Substance use disorders in adults with attention-deficit/hyperactivity disorder: The role of affective temperament

OBJECTIVE

Substance Use Disorders (SUD) are common in adults with Attention-Deficit/Hyperactivity Disorder (ADHD). Although predictors of SUD in this population are relevant for prevention and treatment, they need further clarification. Affective temperaments potentially associated with SUD in adult ADHD patients were explored.

METHODS

ADHD patients with and without SUD were compared for sociodemographic, clinical, and psychological characteristics through: Adult ADHD Self-Report Scale; Wender Utah Rating Scale; Temperament Evaluation Memphis for Pisa, Paris, and San Diego-Autoquestionnaire. Logistic regression investigated factors associated with SUD.

RESULTS

We included one-hundred and thirty-six ADHD patients with (n = 51, 37.5 %) and without SUD (n = 85, 62.5 %). The presence of SUD was associated with irritable temperament (p = 0.009), as well as more frequent school failure (p = 0.038), legal problems (p = 0.039), and lifetime suicide attempts (p = 0.014).

LIMITATIONS

The cross-sectional design, the relatively small sample size, and the use of self-administered questionnaires.

CONCLUSIONS

This study confirms the greater overall severity of adult ADHD-SUD compared with ADHD-only patients and suggests the potential role of irritable temperament as a predictor of substance-related problems.

Treatment of adult attention-deficit hyperactivity disorder (ADHD) with transcranial direct current stimulation (tDCS): study protocol for a parallel, randomized, double-blinded, sham-controlled, multicenter trial (Stim-ADHD)

Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation treatment used as an alternative or complementary treatment for various neuropsychiatric disorders, and could be an alternative or add-on therapy to psychostimulants in attention-deficit hyperactivity disorder (ADHD). Previous studies provided some evidence for improvements in cognition and clinical symptoms in pediatric and adult ADHD patients. However, data from multi-center randomized controlled trials (RCTs) for this condition are lacking. Thus, our aim is to evaluate short- and mid-term effects of tDCS in this multi-center, randomized, double blind, and sham-controlled, parallel group clinical trial with a 1:1 randomization ratio. Primary endpoint is the total score of DSM-IV scale of the internationally established Conners' Adult ADHD Rating Scales (German self-report screening version, CAARS-S-SR), at day 14 post-intervention (p.i.) to detect short-term lasting effects analyzed via analyses of covariance (ANCOVAs). In case of significant between-groups differences at day 14 p.i., hierarchically ordered hypotheses on mid-term lasting effects will be investigated by linear mixed models with visit (5 time points), treatment, treatment by visit interaction, and covariates as fixed categorical effects plus a patient-specific visit random effect, using an unstructured covariance structure to model the residual within-patient errors. Positive results of this clinical trial will expand the treatment options for adult ADHD patients with tDCS and provide an alternative or add-on therapy to psychostimulants with a low risk for side effects.Trial Registration The trial was registered on July 29, 2022 in the German Clinical Trials Register (DRKS00028148).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of executive functions in mediating the relationship between adult ADHD symptoms and hyperfocus in university students

BACKGROUND

Hyperfocus, a state of intense, narrow and prolonged attentional focus, has been associated with symptoms of attention-deficit/hyperactivity disorder (ADHD) in both clinical and non-clinical populations. Hyperfocus may be explained by difficulties in executive control, typically observed in ADHD.

AIMS

To investigate (1) whether ADHD and executive functions (EF) are associated with hyperfocus and (2) whether EF mediate the relationship between ADHD symptoms and hyperfocus.

METHODS AND PROCEDURES

A non-clinical sample of 380 university students (264 females) completed self-reports of ADHD, EF, hyperfocus and hyperfocus during rewarding activities.

OUTCOMES AND RESULTS

Increased difficulties in EF and severity of ADHD symptoms were significantly and positively correlated with a higher frequency of hyperfocus. Moreover, EF difficulties partially mediated the relationship between ADHD and hyperfocus (after controlling for sex and substance use), but not the relationship between ADHD and hyperfocus during rewarding activities.

CONCLUSIONS AND IMPLICATIONS

Difficulties in EF partially explained the higher frequency of hyperfocus, but not of hyperfocus during rewarding activities, among university students reporting more severe ADHD symptoms. Future research should investigate whether and how specific EF and other ADHD-related neurocognitive difficulties (e.g., reward sensitivity) contribute to various types of hyperfocus experiences in ADHD. WHAT THIS PAPER ADDS?: This paper is a first attempt to explain the relationship between adult ADHD symptoms and hyperfocus experiences. Our findings suggest that, although highly correlated, existing self-reports of hyperfocus measure different aspects of this experience: hyperfocus and reward-related hyperfocus. We replicate previous findings that indicated a greater frequency of both types of hyperfocus in ADHD. Additionally, we demonstrate a connection between EF difficulties and different aspects of hyperfocus. Finally, we extend previous findings by proposing that EF difficulties partially explain the relationship between ADHD and hyperfocus, but not the relationship between ADHD and reward-related hyperfocus. We hypothesize that other neurocognitive difficulties (e.g., reward sensitivity) may contribute to explain the relationship between ADHD and different aspects of hyperfocus.

Long-term efficacy of a new 6-session cognitive behavioral therapy for adults with attention-deficit/hyperactivity disorder: A randomized, controlled clinical trial

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that affects about 2.8 % of the adult population. Cognitive behavioral therapy (CBT) has been demonstrated to be the most effective psychological intervention for ADHD. The aim of this study was to explore the efficacy of a new 6-session CBT program in comparison with a 12-session CBT program for adults with ADHD at short- and long-term.

METHODS

81 adults with ADHD (58 % males; mean age = 41.27±9.26 years old) were randomly assigned to each treatment condition (6- or 12-session CBT). Validated instruments were used to assess ADHD symptoms, comorbidities (anxiety and depression), and functional impairments at post treatment, and at 3- and 6-month follow-up.

RESULTS

A significant improvement in ADHD severity, comorbidities (anxiety and depression) and functional impairments were found in both CBT programs after treatment. Furthermore, this improvement was also reported at 3- and 6-month follow-up.

CONCLUSION

The current study highlights that a 6-session CBT program is as effective as a 12-session CBT program for ADHD improvement at post treatment and follow-up. The newly developed 6-session CBT program can be used to treat a larger number of patients, reducing the financial cost.

Abnormal wiring of the structural connectome in adults with ADHD

Current knowledge of white matter changes in large-scale brain networks in adult attention-deficit/hyperactivity disorder (ADHD) is scarce. We collected diffusion-weighted magnetic resonance imaging data in 40 adults with ADHD and 36 neurotypical controls and used constrained spherical deconvolution-based tractography to reconstruct whole-brain structural connectivity networks. We used network-based statistic (NBS) and graph theoretical analysis to investigate differences in these networks between the ADHD and control groups, as well as associations between structural connectivity and ADHD symptoms assessed with the Adult ADHD Self-Report Scale or performance in the Conners Continuous Performance Test 2 (CPT-2). NBS revealed decreased connectivity in the ADHD group compared to the neurotypical controls in widespread unilateral networks, which included subcortical and corticocortical structures and encompassed dorsal and ventral attention networks and visual and somatomotor systems. Furthermore, hypoconnectivity in a predominantly left-frontal network was associated with higher amount of commission errors in CPT-2. Graph theoretical analysis did not reveal topological differences between the groups or associations between topological properties and ADHD symptoms or task performance. Our results suggest that abnormal structural wiring of the brain in adult ADHD is manifested as widespread intrahemispheric hypoconnectivity in networks previously associated with ADHD in functional neuroimaging studies.

ADHD-KG: a knowledge graph of attention deficit hyperactivity disorder

Purpose

Attention Deficit Hyperactivity Disorder (ADHD) is a widespread condition that affects human behaviour and can interfere with daily activities and relationships. Medication or medical information about ADHD can be found in several data sources on the Web. Such distribution of knowledge raises notable obstacles since researchers and clinicians must manually combine various sources to deeply explore aspects of ADHD. Knowledge graphs have been widely used in medical applications due to their data integration capabilities, offering rich data stores of information built from heterogeneous sources; however, general purpose knowledge graphs cannot represent knowledge in sufficient detail, thus there is an increasing interest in domain-specific knowledge graphs.

