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

Cognitive emotion regulation and learning effectiveness in college students with ADHD symptoms

BACKGROUND

College students with ADHD have difficulties with emotion regulation and have poorer academic skills than peers without ADHD; however, less is known regarding the relation between ADHD symptoms, maladaptive cognitive emotion regulation strategies (CERS), and learning effectiveness.

OBJECTIVES

We examined whether maladaptive CERS predicted learning effectiveness, and whether this relation was moderated by ADHD symptoms.

DESIGN

A cross-sectional online survey.

METHODS

College students (N = 4,183; Mage = 19.24; 70.1% female) at eight universities completed a battery as part of a larger study.

RESULTS

College students in our elevated ADHD group used significantly more maladaptive CERS and performed worse in three domains of learning effectiveness (i.e., Academic Self-Efficacy [ASE], Organization and Attention to Study [OAS], Stress and Time Press [STP]) than college students in our non-ADHD group. Further, ADHD symptoms moderated the relation between maladaptive CERS and OAS, such that individuals with the highest levels of ADHD symptoms were less impacted by maladaptive CERS.

CONCLUSION

Increased use of maladaptive CERS is unique to ADHD rather than lack of adaptive CERS. Also, maladaptive CERS and low ADHD symptoms interact to predict poor OAS. Interventions for college students, regardless of ADHD status, should incorporate emotion regulation components to improve learning effectiveness.

Functional impairment and quality of life in newly diagnosed adults attending a tertiary ADHD clinic in Ireland

BACKGROUND

Attention Deficit-Hyperactive Disorder (ADHD) is a neurodevelopmental disorder, often persisting into adulthood.

AIMS

To investigate the levels of functionality and quality of life (QoL) in adult patients newly diagnosed with ADHD and to compare with those without an ADHD diagnosis.

METHODS

Consecutive patients who were referred to and assessed in a tertiary adult ADHD clinic enrolled in the study. Diagnosis of ADHD was based on DSM-5 criteria. Functionality was measured using the Weiss Functional Impairment Rating Scale (WFIRS) and the Global Assessment of Functioning Scale (GAF). QoL was assessed with the Adult ADHD Quality of Life Questionnaire (AAQoL).

RESULTS

Three-hundred and forty participants were recruited, 177 (52.1%) females. Of them 293 (86.2%) were newly diagnosed with ADHD. Those with ADHD had significant lower functionality as it was measured with the WFIRS and GAF, and worse QoL (AAQoL) compared to those without. In addition, a significant correlation between GAF and WFIRS was found.

CONCLUSIONS

The results show that adults with ADHD have decreased functionality and worse QoL when compared against those presenting with a similar symptomatology, but no ADHD diagnosis. ADHD is not just a behavioural disorder in childhood, but a lifelong condition with accumulating problems that can lead to lower QoL and impaired functioning throughout adulthood.

College during COVID-19: The pandemic's effect on college adjustment in first year students with ADHD

Objective: The current study aims to compare college adjustment and the effects of the COVID-19 pandemic on first-year students with and without ADHD. Participants: Two cohorts (pre-pandemic, during the pandemic) of first-year, undergraduate college students (N = 3,006; Mage=18.32) were recruited from a multisite research consortium across several universities. Methods: First-year participants self-reported on ADHD diagnosis and symptoms, functional impairments, and experiences transitioning to college. Results: First-year college students with and without ADHD reported significantly greater academic, daily living, and overall functional impairments during the pandemic compared to pre-pandemic. Compared to college students without ADHD, college students with ADHD reported greater functional impairment, more difficulty adjusting to the academic demands of college, and were less likely to feel valued at their institution. Conclusions: First-year college students with and without ADHD experienced greater difficulties navigating the transition to college during the pandemic. Psychosocial and academic supports to help students transition to college are needed.

Assessing Adult ADHD: An Updated Review of Rating Scales for Adult Attention Deficit Hyperactivity Disorder (ADHD)

METHOD

Scholarly articles on adult ADHD between 1996 and 2022 were reviewed using the PRISMA guidelines. ADHD rating scales with multiple citations were selected and their psychometric properties and symptom coverage were analyzed.

RESULTS

Ten rating scales, with sound psychometric properties, were identified. Out of those reviewed two (BADDS and BAARS-IV) load on the inattentive domain of ADHD, while the rest focus on a comprehensive assessment of ADHD. Only one scale (BARRS-IV) incorporates an assessment of functional impairment. Some scales though widely utilized have not been adequately examined for their sensitivity.

CONCLUSIONS

Rating scales are reliable and valid, in the assessment of adult ADHD. We present a review of recent scales, with an expanded focus, to help clinicians make informed decisions on diagnosis, identifying targets and planning interventions accordingly.

Real-World Efficacy and Safety of Extended-Release Methylphenidate (PRC-063) in the Treatment of ADHD in Pediatric and Adult Subjects: Results of a Phase IV Multicenter Comparison With Lisdexamfetamine Dimesylate

OBJECTIVE

To evaluate the real-world efficacy, safety, and functional outcomes of PRC-063 (multilayer-release methylphenidate) versus lisdexamfetamine (LDX) in ADHD subjects in a phase IV, open-label study.

METHOD

The primary endpoint was the change in the ADHD-DSM-5 Rating Scale (ADHD-5-RS) total score from baseline to Month 4. Secondary endpoints included a non-inferiority comparison between PRC-063 and LDX and measures of functioning and evening behavior.

RESULTS

One hundred forty-three pediatric and 112 adult subjects were enrolled. Mean ADHD-5-RS scores (standard deviation) were reduced in pediatric (-16.6 [10.4]) and adult (-14.8 [10.6]) subjects treated with PRC-063 (p < .001). PRC-063 was non-inferior to LDX in the pediatric population but not in the adult population. Significant improvements were demonstrated in quality of life and functionality. Both medications were well-tolerated; more adverse events led to study discontinuation in pediatric subjects treated with LDX versus PRC-063.

