The Adverse Health Outcomes, Economic Burden, and Public Health Implications of Unmanaged Attention Deficit Hyperactivity Disorder (ADHD): A Call to Action Resulting from CHADD Summit, Washington, DC, October 17, 2019.

Recent research has increasingly documented the adverse effects of ADHD on physical health in addition to its well-known effects on emotional health. Responding to this concern, CHADD organized a summit meeting of health care providers, governmental and other health-related organizations, and health care payers. A White Paper generated from the meeting reviewed the adverse health outcomes, economic burden and public health implications of unmanaged ADHD. Here we summarize the resulting Calls to Action to the various stakeholder groups including: increased awareness and education of providers; development of professional guidelines for diagnosis and treatment; insurance coverage of the relevant services; support of research targeting the role of ADHD in the etiology and treatment of physical illness; and public education campaigns.

Do ADHD Symptoms, Executive Function, and Study Strategies Predict Temporal Reward Discounting in College Students with Varying Levels of ADHD Symptoms? A Pilot Study.

The purpose of this study was to examine the relationship between temporal reward discounting and attention deficit hyperactivity disorder (ADHD) symptoms in college students. Additionally, we examined whether temporal reward discounting was associated with executive functioning in daily life and with learning and study strategies in this group. Thirty-nine college students (19 with ADHD and 20 controls) participated after meeting criteria for ADHD or non-ADHD based on standardized assessment. Strong preferences for small immediate rewards were specifically associated with the ADHD symptom domain hyperactivity-impulsivity. Additionally, these preferences were associated with daily life executive function problems and with weak learning and study strategies. This suggests that steep temporal discounting may be a key mechanism playing a role in the daily life challenges that college students with ADHD symptoms face. If these findings are replicated in larger samples, then intervention strategies may profitably be developed to counteract this strong preference for small immediate rewards in college students with ADHD symptoms.

Feasibility, Acceptability, and Effectiveness of a New Cognitive-Behavioral Intervention for College Students with ADHD.

OBJECTIVE: This purpose of this study was to assess the feasibility, acceptability, and effectiveness of a new group cognitive-behavioral treatment (CBT) to enhance executive function (EF) in college students with ADHD. METHODS: Eighteen students meeting rigorous DSM-5 criteria for ADHD were enrolled in two nine-member groups. The treatment targeted time-awareness, distractibility, procrastination, and failure to plan, and included strategies to facilitate academic EF skills. RESULTS: Eighty-four percent of students attended nine or more of the 12 weekly sessions. Repeated measures analyses of change from pre- to posttreatment yielded improvement in clinician- and self-ratings of DSM-5 ADHD inattentive symptoms, with robust effect sizes. Also improved were scores on standardized scales of time-management, concentration, and total EF. DISCUSSION: Results provide support for the feasibility, acceptability, and effectiveness of a CBT program in reducing inattentive symptoms and enhancing EF in college students with ADHD, and warrant investigation on a larger scale.

The problem of vaccination refusal: a review with guidance for pediatricians.

PURPOSE OF REVIEW: In the wake of multiple recent outbreaks of the measles and other vaccine-preventable diseases, it is crucial to understand and address parental concerns about vaccination. The purposes of this review are: to identify the causes of vaccine resistance, to elucidate the variables that have led to the success or failure of interventions to date, and to consider implications for pediatricians treating children whose parents are vaccination-resistant. RECENT FINDINGS: Recent research draws on insights from cognitive science to understand vaccine resistance and to develop more effective interventions. Studies show that vaccine resistors are more likely to value lifestyle liberty, to favor individualistic over hierarchical worldviews, and to believe in conspiracy theories. Interventions that seek primarily to correct erroneous beliefs about the dangers of vaccination are likely to fail or even backfire. On the other hand, intervention strategies, such as motivational interviewing, in which the provider elicits and shows respect for parents' values and concerns while empowering them to make well informed and well reasoned decisions, are more likely to be successful. Parents cite a trusting relationship with their pediatrician as the most important factor influencing their decision to vaccinate. SUMMARY: Pediatricians are in the best position to successfully apply insights from cognitive science and intervention research to overcome vaccination-hesitancy.

