A Canadian team has published a systematic review examining the effectiveness of Mindfulness-Based Interventions (MBIs) for treating adults with ADHD. MBIs usually involve three forms of meditation – body scan, sitting meditation, and mindful yoga – that are intended to cultivate nonjudgmental awareness of present-moment experience. The team reviewed thirteen studies.

Three were single-group studies with no control group. One used dialectical behavior therapy (DBT). It reported mild to moderate improvements in ADHD symptoms, and substantial improvements in neurocognitive function (with standardized mean difference effect sizes from .99 to 2.22). A second enrolled both adults and adolescents in a mindful awareness program (MAP) which included a psychoeducational component. It found improvements in self-reported ADHD symptoms with standardized mean difference (SMD) effect sizes running from .50 to.93. Following training, it also reported improvement in attentional conflict (.93) set-shifting (.43). The third study also used DBT, focused on acceptance, mindfulness, functional behavioral analysis, and psychoeducation. ADHD symptoms showed mild improvement (.22), and functional impairment was slightly reduced (.15) and remained stable at 3-month follow-up.

The other ten studies used control groups. One used MAP and carefully stratified participants based on their ADHD medication status, then randomly assigned them to mindfulness treatment or waitlist. It reported large effect sizes in improvement of self-reported and clinician ratings of ADHD symptoms (1.35 to 3.14), executive functioning (1.45 to 2.67), and self-reported emotion regulation (1.27 to 1.63). Another study nonrandomly assigned adults to either mindfulness-based training (MBT) or skills training. Effect sizes were small to medium (.06 to .49), with 31% of MBT participants showing some improvement, versus only 11% of skills training participants.

Another study involved a controlled trial of college students with ADHD, randomized to receive either MBT or skills treatments. Treatment response rates were higher for MBT (59-65%, vs. 19-25%). At follow-up, the effect size for MBT on ADHD symptoms was large (.84), and similarly large on executive functioning (.81).

Another study tried a year’s worth of mindfulness training on poor responders to medication. Participants who received the treatment were compared to others who were waitlisted. The study reported a medium effect size (.63) in reducing the severity of ADHD.
Another looked at the impact of MAP on affective problems and impaired attention. It compared adults with ADHD and healthy controls who participated in MAP sessions with similar patients and controls who did not. The authors reported that MAP improved sustained attention and mood with medium to large effect sizes (.50 to .80).

A recent study explored the impact of MAP on neurocognitive performance with a randomized controlled trial. Following an 8-week mindfulness training, researchers “found a significant decrease in ADHD symptoms and significant improvement in task performance in both the MAP and the psychoeducation comparison group post- versus preintervention but did not find evidence for a significant main effect of treatment or a significant interaction effect on any ADHD symptoms (self- and observer-rated) nor on task performance (WM).”

Another study randomly assigned adults with ADHD either to a waitlist or to mindfulness-based cognitive therapy (MBCT). It found that MBCT led to a medium-to-large reduction in self-reported ADHD symptoms (.64) and a large reduction in investigator-reported symptoms (.78). It also found large (.93) improvements in executive functioning.

An 11th study looked at the effects of MBCT on neurophysiological correlates (event-related potentials (ERPs)) of performance monitoring in adults with ADHD. Half the patients were randomly assigned to MBCT, the other half to waitlist. MBCT produced reduced inattention, hyperactivity/impulsivity, and global ADHD index symptoms with medium to large effect sizes (.49 to .93).

A 12th study randomly assigned college students to MBCT or waitlist. At follow-up, participants who had received MBCT exhibited large (1.26) reductions in ADHD symptoms as well as greater treatment response rates (57%-71% vs. 23%-31%) versus waitlist. They also registered greater improvement on most neuropsychological performance and attentional scores.

Finally, another study compared the efficacy of MBCT plus treatment as usual (TAU) versus TAU only in reducing core symptoms in adults with ADHD. Participants were randomly assigned to an 8-weekly group therapy including meditation exercises, psychoeducation, and group discussions, or to TAU only, including pharmacotherapy and/or psychoeducation. At 6-month follow-up, MBCT+TAU patients reported large (SMD = .79) improvements in ADHD symptoms relative to TAU patients.