Methods

In this work we propose a Knowledge Graph of ADHD. In particular, we introduce an automated procedure enabling the construction of a knowledge graph that covers knowledge from a wide range of data sources primarily focusing on adult ADHD. These include relevant literature and clinical trials, prescribed medication and their known side-effects. Data integration between these data sources is accomplished by employing a suite of information linking procedures, which aim to connect resources by relating them to common concepts found in medical thesauri.

Results

The usability and appropriateness of the developed knowledge graph is evaluated through a series of use cases that illustrate its ability to enhance and accelerate information retrieval.

Conclusion

The Knowledge Graph of ADHD can provide valuable assistance to researchers and clinicians in the research, training, diagnostic and treatment processes for ADHD.

Exploring the efficacy of dialectical behaviour therapy and methylphenidate on emotional comorbid symptoms in adults with attention Deficit/Hyperactivity disorder: Results of the COMPAS multicentre randomised controlled trial

This study evaluated the efficacy of dialectical behaviour group therapy (GPT) vs. individual clinical management (CM) and methylphenidate (MPH) vs. placebo (PLB) on emotional symptoms in adults with ADHD. This longitudinal multicentre RCT compared four groups (GPT+MPH, GPT+PLB, CM+MPH, and CM+PLB) over five assessment periods, from baseline to week 130. Emotional symptomatology was assessed using SCL-90-R subscales. Of the 433 randomised participants, 371 remained for final analysis. At week 13, the GPT+MPH group showed smaller reductions in anxiety symptoms than the CM groups, but the differences disappeared at subsequent assessments. Improvements in emotional symptom were significantly predicted by reductions in core ADHD symptoms in all groups except the GPT+MPH group. The unexpected lack of between-group differences may be explained by a "floor effect", different intervention settings (group vs. individual), and psychotherapy type. Multiple regression analyses suggest a more specific effect of combined interventions (GPT+MPH). Implications for clinical practice are discussed. Clinical trial registration: ISRCTN54096201 (Current Controlled Trials).

Transitioning to adult mental health services for young people with ADHD: an Italian-based survey on practices for pediatric and adult services

BACKGROUND

Supporting young ADHD patients in transition to adult services is essential. Yet, the low percentages of successful referrals and the issues reported by patients and clinicians stress the need for further attention to transitioning practices. The present study assessed the transitioning process of Attention-Deficit/Hyperactivity Disorder (ADHD) patients in Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) in the Italian territory. We asked child and adult psychiatrists to report the current state of services and their observations on limitations and possible future matters that must be addressed.

METHOD

Seventy-seven centers (42 CAMHS, 35 AMHS) filled in a web-based survey in which they reported the number of ADHD patients, how many transitioning patients they had within the past year, and how they structured transition.

RESULTS

A fragmented picture emerged from the survey. Lack of resources, training, and communication between services hinder the transition process, and many adult patients remain under CAMHS' care. While some services have a protocol, there is no structured guidance that can help improve integration and continuity of treatment.

CONCLUSION

The observed situation reflects a need for improvement and standard guidelines to enable a successful transition process, considering clinicians' and patients' necessities.

Differential neurocognitive profiles in adult attention-deficit/hyperactivity disorder subtypes revealed by the Cambridge Neuropsychological Test Automated Battery

Adult attention-deficit/hyperactivity disorder (aADHD) represents a heterogeneous entity incorporating different subgroups in terms of symptomatology, course, and neurocognition. Although neurocognitive dysfunction is generally associated with aADHD, its severity, association with self-reported symptoms, and differences between subtypes remain unclear. We investigated 61 outpatients (65.6% male, mean age 31.5 ± 9.5) diagnosed using DSM-5 criteria together with age-, sex-, and education-matched healthy controls (HC) (n = 58, 63.8% male, mean age 32.3 ± 9.6). Neurocognitive alterations were assessed using the Cambridge Neuropsychological Test Automated Battery (CANTAB) and compared between groups using the generalized linear model (GLM) method. Multivariate effects were tested by principal component analysis combined with multivariate pattern analysis. Self-reported symptom severity was tested for correlations with neurocognitive performance. GLM analyses revealed nominally significant differences between the aADHD and HC groups in several domains, however, only the Rapid Visual Information Processing measures survived correction, indicating impaired sustained attention and response inhibition in the aADHD group. Comparison of the predominantly inattentive and the hyperactive-impulsive/combined subtypes yielded nominally significant differences with higher levels of dysfunction in the inattentive group. In the stepwise discriminant analysis aADHD and HC groups were best separated with 2 factors representing sustained attention and reaction time. We found only weak correlations between symptom severity and CANTAB factors. aADHD patients are neuropsychologically heterogeneous and subtypes show different neurocognitive profiles. Differences between the aADHD and HC groups were driven primarily by the inattentive subtype. Sustained attention and its factor derivative showed the most significant alterations in aADHD patients.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Prevalence and clinical correlates of co-morbid attention deficit hyperactivity disorder in euthymic adults with bipolar disorder: A cross-sectional study

Background

Bipolar disorders (BDs) are co-morbid with attention deficit hyperactivity disorder (ADHD), making diagnosis and management more difficult and associated with poorer outcomes. So, this study was planned to find the prevalence and clinical implication of co-morbid ADHD in BD.

Materials and Methods

In this cross-sectional study, a total of 110 euthymic BD patients were taken. They were screened for childhood ADHD symptoms and adult ADHD symptoms using the Wender Utah Rating Scale for ADHD and Adult ADHD Self-Report Screening Scale for DSM-5. Those were divided into three groups: Group A included BD patients without ADHD, Group B included bipolar patients with co-morbid adult ADHD (BD-aADHD), and Group C included bipolar patients who had a diagnosis of childhood ADHD (BD-cADHD).

Results

The ADHD prevalence of 27% was found in bipolar patients. The age of onset of an episode of BD was significantly earlier and the total duration of illness was significantly higher in BD-aADHD and BD-cADHD compared to the BD without ADHD. The BD-aADHD and BD-cADHD groups showed a significantly higher number of total, manic and major depressive episodes as compared to the BD without ADHD group. BD-aADHD showed a significant greater number of hypomanic episodes as compared to BD without ADHD.

Conclusions

The present study concludes that ADHD is a lifetime co-morbid condition in adults with BD. These patients have a more chronic and disabling course of BD which underscores the need to understand the potential benefit of controlling ADHD symptoms in this population.

A novel intervention for treating adults with ADHD using peripheral visual stimulation

Objective

Stimulation of the peripheral visual field has been previously reported as beneficial for cognitive performance in ADHD. This study assesses the safety and efficacy of a novel intervention involving peripheral visual stimuli in managing attention deficit hyperactivity disorder (ADHD).

Methods

One hundred and eight adults, 18-40 years old, with ADHD, were enrolled in a two-month open-label study. The intervention (i.e., Neuro-glasses) consisted of standard eyeglasses with personalized peripheral visual stimuli embedded on the lenses. Participants were assessed at baseline and at the end of the study with self-report measures of ADHD symptoms (the Adult ADHD Self-Report Scale; ASRS), and executive functions (The Behavior Rating Inventory of Executive Function Adult Version; BRIEF-A). A computerized test of continuous performance (The Conners' Continuous Performance Test-3; CPT-3) was tested at baseline with standard eyeglasses and at the end of study using Neuro-glasses. The Clinical Global Impression-Improvement scale (CGI-I) was assessed at the intervention endpoint. Safety was monitored by documentation of adverse events.

Results

The efficacy analysis included 97 participants. Significant improvements were demonstrated in self-reported measures of inattentive symptoms (ASRS inattentive index; p = 0.037) and metacognitive functions concerning self-management and performance monitoring (BRIEF-A; p = 0.029). A continuous-performance test (CPT-3) indicated significant improvement in detectability (d'; p = 0.027) and reduced commission errors (p = 0.004), suggesting that the Neuro-glasses have positive effects on response inhibition. Sixty-two percent of the participants met the response criteria assessed by a clinician (CGI-I). No major adverse events were reported.

