Attention Deficit Hyperactivity Disorder in Adults: Implications for Theories of Diagnosis

The diagnosis of attention deficit hyperactivity disorder (ADHD) in adults has been a source of controversy, with some prominent researchers questioning its very existence and others suggesting it is an urgent clinical problem. This article reviews five domains of data addressing the validity of adult ADHD: clinical correlates, family history, treatment response, laboratory studies, and long-term outcome. It then shows how the debate over adult ADHD reflects a clash of theoretical paradigms and concludes by suggesting ways in which psychological science can collect the data needed to clarify the validity of adult ADHD.     

Attention Deficit/Hyperactivity Disorder in Adults with Sleep Apnea

AAttention deficit hyperactivity disorder (ADHD) is a common childhood illness. In some patients, this illness may persist into adulthood and an association between ADHD and Obstructive Sleep Apnea (OSA) has been found in childhood. However, it is unclear how OSA and ADHD coincide in adulthood. Therefore, to explore the relationship between OSA and adult ADHD the current investigation utilized a clinically-based cross-sectional survey. Subjects consisted of 81 treatment-naïve OSA patients and 32 controls. Measures included each patient completed a questionnaire regarding sleep, Adult ADHD scale. Clinical information, body mass index, 36-item Short Form Health Survey (SF-36), Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale, and polysomnography.The subjects with Apnea-Hypopnea Index (AHI) ≥ 5 events/h were defined as patients with OSA. The control group was accepted as individuals with AHI > 0 events/h. The prevalence of adult ADHD was not different between the patients with OSA and the control group [(7.4 % (6/75) vs. 6.3 % (2/30), p = 0.8, respectively]. OSA patients with ADHD, as compared with those without, had higher anxiety scores and poorer physical component scores of quality of life and higher ESS scores. ADHD scores in patients with OSA were associated with anxiety and depression scores and SF36 physical and mental component scores in bivariate analyses. Thus, in our sample ADHD was not a frequent illness in adult patients with OSA. However, in patients with OSA and ADHD higher levels of anxiety and daytime sleepiness and poorer quality of life was found.     

Inhibition and Attention Deficit Hyperactivity Disorder

This paper updates the author's earlier hypothesis that Attention Deficit Hyperactivity Disorder (ADHD) reflects underactivity in Gray's Behavioral Inhibition System. Five areas of research are reviewed: (1) studies using the stop-signal task, (2) studies of errors of commission, (3) a study of inhibition indexed by eye movements, (4) a neuroimaging study of the corpus callosum, and (5) a study on the prediction of response to methylphenidate. Data from the many different dependent variables in these studies are interpreted as supporting disinhibition as a core deficit in ADHD.     

The Development of Selective Attention in Children With Attention Deficit Hyperactivity Disorder

The influence of age on a selective attention task was studied in a sample of children with and without Attention Deficit Hyperactivity Disorder (ADHD). The impact of methylphenidate (MPH) treatment on selective attention was also investigated in the children with ADHD. Two age groups of children with ADHD and two age groups of control children were tested using a timed computer task. The task consisted of identifying visual target stimuli under various distracter conditions. Distracters varied on the basis of modality (i.e., visual, auditory, or both) and task relevance (i.e., meaningful or irrelevant). Reaction times and accuracy were measured. Children with ADHD were less efficient on the selective attention task than were children without ADHD, and older children were more efficient than younger children in both groups. Children without ADHD were influenced more by the nature of distracters than were children with ADHD. For children with ADHD, MPH improved performance overall.     

Occupational Identity,Competence, and Environments Among Adults With and Without Attention Deficit Hyperactivity Disorder

Exploring occupational adaptation among adults with attention deficit hyperactivity disorder (ADHD) is essential due to associated occupational difficulties. Occupational Performance History Interview scales—identity, competence, and environments—were compared between 51 adults with and 50 without ADHD who participated in occupations. Internal and external resources supporting occupational participations were represented by the competence and environment scales, respectively. The group with ADHD reported fewer internal and external occupational resources compared to the group without ADHD, despite occupational identity similarities. Study findings suggest that occupational interventions aimed at increasing internal and external occupational resources may support occupational adaptation among adults with ADHD.     

