Adult Onset ADHD

Stephen V. Faraone, PhD on August 4, 2016

Adult Onset ADHD: Does it Exist? Is it Distinct from Youth Onset ADHD? There is a growing interest (and controversy) about ‘adult’ onset ADHD. No current diagnostic system allows for the diagnosis of ADHD in adulthood, yet clinicians sometimes face adults who meet all criteria for ADHD, except for age at onset. Although many of these clinically referred adult onset cases may reflect poor recall, several recent longitudinal population studies have claimed to detect cases of adult onset ADHD that showed no signs of ADHD as youth (Agnew-Blais, Polanczyk et al. 2016, Caye, Rocha et al. 2016). They conclude, not only that ADHD can onset in adulthood, but that childhood onset and adult onset ADHD may be distinct syndromes (Moffitt, Houts et al. 2015).

In each study, the prevalence of adult onset ADHD was much larger than the prevalence of childhood-onset adult ADHD). These estimates should be viewed with caution. The adults in two of the studies were 18-19 years old. That is too small a slice of adulthood to draw firm conclusions. As discussed elsewhere (Faraone and Biederman 2016), the claims for adult onset ADHD are all based on population as opposed to clinical studies. Population studies are plagued b the “false positive paradox”, which states that, even when false positive rates are low, many or even most diagnoses in a population study can be false.

Another problem is that the false positive rate is sensitive to the method of diagnosis. The child diagnoses in the studies claiming the existence of adult onset ADHD used reports from parents and/or teachers but the adult diagnoses were based on self-report. Self-reports of ADHD in adults are less reliable than informant reports, which raises concerns about measurement error. Another longitudinal study found that current symptoms of ADHD were under-reported by adults who had had ADHD in childhood and over-reported by adults who did not have ADHD in childhood (Sibley, Pelham et al. 2012). These issues strongly suggest that the studies claiming the existence of adult onset ADHD underestimated the prevalence of persistent ADHD and overestimated the prevalence of adult onset ADHD. Thus, we cannot yet accept the conclusion that most adults referred to clinicians with ADHD symptoms will not have a history of ADHD in youth.

The new papers conclude that child and adult ADHD are “distinct syndromes”, “that adult ADHD is more complex than a straightforward continuation of the childhood disorder” and that that adult ADHD is “not a neurodevelopmental disorder”. These conclusions are provocative, suggesting a paradigm shift in how we view adulthood and childhood ADHD. Yet they seem premature. In these studies, people were categorized as adult onset ADHD if full-threshold ADHD had not been diagnosed in childhood. Yet, in all of these population studies there was substantial evidence that the adult onset cases were not neurotypical in adulthood (Faraone and Biederman 2016). Notably, in a study of referred cases, one-third of late adolescent and adult onset cases had childhood histories of ODD, CD and school failure (Chandra, Biederman et al. 2016). Thus, many of the “adult onsets” of ADHD appear to have had neurodevelopmental roots.

Looking through a more parsimonious lens, Faraone and Biederman (2016)proposed that the putative cases of adult onset ADHD reflect the existence of subthreshold childhood ADHD that emerges with full threshold diagnostic criteria in adulthood. Other work shows that subthreshold ADHD in childhood predicts onsets of the full-threshold ADHD in adolescence (Lecendreux, Konofal et al. 2015). Why is onset delayed in subthreshold cases? One possibility is that intellectual and social supports help subthreshold ADHD youth compensate in early life, with decompensation occurring when supports are removed in adulthood or the challenges of life increase. A related possibility is that the subthreshold cases are at the lower end of a dimensional liability spectrum that indexes risk for onset of ADHD symptoms and impairments. This is consistent with the idea that ADHD is an extreme form of a dimensional trait, which is supported by twin and molecular genetic studies (Larsson, Anckarsater et al. 2012, Lee, Ripke et al. 2013). These data suggest that disorders emerge when risk factors accumulate over time to exceed a threshold. Those with lower levels of risk at birth will take longer to accumulate sufficient risk factors and longer to onset.

