This two-year study examined the effect of digital media use on ADHD symptoms in over 2500 adolescents. An earlier meta-analysis found that traditional media use (TV and video console games) was modestly associated with ADHD-like behaviors (Nikkelen et al 2014). The current study extends the examination to a large sample, with modern digital media delivery of high-intensity stimuli, including mobile platforms. The authors used the Current Symptom Self-Report Scale (Barkley R 1998) to establish ADHD symptoms at baseline and at six-month assessments over a 24 month period. None of the subjects reported having ADHD at study entry. Subjects were considered to be ADHD symptom positive (the primary binary outcome) is they had greater than or equal to six inattentive and/or hyperactive-impulsive symptoms rated on this frequency-based scale (0-3).

Modern digital media use was surveyed on a frequency basis for 14 media activities (including checking social media sites, texting, browsing, downloading or streaming music, posting pictures, online chatting, playing games, online shopping, and video chatting). The most common media activity was high-frequency checking of social media. Of note, high-frequency engagement in each of the digital media activities was significantly, but moderately, associated with having ADHD symptoms at each six-month follow-up (OR 1.10), even after adjusting for covariates.

High-frequency media use at baseline seemed to be associated with development of ADHD symptoms. Among the 495 students who reported no high-frequency media use at baseline, 4.6% met ADHD symptom criteria at follow-up. Among 114 students scoring 7 for high-frequency media use at baseline 9.5% met the symptoms criteria. For the 51 students with a score of 14 for high-frequency media use at baseline, the rate was 10.5% (both comparisons were statistically significant).

This study is important in that it notes that an association between high-frequency digital media use (in current platforms and modalities) may be associated with the development of ADHD-like symptoms. A significant limitation of the study, as noted by the authors, is that ADHD-like symptoms do not establish a diagnosis of ADHD and do not assess impairment; therefore, these results must be interpreted with some caution. It does highlight that even with the current level of understanding it might be prudent for clinicians to recommend limiting high-frequency media use for adolescent patients.

REFERENCES
Barkley RA. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook. 2nd ed. New York, NY: Guilford Press; 1998.

Nikkelen SW, Valkenburg PM, Huizinga M, Bushman BJ. Media use and ADHD-related behaviors in children and adolescents: a meta-analysis. Dev Psychol. 2014;50(9):2228-2241. doi:10.1037/a0037318

Ra CK, Junhan Cho J, Stone MD, De La Cerda J, Goldenson NI, Moroney E, Tung I, Lee SS, Leventhal AM. Association of Digital Media Use With Subsequent Symptoms of Attention-Deficit/Hyperactivity Disorder Among Adolescents JAMA. 2018;320(3):255-263. doi:10.1001/jama.2018.8931

This article provides a review of the cardiovascular effects of ADHD medications including potential effects on blood pressure, heart rate and risk of cardiovascular events (myocardial infarction, sudden death and stroke).

The article notes that meta-analyses have generally found that the effects of stimulant medications and atomoxetine were generally similar on systolic blood pressure (1-3 mm Hg) and heart rate (2-5 beats/minute); these were felt to be of limited clinical significance, except for patients with elevated blood pressures or heart rate antecedent to starting these ADHD therapies. However, as these are average changes, changes in individual patients may vary and important to monitor. Additionally, the meta-analysis and observational data available also do not find significantly higher risks for MI or stroke in patients receiving stimulant medications. These findings are complicated by the use of clinical trial data in the meta-analysis which specifically limit is the enrollment of patients with higher risks of pre-existing cardiovascular illnesses and the observational data were of relatively short treatment exposures.

This article is important for clinicians because it reviews the cardiovascular safety profiles of current ADHD medications and also recommends monitoring of blood pressure and pulse at baseline and during treatment. Furthermore, the authors recommend baseline screening patients for significant cardiovascular histories via family history of cardiovascular disease and sudden death.