Children with Attention Deficit Hyperactivity Disorder

ABSTRACT

It is estimated that there have been over 4,000 articles in the literature on the subject of attentional problems, addressing its etiology, epidemiology, assessment, diagnosis, and treatment. This article reviews recent and relevant literature with an eye toward functional conclusions and linkages between assessment and intervention. The article concludes by providing a problem-solving model that integrates parent or teachers' referral concerns, reasons for these concerns, assessment methods, and intervention strategies. In the end, four definitive conclusions are drawn, and the importance of multimodal strategies that collaboratively involve home, school, and community settings is emphasized.     

Adults With Attention‐Deficit/Hyperactivity Disorder: Assessment and Treatment Strategies

Attention‐deficit/hyperactivity disorder (ADHD) among adults is characterized by inattentiveness and impulsivity. This article provides counselors with information about the etiology, assessment, and treatment of adult ADHD. The identification of the genetic and neurological features of ADHD has led to improvements in evaluation and treatment. Assessment of ADHD requires knowledge of the defining characteristics, subtypes, comorbid features, and functional aspects of ADHD. Effective treatments include both medical management and counseling to address psychosocial deficits.     

Task Switching and Attention Deficit Hyperactivity Disorder

The main goal of the present set of studies was to examine the efficiency of executive control processes and, more specifically, the control processes involved in task set inhibition and preparation to perform a new task in attention deficit hyperactivity disorder (ADHD) and non-ADHD children. This was accomplished by having ADHD children, both on and off medication, and non-ADHD children perform the task-switching paradigm, which involves the performance of two simple tasks. In nonswitch trials, an individual task is performed repeatedly for a number of trials. In switch trials, subjects must rapidly and accurately switch from one task to the other, either in a predictable or unpredictable sequence. Switch costs are calculated by subtracting performance on the nonswitch trials from performance on the switch trials. These costs are assumed to reflect the executive control processes required for the coordination of multiple tasks. ADHD children showed substantially larger switch costs than non-ADHD children. However, when on medication, the ADHD children's switch performance was equivalent to control children. In addition, medication was observed to improve the ADHD children's ability to inhibit inappropriate responses. These data are discussed in terms of models of ADHD and cognition.     

Establishing a Link Between Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder and Childhood Physical Abuse

Attention deficit disorder and attention deficit/hyperactivity disorders (ADD/ADHD) are found in approximately 5% to 10% of school-aged children. This study examined whether childhood physical abuse was associated with ADD/ADHD. Data were derived from a population-based sample of 13,054 adults from the 2005 Canadian Community Health Survey. We used logistical regression analysis in 2 models, both of which had ADD/ADHD as the criterion variable. There were 7 times higher odds of ADD/ADHD among those who reported they had been abused after controlling for several potential mediating factors, including age, race, gender, and 3 other types of adverse childhood experiences (parental divorce, parental addictions, and long-term parental unemployment) in comparison to those who were not abused. The results of this analysis show a strong link between childhood abuse and ADD/ADHD, an association that requires further study.     

Diagnosis and Treatment of Children and Adolescents With Attention‐Deficit/Hyperactivity Disorder

Attention‐deficit/hyperactive disorder (ADHD) has been estimated to affect between 3% and 5% of school‐age children. The disorder frequently has a profound effect on a child's personal, social and academic development and is a risk factor in the development of other comorbid disorders. Diagnostic criteria and methods for identification of ADHD will be presented. Major intervention strategies appropriate for school and community settings are outlined. Because ADHD is 1 of the most common reasons for referral in both school and community agencies, it is important that clinicians be prepared to provide accurate diagnosis and intervention recommendations.     

