Neuropsychological Functioning in Adults With ADHD and Adults With Other Psychiatric Disorders

Prevalence and Predictors of Multimodal Treatment Among U.S. Adults Newly Diagnosed With ADHD

INTRODUCTION

Although a combined treatment of prescription medication and psychotherapy provides long-term benefits for adults with attention deficit/hyperactivity disorder (ADHD), little is known about the prevalence of receiving such multimodal treatment. This study investigated trends in the prevalence and correlates of multimodal treatment among U.S.-insured adults newly diagnosed with ADHD.

METHODS

495,180 U.S. adults from the Komodo Healthcare Map with newly diagnosed ADHD in 2017-2021 were included. Descriptive statistics were used to estimate trends in the prevalence of treatment (no treatment, prescription-only, psychotherapy-only, or both) within 3 months from the index ADHD diagnosis. Multinomial logistic regression was used to examine patient and provider characteristics associated with ADHD treatment. Analysis was conducted in May 2023.

RESULTS

From 2017 to 2021, the prevalence of newly diagnosed ADHD adults receiving multimodal, prescription-only, and psychotherapy-only treatment within 3 months following their first diagnosis increased from 12.9% to 21.4%, 30.2% to 33.3%, and 18.4% to 20.4%, respectively. Over the same period, the prevalence of newly diagnosed ADHD adults receiving no treatment declined from 38.5% to 25%. Relative to their counterparts, the odds of receiving multimodal ADHD treatment were significantly lower (p<0.05) for men, older adults, adults with multiple co-existing conditions, Medicaid and Medicare beneficiaries, and those living in socially disadvantaged areas. Furthermore, the odds of receiving multimodal treatment were higher (p<0.05) for adults who saw a nurse practitioner, physician assistant, or behavioral care (non-physician) provider on their first visit with an ADHD diagnosis, compared to those who saw a physician.

CONCLUSIONS

25% of newly diagnosed ADHD adults received no treatment in 2021 and 53.7% only received a single-modality treatment-raising concerns about the potential implications of untreated ADHD or insufficient treatment on the persistence of ADHD-related impairments, morbidity, productivity, and downstream healthcare cost. The study also highlighted potential sociodemographic, clinical, and provider disparities in ADHD treatment.

The Role of Age in Adult ADHD Quality Care: A Longitudinal Analysis of Electronic Health Record Data

OBJECTIVE

Several studies have shown that Adult ADHD presents differently in younger and older adults. We sought to assess the difference in care between these two groups using previously identified quality measures (QMs).

METHODS

Using electronic health record data, we matched a younger group of ADHD patients to an older group. We then assessed the achievement of the QMs using probit models with and without interaction terms.

RESULTS

The majority of QMs shown an increase in achievement for both groups over time. However, significant differences in quality of care between younger and older adult ADHD patients persisted. By the end of the study period, with the exception of three QMs, younger patients achieved the QMs more.

CONCLUSION

While, in general, the quality of care for adult ADHD increased from 2010 to 2020, there were still differences in care between younger and older adult ADHD patients.

Generalizable prediction of childhood ADHD symptoms from neurocognitive testing and youth characteristics

Childhood attention-deficit/hyperactivity disorder (ADHD) symptoms are believed to result from disrupted neurocognitive development. However, evidence for the clinical and predictive value of neurocognitive assessments in this context has been mixed, and there have been no large-scale efforts to quantify their potential for use in generalizable models that predict individuals' ADHD symptoms in new data. Using data drawn from the Adolescent Brain Cognitive Development Study (ABCD), a consortium that recruited a diverse sample of over 10,000 youth (ages 9-10 at baseline) across 21 U.S. sites, we develop and test cross-validated machine learning models for predicting youths' ADHD symptoms using neurocognitive abilities, demographics, and child and family characteristics. Models used baseline demographic and biometric measures, geocoded neighborhood data, youth reports of child and family characteristics, and neurocognitive tests to predict parent- and teacher-reported ADHD symptoms at the 1-year and 2-year follow-up time points. Predictive models explained 15-20% of the variance in 1-year ADHD symptoms for ABCD Study sites that were left out of the model-fitting process and 12-13% of the variance in 2-year ADHD symptoms. Models displayed high generalizability across study sites and trivial loss of predictive power when transferred from training data to left-out data. Features from multiple domains contributed meaningfully to prediction, including neurocognition, sex, self-reported impulsivity, parental monitoring, and screen time. This work quantifies the information value of neurocognitive abilities and other child characteristics for predicting ADHD symptoms and provides a foundational method for predicting individual youths' symptoms in new data across contexts.