REFERENCES
https://www.healio.com/psychiatry/journals/psycann/2018-7-48-7/%7B426ecc52-e3d9-4f38-afc6-34cbf88548c7%7D/review-of-cardiovascular-effects-of-adhd-medications#divReadThis

Lenard Adler, MD ADHD in AdultsThis article reviews the phenomenology of emotional dysregulation in adult ADHD. The article discusses whether symptoms of emotional dysregulation (ED) are co-traveling symptoms that travel with symptoms of adult ADHD or whether they are part of the core symptoms of the condition.

Symptoms of ED include rapidly shifting affect, changeable mood, mood lability, impulsivity and emotional overactivity. Barkley et al. (7 from article) have posited that ED symptoms are part of a set of executive function deficits which are critical to the core of ADHD symptomtology (8).

In contrast, Wender (13) and co-workers have posited that ED symptoms should be part of the diagnostic criteria of adult ADHD and are included in the Utah criteria they defined and the Wender-Reimherr Adult Attention-Deficit Disorder Scale (WRAADS). Work from Adler and Kessler and co-workers (21) found that ED symptoms tracked separately from symptoms of inattention, hyper-activity impulsivity and executive function and were more likely to load on the Combined presentation of ADHD and be present in sub-threshold cases. The article also reviews a number of scales which have been used to assess ED, including the WRAADS, the expanded Adult ADHD Clinician Diagnostic Scale (ACDS) v.1.2, expanded Adult ADHD Self-Report Scale (ASRS) v1.1 Symptom Checklists and the Brown Adult ADD Scale (BAADS).

This article is important to clinicians because: 1) it defines and highlights the importance of recognizing symptoms of ED, 2) describes assessment methods and 3) notes the lower efficacy of standard adult ADHD pharmacotherapies of stimulants and atomoxetine than on core ADHD symptoms and 4) highlights the potential utility of cognitive behavioral therapy in treating ED symptoms in adults with ADHD.

REFERENCES
https://www.healio.com/psychiatry/journals/psycann/2018-7-48-7/%7Bd9674afc-698a-4cd9-9a24-81e3e4d4d944%7D/emotional-dysregulation-in-adult-adhd

Lenard Adler, MD ADHD in AdultsSilverstein et al. (2017) recently published a study which reported a validation of two expanded adult ADHD scales, self-report (Adult ADHD Self Report Rating Scale (ASRS) v1.1 Symptom Checklist) and clinician/investigator (Adult ADHD Investigator Symptom Rating Scale – AISRS); both scale were expanded beyond the classic 18 DSM symptoms of inattention (IA) and hyperactivity-impulsivity (HI) to include 13 additional commonly co-traveling items of executive function deficits (EFDs) (eg. difficulty with organization, planning, task execution and procrastination) and emotional control deficits (EC) (eg. moodiness, over-reactivity of mood), creating 31 item scales.

Data was examined on 297 individuals (either referred adults with ADHD or individuals in a primary care practice, who were mostly controls) at the NYU School of Medicine. The psychometric properties of both scales were examined in terms of internal consistency (Cronbach’s alpha) and cut-off’s from normative data to predict a diagnosis. The internal consistency was high on both scales for measuring not only DSM IA and HI symptoms but also symptoms of EFD and EC (subscales ranging from 0.84 to 0.96); however, the internal consistency for EC was less for EFD, indicating that EC symptoms are less homogeneous than those of EFD, as had been suggested in a factor analysis by Adler et al (2017). Cut-off scores predictive of adult ADHD on the AISRS for dsm IA and HI 18 symptoms were between 23 and 26; this validates the empirical choice utilized in many clinical trials in adult ADHD of a cut-off score of 24.

This study highlights the importance to clinicians of assessing not only DSM symptoms of IA and HI, but also the co-traveling symptoms of EFD and EC and that clinician or self-report scales can be utilized in clinical practice. Also, the assessment of EFD and EC is especially important for clinicians as these symptom sets are less robustly responsive to pharmacotherapy than classic symptoms of IA and HI and may be more amenable to the addition of psycho-social interventions, such as cognitive behavioral therapy.