Conclusion

Neuro-glasses may offer a safe and effective approach to managing adult ADHD. Results encourage future controlled efficacy studies to confirm current findings in adults and possibly children with ADHD.Clinical trial registration: https://www.clinicaltrials.gov/, Identifier NCT05777785.

Identifying different patterns of emotion dysregulation in adult ADHD

BACKGROUND

Emotion dysregulation (ED) is a core intrinsic feature of adult presenting Attention Deficit Hyperactivity Disorder (ADHD). However, the clinical expressions of ED are diverse and several questionnaires have been used to measure ED in adults with ADHD. Thus, to date, the characteristics of ED in adult ADHD remain poorly defined. The objective of this study is to identify the different patterns of ED in adults with ADHD.

METHODS

A large sample of 460 newly diagnosed adults with ADHD were recruited. Patients completed a total of 20 self-reported questionnaires. Measures consisted in the several facets of ED, but also other clinical features of adult ADHD such as racing thoughts. A factor analysis with the principal component extraction method was performed to define the symptomatic clusters. A mono-dimensional clustering was then conducted to assess whether participants presented or not with each symptomatic cluster.

RESULTS

The factor analysis yielded a 5 factor-solution, including "emotional instability", "impulsivity", "overactivation", "inattention/disorganization" and "sleep problems". ED was part of two out of five clusters and concerned 67.52% of our sample. Among those patients, the combined ADHD presentation was the most prevalent. Emotional instability and impulsivity were significantly predicted by childhood maltreatment. The ED and the "sleep problems" factors contributed significantly to the patients' functional impairment.

CONCLUSIONS

ED in ADHD is characterized along emotional instability and emotional impulsivity, and significantly contributes to functional impairment. However, beyond impairing symptoms, adult ADHD may also be characterized by functional strengths such as creativity.

"I wish it wasn't all on me": women's experiences living with a partner with ADHD

PURPOSE

Grounded in the socio-ecological model of health, this study aims to understand the broader impact of adult attention deficit hyperactivity disorder (ADHD) on the family system. With a notable gap in knowledge concerning the impact of adult ADHD on spouses' well-being, this research explores the lived experiences of women in relationships with partners diagnosed with ADHD.

MATERIAL AND METHODS

Using a descriptive qualitative phenomenological approach, we conducted semi-structured interviews with thirteen women without ADHD, to gain insights into their experiences.

RESULTS

Three main themes were identified- ADHD in Everyday Life, Burden Experience, and Women's Coping Strategies for managing ADHD within relationships. The findings suggest that partners' ADHD symptoms involve a burden on women. In response, women developed coping strategies such as learning about ADHD, setting limits, and cultivating partnership by creating bridges to compensate for ADHD-related barriers.

CONCLUSIONS

This study highlights the substantial burden experienced by women in a relationship with partners diagnosed with ADHD, suggesting they should be recognized as caregivers and a potentially vulnerable group at risk. However, the homogeneous nature of our sample, focusing on white, heterosexual women, underlines the need for further research to better understand the impact of adult ADHD on diverse partners' functioning and health, as well as pathways to support them.

From neurodevelopmental to neurodegenerative disorders: Investigating symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in patients with dementia

Dementia is characterized by a progressive cognitive decline that could be caused by several disorders. Autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) are two prevalent neurodevelopmental disorders that might overlap with dementia symptoms. Hence, this study aimed to evaluate the ASD and ADHD symptoms in dementia patients referred to a memory clinic in Iran. We recruited 65 dementia patients and instructed them to fill out the autism quotient (AQ) and the Conners' Adult ADHD Rating Scales (CAARS) questionnaires. Considering the cutoff points of AQ and CAARS questionnaires, 18.5% of participants were at higher risk of ASD, and 35.4% were at higher risk of ADHD. The results indicated that ADHD and ASD symptoms might be common comorbidities in patients with dementia which can increase the disease burden. Specialized ADHD and ASD screening tools in the elderly population with dementia are needed to prevent misdiagnoses due to symptom overlaps.

Electrophysiological underpinnings of dysfunctional inhibitory control in adults with attention-deficit/hyperactivity disorder: evidence for reduced NoGo anteriorization

Our aim was to delineate the electrophysiological basis of dysfunctional inhibitory control of adult ADHD via investigating the anteriorization of the P3 component of the event-related brain response associated with the NoGo task condition (i.e., NoGo anteriorization, NGA). NGA is a neurophysiological measure of brain topography for cognitive response control, which indexes an overall shift of the brain's electrical activity in anterior direction towards the prefrontal areas. While the NoGo P3 received considerable attention in the adult ADHD literature, the brain topography of this component, which reflects the inhibitory process, remains largely unaddressed. EEG recordings were obtained during a Go/NoGo task from 51 subjects (n = 26 adult patients with ADHD, n = 25 healthy controls) using a high-density, 128-channel BioSemi ActiveTwo recording system. ADHD patients had significantly lower P3 NGA response compared to controls. The decrease in NGA was related to impulsivity scores as measured by the Conners' Adult ADHD Rating Scale: patients with higher impulsivity scores had significantly lower NGA. Treatment with stimulant medication, as compared to the lack of such treatment, was associated with a correction of the lower NGA response in ADHD patients. The current study revealed a lower NGA in adult ADHD, a finding which is consistent with the inhibitory control and frontal lobe dysfunctions described in the disorder. Our finding of the inverse relationship between NGA and impulsivity suggests that clinically more severe impulsivity is linked to a more pronounced frontal dysfunction in adult ADHD subjects.

Effects of methylphenidate on mismatch negativity and P3a amplitude of initially psychostimulant-naïve, adult ADHD patients

BACKGROUND

Deficient information processing in ADHD theoretically results in sensory overload and may underlie the symptoms of the disorder. Mismatch negativity (MMN) and P3a amplitude reflect an individual's detection and subsequent change in attention to stimulus change in their environment. Our primary aim was to explore MMN and P3a amplitude in adult ADHD patients and to examine the effects of methylphenidate (MPH) on these measures.

METHODS

Forty initially psychostimulant-naïve, adult ADHD patients without comorbid ASD and 42 matched healthy controls (HC) were assessed with an MMN paradigm at baseline. Both groups were retested after 6 weeks, in which patients were treated with MPH.

RESULTS

Neither significant group differences in MMN nor P3a amplitude were found at baseline. Although 6-week MPH treatment significantly reduced symptomatology and improved daily functioning of the patients, it did not significantly affect MMN amplitude; however, it did significantly reduce P3a amplitude compared to the HC. Furthermore, more severe ADHD symptoms were significantly associated with larger MMN amplitudes in the patients, both at baseline and follow-up.

CONCLUSION

We found no evidence for early information processing deficits in patients with ADHD, as measured with MMN and P3a amplitude. Six-week treatment with MPH decreased P3a but not MMN amplitude, although more severe ADHD-symptoms were associated with larger MMN amplitudes in the patients. Given that P3a amplitude represents an important attentional process and that glutamate has been linked to both ADHD and MMN amplitude, future research should investigate augmenting MPH treatment of less responsive adults with ADHD with glutamatergic antagonists.

Top-down auditory attention modulates neural responses more strongly in neurotypical than ADHD young adults

Human cognitive abilities naturally vary along a spectrum, even among those we call "neurotypical". Individuals differ in their ability to selectively attend to goal-relevant auditory stimuli. We sought to characterize this variability in a cohort of people with diverse attentional functioning. We recruited both neurotypical (N = 20) and ADHD (N = 25) young adults, all with normal hearing. Participants listened to one of three concurrent, spatially separated speech streams and reported the order of the syllables in that stream while we recorded electroencephalography (EEG). We tested both the ability to sustain attentional focus on a single "Target" stream and the ability to monitor the Target but flexibly either ignore or switch attention to an unpredictable "Interrupter" stream from another direction that sometimes appeared. Although differences in both stimulus structure and task demands affected behavioral performance, ADHD status did not. In both groups, the Interrupter evoked larger neural responses when it was to be attended compared to when it was irrelevant, including for the P3a "reorienting" response previously described as involuntary. This attentional modulation was weaker in ADHD listeners, even though their behavioral performance was the same. Across the entire cohort, individual performance correlated with the degree of top-down modulation of neural responses. These results demonstrate that listeners differ in their ability to modulate neural representations of sound based on task goals, while suggesting that adults with ADHD may have weaker volitional control of attentional processes than their neurotypical counterparts.