Overall, these are promising results for mindfulness-based interventions, and all the more so for those who do not respond well to drug therapy. Nevertheless, they must be seen as tentative. The sum total of participants over all thirteen studies was just 753, or an average of only 58 per study. There was too much variation in the studies to perform a meta-analysis. Only one of the studies included a healthy (non-ADHD) control group. And only one study received a perfect score by Cochrane Collaboration standards. Most studies did not use a suitable control group, i.e., in which there was an expectation of benefit from participating. As the authors noted, “Attrition bias was found to have high or unclear risk in more than a half of the studies. The reason for dropout of participants was not always clearly specified in those studies, so it is difficult to decide if it might be related to adverse effects or to some discomfort with treatment or instead to some incidental reasons.”

REFERENCES
Hélène Poissant, Adrianna Mendrek, Nadine Talbot, Bassam Khoury, and Jennifer Nolan, “Behavioral and Cognitive Impacts of Mindfulness-Based Interventions on Adults with Attention-Deficit Hyperactivity Disorder: A Systematic Review,” Behavioural Neurology, Vol. 2019, Article ID 5682050, 16 pages, https://doi.org/10.1155/2019/5682050.

The study team began with a representative sample of 69,972 U.S. adults aged 18 years or older who completed the 2012 and 2013 U.S. National Health and Wellness Survey. These adults were invited to complete the Validate Attitudes and Lifestyle Issues in Depression, ADHD and Troubles with Eating (VALIDATE) study, which included 1) a customized questionnaire designed to collect data on sociodemographic and clinical characteristics and lifestyle, and 2) several validated work productivity, daily functioning, self-esteem, and health-related quality of life (HRQoL) questionnaires. Of the 22,937 respondents, 444 had been previously diagnosed with ADHD, and 1,055 reported ADHD-like symptoms but had no previous clinical diagnosis.

There were no significant differences between the two groups in terms of age, education, income, health insurance, and most comorbid disorders. But those who had not been previously diagnosed were significantly more likely to be first-generation Americans (p<.001), nonwhite (p<.001), unemployed (p=.024), or suffer from depression, insomnia, or hypertension.

After matching the two groups for sociodemographic characteristics and comorbid conditions, covariate comparisons were made between 436 respondents diagnosed with ADHD and 867 previously undiagnosed respondents. Among respondents who were employed, diagnosed individuals registered a mean work productivity loss of 29% as opposed to 49% for the previously undiagnosed (p<.001). They also registered a 37% level of activity impairment versus a 53% level among the undiagnosed (p<.001). On the Sheehan Disability Scale, which ranges from 0 (no impairment) to 30 (highly impaired), the diagnosed group had a mean of 10, as opposed to a mean of 15 for the undiagnosed (p<.001). Diagnosed respondents also significantly outperformed undiagnosed ones on the Rosenberg Self-Esteem Scale (19 versus 15, on a scale of 0 to 30, p<.001), and on two quality-of-life scales (p<.001).

Applying a linear regression mixed model to the matched sets, the diagnosed still scored 16 points better than the undiagnosed on the WPAI:GH Productivity Loss scale (p<.001), 14 points better on the WPAI:GH Activity Impairment scale (p<.001), 4.5 points better on the Sheehan Disability Scale (p<.001), almost 4 points on the Rosenberg Self-Esteem Scale (p<.0001), with comparable gains on the two quality-of-life scales (p<.001 and p<.0001).

The authors concluded, “This comparison revealed that individuals who had been diagnosed with ADHD were more likely to experience better functioning, HRQoL [health related quality-of-life], and self-esteem than those with symptomatic ADHD. This result appears to be robust, withstanding several levels of increasingly rigorous statistical adjustment.” That points to substantial benefits from the treatment that follows diagnosis of adult ADHD.

REFERENCES
Manjiri Pawaskar, Moshe Fridman, Regina Grebla, and Manisha Madhoo, “Comparison of Quality of Life, Productivity, Functioning and Self-Esteem in Adults Diagnosed With ADHD and With Symptomatic ADH,” Journal of Attention Disorders, Published online May 2, 2019 https://doi.org/10.1177/1087054719841129.

