Screening for Adult Attention-Deficit/Hyperactivity Disorder in a Psychiatric Outpatient Population with Specific Focus on Sex Differences

Methylphenidate and Atomoxetine in Pregnancy and Possible Adverse Fetal Outcomes: A Systematic Review and Meta-Analysis

Importance

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders, and it afflicts about 7% of young people. As a consequence, many young women might be pregnant while taking medication for ADHD, but data about safety have not yet been strictly examined.

Objective

To examine adverse effects in offspring of mothers receiving treatment with atomoxetine and methylphenidate during pregnancy.

Data Sources

Electronic databases (PubMed, Embase, and PsycINFO) were searched for articles published through December 31, 2023, with the following search terms: (atomoxetine OR methylphenidate) AND (pregnancy).

Study Selection

Observational studies (eg, cohort studies, case-control studies, case-crossover studies, cross-sectional studies, and registry-based studies) that reported offspring outcomes in pregnancy with atomoxetine and/or methylphenidate and in mothers with ADHD but unexposed to ADHD treatment during pregnancy or from the general population were included. Ten studies of 656 records satisfied criteria.

Data Extraction and Synthesis

Two independent reviewers performed data extraction according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses were conducted based on reported odds ratios (ORs) and corresponding 95% CIs using a linear random effects model. Each study was inversely weighted by the reported variance of the estimators. Risk of publication bias and analysis of heterogeneity through univariate and multivariate metaregressions were also rated. Data were analyzed from January to March 2024.

Main Outcomes and Measures

Study outcomes included miscarriages and congenital anomalies.

Results

Ten studies involving 16 621 481 pregnant women, 30 830 of them affected by ADHD, were included. Congenital anomalies or miscarriages were not more frequent in offspring of mothers receiving treatment with methylphenidate or atomoxetine during pregnancy compared with unexposed offspring (OR, 1.14; 95% CI, 0.83-1.55; P = .41; I2 = 8% for congenital anomalies; OR, 1.01; 95% CI, 0.70-1.47; P = .96; I2 = 0% for miscarriages) or compared with the general population (OR, 1.19; 95% CI, 0.93-1.53; P = .16; I2 = 74% for congenital anomalies; OR, 1.05, 95% CI, 0.81-1.37; P = .70; I2 = 0% for miscarriage).

Conclusions and Relevance

Evidence from this meta-analysis, which involves a substantial sample of pregnant women with and without ADHD, suggests the maintenance of methylphenidate or atomoxetine during pregnancy is safe, given that congenital anomalies and miscarriages did not appear to significantly increase. Further studies are recommended to support and confirm these findings.

Adult ADHD Symptoms in a Large Metropolitan Area From Brazil: Prevalence and Associations with Psychiatric Comorbidity, Bullying, Sexual Abuse, and Quality of Life

OBJECTIVE

The aim of this study was to investigate the prevalence and psychiatric correlates of symptomatic ADHD in a large metropolitan area of a middle-income country.

METHODS

An in-person household survey with randomly selected 2,297 adults aged 19 to 60 from Rio de Janeiro, Brazil, assessed by trained lay interviewers. The Adult Self-Rating Scale Screener (ASRS-6) was used. Chi-square and logistic regression were conducted.

RESULTS

ADHD prevalence was 4.59 (95% CI [3.56, 5.44]). Those with ADHD were younger and more often unemployed; they displayed more psychiatric symptoms (depression, anxiety, and alcohol abuse) and a history of bullying and sexual abuse. They also had worse physical health indicators. Findings remained significant when controlling for socioeconomic variables.

CONCLUSION

Adults with symptomatic ADHD from a large metropolitan area in Brazil show a pattern of findings consistent with what has been observed in higher-income countries.

Self-reported attention and hyperactivity symptoms among adults with epilepsy

BACKGROUND

 Patients with epilepsy (PWE) frequently have comorbid psychiatric disorders, the most common of which are depression and anxiety. Attention deficit disorder with hyperactivity (ADHD) is also more frequent among PWE, though that condition has been scarcely studied among the adult PWE population.

OBJECTIVE

 This study aimed to compare the presence of ADHD symptoms between adult PWE and the general population.

METHODS

 This was an observational case-control study. Ninety-five adult PWE from a tertiary center in southern Brazil were compared with 100 healthy controls. All subjects were submitted to three structured scales: 1) the World Health Organization Adult ADHD Self-Report Scale version 1.1 (ASRS); 2) the Hospital Anxiety and Depression Scale (HADS); and 3) the Adverse Events Profile (AEP). Dichotomic variables were analyzed through chi-square test and Fisher's exact test, as appropriate, and non-parametric variables were analyzed through the Mann-Whitney U test.