Quantitative EEG Assessment During Neuropsychological Task Performance in Adults with Attention Deficit Hyperactivity Disorder

This study evaluated the neuropsychological performance of adults with and without Attention Deficit Hyperactivity Disorder (ADHD) during the Paced Auditory Serial Addition Test (PASAT), Wisconsin Card Sorting Test: Computerized Version 3 (WCST), and the Integrated Visual and Auditory Continuous Performance Test (IVA). Quantitative electroencephalographic (QEEG) data were also collected during task performance to examine differences in cortical activity between groups and tasks. Results suggest that adults with ADHD demonstrated lower levels of performance on the PASAT and IVA, tasks that involve working memory and processing speed, and sustained attention, respectively. Adults with ADHD also had more upper alpha activity during the IVA. Lastly, for the ADHD group, an increased theta/beta ratio during the IVA was significantly related to poorer attentional performance. The current results support reinforcing specific types of cortical activity though EEG operant conditioning (neurofeedback) as a treatment option in adults with ADHD. This paper is based largely in part on a dissertation by J. Noland White in partial fulfillment of the requirements of his doctoral program at The University of Tennessee. Portions of this study have been presented in summary form at several professional conferences.     

Nature, Nurture, and Attention Deficit Hyperactivity Disorder

This commentary shows that Joseph's (this issue) review of the genetics of attention deficit hyperactivity disorder (ADHD) contains errors of scientific logic and ignores much relevant research. Thus, we reject his conclusions. We also reject Joseph's approach of pitting nature against nurture as if these two facets of human life are at odds with one another. Instead, most scientists who study the genetics of psychiatric disorders embrace the idea that these disorders are influenced by both genes and environmental factors. In fact, the twin studies criticized by Joseph provide the strongest evidence that environmental risk factors play a substantial role in the etiology of ADHD. They do so by showing that when one identical twin has ADHD the risk to the co-twin is much less than 100%, a fact which can only be explained by environmental risk factors. We also reject the idea that genetic studies have hindered psychosocial research, stigmatized patients, or promoted psychopharmacologic treatments. Genetic studies have aimed at solving one part of the puzzle of ADHD. By testing a parsimonious theory, they have set the stage for gene discovery and the delineation of how genes and environment combine to cause this impairing disorder.     

The Assessment and Diagnosis of Attention Deficit Hyperactivity Disorder in Adult Forensic Psychiatric Outpatients

The primary purpose of the present study was to examine the validity of commonly utilized ADHD rating scales within an adult forensic population. Participants were 120 patients assessed for dysfunctional anger and impulsive aggression at a hospital-based clinic. Two psychiatrists made independent diagnoses about the presence or absence of ADHD among individuals presenting with symptoms consistent with this disorder. Following the diagnoses, participants were assessed with multiple ADHD measures, including measures based on self-report, observer-report, or a computerized neuropsychological measure (IVA + Plus). With the exception of the IVA + Plus, the ADHD measures significantly differentiated individuals diagnosed with ADHD from individuals who were not so diagnosed. These measures also demonstrated good diagnostic utility via test specific parameters (sensitivity, specificity, positive predictive power, and negative predictive power). A sub-set of measures demonstrated particularly good classification accuracy, with high sensitivity (91 %) and good specificity (81 %). Implications of these findings for the effective assessment and diagnosis of ADHD in adult outpatient psychiatric settings are discussed.     

Evidence for an Error Monitoring Deficit in Attention Deficit Hyperactivity Disorder

We studied error monitoring in ADHD and control children in a task requiring inhibition of a motor response. The extent of slowing following successful (stopped) and failed (nonstopped) inhibition was compared across groups. We also measured the time required to inhibit a response (stop signal reaction time, SSRT). Compared to controls, ADHD participants slowed less following nonstopped responses. Slowing did not vary with comorbid reading, oppositional, conduct or anxiety disorder, sex or ADHD subtype. Slowing after nonstopped responses was marginally, although significantly correlated with total ADHD symptoms and with age. ADHD participants had significantly longer SSRT than controls, but SSRT was not significantly correlated with slowing. The apparent deficit in error monitoring in ADHD and its independence from the inhibition deficit observed in ADHD has implications for executive control models of ADHD, performance problems associated with the disorder and for component theories of executive control.     

Processing Speed in Children With Attention Deficit/Hyperactivity Disorder,Inattentive Type

Attention Deficit/Hyperactivity Disorder (ADHD) is among the most common and most often reconceptualized neurobehavioral disorders of childhood. In the most recent DSM-IV, a primarily inattentive subtype of ADHD (AD) has again been identified. This study explores the neuropsychological profile of this group of children. Eighty-two children referred for school-related problems participated. Twenty-five met criteria for AD; 52 met criteria for reading disability (RD); 9 were comorbid for RD and AD. AD children performed poorly on measures of information processing speed. Children with comorbid AD/RD were distinguishable from those with RD on speed of processing measures only. Vulnerability to information processing load may be at the root of many of the behavioral manifestations of AD.     