The ENIGMA-ADHD Working Group published their second large study on the brains of people with ADHD in the American Journal of Psychiatry this month. In this second study, the focus was on the cerebral cortex, which is the outer layer of the brain.

ADHD symptoms include inattention and/or hyperactivity and acting impulsively. The disorder affects more than one in 20 (5.3%) children, and two-thirds of those diagnosed continue to experience symptoms as adults.

In this study, researchers found subtle differences in the brain’s outer layer – the cortex – when they combined brain imaging data on almost 4,000 participants from 37 research groups worldwide. The differences were only significant for children; and did not hold for adolescents or adults. The childhood effects were most prominent and widespread for the surface area of the cortex. More focal changes were found for thickness of the cortex. All differences were subtle and detected only at a group level, and thus these brain images cannot be used to diagnose ADHD or guide its treatment.

These subtle differences in the brain’s cortex were not limited to people with the clinical diagnosis of ADHD: they were also present – in a less marked form – in youth with some ADHD symptoms. This second finding results from a collaboration between the ENIGMA-ADHD Working Group and the Generation-R study from Rotterdam, which has brain images on 2700 children aged 9-11 years from the general population. The researchers found more symptoms of inattention to be associated with a decrease in cortical surface area. Furthermore, siblings of those with ADHD showed changes to their cortical surface area that resembled their affected sibling. This suggests that familial factors such as genetics or shared environment may play a role in brain cortical characteristics.

This is the largest study to date to look at the cortex of people with ADHD. It included 2246 people with a diagnosis of ADHD and 1713 people without, aged between four and 63 years old. This is the second study published by the ENIGMA-ADHD Working Group; the first examined structures that are deep in the brain. The ADHD Working Group is one of over 50 working groups of the ENIGMA Consortium, in which international researchers pull together to understand the brain alterations associated with different disorders and the role of genetic and environmental factors in those alterations.

The authors say the findings could help improve understanding of the disorder. ‘We identify cortical differences that are consistently associated with ADHD combining data from many different research groups internationally. We find that the differences extend beyond narrowly-defined clinical diagnoses and are seen, in a less marked manner, in those with some ADHD symptoms and in unaffected siblings of people with ADHD. This finding supports the idea that the symptoms underlying ADHD may be a continuous trait in the population, which has already been reported by other behavioural and genetic studies.’. In the future, the ADHD Working Group hopes to look at additional key features in the brain- such as the structural connections between brain areas – and to increase the representation of adults affected by ADHD, in whom limited research has been performed to date.

See: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2019.18091033

A team at the University of California at Los Angeles (UCLA) has just reported on the first-ever, double-blinded, sham-controlled study of trigeminal nerve stimulation (TNS) for treating ADHD. The trigeminal nerve is the largest cranial nerve. It enables facial sensation, as well as biting and chewing.

Over a four-week period, researchers fitted 62 eight-to-twelve-year-old children with electrodes while they slept; 32 got an active low current, the rest none at all. The active and sham setups were identical in appearance. The children were told, “pulses may come so fast or so slowly that the nerves in the forehead might or might not detect a sensation.” At the conclusion of the four weeks, there was an additional blinded week without intervention.

The primary efficacy outcome measure was the clinician-completed ADHD-RS total score, derived from parent interviews and available clinical information. It was completed at the onset of the study, and repeated over subsequent weeks. The Clinical Global Impression (CGI) score was used as a secondary outcome measure.

Both groups of children showed significant reductions in ADHD symptoms over the first week. But scores leveled off during the remaining three weeks for the group with sham treatment, while scores continued to decline for those in the group with actual stimulation. The standardized mean difference (SMD) between groups was 0.5.

By the conclusion of week 4, 52 percent for those in active treatment were improved or very much improved as indicated by CGI scores; only 14 percent did as well with the sham treatment. The number needed to treat was just 3.

After discontinuation of treatment, total scores in both groups rose at similar rates. At the end of week 5, CGI ratings for active treatment showed 13 percent improvement over baseline, versus 7 percent for sham treatment. The SMD was 0.46, once again indicating persistence of a medium effect size a week after treatment cessation.

