There is evidence to suggest that the broad discrepancy in the ratio of males to females with diagnosed ADHD is due, at least in part, to lack of recognition and/or referral bias in females. Studies ...suggest that females with ADHD present with differences in their profile of symptoms, comorbidity and associated functioning compared with males. This consensus aims to provide a better understanding of females with ADHD in order to improve recognition and referral. Comprehensive assessment and appropriate treatment is hoped to enhance longer-term clinical outcomes and patient wellbeing for females with ADHD.
The United Kingdom ADHD Partnership hosted a meeting of experts to discuss symptom presentation, triggers for referral, assessment, treatment and multi-agency liaison for females with ADHD across the lifespan.
A consensus was reached offering practical guidance to support medical and mental health practitioners working with females with ADHD. The potential challenges of working with this patient group were identified, as well as specific barriers that may hinder recognition. These included symptomatic differences, gender biases, comorbidities and the compensatory strategies that may mask or overshadow underlying symptoms of ADHD. Furthermore, we determined the broader needs of these patients and considered how multi-agency liaison may provide the support to meet them.
This practical approach based upon expert consensus will inform effective identification, treatment and support of girls and women with ADHD. It is important to move away from the prevalent perspective that ADHD is a behavioural disorder and attend to the more subtle and/or internalised presentation that is common in females. It is essential to adopt a lifespan model of care to support the complex transitions experienced by females that occur in parallel to change in clinical presentation and social circumstances. Treatment with pharmacological and psychological interventions is expected to have a positive impact leading to increased productivity, decreased resource utilization and most importantly, improved long-term outcomes for girls and women.
Emotional lability is recognized as an associated feature of attention-deficit/hyperactivity disorder (ADHD). However, the degree of phenotypic and etiologic overlap between emotional lability and ...the ADHD dimensions of hyperactivity-impulsivity and inattention remains unclear. The present study examines these associations in a large, community twin sample.
Structural equation models were fit to data from 1,920 child and adolescent twin pairs (age range, 5-18 years). Symptoms of hyperactivity-impulsivity (HI) and inattention (IA) were assessed using a modified version of the DuPaul rating scale, completed by parents. Symptoms of emotional lability (EL) were assessed using the parent-rated Conners 10-item scale.
There were moderate to strong phenotypic correlations between HI, IA, and EL. Multivariate twin modeling revealed that a common pathway model best accounted for the covariance among these dimensions, represented by a highly heritable latent factor. Ad hoc analyses confirmed that all additive genetic influences on HI, IA, and EL were shared, and identified a significantly stronger association of EL with the latent ADHD factor in older than in younger individuals.
Emotional lability was phenotypically and genetically associated with hyperactivity-impulsivity and inattention in children and adolescents. The finding that a single, heritable, latent factor accounted for covariation among these phenotypes indicates that their co-occurrence is primarily the result of overlapping genetic effects. These data support the hypothesis that emotional lability is etiologically relevant to the core ADHD phenotype, and that it should be targeted in assessment and treatment in clinical practice.
The ability of remote research tools to collect granular, high-frequency data on symptoms and digital biomarkers is an important strength because it circumvents many limitations of traditional ...clinical trials and improves the ability to capture clinically relevant data. This approach allows researchers to capture more robust baselines and derive novel phenotypes for improved precision in diagnosis and accuracy in outcomes. The process for developing these tools however is complex because data need to be collected at a frequency that is meaningful but not burdensome for the participant or patient. Furthermore, traditional techniques, which rely on fixed conditions to validate assessments, may be inappropriate for validating tools that are designed to capture data under flexible conditions. This paper discusses the process for determining whether a digital assessment is suitable for remote research and offers suggestions on how to validate these novel tools.
