinical and neurobiological research is ongoing and could lead to the creation of personalized diagnostic and therapeutic approaches for this disorder.

Psychoeducation for adult ADHD: a scoping review about characteristics, patient involvement, and content

BACKGROUND

Psychosocial interventions such as psychoeducation are increasingly being used to treat adult ADHD, both as an alternative and as a supplement to pharmacotherapy. A thorough overview of the literature on psychoeducation for adult ADHD is lacking. The objectives of this scoping review were therefore to identify the characteristics of psychoeducation interventions designed for adults with ADHD, examine how the patient experience or perspective is considered during the intervention's development and implementation, determine the typical themes covered, and explore how 'psychoeducation' is defined in these interventions.

METHODS

A comprehensive search was performed to identify records in MEDLINE, Embase, PsycINFO, Web of Science, Cochrane CENTRAL, AMED, and ClinicalTrials.gov. Two or more reviewers were included in every step of the screening process and the final selection of included studies. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist (Supplementary Material 1) was used to report the results, and the framework developed by Arksey and O'Malley was used as a guide throughout the scoping process.

RESULTS

A total of 2121 records were identified through the literature search. After screening and full-text analysis, ten studies were included for final analysis. Most studies were conducted in Europe and followed a group format. Seven main themes were identified: Information about the diagnosis, treatment options, somatic health and ADHD, the insider perspective, ADHD and social life, coping and psychological skills, and ADHD and work. There was significant overlap in themes covered, but coverage of each theme varied. Themes deemed important by newer research, such as sexuality and gender-specific issues, were missing. Only one intervention involved patients in its development and implementation, and two interventions involved family members. There was variation in how psychoeducation was defined in the included studies, and the implications of this are discussed.

CONCLUSION

The literature on psychoeducation for adult ADHD is not ready for any systematic effect estimation. Before such estimations are conducted, a shared understanding and definition of psychoeducation are needed. The involvement of end users in the development and delivery of interventions may aid reach this goal but results from this review indicate that such practices are rare.

ADHD medication discontinuation and persistence across the lifespan: a retrospective observational study using population-based databases

BACKGROUND

Although often intended for long-term treatment, discontinuation of medication for ADHD is common. However, cross-national estimates of discontinuation are missing due to the absence of standardised measures. The aim of this study was to determine the rate of ADHD treatment discontinuation across the lifespan and to describe similarities and differences across countries to guide clinical practice.

METHODS

We did a retrospective, observational study using population-based databases from eight countries and one Special Administrative Region (Australia, Denmark, Hong Kong, Iceland, the Netherlands, Norway, Sweden, the UK, and the USA). We used a common analytical protocol approach and extracted prescription data to identify new users of ADHD medication. Eligible individuals were aged 3 years or older who had initiated ADHD medication between 2010 and 2020. We estimated treatment discontinuation and persistence in the 5 years after treatment initiation, stratified by age at initiation (children [age 4-11 years], adolescents [age 12-17 years], young adults [age 18-24 years], and adults [age ≥25 years]) and sex. Ethnicity data were not available.

FINDINGS

1 229 972 individuals (735 503 [60%] males, 494 469 females [40%]; median age 8-21 years) were included in the study. Across countries, treatment discontinuation 1-5 years after initiation was lowest in children, and highest in young adults and adolescents. Within 1 year of initiation, 65% (95% CI 60-70) of children, 47% (43-51) of adolescents, 39% (36-42) of young adults, and 48% (44-52) of adults remained on treatment. The proportion of patients discontinuing was highest between age 18 and 19 years. Treatment persistence for up to 5 years was higher across countries when accounting for reinitiation of medication; at 5 years of follow-up, 50-60% of children and 30-40% of adolescents and adults were covered by treatment in most countries. Patterns were similar across sex.

INTERPRETATION

Early medication discontinuation is prevalent in ADHD treatment, particularly among young adults. Although reinitiation of medication is common, treatment persistence in adolescents and young adults is lower than expected based on previous estimates of ADHD symptom persistence in these age groups. This study highlights the scope of medication treatment discontinuation and persistence in ADHD across the lifespan and provides new knowledge about long-term ADHD medication use.