RESULTS

 Medians and interquartile ranges (IR) were: 1) ASRS: 26.00 (IR: 18 to 38) among PWE versus 17.00 (IR: 11 to 24) among controls, p < 0.001; 2) HADS: 14.00 (IR: 8 to 21) among PWE versus 11.00 (IR: 8 to 16) among controls, p = 0.007; 3) AEP: 3800 (IR: 31 to 49) among PWE versus 33.00 (IR: 23 to 43) among controls, p = 0.001.

CONCLUSION

 PWE showed a higher burden of symptoms of ADHD, depression, and anxiety when compared with controls, which replicates in the Brazilian population the findings of current literature that point toward a higher prevalence of such disorders among PWE.

Gender differences in transdiagnostic domains and function of adults measured by DSM-5 assessment scales at the first clinical visit: a cohort study

BACKGROUND

Measurement-based care has been called for as best practice in psychiatric care and learning health systems and use of transdiagnostic measures was suggested as part of the DSM-5. Our objective is to examine gender differences in first visit socioeconomic, transdiagnostic, and functional characteristics of a dynamic, real-world measurement-based care cohort.

METHODS

Transdiagnostic, functional, and clinical measures were collected from 3,556 patients at first visit in an ambulatory psychiatric clinic. All patients were evaluated at the first visit by board-certified psychiatrists or licensed clinical psychologists. Demographic variables and clinical diagnoses were collected from the Electronic Medical Record. Self-report measures were collected that assessed transdiagnostic symptoms (DSM-5 Level 1 Cross-cutting Measure and Level 2 symptom scales), disability, alcohol use, attention deficit hyperactivity disorder (ADHD) symptoms, depression, anxiety, mania, suicidal thoughts and behaviors, and trauma exposure.

RESULTS

Men and women did not differ in age, BMI, household income, high school graduation rate, race, or ethnicity, but women were more likely to be formerly married and less likely to have commercial insurance. Compared to men, women reported significantly higher overall psychopathology on the transdiagnostic Level 1 Cross-cutting measure and had higher depression, anxiety, sleep, anger, ADHD combined presentation, and suicidality severity. Women also had higher disability scores than men. However, men reported higher alcohol, tobacco and substance use, and more risky behavior than women. Trauma exposure differed significantly by gender; men reported more exposure to accidents, war-related trauma, serious accidents, and major disasters and women reported more unwanted sexual contact.

CONCLUSIONS

This cross-sectional study of a transdiagnostic, ecologically-valid real-word measurement-based care cohort demonstrates gender differences in socioeconomic factors, trauma exposure, transdiagnostic symptoms, and functioning.

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

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

Alarmingly high prevalence and lack of gender differences in ADHD among high school students: Screening for ADHD with ASRS among adolescents and working adults

Introduction: The aim was to examine the psychometric properties of the Polish version of the Adult ADHD Self-Report Scale (ASRS) among adolescents and adult working populations of different genders, the prevalence of ADHD, and its relationship to stress.

Materials and methods: A sample of 723 professionally active people and 1744 high school students participated in the study. Part A of the Adult ADHD Self-Report Scale (ASRS) was used to measure ADHD and the 4-item Perceived Stress Scale (PSS-4) was used to measure stress.

Results: Confirmatory factor analyses showed that the original 6-item two-factor solution of ASRS Part A had a satisfactory fit and showed basic measurement invariance between age groups and genders. Inattention and hyperactivity were related mostly similarly to stress in all groups. The prevalence of ADHD among adolescents was much higher than in previous reports, and no gender differences were found. About every fifth high school student and every tenth adult showed a risk of ADHD. The potential cause of the difference in the prevalence in the studied groups can be generation change.

Conclusions: ASRS is a well-functioning screening measure with good psychometric properties. It is a convenient option for large-scale epidemiological surveys necessary to understand potential generational changes in the prevalence of ADHD and the lack of gender differences among adolescents.

Maternal ADHD and Perinatal Prescription Stimulant Use

OBJECTIVE

To describe patterns and predictors of perinatal prescription stimulant use.

METHODS

We used MarketScan^® commercial claims data (2013-2018) and a repeated cross-sectional study design to assess perinatal use of prescription stimulants. Clinical/demographic characteristics were compared across cohorts of women who continued versus discontinued stimulant treatment at various stages of pregnancy. Associations were tested for significance using chi-square tests (categorical variables) and independent t-tests (continuous variables).

