Stephen_Faraone_PhD_ADHD_in_Adults

If you’ve ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our “Primer” about ADHD, http://rdcu.be/gYyV. Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process.   That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD.  The rule of thumb is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition.  Stimulants are typically the first line treatment due to their greater efficacy compared with non-stimulants.  When considering any medication treatment for ADHD, safety is the first concern which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered.  For very young children (preschoolers) family behavior therapy is typically used prior to medication.  Clinicians also must deal with personal preferences.   Some parents and some adolescents and adults with ADHD simply don’t want to take stimulant medications for the disorder.  When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.   If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate of amphetamine is more appropriate.  Here there is very little guidance for doctors.  Amphetamine compounds are a bit more effective but can lead to greater side effects.   Genetic studies suggest that a person’s genetic background provide some information about who will respond well to methylphenidate but we are not yet able to make very accurate predictions.    After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.  There is no simple rule here; the choice will depend upon the specific needs of each patient.  Many children benefit from longer acting medications to get them through school, homework and late afternoon/evening social activities.  Likewise for adults.  But many patients prefer shorter acting medications especially as these can be used to target specific times of day and can also lower the burden of side effects.   For patients taken down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists.  There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases.  Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient’s response must be closely monitored as there is no guarantee that the first choice of medication will work out well.  In some cases efficacy is low or adverse events are high.  Sometimes this can be fixed by changing the dose and sometimes a trial of a new medication is indicated.  If you are a parent of a child with ADHD or an adult with ADHD, this trial and error approach can be frustrating.  But don’t lose hope.  In the end, most ADHD patients find a dose and a medication that works for them.   Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.  You can read details about these in my other blogs but for here the main point is to find an evidenced-based treatment.  For children the biggest evidence base is for behavioral family therapy.  For adults, cognitive behavior therapy (CBT) is the best choice.   With the exception of preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment.  The reason is that the medications are much more effective and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.  

REFERENCE
Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

Stephen_Faraone_PhD_ADHD_in_Adults

If you’ve ever wondered how experts make treatment recommendations for patients with ADHD, take a look at this ADHD treatment decision tree that my colleagues and I constructed for our “Primer” about ADHD, http://rdcu.be/gYyV. Although a picture is worth a thousand words, keep in mind that this infographic only gives the bare bones of a complex process.   That said, it is telling that one of the first questions an expert asks is if the patient has a comorbid condition that is more severe than ADHD.  The rule of thumb is to treat the more severe disorder first and after that condition has been stabilized plan a treatment approach for the other condition.  Stimulants are typically the first line treatment due to their greater efficacy compared with non-stimulants.  When considering any medication treatment for ADHD, safety is the first concern which is why medical contraindications to stimulants, such as cardiovascular issues or concerns about substance abuse, must be considered.  For very young children (preschoolers) family behavior therapy is typically used prior to medication.  Clinicians also must deal with personal preferences.   Some parents and some adolescents and adults with ADHD simply don’t want to take stimulant medications for the disorder.  When that happens, clinicians should do their best to educate them about the costs and benefits of stimulant treatment.   If, as is the case for most patients, the doctor takes the stimulant arm of the decision tree, he or she must next decide if methylphenidate of amphetamine is more appropriate.  Here there is very little guidance for doctors.  Amphetamine compounds are a bit more effective but can lead to greater side effects.   Genetic studies suggest that a person’s genetic background provide some information about who will respond well to methylphenidate but we are not yet able to make very accurate predictions.    After choosing the type of stimulant, the doctor must next consider what duration of action is appropriate for each patient.  There is no simple rule here; the choice will depend upon the specific needs of each patient.  Many children benefit from longer acting medications to get them through school, homework and late afternoon/evening social activities.  Likewise for adults.  But many patients prefer shorter acting medications especially as these can be used to target specific times of day and can also lower the burden of side effects.   For patients taken down the non-stimulant arm of the decision tree, duration is not an issue but the patient and doctor must choose from among two classes of medications norepinephrine reuptake inhibitors or alpha-2-agonists.  There are not a lot of good data to guide this decision but, again, genetics can be useful in some cases.  Regardless of whether the first treatment is a stimulant or a non-stimulant, the patient’s response must be closely monitored as there is no guarantee that the first choice of medication will work out well.  In some cases efficacy is low or adverse events are high.  Sometimes this can be fixed by changing the dose and sometimes a trial of a new medication is indicated.  If you are a parent of a child with ADHD or an adult with ADHD, this trial and error approach can be frustrating.  But don’t lose hope.  In the end, most ADHD patients find a dose and a medication that works for them.   Last but not least, when medication leads to a partial response, even after adjusting doses and trying different medication types, doctors should consider referring the patient for a non-pharmacologic ADHD treatment.  You can read details about these in my other blogs but for here the main point is to find an evidenced-based treatment.  For children the biggest evidence base is for behavioral family therapy.  For adults, cognitive behavior therapy (CBT) is the best choice.   With the exception of preschoolers, the experts I worked with on this infographic did not recommend these therapies before medication treatment.  The reason is that the medications are much more effective and many non-pharmacologic treatments (such as CBT) have no data indicating they work well in the absence of medication.  