Effects of methylphenidate on subjective sleep parameters in adults with ADHD: a prospective, non-randomized, non-blinded 6-week trial

OBJECTIVE

Methylphenidate is a first-line treatment for ADHD; its contribution to sleep problems in adult ADHD is currently unclear. This study investigates (a) subjective sleep disturbances in a group of initially stimulant medication-naïve adults with ADHD and (b) reported changes in sleep problems after 6 weeks of methylphenidate treatment.

METHOD

A prospective, non-randomized, non-blinded, 6-week follow-up study utilising a self-report measure.

RESULTS

We found (1) a large difference in reported sleep quality between methylphenidate medication-naïve patients and controls at baseline, (2) a marked improvement in patients after methylphenidate medication, and (3) largest improvement for patients with the poorest reported sleep at baseline.

CONCLUSION

The study indicates that treatment with methylphenidate increases subjective sleep quality for at least some adults with ADHD.

Adult ADHD: Underdiagnosis of a Treatable Condition

Attention-deficit/hyperactivity disorder is a common neurodevelopmental disorder, well-characterized within the pediatric population and representing one of the most prevalent mental conditions among children and adolescents. Once diagnosed, pharmacologic and psychosocial therapies can reduce symptomatic expression and functional impairment. Traditionally thought to resolve by young adulthood, it is now recognized that ADHD persists into adulthood. Many of these individuals were never evaluated for ADHD as children and remain undiagnosed as adults, continuing to struggle with symptoms. It is common to develop compensatory strategies geared at mitigating the disruptive effects of ADHD. In this article, we provide an overview of adult ADHD, review changes to DSM-5 diagnostic criteria meant to facilitate diagnosis of ADHD during adulthood, and discuss various factors that serve as barriers to accurate detection of adult ADHD.

A comparison of Barkley's behavioral inhibition model (1997) with Barkley's updated executive functioning model in predicting adult ADHD symptoms: A preliminary report using structural equation modeling

One of the most comprehensive approaches to explaining attention-deficit/hyperactivity disorder (ADHD) symptoms is Barkley's behavioral inhibition model (BBIM) (1997), in which behavioral inhibition (BI) plays a primary role. Due to the substantial role of working memory (WM) in explaining ADHD symptoms, Barkley recently updated his model and elevated WM from a mediator variable (in BBIM) to a primary position as an exogenous variable alongside BI, and titled his new model as Barkley's updated executive functioning model (BUEFM). However, since the information about the explanatory power of the new model is sparse, this study aims to investigate the impact of this change in WM role by comparing these two models to explain ADHD symptoms. The study involved a sample of 184 (96 females and 88 males) undergraduate students with high ADHD symptoms who were selected using the purposive sampling method. For assessing models, we have utilized four tools that include: CNS-Vital Sign Test Battery; Barkley Deficit in Executive Functioning Scale; self-verbalization questionnaire (SVQ); and trail making test. We analyzed the data by running structural equation modeling (SEM) analysis using IBM AMOS software version 22. The results show that Model Comparison Measurement (e.g. AIC was 197.583 and 144.614 for BBIM and BUEFM, respectively) and Model Fit Indices (e.g. root mean square error of approximation (RMSEA) obtained 0.076 and 0.067 for BBIM and BUEFM, respectively) representing that BUEFM had a better value than BBIM, which means that the BUEFM was considered better fitting to the data. The findings of this study show that BUEFM has more Predictive power than BBIM to predict symptoms of ADHD through the motor control fluency (MOT) variable.

Is there a place for dietetic interventions in adult ADHD?

Current treatments for Attention-Deficit/Hyperactivity Disorder (ADHD) in adults are limited by lack of response and side effects in about one third of the individuals. Changes towards a healthier lifestyle could have a positive impact beyond the relief of specific symptoms. However, it is not clear if nutritional interventions influence mental health and cognition. The objective of this study was to summarize the available literature addressing the impact of different diets in ADHD. The most promising dietetic approaches in ADHD are diets considered to be healthy (Mediterranean-type; DASH) and the Few-Foods Diet for children. Studies should take into account the presence of multiple confounders, biases associated with difficulties in blinding participants and researchers, and search for possible mechanisms of action, so we can have better evidence to guide clinical mental care of adults with ADHD.

ADHD in adults with major depressive or bipolar disorder: does it affect clinical features, comorbidity, quality of life, and global functioning?

BACKGROUND

This study compared clinical characteristics, concurrent disorders, level of function, and quality of life in adults with bipolar (BD) or major depressive disorder (MDD) in those with/without adult attention defici1t hyperactivity disorder (AADHD).

METHODS

The participants were recruited among adult inpatients and outpatients with MDD or BD in their current partial remission in a psychiatric hospital. They were evaluated using the interview for adults with ADHD (DIVA-5), Conners' Adult ADHD Rating Scales-Self-Report-Screening Version (CAARS-SR-SV), Structured Clinical Interview for DSM-V (SCID-5), Beck Depression Inventory-II and Young Mania Rating Scale, Global Assessment of Functioning (GAF) and World Health Organization Quality of Life Scale-Brief (WHOQoL-BREF).

RESULTS

In those with MDD (n = 105) and BD (n = 103), AADHD was detected as 13.3% and 16.5%, respectively. The inattentive presentation was the most prevalent type among patients with AADHD. Compared to the patients without AADHD, the results regarding the prevalence of comorbidities, suicidal attempts, severity of affective episodes, the early emergence of the affective disorders, and level of quality of life and global functioning were poorer in the group with AADHD (p < 0.05).

LIMITATIONS

The participants were individuals with major depressive or bipolar type I disorder with a mostly manic episode, chosen among the referrals to a tertiary psychiatric hospital with high comorbidity and more severe psychopathology. This may limit the generalizability of the findings.

CONCLUSION

ADHD was common in adults with MDD and BD, along with high psychiatric comorbidity and negative consequences. Clinicians are suggested to screen adults with mood disorders for the symptoms of ADHD for a more precise and comprehensive diagnosis and to provide a more appropriate therapeutic intervention.

Smartphone-assisted psychoeducation in adult attention-deficit/hyperactivity disorder: A randomized controlled trial

Psychoeducation is generally recommended in the treatment of adult Attention-Deficit/Hyperactivity Disorder (ADHD), but only few studies have systematically assessed the effects of structured clinical psychoeducation. Moreover, although a considerable number of psychoeducational mobile applications exist, none have provided scientific evidence for their effectiveness or safety. Therefore, the present randomized controlled trial investigated a newly developed, free-to-use psychoeducation app for adults with ADHD as a support to a clinical psychoeducation group. 236 adults with ADHD were contacted for study participation, of whom 60 were finally randomized to a psychoeducation group supported either by our developed smartphone app (n = 30) or by traditional pen-and-paper brochures (n = 30). Psychoeducation treatments were conducted in groups of 10, with 8 weekly one-hour sessions between March 2019 and November 2020. Observer-rated ADHD symptom severity (IDA-R interview) was examined as the primary outcome parameter before and after treatment. Across both interventions, ADHD core symptoms were significantly reduced. Notably, the smartphone-assisted psychoeducation was significantly more effective in improving inattention and impulsivity and led to higher homework compliance than the brochure-assisted psychoeducation. No adverse events were reported.

Gender-based differences in prevalence and effects of ADHD in adults: A systematic review

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that starts from childhood and lasts through adulthood. Historically thought as male dominant disorder, researches now emphasized that ADHD also effects females equally. Despite the ascending research on gender differences of ADHD, there is little known about its differences in prevalence and effects and there is a dearth of reviews that can draw a firm conclusion especially in adults. Data from the available medical literature published in English language literature of all time was reviewed systematically and tabulated to evaluate the gender-based differences in prevalence and effects of ADHD in adults. The studies revealed gender differences in adult ADHD in prevalence, and effects. Results showed that males have more prevalence as compared to females but females too have a significant presence of disorder. Females were more impaired as compared to men in most of the effects of ADHD like social functioning, time perception, stress tackling and mood disorder. Males were more impaired in working memory and educational functioning as compared to females. The review shows sufficient evidence of gender differences in adult ADHD in prevalence, and effects, that similarity across genders should not be assumed. It is concluded that there are plenty of conflicting evidence regarding gender differences in many areas of adult ADHD research, and to remove such discrepancies, the existing research is the need for more studies on gender differences and similarities in functioning of adults with ADHD.