Psychological therapy for adults with Attention Deficit Hyperactivity Disorder

In the liteature, the clinical management of adults with Attention Deficit Hyperactivity Disorder has focused almost exclusively on stimulant medication. Yet psychological therapy may be a useful adjunct to stimulant medication. Pharmacotherapy is generally reported to be efficacious and, as such, treated individuals are likely to be more receptive to psychological intervention. The aim of this paper is to consider how an individual may best be supported by psychological therapy. It is recommended that a structured pragmatic, psychoeducative approach is the most appropriate. The development of specific self-management skills is discussed within a cognitive behavioural framework. Family, marital and group therapies are also discussed.     

Very Low Birth Weight and Attention Deficit/Hyperactivity Disorder

It is well recognized that reaction time performance of term-born children with a normal birth weight (NBW > 2500 g) who fulfill the DSM-IV criteria for attention deficit/hyperactivity disorder (ADHD) in the primary school age is sensitive for the presentation rate of stimuli. They have been found to perform more poorly in conditions of relatively slow event rates as compared with fast event rates. The purpose of the current study was to explore whether reaction time performance of children with very low birth weight (VLBW < 1500 g) with or without ADHD showed the same sensitivity for the factor presentation rate of stimuli compared to children with a normal birth weight plus ADHD. To this end, reaction time performance of four groups of children was compared on a Go/No-Go test with a fast presentation rate of 1 second and a slow presentation rate of 6 seconds. Groups were: children with VLBW plus ADHD, children with VLBW only, children born full term with normal birth weight (NBW >2500 g) plus ADHD, and children born full term without ADHD (the control group). Findings indicated that, compared to the non-ADHD groups, the groups with ADHD (NBW and VLBW) showed a more dramatic decline in their reaction time performance in the slow condition: a state regulation deficit. In addition, both groups showed a response inhibition deficit. No difference was found in reaction time performance between the groups of children with VLBW only and the control group.     

Family Correlates of Oppositional and Conduct Disorders in Children With Attention Deficit/Hyperactivity Disorder

Comorbidities among children with ADHD are key determinants of treatment response, course, and outcome. This study sought to separate family factors (parental psychopathology and parenting practices) associated with comorbid Oppositional Defiant Disorder (ODD) from those associated with Conduct Disorder (CD) among children with Attention Deficit/Hyperactivity Disorder. Clinic-referred families (n = 149) were diagnosed using DSM-IV criteria. Parents completed measures of parenting practices. Comorbid ODD and CD were significantly associated with maternal negative/ineffective discipline. Comorbid CD, but not ODD, was significantly associated with lack of maternal warmth and involvement, paternal negative/ineffective discipline, and with paternal Antisocial Personality Disorder (APD). However, the risk of CD posed by parenting appeared concentrated among children without a father having APD. While consistent discipline appears important for addressing comorbid ODD and CD, paternal psychopathology and the quality of the relationship between mother and child may pose risk specifically for comorbid CD. Efforts to prevent and/or treat CD should consider not only provision of structure and prudent discipline, but also the affective qualities of the relationship between the primary caretaker and child.     

Automatic and effortful processing in Attention Deficit/Hyperactivity Disorder

Twenty-five boys with Attention Deficit/Hyperactivity Disorder and 23 age-matched controls were compared on verbal memory tasks differentiating automatic versus effortful information processing. Automatic processing tasks included the recognition of new or old words in a list and the recognition of frequency of occurrence of words in a list. Effortful tasks included free recall of lists of both related and unrelated words. Hyperactive boys did not differ from controls in automatic processing capabilities but demonstrated significantly poorer effortful processing. Intercorrelations of the variables revealed high correlations between scores on effortful measures and also raise questions about the purity of automaticity in some tasks employed. Stepwise discriminant analysis demonstrated that free recall of related words (an effortful task) best discriminated between groups. Effort-related processing in hyperactive and normal children is discussed in relation to variables of motivation, affect, arousal, and other higher-order cognitive processes.