The effect sizes computed for TNS are roughly comparable to effect sizes for nonstimulant medication, but less than those for stimulants.

Though the active group had significant gains in weight and pulse over the sham group, there were no serious adverse events in either group.

The authors concluded: “Results from the Early Impressions Questionnaire showed no differences in outcome expectations between treatment groups after 1 week using the randomized device, suggesting that our sham procedures successfully accomplished double blinding of group assignment. Improvements seen in the active and sham groups at week 1 likely reflect some placebo response secondary to the high level of parental involvement in administering treatment. Nonetheless, further improvement over subsequent weeks with active TNS suggests the emergence of true treatment effects … TNS is a non-medication minimal risk intervention with proven efficacy in alleviating ADHD symptoms. Although the present study finds that only slightly more than half of those receiving therapy have clinically meaningful improvement, the virtual lack of significant side effects should make it a popular treatment choice for many patients with ADHD, particularly for parents who prefer to avoid psychotropic medication.”

Nevertheless, one must keep in mind that this is a single un-replicated study with a small sample size. Further studies with larger numbers of participants are needed, both to confirm efficacy and to further explore the weight gains and higher pulse rates in the treatment group.

REFERENCES
James J. McGough, MD, Alexandra Sturm, PhD, Jennifer Cowen, PhD, Kelly Tung, BS, Giulia C. Salgari, MS, Andrew F. Leuchter, MD, Ian A. Cook, MD, Catherine A. Sugar, PhD, Sandra K. Loo, PhD, “Double-Blind, Sham-Controlled, Pilot Study of Trigeminal Nerve Stimulation for Attention-Deficit/ Hyperactivity Disorder,” Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 58, No. 4 (April 2019), 403-411.

Many college students truly have ADHD and deserve to be treated but some attempt to fake ADHD symptoms with the goal of getting stimulant medications for non-medical uses such as studying and getting high. Some students who fake ADHD also seek to gain accommodations that would give them additional time to complete exams. To address this issue, two psychologists examined data from 514 university students being assessed for ADHD to evaluate the ability of assessment tools to detect students who fake ADHD symptoms.

All participants had asked to be assessed to determine whether they could qualify for disability services. This was therefore by no means a random sample of university students, and could be expected to include some non-ADHD individuals seeking the benefits of an ADHD diagnosis. But this offered a good opportunity to explore which combination of tools would yield the best accuracy, and be best at excluding malingerers.

That was achieved by using both multiple informants and multiple assessment tools, and comparing results. Self-assessment was supplemented by assessment by other informants (e.g. parent, partner, friend, or other relative). These were supplemented with symptom validity tests to check for telltale highly inconsistent symptom reporting, or symptom exaggeration, which could signal false positives.

On the other hand, some individuals with ADHD have executive functioning problems that may make it difficult for them to reliably appraise their own symptoms on self-assessment tests, which can lead to false negatives. Performance validity tests were therefore also administered, in order to detect poor effort during evaluation, which could lead to false negatives.

Observer reporting was found to be more reliable than self-reporting, with significantly lower inconsistency scores (p < .001), and significantly higher exaggeration scores (p < .001). More than twice as many self-reports showed evidence of symptom exaggeration as did observer reports. This probably understates the problem when one considers that the observer reports were performed not by clinicians but by parents and partners who may themselves have had reasons to game the tests in favor of an ADHD diagnosis.

Even so, the authors noted, “External incentives such as procurement of a desired controlled substance or eligibility for a desired disability accommodation are likely to be of more perceived value to those who directly obtain them.” They suggested compensating for this by making ADHD diagnoses only on the basis of positive observer tests in addition to self-reports: “Applying an ‘and’ rule—one where both self- and observer reports were required to meet the diagnostic threshold— generally cut the proportions meeting various thresholds at least in half and washed out the differences between the adequate and inadequate symptom validity groups.”

They also recommended including formal tests of response validity, using both symptom validity tests and performance validity tests. Overall, they found that just over half the subsample of 410 students administered performance validity tests demonstrated either inadequate symptom or performance validity.

