Michael J. Silverstein , Stephen V. Faraone, Terry L. Leon, Joseph Biederman, Thomas J. Spencer, and Lenard A. Adler
Journal of Attention Disorders. 1–11: 2018. DOI: 10.1177/1087054718804347
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5) still defines ADHD symptoms in terms nine inattentive (IA) and nine hyperactive-impulsive (H-I) symptoms, to form the core eighteen symptoms of the disorder; this is in spite of a large literature that indicates that higher level symptoms of organization, planning and prioritization known as Executive Function Deficits (EFDs) common co-travel with symptoms of ADHD and are highly impairing to adults with ADHD. The investigators examined the relationship of core ADHD IA and HI symptoms and EFDs and the predictive utility of the Adult ADHD Investigator Symptom Rating Scale (AISRS) in identifying those with adult ADHD and Executive Dysfunction (ED). The AISRS is a clinician-administered, severity based (0-3), semistructured interview, containing adult ADHD specific prompts, developed to evaluate ADHD symptoms at baseline and during treatment. The Adult ADHD Self-Report Scale (ASRS) Symptom Checklist was also administered. Both the AISRS and ASRS Symptom Checklist were expanded to not only include the 18 core DSM-5 symptoms of ADHD, but also nine additional symptoms of EFD and four symptoms of Emotional Dyscontrol (EC). Executive Function was also assessed via the BRIEF-A, a well-normed scale to assess EF, with patients with global executive complex (GEC) T scores T >= 65 (1.5 standard deviations above the mean, 93 percentile) being indicative of ED. Subjects were recruited from referrals to a university adult ADHD program or a primary care clinical practice; 297 subjects participated (171 with adult ADHD). (IA) and (H-I) symptoms on the AISRS and ASRS Symptom Checklist were moderately to strongly correlated with and highly predictive of EFDs (with correlations being stronger for IA symptoms). Receiver operating characteristic curve analysis showed that an AISRS DSM 18-item score of ⩾ = 28 was most predictive of clinical ED. This study is to clinicians because it highlights the importance of assessing EFDs in addition to core symptoms of IA and HI when evaluating patients with adult ADHD.
This study describes trends the incidence and prevalence of prescribing ADHD medication in a large Canadian Primary Care Physician (PCP) Network over a ten year period from 2005-2015. Canada has public funded health care, creating a system that the provision for chronic disorders (such as ADHD) is often provided by PCPs, who serve as gatekeepers to specialty referrals only when necessary. A population-based retrospective cohort was derived from EMR data from the Canadian Primary Care Sentinel Surveillance Network, which has 11 practice-based research networks (PBRNs) composed of 1,100 primary care practitioners throughout Canada. Total number of prescriptions, type of medication, age group were assessed by year throughout the ten-year span. The annual prevalence was determined by establishing the number of patients prescribed at least one ADHD medication, divided by total number of patients with a PCP visit that year. Annual incidence rates were established using a similar formula for patients who were receiving their initial treatment with ADHD medication. The authors found over the decade a 2.5 and 2.6 fold increase in the prescribing prevalence in preschool and school age children, respectively and a 4 fold increase in prescribing prevalence in adults. Methylphenidate was the most commonly prescribed medication over the decade (65%), with a slight decrease in the later years of the decade, presumably due to the introduction of the long-acting amphetamine lisdexamphetamine. The authors noted that although ADHD disease prevalence was stable, the prescribing prevalence was increasing over the decade. Also gender differences of higher prescribing rates of boys:girls in children and adolescents were not seen in adults. The investigators posit that since the ADHD disease prevalence was noted to be relatively stable in Canada (Hauck et al. 2017), and the frequency of medication prescription remains below ADHD prevalence, the increased prevalence of prescriptions may reflect improved long-term treatment. Several caveats should be noted to this study: 1) the most common annual frequencies of taking medications were in the 20% range for once or >=10/year; this bimodal distribution may indicate ongoing issues with adherence to medications in Canadanian ADHD patients, 2) the authors were unclear as to how they handled patients who switched between medication preparations and 3) as the authors note, the study is only able to examine what was prescribed, but not what was taken. One take home point for US clinicians is the higher utilization of methylphenidate products in the Canadian population as compared to what has been described in US adult ADHD populations.
Rates of ADHD in college students have been increasing somewhat in recent years, as has use of screening tools to help identify individuals at risk for disorders such as ADHD. These investigators designed a trial to examine whether screening for adult ADHD, in essence creating some positive expectation bias of having the disorder in leading to increased reporting of ADHD symptoms and altered performance on cognitive tests. One group was screened for ADHD using the ASRS v.1.1 Screener and received feedback if they screened positive for the disorder and then completed a self ADHD symptom checklist (CAARS: S Long version) and a batter of psychological tests (three subtests on the Woodcock– Johnson IV Tests of Cognitive Abilities (WJ-IV) (processing speed), a mathematical test and Letter-Pattern Matching (LPM)/Number-Pattern Matching (NPM), and Pair Cancelation (PC) for general cognitive efficiency. The control group received the same interventions except were not screened for ADHD. There were no significant differences in the two groups in terms of ADHD symptoms or neuropsychological measures. The authors note that while there was concern that screening positive for ADHD might result in increased expectation of having more ADHD symptoms, these effects were limited and did not significantly affect reporting ADHD symptoms. Several limitations of the trial include the constraint of the sample to only college students which limits the generalizability of the results, the absence of a comparison intervention (ie. Mock screening) in the control group and the use of DSM-IV version of the adult ADHD screener, instead of the most recently validated DSM-5 version. The important take-home point for clinicians seeing college students is the lack of increased reporting of ADHD symptoms and absence of effects on neuropsychological tests introduced by the process of screening for ADHD.
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).