Comorbidity of adult ADHD and substance use disorder in a sample of inpatients bipolar disorder in Iran

BACKGROUNDS

The study of the relationship between adult Attention deficit hyperactivity disorder (ADHD) and bipolar disorder has received more attention in recent years and there is limited information in this area. On the other hand, there is a significant comorbidity between ADHD and bipolar disorder with substance use disorder. In this study, we investigated the prevalence of comorbidity of adult ADHD and substance use disorder among a group of bipolar patients admitted to a psychiatric hospital.

METHODS

One hundred fifty patients from a total of 200 consecutive patients who were referred to the emergency department of Roozbeh Psychiatric Hospital in Tehran, diagnosed with bipolar disorder based on the initial psychiatric interview and needed hospitalization, were evaluated again by an experienced faculty member psychiatrist by using a subsequent interview based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition(DSM-5). They were evaluated using the Structured Clinical Interview for DSM-5 (SCID-5) questionnaire to confirm the diagnosis of bipolar disorder and the comorbidity of adult ADHD and substance use disorder.

RESULTS

From 150 patients diagnosed with bipolar disorder, 106 patients (70.7%) had adult ADHD. 89 patients (59.3%) had substance use disorder and 58 patients (38.7%) had both of these comorbidities with bipolar disorder. Comorbidity of adult ADHD was associated with the earlier onset of the first mood episode in bipolar disorder (p value = 0.025). There was no statistically significant relationship between substance use disorder and age of onset of the first episode. (P value = 0.57).

CONCLUSIONS

Due to the limitations of studies on adult ADHD comorbidity with bipolar disorder, especially in hospital settings, as well as the increased risk of association with substance use disorder, further multicenter studies in this area with larger sample sizes can increase awareness in this regard.

Prevalence of adult ADHD in patients with substance use disorder in North East India

BACKGROUND

Attention deficit and hyperactive disorder (ADHD) often co-exist with substance use disorders (SUD) both in adolescents and adults. Untreated ADHD can lead to multiple relapses, sociooccupational dysfunction and may worsen the outcome of SUD. ADHD is often underdiagnosed in the adult population. Therefore, the present study was intended to determine the types, patterns, and factors related to drug dependence among different age groups and to estimate the prevalence of adult ADHD in SUD patients in North East India.

MATERIALS AND METHODS

This is a cross-sectional hospital-based study carried out in patients diagnosed with SUD as per the Diagnostic and Statistical Manual Disorders, 5^th Edition. Adult ADHD Self-Report Scale (v1.1) Symptom Checklist was applied to screen for symptoms of adult ADHD in the patients.

RESULTS

In the age group of 18-29 years, 82.7% of patients were diagnosed with opioid use disorder (OUD), while 63.9% of the subjects in the age group of 30-49 years patients suffered from Alcohol Use Disorder (AUD). All patients of age 50 years and above were AUD. Our study showed that 24.3% of the total study population had the presence of adult ADHD. Symptoms of Adult ADHD were found in a higher proportion among OUD (28.7%) in comparison to OUD (11.5%).

CONCLUSION

The association of adult ADHD with OUD has been around three times than the AUD group. Hence young people (18-29 years) diagnosed with OUD need to be screened for adult ADHD and should be treated for the same for better abstinence and to prevent complications.

Updates in Pharmacologic Strategies in Adult Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) significantly worsens quality of life and long-term functional outcomes in adults. Individual impairments in adults with ADHD can be further contextualized within considerable costs to society at large. Food and Drug Administration (FDA) approved stimulants and nonstimulant medications can significantly improve ADHD symptoms in adults. In the past 2 decades, the United States FDA has expanded approval of pharmacotherapeutic options for adult ADHD. However, limitations still persist in available psychotropics for certain patient populations such as those with comorbid substance use or cardiovascular illness. Clinicians therefore must appreciate several ongoing investigations into medications with unique mechanisms of action. This article reviews the current FDA approved and emerging medication options while providing guidelines for pharmacologic management of adult ADHD.

Visuo-spatial working memory for objects and configurations in natural scenes in university students with ADHD

Adults with ADHD typically show reduced performance in visuo-spatial working memory (VSWM) tasks. These limitations have been observed mainly in tasks probing VSWM for low-level visual information. The current study investigated whether these limitations extended to memory for real-world objects, and memory for the spatial context in which they were presented. Sixty-four university students with and without ADHD memorised the form of real-world objects embedded in natural scenes. Following a short delay, participants were probed on a single object in the scene that could change in token or orientation, and that could appear within the original scene or in isolation. Consistent with previous studies, memory for the individual objects was impaired in the ADHD group relative to the control group, demonstrating that this deficit extends to complex real-world objects. Nevertheless, participants in the ADHD group benefited from the reinstatement of the scene during retrieval to the same extent as participants in the control group. This finding suggests that participants in the ADHD group formed and maintained a representation of the spatial context of the scene that aided memory retrieval. Overall, the results support an emerging view that VSWM operates on multiple, possibly independent, representations at different hierarchal levels.

New Hematological Parameters as Inflammatory Biomarkers: Systemic Immune Inflammation Index, Platerethritis, and Platelet Distribution Width in Patients with Adult Attention Deficit Hyperactivity Disorder

OBJECTIVES

The potential role of neuroinflammation in adult attention deficit hyperactivity disorder (ADHD) patients has been investigated with peripheral hemogram-related inflammatory markers. Systemic immune inflammation index (SII) is defined as a new index that has been developed for the balance of inflammatory and immune status.

METHODS

Our study was based on a prospective routine complete blood count(CBC) analysis of 74 Adult ADHD patients and 70 healthy participants. The DSM-5-Clinician version and Barratt impulsivity scale-11 were used to evaluate the participants.

RESULTS

There was no statistical difference in the comparison of the SII ratios, platelet distribution width (PDW), and plateretritis (PCT) (p>0.05 for each) in a group of a young adults with ADHD and in a comparison control group. These inflammatory indicators were found to be similar between patients newly diagnosed with ADHD (n=40) and patients using methylphenidate (n=34) (p>0.05 for each). The relationship between ADHD clinical symptoms and severity and inflammation was evaluated. A significant negative correlation was observed between attention deficit scores and PCT (r=-0.301, p=0.009). A positive significant correlation was found between hyperactivity scores and SII (r=0.247, p=0.034). A significant positive correlation was found between Barrat motor scores and PDW(r=241, p=0.038). In the regression analysis, the PCT variable changed the attention deficit variable (β=.33, t(70)= -2.703, p=.009, pr ²= .094) predicted negatively and significantly.

CONCLUSIONS

We demonstrated the association of SII, which is independently associated with adverse outcomes in many diseases, and the severity of hyperactivity symptoms in adult ADHD. The fact that PCT predicts attention deficit negatively and decisively shows the importance of inflammatory assessments specific to clinical presentations. The critical importance of platelets in inflammatory processes in ADHD has been demonstrated once again with inflammatory markers such as SII, PLT, and PDW, which can be accessed by an easily applicable complete blood count method.

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.

Adult ADHD and sleep disorders: Prevalence, severity and predictors of sleep disorders in a sample of Italian psychiatric outpatients

OBJECTIVE

Sleep disorders are frequent in adult subjects diagnosed with ADHD. The aims of the present study were to assess the prevalence and the severity of sleep disorders in a sample of Italian psychiatric outpatients, to compare the prevalence and severity of sleep disorders in patients with and without diagnosis of adult ADHD, and to evaluate the role of ADHD as an individual predictor of sleep disturbances severity.

