Stimulant Prescribing Error Assessment Rubric Development.

Updated European Consensus Statement on diagnosis and treatment of adult ADHD

We found no certain evidence that IR methylphenidate compared with placebo or lithium can reduce symptoms of ADHD in adults (low- and very low-certainty evidence). Adults treated with IR methylphenidate are at increased risk of gastrointestinal and metabolic-related harms compared with placebo. Clinicians should consider whether it is appropriate to prescribe IR methylphenidate, given its limited efficacy and increased risk of harms. Future RCTs should explore the long-term efficacy and risks of IR methylphenidate, and the influence of conflicts of interest on reported effects.

4 - The Assessment Process: Conditions and Comorbidities

Attention Deficit Hyperactivity Disorder (ADHD) is an early onset clinical condition characterized by attention difficulties, hyperactivity and impulsivity which can persist across the lifespan, significantly influencing the evolutionary course and facilitating the rise of psychiatric comorbidities. The presence of different ADHD subtypes in adults is a heterogeneity factor to be recognized in order to orient prognosis and treatment, as indicated by studies that described differences in the characterization of different subtypes in relation to both severity and comorbidities. In the present study we evaluated the socio-demographic and clinical characteristics of a sample of adults with ADHD and the characteristics associated with the different disorder subtypes. We described 60 patients aged between 18 and 65 years (mean age 34.1) with primary diagnosis of ADHD consecutively admitted to the Regional Centre for diagnosis and treatment of ADHD in adults in Milan. We observed high severity of symptoms and low quality of life, in particular in the "life outlook" dimension. The subtypes distribution was the following: 18.3% inattentive subtype, 8.3% hyperactive/impulsive subtype and 70% combined subtype. The hyperactive/impulsive subtype showed a significantly higher frequency in females, while the inattentive subtype was more frequent in males. Patients with the hyperactive/impulsive subtype showed worse quality of life and more frequent anxiety disorders. Considering the different clinical profiles among various subtypes, these data add relevance to subtypes classification of adult ADHD.

Attention Deficit Hyperactivity Disorder (ADHD) is well recognised in childhood. However, recognition that it commonly persists into adulthood is relatively recent. This study is the 2nd phase of a two-phase epidemiological investigation of the prevalence of adult ADHD in outpatients in Ireland. In phase-1, 634 participants were screened with Adult ADHD Self-Report Scale (ASRS) and Wender Utah Rating Scale (WURS). Those scoring positive in both scales have been invited to participate in the 2nd phase where the scales Conners' Adult ADHD Diagnostic Interview (CAADID), Mini International Neuropsychiatric Interview (MINI), and Global Assessment of Functioning (GAF) were administered, plus clinical evaluation based in DSM-5. 131 were eligible, 110 participated (84.0%). Using the CAADID (DSM-IV criteria) 71 were diagnosed with ADHD. Projecting to the total sample (N = 634) the prevalence was 13.25%, CI:95%:10.71-16.14. Converting the DSM-IV criteria to DSM-5, 89 had ADHD (prevalence:16.72%, CI: 13.9-19.86). Using clinical evaluation, 86 were diagnosed with ADHD (prevalence:16.09%, CI:13.31-19.18). Only 3 cases were diagnosed before with ADHD. Comorbidity was higher in those with ADHD, with the median number of additional diagnoses 2 (min 0 max 8, IQR 3) Also, they had significantly higher rates of depression and recurred depression. Agreement between DSM-IV and DSM-5 was high (rho = 0.90, p < .0001). High rates of undiagnosed ADHD were found to be present among AMHS attendees. Clinicians in AMHS need to be knowledgeable and alert to possible ADHD among their caseloads, and offer appropriate intervention. Interventions are urgently required to increase the detection and treatment of adult ADHD.

Few studies have examined the impact of childhood attention deficit hyperactivity disorder (ADHD) symptoms on adult ADHD functional outcomes. To address this issue dimensionally, ADHD symptoms in childhood and adulthood and their relation to educational deficits and work disability are studied in a clinical sample of adult patients with previously untreated ADHD. About 250 adults diagnosed systematically with ADHD according to DSM-IV were prospectively recruited. Primary outcomes were high school dropout and being out of the work last year. Childhood ADHD symptoms, sex differences, comorbidities of other mental disorders, and adult ADHD symptoms were examined by historical data, clinician interviews, and questionnaires. High levels of ADHD symptom severity in childhood were related to dropping out of high school [odds ratio (OR) = 3.0], as were higher numbers of hyperactive–impulsive symptoms in childhood. Significantly, more women than men were long-term work disabled (OR = 2.0). After adjusting for age and gender, persisting high levels of ADHD inattention symptoms in adulthood (OR = 2.5), number of comorbid disorders, and particularly anxiety disorders were significantly related to long-term work disability. Childhood hyperactive–impulsive symptoms and overall severity of childhood ADHD symptoms were associated with high school dropout rates; however, persisting ADHD inattention symptoms and comorbid mental disorders in adulthood were more correlated to occupational impairment. These findings underline proposals for studies on early recognition and interventions for ADHD and psychiatric comorbidity. They further suggest that inattentive symptoms be a focus of adult ADHD treatment and that workplace interventions be considered to prevent long-term work disability.