Finally, they recommended “that clinicians give considerable weight to direct, objective evidence of functional impairment when making decisions about the presence of ADHD in adults. The degree to which symptoms cause significant difficulty functioning in day-to-day life is a core element of the ADHD diagnostic criteria (American Psychiatric Association, 2013), and it cannot be assumed that significant symptoms cause such difficulty, as symptoms are only moderately associated with functional impairment. … we urge clinicians to procure objective records (e.g., grade transcripts, work performance evaluations, disciplinary and legal records) to aid in determining functional impairment in adults assessed for ADHD.”

REFERENCES
Jason M. Nelson and Benjamin J. Lovett, “Assessing ADHD in College Students: Integrating Multiple Evidence Sources With Symptom and Performance Validity Data,” Psychological Assessment, published online January 31, 2019 http://dx.doi.org/10.1037/pas0000702.

Behavioral disinhibition is a trait associated with both ADHD and several genes that affect dopamine signaling. A new study by three American medical researchers set out to examine how these ADHD risk genes – DRD4 (dopamine 4 receptor density), DAT1 (dopamine 1 transporter), and DBH (dopamine beta-hydroxylase) – affect estimated life expectancy in young adulthood.

The method used was a longitudinal study of 131 hyperactive children and 71 matched controls through early adulthood. The original evaluations were done in 1979-1980, when both groups were children in the 4 to 12 age range. They were reevaluated in 1987-1988 as adolescents aged 12 to 20. The next follow-up was in 1992-1996 in early adulthood, aged 19 to 25. The final follow-up was in 1998-2004, as adults aged 24 to 32. All agreed to physical examinations that formed the basis for calculating estimated life expectancy using actuarial tables that factor in the effects of smoking, body mass index, alcohol, and other risk factors on expected longevity. Participants also provided blood samples that enabled gene typing.

For the DAT1 gene, participants who had the homozygous nine-repeat allele (9/9) had a five-year reduction in estimated life expectancy relative to those with the ten-repeat allele (10/10). Those with the intermediate (9/10) configuration had a three-year reduction in estimated life expectancy.

For the DBH Taq1 gene, those with a heterozygous (A1/A2) combination had almost a three-year reduction in estimated life expectancy relative to those with homozygous (A1/A1 or A2/A2) configurations.

For DRD4, on the other hand, no significant differences were found for estimated life expectancy.

In a related study, several background traits were found to be significantly predictive of variance in estimated life expectancy. The largest of these was behavioral disinhibition, followed by verbal IQ, self-rated hostility, and a nonverbal fluency test. But no significant differences were found between any of the gene polymorphisms on any of these four measures, indicating that the present gene associations were independent of the background traits.

The researchers next sought to determine which variables used in the estimated life expectancy calculations were associated with the two significant genes. For DBH, one variable stood out. Those with the A1/A2 heterozygous pairings had almost twice the alcohol consumption of those with homozygous pairings (p = 0.023).

For DAT1, two variables stood out. Overall, the 9/9 pairings smoked two and a half times as much as the 10/10 pairings, with the 9/10 pairings midway between the extremes (p = 0.036). They were also 73 percent more likely to be smokers relative to the 10/10 pairings, and 61 percent more likely relative to the 9/10 pairings. They also had significantly less education than the 10/10 pairings, with the 9/10 pairings again being intermediate (p = 0.027).

An obvious limitation of the study was its small sample size. The authors cautioned, “our findings should be considered quite preliminary and in need of much greater research before being given much weight in the literature or in public policy.”

“With these limitations in mind,” they concluded, “the present study demonstrated that two ADHD risk genes (DBH and DAT1) independently contributed to a reduction in ELE [estimated life expectancy] beyond the second order variables of behavioral disinhibition, IQ, hostility, and nonverbal fluency that contributed in the related study to variation in ELE. The gene polymorphisms seemed to be influencing ELE through their affiliation with first-order or more proximal factors related to ELE such as education, smoking, alcohol use, and possibly exercise.”

