Clarifying Relations Between ADHD and Functional Impairment in Adulthood: Utilization of Network and Machine Learning Approaches.

Using network analysis and random forest regression, this study identified attention-deficit/hyperactivity disorder (ADHD) symptoms most important for indicating impairment in various functional domains. Participants comprised a nationally representative sample of 1249 adults in the United States. Bridge symptoms were identified as those demonstrating unique relations with impairment domains that, in total, were stronger than those involving other symptoms. Results suggested three inattentive (i.e., difficulty organizing; does not follow through; makes careless mistakes) and one hyperactive (difficulty engaging in leisure activities) bridge symptoms. Random forest regression results supported bridge symptoms as most important (compared to other symptoms) for predicting global and specific impairment domains. Hyperactive/impulsive symptoms appeared more strongly related to impairment in women, whereas difficulty organizing and easily distracted appeared more related to impairment in men. Clarification of bridge symptoms may help identify core characteristics of ADHD in adulthood and specify screening and intervention targets to reduce risk for related impairment.

Report of a Work Group on Sluggish Cognitive Tempo: Key Research Directions and a Consensus Change in Terminology to Cognitive Disengagement Syndrome.

OBJECTIVE: The aim of this work was 2-fold: (1) to evaluate current knowledge and identify key directions in the study of sluggish cognitive tempo (SCT); and (2) to arrive at a consensus change in terminology for the construct that reflects the current science and may be more acceptable to researchers, clinicians, caregivers, and patients. METHOD: An international Work Group was convened that, in early 2021, compiled an online archive of all research studies on SCT and summarized the current state of knowledge, noted methodological issues, and highlighted future directions, and met virtually on 10 occasions in 2021 to discuss these topics and terminology. RESULTS: Major progress has been made over the last decade in advancing our understanding of SCT across the following domains of inquiry: construct measurement and stability; genetic, environmental, pathophysiologic, and neuropsychological correlates; comorbid conditions; functional impairments; and psychosocial and medication interventions. Findings across these domains are summarized, and potential avenues to pursue in the next generation of SCT-related research are proposed. Following repeated discussions on terminology, the Work Group selected "cognitive disengagement syndrome" (CDS) to replace "SCT" as the name for this construct. This term was deemed to best satisfy considerations that should apply when selecting terms for a condition or syndrome, as it does not overlap with established terms for other constructs, is not offensive, and reflects the current state of the science. CONCLUSION: It is evident that CDS (SCT) has reached the threshold of recognition as a distinct syndrome. Much work remains to further clarify its nature (eg, transdiagnostic factor, separate disorder, diagnostic specifier), etiologies, demographic factors, relations to other psychopathologies, and linkages to specific domains of functional impairment. Investigators are needed with interests and expertise spanning basic, clinical, and translational research to advance our understanding and to improve the lives of individuals with this unique syndrome.

Review: Adult Outcome as Seen Through Controlled Prospective Follow-up Studies of Children With Attention-Deficit/Hyperactivity Disorder Followed Into Adulthood.

OBJECTIVE: To describe adult outcome of people with attention-deficit/hyperactivity disorder (ADHD) diagnosed in childhood and its several key predictors via a review of 7 North American controlled prospective follow-up studies: Montreal, New York, Milwaukee, Pittsburgh, Massachusetts General Hospital (MGH), Berkeley, and 7-site Multimodal Treatment Study of Children With ADHD (MTA). METHOD: All studies were prospective and followed children with a diagnosis of ADHD and an age- and gender-matched control group at regular intervals from childhood (6-12 years of age) through adolescence into adulthood (20-40 years of age), evaluating symptom and syndrome persistence, functional outcomes, and predictors of these outcomes. RESULTS: The rates of ADHD syndrome persistence ranged from 5.7% to 77%, likely owing to varying diagnostic criteria and the source of information (self-report vs informant report) across the studies. However, all studies observed high rates of symptomatic persistence ranging from 60% to 86%. The 7 studies were largely consistent in finding that relative to control groups, research participants with childhood-diagnosed ADHD had significant impairments in the areas of educational functioning, occupational functioning, mental health, and physical health as well as higher rates of substance misuse, antisocial behavior, and unsafe driving. The most consistently observed predictors of functional outcomes included ADHD persistence and comorbidity, especially with disruptive behavior disorders. CONCLUSION: Childhood ADHD has high rates of symptomatic persistence, which is associated with negative functional outcomes. Characteristics that predict these negative outcomes, such as comorbid disruptive behavior disorders, may be important targets for intervention.

