ADHD Screener

Lenard A. Adler, on May 17, 2018

Ustun 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.

Neural Correlates of ADHD

Lenard A. Adler, on September 29, 2016

Neural 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.

ADHD and Cognitive Function in Older Adults

Lenard A. Adler, on September 22, 2016

E. 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.

Collateral Information in Adult ADHD

Lenard A. Adler, on March 3, 2016

Breda,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.

ADHD Diagnosis Collateral Retrospectives

Lenard A. Adler, on March 3, 2016

Breda,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.

ASRS in College Students

Lenard A. Adler, on February 25, 2016

Gray 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 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).

Atomoxetine: Real World Dosing

Lenard A. Adler, on February 4, 2016

Kabul,S; Alatorre,C; Montejano,LB; Farr,AM; Clemow, DB.

 

CNS Neuroscience & Therapeutics 21 (2015) 936–942.

 

This study describes a large prescription database survey of dosing patterns of atmoxetine, between January 2006 and December 2001, in adults with ADHD. 12,412 adults >= 18 y.o. met inclusion criteria of: 1) having at least one claim coded for ADHD, 2) having continuous medical and prescription benefits for the 6 months prior and 12 after the index (initial atomoxetine prescription) and 3) having been treated with atomoxetine monotherapy. The survey examined dosing patterns and the average daily dose of atomoxetine prescribed in the 31 to 365 days following the index prescription of atomoxetine (to allow titration). Adults were divided into four dosing cohorts: 1) suboptimal (average daily dose < 80 mg/day) (n=4548, 36.6%) , recommended (80-100 mg/day) (n=3323, 26.8%) , above-recommended (> 100 mg/day) (n=213, 1.7%) and fluctuating (adults who could not be classified readily into one of the above three cohorts as their dose changed commonly during the treatment period). The fluctuating dose cohort (n=4328, 34.9%) was excluded from subsequent analyses of patient characteristics.

 

The suboptimal and recommended cohorts were quite similar in patient characteristics, with the exception of a somewhat higher proportion of younger patients (aged 25-44 years) in the recommended vs. the suboptimal group (45.3% vs. 40.6%); the suboptimal group had somewhat higher percentage of females (53.5% vs. 44%) and lower rates of use of ADHD medication prior to the survey period (16.8% vs. 20.0%) versus the recommended dosing cohort. Rates of co-morbid psychiatric disorders were generally the same in these two groups. The overall dose after titration in the three cohorts was 43 mg/day. Slightly greater than 90% of patients discontinued atomoxetine during the one year observation period.

 

Conclusions drawn from this trial should be tempered by the retrospective, survey based nature of the investigation. Additionally, the assignment of 80 mg/day as the recommended dose is purely based upon the atomoxetine label, whereas the clinical trials examined doses in the 40 to 100 mg/day range. Additionally the four month average treatment period with atomoxetine might have led to an under-estimation of final dosing as a percentage of patients were not titrated to final dosing. However, even with these caveats, there are several important findings for clinicians. Atomoxetine in this claims database seems to be at the lower register of recommended ranges; clinicians should attempt to titrate atomoxetine to optimal dosing based on observed side effects and potential side effects. Adherence to atomoxetine treatment in this claim database was poor, as has been reported in several other studies of ADHD medications in general (stimulants and non-stimulants). Clinicians should make all attempts to improve adherence to medication treatment and attempt to mitigate potential reasons for non-adherence, as patients will only get better if they take their medications.

Epilepsy and ADHD Treatments

Lenard A. Adler, on January 8, 2016

Ettinger AB1, Ottman R, Lipton RB, Cramer JA, Fanning KM, Reed ML. Attention-deficit/hyperactivity disorder symptoms in adults with self-reported epilepsy: Results from a national epidemiologic survey of epilepsy. Epilepsia. 2015 Jan 15. doi: 10.1111/epi.12897.

The purpose of this study was to examine symptoms of ADHD and resulting functional consequences in a large community cohort of individuals with epilepsy. There is a somewhat higher rate of ADHD observed in pediatric samples of ADHD, but little data exists in terms of the comparative rates of ADHD, co-morbidity and quality of life in adults with epilepsy.

This study is important because it extends the observation of higher rates of ADHD seen in studies of pediatric ADHD to adult ADHD; the observed prevalence rate of ADHD (using a proxy of being screen positive on the ASRS v1.1) was nearly three times in this population of adults with epilepsy as compared to the general population, with substantial functional consequences in these individuals. The study also highlights the need to examine adults with epilepsy for the possibility of co-morbid ADHD.