In conclusion, it is premature to accept the idea that there exists an adult onset form of ADHD that does not have its roots in neurodevelopment and is not expressed in childhood. It is, however, the right time to carefully study apparent cases of adult onset ADHD to test the idea that they are late manifestations of a subthreshold childhood condition.
 

REFERENCES
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Scheftner, G. D. Schellenberg, S. W. Scherer, N. J. Schork, T. G. Schulze, J. Schumacher, M. Schwarz, E. Scolnick, L. J. Scott, J. Shi, P. D. Shilling, S. I. Shyn, J. M. Silverman, S. L. Slager, S. L. Smalley, J. H. Smit, E. N. Smith, E. J. Sonuga-Barke, D. St Clair, M. State, M. Steffens, H. C. Steinhausen, J. S. Strauss, J. Strohmaier, T. S. Stroup, J. S. Sutcliffe, P. Szatmari, S. Szelinger, S. Thirumalai, R. C. Thompson, A. A. Todorov, F. Tozzi, J. Treutlein, M. Uhr, E. J. van den Oord, G. Van Grootheest, J. Van Os, A. M. Vicente, V. J. Vieland, J. B. Vincent, P. M. Visscher, C. A. Walsh, T. H. Wassink, S. J. Watson, M. M. Weissman, T. Werge, T. F. Wienker, E. M. Wijsman, G. Willemsen, N. Williams, A. J. Willsey, S. H. Witt, W. Xu, A. H. Young, T. W. Yu, S. Zammit, P. P. Zandi, P. Zhang, F. G. Zitman, S. Zollner, B. Devlin, J. R. Kelsoe, P. Sklar, M. J. Daly, M. C. O’Donovan, N. Craddock, P. F. Sullivan, J. W. Smoller, K. S. Kendler and N. R. 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Sibley, M. H., W. E. Pelham, B. S. Molina, E. M. Gnagy, J. G. Waxmonsky, D. A. Waschbusch, K. J. Derefinko, B. T. Wymbs, A. C. Garefino, D. E. Babinski and A. B. Kuriyan (2012). “When diagnosing ADHD in young adults emphasize informant reports, DSM items, and impairment.” J Consult Clin Psychol 80(6): 1052-1061.

ADHD Parenting among ADHD Adults

Anthony L. Rostain, MD MA on July 21, 2016

Journal of Clinical Child and Adolescent Psychology. 2014. DOI: 10.1080/15374416.2014.963858

“The Role of Parental ADHD in Sustaining the Effects of a Family-School Intervention for ADHD”

Dawson, A.E., Wymbs, B.T., Marshall, S.A., Mautone, J.A., Power, T.J.

This paper reports on the extent to which parental ADHD impacts child and parent functional outcomes of a multimodal family-school intervention designed to boost academic performance of 139 school-aged children with ADHD.

The initial results of this randomized controlled trial (N = 199) comparing an experimental intervention, the Family School Success Program (FSS) to an active-control condition, Coping with ADHD through Relationships and Education (CARE), revealed that participants in each group showed gains in the primary targeted outcomes.

For children, these included rates of completing homework, academic productivity, and symptoms of ADHD and oppositional defiant disorder (ODD) as measured by the Swanson, Nolan and Pelham Questionnaire (SNAP).  Parental outcomes included parents’ view of their efficacy as their child’s educator, quality of the parent-teacher relationship, and quality of the parent-child relationship.  While both groups showed improvements, there were modest treatment effect sizes seen in the FSS group as compared to the CARE group in ratings of homework performance, self-reported parenting practices, and overall quality of school-family relationships (Power et al, 2012).

The last two outcomes were also better in the FSS group at a follow-up assessment conducted by the researchers three months after the conclusion of the study.