RESULTS

Out of 612,001 pregnancies, 15,413 involved pre-pregnancy stimulant use. Of these, stimulant treatment was discontinued prior to conception in 6,416 (42%), discontinued during trimester 1 in 5,977 (39%), and continued into later trimesters in 3,020 (19%). Compared with pregnancies involving stimulant discontinuation prior to conception, those that continued into pregnancy occurred in women who were older (29.9 vs. 28.9 years) and had more severe ADHD (3.1 vs. 1.8 ADHD-related billing claims).

CONCLUSIONS

There is considerable heterogeneity in the management of ADHD during pregnancy.

Screening for ADHD in a general outpatient psychiatric sample of adults

Adults (n = 805) seeking outpatient psychiatric care completed the Adult ADHD Self-Report Scale (ASRS) and measures of impairment and co-occurring psychopathology as part of a measurement-based care initiative. Diagnostic indicators of ADHD (i.e., formal diagnosis and/or medication treatment) were recorded from the electronic medical record (EMR). Agreement between screening positive for ADHD and EMR indicators for the diagnosis was explored, and clinical characteristics of adults identified with ADHD using these indicators were examined. Lastly, the contribution of ADHD to functional impairment was examined, controlling for the contribution of other demographic and psychiatric comorbidities. In the full sample, 54.78% of adults screened positive for ADHD based on the ASRS, and using EMR indicators, only 11.93% of adults were identified with ADHD. Agreement emerged between self-reported ADHD and ADHD EMR indicators, although adults screening positive for ADHD generally reported greater psychiatric complexity relative to adults identified with ADHD in the EMR. ADHD was associated with clinical impairment even when controlling for other psychiatric comorbidities. The considerable difference in prevalence of ADHD based on self-report screening versus EMR indicators suggests that ADHD may be overlooked in adult psychiatric care. Findings point to the importance of assessing adult ADHD in routine psychiatric care.

High Yield of Screening for ADHD in the Epilepsy Monitoring Unit

Objective: ADHD is common in patients with epilepsy, but adult patients with possible epilepsy are not routinely screened for ADHD. We aimed to characterize the results of two validated screening tools in the setting of an Epilepsy Monitoring Unit (EMU). Method: This study utilized the validated Adult ADHD Self-Report Scale version 1.1 (ASRS) and Conners Continuous Performance Test, third edition (CPT-III) to screen patients who were admitted to the EMU at a Level 4 epilepsy center. Patients with epileptic seizures (ES) were compared with patients with psychogenic nonepileptic seizures (PNES). Results: In all, 40.6% of patients screened positive using the ASRS. A significantly greater proportion of patients with PNES (63.6%) screened positive compared with patients with ES (27.8%, Fisher's exact test, p = .005). Positive ASRS screens showed no significant association with positive CPT screens (chi-square test, p = .146). Conclusion: Adult patients admitted to the EMU are at a high risk of comorbid attention deficits.

Gender differences in adult ADHD: Cognitive function assessed by the test of attentional performance

Introduction

The aim of this study was to assess cognitive differences between male and female adults with Attention Deficit Hyperactivity Disorder (ADHD).

Methods

Patients with an ADHD diagnosis according to the DSM-IV guidelines were included in a cross-sectional study evaluating cognitive measures. 28 women and 41 men from ages 19 to 56 completed self-report questionnaires and performed a computer-based test of attentional performance (TAP). The TAP assesses cognitive functions highly affected in ADHD patients, including working memory, alertness and attention as well as behavioral control and response inhibition.

Results

There were no measurable differences in self-report scales assessing current symptomology between the sexes, however men scored higher on the scale for childhood symptoms. Performance measures for general wakefulness were comparable between men and women, while working memory and behavioral control test results differed. Females reacted significantly slower and more unstable for both the TAP Go/NoGo paradigm and working memory subtest, while also making more errors in the latter.

Conclusions

We found gender-specific effects regarding working memory and behavioral control in this sample of adult patients with ADHD. Further studies are warranted, examining whether these differences relate to differences in clinical presentation and comorbidity patterns between men and women.

Psychometric Properties of a Brief Screening Measure for ADHD in Adults

The use of screening tools is an effective and practical approach within the clinical diagnostic assessment of attention deficit hyperactivity disorder (ADHD) in adults. Existing screening measures for adult ADHD have focused on a younger population. Subsequently, the current study aimed to evaluate the utility and general usability of an adapted four-item screening tool for adult ADHD: a brief version of the Wender Utah Rating Scale (WURS-brief), within a middle-aged population. The sample consisted of 69 adults, aged between 30 and 63 (age M= 45, SD=6.95), who had been referred to a specialist adult ADHD outpatients clinic. Using factor analysis, the WURS-brief screening measure was compared to existing ADHD diagnostic tools that were used as reference measures within the analysis. The WURS-brief had respectable sensitivity when compared with existing diagnostic tools. This study highlights the importance of validating brief screening measures for middle-aged adults with ADHD within clinical settings and offers suggestions for future research.