REFERENCES
Adler LA, Faraone SV, Spencer TJ, Berglund P, Alperin S, Kessler RC. The structure of adult ADHD. Int J Methods Psychiatr Res. 2017 Mar;26(1). doi: 10.1002/mpr.1555. Epub 2017 Feb 17

Silverstein MJ, Faraone SV, Alperin S, Leon TL, Biederman J, Spencer TJ, Adler LA. Validation of the Expanded Versions of the Adult ADHD Self-Report Scale v1.1 Symptom Checklist and the Adult ADHD Investigator Symptom Rating Scale. J Atten Disord. 2018 Feb 1:1087054718756198. doi: 10.1177/1087054718756198. [Epub ahead of print].

Lenard Adler, MD ADHD in AdultsUstun et al. (2017) recently published an updated version of the adult ADHD screener which is validated for DSM-5: the ASRS v1.1 Screener: DSM-5. The prior DSM-IV version of the screener was established using two populations: a community-based sample from the National Co-Morbidity Survey (NCS-R) and a sample of individuals from a health care plan.

The first step was to recalibrate the new screener using these same two samples, but applying updated DSM-5 criteria; symptoms included not only core symptoms of inattention (IA) and hyperactivity-impulsivity (HI) as defined in DSM, but additional co-traveling symptoms of executive dysfunction (eg: deficits in organization, planning, working memory) or emotional dysregulation (eg: over emotionality, changeable mood).

The symptoms of executive dysfunction have been shown to carry a high symptom burden and in many ways drive the symptom presentation when present in a recent factor analysis (Adler et al. 2017). The selection and weighting of the symptoms was selected by SLIM artificial intelligence – six items were selected: four were from DSM classic symptoms of IA and HI, but two were symptoms of executive dysfunction beyond those defined in the DSM. The process was again repeated and validated in a new sample of referred individuals for ADHD evaluations and controls from primary care practices from the NYU School of Medicine as second validation. The screener is again self-report and rated on a frequency basis of 0-4 (never to very often), with a cut-off score of > = 14 indicating a positive screen. The weighting of items in the screener is not evenly distributed and the scoring algorithm will shortly be available through an educational program on this website.

The ASRS v1.1 Sceener: DSM-5 has a high degree of sensitivity and specificity (first sample: 91.4%; 96.0%, respectively; second NYU sample: 91.9%, 74.0%, respectively). Given the high sensitivity and specificity, the new screener can be a highly effective tool for clinicians to identify individuals at risk for adult ADHD who merit further evaluation and a full diagnostic evaluation.

REFERENCES
Adler LA, Faraone SV, Spencer TJ, Berglund P, Alperin S, Kessler RC. The structure of adult ADHD. Int J Methods Psychiatr Res. 2017 Mar;26(1). doi: 10.1002/mpr.1555. Epub 2017 Feb 17.

Ustun B, Adler LA, Rudin C, Faraone SV, Spencer TJ, Berglund P, Gruber MJ, Kessler RC. The World Health Organization Adult Attention-Deficit/Hyperactivity Disorder Self-Report Screening Scale for DSM-5. JAMA Psychiatry. 2017 May 1;74(5):520-526. doi: 10.1001/jamapsychiatry.2017.0298.

Lenard Adler, MD ADHD in AdultsNeural Correlates of Symptom Improvement Following Stimulant Treatment in Adults
with Attention-Deficit/Hyperactivity Disorder, Zhen Yang, PhD, Clare Kelly, PhD, Francisco X. Castellanos, MD, Terry Leon, MS, Michael P. Milham, MD, PhD, and Lenard A. Adler, MD
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY, p. 1–10,DOI: 10.1089/cap.2015.0243