METHOD

634 outpatients accessing psychiatric services were assessed with the Mini-International Neuropsychiatric Interview (MINI) Plus V. 5.0.0 interview and the Adult ADHD self-report Scale Symptoms Checklist (ASRS)-V 1.1 Short Form. Patients positive to the ASRS-V 1.1 were assessed with the Diagnostic Interview for ADHD in Adults (DIVA) 2.0. Sleep disorders and sleep disturbances' severity were assessed with the PROMIS Adult Sleep Disturbance Scale.

RESULTS

Sleep disorders were more frequent (p < 0.001) and sleep disturbances were more severe (d = 1.26, p < 0.001) in subjects diagnosed with adult ADHD compared to other outpatients. Among the 44 subjects diagnosed with ADHD, 15 (34.1%) reported no or slight sleep disturbances, 9 (20.5%) a mild sleep disorder, 17 (38.6%) a moderate sleep disorder and 3 (6.8%) a severe sleep disorder. ADHD diagnosis, multiple psychiatric comorbidity and history of suicide attempts emerged as individual predictors of worse sleep disturbances.

CONCLUSION

Sleep disorders are more frequent and severe in subjects diagnosed with ADHD compared to other adult outpatients. Sleep disturbances might represent an intrinsic feature in adult ADHD subjects, presenting important clinical repercussions, and should be routinely evaluated and monitored in this population.

Internalizing and externalizing comorbidity and symptom burden in a VA ADHD specialty evaluation clinic

The purpose of this study was to evaluate psychiatric diagnosis and symptom comorbidity in veterans diagnosed with attention-deficit/hyperactivity disorder (ADHD). Study design was retrospective chart review from an ADHD evaluation clinic at a Veterans Affairs hospital. Participants were 227 military veterans who completed a standardized ADHD assessment and produced valid Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) profiles. There were no differences in rates of internalizing or externalizing psychiatric conditions diagnosed in inattentive compared to combined ADHD presentations. However, compared to a subsample with no psychiatric diagnoses, individuals diagnosed with ADHD endorsed significantly more internalizing symptom burden, with combined ADHD veterans also endorsing significantly greater levels of negative emotions and neuroticism. Base rates of comorbid classes of psychiatric diagnoses were not increased in individuals with ADHD, though higher rates of trauma disorders were seen in the combined group compared to the inattentive group. Multivariate base rates of MMPI-2-RF Restructured Clinical scales across various subgroups are presented. There was evidence for differential phenotypes of psychiatric symptoms across ADHD presentations in clinically referred veterans, predominantly related to higher rates of internalizing symptoms.

Attention-Deficit/Hyperactivity Disorder, Insomnia, and Sleepiness Symptoms among a Community Adult Sample: The Mediating Effect of Executive Behavioral Regulation and Metacognition Abilities

OBJECTIVE

Adult attention-deficit/hyperactivity disorder (ADHD) is characterized by a dysexecutive syndrome reflected in cognitive, emotional, and behavioral areas. Independently of a formal diagnosis of ADHD, higher ADHD symptoms are associated with higher levels of insomnia and sleepiness symptoms in adult population-based samples. Insomnia and sleepiness are sleep disorders that are both associated with deficits in several aspects of executive functions which in turn are likely to mimic a range of ADHD symptoms. Our objective was to explore the interrelationships between ADHD, insomnia, and sleepiness symptoms and executive functioning in community-dwelling adults.

METHOD

A total of 442 participants (18-89 years, 56% females) underwent a semistructured clinical interview and completed questionnaires for insomnia, sleepiness, and everyday behaviors in which executive functions are implicated. Mediation Models were applied.

RESULTS

Insomnia and sleepiness symptoms did not play a mediating role between ADHD symptoms and executive functioning. Conversely, our results highlighted a mediating effect of daytime insomnia consequences and sleepiness on ADHD symptoms via behavioral regulation executive symptoms (respectively, β = -0.32, p < .001, 95% CI [-0.46, -0.20]; β = 0.09, p < .05, 95% CI [0.02, 0.16]) and metacognitive executive symptoms (respectively, β = -0.30, p < .001, 95% CI [-0.44, -0.18]; β = 0.12, p < .01, 95% CI [0.04, 0.22]).

CONCLUSIONS

Daytime insomnia consequences and sleepiness symptoms could lead to ADHD-like symptoms through their associated executive symptoms expressed in daily life. When faced with symptoms suggestive of ADHD in adults, insomnia and sleepiness should be systematically screened with standardized instruments.

Adult Attention-Deficit Hyperactivity Disorder/Substance Use Disorder Dual Disorder Patients: A Dual Disorder Unit Point of View

Substance Use Disorders (SUDs) are often associated with Attention-Deficit Hyperactivity Disorder (ADHD) in adult populations due to multiple neurobiological, genetic, and psychosocial risk factors. This chapter provides a picture of the clinical aspects of adults with both ADHD and SUDs at treatment entry into a Dual Disorder Unit introducing the concept of different types of craving that may lead to substance use and abuse. At treatment entry, the presence of different comorbid SUD clusters, characterized by either stimulants/alcohol or by the use of cannabinoids, has not been shown to influence ADHD-specific symptomatology or severity, despite being crucial for the identification of a specific type of craving. We identified four clinical presentations of adult ADHD: Emotional Dysregulation, Substance Use, Core-ADHD Symptoms, and Positive Emotionality variants, that offer a practical guide in diagnosing and managing adult ADHD patients. Although the evidence of an effective medical treatment for Cocaine Use Disorder is insufficient, in our experience, toxicomanic behavior during stimulant treatment is sharply reduced in ADHD patients with cocaine addiction. Moreover, caffeinated compounds in military soldiers with ADHD may help reduce ADHD symptoms, making caffeine a potential pharmacological tool worth further investigation. Finally, substance use comorbidity does not influence treatment retention rate.

Adults referred to a national ADHD clinic in Iceland: clinical characteristics and follow-up status

OBJECTIVE

Evaluate adults referred to a national ADHD clinic, by comparing those diagnosed with those who were not, and those who screened negative and to evaluate changes among those diagnosed at follow-up.

METHOD

Data obtained from 531 patients' medical records (49.7% males). One hundred thirty-six screened negative, 395 positive and 305 met diagnostic criteria for ADHD. Eighty-three of them were contacted by phone at follow-up.

RESULTS

ADHD diagnosis was associated with lower educational status and more concerns expressed by parents and teachers during childhood. Participants not diagnosed with ADHD more often met diagnostic criteria for dysthymia, agoraphobia and generalized anxiety, and were more likely to be diagnosed with two or more comorbid disorders. At follow-up, all reported a significant reduction of ADHD symptoms, irrespective of medication, but the medicated participants reported fewer symptoms of inattention and better functioning in daily life.

CONCLUSION

Adults referred to ADHD clinics may have multiple mental health problems, regardless of whether they receive ADHD diagnosis or not. This could have implications for differential diagnoses of ADHD in adults and emphasises the need to have appropriate treatment available for both groups. Psychoeducation about ADHD may be very helpful in decreasing anxiety and ADHD symptoms.

Methylphenidate for attention-deficit/hyperactivity disorder in adults: a narrative review

RATIONALE

Psychostimulants, including methylphenidate (MPH), are the mainstay of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) in adults. Even though MPH is the most commonly used medication for ADHD these days, there are relatively few resources available that provide comprehensive insight into the pharmacological and clinical features of the compound.

OBJECTIVE

The aim of this paper is to provide an up-to-date outline of the pharmacology and clinical utility of MPH for ADHD in adult patients.

METHODS

While conducting the narrative review, we applied structured search strategies covering the two major online databases (MEDLINE and Cochrane Central Register of Controlled Trials). In addition, we performed handsearching of reference lists of relevant papers.

RESULTS

Methylphenidate exhibits multimodal mechanism of action, working primarily as a dopamine and noradrenaline reuptake inhibitor. It also protects the dopaminergic system against the ongoing 'wearing off' (by securing a substantial reserve pool of the neurotransmitter, stored in the presynaptic vesicles). In placebo-controlled trials, MPH was shown to be moderately effective both against the core ADHD symptoms (standardized mean difference [SMD], 0.49; 95% confidence interval [CI], 0.35-0.64), and the accompanying emotion regulation deficits (SMD, 0.34; 95% CI, 0.23-0.45). The most common adverse events related to long-term treatment with MPH are decreased appetite (~ 20%), dry mouth (15%), heart palpitations (13%), gastrointestinal infections (~ 10%), and agitation/feeling restless (~ 10%).

