Lenard A. Adler, MD, ADHD in Adults
Ettinger AB1, Ottman R, Lipton RB, Cramer JA, Fanning KM, Reed ML. Attention-deficit/hyperactivity Len_Adler_AIAdisorder 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.

ASRS Professional Screener Download

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.

Graziano PA, Reid A, Slavec J, Paneto A, McNamara JP, Geffken GR.  “ADHD Symptomatology andTony_Rostain_AIA-5Risky Health, Driving, and Financial Behaviors in College: The Mediating Role of Sensation Seeking and Effortful Control” Journal of Attention Disorders (2014) Epub ahead of print April. DOI: 10.1177/1087054714527792.

This study explores the relative contributions of “top-down” (i.e. effortful control) and “bottom up” (i.e. sensation seeking) mental processes to maladaptive risky behaviors in college students with ADHD.  The authors review these constructs by pointing out that effortful aspects of self-regulation involve intact prefrontal circuits underlying executive functions whereas reactive behaviors not requiring conscious mental resources are influenced by emotional stimuli and are mediated by subcortical brain structures.  Given that ADHD involves difficulties in both these domains of psychological functioning, it makes sense to explore which contribute to the onset of maladaptive risk-taking in college students with ADHD.

The authors studied 555 college students attending a southeastern university using an online survey for which they received class credit.   Participants filled out standardized rating scales to assess outcomes.  Of the total sample, 5.7% reported a history of an ADHD diagnosis and 10.8% reported elevated ADHD symptoms (> 1.5 SD above the mean) on an ADHD rating scale. There were two distinct patterns of risk behaviors: risky driving/financial behaviors and risky health behaviors.  ADHD symptoms were highly correlated with these two factors as well as with sensation seeking and effortful control.   More ADHD symptoms were associated with risky behaviors ONLY when effortful control was low.   Sensation seeking was more highly associated with risky health behaviors but not risky driving/financial behaviors. 

The authors note that the study’s reliance on self-report scales and measures limits its validity.  ADHD individuals are known to underreport severity of symptoms.  Moreover, it was not possible to detect the presence of antisocial behaviors (e.g. Conduct Disorder) that might have a greater impact on risky behaviors than ADHD symptoms.  Finally, the fact that the study was conducted on a single campus may limit the generalizability of its findings to the entire population of US college students.  (Note: Watch our Ask the ADHD Experts Session on ADHD and College Students.)

Despite these limitations, this paper reports interesting results suggesting that ADHD symptoms may not be as important as effortful control deficits and as high stimulus seeking in mediating the onset of risk behaviors in this population.    These could be important targets for psychological therapies.  It also points to the relevance of these two aspects of psychological functioning for preventive health efforts to reduce health, driving and financial risk behaviors, and for clinical approaches to dealing with patients presenting with maladaptive coping mechanisms.  

Lenard Adler, MD ADHD in AdultsThis 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

ADHD and PTSD

Lenard_A_Adler_MD_ADHD_in_Adults

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 article describes an examination of potential differences in neuropsychological functioning between a cohort of adults with ADHD (n=186), ADHD and 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). 

CME LEARN HERE  Improving Executive Function   in Adult ADHD

Overall the group with ADHD (whether they had PTSD or not) had significantly lower scores on the battery of neuro-psychological tests than the non-ADHD controls. However, the group with ADHD and 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. Additionally, in this study, 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 and PTSD patients.  Never the less, 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 that should be accounted for in making the adult ADHD diagnosis.

Driving and ADHD

Lenard Adler, MD ADHD in AdultsZheng Chang, PhD; Paul Lichtenstein, PhD; Brian M. D’Onofrio, PhD; Arvid Sjölander, PhD; Henrik Larsson, PhD. “Serious Transport Accidents in Adults With Attention-Deficit/Hyperactivity Disorder and the Effect of Medication: A Population-Based Study” JAMA Psychiatry. doi:10.1001/jamapsychiatry.2013.4174. Published online January 29, 2014.

This study examines the association of adult ADHD with transport accidents and potential effects of ADHD treatment. The authors note that transport accidents exert a substantial burden on the world economy, such that they account for 2% of the global GNP. Untreated adult ADHD has been previously associated with increased rates of transport accidents or poor driving (increased accidents, false brakes and speeding) when adults with ADHD are examined on a driving stimulator. ADHD pharmacotherapy has also been shown to ameliorate performance on the driving simulator in these adults (Barkley RA, Cox D. J Safety Res. 2007;38(1):113-28. Epub 2007 Feb 15.) However, these studies are of relatively small sample sizes and concerns have been raised regarding potential referral bias influencing the study results.

Chang and co-authors examined over 17,000 individuals with ADHD over a four year period in the Swedish national registries. Cox proportional hazards regressions were used to examine the association between ADHD and serious traffic accidents (resulting in death or emergency room visit). Stratified Cox regressions were used within patients to examine the rates of accidents on and off medication. ADHD treatment was defined as filling a prescription for an ADHD medication within a six month period.

The study found significantly higher rates of transport accidents in men (adjusted hazard ratio, 1.47; 95%CI, 1.32-1.63) and women (1.45; 1.24-1.71) with ADHD, compared to the control group. Medication treatment was associated with a 58% risk reduction in men, but no significant risk reduction in women. The potential reasons for this gender difference is not fully known, but the 40% lower base rate of accidents in women versus men may have created a floor effect, where the base rates were lower in women to an extent which minimized potential ameliorative effects of medication. It was estimated that continuous medication treatment would have cut accident rates almost in half, presumably from positive effects on ADHD related symptoms and impairment and resulting improvement in driving (the ameliorative effects of medication on accidents is associative not causative in this trial).

This is a very important trial as it extends observations of increased motor vehicle accidents in untreated adults with ADHD to a large community based sample. It further highlights the ameliorative effects of ADHD pharmacotherapy observed in driving simulator studies to a large population based sample, which further emphasizes the importance of adults with ADHD receiving treatment. Of note, the definition of being on medication in the study, of filling a prescription in the last six months, is a fairly liberal definition of adherence to treatment; therefore, the potential beneficial effects of medication may if anything be under-estimated by this study given the long period of time individuals presumed to be treated with medication might have been off medication. Furthermore, the authors did examine whether defining medication treatment as filling a prescription within three months, would influence the findings; this tighter definition of treatment yielded similar results.

Overall adherence rates to treatment in ADHD are fairly poor, whereby most adults and young adults do not fill beyond their second prescription of psychostmulants. (Adler LD, Nierenberg AA. Review of medication adherence in children and adults with ADHD. Postgrad Med. 2010 Jan;122(1):184-91. doi: 10.3810/pgm.2010.01.2112.) It is important, given the earlier findings and results of the current study, for ADHD adults and young adults to be treated pharmacologically in periods when they are driving motor vehicles. Overall treatment principles for adults and young adults with ADHD suggest treatment throughout the day, to ensure symptomatic relief for longer periods of time during the day and especially during periods when driving (Adler LA, Barkley RA, Newcorn JH. Performance improvement CME: adult ADHD. J Clin Psychiatry. 2011 Apr;72(4):e15. doi: 10.4088/JCP.9066pi4c.). Clinicians may use the increased risk of motor vehicle accidents in untreated adults with ADHD as means of reinforcing the importance of medication adherence, when discussing adherence to pharmacotherapy with patients.