FUNDING

European Union Horizon 2020 Research and Innovation Programme.

Does Emotion-Related Impulsivity Relate to Specific ADHD Symptom Dimensions, and Do the Effects Generalize Across Comorbid Internalizing and Externalizing Syndromes?

BACKGROUND

Recent work highlights the role of emotion dysregulation in the pathology of Attention-Deficit/Hyperactivity Disorder (ADHD). As such, emotion-related impulsivity (ERI), the trait-like tendency toward disinhibited thoughts (Pervasive Influence of Feelings, PIF) and actions (Feelings Trigger Action, FTA) during heightened emotional states, may be particularly relevant. We explored whether Inattention (IN) and Hyperactivity/Impulsivity (HI), two core symptom dimensions of ADHD, would relate to distinct facets of ERI, and whether externalizing and internalizing symptoms would moderate these relations.

METHOD

Using structural equation modeling, we examined hypotheses among 364 adults recruited for high internalizing and externalizing symptoms.

RESULTS

We identified significant paths for FTA regressed on HI and PIF regressed on IN, supporting our hypotheses about main effects. Moderating paths were not significant.

CONCLUSIONS

IN and HI correlate with distinct forms of ERI, These effects appear to generalize across co-occurring internalizing and externalizing symptoms. Theoretical and clinical implications are discussed.

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).

Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage

Objective

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental condition which is underdiagnosed and undertreated in women. For decades, the ADHD field has called for more insight into female-specific therapy. Preliminary findings postulate that changes in sex hormones during the menstrual cycle may influence the effectiveness of psychostimulant medication. Yet, pharmacotherapeutic interventions tailored to women with ADHD remain scarce. Previously, our group showed an increase in mood symptoms in the premenstrual week in women with ADHD. Premenstrual worsening of depressive and ADHD symptoms represent a treatment challenge. In our adult ADHD clinic, we noted several women describing exacerbation of their ADHD and depressive symptoms in the premenstrual week and/or insufficient effect of their established dosage of psychostimulant. We responded to the need expressed by these women by increasing their stimulant dosage in the premenstrual week, while monitoring the response and side effects.

Methods

This community case study of nine consecutive women being treated for ADHD and co-occurring conditions (including depression and premenstrual dysphoric disorder), reports our local experience of increasing the individually prescribed psychostimulant dosage during the premenstrual period. We methodically monitored the effect of this increased dosage on ADHD symptoms, mood and somatic symptoms for the following 6-24 months.

Results

With premenstrual dose elevation, all nine women experienced improved ADHD and mood symptoms with minimal adverse events. Premenstrual inattention, irritability and energy levels improved, and now resembled the other non-premenstrual weeks more closely. All women decided to continue with the elevated premenstrual pharmacotherapy.

Discussion

Our preliminary results demonstrate potential benefits of increasing premenstrual psychostimulant dosage in women with ADHD, experiencing premenstrual worsening of ADHD and mood symptoms. The results concur with previous findings of diminished response to amphetamines in the late luteal phase. Increased dosage may help combat premenstrual worsening of cognitive and emotional symptoms in women with ADHD, with significant clinical implications. Better management of premenstrual ADHD and mood symptoms in vulnerable women can improve treatment outcome and meet an unmet need. However, implementation should be individually explored. Further investigation of luteal phase psychostimulant dose adjustment is required for safe, optimal and individualised treatment for women with ADHD.

Patterns of Childhood Adversity among Women with and without Childhood ADHD: Links to Adult Psychopathology and Global Functioning

We examine the outcomes associated with childhood adversity for women with and without carefully diagnosed childhood ADHD, via an ethnically diverse sample of 140 participants with ADHD (Mage = 9.7) and 88 age- and ethnicity-matched comparisons (Mage = 9.4). At adult follow-up, we retained 211 of the original 228 participants (92.6%; Mage = 25.6). We used latent class analysis to identify patterns of childhood adversity and examine their association with adult global functioning and psychopathology. Key findings: (1) Four childhood adversity classes emerged (Low Exposure, Familial Dysfunction, Emotional Maltreatment, Pervasive Exposure); (2) Childhood ADHD predicted membership in the Emotional Maltreatment class; and (3) Childhood adversity classes were differently associated with adult outcomes, such that membership in both the Emotional Maltreatment and Pervasive Exposure classes predicted significantly higher internalizing and externalizing symptoms as well as significantly lower global functioning than women in the Low Exposure class. Furthermore, compared to the Emotional Maltreatment class, the Familial Dysfunction class had lower externalizing symptoms, whereas the Pervasive Exposure class had lower global functioning and higher internalizing symptoms by adulthood. Findings provide information about girls and women who could be targeted for intervention in terms of ADHD behavior patterns plus adverse experiences in childhood. Beyond limitations, we discuss the need to investigate the confluence of neurodevelopmental conditions and adverse child events with respect to maladaptive outcomes.