Given growing concern regarding the role that parental ADHD may play in moderating the effectiveness of treatments for children with ADHD (a topic that is thoroughly reviewed in the introduction section of this paper), these investigators went on to examine the impact of parental ADHD symptoms on the study’s outcomes.

Parental ADHD was determined by administering a self-report scale, the Conners’ Adult ADHD Rating Scale (CAARS) to 139 of the parent participants in the study.  Both dimensional and dichotomous ADHD variables were created but only the latter was used in the analysis because of the small size of the ADHD group (N = 23, or roughly 16% of the total).

Results showed that parental ADHD did not affect treatment outcome for either the experimental (FSS) or the control (CARE) condition at the end of the study period.  However, at the three month follow-up assessment, parental ADHD was associated with declines in treatment gains only in the FSS group, particularly in the quality of parent-teacher relationship and the child’s homework performance.  This finding surprised the investigators who hypothesized that ADHD parents in both groups would show declines in outcomes as compared to non-ADHD parents.

They concluded that the control condition may have provided ADHD parents with greater opportunities to develop strategies and to practice problem-solving skills on their own, whereas ADHD parents in the experimental condition might have become overly dependent on study clinicians to implement the parenting practices that were the focus of the intervention.

This study illustrates the importance of modifying parent-focused treatment interventions to the specific characteristics of the patient and family.  In particular, when parents of ADHD children also exhibit the symptoms of ADHD, it may be helpful to provide additional opportunities for them to develop strategies, cultivate resources, and practice parenting skills aimed at helping their ADHD children succeed at school.

CAARS = Conners’ Adult ADHD Rating Scale

CARE = Coping with ADHD through Relationships and Education

FSS = Family School Success Program

Power, T.J., Mautone, J.A., Soffer, S.L. Clarke, A.T., et al (2012). “A family-school intervention for children with ADHD: Results of a randomized clinical trial.” Journal of Clinical Child and Adolescent Psychology. 80: 611-623 DOI: 10.1037/a0028188.

ADHD CME for Primary Care Professionals

p p on July 15, 2016

This ADHD in Adults program is very exciting to us for a number of reasons.

First, it’s a groundbreaking campaign where we can educate all kinds of health professionals about the realities of ADHD, the treatment protocols we know that work, and the medications and other kinds of modalities that help make ADHD patients successful.

We’ve got the participation of the best clinicians and researchers in the country, who are taking part in educating healthcare professionals about this adult ADHD disorder. They’ll be bringing us the latest information and updates.

We’re also using the latest technologies that help you as practitioners learn about adult ADHD. You’ll benefit from videos, from group updates, from emails, and you’ll really be able to take this information into your practice so that you can best change your practice behaviors and help your ADHD patients.

We’re looking to build a leadership-base of physicians, nurses, nurse practitioners, physician assistants, who want to take out this new research and information about ADHD and bring it to their patients for the benefit not only of the patients, but the millions of people who are around them.

We have fertile ground now in the treatment of ADHD. We have the research that proves it exists, we have the medications and treatment modalities that are successful. All we need now is to get the information out there so that everyone can benefit.

Join us in our information and educational program at adhdinadults.com. We will be helping over ten million adults and, as I mentioned before, everyone who supports them. Thank you.

ADHD Coaching an Integral Component of Effective Comprehensive Treatment for Adults with ADHD

David Giwerc, MCAC, MCC on July 14, 2016

Research clearly indicates psychopharmacology’s prominent role as an ADHD intervention.

Even if the primary care physician is comfortable with treating an ADHD adult, the typical office visit does not allow sufficient time to address every issue that confronts the newly diagnosed adult ADHD patient. The patient may leave with an appropriate ADHD medication regimen, but many other critical problems related to the diagnosis may remain unaddressed.

Medications can significantly improve focus while reducing other symptoms of ADHD. However, ADHD medications alone cannot teach the patient how to compensate for life skills that were never learned due to the years of executive function impairment.