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

Stephen V. Faraone, PhD - ADHD in Adults


The diagnosis of ADHD should only be done by a licensed clinician and that clinician should have one goal in mind: to plan a safe and effective course of evidenced-based treatment.  The infographic below gives a summary of this diagnostic approach over time, which my colleagues and I prepared for our “Primer” about ADHD, referenced below.

.   A key point that parents of ADHD youth and adults with ADHD should keep in mind is that there is only one way to diagnose ADHD.  An expert clinician must document the criteria for the disorder as specified by either the Diagnostic and Statistical Manual of the American Psychiatric Association, which is now in its fifth edition (DSM-5) or the World Health Organizations International Classification of Diseases (ICD-10).  The two sets of criteria are nearly identical.  These criteria are most commonly applied by a clinician asking questions of the parent (for children) and/or patient (for adolescents and adults).  For children, information from the teacher can be useful.  Some clinicians get this information by having the parent ask the teacher to fill out a rating scale.  This information can be very useful if it is available.   

When diagnosing adults, it is also useful to collect information from a significant other which can be a parent for young adults or a spouse for older adults.  But when such informants are not available, diagnosing ADHD based on the patient’s self-report is valid.  As the infographic indicates, any diagnosis of ADHD should also assess for comorbid psychiatric disorders as these have implications for which ADHD medications will be safe and effective.  And because a prior history of cardiovascular disease or seizures frequently contraindicate stimulants, these must also be assessed.

REFERENCE

Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 ;  http://rdcu.be/gYyV

 

J Russell Ramsay AIA lDQiPt

Assessment and Treatment Monitoring Tools for Adult ADHD

Despite the evidence that ADHD is a distinct condition from other psychiatric and neurodevelopmental disorders that affect adults, it is a challenging one to assess because of its overlap with other conditions. It is fortunate that there are several evidence-supported pharmacologic and psychosocial treatments available to adult ADHD. However, accurate assessment and measurement strategies during treatment are needed to optimize outcomes. Even for clinicians who may not specialize in ADHD, screening tools are needed to determine if further evaluation or specialized treatment is indicated for patients suspected of having ADHD.

There are several options of various symptom measures, adult ADHD inventories that go beyond DSM symptomatology, and additional means for assessing executive functioning, impairment, and screening measures that are available to practicing clinicians who perform diagnostic evaluations and/or provide treatment. This blog will provide a general overview of essential topics that are covered in greater detail in a recently published article, including a review of a menu of specific assessment and tracking tools relevant for clinical practice.1

Structured Diagnostic Interviews

            Although often associated with research, there are several structured diagnostic interviews that can be used to systematically guide the evaluation of ADHD in adults. All of them adhere to existing DSM criteria as well as assessing for age of onset, symptoms in multiple settings, and evidence of impairment. Even those developed during the advent of DSM-IV can be easily adapted to the changes in DSM-5 regarding age-of-onset criterion and reduced number of symptoms required for the diagnosis in adults.

ADHD Symptom Measures

            As with the structured interviews, there are multiple adult ADHD symptom checklists that can be used in the diagnostic evaluation as well as in monitoring treatment progress. Again, even those symptom measures published using DSM-IV criteria can be adapted to DSM-5. Several of the measures provided normative data with regarding the percentile rank of different scores, including symptom count and overall symptom rating scores.