This study examined through telephone survey as part of The Epilepsy Comorbidities and Health Study (EPIC), 1361 respondents who had been told they had epilepsy and were receiving anti-epileptic drugs (AEDs). The group was divided into a likelihood of having ADHD via the ASRS v1.1 Screener, if they had a total score on these six items > 14 (ASRS v1.1 Screen positive and ASRS v1.1 Screen negative). Measures of co-morbidity included depression: the Physicians Health Questionnaire (PHQ-9), and generalized anxiety disorder: the Generalized Anxiety Disorder Assessment 7 (GAD-7). Quality of life and disability were assessed with the Quality of Life in Epilepsy Inventory 10 (QOLIE-10), Quality of Life and Satisfaction Questionnaire (Q-LES-Q) and the Sheehan Disability Scale (SDS). 251 of the 1361 (18.4%) respondents were found to be at risk for having adult ADHD (ADHD+). ASRS v1.1 Screener positive vs. negative cases were significantly more likely to have seizures and AED use, along with significantly higher depression and anxiety symptom scores. The ASRS v1.1 Screen positive cohort (controlling for covariates) had lower QoL and social functioning (Q-LES-Q) and increased family and occupational disability (SDS). Potential confounds in the data include: 1) that a formal diagnosis of adult ADHD was not obtained (just individuals at risk for the disorder (but prior trials have found that a substantial proportion of screen positive individuals when assessed, actually have adult ADHD) and 2) the possible presentation of ADHD-like symptoms from epilepsy or treatment with AEDs.

ADHD in Young Adults – A Longitudinal Study

Lenard A. Adler, on December 17, 2015

P, Kuntsi J. Childhood predictors of adolescent and young adult outcome in ADHD.   J Psychiatr Res. 2015 Jan 29. pii: S0022-3956(15)00022-9. doi: 10.1016/j.jpsychires.2015.01.011.


This investigation examined predictors, including a variety of cognitive measures, demographics and ADHD symptoms and impairments in 116 adolescents followed for an average of 6.6 years into early adulthood.  This study is important as it addresses the critical issue of identifying risk factors for persistence of ADHD into adulthood, which would allow in the future, targeted interventions to potentially improve remission rates.  Remission was defined if individuals no longer met DSM-IV symptom (via DIVA) or impairment (via BFIS) criteria from parental and subject interviews. Symptoms and impairments were established from periods off medication.  62% of the sample was treated with medication.  21% of the sample was found to have remitted.  A number of risk factors were identified as increasing the risk of persistence of ADHD, including higher parental reports of ADHD symptoms, lower IQ and lower socio-economic status (SES).  Medication status did not significantly influence whether a subject was classified as having remitted or persistent ADHD.  These findings of significant associations of low SES and IQ and high ADHD symptoms with persistence of ADHD into young adulthood reinforce similar findings from prior studies and should be included as some of the foci of other longitudinal studies in ADHD.

University Healthcare Provider Survey on ADHD

Lenard A. Adler, on October 29, 2015

This study provides the 2015 results of a survey of college and university health care providers (physicians, psychologists and nurses) about their knowledge about and treatment preferences concerning ADHD. The survey consisted of 37 forced choice questions, which took less than 15 minutes to complete; the overall response rate was somewhat low (8%), creating the possibility of sampling error, but never the less this is a sufficiently large sample from which interesting conclusions can be drawn. Even though about half of providers felt quite comfortable recognizing ADHD, over 90% still referred students to other providers to make an ADHD diagnosis. Over 90% of respondents felt that ADHD medication therapy was useful for treating ADHD and over 50% treated the students themselves or in consultation with a specialist. Nurse practitioners were more likely to refer students for treatment as compared to physicians. This survey highlights potential areas of improvement in the post-secondary school handling of ADHD in their students, including the potential for increased training re: diagnosis and treatment so that physicians and nurse practitioners in these settings will be more likely to diagnose and treat students in their institutions. This could lead to potential removal of barriers to care and treatment of university students with ADHD.

 

Thomas M1, Rostain A2, Corso R3, Babcock T4, Madhoo M . ADHD in the College Setting: Current Perceptions and Future Vision. Journal of Attention Disorders. 19(8):643-54, 2015. doi: 10.1177/1087054714527789. Epub 2014 Apr 17.