Abstract Background Adults with attention-deficit hyperactivity disorder (ADHD) frequently report emotional lability (EL). However, it is not known whether EL may be accounted for by comorbid ...psychiatric conditions or symptoms. This study evaluates the influence of comorbid clinical symptoms on EL, and investigates the relationship between EL and impairment. Methods Over 500 consecutive male adult referrals at the ADHD Clinic for adults at the South London and Maudsley Hospital (U.K) were screened. 41 individuals with ADHD without comorbidity, current medication or frequent substance were identified, and compared with 47 matched healthy male control participants. Measures included IQ, clinical interview and self-reported ADHD symptoms, EL, impairment and antisocial behaviour. Results ADHD participants reported elevated EL, showing good case-control differentiation in receiver operating curve analysis. EL was most strongly predicted by hyperactivity–impulsivity rather than subsyndromal comorbid symptoms, and contributed independently to impairment in daily life. Limitations Results may not generalise to children with ADHD, or many adults with ADHD, who are frequently affected by comorbid psychiatric conditions and substance use disorders. Conclusions EL in adults with ADHD appears to be primarily associated with ADHD itself rather than comorbid conditions, and helps to explain some of the impairments not accounted for by classical features of the disorder. Results indicate that adults presenting with long-term problems with EL should routinely be screened for the presence of ADHD.
Abstract
Background
ADHD in adults is a common and debilitating neurodevelopmental mental health condition. Yet, diagnosis, clinical management and monitoring are frequently constrained by scarce ...resources, low capacity in specialist services and limited awareness or training in both primary and secondary care. As a result, many people with ADHD experience serious barriers in accessing the care they need.
Methods
Professionals across primary, secondary, and tertiary care met to discuss adult ADHD clinical care in the United Kingdom. Discussions identified constraints in service provision, and service delivery models with potential to improve healthcare access and delivery. The group aimed to provide a roadmap for improving access to ADHD treatment, identifying avenues for improving provision under current constraints, and innovating provision in the longer-term. National Institute for Health and Care Excellence (NICE) guidelines were used as a benchmark in discussions.
Results
The group identified three interrelated constraints. First, inconsistent interpretation of what constitutes a ‘specialist’ in the context of delivering ADHD care. Second, restriction of service delivery to limited capacity secondary or tertiary care services. Third, financial limitations or conflicts which reduce capacity and render transfer of care between healthcare sectors difficult. The group recommended the development of ADHD specialism within primary care, along with the transfer of routine and straightforward treatment monitoring to primary care services. Longer term, ADHD care pathways should be brought into line with those for other common mental health disorders, including treatment initiation by appropriately qualified clinicians in primary care, and referral to secondary mental health or tertiary services for more complex cases. Long-term plans in the NHS for more joined up and flexible provision, using a primary care network approach, could invest in developing shared ADHD specialist resources.
Conclusions
The relegation of adult ADHD diagnosis, treatment and monitoring to specialist tertiary and secondary services is at odds with its high prevalence and chronic course. To enable the cost-effective and at-scale access to ADHD treatment that is needed, general adult mental health and primary care must be empowered to play a key role in the delivery of quality services for adults with ADHD.
Despite evidence-based national guidelines for ADHD in the United Kingdom (UK), ADHD is under-identified, under-diagnosed, and under-treated. Many seeking help for ADHD face prejudice, long waiting ...lists, and patchy or unavailable services, and are turning to service-user support groups and/or private healthcare for help.
A group of UK experts representing clinical and healthcare providers from public and private healthcare, academia, ADHD patient groups, educational, and occupational specialists, met to discuss shortfalls in ADHD service provision in the UK. Discussions explored causes of under-diagnosis, examined biases operating across referral, diagnosis and treatment, together with recommendations for resolving these matters.
Cultural and structural barriers operate at all levels of the healthcare system, resulting in a de-prioritization of ADHD. Services for ADHD are insufficient in many regions, and problems with service provision have intensified as a result of the response to the COVID-19 pandemic. Research has established a range of adverse outcomes of untreated ADHD, and associated long-term personal, social, health and economic costs are high. The consensus group called for training of professionals who come into contact with people with ADHD, increased funding, commissioning and monitoring to improve service provision, and streamlined communication between health services to support better outcomes for people with ADHD.