Adult ADHD Inventories

            There are several adult ADHD inventories that often build on the foundation of the extant diagnostic criteria but cast a wider net in terms of other clinically-relevant manifestations of ADHD. These inventories are more likely to include items related to emotional regulation, issues related to organization and procrastination, which may offer a better means for tracking progress in terms of functioning in day-to-day life. These measures may be particularly relevant in tracking progress in psychosocial treatment, where functional impairments and the targets of treatment more than pure symptom improvement.

Executive Functioning Inventories

            Following up on the point made above about treatment promoting functional improvements, executive functioning inventories provide another useful means for assessing this aspect of the clinical presentation of adults with ADHD. It is most often issues related to poor time management, disorganization, and poor initiation and follow through on tasks that lead individuals to seek treatment. Emotional regulation issues are also captured in these scales and other executive functioning issues that are not represented in the official diagnostic criteria.

Functional Impairment/Quality of Life Inventories

            Many evaluations are asked to assess and address level of impairment, not to mention that evidence of impairment is one of the criteria for establishing whether symptoms reflect a diagnosable disorder. Although there are other ways to make the case for the existence of impairment, such as academic disruption or workplace evaluations, these measures provide another means to do so, as well as a way to track the effects of treatment on these life domains.           

Selecting and Using Interviews, Measures, and Inventories

            The primary guiding principle is that the clinical data gathered from these tools cannot be taken at face value and each must be considered as one component of the overall clinical picture, which includes a thorough clinical and developmental interview. A related principle is that these measures may be necessary for establishing a diagnosis of ADHD, but no one is sufficient. Many of the scales include observer rating forms which allows a means for collecting collateral data with which to make a diagnosis and/or assess treatment progress.

Summary

            The evaluation of ADHD requires a thorough evaluation of emergence and persistence of symptoms across time and establishing evidence of impairments, including gathering collateral data and ruling out other diagnoses. Similarly, because it is a neurodevelopmental disorder, treatment focuses on the effective management of symptoms and impairments and tracking progress is more challenging than a condition that is episodic. However, there are many useful clinical tools available to clinicians in practice that help improve diagnostic accuracy, assessment of treatment progress, and, ultimately, clinical outcomes.           

Reference

1Ramsay, J. R. (2017). Assessment and monitoring of treatment response in adult ADHD patients: current perspectives. Neuropsychiatric Disease and Treatment, 13, 221-232. doi.org/10.2147/NDT.S104706

 

http://medicalwritingtraining.com/ADHD is a serious disorder that requires treatment to prevent many adverse outcomes. But, because the diagnosis of ADHD is based on how the patient responds to questions, it is possible for people to pretend that they have ADHD, when they do not. In fact, if you Google “fake ADHD” you’ll get many pages of links including a Psychology Today article on the topic and bloggers describing how they were able to fool doctors into giving them ADHD medications. Is fake ADHD a serious problem? Not really.

The Internet, it seems, is faking an epidemic of fake ADHD. I say that because we have decades of research that show many objective measures of abnormality and impairment in people who say they have ADHD. These include traffic accidents, abnormalities on brain imaging and molecular genetic differences. Some studies even suggest that ADHD adults downplay their ADHD symptoms. For example, one study diagnosed ADHD in children and then contacted them many years later when they were young adults. When they were interviewed as young adults, their responses to questions about ADHD suggested that they did not have the disorder. But when the same questions about the patient were asked to someone who lived with the patient as a young adult, it was clear that they still had ADHD. So rather than faking ADHD, many ADHD adults do not recognize that they have symptoms of the disorder.

That said, we also know from research studies that, when asked to pretend that they have ADHD, adults can fake the disorder. That means that they can learn about the symptoms of the disorder and make up examples of how they have had them, when they have not. This research suggests that this is not common, but we do know that some people have motives for faking ADHD. For example, some college students seek special accommodations for taking tests; others may want stimulants for abuse, misuse or diversion.

Fortunately, doctors can detect fake ADHD in several ways. If an adult is self-referred for ADHD and asks specifically for stimulant medication, that raises the possibility of fake ADHD and drug seeking. Because the issue of stimulant misuse has been mostly a concern on college campuses, many doctors treating college students will require independent verification of the patients ADHD symptoms by speaking with a parent, even over the phone if an in-person visit is not possible. Using ADHD rating scales will not detect fake ADHD and it is easy to fake poor performance on tests of reading or math ability. Neuropsychological tests can sometimes be used to detect malingering but require referral to a specialist. Researchers are developing methods to detect faking of ADHD symptoms. These have shown some utility in studies of young adults but are not ready for clinical practice.