CONCLUSION

PRC-063 and LDX significantly improved ADHD symptomatology and functioning and were well-tolerated.

Predictors of Quality of Life and Functional Impairments in Emerging Adults With and Without ADHD: A 10-Year Longitudinal Study

OBJECTIVE

We tested the hypotheses that (1) a diagnosis of ADHD in childhood or adolescence is associated with reduced quality of life (QoL) and everyday functioning in emerging adulthood, and (2) executive function (EF) deficits, internalizing difficulties, and ADHD symptoms predict reduced QoL and more functional impairments.

METHOD

We assessed 85 children and adolescents with ADHD and 50 typically developing (TD) peers at baseline (M_age = 11.6 years, 58% males), 2-year follow-up, and 10-year follow-up with neuropsychological tests of EF and self-reports.

RESULTS

Individuals with ADHD reported lower QoL and functional impairments in emerging adulthood compared to TD peers. More internalizing difficulties and ADHD symptoms at baseline and 2-year follow-up significantly predicted lower QoL and more functional impairments at the 10-year follow-up.

CONCLUSION

ADHD and internalizing difficulties in childhood or adolescence have a negative impact on QoL and everyday functioning in emerging adulthood.

Functional outcomes of extended-release methylphenidate and atomoxetine in children: retrospective chart analysis

Background

Recent guidelines emphasize the importance of functional outcomes in children with attention-deficit/hyperactivity disorder (ADHD). Here, we assess the functional outcomes of the oral delivery system of osmotic-release methylphenidate (OROS-MPH) and atomoxetine (ATX) from the retrospective review of the chart for the last 2 years in the clinic.

Results

Linear mixed-effects models were performed with outcome measures of difference in ADHD symptoms and functional impairment. After 9–12 weeks, OROS-MPH and ATX were statistically equivalent for total Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) scores (difference in slope is β = 0.004, p = 1.000). However, OROS-MPH was superior to ATX in terms of school domain (difference in slope is β = 0.139, p < 0.001); ATX was superior in the family domain (slope difference in slope is β = 0.103, p < 0.001). The other domains of functioning both were not responsive to pharmacotherapy and were similar between the two medications.

Conclusions

Optimal management should monitor functional progress in ADHD beyond the core symptoms. As expected, ADHD medications provide a distinct pattern of functional improvement. Pharmacotherapy alone offers promising and reliable outcomes to improve school and family functions in ADHD. Some functional improvements did not respond to the medication; therefore, many of the techniques derived from behavioral interventions should be considered.

Adult-Onset ADHD: A Critical Analysis and Alternative Explanations

Attention deficit/hyperactivity disorder (ADHD) is characterized as a neurodevelopmental disorder. However, data from several recent studies suggest that there may be adults who meet current criteria for ADHD, yet did not experience symptoms until adulthood (i.e., "adult-onset ADHD"). This systematic review evaluated and synthesized the empirical evidence on adult-onset ADHD to answer the question: Is the extant literature strong enough to evaluate adult-onset ADHD? Nine studies met strict inclusion/exclusion criteria. Results suggest that the methodologies of the extant studies were not strong enough to evaluate adult-onset ADHD. Insufficient methodologies provide presently unclear information about the nature of late-onset symptoms. These symptoms seem to exist but their source could be (1) adult-emergent symptoms that were previously surpassed due to lower environmental demands/supportive facilitators, (2) mimics that were not properly assessed, or (3) childhood-onset symptoms that were not detected earlier due to failure to come to clinical attention. Future directions, clinical recommendations, and limitations of the literature and the current review are discussed.

Cognitive behavioural group therapy as addition to psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: a randomised controlled trial

BACKGROUND

Cognitive behavioural therapy (CBT) is recommended for attention-deficit/hyperactivity-disorder (ADHD) in adolescents. However, all CBTs are not created equal, and the guidelines do not specify which CBT interventions are the most effective for this patient group. This study examines the efficacy of a group CBT without parent involvement as follow-up treatment compared to no additional CBT in adolescents with persistent and impairing ADHD symptoms after a short psychoeducational intervention and medical treatment.

METHODS

The authors conducted a two-arm parallel randomized controlled trial in two child and adolescent mental health outpatient clinics in Norway. One hundred patients aged 14-18 years with a diagnosis of ADHD (66%) or subthreshold ADHD (34%) were randomized to either a 12-week group CBT program (N = 50) or a non-CBT control condition (N = 50). Assessments were made at admission to the clinic, two weeks before and two weeks after treatment. The primary outcomes were parent-, teacher- and self-ratings of ADHD symptoms (ADHD Rating Scale-IV), and the secondary outcomes were ratings of ADHD symptom severity, executive function, functional impairment, and emotional problems. Evaluators blinded to group allocation rated ADHD symptom severity with the Clinical Global Impression Scale for Severity (CGI-S) at baseline and post-treatment.

RESULTS

Analyses using mixed-effects models showed no difference between the treatment arms from baseline to post treatment in primary and secondary outcomes.

CONCLUSIONS

Contrary to our hypothesis, we found no incremental treatment effect on the part of a group CBT as follow-up to psychoeducation and pharmacological treatment on ADHD symptoms and accompanying impairments. Limitations with the CBT was the large number and low dosage of treatment components, causing restricted time for practice. Unlike evidence-based, individualized targeted CBTs with parent involvement, a group CBT directed solely at the adolescents with no parent involvement does not appear effective for treating ADHD.

TRIAL REGISTRATION

NCT02937142 , 18/10/2016.

ADHD prevalence in the psychiatric population

OBJECTIVE

This article presents a systematic literature review of the prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in the adult psychiatric population.

METHODS

Three databases were searched using keywords relating to ADHD and psychiatric disorders. Fifteen studies published before May 2020 met inclusion criteria.