The effects of tryptophan loading on Attention Deficit Hyperactivity in adults: A remote double blind randomised controlled trial

BACKGROUND

Despite the impact and prevalence of Attention Deficit Hyperactivity Disorder (ADHD), current treatment options remain limited and there is a drive for alternative approaches, including those building on evidence of a role for tryptophan (TRP) and serotonin (5-HT). This study aimed to evaluate the effect of acute TRP loading on attention and impulsivity in adults with ADHD.

TRIAL DESIGN AND METHODS

We conducted a remote double blind randomised controlled trial (RCT) using TRP loading to examine the effects of a balanced amino acid load in comparison to low and high TRP loading in individuals with ADHD (medicated, N = 48, and unmedicated, N = 46) and controls (N = 50). Participants were randomised into one of three TRP treatment groups using stratified randomisation considering participant group and gender using a 1:1:1 ratio. Baseline testing of attention and impulsivity using the Test of Variables of Attention Task, Delay Discounting Task, and Iowa Gambling Task was followed by consumption of a protein drink (BAL, LOW, or HIGH TRP) before repeated testing.

RESULTS AND CONCLUSIONS

No effects of TRP were observed for any of the measures. In the present study, TRP loading did not impact on any measure of attention or impulsivity in those with ADHD or Controls. The findings need to be confirmed in another trial with a larger number of patients that also considers additional measures of dietary protein, plasma TRP and aggression. (Registration ID ISRCTN15119603).

Relationship between hair cortisol concentrations and cognitive functioning in adolescents with ADHD

Background: Our study aimed to explore whether the hair cortisol concentration (HCC), a measure of long-term cortisol output, is associated with poorer cognitive functioning in adolescents with attention deficit and hyperactivity disorder (ADHD). We further aimed to test the potential moderating effects of sex and childhood maltreatment.Methods: In this cross-sectional study, fifty-three adolescents with ADHD were studied. The ADHD Rating Scale (ADHD-RS) and Childhood Trauma Questionnaire (CTQ) were administered. Seven cognitive tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB) were administered, and two cognitive factors (attention and memory and executive functioning) were identified by confirmatory factor analysis. A 3-cm hair sample from the posterior vertex region of the head was obtained. HCCs were determined by a high-sensitivity enzyme immunoassay kit. Multiple linear regression analyses were used to explore the association between HCCs and either cognitive performance or ADHD severity while adjusting for sex, childhood maltreatment and the ADHD-RS total score.Results: Sex moderated the relationship between HCCs and attention/memory confirmatory factor analysis (CFA) scores, with better performance in boys with higher HCCs. HCCs were not associated with executive functioning or ADHD symptoms. Childhood maltreatment was associated with inattention symptoms in adolescents with ADHD.Conclusions: Our study suggests that HCCs are positively associated with attention and memory performance in adolescents with ADHD, with a moderating effect of sex (the relationship is strongest in boys).

Psychiatric comorbidities in women with cardiometabolic conditions with and without ADHD: a population-based study

BACKGROUND

Leveraging a large nationwide study of Icelandic women, we aimed to narrow the evidence gap around female attention-deficit/hyperactivity disorder (ADHD) and cardiometabolic comorbidities by determining the prevalence of obesity, hypertension, type 2 diabetes, and cardiovascular diseases among women with ADHD and examine the association between cardiometabolic conditions and co-occurring ADHD with anxiety and mood disorders, alcoholism/substance use disorder (SUD), self-harm, and suicide attempts.