The prevalence of attention deficit hyperactivity disorder (ADHD) in the population is currently 4%. It is usually associated with problems related to executive functions, attention and emotional regulation. Non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS), may compensate for cognitive impairment, thereby benefiting neuroplasticity and long-term outcomes. The aim is to find evidence concerning the dual application of tDCS with cognitive stimulation activities in the treatment of ADHD in adults, in relation to attention, executive functions and emotional regulation. Two reviewers conducted a literature search of Web of Science and PubMed on 22.02.2023, and selected articles that included ADHD patients aged 17-65 years old. The results were analysed using synthesis without meta-analysis (SWiM). Seven of 956 articles were selected for the present review, and were all related to executive functions and attention. No article related to neuromodulation of emotional regulation in adults with ADHD was found. Significant results related to attention and executive functions, and specifically inhibitory control, were found. All studies followed the international 10-20 system developed for the electroencephalogram. Further research is required in view of the limited number of studies found on the symptomatological treatment of ADHD with tDCS in adult populations and the lack of awareness of emotional regulation. This research should use a treatment involving more than two sessions. These tasks do not involve learning and involve a stimulation of more than 1.5 mA.

Background: Current research indicates clear distinctions between the general population and individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD), specifically in cognitive processes and physiological brain activity. Stimulant medications have been shown to improve and, in some cases, normalize dysfunction in both these areas. The majority of extant brain imaging literature has included functional magnetic resonance imaging (fMRI) in tandem with neuropsychological tests to explore these relationships. However, functional near-infrared spectroscopy (fNIRS) is a promising neuroimaging technology that offers some unique features including portability, ecological validity, and the ability to detect brain activity via concentrations of oxygenated and deoxygenated blood. Very few studies have used fNIRS as a tool to investigate the impact of medication on adults with ADHD, both in their cognitive functioning and brain hemodynamics. However, there is evidence that this technology may-in addition to providing novel information about cognitive and physiological functioning-actually be better suited to evaluating the ADHD population. Objectives: The present study sought to: 1) compare differences in cognition (using neuropsychological tests) and neurophysiology (using fNIRS) between adults withADHD (when unmedicated) and age-, gender-, and education-matched healthy control(HC) adults, and 2) compare differences in cognition and neurophysiology betweenmedicated and unmedicated states in adults with ADHD. Ultimately, the goal was to investigate the potential application of fNIRS as an assessment tool for both diagnostic(of the physiological underpinnings of the disorder) and monitoring (of the effectiveness of cognition-improving medications) purposes. Participants: Nine individuals aged 18-25 diagnosed with ADHD and nine age-, gender-, and education-matched healthy control participants (HCs). Method: All participants completed two testing sessions. HCs completed both sessions under normal conditions whereas ADHD participants completed one testing session while medicated and the other while unmedicated. Cognitive testing focused on working memory, a domain relevant to ADHD. Testing included 1) a two-subtest WAIS-IV; 2) a Sternberg delayed recognition task (a test of working memory); and 3) a visual n-back task (another working memory test). The latter two tasks were completed while participants were connected to a continuous wave fNIRS system to record cerebral hemodynamic activity during working memory performance. Demographic variables, confirmation of diagnosistic status, medications, and recent daily activities regarding caffeine, alcohol, tobacco, and other behaviors that could impact fNIRS data were recorded. Results: Cognitively, while healthy controls performed better on working memory tasks than ADHD participants, and ADHD participants generally performed better when medicated than unmedicated, neither comparison reached significance. Physiologically, there were no significant differences in PFC activation between the HC and ADHD groups, nor between medicated and unmedicated states within the ADHD group. Conclusions: The findings of this study mirror previous findings of the cognitive effects of medication in ADHD. Not surprisingly, individuals with ADHD performed working memory tasks less accurately and more slowly than controls and the intake of stimulant medication led to an improvement in performance that reached levels similar to healthy individuals. By contrast, the medication-induced working memory improvements among adults with ADHD were not reflected in corresponding physiological changes measured by fNIRS. The lack of significant findings in this study may be due to low statistical power, though alternative explanations are also explored. Nonetheless, before fNIRS can contribute to clinical diagnosis and treatment of ADHD, more research is needed to establish its clinical application.