REFERENCES
Russell A. Barkley, Karen Müller Smith, and Mariellen Fischer, “ADHD risk genes involved in dopamine signaling and metabolism are associated with reduced estimated life expectancy at young adult follow-up in hyperactive and control children,” American Journal of Medical Genetics (2019), DOI: 10.1002/ajmg.b.32711.

ADHD is far more prevalent among persons with AUD (roughly 20 percent) than it is in the general population. The most accurate way of identifying ADHD is through structured clinical interviews. Given that this is not feasible in routine clinical settings, ADHD self-report scales offer a less reliable but much less resource-intensive alternative. Could the latter be calibrated in a way that would yield diagnoses that better correspond with the former?

A German team compared the outcomes of both methods on 404 adults undergoing residential treatment for AUD. All were abstinent while undergoing evaluations. First, to obtain reliable ADHD diagnoses, each underwent the Diagnostic Interview for ADHD in Adults, DIVA. If DIVA indicated probable ADHD, two expert clinicians conducted successive follow-up interviews. ADHD was only diagnosed when both experts concurred with the DIVA outcome.

Participants were then asked to use two adult ADHD self-report scales, the six-item Adult ADHD Self Report Scale v1.1 (ASRS) and the 30-item Conners’ Adult ADHD Rating Scale (CAARS-S-SR). The outcomes were then compared with the expert interview diagnoses.

Using established cut-off values for the ASRS, less than two-thirds of patients known to have ADHD were scored as having ADHD by the test. In other words, there was a very high rate of false negatives. Lowering the cut-off to a sum score ≥ 11 resulted in correct diagnosis of more than seven out of eight. But the rate of false positives soared to almost two in five. Similarly, the CAARS-S-SR had its greatest sensitivity (ability to accurately identify those with ADHD) at the lowest threshold of ≥ 60, but at a similarly high cost in false positives (more than a third).

The authors found it was impossible to come anywhere near the precision of the expert clinical interviews. Nevertheless, they judged the best compromise to be to use the lowest thresholds on both tests, and then require positive determinations from both. That led to successfully diagnosing more than three out of four individuals known to have ADHD, with a false positive rate of just over one in five.

Using this combination of the two self-reporting questionnaires with lower thresholds, they suggest, could substantially reduce the under-diagnosis of ADHD in alcohol dependent patients.

REFERENCES
Mathias Luderer, Nurcihan Kaplan-Wickel, Agnes Richter, Iris Reinhard, Falk Kiefer, Tillmann Weber, “Screening for adult attention-deficit/hyperactivity disorder in alcohol dependent patients: Underreporting of ADHD symptoms in self-report scales,” Drug and Alcohol Dependence (2019), 195:52-58.

Mindfulness has been defined as “intentionally directing attention to present moment experiences with an attitude of curiosity and acceptance.” Mindfulness-based interventions (MBIs) aim to improve mindfulness skills.

A newly-published meta-analysis of randomized controlled trials (RCTs) by a team of British neurologists and psychiatrists explores the effectiveness of MBIs in treating a variety of mental health conditions in children and adolescents. Among those conditions is the attention deficit component of ADHD.

A comprehensive literature search identified studies that met the following criteria:

  1. The effects of mindfulness were compared against a control condition – either no contact, waitlist, active, or attention placebo. Waitlist means the control group receives the same treatment after the study concludes. Active control means that a known, effective treatment (as opposed to a placebo) is compared to an experimental treatment. Attention placebo means that controls receive a treatment that mimics the time and attention received by the treatment group but is believed not to have a specific effect upon the subjects. Participants were randomly assigned to the control condition.
  2. The MBI was delivered in more than one session by a trained mindfulness teacher, involved sustained meditation practice, and it was not mixed in with another activity such as yoga.

Eight studies evaluating attention deficit symptoms, with a combined total of 1,158 participants, met inclusion criteria. The standardized mean difference (SMD) was 0.19, with a 95% confidence range of 0.04 to 0.34 (p = .02). That indicates a small effect size for MBIs in reducing attention deficit symptoms. Heterogeneity was low (I2 = 35, p = .15), and the Egger test showed little sign of publication bias (p = 0.42).