So, currently, doctors concerned about fake ADHD should look for objective indicators of impairment (e.g., documented traffic accidents; academic performance below expectation) and speak to a parent of the patient to document that impairing symptoms of the disorder were present before the age of twelve. Because the issue of fake ADHD is of most concern on college campuses, it can also be helpful to speak with a teacher who has had frequent contact with the patient. In an era of large lecture halls and broadcast lectures, that may be difficult. And don’t be fooled by the Internet. We don’t want to deny treatment to ADHD patients out of undocumented reports of an epidemic of fake ADHD.
The best way for health professionals to determine if someone has ADHD by the way, is by performing a complete diagnosis. We teach that in our FREE online CME courses on ADHD in Adults.
 

References:
Harrison, A. G., Edwards, M. J. & Parker, K. C. (2007). Identifying students faking ADHD: Preliminary findings and strategies for detection. Arch Clin Neuropsychol 22, 577-88.
Sansone, R. A. & Sansone, L. A. (2011). Faking attention deficit hyperactivity disorder. Innov Clin Neurosci 8, 10-3.
Loughan, A., Perna, R., Le, J. & Hertza, J. (2014). C-88Abbreviating the Test of Memory Malingering: TOMM Trial 1 in Children with ADHD. Arch Clin Neuropsychol 29, 605-6.
Loughan, A. R. & Perna, R. (2014). Performance and specificity rates in the Test of Memory Malingering: an investigation into pediatric clinical populations. Appl Neuropsychol Child 3, 26-30.
Quinn, C. A. (2003). Detection of malingering in assessment of adult ADHD. Arch Clin Neuropsychol 18, 379-95.
Suhr, J., Hammers, D., Dobbins-Buckland, K., Zimak, E. & Hughes, C. (2008). The relationship of malingering test failure to self-reported symptoms and neuropsychological findings in adults referred for ADHD evaluation. Arch Clin Neuropsychol 23, 521-30.
Greve, K. W. & Bianchini, K. J. (2002). Using the Wisconsin card sorting test to detect malingering: an analysis of the specificity of two methods in nonmalingering normal and patient samples. J Clin Exp Neuropsychol 24, 48-54.
Killgore, W. D. & DellaPietra, L. (2000). Using the WMS-III to detect malingering: empirical validation of the rarely missed index (RMI). J Clin Exp Neuropsychol 22, 761-71.
Ord, J. S., Greve, K. W. & Bianchini, K. J. (2008). Using the Wechsler Memory Scale-III to detect malingering in mild traumatic brain injury. Clin Neuropsychol 22, 689-704.
Wisdom, N. M., Callahan, J. L. & Shaw, T. G. (2010). Diagnostic utility of the structured inventory of malingered symptomatology to detect malingering in a forensic sample. Arch Clin Neuropsychol 25, 118-25.

http://medicalwritingtraining.com/A recent paper by Margaret Sibley and colleagues addresses a key issue in the diagnosis of adult ADHD. Is it sufficient to only collect data from the patient being diagnosed or are informants useful or, perhaps, essential, for diagnosing ADHD in adults. Dr. Sibley presented as systematic review of twelve studies that prospectively followed ADHD children into adulthood. Each of these studies asked a simple question: What faction of ADHD youth continued to have ADHD in adulthood. Surprisingly, the estimates of ADHD’s persistence ranged from a low of 4% to a high of 77%. They found two study features that accounted for much of this wide range. The first was the nature of the informant; did the study rely only on the patient’s report or were other informants consulted. The second was the use of a strict diagnostic threshold of six symptoms. When they limited the analysis to studies that used informant and eliminated the six symptom threshold, the range of estimates was much narrower, 40% to 77%. From studies that computed multiple measures of persistence using different criteria, the authors concluded: “(1) requiring impairment to be present for diagnosis reduced persistence rates; (2) a norm-based symptom threshold led to higher persistence than a strict six-symptom DSM-based symptom count criterion; and (3) informant reports tended to show a higher number of symptoms than self-reports.” These data have clear implications for what clinicians can do to avoid false positive and false negative diagnoses when diagnosing adult ADHD. It is reassuring that the self-reports of ADHD patients tend to underestimate the number and severity of ADHD symptoms. This means that your patients are not typically exaggerating their symptoms. Put differently, self-reports will not lead you to over-diagnose adult ADHD. Instead, reliance on self-reports can lead to false negative diagnoses, i.e., concluding that someone does not have ADHD when, in fact, they do. You can avoid false negatives by doing a thorough assessment, which is facilitated by some tools available at www.adhdinadults.com and described in CME videos there. If you think a patient might have ADHD but are not certain, it would be helpful to collect data from an informant, i.e., someone who knows the patient well such as a spouse, partner, roommate or parent. You can collect such data by sending home a rating scale or by having the patient bring an informant to a subsequent visit. Dr. Sibley’s paper also shows that you can avoid false negative diagnoses by using a lower symptom threshold than what is required in the diagnostic manual. In fact, the new DSM 5 lowered the symptom threshold for adults from six to five. Can you go lower? Yes, but it is essential to show that these symptoms lead to clear impairments in living. Importantly, this symptom threshold refers to the number of symptoms documented in adulthood, not to the number of symptoms retrospectively reported in childhood. To be diagnosed with ADHD in adulthood, one must document that the patient had at least six impairing symptoms of ADHD prior to the age of 12.
 