Field of daydreams? Integrating mind wandering in the study of sluggish cognitive tempo and ADHD.

In this editorial perspective, we consider the potential conceptual and empirical overlap between the research on mind wandering, particularly in its pathological extreme, and that on sluggish cognitive tempo (SCT) as it has diverged from research on attention-deficit/hyperactivity disorder. The more advanced state of research findings on the nature and correlates of mind wandering relative to that of SCT is used to suggest a variety of avenues of investigation into SCT, such as its phenomenology, positive and negative correlates, research methods, theory building, and potential to inform interventions. These and other avenues drawn from the field of mind wandering are likely to prove fruitful in further revealing the nature of SCT and its relationship to mind wandering.

Clarifying ADHD and Sluggish Cognitive Tempo Item Relations with Impairment: A Network Analysis.

Despite the pervasive nature of various forms of impairment associated with attention-deficit/hyperactivity disorder (ADHD), the precise nature of their associations with ADHD and related sluggish cognitive tempo (SCT), particularly at the heterogeneous item level, remains ambiguous. Using innovative network analysis techniques, we sought to identify and examine the concurrent validity of ADHD and SCT bridge items (i.e., those demonstrating the most robust relations with various forms of impairment) with respect to Overall, Home-School, and Community-Leisure impairment domains. Parents of a nationally representative sample of 1742 children (50.17% male) aged 6-17 years completed rating scales of ADHD, SCT, and impairment. Assessment of Bridge Expected Influence suggested eight bridge items primarily from impulsive and Task Completion (i.e., overlapping SCT and inattentive) domains that demonstrated relations with impairment in school performance, completing chores at home, interacting with family members, following rules, and playing sports. Sum scores only including bridge items exhibited relations with Overall, Home-School, and Community-Leisure impairment domains comparable to that of sum scores including all items. Bridge impairment areas were generally consistent across "Childhood" (6-11 years) and "Adolescence" (12-17 years). Problems listening and slowness emerged as bridge items in Childhood, whereas difficulties following through on instructions, problems waiting one's turn, and social withdrawal emerged in Adolescence. Given the comparable validity of ADHD- and SCT-related bridge items versus all items, bridge items, together, may be the most efficient indicators of impairment. Further clarification is needed across development to inform personalized assessment and intervention protocols that account for item-level heterogeneity in ADHD, SCT, and impairment phenotypes.

Dutch translation and adaptation of the Barkley Deficits in Executive Functioning Scale (BDEFS)

Abstract Background Based on his model of self-regulation and executive functions, Barkley developed a self- and other-report questionnaire (the Barkley Deficits in Executive Functioning Scale - BDEFS). The BDEFS measures deficits in executive functions as expressed in daily life activities like self-management of time, self-organization, self-restraint, self-motivation, and self-regulation of emotion. Objectives This study created and analyzed a Dutch translation and adaptation in conformance with official guidelines. Methods The Dutch and English BDEFS were completed by 25 bilingual Dutch adults to evaluate semantic correspondence. Consequently, 60 Dutch participants completed the Dutch BDEFS, Barratt Impulsiveness Scale-Eleventh edition (BIS-11) and the Dysexecutive Questionnaire (DEX) to evaluate concurrent validity and internal consistency. Results The versions demonstrated sufficient semantic equivalence and Spearman's rho of total scores was high; items mostly showed moderate-to-high correlations. Regression analysis showed no proportional bias. Internal consistency was also high. Correlations between BDEFS, BIS-11 and DEX supported concurrent validity. Discussion We conclude that a successful BDEFS translation and adaptation was created with satisfactory reliability and validity. Further research should assess the utility of the BDEFS in Dutch clinical practice.

ADHD risk genes involved in dopamine signaling and metabolism are associated with reduced estimated life expectancy at young adult follow-up in hyperactive and control children.