ADHD coaching builds a bridge between biology and behavior and narrows the gap between ability and performance. Patients and physicians are beginning to realize the importance of including an ADHD coach as part of the treatment team. Just as an athletic coach motivates an athlete, ADHD coaches are very adept at motivating their clients who have ADHD, while partnering with them to develop and practice newly learned personal, social, and professional skills. For some patients, these skills may not have been developed due to lack of ADHD education, proper diagnosis, and treatment.

The stigma surrounding ADHD as nothing more than an “unruly child syndrome,” coupled with the popularity of incorrectly self-diagnosing an ADHD impairment, means too many patients are conditioned not to speak up and not to seek support, especially in the workplace. Adult ADHD coaching clients have often stated that an ADHD coach was the first person to not only understand the frustration of their invisible challenges, but also to sincerely believe all of their ADHD stories.

Physicians can rarely provide the level of attention and encouragement an adult patient needs within the restrictions of the typical office visit. The coach, therefore, can reinforce their patients’ natural talents and successes. The PAAC* or ICF**-certified ADHD coach can create an environment that encourages open communication (necessary for behavioral changes to occur) and forms a foundation of unconditional acceptance. Coupled with science-based instruction about ADHD, the coach focuses on identifying the patient’s natural talents and successes and develops a plan to convert that into daily strengths.

ADHD coaches help the client develop coping strategies, a valuable adjunct to medication management. They are highly specialized professionals, well-versed in ADHD-specific coaching competencies. The coach provides psycho-educational support, improves self-awareness of how symptoms of ADHD, and helps translate that into improved short and long-term performance.

While coaching cannot replace stimulant medications or therapy as a treatment, a coach can provide customized strategies and education that work alongside medication. The ADHD coach may suggest lifestyle changes such as proper sleep, nutrition, physical activity, and breathing exercises. In addition, ADHD coaching is accessible, with most coaching being conducted via phone/Skype, eliminating the need for geographical proximity or disruption to the work day.

*PAAC: Professional Association of ADHD Coaches, (PAAC)

**ICF: International Coach Federation

 

Resources:

Lidia Zylowska, The Mindfulness Prescription for Adult ADHD (Boston, Trumpeter, 2012)

Thomas E. Brown, A New Understanding of ADHD in Children and Adults, Executive Function Impairments (New York, Rutledge, 2013)

David Giwerc, Permission to Proceed: The Keys to Creating a Life of Passion, Purpose and Possibility (Albany New York, ADD Coach Academy Press, 2011)

John Ratey, Spark Revolutionary New Science of Exercise & the Brain (New York, Little, Brown & Co. 2008)

African American Adults with ADHD – Cultural Barriers and Reduced Access to Care

Anthony L. Rostain, MD MA on March 24, 2016

Clin Psychiatry. 2015; 76(3):279-283.
“Cultural Background and Barriers to Mental Health Care for African American Adults”
Rostain, A.L., Ramsay, J.R., Waite, R.

This article delineates key patient and provider cultural biases that interfere with access to care for African American Adults with ADHD. It provides an important framework for understanding how these biases come about and what clinicians can do to address them. A brief review of the relationship between psychiatry and African Americans points out that beginning with slavery and continuing through the Tuskegee experiment, there is a legacy of racism in American medicine that influences the way patients view health care providers (and vice versa).

For instance, drapetomania was a clinical diagnosis given to slaves who demonstrated resistance to the institution by running away, refusing to follow rules, destroying property and fighting the plantation slave owners. In this fashion, psychiatry played an important role in supporting racism and racist beliefs. Similar analogies can be made to the ways that psychiatry classified homosexuality as a mental illness.

 

The point of this historical review is to underscore the longstanding mistrust that exists within the African American community toward medicine in general and psychiatry in particular. Add to this, the stigma associated with mental illness and substance abuse, it becomes easier to understand why many African American adults fail to seek treatment for disorders like ADHD.