METHODS

We conducted a cross-sectional analysis of the nationwide, all-female, population-based SAGA Cohort Study (n = 26,668). To ascertain diagnoses and symptoms, we used self-reported history of ADHD diagnoses, selected cardiometabolic conditions and psychiatric disorders, and measured current depressive, anxiety, and PTSD symptoms through appropriate questionnaires (PHQ-9, GAD-7, and PCL-5). We calculated age-adjusted prevalences of cardiometabolic conditions by women's ADHD status and estimated adjusted prevalence ratios (PR) and 95% confidence intervals (CI), using modified Poisson regression models. Similarly, we assessed the association of cardiometabolic conditions and co-occurring ADHD with current psychiatric symptoms and psychiatric disorders, using adjusted PRs and 95% CIs.

RESULTS

We identified 2299 (8.6%) women with a history of ADHD diagnosis. The age-adjusted prevalence of having at least one cardiometabolic condition was higher among women with ADHD (49.5%) than those without (41.7%), (PR = 1.19, 95% CI 1.14-1.25), with higher prevalence of all measured cardiometabolic conditions (myocardial infarctions (PR = 2.53, 95% CI 1.83--3.49), type 2 diabetes (PR = 2.08, 95% CI 1.66-2.61), hypertension (PR = 1.23, 95% CI 1.12-1.34), and obesity (PR = 1.18, 95% CI 1.11-1.25)). Women with cardiometabolic conditions and co-occurring ADHD had, compared with those without ADHD, substantially increased prevalence of (a) all measured mood and anxiety disorders, e.g., depression (PR = 2.38, 95% CI 2.19-2.58), bipolar disorder (PR = 4.81, 95% CI 3.65-6.35), posttraumatic stress disorder (PR = 2.78, 95% CI 2.52-3.07), social phobia (PR = 2.96, 95% CI 2.64-3.32); (b) moderate/severe depressive, anxiety, and PTSD symptoms with PR = 1.76 (95% CI 1.67-1.85), PR = 1.97 (95% CI 1.82-2.12), and PR = 2.01 (95% CI 1.88-2.15), respectively; (c) alcoholism/SUD, PR = 4.79 (95% CI 3.90-5.89); and (d) self-harm, PR = 1.47 (95% CI 1.29-1.67) and suicide attempts, PR = 2.37 (95% CI 2.05-2.73).

CONCLUSIONS

ADHD is overrepresented among women with cardiometabolic conditions and contributes substantially to other psychiatric comorbidities among women with cardiometabolic conditions.

Measuring patient satisfaction with four items: validity of the client satisfaction questionnaire 4 in an outpatient population

INTRODUCTION

Patient satisfaction with mental health services has for several decades been considered an important component when evaluating service quality. It is often assessed in the context of monitoring quality of care, developing or evaluating newly implemented interventions or changes in practice. Because of this, patient satisfaction questionnaires are often added to longer questionnaire batteries, and shorter questionnaires are preferred to prevent respondent fatigue and non-compliance and to secure easy implementation. However, most studies use unvalidated patient satisfaction measures, making comparisons between studies difficult. Validation studies of short patient satisfaction measures are therefore warranted.

METHODS

The primary aim was to examine the construct validity and internal reliability of the Client Satisfaction Questionnaire-4 (CSQ-4) in a Norwegian outpatient mental health setting. A total of 467 patients were recruited from an outpatient psychiatric care clinic in Central Norway. The secondary aim was to examine an earlier proposed cutoff for classifying dissatisfied patients in this new population. A principal component analysis was conducted to evaluate factor structure, correlation analyses were conducted to test for predicted relationships, and Cronbach's alpha was calculated to examine internal reliability.

RESULTS

The CSQ-4 showed a clear unidimensional structure with one factor explaining 80% of its variance. Its internal reliability was very high, with a Cronbach's alpha of 0.92. As hypothesised this study found no statistically significant sex differences in satisfaction and no statistically significant association between age and satisfaction. Positive changes in symptoms during treatment and higher post-treatment functional impairment were associated with higher patient-reported treatment satisfaction scores, which indicates good construct validity.