ADHD is associated with an elevated risk of mortality and reduced estimated life expectancy (ELE) by adulthood. Reduced life expectancy is substantially related to the trait of behavioral disinhibition; a correlate of both ADHD and of several dopamine genes related to dopamine signaling and metabolism. We therefore hypothesized that several ADHD risk genes related to dopamine might also be predictive of reduced ELE. Using a longitudinal study of 131 hyperactive children and 71 control cases followed to young adulthood, we examined whether several polymorphisms involving DRD4, DAT1, and DBH were related to ELE. The homozygous 9/9 allele of DAT1 and the heterozygous allele of DBH TaqI were associated with 5- and 2-year reductions, respectively, in total ELE. They did not operate on ELE through any relationships to ADHD specifically or behavioral disinhibition more generally. Instead, they showed links to alcohol use (DBH), reduced education, smoking, and reduced exercise (DAT1) employed in the computation of ELE. We conclude that polymorphisms of two dopamine genes are linked to reductions in ELE independently of their association with ADHD.

Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors.

OBJECTIVE: We examined if ADHD Combined Type or Presentation (ADHD-C) reduced estimated life expectancy (ELE) at young adulthood and if the persistence of ADHD to adulthood further adversely affected ELE. METHOD: A young adult follow-up of 131 hyperactive and 71 control cases was used to derive 14 variables that were entered into a life expectancy calculator to generate ELE scores. Both ratings of executive function (EF) in everyday life and tests of EF and IQ were measured along with comorbid psychopathologies. RESULTS: Childhood ADHD-C was associated with a 9.5-year reduction in healthy ELE, and a 8.4-year reduction in total ELE relative to control children by adulthood. The persistence of ADHD to adulthood was linked to a 12.7-year reduction in ELE. Several background traits accounted for more than 39% of variation in ELE. CONCLUSION: Childhood ADHD-C predicts a significantly reduced ELE by adulthood, which is further reduced by the persistence of ADHD to adult follow-up.

Time Reproduction Deficits at Young Adult Follow-Up in Childhood ADHD: The Role of Persistence of Disorder and Executive Functioning.

No studies have examined if time reproduction deficits exist in children with attention deficit hyperactivity disorder (ADHD) by adulthood. We followed 131 ADHD and 71 community control (CC) cases for 20+ years to young adulthood at which time they were given a time reproduction task. The ADHD group made smaller time reproductions and showed greater variability of errors at the longer durations compared to CC cases, whether ADHD was still present or not at follow-up. Nonverbal working memory and design fluency tests were related to timing errors while anxiety and depression were not. Childhood ADHD is associated with timing deficits at adult follow-up.

Early Morning Functional Impairments in Stimulant-Treated Children with Attention-Deficit/Hyperactivity Disorder Versus Controls: Impact on the Family.

OBJECTIVE: Children with attention-deficit/hyperactivity disorder (ADHD) frequently manifest early morning functional (EMF) impairments before school. We conducted a quantitative research survey to assess the impact of these EMF impairments on the family unit (caregiver, spouse/partner, and siblings). STUDY DESIGN: We developed an online survey questionnaire to collect data from 300 primary caregivers of children with ADHD and 50 primary caregivers of children who did not have ADHD. RESULTS: Although the ADHD children we surveyed were currently treated with stable doses of stimulants as their primary ADHD medication for at least 3 months, their parents reported high levels of EMF impairments in the child, which had a substantial negative effect on the emotional well-being of parents, on parents' functioning during the early morning routine, and on the level of conflict with siblings. The impact of EMF impairments on family functioning was mediated by the severity of the index child's impairments. CONCLUSIONS: EMF impairments exert a pervasive and significantly negative emotional and functional burden on not only the primary caregiver but also on the spouse/partner and siblings. This work suggests that adequate ADHD symptom control during the early morning period may be an unmet need for school-age children with ADHD being treated with stimulants. More work is needed to confirm this finding and determine the degree to which symptom control at other times of day is also an unmet need.

Recent longitudinal studies of childhood attention-deficit/hyperactivity disorder: Important themes and questions for further research.

What we can see from the studies included here are that most cases of attention-deficit/hyperactivity disorder (ADHD) persist from the preschool years into elementary school and on into adolescence, although trajectories vary considerably across individuals. Several studies here identified a small set of unique developmental trajectories for the symptoms of ADHD. All in all, the longitudinal studies of ADHD included here have greatly advanced our understanding of the developmental course and outcomes associated with childhood ADHD.

Commentary: One way attention-deficit/hyperactivity disorder can be life threatening? A travelogue on Nikolas et al. (2016).

I provide a brief commentary on the brilliant accompanying study of Nikolas et al. concerning risky bicyclist-automobile behavior in ADHD and typical youth. The sophistication of the simulator and procedures and the number and precision of measurements are remarkable and afford us an excellent glimpse into the specific mechanisms by which previously documented injury risk in such natural settings may be increased by ADHD in youth. I also briefly note clinically important implications of these and other research results on accident risk in ADHD.