CONCLUSIONS

There is substantial body of evidence to suggest that MPH is an effective and safe treatment option for adults with ADHD.

Prevalence of ADHD Symptomatology in Adult Population in the Czech Republic-A National Study

Background: Attention deficit/hyperactivity disorder is a common neurodevelopmental disorder frequently diagnosed between the ages 7 and 10 years. We measured ADHD symptomatology in a representative sample of the Czech population. Material and Methods: Data collection was performed in January 2019 through the European National Panel. The respondents completed a demographic questionnaire focusing on ADHD history and a standardized questionnaire, the Adult ADHD Self-Report Scale (ASRS) screener for ADHD symptomatology in adulthood. Results: From the sample of 1,518 respondents, 3% of the respondents reported having been diagnosed with ADHD/hyperkinetic disorder in their lifetime. According to ASRS scoring, 119 respondents were classified as suspected ADHD. Overall, more males than females reported ADHD symptomatology. Age was also significantly associated with ASRS. Education status yielded no significant results. Conclusion: Our study documents that the prevalence of ADHD symptomatology in adults is comparable with that in Western countries despite the different historical and health care backgrounds.

The association between adult ADHD and food addiction: A mediation analysis

OBJECTIVES

The aim of this study was to investigate the association between food addiction severity (FA) and ADHD symptomatology. Furthermore, we investigated whether emotional distress, and the mentalization deficits could mediate this relationship.

METHODS

Three hundred eighty-five Italian adults (307 women and 78 men) participated in the study and completed the Italian versions of the Modified Yale Food Addiction Scale version 2.0, the Adult ADHD Self-Report Scale, the Depression Anxiety Stress Scales 21 and the Mentalization Questionnaire.

RESULTS

ADHD symptoms severity and general distress were significantly and independently associated with FA. Emotional distress partly mediated the relationship between FA and ADHD symptoms severity. In addition, mentalization deficits partly mediated this relationship only when evaluating the influence of FA on ADHD symptoms severity.

LIMITATIONS

This is a cross-sectional study and causal interpretations of the relationships among the variables are speculative.

CONCLUSIONS

It is important to assess emotional distress and mentalization deficits in individuals at risk of ADHD and FA because these conditions could increase the risk for the presence of disordered eating patterns.

Helpful family climate moderates the relationship between perceived family support of ADHD symptoms and depression: a conditional process model

BACKGROUND

Symptoms of attention deficit hyperactivity disorder (ADHD) are commonly comorbid with depression This study aimed to examine the relationship between ADHD symptoms and depression through perceived family support and to explore whether the magnitude of the relationship depended on the type of family climate of medical students.

METHODS

This cross-sectional study was conducted among 124 first year medical students in Thailand. Participants completed questionnaires on ADHD symptoms, depression, perceived family support, and 9 types of family climate. The questionnaires included the Adult ADHD Self-Report Scale Screener, Patient Health Questionnaire-9, and revised Thai Multidimensional Scale of Perceived Social Support. Mediational analysis was adopted to examine the mediating role of perceived family support in the relationship between ADHD symptoms and depression, while moderation analysis was applied to examine the extent of the relationship depending on family climate.

RESULTS

The relationship between ADHD symptoms and depression was moderate. Perceived family support partially mediated this relationship after controlling for age and sex. Among the types of family climate, only helpful family climate was a significant moderator of perceived family support and depression. The moderated mediation model increased the variance in depression from 17% by the mediation model to 21%. However, follow-up conditional mediational analysis showed that the indirect effect of ADHD symptoms on depression via perceived family support was not significant and that this effect did not vary linearly as a function of helpful family climate.

CONCLUSION

The findings of the study revealed that poor family support might be one risk of developing depression in the context of ADHD symptoms. Further study on providing intervention concerning family support among those with ADHD symptoms should be warranted. In addition, a study on helpful family climate in a larger sample size, in other populations, and in a longitudinal fashion for a more robust conclusion is encouraged.

Adult attention-deficit hyperactivity disorder symptoms and psychological distress, hazardous drinking, and problem gambling: A population-based study

Recognition of ADHD in the adult population is relatively recent. Epidemiological research examining the mental health impact of ADHD in adulthood is thus limited. The objective of this study was to examine whether adult ADHD symptoms are associated with psychological distress, hazardous drinking, and problem gambling, after controlling for traumatic brain injury and sociodemographic characteristics. We analyzed data from a population-based survey administered in 2015 and 2016 to adults aged 18 years and over in Ontario, Canada (N = 3,817). Logistic regression was used to construct unadjusted and multivariable models for each of the three focal relationships. In the unadjusted models, ADHD symptoms were significantly related to psychological distress (OR = 9.3; 95% CI:6.1, 14.0) and hazardous drinking (OR = 2.1; 95% CI: 1.3, 3.4), but not to problem gambling (OR = 1.5; 0.5, 4.3). After adjustment, ADHD symptoms were significantly related to psychological distress (OR = 7.1; 95% CI: 4.6, 11.1), but not hazardous drinking (OR = 1.4; 95% CI: 0.8, 2.5) or problem gambling (OR = 0.6; 95% CI: 0.2, 2.5). This study further highlights the importance of clinicians assessing for concomitant ADHD and psychological distress in adults.

Evaluating a Web-Based Adult ADHD Toolkit for Primary Care Clinicians

INTRODUCTION

Approximately 5% of the US adult population has Attention Deficient Hyperactivity Disorder (ADHD) that can negatively impact quality of life. Health care professionals report a need to increase their knowledge of and confidence in treating adult ADHD. The American Academy of Family Physicians National Research Network (AAFP NRN) collaborated with a panel of experts to create a web-based AAFP Adult ADHD Toolkit composed of resources to aid in the diagnosis, management, and treatment of adults with ADHD.

OBJECTIVES

Assess the impact of using an AAFP Adult ADHD Toolkit in a practice setting.

METHODS

Ninety-seven primary and behavioral health care professionals from AAFP NRN practices (n=6) used the Toolkit for 17 weeks. Data on Toolkit use, usefulness, implementation, impact, and changes in knowledge and confidence were collected via pre-post and weekly surveys. Mixed methods, regression analyses, t-tests, and mixed ANOVA were used to assess change over time.

RESULTS

Use of the Toolkit improved health care providers' knowledge by midpoint relative to baseline in areas related to treatment effects, side effects, and outcomes (3.6 vs 3.0; P = .004); existing ADHD resources (3.3 vs 2.9; P = .03); and management of ADHD in patients with comorbid conditions (3.2 vs 2.7; P = .01). By the end of the study, Toolkit use was associated with increased confidence in mental health and life history interview techniques (3.5 vs 3.0; P = .03); treatment options for ADHD with comorbid mental health disorders (3.2 vs 2.3; P ≤ .001); and treatment options for ADHD with coexisting substance use disorders (3.0 vs 2.3; P = .003). By the end of the study, most participants (n=47, 87%) reported the Toolkit addressed most of their needs related to diagnosis, treatment, and management of adult ADHD.

CONCLUSION

Availability and adoption of the Toolkit into the routine care of adults with ADHD measurably increased health care professionals' knowledge especially in those providers who regularly see adult patients with ADHD.

Beyond motor hyperactivity: Racing thoughts are an integral symptom of adult attention deficit hyperactivity disorder

Adults with ADHD experience mental restlessness, akin to racing thoughts, but data on this symptom in ADHD remain scarce. Our study aims at investigating self-reported racing thoughts in adults with ADHD, and its relationship with affective dysregulation and insomnia. We were also interested in whether racing thoughts may aid differential diagnosis with bipolar disorder (BD). 182 adults with ADHD, 30 ADHD+BD, 31 hypomanic BD, and 20 euthymic BD patients completed the Racing and Crowded Thoughts Questionnaire (RCTQ). ADHD, anxiety, insomnia and depression symptoms, as well as affective temperament were also assessed in ADHD and ADHD+BD subjects. Results show that RCTQ scores were higher in ADHD compared to hypomania and euthymia and were associated with cyclothymic traits and anxiety. Moreover, in ADHD and ADHD+BD, racing thoughts increased in the evening and at bedtime and were associated with insomnia severity. In conclusion, self-reported racing thoughts are a neglected but an intrinsic feature of adult ADHD that is particularly related to cyclothymia and anxiety, but cannot differentiate ADHD and BD.