Executive Functioning Outcomes Over 6 Months of Atomoxetine for Adults With ADHD: Relationship to Maintenance of Response and Relapse Over the Subsequent 6 Months After Treatment.

Objective: This study examines the relationship between maintenance of improved executive functioning (EF) in adults with ADHD with long-term symptom improvement with atomoxetine. Method: Data were collected from a yearlong, double-blind, placebo-controlled clinical study on adult patients with ADHD receiving atomoxetine (80-100 mg/day) for 24 weeks. Patients were then randomized to continue atomoxetine or placebo for 6 months. Executive functioning was rated with Behavior Rating Inventory of Executive Function-Adult Version: Self-Report™ (BRIEF-A: Self-Report™), and the T-scores were determined. Results: Postrandomization T-scores for atomoxetine patients were significantly better than those of placebo patients (3 and 6 months postrandomization). Patients with greater improvements in EF were more likely to show worsening of EF and to relapse after atomoxetine discontinuation. The maintenance of improved EF was significantly associated with improved ADHD symptoms (Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version [CAARS-Inv:SV] with adult prompts). Conclusion: Treatment with atomoxetine improved EF during the treatment phases. Improved EF was maintained up to 6 months after discontinuation of atomoxetine.

The Prevalence of "Late-Onset" ADHD in a Clinically Referred Adult Sample.

OBJECTIVE: Three recent prospective longitudinal studies of population cohorts reported nontrivial rates of "adult-onset" ADHD. Given that this result is at odds with the neurodevelopmental conceptualization of ADHD, as well as with general clinical experience, we obtained report of onset of symptoms in a clinical sample of adults diagnosed with ADHD. METHOD: One hundred four adults diagnosed with ADHD completed retrospective ratings of DSM-IV/DSM-5 ADHD symptoms between the ages of 5 and 12 years. RESULTS: Fifty percent of the sample met full retrospective child diagnostic symptom criteria of six ADHD symptoms in either the inattentive or hyperactive-impulsive domains. Seventy-five percent met a less stringent criterion of four symptoms in either domain. DISCUSSION: These results are interpreted in light of a dimensional model of ADHD that posits emergence of ADHD symptoms and corresponding impairment as a function of increasing performance demands and/or decreasing environmental supports during the course of development.

The efficacy of cognitive-behavioral therapy for older adults with ADHD: a randomized controlled trial.

Older adults with ADHD exhibit significant functional impairment, yet there is little research to guide clinicians in evidence-based care of these adults. This study examined response to treatment in older adults who participated in a previous study of the efficacy of cognitive-behavioral treatment (CBT) in adult ADHD. It was hypothesized that older adults would respond less well to CBT than younger adults, given the cognitive demands of the treatment. As described in the original publication, 88 adults who met DSM-IV criteria for ADHD were randomized to receive either a manualized 12-week CBT group intervention targeting executive dysfunction or a parallel Support group. In the current study, outcomes for 26 adults, aged 50 or older, were compared with those of 55 younger adults with respect to inattentive symptoms assessed on a structured interview by a blind clinician, as well as on ratings by self and/or collateral on measures of attention, executive dysfunction, and comorbidity. Contrary to the hypothesis, older and younger adults were equally responsive to CBT on measures of attention. The older adults also responded as well to Support as to CBT on several outcome measures. The results provide preliminary evidence that CBT is an effective intervention for older adults with ADHD. The unexpected response to support highlights a possible age-specificity of effective therapeutic intervention that requires further investigation.

RETRACTED: Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD.

Leikauf, J. E., & Solanto, M. V. (2016). Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD. Journal of Attention Disorders. Advance online publication. doi: 10.1177/1087054716659361.