Psychopathological Dissection of Bipolar Disorder and ADHD: Focussing on Racing Thoughts and Verbal Fluency

In the present study, we propose a review and a synthesis of the work of our group about the phenomenology and the cognitive mechanisms of racing thoughts in bipolar disorder (BD) and ADHD. Contrary to the mainstream idea according to which racing thoughts are pathognomonic of BD, our work suggests that racing thoughts are enhanced in ADHD compared to hypomanic episodes of BD, whereas in euthymic episodes of BD self-reported racing thoughts are similar to the rates reported by healthy controls. Using verbal fluency tasks, we found many similarities between bipolar and ADHD subjects with one clear difference: lexical search strategy in hypomania is based on phonemic similarities rather than semantic-relatedness. However, this distinction observed in this cognitive task is certainly difficult to grasp during a clinical interview aiming to differentiate mild hypomania from combined ADHD presentation. The main landmark to distinguish them remains the episodic nature of bipolar disorders as opposed to the lifelong presentation of ADHD symptoms, a dichotomous view that is not so clear-cut in clinical practice.

Networks of Neuropsychological Functions in the Clinical Evaluation of Adult ADHD

This study applied network analysis to explore the relations between neuropsychological functions of individuals in the clinical evaluation of attention-deficit/hyperactivity disorder (ADHD) in adulthood. A total of 319 participants from an outpatient referral context, that is, 173 individuals with ADHD (ADHD group) and 146 individuals without ADHD (n-ADHD group), took part in this study and completed a comprehensive neuropsychological assessment. A denser network with stronger global connectivity was observed in the ADHD group compared to the n-ADHD group. The strongest connections were consistent in both networks, that is, the connections between selective attention and vigilance, and connections between processing speed, fluency, and flexibility. Further centrality estimation revealed attention-related variables to have the highest expected influence in both networks. The observed relationships between neuropsychological functions, and the high centrality of attention, may help identify neuropsychological profiles that are specific to ADHD and optimize neuropsychological assessment and treatment planning of individuals with cognitive impairment.

Differences in executive functioning between adults with ADHD and those diagnosed with other psychiatric diagnoses: Utility of the CTMT and the WAIS-IV

In this study, the utility of the Comprehensive Trail Making Test (CTMT) and WAIS-IV working memory (WMI) and processing speed (PSI) indices in assessment of ADHD were examined. Using retrospective analysis of data from two private practices, patients were classified as having ADHD, having another psychiatric disorder, or having comorbid ADHD and other psychiatric disorder. Results indicated that significant differences existed in performance across the three groups [F(6, 246) = 3.38, p = .003; Pillai's Trace = 0.152, partial η2 = 0.076] on CTMT scores (p < .05), WMI scores (p ≤ .001) and PSI scores (p < .05). Logistic regression analyses indicated WMI and CTMT trail 5 scores were individually useful indicators in identifying the presence of ADHD. Analysis also indicated minimal increase in correct classification of presence or absence of ADHD through combining CTMT, WMI, and PSI scores. Clinical implications for neuropsychological assessment and differential diagnosis of ADHD are discussed.