Several prior studies have examined effects of stimulant medications on functional connectivity during resting state fMRI (R-fMRI). This study appears to be the first study to examine effects of ADHD treatment on functional connectivity in adults. Nineteen adults with ADHD were received two, six minute R-fMRI scans at baseline and after three weeks of single-blind treatment with amphetamine (mixed amphetamine salts (MAS) or lisdexamfetamine (LDX)). A comparison group of healthy controls (HC) was scanned once at baseline. Potential amphetamine effects on the entire connectome relating to R-fMRI were examined through a data driven analytic approach. Clinical effects of amphetamines on ADHD symptoms were examined via the prompted ADHD Rating Scale (ADHD-RS) administered by a clinician and the Adult Self Report Scale (ASRS) v1.1 Symptom Checklist. MAS and LDX both significantly improved ADHD symptoms on the ADHD-RS and ASRS. Functional connectivity analyses showed that stimulants altered multivariate connectivity in medial prefrontal cortex (MPFC)/paracingulate gyrus and the dorsolateral PFC. Seed based correlation analyses were defined for the left DLPFC and bilateral MPFC. Functional connectivity analyses showed that amphetamines decreased positive functional connectivity between: a) left DLPFC and bilateral dorsal ACC, right insula and left insula and b) bilateral MPFC. These reductions in functional connectivity led to a pattern of function similar to the healthy controls, which is important as the increased functional segregation of these units may be involved in the improvement with amphetamine treatment. Although these results cannot be directly translated into the clinic, they hold open the promise that, in the future, imaging methodologies may be useful for either predicting or tracking treatment response.

Lenard Adler, MD ADHD in AdultsE. J. Semeijn, N. C. M. Korten, H. C. Comijs, M. Michielsen, D. J. H. Deeg, A. T. F. Beekman and J. J. S. Kooij. No lower cognitive functioning in older adults with attention-deficit/hyperactivity disorder. International Psychogeriatrics: International Psychogeriatric Association 2015 doi:10.1017/S1041610215000010.

The largest percentage growth in stimulant prescriptions in the last year is in adults over the age of 50 years of age (Adler LA. ADHD in Older Adults. Paper Presentation at the Annual Meeting of the American Psychiatric Association, New York , New York, May 2014). Even though stimulant prescriptions may be increasing in older adults with ADHD, the number of studies which have examined older adults with ADHD is relatively small. One concern in studying adults with ADHD is the potential confound of cognitive decline that may occur with aging in assessing ADHD symptoms. This study examined the cognitive function of older adults without ADHD vs. those with ADHD (n=231) in the Longitudinal Study Amsterdam (LASA). Cognitive function was assessed via neuropsychological measures of functioning, information processing speed, memory, and attention/working memory. The authors only found a negative association of ADHD symptom severity and attention/working memory domain; however, when depressive symptoms were controlled for, this association was no longer significant. Neuropsychological impairments in attention and working memory have also been shown in younger adults with ADHD. This study highlights the need for further investigations of cognitive functioning in older adults with ADHD and the importance of screening for depression in these individuals.

Lenard_A_Adler_MD_ADHD_in_AdultsBreda,V;, Rovaris, DL; Schneider Vitola, E.; et al.  Does collateral retrospective information about childhood attention- deficit/hyperactivity disorder symptoms assist in the diagnosis of attention- deficit/hyperactivity disorder in adults? Findings from a large clinical sample.  Australian & New Zealand Journal of Psychiatry, 1–9, DOI: 10.1177/0004867415609421.

Collateral information is commonly used in making the diagnosis of ADHD in a child or adolescent. The role of collateral retrospectives in making the diagnosis in adults presenting for evaluation for ADHD has been less well investigated. 

ADHD Diagnosis Collateral Retrospectives
This is an investigation of the relative importance of childhood collateral information in making a diagnosis of ADHD in an adult presenting for evaluation.  449 adults with ADHD and 143 controls were evaluated for the diagnosis of ADHD and co-morbidities with a modification of the K-SADS, ADHD symptoms with the SNAP-IV, and current/childhood impairment with the Barkley Current and Childhood Symptom scales.  Collateral childhood ADHD symptoms/impairments were also evaluated with the Barkley Childhood Symptom Scale, completed by a first or second degree relative. 