Sluggish Cognitive Tempo, Internalizing Symptoms, and Executive Function in Adults With ADHD.

OBJECTIVE: We sought to characterize relationships between sluggish cognitive tempo (SCT) and both internalizing symptoms and executive functioning in adults with ADHD. METHOD: A total of 102 adults with ADHD completed clinical interviews and clinical rating scales. Hierarchical regression analyses were conducted to ascertain the independent predictive power of SCT symptoms for deficits in executive function (EF) after considering severity of ADHD inattentive and hyperactive-impulsive symptoms and internalizing symptoms. RESULTS: SCT correlated with ADHD inattentive symptoms and dimensional measures of depression and anxiety but not with clinical diagnosis of depression or anxiety. SCT predicted EF deficits over and above the effects of internalizing and ADHD symptoms. This relationship between SCT and EF was limited to the subset of participants ( n = 48) receiving stimulant treatment. CONCLUSION: SCT in adults with ADHD is associated with internalizing symptoms, ADHD inattentive symptoms, and, independently, with EF deficits. Further research is needed to ascertain why this relationship occurred primarily in adults concurrently receiving stimulants.

Commentary: Development of a new, much-needed, cognitive-behavioral intervention for adolescents with ADHD - a reflection on Sprich et al. (2016).

Adolescents with attention deficit hyperactivity disorder (ADHD) can be challenging to treat. often, they are resistant to taking medication. Furthermore, the behavioral and cognitive-behavioral interventions developed for children and adults with ADHD, are not appropriate or are not effective for adolescents. Thus, this study, showing the effectiveness of a cognitive-behavioral treatment (CBT) program specifically designed for adolescents, represents an important step forward. Methodological strengths include a wait-list control group and outcome ratings by a blind evaluator. We look forward to further development of this treatment, particularly a trial in adolescents not concomitantly medicated for ADHD and comparison to an active control group.

Adult ADHD vs. bipolar disorder in the DSM-5 era: a challenging differentiation for clinicians.

OBJECTIVE: Patients with adult attention-deficit/ hyperactivity disorder (ADHD) and bipolar disorder can present with similar symptoms, including increased energy, distractibility, disorganization, impulsivity, hyperactivity, and rapid speech. Determining whether the patient has either, or possibly both, of these syndromes can be a complex task. This review attempts to clarify where these disorders overlap, both symptomatically and epidemiologically, and where they diverge, to help clinicians increase the accuracy of their diagnoses. Changes to diagnostic criteria from the fourth to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (from DSM-IV-TR to DSM-5) are discussed, as is the evidence base for pharmacological treatments. METHOD: Studies and sources were identified using computerized searches. RESULTS: Adult ADHD and bipolar disorder have multiple overlapping symptoms, but there are differences in prevalence (ADHD affects 4.4% of adults in the United States versus 1.4% for bipolar disorder), onset of symptoms (usually before age 7 years in ADHD versus after age 12 years in bipolar disorder), disease course (chronic in ADHD versus cyclical in bipolar disorder), mood symptoms (absent in ADHD but always present in bipolar disorder), and psychotic symptoms (absent in ADHD but sometimes present in bipolar disorder). Approximately 20% of adult patients with ADHD also have bipolar disorder, while 10%-20% of patients with bipolar disorder have adult ADHD. Comorbidity of bipolar disorder and ADHD is associated with an earlier age of onset and a more chronic and disabling course of bipolar disorder, as well as more psychiatric comorbidity. CONCLUSION: Distinguishing between adult ADHD and bipolar disorder requires careful attention to phenomenology and awareness of epidemiology, with a focus on childhood history, lifetime course of symptoms, and the possibility of comorbidity.

Validity of DSM-IV attention deficit/hyperactivity disorder symptom dimensions and subtypes.

Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for attention deficit/hyperactivity disorder (ADHD) specify two dimensions of inattention and hyperactivity-impulsivity symptoms that are used to define three nominal subtypes: predominantly hyperactive-impulsive type (ADHD-H), predominantly inattentive type (ADHD-I), and combined type (ADHD-C). To aid decision making for DSM-5 and other future diagnostic systems, a comprehensive literature review and meta-analysis of 546 studies was completed to evaluate the validity of the DSM-IV model of ADHD. Results indicated that DSM-IV criteria identify individuals with significant and persistent impairment in social, academic, occupational, and adaptive functioning when intelligence, demographic factors, and concurrent psychopathology are controlled. Available data overwhelmingly support the concurrent, predictive, and discriminant validity of the distinction between inattention and hyperactivity-impulsivity symptoms, and indicate that nearly all differences among the nominal subtypes are consistent with the relative levels of inattention and hyperactivity-impulsivity symptoms that define the subtypes. In contrast, the DSM-IV subtype model is compromised by weak evidence for the validity of ADHD-H after first grade, minimal support for the distinction between ADHD-I and ADHD-C in studies of etiological influences, academic and cognitive functioning, and treatment response, and the marked longitudinal instability of all three subtypes. Overall, we conclude that the DSM-IV ADHD subtypes provide a convenient clinical shorthand to describe the functional and behavioral correlates of current levels of inattention and hyperactivity-impulsivity symptoms, but do not identify discrete subgroups with sufficient long-term stability to justify the classification of distinct forms of the disorder. Empirical support is stronger for an alternative model that would replace the subtypes with dimensional modifiers that reflect the number of inattention and hyperactivity-impulsivity symptoms at the time of assessment. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

Diagnosis of ADHD in adults: what is the appropriate DSM-5 symptom threshold for hyperactivity-impulsivity?

OBJECTIVE: To empirically identify the appropriate symptom threshold for hyperactivity-impulsivity for diagnosis of ADHD in adults. METHOD: Participants were 88 adults (M [SD] age = 41.69 [11.78] years, 66% female, 16% minority) meeting formal DSM-IV criteria for ADHD combined or predominantly inattentive subtypes based on a structured diagnostic interview keyed to DSM-IV (Conners' Adult ADHD Diagnostic Interview for DSM-IV [CAADID]). All participants also completed the Conners' Adult ADHD Rating Scale (CAARS), which was normed on the general adult population and includes subscales for DSM-IV inattentive and DSM-IV hyperactive-impulsive symptoms. A T-score threshold of 65 (at least 1.5 SD above population mean) on the CAARS DSM-IV hyperactive-impulsive dimension was used to identify participants with empirically elevated symptom severity. RESULTS: Of 88 participating adults, 48 (55%) had a T-score of at least 65 (1.5 SD) on the CAARS DSM-IV Hyperactive-Impulsive scale. Of these, only 25 (52%) met the DSM-IV cutoff of six hyperactive-impulsive symptoms on the CAADID. Thus, approximately half of those who reported empirically elevated hyperactive-impulsive complaints on the CAARS did not concurrently meet the six-symptom DSM-IV cutoff on the CAADID. An alternative cutoff of four hyperactive-impulsive symptoms on the CAADID captured 39 (81%) cases identified by the CAARS. CONCLUSION: In adults, mandating at least six hyperactive-impulsive symptoms excludes a significant percentage (almost half) of adults who are at least 1.5 SD above the population mean on a dimensional measure of hyperactivity-impulsivity. These data provide a compelling basis for lowering the symptom threshold of hyperactivity-impulsivity for adults in the DSM-5.

Managing ADHD across the lifespan in the primary care setting.