ADHD symptoms and use of anabolic androgenic steroids among male weightlifters

Use of anabolic androgenic steroids (AAS) is associated with adverse health effects. The factors that predispose to AAS use among athletes are poorly understood, but attention deficit/hyperactivity disorder (ADHD), which is known to occur among athletes more often than in the general population, is associated with risk behaviors, including substance abuse. We aimed to see if AAS use in male weightlifters was associated with ADHD symptoms, and test the link between ADHD symptoms and cognitive performance. Hundred and forty male weightlifters, 72 AAS users and 68 weightlifting controls (WLC), completed the Achenbach system of empirically based assessment (ASEBA) for ADHD symptoms and underwent cognitive examination. Self-reported ADHD symptom scores were significantly higher among AAS users compared to WLC, and scores in the range indicating clinically important ADHD was significantly more common in the AAS-using group. Age of onset of AAS use correlated inversely with ADHD scale score (r = - 0.35; p = 0.003). ADHD score correlated inversely with cognitive scores for working memory (r = - 0.25, p < 0.001), processing speed (r = - 0.24, p < 0.001), verbal learning and memory (r = - 0.19, p = 0.03), and problem solving (r = - 0.20, p = 0.02). AAS use among weightlifters is associated with ADHD symptoms and corresponding lower cognitive performance. Recognising a relationship between ADHD symptoms and AAS use may guide drug prevention strategies in sports.

Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

An overactive mind: Investigating racing thoughts in ADHD, hypomania and comorbid ADHD and bipolar disorder via verbal fluency tasks

BACKGROUND

Adults with Attention Deficit Hyperactivity Disorder (ADHD) often report mental restlessness akin to racing thoughts found in hypomanic and mixed episodes of bipolar disorder (BD). Past research has suggested that racing thoughts in BD can be tackled via process-oriented verbal fluency measures. In ADHD, it is still unknown whether racing thoughts is due to comorbid BD, and its neuropsychological underpinnings remain to be investigated. To this aim, this study investigates process-oriented verbal fluency measures in adults with ADHD compared to adults with BD in a hypomanic episode, adults with ADHD + BD and healthy controls.

METHODS

Three verbal fluency tasks, i.e., the free, the letter and the semantic conditions, were administered to 37 adults with ADHD, 25 adults with BD in a hypomanic episode, 22 adults with comorbid ADHD + BD (euthymia) and 31 healthy subjects. Word production, clustering, and switching were analysed in verbal fluency tasks.

RESULTS

Adults with ADHD, ADHD + BD and hypomania showed increased switches in the free verbal fluency task, compared to healthy controls, despite equivalent number of words produced. Unlike the ADHD and ADHD + BD groups, phonological clustering measures in the semantic task were increased in the hypomanic group compared to healthy controls.

LIMITATIONS

BD groups were under medication.

CONCLUSIONS

Semantic overactivation, reflected by increased switches in the unconstrained verbal fluency task, appear to be a common mechanism involved in racing thoughts in both ADHD and BD. By contrast, unusual sounds-based associations are specific of hypomanic speech and might contribute to the distinction trait and state racing thoughts.

A Systematic Review and Comparison of Neurocognitive Features of Late-Life Attention-Deficit/Hyperactivity Disorder and Dementia With Lewy Bodies

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) in adulthood and dementia with Lewy bodies (DLB) share many cognitive and noncognitive similarities. The overlapping features between both disorders complicate differential diagnosis. The aim of the current systematic review was to compare patterns of neuropsychological profiles in older adults with ADHD and DLB.

METHOD

Of the 1989 ADHD-related articles and 1332 DLB-related articles screened, 3 ADHD and 25 DLB articles were retained for qualitative synthesis and review.

RESULTS

A synthesis of individual study findings revealed isolated working memory deficits for late-life ADHD, and performance deficits in areas of attention, memory, language, and visuoperceptual abilities for DLB. Results were limited by small samples and absence of data in some cognitive domains.