RESULTS

Prevalence rates ranged from 6.9 to 38.75%. There was considerable heterogeneity with regards to the assessment methods of ADHD and comorbidities, the sampling as well as inclusion and exclusion of psychiatric comorbidities. Research concluded that ADHD is underdiagnosed in this population. Gender ratios also varied between 1.8:1 and 1:2.5 (male:female).

CONCLUSIONS

All ADHD prevalence rates for the psychiatric population were considerably higher than the 2.8% estimated for the general adult population. ADHD should be kept in mind for psychiatric patients to ensure accurate diagnosis and optimal treatment options.Key PointsADHD is considerably underdiagnosed in the psychiatric populationGender ratios between 1.8:1 and 1:2.5 (male:female) reported in researchMore research is needed to ascertain if the use of ADHD screening instruments would improve the recognition and treatment of adult ADHD in the psychiatric population.

Decision-making and Risky Behavior in Individuals with Attention-Deficit/Hyperactivity Disorder: A 10-year Longitudinal Study

We assessed 85 children with Attention-Deficit/Hyperactivity Disorder (ADHD) and 50 typically developing children (TD) (M_age = 11.59, 57.8% boys) with the Hungry Donkey Task (HDT) at baseline and 2-year follow-up, and the Iowa Gambling Task at 10-year follow-up (75% retention). Improvement in the proportion of advantageous choices was observed from two- to 10-year follow-up, but the ADHD group improved less and was outperformed by the TD group at the 10-year follow-up. More advantageous choices on the HDT at baseline predicted less risky behavior at 10-year follow-up. Male sex and more inattentive or externalizing symptoms at baseline predicted more risky behavior.

Personalized Remote Mobile Surveys of Adult ADHD Symptoms and Function: A Pilot Study of Usability and Utility for Pharmacology Monitoring

OBJECTIVE

Validate the usability and treatment-sensitivity of a remote SMS-based ADHD monitoring method.

METHOD

206 adults taking stimulants for ADHD participated. Participants selected ADHD symptoms and functional impairments that they anticipated to be stimulant-sensitive, which were rated via mobile messages up to 20 times over 10 days.

RESULTS

A majority of participants found it only somewhat or not at all difficult to identify an ADHD symptom sensitive to presence of stimulant medication, and 79% responded to at least one survey message. As expected, a majority of participants endorsed it was "easy" to participate, and less burdensome than a paper diary. Surveys significantly discriminated between on and off medication states, both between days, and within the same day.

CONCLUSION

Our findings suggest SMS-based monitoring of patient-selected ADHD-related challenges is both feasible and sensitive to stimulant treatment. This remote assay method may be a meaningful adjunct to in-visit treatment monitoring.

A measure of functioning in adults With ADHD: Psychometric properties of the general life functioning scale-parent version

OBJECTIVE

The General Life Functioning Scale (GLF) was developed to provide a complementary alternative to existing measures of impairment. We examined the psychometric properties of the GLF-Parent version (GLF-P), given the known value of informant ratings.

METHODS

The GLF-P was administered to parents of adults with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and a nonADHD comparison group in the Pittsburgh ADHD Longitudinal Study. GLF-P ratings described 334 participants (ADHD = 186; comparison = 148) rated at age 25 (Mage  = 24.80 years, SDage  = 0.46, range = 24-26) and 401 participants (ADHD = 237; comparison = 164) rated at age 30 (Mage  = 29.30, SDage  = 0.64, range = 28-33). Exploratory (EFA) and confirmatory (CFA) factor analyses were used.

RESULTS

EFAs suggested and CFAs confirmed a five-factor solution. We found measurement invariance across diagnostic and age groups, satisfactory internal consistency, construct validity, and known-group validity.

CONCLUSION

Psychometric results suggest the GLF-P as a helpful adjunctive measure of functioning. Further research is needed to determine the utility of the GLF across diverse settings.

Executive and Daily Life Functioning Influence the Relationship Between ADHD and Mood Symptoms in University Students

Objectives: Many studies have indicated a close relationship between ADHD and mood symptoms in university students. In the present study, we explore the role of daily functional impairments and executive functioning in the ADHD-mood relationship. Method: A total of 343 adults (126 males) filled out (a) the Conners' Adult ADHD Rating Scale, (b) the Depression Anxiety and Stress Scale, (c) the Weiss Functional Impairment Rating Scale, and (d) the Executive Function Index Scale. Results: The correlation between mood symptoms and ADHD was .48 (moderate correlation) and dropped to .15 (weak correlation) when controlling for functional problems and executive functioning. Hierarchical regression analyses showed that both functional impairments and executive functioning significantly explained 42% to 53% of the variance of mood symptoms. The addition of ADHD symptoms to the model slightly increased the explained mood variance by only 1%. Conclusion: These findings underline the role of experienced difficulties in triggering mood symptoms in ADHD symptomatology.

Basic and complex cognitive functions in Adult ADHD

Background

Many clinical studies reported deficits in basic and complex cognitive functions in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). However, the extent in which deficits in basic functions (i.e., processing speed and distractibility) contribute to complex cognitive impairments (i.e., working memory, planning, cognitive flexibility, memory functions) in adults with ADHD is not well-studied. So far, literature show only one study, revealing that basic functions explain 27–74% of executive dysfunctions. Yet, the authors reported that findings could be affected by the selection of neuropsychological tests. The goal of the present research is to replicate such a finding using a different sample and a different set of neuropsychological tests.

Methods

Forty-eight adult patients with ADHD were compared with 48 healthy controls in basic cognitive functions, namely processing speed and distractibility and more complex cognitive functions, namely selective attention, cognitive flexibility, planning, working memory, verbal fluency, and verbal memory. Basic and complex cognitive functions were assessed using the Vigilance and Sustained Attention, Selective Attention, N-Back, Tower of London, Trail Making Test, Word Fluency, and Verbal Learning and Memory.