Click: Managing   ADHD MedicationsA diagnosis of ADHD via patient or collateral report required full childhood symptom onset prior to the age of 12.  A subset of adults with ADHD were also treated with methylphenidate immediate release (0.13-1.23 mg/kg/day); treatment response was measured via changes in SNAP-IV from baseline to endpoint. 

The data analyses were performed on three cohorts: 1) adults with ADHD where there was agreement as to childhood symptoms from the subject and informant (n=277), 2) adults with ADHD where there was disagreement between subjects and informants (n=172) and 3) controls.  ADHD patients (all) vs. controls did not significantly differ in terms of age, gender, years of education or income, but did have significantly more school failure problems with discipline and problems with the law.   The levels of impairment for the ADHD cohort were quite similar (collateral agreement + vs. -), except that the group with collateral and patient childhood agreement had higher levels of school suspensions and problems with discipline.  It is not that surprising that the collaterals and subjects had better agreement in these areas as school suspensions and discipline problems are more likely to be remembered by both subjects and collaterals. 

The ADHD cohorts (collateral agreement + vs. -) had similar levels of co-morbidity and treatment response to methylphenidate.  The combined ADHD cohorts had higher rates of tobacco use, bipolar disorder, current ODD, conduct disorder and non-alcohol SUD than controls.  A salient finding of this investigation is that 40% of subjects with adult ADHD had collateral informants who were unable to extensively corroborate their symptoms. 

Limitations of this study include the self-report nature of the SNAP-IV and the fact that this scale has not been validated for adults.  Also, of note, the subjects with adult ADHD had full childhood onset of the disorder retrospectively, which is a more stringent criteria than was utilized in DSM-IV.  It is not clear how utilizing more strict childhood criteria will influence the generalizability of these findings to clinically evaluated subjects using DSM-IV or DSM-5 guidelines. Download DSM-V Guidelines  for ADHD Diagnosis

Clinicians remain the final and optimal arbiter in establishing a diagnosis of adult ADHD; it remains up to clinicians to integrate information from all sources in establishing this diagnosis, be it from the subject, current significant others, collateral informants about childhood or clinician observations during the interview.

Lenard Adler, MD ADHD in AdultsBreda,V;, Rovaris, DL; Schneider Vitola, E.; et al.

Does collateral retrospective information about childhood attention- deficit/hyperactivity disorder symptoms assist in the diagnosis of attention- deficit/hyperactivity disorder in adults? Findings from a large clinical sample.

Australian & New Zealand Journal of Psychiatry, 1–9, DOI: 10.1177/0004867415609421.

Collateral information is commonly used in making the diagnosis of ADHD in a child or adolescent. The role of collateral information in making the diagnosis in adults presenting for evaluation for ADHD has been less well investigated.

This is an investigation of the relative importance of childhood collateral information in making a diagnosis of ADHD in an adult presenting for evaluation. 449 adults with ADHD and 143 controls were evaluated for the diagnosis of ADHD and co-morbidities with a modification of the K-SADS, ADHD symptoms with the SNAP-IV, and current/childhood impairment with the Barkley Current and Childhood Symptom scales. Collateral childhood ADHD symptoms/impairments were also evaluated with the Barkley Childhood Symptom Scale, completed by a first or second degree relative.

A diagnosis of ADHD via patient or collateral report required full childhood symptom onset prior to the age of 12. A subset of adults with ADHD were also treated with methylphenidate immediate release (0.13-1.23 mg/kg/day); treatment response was measured via changes in SNAP-IV from baseline to endpoint.