CONCLUSION

These initial findings support potentially unique neurocognitive profiles for ADHD in later life and DLB that would enable practitioners to differentially diagnose and appropriately treat older adults presenting with these phenotypically similar disorders.

Neuropsychological functioning of individuals at clinical evaluation of adult ADHD

OBJECTIVES

Numerous studies showed that adults with attention deficit hyperactivity disorder (ADHD) suffer from impairments in a range of cognitive functions when compared to healthy controls. However, only little is known about the neuropsychological functions when compared to various clinical control groups and whether a distinct neuropsychological profile can be identified for adult ADHD.

METHOD

This retrospective study examined data of 199 outpatients referred for clinical evaluation of adult ADHD, allocated either to an ADHD group (n = 78) or to one of two clinical comparison groups, depending on whether they show indications (n = 71) or no indications (n = 50) for the presence of psychiatric disorders other than ADHD. All individuals performed a comprehensive neuropsychological test battery.

RESULTS

Data analysis revealed impairments in a range of cognitive functions in a substantial number of patients of all three groups. However, profiles of neuropsychological impairments were similar between groups. Furthermore, significant small- to medium-sized correlations between basic and higher-order cognitive functions were revealed in the ADHD group and the clinical comparison group with indications for psychiatric disorders other than ADHD.

CONCLUSION

Neuropsychological impairments are prominent in psychiatric outpatients seeking a clinical evaluation of adult ADHD but are not specific for ADHD. It is concluded that neuropsychological test performance may have limited incremental value to support the psychiatric differential diagnosis. Furthermore, a clinical trajectory may need to take into account that deficits in a range of higher-order cognitive functions can be substantially explained by deficits in basic cognitive functions.

Differentiation of ADHD and Depression Based on Cognitive Performance

Objective: The aim of this study was to assess whether self-report scales and neuropsychological tests used for adult patients with ADHD can help to distinguish between ADHD-specific and depressive symptoms. Method: In a cross-sectional design, differences in self-report questionnaires and neuropsychological tests among clinical subgroups and healthy controls (HC) were evaluated. Patients in clinical groups were diagnosed with major depressive disorder (MDD) or ADHD with or without depressive symptoms according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) guidelines. Results: The Hyperactivity subscales of the Conners' Adult ADHD Rating Scale (CAARS) differed between MDD and ADHD, whereas self-concept and inattention scales even distinguished comorbidity subgroups within the ADHD population. A reduced alertness and higher variations in reaction times measured by performance tests indicated problems in sustained attention in ADHD patients compared with HC. Conclusion: The diagnostic process of ADHD, and thereby the distinction from other symptom-overlapping, comorbid mental disorders, might be improved by utilizing ADHD-specific self-report questionnaires and neuropsychological tests, which are short, cost-effective, and standardized screening methods.

Cognitive characterization of adult attention deficit hyperactivity disorder by domains: a systematic review

Attention deficit hyperactivity disorder (ADHD) is reportedly the most frequent neurodevelopmental disorder diagnosed during childhood, and it is recognized as a common condition in adulthood. We review the evidence to help identify cognitive domains associated to deficits in adult ADHD. A systematic review with narrative synthesis was performed, assessing studies on adult ADHD, neuropsychology and research on involved cognitive domains in adults 18+ years old with an established diagnosis of ADHD, in seven electronic databases (PubMed, PsychInfo, WebOfScience, Embase, Scopus, OvidSPMedline, and Teseo), and Worldcat and OpenGrey grey literature databases. 93 studies were included for this review, encompassing findings from a total 5574 adults diagnosed only with ADHD, medication-naïve or non-medicated at the moment of the assessment and 4880 healthy controls. Adults diagnosed with ADHD may show, when compared to healthy controls, a cognitive profile characterized by deficits across all attention modalities, processing speed, executive function (mainly working memory and inhibition with emphasis on reward delay and interference control), verbal memory, reading skills, social cognition and arithmetic abilities. A cognitive characterization of adult ADHD by domains is established beyond the sole consideration of attention and executive function problems. Along with these, verbal memory, language (mainly reading), social cognition and arithmetic abilities may also contribute to a more comprehensive characterization of the cognitive profile in adult ADHD.