Results and conclusion

Logistic regression analyses showed that impairments in complex cognitive functions explained 25% of the variance in ADHD diagnosis. The explained variance dropped from 25% to 9% after considering basic functions of processing speed and distractibility. This 64% reduction highlights the importance of basic functions for impairments in complex functions in patients with ADHD.

More than off-task: Increased freely-moving thought in ADHD

Off-task thought has been found to occur at high rates and is related to impairment in ADHD. However, off-task thought is heterogenous and it remains unclear which specific dimensions of off-task thought are more prevalent in this disorder. It is therefore important to dissociate different aspects of off-task thought in order to better understand the mechanisms underlying impairment. The current study focused on the dimension of constrained (focused) to freely moving off-task thought. Self-report and neurophysiological measures during a computerized attention tasks provided convergent evidence that individuals with ADHD not only have more off-task thought than those without, but also engaged in a greater proportion of freely moving off-task thought than non-ADHD controls. Overall, this work demonstrated differences in both the quantity and type of off-task thought in adults with ADHD. It provides novel insight into both the phenomenology of off-task thought, as well as potential mechanisms underlying impairment in ADHD.

What can we learn about performance validity from TOVA response profiles?

Given the functional impairments associated with Attention Deficit/Hyperactivity Disorder (AD/HD), a valid diagnosis is important. However, particularly when carried out in adulthood, the diagnostic process can be challenging and is complicated by conclusive evidence that a proportion of individuals referred for evaluation of AD/HD exaggerate or feign their symptoms. Relatively few methods, however, exist to identify such feigning. While continuous performance tests (CPTs) may provide useful information regarding performance validity, the question remains as to whether there are consistent patterns of exaggeration demonstrated by those feigning AD/HD. Thus, this study used cluster analysis to determine whether valid and reliable performance clusters would emerge based on CPT performance. Using archival data from a university-based AD/HD screening clinic, we investigated the performance of 305 adults on the Test of Variables of Attention (TOVA). Three profiles emerged, including one cluster who demonstrated exceptionally low performance on the TOVA, exceptionally high reports of AD/HD symptomology, and higher rates of failure on symptom and performance validity tests. The implication from our analysis is that this group most likely represents individuals who were exaggerating or magnifying their difficulties. The results reaffirm previous research showing that performance profiles on a continuous performance test can be used as an indicator of credible performance.

Unique considerations in the assessment of ADHD in college students

Evidence-based practice in psychology (EBPP) has long focused on treatment, but evidence-based psychological assessment (EBPA) is also crucial given the important role of accurate and reliable diagnostic practices in treatment planning. In terms of the diagnosis of attention-deficit/hyperactivity disorder (ADHD), EBPA practices are well-established for children, and more recently for adults, but for college students in particular there are special considerations that warrant attention. College students with symptoms of ADHD have some challenges that are unique, and thus the assessment and diagnosis of ADHD in these students is unique. The aim of this review is not to cover all EBPA strategies for diagnosing ADHD in emerging adult college students; rather, we will focus on the unique considerations at play in college ADHD assessment. These include (a) conceptual matters such as the appropriateness of the DSM-5 criteria for college students, the limitations of our understanding of ADHD this population because of a lack of diversity in research studies, and the issue of late-identified ADHD; and (b) practical matters, such as specific documentation needs, how to gather and interpret self- and other-report of symptoms, how to assess impairment, and alternate explanations for ADHD-like symptoms in college students.

Study of Functional Impairment in Students of Elementary and Secondary Public Schools in Iran

OBJECTIVE

The current study aimed to investigate the frequency of impairment in different functional domains of life and the relationship between sex and age and functional impairment in school-based samples of Iranian children and adolescents.

METHOD

A sample of 270 children (ages 6-11) enrolled in two public elementary schools and a sample of 386 adolescents (ages 12-17) enrolled in four public secondary schools were selected by multistage sampling. The Persian version of the parent report form and self-report form of the Weiss Functional Impairment Rating Scale (WFIRS-P and WFIRS-S) were used for evaluating functional impairment in children and adolescents, respectively. Two-way analyses of variance (two-way ANOVAs) were conducted to explore the main effects and the interaction effect of sex and age on functional impairment.

RESULTS

11.9% of children and 29.5% of adolescents showed impairment in at least two functional domains of life. The most frequent impaired domain was life skills (22.6% of children and 30.3% of adolescents). While no significant sex and age effect was found during childhood, male adolescents showed more impairment in externalizing domains and female adolescents showed more internalizing difficulties. In addition, older adolescents showed more functional impairment relative to younger adolescents.

CONCLUSIONS

Detailed knowledge of the relationship between sex and age and functional impairment could be a starting point to target the major psychosocial elements of these challenges.

Psychometric properties of the Weiss Functional Impairment Rating Scale parent and self-reports in a Norwegian clinical sample of adolescents treated for ADHD

OBJECTIVE

To analyze the psychometric properties of the Norwegian version of the Weiss Functional Impairment Rating Scale parent and self-reports (WFIRS-P and WFIRS-S) in adolescents with ADHD.

METHODS

102 clinically referred patients, of which 86% were enrolled in an ongoing RCT program (Clinical trials NCT02937142), were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders version IV (DSM-IV). The conceptual framework of the WFIRS-P and the WFIRS-S was evaluated using confirmatory factor analysis (CFA), reliability was estimated using Cronbach's alpha, convergent and divergent validity was assessed using correlations with the Children's Global Assessment Scale (C-GAS) and the ADHD Rating Scale-IV (ADHD-RS-IV).

RESULTS

CFA supported the original factor structure of the questionnaires, both a first-order and a second-order model revealed acceptable model fit. Internal consistency was satisfactory across domains. The parent-adolescent agreement was moderate. The correlations between the C-GAS and the total scores of the WFIRS-P and WFIRS-S were low to moderate (r = -0.29 to -0.38). The ADHD-RS-IV correlated moderately (r = 0.49) with WFIRS-P, the correlation with WFIRS-S was weak (r = 0.28) supporting divergent validity. In multiple regression analyses, the ADHD-RS total score was the strongest predictor of the total score in both the WFIRS questionnaires, with internalizing disorder showing an additional small contribution. Age, gender and full-scale IQ gave no additional contribution in explaining the variance.