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobehavioral condition that affects most patients throughout their lives and is associated with occupational underachievement, psychiatric comorbidity, and substance abuse. Primary care physicians (PCPs) are at the forefront of helping patients with ADHD manage symptoms and overcome functional impairments. In this article, the problems of recognizing and effectively managing ADHD are explored through the presentation of 2 composite patient cases based on real patients in the authors' practices. Both cases highlight maturational changes in ADHD-related problems as patients develop through childhood, adolescence, and into adulthood. The striking differences between the cases serve to illustrate the highly varied clinical presentation and developmental trajectories of ADHD, moderated by family environment, patient characteristics, and life events. Emphasis is placed on understanding the crucial developmental turning points from early childhood through adulthood at which patients with ADHD are most likely to need increased support and specialized behavioral interventions. Diagnosis of adult ADHD is also reviewed, including an overview of potentially clinically relevant patient characteristics that should alert PCPs to the possible presence of ADHD and use of the World Health Organization's rapid 6-item adult ADHD Self-Report Scale as a screening device. The present discussion challenges PCPs to recognize the varied presentations of what ADHD "looks like," and describes the need for PCPs to establish and maintain working partnerships with families, patients, and mental health care professionals in their local communities to successfully treat ADHD across the lifespan.

Bipolar disorder and comorbid attention deficit hyperactivity disorder. A distinct clinical phenotype? Clinical characteristics and temperamental traits.

OBJECTIVES: It has been suggested that bipolar disorder (BD) with comorbid ADHD represents a distinct clinical phenotype of BD. There are no data regarding potential heterogeneity between BD subjects with a diagnosis of ADHD in childhood whose ADHD remitted in adulthood (cADHD-BD) vs. BD patients with persistent ADHD diagnosis in adulthood (aADHD-BD). This heterogeneity may constitute a confounder in investigations of the nature of the co-occurrence between BD and ADHD. The aim of this paper is to compare BD patients without ADHD, to those with aADHD-BD, and those with cADHD-BD on clinical and temperamental characteristics, hypothesizing that maladaptive temperament will be increased in BD subjects with a stable diagnosis of ADHD in adulthood compared to those whose ADHD remitted. We further hypothesize that maladaptive temperament will be associated with the severity of both illnesses. METHODS: A total of 100 outpatients (aged 18-30 years) with BD in remission were included. The assessment of ADHD was made according to a procedure aimed to reduce potential recall biases. Subjects had to have a parent available and had never been treated with stimulants. Temperamental traits were assessed with the California Child Q-sort (CCQ) and the Early Adolescent Temperament Questionnaire (EATQ). RESULTS: Rate of co-occurrence of ADHD-BD was 18% lifetime and 10% current diagnosis. Patients with ADHD-BD (aADHD-BD+cADHD-BD) reported a significantly earlier onset of mood disorder, higher number of previous mood episodes, and significantly higher impulsivity than BD patients without ADHD. aADHD-BD showed a significantly earlier BD onset, higher number of previous mood episodes, higher impulsivity, decreased Reactive Control and higher Negative Emotionality temperamental scores than cADHD patients. CONCLUSION: Findings suggest that patients with aADHD-BD present a clinical phenotype distinct from that of patients with BD without ADHD or with a childhood ADHD diagnosis that remitted with the age. This appealing hypothesis of a BD-distinct phenotype that can be detected early due to its associated maladaptive temperamental traits requires further investigation in larger samples, supported by neuropsychological, genetic and imaging data.

Efficacy of meta-cognitive therapy for adult ADHD.

OBJECTIVE: The authors investigated the efficacy of a 12-week manualized meta-cognitive therapy group intervention designed to enhance time management, organization, and planning in adults with attention deficit hyperactivity disorder (ADHD). METHOD: Eighty-eight clinically referred adults who met DSM-IV criteria for ADHD according to clinical and structured diagnostic interviews and standardized questionnaires were stratified by ADHD medication use and otherwise randomly assigned to receive meta-cognitive therapy or supportive psychotherapy in a group modality. Meta-cognitive therapy uses cognitive-behavioral principles and methods to impart skills and strategies in time management, organization, and planning and to target depressogenic and anxiogenic cognitions that undermine effective self-management. The supportive therapy condition controlled for nonspecific aspects of treatment by providing support while avoiding discussion of cognitive-behavioral strategies. Therapeutic response was assessed by an independent (blind) evaluator via structured interview before and after treatment as well as by self-report and collateral informant behavioral ratings. RESULTS: General linear models comparing change from baseline between treatments revealed statistically significant effects for self-report, collateral report, and independent evaluator ratings of DSM-IV inattention symptoms. In dichotomous indices of therapeutic response, a significantly greater proportion of members of the meta-cognitive therapy group demonstrated improvement compared with members of the supportive therapy group. Logistic regression examining group differences in operationally defined response (controlling for baseline ADHD severity) revealed a robust effect of treatment group (odds ratio=5.41; 95% CI=1.77-16.55). CONCLUSIONS: Meta-cognitive therapy yielded significantly greater improvements in dimensional and categorical estimates of severity of ADHD symptoms compared with supportive therapy. These findings support the efficacy of meta-cognitive therapy as a viable psychosocial intervention.

