Adult Attention Deficit/Hyperactivity Disorder (ADHD) is prone to misdiagnosis because its symptoms are subjective, share features with a broad range of mental, behavioral and physical disorders, and ...express themselves heterogeneously. Furthermore, Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for adult ADHD diagnosis remain underdeveloped, prompting a need for systematic and empirically-informed guidelines.
This article presents a brief history of research on adult ADHD and reviews common sources of false positive and false negative diagnoses. A systematic, stepped diagnostic procedure is described that adheres to DSM guidelines and integrates the latest science on adult ADHD assessment and diagnosis.
Seven steps are recommended: a structured diagnostic interview with the patient, collection of informant ratings, casting a wide net on symptoms using "or rule" to integrate informant reports, providing checks and balances on the "or rule" by enforcing the impairment criterion, chronicling a symptom timeline, ruling out alternative explanations for symptoms, and finalizing the diagnosis.
Based on the extant research, it is expected that the stepped diagnostic procedure will increase detection of malingering, improve diagnostic accuracy, and detect non-ADHD cases with subclinical difficulties or non-ADHD pathologies.
Several studies have questioned the stability of attention-deficit hyperactivity disorder (ADHD) from childhood to adulthood. This systematic review illustrates how variability in diagnostic methods ...influences adult ADHD persistence estimates. Systematic database searches identified studies reporting adult ADHD persistence rates that were published in English between Jan 1, 1992, and May 31, 2016. Study inclusion criteria were systematic childhood diagnosis of attention-deficit disorder, ADHD, or a research diagnostic protocol that matched DSM-III, DSM-III-R, or DSM-IV standards; mean childhood age of younger than 12·0 years with no participants older than 18·0 years; and mean adult age of 18·0 years or older with no participants younger than 17·0 years. Across 12 included samples, we identified 41 estimates of ADHD persistence, which ranged from 4·0% to 77·0%. Methods of diagnosing ADHD in adulthood varied widely with respect to source of information, diagnostic instruments (eg, rating scales, interviews), diagnostic symptom threshold, and whether impairment was required for diagnosis. Sole reliance on self reports and a strict threshold of six DSM symptoms led to very low persistence estimates. To minimise false-negative and false-positive classifications, recommended methods for determining adult persistence of ADHD include collecting self and informant ratings, requiring the presence of impairment, and using an age-appropriate symptom threshold. Very few persistence estimates utilised these methods, but those that did indicated persistence rates of 40-50%.
The transition from Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) to Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) attention ...deficit/hyperactivity disorder (ADHD) checklists included item wording changes that require psychometric validation. A large sample of 854 adolescents across four randomized trials of psychosocial ADHD treatments was used to evaluate the comparability of the DSM-IV-TR and DSM-5 versions of the ADHD symptom checklist. Item response theory (IRT) was used to evaluate item characteristics and determine differences across versions and studies. Item characteristics varied across items. No consistent differences in item characteristics were found across versions. Some differences emerged between studies. IRT models were used to create continuous, harmonized scores that take item, study, and version differences into account and are therefore comparable. DSM-IV-TR ADHD checklists will generalize to the DSM-5 era. Researchers should consider using modern measurement methods (such as IRT) to better understand items and create continuous variables that better reflect the variability in their samples.
ADHD symptom severity appears to be exacerbated during the COVID-19 pandemic. The present study surveyed top problems experienced by adolescents and young adults (A/YAs) with ADHD during the COVID-19 ...pandemic to identify possible reasons for symptom escalation and potential targets for intervention. We also explored perceived benefits of the pandemic for A/YAs with ADHD.
At the outbreak of the COVID-19 pandemic (April–June 2020), we administered self and parent ratings about current and pre-pandemic top problem severity and benefits of the pandemic to a sample of convenience (N = 134 A/YAs with ADHD participating in a prospective longitudinal study).