The role of neuropsychological assessment in adults with attention deficit/hyperactivity disorders

Attention-Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, hyperactivity and/or impulsivity. While ADHD was initially recognized as a childhood syndrome, scientific evidence accumulated to indicate that a significant proportion of ADHD children continue to experience symptoms of ADHD in adulthood. Moreover, the question of ADHD diagnosis can arise in adult patients who were not diagnosed in childhood. Currently, the diagnosis of ADHD in adulthood is based on the revised criteria described for children. However, their application for adults may be difficult for many reasons including compensation and comorbid disorders. To date, no clinical, neuropsychological, biological or imaging marker is available for the diagnosis of ADHD. Considering that ADHD is based on a neuropsychological model, in this article we will examine the usefulness of neuropsychological testing in the diagnosis in adults. We will first present diagnostic criteria of ADHD and the limits of their application in adults. We will then detail the neuropsychological data available in adult ADHD and the French and international clinical recommendations for neuropsychological assessment. Finally, we will explore the predictive value of neuropsychological scores in the diagnosis of ADHD and discuss key methodological points and perspectives for clinical research.

ADHD as a Potential Risk Factor in Poor Antiretroviral Adherence Rates in HIV: A Brief Narrative Review and Suggestions for Future Research

This was a narrative review of the literature pertaining to antiretroviral adherence rates in patients with HIV, with a focus on ADHD as a potential risk for poor adherence. A connection is drawn between the cognitive symptoms of ADHD and risk factors for poor treatment adherence in HIV. Parallel associations between ADHD and poor treatment adherence in patients with diabetes are also discussed. Finally, some of the challenges in measuring medication adherence in patients with HIV are summarized. Future research may assess whether patients with comorbid ADHD and HIV have lower rates of adherence than those with HIV alone. Samples will need to be large to manage other contributing factors such as age; in our clinic, patients with HIV referred for ADHD evaluations tend to be younger than patients with HIV referred for assessment of other neurocognitive conditions. This artifact confounds attempts to compare adherence rates in patients with both ADHD and HIV versus those without, as younger age is independently associated with poorer medication compliance. Future research should also include the development of strategies to help infectious disease clinicians to measure adherence as well as the development of cognitive and behavioral strategies for improving adherence rates in patients at risk for poor medication compliance.

Switch Off Totally or Switch Off Strategically? The Consequences of Thinking About Work on Job Performance

As a universal workplace phenomenon, the impact of work-related rumination on job performance is attracting scholars' attention. In the current study, the relationship between two types of work-related rumination, counterproductive behavior, and creativity at work were examined, as well as the mechanism of this association. Participants were 1109 employees from a variety of jobs in mainland China. The results showed that affective rumination was negatively associated with employees' work creativity and positively associated with counterproductive behavior. On the contrary, problem-solving pondering was positively related to creativity and negatively related to counterproductive behavior. The loss of self-control resource partially mediated the link between affective rumination and counterproductive behavior. Problem-solving pondering had no significant impact on self-control resource. Results suggest the significant effects of problem-solving pondering may be positive in the workplace and clarify the self-control resource is the internal mechanism linking rumination and job performance.

Neuropsychological deficits in adults age 60 and above with attention deficit hyperactivity disorder

Objective:

Neuropsychological deficits are of major importance in ADHD, yet no previous studies have assessed clinically referred samples of older adults. The authors compared older adults with ADHD (60–75 years) with both younger adults with ADHD (18–45 years) and older healthy controls with regard to various neuropsychological deficits.

Methods:

Well-established tests were used to investigate working memory, inhibition, switching, planning, fluency, and speed of processing. Self-ratings of executive functioning and delay-related behaviors were also included. Both variable-oriented and person-oriented analyses were conducted.