Adult attention-deficit hyperactivity disorder: key conceptual issues

Psychostimulants are effective treatments for attention-deficit/hyperactivity disorder (ADHD) but may be associated with euphoric effects, misuse/diversion, and adverse effects. These risks are perceived by some clinicians to be greater in substance-abusing adolescents relative to non-substance-abusing adults. The present study evaluates the subjective effects, misuse/diversion, and adverse effects associated with the use of osmotic-release oral system methylphenidate (OROS-MPH), relative to placebo, for treating ADHD in adolescents with a substance use disorder (SUD) as a function of substance use severity and compared these risks with those associated with the treatment of ADHD in adults without a non-nicotine SUD. Datasets from two randomized placebo-controlled trials of OROS-MPH for treating ADHD, one conducted with 303 adolescents (13-18) with at least one non-nicotine SUD and one with 255 adult smokers (18-55), were analyzed. Outcome measures included the Massachusetts General Hospital Liking Scale, self-reported medication compliance, pill counts, and adverse events (AEs). Euphoric effects and misuse/diversion of OROS-MPH were not significantly affected by substance use severity. The euphoric effects of OROS-MPH did not significantly differ between the adolescent and adult samples. Adults rated OROS-MPH as more effective in treating ADHD, whereas adolescents reported feeling more depressed when taking OROS-MPH. The adolescents lost more pills relative to the adults regardless of treatment condition, which suggests the importance of careful medication monitoring. Higher baseline use of alcohol and cannabis was associated with an increased risk of experiencing a treatment-related AE in OROS-MPH, but baseline use did not increase the risk of serious AEs or of any particular category of AE and the adolescents did not experience more treatment-related AEs relative to the adults. With good monitoring, and in the context of substance abuse treatment, OROS-MPH can be safely used in adolescents with an SUD despite non-abstinence.

To the Editor: Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent psychiatric disease in children and adolescents, affecting approximately 5% of children worldwide.1 The pathophysiologic profile of ADHD has not been fully characterized, although structural and functional imaging studies consistently suggest dysfunction in fronto-subcortical pathways and imbalances in dopaminergic and noradrenergic systems in the origin of the core symptoms.2 The central nervous system (CNS) stimulants, especially the immediate and long-acting forms of methylphenidate, are the first-line treatments for ADHD. Studies analyzing the effect of methylphenidate on the neuropsychologic performance of adults with ADHD report significant improvements in performance associated with marked therapeutic response.3 The common side effects of CNS stimulants include sleep disturbance, depressed mood, stomachache, tics, and mannerisms. However, no case of concurrence of urinary and fecal incontinence (double incontinence) associated with the administration of osmotic release oral system (OROS) methylphenidate has been reported before. Here, we present a case of a young patient with ADHD who developed simultaneous double incontinence after the use of OROS methylphenidate 36 mg. Case report. An 8-year-old boy was brought to our child and adolescent psychiatric outpatient clinic in August 2007 because of frequent delays in completing schoolwork and difficulty in maintaining attention in class. His academic performance was above average but unstable. His weight was 25 kg and his height was 126 cm. No major physical or mental illness was previously noted. There was no family history of enuresis and encopresis. His motor and language development have followed the normal developmental milestones. He was diagnosed with ADHD according to the DSM-IV criteria. The outcome measure Swanson, Nolan, and Pelham Scale, version IV (SNAP-IV),4 was completed by his mother. The boy took immediate-release methylphenidate 10 mg every morning for the first 2 weeks, which was then switched to OROS methylphenidate 18 mg/d. No overt side effect was reported by his mother. In order to reach the optimal response, the medication was further switched to OROS methylphenidate 36 mg/d for 2 weeks. The patient developed stool incontinence during the use of OROS methylphenidate 36 mg daily. His mother reported that loss of bowel control occurred every day and was frequent during the daytime. It was also reported that this child experienced urinary incontinence almost every day. He was scolded by his mother but continued to take medication because of a marked improvement of his ADHD symptoms as rated on the SNAP-IV. Two weeks later, his mother brought him back to our clinic. Urologic and gastroenterologic consultation did not reveal any abnormal finding. A routine laboratory examination did not suggest any organic cause for the double incontinence. He did not take any other medication during the administration of OROS methylphenidate. The condition of double incontinence completely resolved rapidly after the discontinuation of OROS methylphenidate 36 mg. ADHD is a CNS disorder. Children with ADHD often require additional supervision or a more structured learning environment to keep up with their peers. Although CNS stimulants have been the standard treatment for ADHD, their mechanism of action is still not well understood. It is clear that methylphenidate mainly affects the dopaminergic and norepinephrine systems.5 The brain noradrenergic pathway facilitates neuronal processes promoting behavioral activation, alertness, and attention. Stimulants are associated with loss of appetite, headache, stomachache, and insomnia.6 Though many side effects of stimulants are transient in nature and may resolve without treatment,7 it is prudent to monitor side effects that do not compromise the patient's health or cause discomfort that interferes with functioning. The bladder is vulnerable to the adverse effects of drugs because of its complex control and the frequent excretion of drug metabolites in the urine. Incontinence results when bladder pressure exceeds sphincter resistance.8 The Adverse Drug Reaction Probability score9 in this patient was 7, denoting a probable adverse reaction caused by OROS methylphenidate 36 mg. Because of ethical considerations, this patient did not undergo rechallenge with OROS methylphenidate. The pathophysiology of the side effects he encountered is likely to be derived from certain actions on central mechanism and increased vulnerability to the sympathomimetic effects of a stimulant drug. Adrenergic blockade effect is suggested to cause fecal incontinence by decreasing the tonus of the internal anal sphincter10 and urinary incontinence by decreasing the tonus of the internal urethral sphincter.11 The antagonist effect of OROS methylphenidate on the α1 receptors of the internal anal sphincter may cause fecal incontinence, and the effect on the internal bladder sphincter may cause urinary incontinence. To our knowledge, this is the first case report of double incontinence observed during the treatment of ADHD with OROS methylphenidate 36 mg. This phenomenon had rapid remission after discontinuation of the drug. It is likely that individual patient characteristics contribute to the possibility of such an adverse event. The causality in this case might be dose-related, and careful monitoring is highly suggested.