Stimulant drug response in the predominantly inattentive and combined subtypes of attention-deficit/hyperactivity disorder.

OBJECTIVE: This study compared the methylphenidate (MPH) dose-response profiles of children with the Predominantly Inattentive (PI) and Combined (CB) subtypes of attention-deficit/hyperactivity disorder (ADHD). It is the first such study to enroll a sample comprised exclusively of children, all but one of whom had no prior exposure to ADHD medications. METHOD: The design was a double-blind crossover with 1-week exposures to placebo and low, medium, and high, fixed, three times daily (t.i.d.) dosage regimens of immediate-release MPH, administered in random order. Parents and teachers completed weekly behavioral questionnaires (Conners, Swanson, Kotkin, Agler, M-Flynn and Pelham Scale [SKAMP]) and a child psychiatrist provided weekly ratings of symptom severity (ADHD Rating Scale [ADHD-RS]), side effects (Side Effects Rating Scale), and a Clinical Global Impressions-Severity (CGI-S). In addition, laboratory measures of vigilance (Continuous Performance Test [CPT]) and resistance to cognitive interference (Stroop) were administered weekly. RESULTS: Twenty-five children (15 CB, 10 PI), who met rigorous diagnostic criteria for their ADHD subtype, completed the study. Groups did not differ on demographic variables or severity at baseline. Behavioral questionnaires and clinical ratings indicated significant improvement on MPH for both subtypes but no differences in response profiles of the two groups. Drug effects were predominantly linear for both subtypes. Effects of MPH were significant for the CPT, but not the Stroop, instrument with no differences between ADHD subtypes. CONCLUSIONS: Results support the clinical utility of MPH in the treatment of the PI subtype and provide no evidence of differences in response between the subtypes.

Event-related FMRI of inhibitory control in the predominantly inattentive and combined subtypes of ADHD.

BACKGROUND AND PURPOSE: To examine the neurophysiological basis for the pronounced differences in hyperactivity and impulsiveness that distinguish the predominantly inattentive type of attention-deficit/hyperactivity disorder (ADHD-PI) from the combined type of the disorder (ADHD-C). METHODS: Event-related brain responses to a go/no-go test of inhibitory control were measured with functional magnetic resonance imaging (fMRI) in 11 children with ADHD-C and 9 children with ADHD-PI, aged 7 to 13 years, who were matched for age, sex, and intelligence. RESULTS: There were no significant group differences in task performance. Children with ADHD-C and ADHD-PI activated overlapping regions of right inferior frontal gyrus, right superior temporal lobe, and left inferior parietal lobe during inhibitory control. However, the magnitude of the activation in the temporal and parietal regions, as well as in the bilateral middle frontal gyrus, was greater in children with ADHD-PI than those with ADHD-C. Conversely, children with ADHD-C activated bilateral medial occipital lobe to a greater extent than children with ADHD-PI. CONCLUSIONS: The results provide preliminary evidence that phenotypic differences between the ADHD-C and ADHD-PI subtypes are associated with differential activation of regions that have previously been implicated in the pathophysiology of ADHD and are thought to mediate executive and attentional processes.