The data analyses were performed on three cohorts: 1) adults with ADHD where there was agreement as to childhood symptoms from the subject and informant (n=277), 2) adults with ADHD where there was disagreement between subjects and informants (n=172) and 3) controls. ADHD patients (all) vs. controls did not significantly differ in terms of age, gender, years of education or income, but did have significantly more school failure problems with discipline and problems with the law. The levels of impairment for the ADHD cohort were quite similar (collateral agreement + vs. -), except that the group with collateral and patient childhood agreement had higher levels of school suspensions and problems with discipline. It is not that surprising that the collaterals and subjects had better agreement in these areas as school suspensions and discipline problems are more likely to be remembered by both subjects and collaterals.

The ADHD cohorts (collateral agreement + vs. -) had similar levels of co-morbidity and treatment response to methylphenidate. The combined ADHD cohorts had higher rates of tobacco use, bipolar disorder, current ODD, conduct disorder and non-alcohol SUD than controls. A salient finding of this investigation is that 40% of subjects with adult ADHD had collateral informants who were unable to extensively corroborate their symptoms.

Limitations of this study include the self-report nature of the SNAP-IV and the fact that this scale has not been validated for adults. Also, of note, the subjects with adult ADHD had full childhood onset of the disorder retrospectively, which is a more stringent criteria than utilized in DSM-IV. It is not clear how utilizing more strict childhood criteria will influence the generalizability of these findings to clinically evaluated subjects using DSM-IV or DSM-5 guidelines.

Clinicians remain the final and optimal arbiter in establishing a diagnosis of adult ADHD; it remains up to clinicians to integrate information from all sources in establishing this diagnosis, be it from the subject, current significant others, collateral informants about childhood or clinician observations during the interview.

Lenard A Adler, MDGray et al. (2014), The Adult ADHD Self-Report Scale (ASRS): utility in college students with attention- deficit/hyperactivity disorder. PeerJ 2:e324; DOI 10.7717/peerj.324

There has been ongoing interest in the identification of ADHD in college students; many transitional adults will present with ADHD related symptoms and problems with the transition to post-secondary education and the related demands on attention and executive function. This investigation examined the utility of the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) in identifying college students at risk for ADHD.

135 college students (mean age 24 years) who were enrolled in disability service programs at their respective institutions were surveyed; all students had received a prior diagnosis of ADHD and were asked to complete all scales as if they were not on ADHD medication (59% of the students were on medication at the time of the evaluation). Students first completed the six item ASRS screener by telephone and then, several weeks later, the completed a paper version of the 18 item ASRS symptom checklist. A collateral version “other-report” of the 18 item ASRS symptom checklist, and a self-report measure of executive function (BDEFS), were also collected.

There was a modest correlation of the other-report and self-report of ASRS symptoms (r(59) = .46, p < .001) and other-report scores were significantly lower than self-report scores (F(1,57) = 8.92, p = .004). There was a moderately high correlation of student self-report of symptoms on the ASRS Screener (telephonic) and the identical six items when completed on the 18 item ASRS Symptom Checklist several weeks later (r (131) = .66, p < .001), indicating some stability of self-report of ADHD symptoms. There were moderate correlations between the total score on the ASRS screener and total executive function (BDEFS summary) scores (r (129) = .40, p < .001); correlations between total scores on 18 item ASRS symptom checklist and summary score on BDEFs were higher than seen with the screener (r (131) = .62, p < .001), indicating that a total symptom inventory of ADHD symptoms better correlates with executive function than the screening subset (which is not surprising). This study has several limitations including: 1) the subjects being asked to complete scales in the hypothetical sense of when they were not on medication (and with 3/5 students being treated for ADHD), creating the possibility of reporter bias, and 2) the study utilized a non-validated version of the other report version of the ASRS symptom checklist which was not sanctioned by WHO.

The study does highlight the utility of the ASRS symptom checklist as a self-report measure in college students; this instrument carries the advantages of being easy to use and being in the public domain. It also indicates that gathering collateral information can be helpful, but as seen in other reports, collateral reports of symptoms are often lower than self and clinician symptom scores as the informant only sees the patient for a portion of their day (home vs. work vs. social).