Relevance of hoarding behavior and the traits of developmental disorders among university students: a self-reported assessment study

Background

Previous studies have shown that hoarding behavior usually starts at a subclinical level in early adolescence and gradually worsens; however, a limited number of studies have examined the prevalence of hoarding behavior and its association with developmental disorders in young adults. The aims of this study were to estimate the prevalence of hoarding behavior and to identify correlations between hoarding behavior and developmental disorder traits in university students.

Methods

The study participants included 801 university students (616 men, 185 women) who completed questionnaires (ASRS: Adult ADHD Self-Report Scale version 1.1, AQ16: Autism-Spectrum Quotient with 16 items, and CIR: Clutter Image Rating).

Results

Among 801 participants, 27 (3.4%) exceeded the CIR cut-off score. Moreover, the participants with hoarding behavior had a significantly higher percentage of ADHD traits compared to participants without hoarding behavior (HB(+) vs HB(−), 40.7% vs 21.7%). In addition, 7.4% of HB(+) participants had autism spectrum disorder (ASD) traits, compared to 4.1% of HB(−) participants. A correlation analysis revealed that the CIR composite score had a stronger correlation with the ASRS inattentive score than with the hyperactivity/impulsivity score (CIR composite vs ASRS IA, r = 0.283; CIR composite vs ASRS H/I, r = 0.147).

Conclusions

The results showed a high prevalence of ADHD traits in the university students with hoarding behavior. Moreover, we found that the hoarding behavior was more strongly correlated with inattentive symptoms rather than with hyperactivity/impulsivity symptoms. Our results support the concept of a common pathophysiology behind hoarding behavior and ADHD in young adults.

A pilot study: Use of the Adult Attention-Deficit/Hyperactivity Disorder Self-Report Scale in a South African patient population

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder which typically presents in childhood. This diagnosis may often be overlooked in adulthood, particularly in psychiatric populations. The Adult ADHD Self-Report Scale (ASRS) is an internationally used and reliable screener; however, studies investigating its use in African populations are limited.

AIM

To investigate the application of the ASRS in a South African setting.

SETTING

A patient population in Port Elizabeth, South Africa, was identified as representing a developing or low- and middle-income country population.

METHODS

A convenience sample of acutely presenting psychiatric participants admitted for stabilisation was used. Fieldworkers administered the ASRS; collected information relating to demographics, differential diagnoses, substance use disorder (SUD) presence and substance consumption; and prescribed medication relating to current or historical treatment of ADHD.

RESULTS

The study sample included 30 participants, with black people representing the majority of participants. Adult ADHD Self-Report Scale completion revealed the rate of ADHD within the study population to be 43.3%, a contrast to the initially presumed prevalence of 6.7% which was based on reported methylphenidate therapy. A difference in SUD prevalence was identified between subjects screening positively and negatively for ADHD with a greater tendency towards SUDs seen for ASRS-positive individuals. Significant differences were identified in relation to cannabis- and polysubstance use for ASRS-positive individuals.

CONCLUSION

Despite limitations related to the sample used and challenges in ASRS administration, investigation findings support recommendations for ADHD screening inclusion in acute inpatient settings in South Africa and ASRS translation into indigenous African languages.

Attention Deficit Hyperactivity Disorder (ADHD) in the Prison System

PURPOSE OF REVIEW

To examine recent advances in the understanding of attention deficit hyperactivity disorder (ADHD) among the prison population.

RECENT FINDINGS

Efforts have been made to develop useful tools for assessing ADHD among prisoners. Prisoners with ADHD demonstrate incremental vulnerability due to comorbid psychiatric disorders, neurodevelopmental disorders and traumatic brain injury. Compared with prisoners without ADHD, prisoners with ADHD become involved in the criminal justice system at a younger age and have higher rates of recidivism in adulthood. Recent studies demonstrate the effectiveness of extended release stimulant medication and psychological interventions. Early identification and treatment of prisoners with ADHD have the potential to demonstrate health economic benefits. Our understanding of ADHD among prisoners continues to develop. However, further research is needed, particularly among neglected groups such as females. Much more attention is needed by the prison service to engender better outcomes for this at-risk population.

