The Relationship Between Executive Function Deficits and DSM-5-Defined ADHD Symptoms

Lenard A. Adler, on December 6, 2018

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.

Recent Trends in the Prescribing of ADHD Medications in Canadian Primary Care

Lenard A. Adler, on November 29, 2018

Rachael Morkem, Scott Patten, John Queenan, and David Barber

Journal of Attention Disorders 1 –8 , 2017 DOI: 10.1177/1087054717720719

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.

REFERENCES:
Hauck, T. S., Lau, C., Wing, L. L. F., Kurdyak, P., & Tu, K. (2017). ADHD treatment in primary care: Demographic factors, medication trends, and treatment predictors. Canadian Journal of Psychiatry, 62, 393-402.

Maternal Smoking During Pregnancy and ADHD: Results From a Systematic Review and Meta-Analysis of Prospective Cohort Studies

Lenard A. Adler, on November 22, 2018

Yan He, Jian Chen, Li-Hua Zhu, Ling-Ling Hua, and Fang-Fang Ke

Journal of Attention Disorders 1 –11 , 2017 DOI: 10.1177/1087054717696766

This article describes a meta-analyses of studies which examined the potential effects of maternal smoking on the risk of childhood ADHD. A prior meta-analysis in 2005 (Langley, Rice, Van den Bree, & Thapar, 2005) found a strong association between maternal smoking and subsequent development of childhood ADHD in exposed offspring. Several recent individual studies also found an association be, tween maternal smoking and childhood ADHD, but one prospective study (Ball et al., 2010) did not find such an association. Therefore, given the length of time since the last meta-analysis and the one negative study noted above, highlighted the need for an updated meta-analysis. The authors employed fairly standard meta-analysis guidelines via the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, which included a selection of studies, data extraction and assessment of study quality. The risk ratios (RRs) and 95% CIs reported in the individual studies were pooled across studies to examine the potential association of maternal smoking during pregnancy and childhood ADHD risk. The authors also examined for presence of publication bias and changing association over time. 265 studies were originally identified, with 12 meeting the stringent criteria to be included in the meta-analysis. The main finding of the analysis was the maternal smoking was modestly association with an increased risk of ADHD in children (pooled RR = 1.58, 95% CI = ) and this association seemed to increase over time (by examining publication year); no significant publication bias was seen. The authors that the association they observed was not as robust as the one seen by Langley et al. for several reasons: their including a larger number of trials, which were limited to those with prospective and not case-controlled desi This meta-analysis is important for clinicians as it highlights the importance of the need to caution their patients as to potential risks of offspring developing ADHD in mothers who smoke during pregnancy.

REFERENCES:
Ball, S. W., Gilman, S. E., Mick, E., Fitzmaurice, G., Ganz, M. L., Seidman, L. J., & Buka, S. L. (2010). Revisiting the association between maternal smoking during pregnancy and ADHD. Journal of Psychiatric Research, 44, 1058-10

Langley, K., Rice, F., Van den Bree, M. B., & Thapar, A. (2005). Maternal smoking during pregnancy as an environmental risk factor for attention deficit hyperactivity disorder behaviour. A review. Minerva Pediatrica, 57, 359-37

The Adult ADHD Quality Measures Initiative

Lenard A. Adler, on November 15, 2018

Stephen V. Faraone, Michael J. Silverstein , Kevin Antshel, Joseph Biederman, David W. Goodman, Oren Mason, Andrew A. Nierenberg, Anthony Rostain, Mark A. Stein and Lenard A. Adler