CONCLUSION

This is the first study to evaluate the CSQ-4 in a psychiatric population. The CSQ-4 demonstrated good structural validity and internal reliability and was correlated with outcome variables in terms of symptom change and post-treatment functioning. In sum, this indicates that the CSQ-4 is a good short alternative for evaluating patient satisfaction in routine outpatient mental health care.

Low Persistence of Inattention Symptoms From Childhood to Adolescence: A Population-Based Study

OBJECTIVE

To investigate the persistence of dimensional measures of inattention in a population-based, gender-balanced sample of adolescents with parent reports of inattention from childhood and self-reports of inattention in adolescence.

METHOD

Adolescents, 16-19 years old, completed the Adult ADHD Self Report Scale. Their parents completed the Swanson, Nolan, and Pelham Rating Scale-4th Edition when they were 7-9 and 11-13 years old.

RESULTS

More severe inattention in boys than girls in childhood shifted to a female predominance in adolescence. The correlation between reports of inattention in childhood and adolescence was weak, with parent reports explaining only ~5% of the variance in the inattention score reported in adolescence.

CONCLUSION

The weak association between inattention in childhood and adolescence is consistent with the emerging challenges associated with being an adolescent, but the impact of shifts in informants, gender and age on symtpom presentations should be investigated in future studies.

"Dysregulated not deficit": A qualitative study on symptomatology of ADHD in young adults

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) is a common condition that often persists into adulthood, although data suggest that the current diagnostic criteria may not represent how the condition presents in adults. We aimed to use qualitative methods to better understand ADHD symptomatology in young adults, especially regarding attentional and emotional dysregulation.

METHODS

Nine focus groups involving young adults (aged 18-35 years; N = 43; 84% female; 86% US and Canada) with diagnoses of ADHD were conducted. Participants were asked about their perceptions of the current diagnostic criteria and how their symptoms have presented and changed over time. Data were analyzed using an interpretive phenomenological analysis framework.

RESULTS

Most participants reported that the diagnostic criteria did not accurately capture their experiences with ADHD. They reported struggling with attention dysregulation, including hyperfocusing, and emotional dysregulation, including rejection-sensitive dysphoria. Many participants believed that their changing environments and behavioral adaptations influenced how their symptoms presented into adulthood.

CONCLUSION

Current diagnostic criteria for ADHD may not capture the range of symptoms present in young adults. More research is needed to characterize attentional and emotional dysregulation in this population.

Resting-state EEG dynamics help explain differences in response control in ADHD: Insight into electrophysiological mechanisms and sex differences

Reductions in response control (greater reaction time variability and commission error rate) are consistently observed in those diagnosed with attention-deficit/hyperactivity disorder (ADHD). Previous research suggests these reductions arise from a dysregulation of large-scale cortical networks. Here, we extended our understanding of this cortical-network/response-control pathway important to the neurobiology of ADHD. First, we assessed how dynamic changes in three resting-state EEG network properties thought to be relevant to ADHD (phase-synchronization, modularity, oscillatory power) related with response control during a simple perceptual decision-making task in 112 children/adolescents (aged 8-16) with and without ADHD. Second, we tested whether these associations differed in males and females who were matched in age, ADHD-status and ADHD- subtype. We found that changes in oscillatory power (as opposed to phase-synchrony and modularity) are most related with response control, and that this relationship is stronger in ADHD compared to controls. Specifically, a tendency to dwell in an electrophysiological state characterized by high alpha/beta power (8-12/13-30Hz) and low delta/theta power (1-3/4-7Hz) supported response control, particularly in those with ADHD. Time in this state might reflect an increased initiation of alpha-suppression mechanisms, recruited by those with ADHD to suppress processing unfavourable to response control. We also found marginally significant evidence that this relationship is stronger in males compared to females, suggesting a distinct etiology for response control in the female presentation of ADHD.

Female sex and burden of depressive symptoms predict insufficient response to telemedical treatment in adult attention-deficit/hyperactivity disorder: results from a naturalistic patient cohort during the COVID-19 pandemic

Background

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neuropsychiatric disorder, that typically manifests itself during childhood and persists in a majority of the affected individuals into adulthood, negatively affecting physical and mental health. Previous studies have shown detrimental effects of the COVID-19 pandemic on mental health in individuals with ADHD. Thus, telemedicine could be a useful tool for optimizing treatment-outcomes in adult ADHD by improving treatment adherence and persistence. However, data on telemedical treatment outcomes in adult patients with ADHD is scarce.