Evidence-based national clinical guidelines for ADHD are not being met. People with ADHD should have access to healthcare free from discrimination, and in line with their legal rights. UK Governments and clinical and regulatory bodies must act urgently on this important public health issue.
IntroductionNeurodegenerative and psychiatric disorders (NPDs) confer a huge health burden, which is set to increase as populations age. New, remotely delivered diagnostic assessments that can detect ...early stage NPDs by profiling speech could enable earlier intervention and fewer missed diagnoses. The feasibility of collecting speech data remotely in those with NPDs should be established.Methods and analysisThe present study will assess the feasibility of obtaining speech data, collected remotely using a smartphone app, from individuals across three NPD cohorts: neurodegenerative cognitive diseases (n=50), other neurodegenerative diseases (n=50) and affective disorders (n=50), in addition to matched controls (n=75). Participants will complete audio-recorded speech tasks and both general and cohort-specific symptom scales. The battery of speech tasks will serve several purposes, such as measuring various elements of executive control (eg, attention and short-term memory), as well as measures of voice quality. Participants will then remotely self-administer speech tasks and follow-up symptom scales over a 4-week period. The primary objective is to assess the feasibility of remote collection of continuous narrative speech across a wide range of NPDs using self-administered speech tasks. Additionally, the study evaluates if acoustic and linguistic patterns can predict diagnostic group, as measured by the sensitivity, specificity, Cohen’s kappa and area under the receiver operating characteristic curve of the binary classifiers distinguishing each diagnostic group from each other. Acoustic features analysed include mel-frequency cepstrum coefficients, formant frequencies, intensity and loudness, whereas text-based features such as number of words, noun and pronoun rate and idea density will also be used.Ethics and disseminationThe study received ethical approval from the Health Research Authority and Health and Care Research Wales (REC reference: 21/PR/0070). Results will be disseminated through open access publication in academic journals, relevant conferences and other publicly accessible channels. Results will be made available to participants on request.Trial registration numberNCT04939818.
Background
Story recall is a simple and sensitive cognitive test that is commonly used to measure changes in episodic memory function in early Alzheimer disease (AD). Recent advances in digital ...technology and natural language processing methods make this test a candidate for automated administration and scoring. Multiple parallel test stimuli are required for higher-frequency disease monitoring.
Objective
This study aims to develop and validate a remote and fully automated story recall task, suitable for longitudinal assessment, in a population of older adults with and without mild cognitive impairment (MCI) or mild AD.
Methods
The “Amyloid Prediction in Early Stage Alzheimer’s disease” (AMYPRED) studies recruited participants in the United Kingdom (AMYPRED-UK: NCT04828122) and the United States (AMYPRED-US: NCT04928976). Participants were asked to complete optional daily self-administered assessments remotely on their smart devices over 7 to 8 days. Assessments included immediate and delayed recall of 3 stories from the Automatic Story Recall Task (ASRT), a test with multiple parallel stimuli (18 short stories and 18 long stories) balanced for key linguistic and discourse metrics. Verbal responses were recorded and securely transferred from participants’ personal devices and automatically transcribed and scored using text similarity metrics between the source text and retelling to derive a generalized match score. Group differences in adherence and task performance were examined using logistic and linear mixed models, respectively. Correlational analysis examined parallel-forms reliability of ASRTs and convergent validity with cognitive tests (Logical Memory Test and Preclinical Alzheimer’s Cognitive Composite with semantic processing). Acceptability and usability data were obtained using a remotely administered questionnaire.
