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. [Epub ahead of print]
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 itself is associated with sleep difficulties, independent of ADHD medications. Thus, it is very important that sleep quality is assessed prior to treatment so that the changes due to treatment can be correctly inferred.
In clinical trials of stimulant medications for ADHD, insomnia is typically noted a side effect of the medications. But most of these studies have used subjective patient or parent reports of sleep quality. A new meta analysis, reviews 9 studies of a total of 246 patients enrolled in randomized controlled trials of a stimulant medication. To be included, studies must have had an objective measure of sleep quality, either polysomnography or actigraphy. The analysis showed that stimulant medications led to a) a longer time to get to sleep; b) worse sleep efficiency and c) a shorter duration of sleep. Some of these sleep measures worsened with an increasing number of doses and a shorter time on medication.
Given the adverse effects that lack of sleep can have on cognition and behavior, these data provide further impetus for clinicians, parents and patients to monitor the effects of stimulant ADHD medication on sleep and to take appropriate action (e.g., dose reduction, change of medication) as warranted.
A systematic review of the literature and a meta-analysis investigating the relationship between mild traumatic brain injury (mTBI) and ADHD has been completed. The study indicates that mTBI is cerebral concussion and that there has been increasing interest from the coverage in the lay press re: the effects of mTBI in professional sports.
The authors hypothesize that individuals with ADHD commonly have a history of being risk-takers and have higher accident rates, which may predispose them to mTBI. Conversely, it has been hypothesized that mTBI could create a secondary ADHD-like condition.
The authors used reasonable inclusion criteria re: the studies included in the analyses (including being original research which examined ADHD and mTBI, used diagnostic criteria for ADHD and differentiated ADHD from learning disorders and mTBI from other types of TBI). They found five articles which met entry criteria for the meta-analysis; most, but not all, of the trials involved children.
They then examined the relative risk for one disorder being associated with the other disorder, based upon the temporal sequence of disorder onset. The authors found that there was no increased risk for TBI if ADHD occurred first.
However, if mTBI occurred first or if the temporal sequence was unclear there was about a two times elevated risk for ADHD. The overall finding of increased relative risks of ADHD and mTBI is important and highlights the need for clinicians to screen for the potential of these co-occurring disorders.
J Atten Disord. 2014 Oct;18(7):576-84. doi: 10.1177/1087054714543371. Epub 2014 Jul 21. Mild traumatic brain injury and ADHD: a systematic review of the literature and meta-analysis. Adeyemo BO1, Biederman J2, Zafonte R1, Kagan E3, Spencer TJ3, Uchida M3, Kenworthy T3, Spencer AE3, Faraone SV4.
J Atten Disord. 2014 Feb 24. [Epub ahead of print]
The Neuropsychological Profile of Comorbid Post-Traumatic Stress Disorder in Adult ADHD.
Antshel KM, Biederman J, Spencer TJ, Faraone SV.
This study is important as it is the first investigation to examine neuropsychological deficits in individuals with ADHD and PTSD; it also adds to our increasing understanding of the increased burden of having ADHD and PTSD. Prior studies have shown that PTSD may be a vulnerability factor for developing future ADHD. These studies indicate that clinicians should be careful in screening individuals with ADHD for co-morbid PTSD and that the combination of disorders may carry a higher neuropsychological burden.
Overall the group with ADHD (whether they had PTSD or not) had significantly lower scores on the battery of neuropsychological tests; however, the group with ADHD+PTSD had lower neuropsychological test scores on a number of measures versus the group with ADHD alone (WAIS full scale IQ and block design, ROCF copy accuracy and copy time and Stroop Color T-score). Measures of quality of life were not shown to be predictors of PTSD status.
This article describes an examination of potential differences in neuropsychological functioning between a cohort of adults with ADHD (n=186), ADHD with PTSD (n=20) and a non-ADHD control group (n=123) who received psychiatric evaluations and neuropsychological tests (including WAIS intelligence, tests of frontal executive function (Wisconsin Card Sorting Test, Stroop Color and Word Test) the California Verbal Learning Test (CVLT) the Rey-Osterrieth Complex Figure Test (ROCF) and an auditory working memory continuous performance task (CPT). The group with ADHD had lower socio-economic status and were more likely to be of non-Caucausian ethnicity. Interpretation of the findings of this trial is somewhat limited by the small cohort of ADHD+PTSD patients.
This article** examines the co-occurrence of adverse life events and depression in a cohort of older adults with ADHD. The study is important as ADHD and depression are highly co-morbid in both younger and older adults. The authors examined the co-occurrence of life events as a possible link with ADHD and depression. Patients (n=230) in the Longitudinal Aging Study Amsterdam (LASA) were examined for the presence of ADHD with the DIVA (Diagnostic Interview for ADHD in Adults).
The authors found that the older adults with ADHD had significantly more depressive symptoms and life events than the older adults without ADHD. One caveat to the interpretation of this data is that non-DSM diagnostic criteria were employed. Never the less, this association of depression and life events is of interest as it may highlight another potential consequence of the inattention or impulsivity seen with ADHD and highlights the need for future study of this association.
Logistic and linear regression analyses were used to examine the relationship between ADHD symptoms, depressive symptoms and life events. Subjects with significant cognitive decline were excluded from the sample to remove this potential confound. ADHD symptom criteria were defined as having four significant symptoms of inattention and/or hyperactivity-impulsivity in the six months prior to the interview, which is more liberal than the cut-off of five significant symptoms in DSM-5 and six significant symptoms in DSM-IV; however a stricter cut-off than DSM criteria was used of requiring six symptoms of inattention and/or hyperactivity-impulsivity in childhood. Depressive symptoms were assessed with the Center for Epidemiological Studies-Depression scale (CES-D).
** E.J. Semeijn, H.C. Comijs, J.J.S. Kooij, M. Michielsen, A.T.F. Beekman, D.J.H. Deeg. The role of adverse life events on depression in older adult with ADHD. Journal of Affective Disorders. DOI: http://dx.doi.org/10.1016/j.jad.2014.11.048