The second attention disorder? Sluggish cognitive tempo vs. attention-deficit/hyperactivity disorder: update for clinicians.

Sluggish cognitive tempo (SCT) refers to an impairment of attention in hypoactive-appearing individuals that first presents in childhood. At this time, it exists only as a research entity that has yet to debut in official diagnostic taxonomies. However, it seems likely that a constellation of characteristic features of SCT may form the criteria for a newly defined childhood disorder in the foreseeable future, provided limitations in the extant findings can be addressed by future research. Most clinicians who assess and treat cases of attention- deficit/hyperactivity disorder (ADHD) have likely seen and treated someone who falls within the parameters for SCT. This article outlines the history of SCT and reviews the current understanding of the disorder, how it is distinguishable from and similar to other attention disorders, and what future directions research and treatment may take. Based on this review and their clinical experience, the authors conjecture that SCT is probably distinct from ADHD rather than being an ADHD subtype, although there is notable overlap with the ADHD predominantly inattentive and combined presentations.

Sluggish cognitive tempo (concentration deficit disorder?): current status, future directions, and a plea to change the name.

Symptoms of sluggish cognitive tempo (SCT) have been recognized for nearly 30 years as comprising a semi-independent set(s) of symptoms from the inattentive (IN) and hyperactive-impulsive (HI) symptoms involved in attention-deficit/hyperactivity disorder (ADHD). It has only been within the past decade that research focusing specifically on SCT symptoms and on samples of SCT cases chosen independently from ADHD samples has increased so as to address the question of whether SCT is a distinct condition from ADHD or other disorders. All but two of these studies have focused on children but the two extant large scale studies on adults have replicated those findings. This Commentary highlights not only those findings concerning SCT that appear to be relatively robust, but also those patterns that appear to be emerging yet in need of further research to corroborate their association with SCT, as well as those barely or unexplored areas that may deserve more research. Evidence to date, including the many findings in this special issue, is nearing a critical mass that likely supports the conclusion that SCT is a distinct disorder of attention from ADHD, yet one that may overlap with it in about half of all cases. SCT has unique symptom dimensions and comorbidities from ADHD, probably distinct though lesser domains of impairment and demographic correlates, and perhaps unique cognitive deficits, causes and life course risks. These latter areas, however, are in need of substantially more research as is SCT in adults and treatments specifically designed for cases of SCT. Meanwhile, the name of the condition is premature, implying a known cognitive deficit that is as yet unknown, and is proving derogatory and offensive to patients, leading this author to recommend a change to Concentration Deficit Disorder.

Does executive functioning (EF) predict depression in clinic-referred adults? EF tests vs. rating scales.

BACKGROUND: Deficits in executive functioning (EF) are implicated in neurobiological and cognitive-processing theories of depression. EF deficits are also associated with Attention-deficit/hyperactivity disorder (ADHD) in adults, who are also at increased risk for depressive disorders. Given debate about the ecological validity of laboratory measures of EF, we investigated the relationship between depression diagnoses and symptoms and EF as measured by both rating scales and tests in a sample of adults referred for evaluation of adult ADHD. METHOD: Data from two groups of adults recruited from an ADHD specialty clinic were analyzed together: Adults diagnosed with ADHD (N=146) and a clinical control group of adults referred for adult ADHD assessment but not diagnosed with the disorder ADHD (N=97). EF was assessed using a rating scale of EF deficits in daily life and a battery of tests tapping various EF constructs. Depression was assessed using current and lifetime SCID diagnoses (major depression, dysthymia) and self-report symptom ratings. RESULTS: EF as assessed via rating scale predicted depression across measures even when controlling for current anxiety and impairment. Self-Management to Time and Self-Organization and Problem-Solving showed the most robust relationships. EF tests were weakly and inconsistently related to depression measures. LIMITATIONS: Prospective studies are needed to rigorously evaluate EF problems as true risk factors for depressive onset. CONCLUSIONS: EF problems in everyday life were important predictors of depression. Researchers and clinicians should consistently assess for the ADHD-depression comorbidity. Clinicians should consider incorporating strategies to address EF deficits when treating people with depression.

Distinguishing sluggish cognitive tempo from ADHD in children and adolescents: executive functioning, impairment, and comorbidity.