Results
Of the 200 participants recruited in the AMYPRED studies, 151 (75.5%)—78 cognitively unimpaired (CU) and 73 MCI or mild AD—engaged in optional remote assessments. Adherence to daily assessment was moderate and did not decline over time but was higher in CU participants (ASRTs were completed each day by 73/106, 68.9% participants with MCI or mild AD and 78/94, 83% CU participants). Participants reported favorable task usability: infrequent technical problems, easy use of the app, and a broad interest in the tasks. Task performance improved modestly across the week and was better for immediate recall. The generalized match scores were lower in participants with MCI or mild AD (Cohen d=1.54). Parallel-forms reliability of ASRT stories was moderate to strong for immediate recall (mean rho 0.73, range 0.56-0.88) and delayed recall (mean rho=0.73, range=0.54-0.86). The ASRTs showed moderate convergent validity with established cognitive tests.
Conclusions
The unsupervised, self-administered ASRT task is sensitive to cognitive impairments in MCI and mild AD. The task showed good usability, high parallel-forms reliability, and high convergent validity with established cognitive tests. Remote, low-cost, low-burden, and automatically scored speech assessments could support diagnostic screening, health care, and treatment monitoring.
Introduction
Biomarkers of mental effort may help to identify subtle cognitive impairments in the absence of task performance deficits. Here, we aim to detect mental effort on a verbal task, using ...automated voice analysis and machine learning.
Methods
Audio data from the digit span backwards task were recorded and scored with automated speech recognition using the online platform NeuroVocalix
TM
, yielding usable data from 2,764 healthy adults (1,022 male, 1,742 female; mean age 31.4 years). Acoustic features were aggregated across each trial and normalized within each subject. Cognitive load was dichotomized for each trial by categorizing trials at >0.6 of each participants' maximum span as “high load.” Data were divided into training (60%), test (20%), and validate (20%) datasets, each containing different participants. Training and test data were used in model building and hyper-parameter tuning. Five classification models (Logistic Regression, Naive Bayes, Support Vector Machine, Random Forest, and Gradient Boosting) were trained to predict cognitive load (“high” vs. “low”) based on acoustic features. Analyses were limited to correct responses. The model was evaluated using the validation dataset, across all span lengths and within the subset of trials with a four-digit span. Classifier discriminant power was examined with Receiver Operating Curve (ROC) analysis.
Results
Participants reached a mean span of 6.34 out of 8 items (SD = 1.38). The Gradient Boosting classifier provided the best performing model on test data (AUC = 0.98) and showed excellent discriminant power for cognitive load on the validation dataset, across all span lengths (AUC = 0.99), and for four-digit only utterances (AUC = 0.95).
Discussion
A sensitive biomarker of mental effort can be derived from vocal acoustic features in remotely administered verbal cognitive tests. The use-case of this biomarker for improving sensitivity of cognitive tests to subtle pathology now needs to be examined.
Anxiety and depression are associated with a range of impairments in cognitive functioning. Understanding the nature of these deficits may identify targets for intervention and prevent functional ...decline. We used observational and genetic methods to investigate the relationship of anxiety and depression with three cognitive domains: emotion recognition, response inhibition, and working memory, in the Avon Longitudinal Study of Parents and Children (ALSPAC). We examined: (i) cross-sectional associations between anxiety, depression, and cognition at age 24 (
= 2187), (ii) prospective associations between anxiety and depression at age 18 and cognition at age 24 (
= 1855), and (iii) the casual effect of anxiety and depression on cognition using Mendelian randomization (MR). Both disorders were associated with altered emotion recognition; anxiety with decreased happiness recognition (
0.27 -0.54,0.01,
= 0.045), and depression with increased sadness recognition (
0.35 0.07,0.64,
= 0.016). Anxiety was also associated with poorer working memory (
0.14 -0.24,0.04,
= 0.005). There was no evidence for an association with response inhibition. MR provided no clear evidence of causal relationships between mental health and cognition, but these analyses were underpowered. Overall, there was little evidence for impairments in executive functioning, but moderate alterations in emotion recognition. This may inform the development of psychosocial interventions.
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