When looking only at studies with active controls, five studies with a total of 787 participants yielded an SMD of 0.13, with a 95% confidence interval of -0.01 to 0.28 (p = .06), indicating a tiny effect size that failed to reach significance. Active controls most commonly received health education, with a few receiving social responsibility trainings or Hatha yoga.

Overall, this meta-analysis suggests limited effectiveness, especially when compared with active controls. If MBIs are effective for ADHD, there effect on symptoms is very small. Thus, such treatments should not be used in place of the many well-validated, evidenced-based therapies available. Whether longer periods of MBI (training times varied between 2 and 18 hours spread out over 2 to 24 weeks) might result in greater effect sizes remains unexplored.

REFERENCES
Darren L. Dunning, Kirsty Griffiths, Willem Kuyken, Catherine Crane, Lucy Foulkes, Jenna Parker, and Tim Dalgleish, “Research Review: The effects of mindfulness-based interventions on cognition and mental health in children and adolescents – a meta-analysis of randomized controlled trials,” Journal of Child Psychology and Psychiatry (2018), doi:10.1111/jcpp.12980.

A newly-published systematic review by a British team identified 48 qualitative and quantitative studies that explored “ADHD in primary care, including beliefs, understanding, attitudes, and experiences.” The studies described primary care experiences in the U.S., Canada, Europe, Australia, Singapore, Iran, Pakistan, Brazil, and South Africa.

More than three out of four studies identified deficits in education about ADHD. Of particular concern was the training of primary care providers (PCPs), most of whom received no specific training on ADHD. In most places, a quarter or less of PCPs received such training. Even when such training was provided, PCPs often rated it as inadequate, and said they did not feel they could adequately evaluate children with ADHD. There was even less training for adult ADHD.

A 2009 survey of 194 PCPs in Pakistan found that ADHD was not included at all in medical training there, and that most learned from colleagues. Half readily admitted to having no competence, and less than one in five were shown to have adequate knowledge about ADHD. In a 2009 survey of 229 South African PCPs, only 7 percent reported adequate training in childhood ADHD, and a scant one percent in adult ADHD.

These problems were by no means limited to less developed countries. A 2001 U.K. survey of 150 general practitioners found that only 6 percent of them had received formal ADHD training. In a 2002 study of 499 Finnish PCPs, only half felt confident in their ability to diagnose ADHD. A 2005 survey of 405 Canadian PCPs likewise found that only half reported skill and comfort in diagnosis. In a 2009 survey of 400 U.S. primary care physicians, only 13 percent said they had received adequate training. A 2017 study of Swiss PCPs found that only five of the 75 physicians in the sample expressed competence in diagnosis.

Eight studies explored knowledge of DSM (Diagnostic and Statistical Manual of Mental Disorders) criteria and clinical guidelines among PCPs. Only a quarter of PCPs were using DSM criteria, and only one in five were using published guidelines. In a 1999 survey of 401 pediatricians in the U.S. and Canada, only 38 percent reported using DSM criteria. A 2004 survey of 723 U.S. PCPs found only 44 percent used DSM criteria. In a 2006 UK study of 40 general practitioners, only 22 percent were aware of ADHD criteria. In the same year, a survey of 235 U.S. physicians found that only 22 percent were familiar with ADHD guidelines, and 70 percent used child behavior in the office to make a diagnosis. More encouragingly, a 2010 U.S. study reported that use of APA (American Psychological Association) guidelines by PCPs had expanded markedly between 1999 and 2005, from one in eight to one in two.

Given these facts, it is unsurprising that many PCPs expressed lack of confidence in treating ADHD. In a 2003 survey of 143 South African general practitioners, two thirds thought it was difficult to diagnose ADHD in college students. A 2012 U.S. study of 1,216 PCPs found that roughly a third lacked confidence in diagnosis and treatment. More than a third said they did not know how to manage adult ADHD. In a 2015 survey of 59 physicians and 138 nurses in the U.S., half lacked confidence in their ability to recognize ADHD symptoms. This was especially pronounced among the nurses. A 2001 U.K. survey of 150 general practitioners found that nine out of ten wanted further training in drug treatment, and more than one out of ten were unwilling to prescribe due to insufficient knowledge.