Methods

We report here the sub-cohort analysis of a naturalistic cohort of adult patients (N = 254) recruited between April 2020-April 2021, comparing the effects of telemedical treatment on participants either clinically diagnosed with depression (N = 54) or ADHD (N = 67). Participants were asked to fill out the WHO-5 repetitively during >12 weeks of telemedical treatment. Furthermore scores of WHO-5, SCL-90R and BDI-II, psychopathology, psychosocial functioning, sociodemographic data, medical records and a feedback survey were analyzed for both groups and compared. Participants with ADHD were further stratified according to the development of well-being during the study period in order to identify factors associated with a satisfactory treatment outcome.

Results

Participants with depression reported a significant improvement of well-being during the course of the study, while no such effect could be seen in participants with ADHD on a group level. Despite the good outcome, participants with depression were more severely affected at baseline, with significantly worse psychopathology and a more precarious labor and financial situation. A detailed analysis of ADHD participants without clinical improvement revealed significantly higher BDI-II scores than for ADHD participants with a satisfactory outcome (p = 0.03, Mann-Whitney-U-Test), suggesting successful treatment was hampered by the combination of ADHD and depressive symptoms. Furthermore, female sex among ADHD patients was correlated with an unfavorable treatment outcome during the course of the study (p = 0.001, Spearman correlation) as well as living with children (p = 0.02, Spearman correlation).

Conclusion

Besides screening for depressive symptoms before telemedical treatment, future research should address the specific needs of female ADHD patients as these patients may be at a particularly high risk of being overburdened with family work.

Clinical utility of new cut-off scores for the world health organization ADHD self-report scale among adolescents in psychiatric outpatient care

Previous analyses of the proposed cut-off score for the 18-item World Health Organization ADHD Self-Report Scale (ASRS-18) among psychiatrically referred adolescents have shown limited clinical utility. This prospective study examined the diagnostic accuracy and clinical utility of new cut-off scores of the ASRS-18 in a consecutive sample of 111 Swedish adolescent psychiatric outpatients. Using the Kiddie Schedule of Affective Disorders and Schizophrenia (K-SADS) as the reference standard and based on predefined sensitivity and specificity criteria, multiple new general and sex-specific cut-off scores were evaluated. Results showed that clinical utility was greater for sex-specific cut-off scores than for general cut-off scores. The greatest change in pre-test to post-test probability of ADHD diagnosis was observed with a balanced, high-specificity diagnostic cut-off score for girls, where the probability of ADHD increased from 40% pre-test to 82% post-test. The proposed new cut-off levels for the ASRS-18 are useful for the detection and identification of ADHD among adolescents in general psychiatric outpatient settings.

Sociodemographic disparities in ADHD diagnosis and treatment among U.S. elementary schoolchildren

We examined whether some groups of U.S. elementary schoolchildren are less likely to be diagnosed and treated for ADHD in analyses of a population-based cohort (N = 10,920). We predicted ADHD diagnosis using measures of race and ethnicity, age, socioeconomic status, birthweight, individually assessed academic, behavioral, and executive functioning, family language use, mental health, health insurance coverage, marital status, school composition, and geographic region. We predicted prescription medication use among those diagnosed with ADHD. We stratified additional analyses by biological sex. Black children (aOR, 0.60), girls (aOR, 0.55), and emergent bilinguals (aOR, 0.29) were less likely to have an ADHD diagnosis than observationally similar White children, boys, or those from English-speaking households. Black children's under-diagnosis occurred among boys. Emergent bilingual children's under-diagnosis occurred among both boys and girls. Girls (aOR, 0.52) and emergent bilinguals (aOR, 0.24) with ADHD were less likely to use prescription medication. Sociodemographic disparities in ADHD diagnosis and treatment occur among U.S. elementary schoolchildren. Measured confounds including independently assessed ADHD symptomatology and impairment do not explain the disparities. The findings empirically support cultural, linguistic, and biological sensitivity in the ADHD diagnostic and treatment procedures in use for the U.S. pediatric population.