The article goes on to discuss barriers to obtaining mental health treatment including patient factors (e.g. low income, lack of health insurance, fear and other negative attitudes) and health care system factors (e.g. limited access to culturally and technically competent providers and provider biases). Without question, higher rates of poverty and of lack of insurance among the minority population leads to markedly reduced access to care. The article points out that whereas rates of adequate mental health treatment among whites is 33%, the figure drops to 12% for African Americans. Moreover. white 
children are twice as likely to receive ADHD medication as African American children. Cultural biases among providers may lead them to be insufficiently attuned to the presence of ADHD in adult patients, ascribing the symptoms of ADHD, such as inattention, restlessness and disorganization either to personal failing (e.g. lack of self-discipline) or to environmental factors (e.g. low SES, lack of education) rather than to the influence of ADHD.

The paper concludes with practical recommendations for clinicians to address these barriers including providing accurate science based information, listening and being sensitive to stigmatizing experiences that African American patients may have encountered, and recognizing the deleterious effects of conscious and unconscious biases among well-meaning providers.

Risk of Suicide in ADHD

Stephen V. Faraone, PhD on March 18, 2016

Suicide is one of the most feared outcomes of any psychiatric condition. Although its association with depression is well known, a small but growing research literature shows that ADHD is also a risk factor for suicidality.

Suicide is difficult to study. Because it is relatively rare, large samples of patients are needed to make definitive statements. Studies of suicide and ADHD must also consider the possibility that medications might elevate that risk.

For example, the FDA placed a black box warning on atomoxetine because that ADHD medication had been shown to increase suicidal risk in youth. A recent study of 37,936 patients with ADHD now provides much insight into these issues (Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B. M., Lichtenstein, P. & Larsson, H. (2014). Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348, g3769.). In Sweden, such large studies are possible because researchers have computerized medical registers that describe the disorders and treatments of all people in Sweden. Among 37,936 patients with ADHD, 7019 suicide attempts or completed suicides occurred during 150,721 person years of follow-up. This indicates that, in any given year, the risk for a suicidal event is about 5%.

For ADHD patients, the risk for a suicide event is about 30% greater than for non-ADHD patients. Among the ADHD patients who attempted or completed suicide, the risk was increased for those who had also been diagnosed with a mood disorder, conduct disorder, substance abuse or borderline personality. This is not surprising; the most serious and complicated cases of ADHD are those that have the greatest risk for suicidal events.

The effects of medication were less clear. The risk for suicide events was greater for ADHD patients who had been treated with non-stimulant medication compared with those who had not been treated with non-stimulant medication. A similar comparison showed no effect of stimulant medications.

This first analysis suffers from the fact that the probability of receiving medication increases with the severity of the disorder. To address this problem, the researchers limited the analyses to ADHD patients who had had some medication treatment and then compared suicidal risk between periods of medication treatment and periods of no medication treatment. This analysis found no increased risk for suicide from non-stimulant medications and, more importantly, found that for patients treated with stimulants, the risk for suicide was lower when they were taking stimulant medications. This protective effect of stimulant medication provides further evidence of the long-term effects of stimulant medications which have also been shown to lower the risks for traffic accidents, criminality, smoking and other substance use disorders.

ADHD and Suicide

Stephen V. Faraone, PhD on March 17, 2016

Suicide is one of the most feared outcomes of any psychiatric condition.  Although its association with depression is well known, a small but growing research literature shows that ADHD is also a risk factor for suicidality.  

Suicide is difficult to study. Because it is relatively rare, large samples of patients are needed to make definitive statements.  Studies of suicide and ADHD must also consider the possibility that medications might elevate that risk. 

For example, the FDA placed a black box warning on atomoxetine because that ADHD medication had been shown to increase suicidal risk in youth.   A recent study of 37,936 patients with ADHD now provides much insight into these issues (Chen, Q., Sjolander, A., Runeson, B., D’Onofrio, B. M., Lichtenstein, P. & Larsson, H. (2014). Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ 348, g3769.).    In Sweden, such large studies are possible because researchers have computerized medical registers that describe the disorders and treatments of all people in Sweden.  Among 37,936 patients with ADHD, 7019 suicide attempts or completed suicides occurred during 150,721 person years of follow-up.  This indicates that, in any given year, the risk for a suicidal event is about 5%. 