CONCLUSIONS

The findings support the use of the Norwegian version of the WFIRS-S and the WFIRS-P in the evaluation of functional impairment in adolescents with ADHD.

Functional impairment outcomes in clinical trials of different ADHD medications: post hoc responder analyses and baseline subgroup analyses

Several recent phase 3 clinical trials of attention-deficit/hyperactivity disorder (ADHD) medications have used the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P). Here, we assess WFIRS-P response in individual patients in two pivotal trials of lisdexamfetamine dimesylate (LDX) and guanfacine extended release (GXR). We also analysed pooled WFIRS-P data from seven phase 3 studies of ADHD medications to shed light on factors associated with baseline functional impairment. The proportion of patients with a change in WFIRS-P score that exceeded the minimal important difference (MID) criteria for response was greater for LDX than placebo in the Family, Learning and School, and Risky Activities domains, and was greater for GXR than placebo in the Social Activities, Learning and School, and Family domains. Responders had significantly worse baseline scores in all WFIRS-P domains (all p < 0.001) than non-responders. In the pooled analyses, baseline WFIRS-P scores in all domains were significantly worse in participants with oppositional defiant disorder (ODD) than in those without ODD. Having combined type or hyperactive-impulsive type ADHD, being enrolled into a study in Europe, being male and being younger also had modest negative effects on baseline WFIRS-P scores. The present analysis of WFIRS-P response shows that previously reported group-level improvements in WFIRS-P functional impairment score translated into clinically relevant improvements in many individual participants. Functional impairment is a diverse and subjective construct that is influenced by multiple factors. Optimal management of individuals with ADHD should involve monitoring improvements in functioning and quality of life, as well as symptomatic improvement.

Negative parenting behaviour as a mediator of the effects of telephone-assisted self-help for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder

A previous randomised controlled trial demonstrated the effects of a telephone-assisted self-help (TASH) intervention for parents of pharmacologically treated children with attention-deficit/hyperactivity disorder (ADHD) on ADHD symptoms, oppositional symptoms, functional impairment, and negative parenting behaviour (per-protocol analyses). In the current study, we examined whether changes in positive and negative parenting behaviour mediated the effects on symptoms and impairment. Parents in an enhancement group (n = 51) participated in a 12-month TASH intervention (eight booklets plus up to 14 telephone consultations) as an adjunct to routine clinical care, whereas parents in a waitlist control group (n = 52) received routine clinical care only. Parents completed measures of child symptoms, child functional impairment, and parenting behaviour at baseline, at 6 months, and at 12 months. The mediating effects of parenting behaviour were examined using regression analyses. Per-protocol analyses (n = 74) revealed a significant indirect intervention effect on functional impairment through negative parenting behaviour at 6 months as well as indirect intervention effects on oppositional symptoms and functional impairment through negative parenting behaviour at 12 months. The indirect effect on ADHD symptoms through negative parenting behaviour at 12 months just failed to reach significance. The analyses yielded no indirect intervention effects through positive parenting behaviour. The study provides some, albeit limited, support for the importance of changes in negative parenting behaviour to achieve changes in symptoms and functional impairment during parent training. In consideration of the inconsistent results of previous studies concerning the mediating role of positive and negative parenting behaviour, further research is required to better understand the mechanisms of change during parent training, also including other possible mediators like parenting stress and parental self-efficacy.

Cognitive-behavioural group therapy for adolescents with ADHD: study protocol for a randomised controlled trial

INTRODUCTION

Persistence of attention deficit hyperactivity disorder (ADHD) into adolescence is a significant burden to patients. Clinical guidelines recommend non-pharmacological therapies, but the evidence to support this recommendation is sparse. This study aims to evaluate the effect of a 12-week group cognitive-behavioural therapy (CBT) programme for adolescents with ADHD aged 14-18 years, who still have impairing symptoms after treatment with medication. We will study the effect of the treatment on ADHD symptoms and examine moderators and mediators of the effect of the treatment on ADHD.

METHODS AND ANALYSIS

We conduct a randomised controlled trial of CBT group therapy in adolescents with ADHD recruited from child psychiatric outpatient units in Mid-Norway. 99 adolescents who met inclusion criteria and consented to participation have been randomised to a 12-week group intervention or to a control group receiving treatment as usual. Assessments are made at admission to the clinic, preintervention, postintervention and at a 9-month follow-up, obtaining adolescent, parent and teacher reports. Clinicians blinded to group allocation rate all participants as to their functioning preintervention and at the two postintervention assessment points. The primary outcome is change in symptom scores on the ADHD Rating Scale-IV.

ETHICS AND DISSEMINATION

The Regional Committee for Medical and Health Research Ethics in South East Norway approved the study protocol (2015/2115). We will disseminate the findings in peer-reviewed publications and conference presentations, to user organisations and at courses attended by families and professionals. Two PhD students will publish and defend dissertations relating to the study. Planned publications include primary and secondary outcomes and patient satisfaction with the treatment. Furthermore, we plan to publish a manual of CBT group therapy in adolescent ADHD to benefit treatment of patients in Norway and elsewhere.

TRIAL REGISTRATION NUMBER

NCT02937142.

Empirical examination of executive functioning, ADHD associated behaviors, and functional impairments in adults with persistent ADHD, remittent ADHD, and without ADHD

BACKGROUND

Previous studies suggest that childhood attention deficit hyperactivity disorder (ADHD) may continue in adulthood, producing adverse effects. Therefore, identifying factors that help to differentiate characteristics of ADHD persistence and remission has practical implications for evaluation and treatment. The first aim of this study was to analyze differences in executive functions (shift, working memory, inhibition, and plan/organize), symptoms associated with ADHD (inattention, hyperactivity, emotional lability, and self-concept), and functional impairments in adults with persistent ADHD (ADHD-P), with remittent ADHD (ADHD-R), and without ADHD (N-ADHD). The second aim was to study the contribution of functional impairments in these three groups based on executive functions and associated ADHD behaviors.