The most common top problems reported in the sample were social isolation (parent-report: 26.7%; self-report: 41.5%), difficulties engaging in online learning (parent-report: 23.3%, self-report: 20.3%), motivation problems (parent-report: 27.9%), and boredom (self-report: 21.3%). According to parent (d = 0.98) and self-report (d = 1.33), these top problems were more severe during the pandemic than in prior months. Contrary to previous speculation, there was no evidence that pandemic-related changes mitigated ADHD severity. Multi-level models indicated that A/YAs with higher IQs experienced severer top problems exacerbations at the transition to the COVID-19 pandemic.
For A/YAs with ADHD, several risk factors for depression and school dropout were incurred during the early months of the COVID-19 pandemic. A/YAs with ADHD should be monitored for school disengagement and depressive symptoms during the COVID-19 pandemic. Recommended interventions attend to reducing risk factors such as increasing social interaction, academic motivation, and behavioral activation among A/YAs with ADHD.
It is estimated that childhood attention deficit hyperactivity disorder (ADHD) remits by adulthood in approximately 50% of cases; however, this conclusion is typically based on single endpoints, ...failing to consider longitudinal patterns of ADHD expression. The authors investigated the extent to which children with ADHD experience recovery and variable patterns of remission by adulthood.
Children with ADHD (N=558) in the Multimodal Treatment Study of ADHD (MTA) underwent eight assessments over follow-ups ranging from 2 years (mean age, 10.44 years) to 16 years (mean age, 25.12 years) after baseline. The authors identified participants with fully remitted, partially remitted, and persistent ADHD at each time point on the basis of parent, teacher, and self-reports of ADHD symptoms and impairment, treatment utilization, and substance use and mental disorders. Longitudinal patterns of remission and persistence were identified that considered context and timing.
Approximately 30% of children with ADHD experienced full remission at some point during the follow-up period; however, a majority of them (60%) experienced recurrence of ADHD after the initial period of remission. Only 9.1% of the sample demonstrated recovery (sustained remission) by study endpoint, and only 10.8% demonstrated stable ADHD persistence across study time points. Most participants with ADHD (63.8%) had fluctuating periods of remission and recurrence over time.
The MTA findings challenge the notion that approximately 50% of children with ADHD outgrow the disorder by adulthood. Most cases demonstrated fluctuating symptoms between childhood and young adulthood. Although intermittent periods of remission can be expected in most cases, 90% of children with ADHD in MTA continued to experience residual symptoms into young adulthood.
The Attention Deficit Hyperactivity Disorder (ADHD) Teen Integrative Data Analysis Longitudinal (TIDAL) dataset integrates data from four randomized trials.
Participants with ADHD (N = 854; 72.5% ...male, 92.5% racial/ethnic minority, ages 10-17) were assessed three times across 12 months. Data includes parent, self, and teacher ratings, observations, and school records. The battery was harmonized using an Integrative Data Analysis (IDA) approach to form variables that assign unique values to all participants.
The data will be used to investigate: (1) profiles that organize the heterogeneous population into clinically meaningful subgroups, (2) whether these profiles predict treatment response, (3) heterogeneity in treatment response and variables that predict this response, (4) how treatment characteristics and adjunctive supports predict treatment response, and (5) mediators of treatment and whether these mechanisms are moderated by treatment characteristics.
The ADHD TIDAL Dataset will be openly shared with the field to maximize its utility.