For ADHD patients, the risk for a suicide event is about 30% greater than for non-ADHD patients.  Among the ADHD patients who attempted or completed suicide, the risk was increased for those who had also been diagnosed with a mood disorder, conduct disorder, substance abuse or borderline personality.  This is not surprising; the most serious and complicated cases of ADHD are those that have the greatest risk for suicidal events.  

The effects of medication were less clear.   The risk for suicide events was greater for ADHD patients who had been treated with non-stimulant medication compared with those who had not been treated with non-stimulant medication.  A similar comparison showed no effect of stimulant medications. 

This first analysis suffers from the fact that the probability of receiving medication increases with the severity of the disorder.  To address this problem, the researchers limited the analyses to ADHD patients who had had some medication treatment and then compared suicidal risk between periods of medication treatment and periods of no medication treatment.  This analysis found no increased risk for suicide from non-stimulant medications and, more importantly, found that for patients treated with stimulants, the risk for suicide was lower when they were taking stimulant medications.  This protective effect of stimulant medication provides further evidence of the long-term effects of stimulant medications which have also been shown to lower the risks for traffic accidents, criminality, smoking and other substance use disorders.

ADHD Medication and Parenting

Stephen V. Faraone, PhD on March 8, 2016

Raising children is not easy. I should know. As a clinical psychologist, I’ve helped parents learn the skills they need to be better parents. And my experience raising three children confirmed my clinical experience. Parenting is a tough job under the best of circumstances but it is even harder if the parent has ADHD. For example, an effective parent establishes rules and enforces them systematically. This requires attention to detail, self-control and good organizational skills. Given these requirements, it is easy to see how ADHD symptoms interfere with parenting. These observations have led some of my colleagues to test the theory that treating ADHD adults with medication would improve their parenting skills. I know about two studies that tested this idea. In 2008, Dr. Chronis-Toscano and colleagues published a study using a sustained release form of methylphenidate for mothers with ADHD. As expected, the medication decreased their symptoms of inattention and hyperactivity/impulsivity. The medication also reduced the mothers use of inconsistent discipline and corporal punishment and improved their monitoring and supervision of their children. In a 2014 study, Waxmonsky and colleagues observed ADHD adults and their children in a laboratory setting once when the adults were off medication and once when they were on medication. They used the same sustained release form of amphetamine for all the patients. As expected, the medications reduced ADHD symptoms in the parents. This laboratory study is especially informative because the researchers made objective ratings of parent-child interactions rather than relying on the parent’s report of those interactions. Twenty parents completed the study. The medication led to less negative talk and commands and more praise by parents. It also reduced negative and inappropriate behaviors in their children. Both studies suggest that treating ADHD adults with medication will improve their parenting skills. That is good news. But they also found that not all parenting behaviors improved. That makes sense. Parenting is a skill that must be learned. Because ADHD interferes with learning, parents with the disorder need time to learn these skills. Medication can eliminate some of the worst behaviors but doctors should also provide the adjunct behavioral or cognitive behavioral therapies that could help ADHD parents learn parenting skills and achieve their full potential as parents.
 

REFERENCES
Chronis-Tuscano, A., K. E. Seymour, et al. (2008). “Efficacy of osmotic-release oral system (OROS) methylphenidate for mothers with attention-deficit/hyperactivity disorder (ADHD): preliminary report of effects on ADHD symptoms and parenting.” J Clin Psychiatry 69(12): 1938-1947.
Waxmonsky, J. G., D. A. Waschbusch, et al. (2014). “Does pharmacological treatment of ADHD in adults enhance parenting performance? Results of a double-blind randomized trial.” CNS Drugs 28(7): 665-677.

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.