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.

Atypical resting-state gamma band trajectory in adult attention deficit/hyperactivity disorder

Decreased gamma activity has been reported both in children and adults with attention deficit/hyperactivity disorder (ADHD). However, while ADHD is a lifelong neurodevelopmental disorder, our insight into the associations of spontaneous gamma band activity with age is limited, especially in adults. Therefore, we conducted an explorative study to investigate trajectories of resting gamma activity in adult ADHD patients (N = 42) versus matched healthy controls (N = 59). We investigated the relationship of resting gamma activity (30–48 Hz) with age in four right hemispheric electrode clusters where diminished gamma power in ADHD had previously been demonstrated by our group. We found significant non-linear association between resting gamma power and age in the lower frequency gamma₁ range (30–39 Hz) in ADHD as compared to controls in all investigated locations. Resting gamma₁ increased with age and was significantly lower in ADHD than in control subjects from early adulthood. We found no significant association between gamma activity and age in the gamma₂ range (39–48 Hz). Alterations of gamma band activity might reflect altered cortical network functioning in adult ADHD relative to controls. Our results reveal that abnormal gamma power is present at all ages, highlighting the lifelong nature of ADHD. Nonetheless, longitudinal studies are needed to confirm our results.

Metacognition, psychopathology and daily functioning in adult ADHD

OBJECTIVE

Previous research indicated that adults with ADHD may have deficits in metacognition, yet the evidence base is scarce. This study aims to explore the existence and nature of metacognitive deficits in adults with ADHD, how psychopathology (such as inattention and depression) may affect metacognition and whether metacognition may impact daily functioning in adults with ADHD.

METHOD

Forty-six adult patients with ADHD and 46 controls completed questionnaires for metacognition, psychopathology and daily functioning (subjective assessment; self- and informant report). Participants performed two attention tests in a neuropsychological assessment. After test completion, participants were asked to evaluate their performance with the help of a visual aid and this self-evaluation of test performance was compared with their actual test performance (objective assessment).

RESULTS

Patients with ADHD reported large deficits in knowledge of cognition and medium deficits in regulation of cognition compared to controls. Self-evaluation of cognitive test performance revealed no significant deficits. Regression analyses revealed that psychopathology may explain a part of the variation in metacognition. Further regressions indicated that metacognition may account for a significant and meaningful proportion of variance in daily functioning, both self-rated and informant-rated.

CONCLUSIONS

Current findings of compromised metacognitive functioning of adults with ADHD suggest that clinicians may not want to rely on patients' self-reports in the clinical assessment. Inattention predicted impairments in metacognition, pointing toward the importance of attention for awareness and metacognition. Finally, we recommend that metacognition is addressed in the treatment trajectory of patients with ADHD, given that aspects of metacognition were directly linked to impairments in daily functioning as rated by participants and their relatives.

Electrophysiological correlates of improved executive function following EEG neurofeedback in adult attention deficit hyperactivity disorder

OBJECTIVE

Event-related potentials (ERPs) are reported to be altered in relation to cognitive processing deficits in attention deficit hyperactivity disorder (ADHD). However, this evidence is mostly limited to cross-sectional data. The current study utilized neurofeedback (NFB) as a neuromodulatory tool to examine the ERP correlates of attentional and inhibitory processes in adult ADHD using a single-session, within-subject design.

METHODS

We recorded high-density EEG in 25 adult ADHD patients and 22 neurotypical controls during a Go/NoGo task, before and after a 30-minute NFB session designed to down-regulate the alpha (8-12 Hz) rhythm.

RESULTS

At baseline, ADHD patients demonstrated impaired Go/NoGo performance compared to controls, while Go-P3 amplitude inversely correlated with ADHD-associated symptomatology in childhood. Post NFB, task performance improved in both groups, significantly enhancing stimulus detectability (d-prime) and reducing reaction time variability, while increasing N1 and P3 ERP component amplitudes. Specifically for ADHD patients, the pre-to-post enhancement in Go-P3 amplitude correlated with measures of improved executive function, i.e., enhanced d-prime, reduced omission errors and reduced reaction time variability.

CONCLUSIONS

A single-session of alpha down-regulation NFB was able to reverse the abnormal neurocognitive signatures of adult ADHD during a Go/NoGo task.

SIGNIFICANCE

The study demonstrates for the first time the beneficial neurobehavioral effect of a single NFB session in adult ADHD, and reinforces the notion that ERPs could serve as useful diagnostic/prognostic markers of executive dysfunction.

Effects of methylphenidate on sensory and sensorimotor gating of initially psychostimulant-naïve adult ADHD patients

Deficient information processing in ADHD theoretically results in sensory overload, which in turn may underlie its symptoms. If this sensory overload is caused by deficient filtering of environmental stimuli, then one would expect finding deficits in P50 gating and prepulse inhibition of the startle reflex (PPI). Previous reports on these measures in ADHD have shown inconsistent findings, which may have been caused by either medication use or comorbidity (e.g. ASD). The primary aim of this study was therefore to explore P50 suppression and PPI in adult, psychostimulant-naïve patients with ADHD without major comorbidity, and to examine the effects of 6 weeks treatment with methylphenidate (MPH) on these measures. A total of 42 initially psychostimulant-naive, adult ADHD patients without major comorbidity and 42 matched healthy controls, were assessed for their P50 gating, PPI, and habituation/sensitization abilities at baseline and after 6 weeks of treatment with methylphenidate. Although six weeks of treatment with MPH significantly reduced symptomatology as well as improved daily life functioning in our patients, it neither significantly affected PPI, P50 suppression nor sensitization, but habituation unexpectedly decreased. The absence of PPI and P50 suppression deficits in our patients in the psychostimulant-naïve state indicates no gating deficits. In turn, this suggests that the difficulties to inhibit distraction of attention by irrelevant stimuli that many patients with (adult) ADHD report, have a different origin than the theoretical causes of sensory overload frequently reported in studies on patients with schizophrenia.

Impaired auditory and visual time reproduction in adult patients with attention deficit-hyperactivity disorder

Objective: Although impaired time perception is associated with significant disturbance in the everyday functioning of adult patients with Attention Deficit-Hyperactivity Disorder (ADHD), it is not very well studied. The present study aimed to evaluate both visual and auditory time reproduction (TR) by using eight time intervals in adult ADHD patients compared to healthy controls (HC).Method: Wechsler Adult Intelligence Scale-R (WAIS-R), Adult Attention Deficit-Hyperactivity Disorder Self-Report Scale (ASRS), Wender Utah Rating Scale (WURS), Hyperfocusing Scale (HS), Beck Depression Inventory (BDI) and a 2-back task were administered to participants. In TR tasks, participants reproduced the same duration of the auditory/visual stimulus by pressing a key and absolute discrepancy scores (ADS) were calculated. A 2 (Group) x 2 (Task Modality) x 8 (Time Interval: 500, 1000, 2000, 4000, 6000, 8000, 12000 and 16000 msec) mixed-design ANOVA was performed.Results: All clinical scores of ADHD group were higher than HC (p < .001) while WAIS-R and 2-back performances of the groups were similar. Mixed-design ANOVA yielded significant Group and Time Interval main effects as well as a Group X Time Interval effect (both p < .001). ADHD patients had larger ADS than HC and as time intervals increased, error levels increased. Errors for time intervals >8000 msec were more prominent in patients. For both TR tasks, ASRS-hyperactivity/impulsivity scores were the main predictor of ADS in the linear regression analysis, while ASRS-attention deficit and HS scores were excluded.Conclusion: Results of the present study indicate significant TR impairment in adult ADHD regardless of task modality (visual or auditory), depressive symptoms and working memory performances. Longer time intervals in TR tasks differentiated patients better and TR impairment was associated with hyperactivity/impulsivity. These findings should be replicated in larger samples and underlying neurobiological components of impaired TR need to be examined in future research.