Results:

Older adults with ADHD differed from controls with regard to working memory, inhibition, switching, and delay-related behaviors. In comparison to younger adults with ADHD, they performed at a similar level with regard to working memory and planning, but significantly better with regard to inhibition, switching, fluency, speed of processing, and delay aversion. Despite several significant group differences relative to controls, person-oriented analyses demonstrated that a majority of older adults with ADHD performed within the average range on each test and 20% showed no clear deficit within any neuropsychological domain.

Conclusions:

The results are in line with models of heterogeneity that have identified different neuropsychological subtypes in ADHD as well as a subgroup of patients without any clear neuropsychological deficits. For older adults with ADHD, it will be important to assess their functioning across time as normal aging is related to memory decline and these patients could therefore end up with severe deficits as they grow older, which in turn could have serious negative effects on daily life functioning.

Social problem solving in adult patients with attention deficit hyperactivity disorder

Patients with Attention Deficit Hyperactivity Disorder (ADHD) experience interpersonal difficulties potentially linked to impaired social cognition. We aimed to investigate social problem solving strategies in adults with ADHD. Nineteen patients with ADHD and 20 healthy controls were assessed with a scenario-based battery gauging the ability to understand other people's mental states, to recognize interpersonal conflicts and to generate and identify optimal (i.e. both socially sensitive and practically effective) solutions to these conflicts. Furthermore, measures of socioemotional and executive functioning were administered. Patients and controls performed on a similar level with respect to theory of mind, the generation of the "best" solution to problematic social situations and the selection of the optimal solution out of alternatives. However, in a fluency task, patients generated fewer optimal solutions, while the number of only socially sensitive, only practically effective or irrelevant solutions was comparable in both groups. The overall ability to freely generate problem solutions was not linked to executive functioning or trait empathy, but better generation abilities were related to lower social interaction anxiety in the patients only. This suggests impaired generation fluency of optimal interpersonal conflict solutions in patients with ADHD which might contribute to higher levels of anxiety in social interactions.

Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder

OBJECTIVES

Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals.

METHODS

The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review.

RESULTS

According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching.

CONCLUSION

The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.

Can neuropsychological testing facilitate differential diagnosis between at-risk mental state (ARMS) for psychosis and adult attention-deficit/hyperactivity disorder (ADHD)?

Background:

Patients with an at-risk mental state (ARMS) for psychosis and patients with attention-deficit/hyperactivity disorder (ADHD) have many overlapping signs and symptoms and hence can be difficult to differentiate clinically. The aim of this study was to investigate whether the differential diagnosis between ARMS and adult ADHD could be improved by neuropsychological testing.

Methods:

168 ARMS patients, 123 adult ADHD patients and 109 healthy controls (HC) were recruited via specialized clinics of the University of Basel Psychiatric Hospital. Sustained attention and impulsivity were tested with the Continuous Performance Test, verbal learning and memory with the California Verbal Learning Test, and problem solving abilities with the Tower of Hanoi Task. Group differences in neuropsychological performance were analyzed using generalized linear models. Furthermore, to investigate whether adult ADHD and ARMS can be correctly classified based on the pattern of cognitive deficits, machine learning (i.e. random forests) was applied.

Results:

Compared to HC, both patient groups showed deficits in attention and impulsivity and verbal learning and memory. However, in adult ADHD patients the deficits were comparatively larger. Accordingly, a machine learning model predicted group membership based on the individual neurocognitive performance profile with good accuracy (AUC = 0.82).

Conclusions:

Our results are in line with current meta-analyses reporting that impairments in the domains of attention and verbal learning are of medium effect size in adult ADHD and of small effect size in ARMS patients and suggest that measures of these domains can be exploited to improve the differential diagnosis between adult ADHD and ARMS patients.