METHODS

Participants were 115 adults, 61 with a childhood ADHD diagnosis (40 persisters and 21 remitters) and 54 individuals with typical development. Self-reports were collected on executive functions, symptoms associated with ADHD, and functional impairments. Multivariate Analyses of Variance were conducted to test differences between the ADHD-P, ADHD-R, and N-ADHD groups on the evaluated variables. In addition, analyses were performed using two structural equation models with observed variables (path analyses).

RESULTS

The results indicated that significant executive and behavioral impairments and adverse functional outcomes in different life domains are related to the diagnostic persistence of ADHD. Recovery from the disorder is associated with better results, although hyperactivity/restlessness behaviors and plan/organize deficits continue to be present in remitter individuals.

CONCLUSIONS

The ADHD-P and ADHD-R groups showed some differences in their executive, behavioral, and functional impairments. Furthermore, the impairments in each group can be predicted by different executive functions and other symptoms associated with the disorder. These results should be taken into account in order to improve clinical practice.

Executive Functioning and Impairment in Emerging Adult College Students With ADHD Symptoms

Objective: To better understand current issues with adult ADHD assessment contributing to adult ADHD being under recognized and undertreated. Method: This study examined the relationship between symptoms, impairment, and executive functioning (EF) in a college sample. Results: Among individuals screening negative for ADHD, those higher in EF experienced significantly less impairment than those lower in EF. Executive functioning was shown to have a negative relationship with impairment while ADHD symptomology was shown to have a positive relationship with impairment. In addition, impairment was significantly predicted by ADHD symptom level and EF, and there was a significant interaction between EF and ADHD symptom level in predicting impairment. However, high EF did not significantly protect against impairment in individuals reporting a significant level of ADHD symptoms. Conclusion: Further research is needed to clarify the relationships between these variables in emerging adult college students.

Psychometric Properties of the Persian Version of the Weiss Functional Impairment Rating Scale-Self-Report Form in Iranian Adolescents

OBJECTIVE

The Weiss Functional Impairment Rating Scale-Self-Report Form (WFIRS-S) was developed as a measure of functional impairment in adolescents and adults with ADHD. This study reports the psychometric properties of the Persian version of the WFIRS-S in a sample of normal Iranian adolescents.

METHOD

Internal consistency and factor structure of the WFIRS-S were tested on a sample of 386 students (Grades 7-12). The test-retest reliability and the convergent validity of the WFIRS-S were evaluated by using two different subsamples including 50 and 100 students, respectively.

RESULTS

The Cronbach's alpha values were between .72 and .94 for the WFIRS-S subdomains and total scale. The test-retest reliability was .80 for the total scale. The WFIRS-S subdomains had moderate to high significant correlations with the Pediatric Quality of Life total scale.

CONCLUSION

The Persian version of the WFIRS-S has acceptable psychometric properties and could be used as a functional impairment assessment for adolescents.

Validation of the French Version of the Weiss Functional Impairment Rating Scale-Self-Report in a Large Cohort of Adult Patients With ADHD

Objective: To analyze the psychometric properties of the French version of the Weiss Functional Impairment Rating Scale-Self Report (WFIRS-S) in a large clinical sample of adults with ADHD. Method: Patients (N = 363) were diagnosed with ADHD according to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) criteria. Psychometric properties of the French version of the WFIRS-S were tested including construct validity with a confirmatory factor analysis, internal structural validity with Cronbach's alpha coefficient, external validity by correlations with the Beck Depression Inventory-II (BDI-II), and the EuroQol five-dimension (EQ-5D) questionnaire. Results: The confirmatory factor analysis found the following: root mean square error of approximation (RMSEA) = 0.061, 90% confidence interval (CI) = [0.058, 0.063]; comparative fit index (CFI) = 0.67. Cronbach's alpha coefficient was .91. Correlations with EQ-5D descriptive index, visual analogue scale (VAS) scores, and BDI-II scores were -0.48, -0.55, and 0.53, respectively. Conclusion: The French version of the WFIRS-S is a psychometrically acceptable self-reported questionnaire for the multi-domain evaluation of functional impairments in adults with ADHD, for research and clinical purposes.

Error monitoring and daily life executive functioning

Error monitoring during task execution is reflected in post-error slowing (PES), which refers to the tendency to slow down performance after making an error in order to prevent future mistakes. The key question of the present study is whether poor error monitoring (reduced magnitude of PES) has negative consequences for daily life executive function skills, as well as functioning in different life settings such as work, family, social, and academic settings. Eighty-five university students performed a lexical decision task and completed The Executive Function Index Scale (EFI), and the Weiss Functional Impairments Rating Scale (WFIRS). Individual academic achievement was measured using the Grade Point Average. Statistical analysis revealed that a decreased magnitude of PES was weakly associated with less efficient planning (one of the executive functions). Results suggest that error monitoring, as measured by PES, was not associated with functioning in a naturalistic environment, but could be interpreted to some extent as an experimental marker of planning in daily life executive functioning.

Is it possible to determine the level of functional impairment that distinguishes the patients with ADHD from those without ADHD?

INTRODUCTION

Functional impairment in attention deficit hyperactivity disorder (ADHD) can occur in many areas such as in family, social activities, and problems related to school and may also persist during adulthood. The Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P) is designed to measure the functional impairment related to ADHD symptoms. The aim of this study was to determine the level of functional impairment that distinguishes the patients with ADHD who were diagnosed through semi-structured interviews from those without ADHD.