Correlation between Taijin-Kyofu-sho and Attention Deficit Hyperactivity Disorder among University Students: A Self-Reported Assessment Study

Taijin-Kyofu-sho (TK) is regarded as a culture-bound anxiety disorder in East Asian counties. Despite its earlier discovery in Japan, fewer studies have focused on TK than on social anxiety disorder (SAD) and even fewer on TK comorbidity with developmental disorders. Thus, we examined the association between TK and attention deficit hyperactivity disorder (ADHD) among Japanese university students. A total of 673 students (500 male, 173 female) were assessed on the Japanese version of Liebowitz Social Anxiety Scale (LSAS-J), TK scale, and adult ADHD Self-Report Scale (ASRS; version 1.1). On the TK scale and LSAS-J, 17.4 and 10.3 percent of students, respectively, exceeded the cut-off value. Furthermore, ASRS scores more strongly correlated with TK scale than LSAS-J scores (TK scale: r = 0.427; LSAS-J: r = 0.330). To evaluate how TK or SAD with ADHD affects those scores, we divided subjects into four groups: healthy subjects, subjects with TK, those with SAD, and those with both disorders. The total ASRS score was significantly higher in TK-only subjects than in healthy subjects (p < 0.0001). However, there was no significant difference between scores of healthy and SAD-only subjects (p = 0.281). Our results indicate a possible link between ADHD and later development of TK in Japan.

Evaluating a scale of excessive mind wandering among males and females with and without attention-deficit/hyperactivity disorder from a population sample

Recent studies highlight the role of excessive mind wandering in attention-deficit/hyperactivity disorder (ADHD) and its association with impairment. We believe assessing mind wandering could be especially relevant to individuals, including many females, who present with less externalising manifestations of ADHD. Using a new measure based on ADHD patient reports, the Mind Excessively Wandering Scale (MEWS), we previously found adults with ADHD had elevated levels of mind wandering that contributed to impairment independently of core ADHD symptoms. Using data from an online general population survey, the current study assessed the factor-structure, reliability, validity and measurement invariance of the MEWS. We also investigated sex differences in mind wandering, as well as ADHD symptoms, impairment and wellbeing in those with and without ADHD. The MEWS had a unidimensional structure, was invariant across sex, age and ADHD status, and accounted for unique variance in impairment and wellbeing beyond core ADHD symptoms. Among those with ADHD, we found no evidence for sex differences in mind wandering and among those without ADHD males had higher scores. We also found similar levels of hyperactivity/impulsivity, emotional lability, and impairment in males and females with ADHD, but males reported greater inattention and lower wellbeing. Results suggest the MEWS is a reliable and valid instrument measuring the same construct across sex, age and ADHD status, which could aid diagnosis and monitoring of outcomes.

The Association Between Insomnia and Sleep Duration in Adults With Attention-Deficit Hyperactivity Disorder: Results From a General Population Study

STUDY OBJECTIVES

Insomnia and short or long sleep duration are important comorbid conditions in adults with attention-deficit hyperactivity disorder (ADHD), but reports of the association vary. In a general population study, we evaluated the relationship between ADHD symptom severity, insomnia symptoms, and sleep duration in adults.

METHODS

Data were from the third wave of the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2; n = 4,618). ADHD symptom severity and symptom dimensions (hyperactivity and inattention) were assessed using the Adult ADHD Self-Report Scale screener. Self-reported insomnia symptoms (Insomnia Rating Scale; IRS) were defined as clinically relevant if IRS ≥ 9. Self-reported short sleep duration was defined as ≤ 6 hours, and long sleep duration as ≥ 10 hours.

RESULTS

Within the group with clinically relevant ADHD symptoms, 43% reported significant insomnia symptoms (odds ratio [OR] = 2.66, 95% confidence interval [CI] 1.74-4.07); 41% short sleep duration (relative risk ratio [RRR] = 1.94, 95% CI 1.31-2.85) and 6% long sleep (RRR = 5.87, 95% CI 1.97-17.45). Increased inattention symptoms were associated with IRS ≥ 9, short and long sleep duration in fully adjusted models (OR = 1.10, 95% CI 1.06-1.14; RRR = 1.06, 95% CI 1.02-1.09; RRR = 1.16, 95% CI 1.05-1.28, respectively). Increased hyperactivity symptoms were associated with IRS ≥ 9 (OR = 1.17, 95% CI 1.11-1.23) and short sleep duration (RRR = 1.12, 95% CI 1.05-1.19).

CONCLUSIONS

Both clinically significant ADHD symptoms and inattention and hyperactivity symptom dimensions were consistently associated with insomnia symptoms and altered sleep duration. These associations confirm that sleep disturbances should be assessed and given appropriate clinical attention in adults with ADHD.