REFERENCE
Sibley, M. H., Mitchell, J. T. & Becker, S. P. (2016). Method of adult diagnosis influences estimated persistence of childhood ADHD: a systematic review of longitudinal studies. Lancet Psychiatry 3, 1157-1165.

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_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.

Anthony_Rostain_AIA_15_Bzb6ml.png.jpgThis article reviews existing evidence for the use of locomotor activity measures in diagnosing ADHD. The authors conducted a meta-analysis of published studies using motion measures to compare patients with ADHD with controls and then conducted a case control study using the McLean motion activity test (MMAT) on a sample of child, adolescent and adult ADHD patients (N=81) and matched controls (N=91).

The meta-analysis procedure involved searching several electronic medical databases and selecting only articles which used validated methods for diagnosing ADHD, which compared ADHD subjects to healthy controls and which reported data in ways that enabled the authors to calculate the effect sizes as measured by standardized mean differences (SMD) between study groups. A total of 18 studies were chosen, 13 of which involved actigraphy measures and 5 which used motion tracking systems. The combined sample sizes were 570 ADHD patients (305 children and adolescents and 265 adults) and 515 controls (equally divided between youth and adults). The SMD (or effect size) between ADHD subjects and controls was 0.64 using actigraphy measures and 0.92 using the motion tracking systems. The SMD or pooled effect size for youth was 0.75 and for adults was 0.73, indicating that excessive motion is seen as often in adult ADHD patients as in children and adolescents. This contradicts the prevailing view that excessive motor activity is less prominent in adults as compared to youth with ADHD.

The authors then conducted a case control study comparing ADHD patients and controls. Patients were diagnosed using a comprehensive assessment procedure consisting of structured psychiatric interviews, Conners’ rating scales and the BRIEF (a measure of executive functioning). Subjects were administered the MMAT, an infrared motion tracking system that measures the micro-movements of participants during a Go/No-Go task (15 minutes for youth and 20 minutes for adults). ADHD groups differed significantly from controls on most motion measures, with an effect size of 0.83 for adults and 0.45 for children and adolescents. Reaction time variability was also significantly greater in the ADHD sample across all ages (p<0.05). Interestingly, there were no differences in excessive motion seen among the different ADHD subtypes (combined vs inattentive vs hyperactive vs NOS).

The authors conclude that locomotor hyperactivity is a core constituent feature of ADHD even in adults and across all diagnostic subtypes. They further suggest that objective locomotion measures may be useful in improving the process of diagnosing difficult cases of ADHD. While it is still premature to suggest that movement measurement devices like the MMAT are necessary for diagnosing ADHD in most patients, there is certainly a role for using them in clinical practice. Future research will help delineate additional uses for these tools in diagnosing other neurodevelopmental disorders.

 

Murillo LG, Cortese S, Anderson D, DiMartino A, Castellanos FX (2015). “Locomotor activity measures in the diagnosis of attention deficit hyperactivity disorder: Meta-analyses and new findings.” Journal of Neuroscience Methods Epub ahead of print March 11, 2015. DOI: 10.1016/j.jneumeth.2015.03.001.