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

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

Diagnosing ADHD in Adults: An Examination of the Discriminative Validity of Neuropsychological Tests and Diagnostic Assessment Instruments

OBJECTIVE

The objective of this study is to investigate the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population.

METHOD

Of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated.

RESULTS

All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3.

CONCLUSION

Neuropsychological tests have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD, but variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA.

Adult executive functioning inventory (ADEXI): Validity, reliability, and relations to ADHD

This study examined the psychometric properties of the Adult Executive Functioning Inventory (ADEXI). This new executive functioning (EF) rating instrument has the advantage of being brief (14 items) and focusing specifically on working memory and inhibitory control. Results showed that scores on the ADEXI had high internal consistency and adequate test-retest reliability, but low concurrence between self-ratings and other ratings. High and statistically significant correlations were found between ADEXI scores and scores from another EF rating instrument, whereas the correlations between ADEXI scores and neuropsychological test scores were weak and often non-significant. Furthermore, with regard to discriminant validity, individuals with attention deficit hyperactivity disorder (ADHD) had significantly higher scores on both the inhibition and working memory subscales compared to clinical as well as non-clinical controls. The results showed high specificity, but relatively low sensitivity, when discriminating between adults with ADHD and non-clinical controls. Conclusively, the ADEXI can be a valuable screening instrument for assessing deficits in working memory and inhibitory control. However, similarly to other EF ratings, the ADEXI should be used as a complement rather than as a replacement for neuropsychological tests, and the low interrater reliability suggests that ratings from multiple sources is preferable compared to relying solely on self-ratings.

Treatment of adult ADHD: a clinical perspective

Adult attention deficit/hyperactivity disorder (ADHD) has moved from the blurred edge of clinical focus to clear recognition as a prevalent and significant disorder in its own right. It is a relatively common comorbidity which if identified and treated may open the door to better outcomes for hard-to-treat patients. Conversely, failure to identify and treat adult ADHD is linked to negative outcomes. The recognition of the importance of adult ADHD in a subset of our patients challenges us to overcome our anxiety about this diagnosis and prevent the societal marginalization of vulnerable patients. Adult ADHD responds well to integrated pharmacological and psychotherapeutic intervention. Its treatment responsiveness reduces disability and allows the comorbidity which is typically present to be addressed. Mastering this challenge can make the diagnosis and treatment of adult ADHD a rewarding experience.

Cognitive heterogeneity in adult attention deficit/hyperactivity disorder: A systematic analysis of neuropsychological measurements

Attention Deficit/Hyperactivity Disorder (ADHD) in childhood is associated with impaired functioning in multiple cognitive domains: executive functioning (EF), reward and timing. Similar impairments have been described for adults with persistent ADHD, but an extensive investigation of neuropsychological functioning in a large sample of adult patients is currently lacking. We systematically examined neuropsychological performance on tasks measuring EF, delay discounting, time estimation and response variability using univariate ANCOVA's comparing patients with persistent ADHD (N=133, 42% male, mean age 36) and healthy adults (N=132, 40% male, mean age 36). In addition, we tested which combination of variables provided the highest accuracy in predicting ADHD diagnosis. We also estimated for each individual the severity of neuropsychological dysfunctioning. Lastly, we investigated potential effects of stimulant medication and a history of comorbid major depressive disorder (MDD) on performance. Compared to healthy adults, patients with ADHD showed impaired EF, were more impulsive, and more variable in responding. However, effect sizes were small to moderate (range: 0.05-0.70) and 11% of patients did not show neuropsychological dysfunctioning. The best fitting model predicting ADHD included measures from distinct cognitive domains (82.1% specificity, 64.9% sensitivity). Furthermore, patients receiving stimulant medication or with a history of MDD were not distinctively impaired. To conclude, while adults with ADHD as a group are impaired on several cognitive domains, the results confirm that adult ADHD is neuropsychologically heterogeneous. This provides a starting point to investigate individual differences in terms of impaired cognitive pathways.