Controversy continues as to whether sluggish cognitive tempo (SCT) is a subtype of attention-deficit/hyperactivity disorder (ADHD) or a distinct disorder. This study examined differences between these disorders in demographics, executive functioning (EF), impairment, and prior professional diagnoses to address the issue. There were 1,800 children 6 to 17 years of age of both sexes from various U.S. ethnic backgrounds who were divided into four groups: (a) high SCT but not ADHD (N = 41), (b) high ADHD but not SCT (N = 95), (c) high in both SCT and ADHD (N = 61), and (d) the control group (N = 1,603). Besides providing demographics, parents completed scales assessing ADHD and SCT symptoms, EF deficits, and psychosocial impairment and reported their child's history of professional diagnoses. SCT symptoms formed two distinct but interrelated factors separate from those for ADHD. SCT differed from ADHD in demographics (age, sex ratio, parental education, income). ADHD was associated with more severe and pervasive EF deficits than SCT, whereas SCT was chiefly associated with mild deficits in Self-Organization. ADHD contributed far more variance to EF deficits than did SCT. Both disorders were impairing, but ADHD was more severely and pervasively so than SCT, especially in Home-School domains; SCT was most impairing in Community-Leisure domains. Different patterns of comorbidity were evident between SCT and ADHD. SCT showed less comorbidity and was particularly associated with depression. SCT may comprise a distinct disorder from ADHD but both may coexist in 39% to 59% of cases each.

The earliest reference to ADHD in the medical literature? Melchior Adam Weikard's description in 1775 of "attention deficit" (Mangel der Aufmerksamkeit, Attentio Volubilis).

OBJECTIVE: The present article reports on the discovery and translation of a chapter in a 1775 medical textbook by the German physician, Melchior Adam Weikard, which describes attention disorders. This article is believed to be the earliest reference to the syndrome that today is known as attention deficit hyperactivity disorder, or ADHD. METHOD: The authors briefly discuss previous efforts to identify the earliest description of ADHD thought to be the lectures of George Still in 1902 and subsequently, the medical textbook by the physician, Alexander Crichton, in 1798. Background is provided on Weikard followed by the English translation of his short chapter on attention deficits and the rationale for why it should be viewed as relevant to the history of ADHD. RESULTS AND CONCLUSIONS: The authors argue that Weikard's description in 1775 now deserves to be credited with providing the first description of attention disorders in the medical literature known to date.

Distinguishing sluggish cognitive tempo from attention-deficit/hyperactivity disorder in adults.

Researchers who study subtypes of attention-deficit/hyperactivity disorder (ADHD) in children have identified a subset having a sluggish cognitive tempo (SCT) typified by symptoms of daydreaming, mental confusion, sluggish-lethargic behavior, and hypoactivity, among others who differ in many respects from ADHD. No studies have examined the nature and correlates of SCT in adults. This study sought to do so using a general population sample in which those having high levels of SCT symptoms were identified (≥95th percentile) and compared to adults having high levels of ADHD symptoms and adults having both SCT and ADHD symptoms. From a representative sample of 1,249 U.S. adults 18-96 years four groups were created: (a) high levels of SCT but not ADHD (N = 33), (b) high levels of ADHD but not SCT (N = 46), (c) high levels of both SCT and ADHD (N = 39), and (d) the remaining adults as a control group (N = 1,131). As in children, SCT formed a distinct dimension from ADHD symptoms that was unrelated to age, sex, or ethnicity. Adults in both ADHD groups were younger than those with SCT only or control adults. The SCT-only group had less education than the control group, whereas both SCT groups earned less annual income than the control or ADHD-only group. More individuals in the combined group were out of work on disability. In their EF, both SCT groups reported greater difficulties with self-organization and problem solving than controls or the ADHD-only group. Otherwise, the SCT + ADHD group reported significantly greater problems with all other domains of EF than the other groups. But both the SCT-only and ADHD-only groups had significantly more EF difficulties than controls though not differing from each other. A similar pattern was evident on most ratings of psychosocial impairment, except in work and education where SCT was more impairing than ADHD alone and in driving where ADHD was more impairing. SCT contributed unique variance to EF deficits and psychosocial impairment apart from ADHD inattention and hyperactive-impulsive symptoms. Results further suggested that a symptom threshold of 5 or more out of 9 along with a requirement of impairment would result in 5.1% of the population as having SCT. It is concluded that SCT may be a separate disorder from ADHD yet with comorbidity occurring in approximately half of all cases of each.