METHOD

This study consists of ADHD patients who were diagnosed through semi-structured interview aged 5-18 years (n = 250) and same age gender-matched healthy controls (n = 250). A receiver operating characteristic (ROC) curve was constructed by calculating the sensitivity and specificity of the scale cut-off values.

RESULTS

An area under the curve (AUC) of 0.974 (95% CI 0.956-0.986) was found in this study. For WFIRS-P subdomains, AUC curves, which range from 0.76 to 0.95, were also having strong power for differentiation between groups. The optimal cut-off value for WFIRS-P using Youden's J Index is 0.32. There is no significant gender and age group differences in AUC for either the total or subdomain scores.

CONCLUSION

Our findings provide that Turkish version of WFIRS-P could be a reliable way of distinguishing the level of functional impairment in ADHD from controls.

Descriptive and psychometric properties of the Persian version of the Weiss functional impairment rating scale: parent report form in Iranian children

Background

This study evaluates the descriptive and psychometric properties of the Persian version of the Weiss Functional Impairment Rating Scale-Parent Report Form (WFIRS-P) in a normal sample of Iranian children.

Method

Parents of 282 students (grades 1–6) completed the WFIRS-P. Means and standard deviations were computed for the total scale, each domain, and each item of the WFIRS-P. Internal consistency, interdomain correlations, and test-retest reliability were used to assess the reliability of the scale.

Results

Among the WFIRS-P domains, life skills had the highest rated impairment (M = 0.50, SD = 0.37) and risky activities had the lowest. Internal consistency (α = .88) and test-retest reliability (r = 0.77) were strong for the WFIRS-P total scale. The correlation between the WFIRS-P domains and the total scale ranged from 0.52 to 0.81.

Conclusions

Results suggest that the Persian version of the WFIRS-P is a useful and psychometrically reliable measure for assessing functional skills in children.

Conceptual review of measuring functional impairment: findings from the Weiss Functional Impairment Rating Scale

Objective

This is a narrative review of validation and outcome studies using the Weiss Functional Impairment Rating Scale (WFIRS). The objective of the review is to establish a framework for understanding functional impairment and create a definition for functional response and remission.

Methods

We conducted a literature search via MEDLINE, EBSCO and Google Scholar with no date restrictions and reviewed bibliographies of selected publications. Publications found in languages other than English were translated and clarification obtained from the author(s) if needed. Inclusion criteria were any manuscript that was either a WFIRS psychometric validation study or a clinical trial using the WFIRS as an outcome. There were no exclusion criteria.

Results

The WFIRS has been validated in multiple cultures, and in clinical, research and control populations. The WFIRS has robust psychometric properties across ages, psychiatric status and informants. Outcome studies show variable improvement, with different response patterns between domains and among different interventions.

Conclusion

Symptom improvement and remission needs to be complemented with evaluation of functional improvement and remission to obtain a full picture of clinical status over the course of treatment.

The Compensatory ADHD Behaviors Scale (CABS): Development and Initial Validation

Several measures are available that assess inattention, hyperactivity/impulsivity, and executive functioning deficits. Treatments for adults with attention-deficit/hyperactivity disorder (ADHD) and skill-based academic interventions focus on improving compensatory strategies to ameliorate functional impairment; however, no measure exists that examines the compensatory behaviors adults utilize to compensate for the functional deficits associated with inattention and hyperactivity/impulsivity. The current study aimed to determine the psychometric properties of the Compensatory ADHD Behaviors Scale (CABS). Five-hundred participants (M_age = 36.83, SD = 11.57) completed measures of ADHD symptomatology, executive functioning, functional impairment, mood disorder symptoms, and the CABS. Analyses revealed that scales assessing both use and effectiveness of compensatory behaviors subscales had similar factor structures, reflecting present- and future-oriented behaviors. The present-, but not future-oriented, behaviors significantly related to ADHD symptomatology, executive dysfunction, and functional impairment; effectiveness of present-oriented compensatory behaviors demonstrated incremental validity in predicting impairment. Compensatory strategies may be a useful variable to measure when examining functional impairment associated with inattention and hyperactivity/impulsivity. The current study provides preliminary evidence of the ability of CABS to validly measure various strategies associated with (clinical and subclinical) ADHD symptomatology, executive functioning, and overall impairment.

Individualised short-term therapy for adolescents impaired by attention-deficit/hyperactivity disorder despite previous routine care treatment (ESCAadol)-Study protocol of a randomised controlled trial within the consortium ESCAlife

BACKGROUND

Despite the high persistence rate of attention-deficit/hyperactivity disorder (ADHD) throughout the lifespan, there is a considerable gap in knowledge regarding effective treatment strategies for adolescents with ADHD. This group in particular often shows substantial psychosocial impairment, low compliance and insufficient response to psychopharmacological interventions. Effective and feasible treatments should further consider the developmental shift in ADHD symptoms, comorbidity and psychosocial adversity as well as family dysfunction. Thus, individualised interventions for adolescent ADHD should comprise a multimodal treatment strategy. The randomised controlled ESCAadol study addresses the needs of this patient group and compares the outcome of short-term cognitive behavioural therapy with parent-based telephone-assisted self-help.

METHODS/DESIGN

In step 1, 160 adolescents aged 12 to 17 years with a diagnosis of ADHD will undergo a treatment as usual (TAU) observation phase of 1 month. In step 2, those still severely affected are randomised to the intervention group with an Individualised Modular Treatment Programme (IMTP) or a telephone-assisted self-help programme for parents (TASH) as an active control condition. The IMTP was specifically designed for the needs of adolescent ADHD. It comprises 10 sessions of individual cognitive behavioural therapy with the adolescents and/or the parents, for which participants choose three out of 10 available focus modules (e.g. organisational skills and planning, emotion regulation, problem solving and stress management, dysfunctional family communication). TASH combines a bibliotherapeutic component with 10 counselling sessions for the parents via telephone. Primary outcome is the change in ADHD symptoms in a clinician-rated diagnostic interview. Outcomes are assessed at inclusion into the study, after the TAU phase, after the intervention phase and after a further 12-week follow-up period. The primary statistical analysis will be by intention-to-treat, using linear regression models. Additionally, we will analyse psychometric and biological predictors and moderators of treatment response.