Journal of Attention Disorders, 1–15, 2018, DOI: 10.1177/1087054718804354

This manuscript reviews the results of the first phase of Quality Measures (QM) Initiative of the American Professional Society of ADHD and Related Disorders (APSARD). QMs (sometimes described as Quality Indicators) are critical metrics to the delivery and assessment of state-of-the-art health care; QMs numerically describe outcomes, patient perceptions, processes quantify health care processes, outcomes, patient perceptions, and systems. The authors followed the pathway outlined by the U.S. Agency for Healthcare Research and Quality (AHRQ) for the development of QMs; the manuscript describes the first phase, the development of draft QMs. This was a four-step process: 1) a literature search for adult ADHD QMs; (2) having experts develop a “wide net” of potential QMs in the areas of screening, diagnosis, treatment, follow-up, care coordination, and patient experience; (3) cross-referencing this “wide-net” of QMs to existing adult ADHD guidelines; (4) have ADHD experts rate the importance, reliability, validity, feasibility, and usability of the QMs via an online survey. The top 10 QMs from the expert survey were: Screening: % high-risk patients screened (e.g., depressed patients, family history of ADHD), Diagnosis: % patients treated for ADHD having documented DSM-5 diagnosis of ADHD, % patients with ADHD with review of other psychiatric disorders, % patients with ADHD with documentation of impairment, Treatment initiation: % patients receiving ADHD medications for whom treatment alternatives, benefits and risks have been discussed, % patients with ADHD assessed for vitals prior to medication treatment, % patients with ADHD for whom warnings and contraindications for medication were reviewed, Treatment follow-up: % patients with ADHD where validated measure of symptom change used to assess treatment efficacy at least annually, % patients stabilized on an ADHD medication seen at least once per year, % patients prescribed medication for ADHD seen within 1 month of initial prescription. This manuscript is important for clinicians because it is the first step toward the development of QMs for adult ADHD, which have not existed to date; if validated through field testing in the second phase of the initiative, these QM may be important metrics of health care quality in the care of patients with ADHD.

Are ADHD Screeners Safe to Use?

Lenard A. Adler, on November 8, 2018

Journal of Attention Disorders 1 –7 DOI: 10.1177/1087054718763736 journals.sagepub.com/home/jad

Benjamin J. Lovett and Alexander H. Jordan

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.

Sluggish Cognitive Tempo in Adults Referred for an ADHD Evaluation: A Psychometric Analysis of Self and Collateral Report

Lenard A. Adler, on November 1, 2018

Journal of Attention Disorders 1 –10 © The Author(s) DOI: 10.1177/1087054718787894 journals.sagepub.com/home/jad

Jessica R. Lunsford-Avery, Scott H. Kollins, and John T. Mitchell

Sluggish cognitive tempo is a constellation of symptoms including sluggishness, daydreaming, being slow to react, easily bored and fogginess in thinking, which has been shown to exist in several disorders, but commonly in children with ADHD (Barkley 2014). This investigation is important as the authors characterize the psychometric properties of self and collateral report of the Barkley SCT scale (BAARS-IV: SCT subscale – nine items) versus the Conners Adult ADHD Scale in 124 adults (80 of whom had ADHD). The Barkley SCT scale had high internal consistency (self-report Cronbach’s α = .79, collateral-report Cronbach’s α = .82). The self and collateral versions of the Barkley SCT scale were significantly, moderately correlated after covarying for age and sex (r = .41, p < .001). Factor analyses supported the same three factors generally found in studies of childhood SCT: Slow/Daydreamy, Sleepy/Sluggish and Low Initiation/Persistence Symptoms. The Barkley SCT scale was fairly highly correlated with ADHD symptoms in the CAARS, except for the Sleepy/Sluggish factor not correlating with Hyperactivity/Restlessness or Impulsivity and lower association with Emotional Lability. The lack of association of the Sleepy/Sluggish factor with Restlessness and Impulsivity appears to have some face validity given the differential nature of the symptoms. This article is important to clinicians because it highlights the importance of assessing adult ADHD patients for symptoms of sluggish cognitive tempo and how these SCT symptoms may relate to DSM-5 ADHD symptoms.

REFERENCES
Barkley, R. A. (2014). Sluggish cognitive tempo (concentration deficit disorder?): Current status, future directions, and a plea to change the name. Journal of Abnormal Child Psychology, 42, 117-125. doi:10.1007/s10802-013-9824-y

Digital Media Use and ADHD

Lenard A. Adler, on August 9, 2018

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

Review of Cardiovascular Effects of ADHD Medications

Lenard A. Adler, on August 2, 2018

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

Emotional Dysregulation in Adult ADHD

Lenard A. Adler, on July 26, 2018

This 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

Self vs Clinician Rating Scales

Lenard A. Adler, on May 24, 2018

Silverstein 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.