Misconceptions about ADHD were widespread. In a survey of 380 U.S. PCPs, almost half thought ADHD medications were addictive, one in five thought ADHD was “caused by poor diet,” more than one in seven thought “the child does it on purpose,” and one in ten thought medications can cure ADHD. Some studies reported that many PCPs believed ADHD was related to consumption of sugary food and drink. Others reported a gender bias. A 2002 U.S. study of 395 PCPs found that when presented with boys and girls with parent reported problems, they were significantly more likely to diagnose ADHD in boys.

A 2010 Iranian study of 665 PCPs found that 82 percent believed children adopted ADHD behavior patterns as a strategy to avoid obeying rules and doing assignments. One third believed sugary food and drink contributed to ADHD. Only 6 percent believed it could be a lifelong condition. Half blamed dysfunctional families. The aforementioned large 2012 U.S. study similarly found that almost half of PCPs believed ADHD was caused by absent or bad parenting. More than half of 399 Australian PCPs surveyed in 2002 believed inadequate parenting played a key role. In a 2003 study of 48 general practitioners in Singapore, a quarter blamed sugar for ADHD. A 2014 survey of 57 French pediatricians found that a quarter thought ADHD was a foreign construct imported into France, and 15 percent attributed it to bad parenting.

In all, ten studies reported a widespread belief that ADHD was due to bad parenting, with ratios varying from over one in seven PCPs to more than half. They were particularly likely to attribute hyperactivity to dysfunctional families, and to dismiss parents’ views of hyperactivity as a medical problem as a way to deflect attention from inadequate parenting.

While a third of the studies reported on stigma, the surprise was that it did not seem to play as big a role as expected. A 2012 study in the Netherlands found that 74 physicians and 154 non-medical professionals matched by age, sex, and education showed no differences in level of stigmatization toward ADHD.

On the other hand, the studies identified significant resource constraints limiting more effective understanding, diagnosis, and treatment. Given the complex nature of ADHD, the time required to gain relevant information, especially in the context of competing demands on the attention of PCPs, was a limiting factor. Many studies identified a need for better assessment tools, especially for adults.

Another major constraint was PCP uneasiness about medication. Studies found a widespread lack of knowledge about treatment options, and more specifically the pros and cons of medication relative to other options. This often led to an unwillingness to prescribe.

Yet another limitation was difficulties PCPs had in communicating with mental health specialists. One study found that less than one in six PCPs received communications from psychiatrists. Much of this was ascribed to “system failure”: discontinuity of care, no central accountability, limited resources, buck passing. Many PCPs were unsure who to turn to.

Another problem is in often faulty interactions between schools, parents, children, and providers. Parents often fail to keep appointments. Schools and parents often are less than cooperative in providing information. In a 2004 survey of 786 U.S. school nurses, less than half reported good levels of communication between schools and physicians. Schools and parents often apply pressure on PCPs to issue a diagnosis. In a U.S. survey of 723 PCPs, more than half reported strong pressure from teachers to diagnose ADHD, and more than two-thirds said they were under pressure to prescribe medication.

The authors noted, “The need for education was the most highly endorsed factor overall, with PCPs reporting a general lack of education on ADHD. This need for education was observed on a worldwide scale; this factor was discussed in over 75% of our studies, in 12 different countries, suggesting that lack of education and inadequate education was the main barrier to understanding of ADHD in primary care.”

In addition, “time and financial constraints affect the opportunities for PCPs to seek extra training and education but also affect the communication with other professionals such as secondary care workers, teachers and parents.”

The authors cautioned that only eleven of the 48 studies were published since 2010. Also, because it was a systematic review and not a meta-analysis, there was no way to evaluate publication bias.

They concluded, “Better training of PCPs on ADHD is, therefore, necessary but to facilitate this, dedicated time and resources towards education needs to be put in place by service provider and local authorities.”

REFERENCES
B. French, K. Sayal, D. Daley, “Barriers and facilitators to understanding of ADHD in primary care: a mixed‐method systematic review,” European Child & Adolescent Psychiatry (2018), https://doi.org/10.1007/s00787-018-1256-3.

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

Lenard Adler, MD ADHD in AdultsThe 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.