DISCUSSION

ESCAadol compares two short-term non-pharmacological interventions as cost-efficient and feasible treatment options for adolescent ADHD, addressing the specific needs and obstacles to treatment success in this group. We aim to contribute to personalised medicine for adolescent ADHD intended to be implemented in routine clinical care.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS), Current Controlled Trial DRKS00008974, http://apps.who.int/trialsearch/Trial2.aspx?TrialID=DRKS00008974 ; http://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00008974 ; Registered on 28 December 2015.

ADHD in acute care psychiatric inpatients

Attention-deficit hyperactivity disorder (ADHD) is a neurocognitive disorder characterized by symptoms of inattention, impulsivity and motor hyperactivity. The worldwide prevalence of ADHD, in the general adult population, has been estimated to be 2.8%. Patients with ADHD have a high incidence of comorbidity with other psychiatric disorders. Those with a psychiatric disorder as well as ADHD have more psychosocial difficulties than those without ADHD. Despite knowing that ADHD is often comorbid with other psychiatric diagnoses, there are currently no studies elucidating the prevalence of ADHD in the inpatient psychiatric population, nor is there significant information about its impact. The lack of research into this topic suggests more needs to be done in the field of adult ADHD, especially in the inpatient psychiatric population and with respect to impairment in patient function. Knowing the prevalence of ADHD and its impact on quality of life in adult inpatients will help lay the groundwork for effective screening and management. The purpose of this study was to understand the prevalence rates of ADHD among psychiatric acute care inpatients. Other objectives included comparing the quality of life and functioning between patients with a primary psychiatric diagnosis and ADHD (treated or untreated) versus those with a primary psychiatric diagnosis and no ADHD. Thirty-three (N = 31) psychiatric inpatients were screened using the Adult ADHD Self-Report Scale. Those that screened positive for ADHD received a full diagnostic assessment for ADHD. All patients completed the Weiss Functional Impairment Rating Scale (WFIRS) to assess level of functioning and a Clinical Global Impression of Severity/Improvement Scale (on admission and discharge). Demographic information was also obtained. Of the 31 patients analyzed, 12 had a diagnosis of ADHD (36.4%). The participants diagnosed with ADHD scored significantly higher on the WFIRS, suggesting decreased functioning compared to patients without comorbid ADHD. Patients with ADHD also scored significantly higher in the individual domains of this rating scale, suggesting impairment in family, work and social functioning as well as decreased life-skills, poor self-concept and increased risk-taking behavior. In this sample, the prevalence of ADHD is significantly higher among acute care psychiatric inpatients than in the general population. Patients with concomitant ADHD suffer more functional impairment than those without. These findings merit further investigation into the value of routine screening and patient-specific treatment of ADHD in this patient population.

Psychometric Properties of the Impairment Rating Scale in Samples of Adults With Attention Deficit Hyperactivity Disorder

Adults with attention deficit hyperactivity disorder (ADHD) are impaired in numerous domains. However, psychometrically sound measures assessing broad-ranging impairment, particularly brief scales for diagnostic purposes, are scarce. The Impairment Rating Scale (IRS), originally developed to assess ADHD-related impairment in children, has been adapted to a 12-item self-report measure of impairment in adults. In this study, the psychometric properties of the adult IRS were examined in three samples. In Studies 1 and 2, the adult IRS demonstrated good convergent, divergent, and incremental validity among college students and an online sample of adults, respectively. In the same studies, an appropriate clinical cutoff score was identified (IRS item score ≥1) using diagnostic tests. In Study 3, the adult IRS demonstrated good interrater reliability between ratings provided by romantic partners. Overall, findings support the clinical utility of the adapted IRS for assessing the impairment diagnostic criterion for ADHD in adults.

The Weiss Functional Impairment Rating Scale-Parent Form for assessing ADHD: evaluating diagnostic accuracy and determining optimal thresholds using ROC analysis

Purpose

The Weiss Functional Impairment Rating Scale-Parent Form (WFIRS-P) is a 50-item scale that assesses functional impairment on six clinically relevant domains typically affected in attention-deficit/hyperactivity disorder (ADHD). As functional impairment is central to ADHD, the WFIRS-P offers potential as a tool for assessing functional impairment in ADHD. These analyses were designed to examine the overall performance of WFIRS-P in differentiating ADHD and non-ADHD cases using receiver operating characteristics (ROC) analysis. This is the first attempt to empirically determine the level of functional impairment that differentiates ADHD children from normal controls.

Methods

This observational study comprised 5–19-year-olds with physician-diagnosed ADHD (n = 476) and non-ADHD controls (n = 202). ROC analysis evaluated the ability of WFIRS-P to discriminate between ADHD and non-ADHD, and identified a WFIRS-P cut-off score that optimises correct classification. Data were analysed for the complete sample, for males versus females and for participants in two age groups (5–12 versus 13–19 years).

Results

Area under the curve (AUC) was 0.91 (95% confidence interval 0.88–0.93) for the overall WFIRS-P score, suggesting highly accurate classification of ADHD distinct from non-ADHD. Sensitivity (0.83) and specificity (0.85) were maximal for a mean overall WFIRS-P score of 0.65, suggesting that this is an appropriate threshold for differentiation. DeLong’s test found no significant differences in AUCs for males versus females or 5–12 versus 13–19 years, suggesting that WFIRS-P is an accurate classifier of ADHD across gender and age.

Conclusions

When assessing function, WFIRS-P appears to provide a simple and effective basis for differentiating between individuals with/without ADHD in terms of functional impairment.

Classification

Disease-specific applications of QOL research.