The goal of this study was to evaluate the comparative efficacy of 2 clinic-based psychosocial treatment modalities for adolescent attention deficit/hyperactivity disorder (ADHD) and identify ...characteristics that facilitate patient-modality matching. Culturally diverse adolescents with ADHD (N = 123) were randomized to 1 of 2 versions of a parent-teen psychosocial treatment for ADHD (Supporting Teens' Autonomy Daily STAND): (a) group parent and adolescent skills training or (b) dyadic skills training blended with motivational interviewing. Participants were assessed at baseline, posttreatment, and 6-month follow-up on ADHD symptom severity and functional treatment targets. Differences in therapy process and cost were documented. Modality differences in outcome were examined using linear mixed and general linear models. Each modality successfully engaged the proposed therapy processes. Dyadic and group STAND produced equivalent overall outcomes. However, the dyadic modality demonstrated superior efficacy when parents had elevated ADHD or depression symptoms or high conflict with the teen. Families with lower parent education level and higher parental depression showed lower overall attendance; married parents were more likely to attend dyadic STAND (vs. group). Naturalistic stimulant medication did not influence treatment outcome. At less than one third of the cost of dyadic treatment, group models may be an economical option for treating parents and adolescents with ADHD. Screening adolescents with ADHD for parental psychopathology and parent-teen conflict may allow clinics to match higher risk patients to more personalized approaches that can enhance efficacy.
•Family impairment reported during ADHD assessments may be due to other sources.•High stress and low ADHD severity were related to greater family impairment on IRS.•Clinicians should consider using ...ADHD specific family impairment items.
The DSM-5 requires clinicians to link ADHD symptoms to clinically meaningful impairments in daily life functioning. Measuring impairment during ADHD assessments may be particularly challenging in adolescence, when ADHD is often not the sole source of a youth's difficulties. Existing impairment rating scales are criticized for not specifying ADHD as the source of impairment in their instructions, leading to potential problems with rating scale specificity. The current study utilized a within subjects design (N = 107) to compare parent report of impairment on two versions of a global impairment measure: one that specified ADHD as the source of impairment (Impairment Rating Scale–ADHD) and a standard version that did not (Impairment Rating Scale). On the standard family impairment item, parents endorsed greater impairment as compared to the IRS–ADHD. This finding was particularly pronounced when parents reported high levels of parenting stress. More severe ADHD symptoms were associated with greater concordance between the two versions. Findings indicate that adolescent family related impairments reported during ADHD assessments may be due to sources other than ADHD symptoms, such as developmental maladjustment. To prevent false positive diagnoses, symptom-specific wording may optimize impairment measures when assessing family functioning in diagnostic assessments for adolescents with ADHD.
Pioneering longitudinal studies of boys with hyperactivity by Satterfield et al.
indicated that one of the most deleterious outcomes associated with attention-deficit/hyperactivity disorder (ADHD) is ...later antisocial behaviors. This risk grows when ADHD is accompanied by severe behavior problems.
Though most children with ADHD will not go on to engage in criminal behavior, dimensional measures of externalizing behavior problems as well as categorical diagnoses of oppositional defiant disorder and conduct disorder have strong associations with ADHD. Moreover, cross-sectional studies of incarcerated adults indicate that 20% to 30% meet diagnostic criteria for ADHD.
These associations between childhood ADHD, oppositional defiant disorder, and conduct disorder and later criminal behavior beg the question of whether treatment of ADHD can reduce the severity of, or in some cases prevent, criminal behavior.
Practice parameters recommend medication as first-line treatment for adolescent attention-deficit/hyperactivity disorder (ADHD), with psychosocial treatment encouraged as needed.1,2 Despite the ...efficacy of both approaches, adolescents with ADHD access far fewer services than children in their communities.3-5 Medication is the cornerstone childhood ADHD treatment; however, adolescents often discontinue ADHD medication because of perceiving adverse effects, stigma, and ineffectiveness,6,7 Adolescents with ADHD appear to be willing to engage in psychosocial treatments.8,9 However, evidence-based practices (EBPs) are costlier and more burdensome to implement than medication and usual-care (UC) psychological services10,11; as a result, they are offered in few community clinics.12 To bridge this gap, research should adapt and refine adolescent ADHD EBPs to fit the constraints of community contexts, evaluating their implementation and effectiveness. In this trial, we use a Hybrid Type 1 implementation-effectiveness design13 to evaluate an EBP for adolescent ADHD (Supporting Teens’ Autonomy Daily STAND)14-16 compared to UC at 4 community clinics. Implementation outcomes have previously been reported.17
PDF