To examine the prevalence of comorbidities and the use of psychiatric comedication among individuals in medical treatment for attention deficit hyperactivity disorder (ADHD), in comparison to a matched control group from the general population. This nationwide case-control study included 1,082,378 Danish individuals aged 7-64 of whom 98,398 had at least one prescription of ADHD medication during 2023. Data was collected over an observation period spanning from 2013 to 2023. Cases were matched to controls (1:10) from the general population on birth year and sex. Data were obtained and accessed through The Danish Health Data Authority. Associations were estimated using conditional logistic regression models. Somatic and particularly psychiatric comorbidities were more common among individuals in ADHD treatment across all age groups. Among those in ADHD treatment 46.7% had at least one comorbidity compared to 23.3% in the control group. The use of psychiatric comedications (besides ADHD medication) was likewise more common among individuals in ADHD treatment (32.7%) compared to the controls (7.2%). The association estimates from conditional logistic regression revealed a higher likelihood of somatic and psychiatric comorbidities among those in ADHD treatment in all age groups. Females in ADHD treatment had 4.48-4.50 times higher odds of comorbidities compared to females not in ADHD treatment (OR7 - 17 years = 4.48, 95% CI: 4.27-4.70; OR18 - 29 years = 4.50, 95% CI: 4.37-4.64). Similar patterns were observed for males but with slightly lower ORs (OR7 - 17 years = 2.35, 95% CI: 2.27-2.44; OR18 - 29 years = 3.38, 95% CI: 3.28-3.50). This study reveals that both prevalence of somatic and psychiatric comorbidities and the use of psychiatric comedication are significantly higher among individuals in ADHD treatment. The highest occurrence is seemingly among females aged 7-17 year and 18-29 years. The coexistence of ADHD with other somatic and psychiatric conditions can constitute a more complex disease burden, necessitating enhanced disease management strategies to reduce complications and enhance quality of life. Longitudinal studies are needed to confirm the temporal association of these results.

With increased awareness that attention-deficit/hyperactivity disorder (ADHD) can persist beyond childhood, pharmacological treatment options for adults have expanded. Short-acting stimulants continue to be the first-line approach, demonstrating clinical efficacy and few adverse events in well-controlled trials, with long-acting stimulants also showing promise. Atomoxetine has also been reported to improve ADHD symptoms and associated dysfunction, although longer-term, head-to-head studies with stimulants are needed. Several antidepressants (e.g., desipramine and buproprion) appear to be effective in the treatment of adult ADHD, but to a lesser extent than stimulants. Data are limited in evaluating the impact of combining pharmacological treatments for ADHD and comorbid conditions. This paper describes the safety and efficacy of medications for treating the core symptoms, psychosocial features and cognitive dysfunctions associated with adult ADHD.

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity. ADHD impairments arise from irregularities primarily in dopamine (DA) and norepinephrine (NE) circuits within the prefrontal cortex. Due to ADHD medication’s controversial side effects and high rates of diagnosis, alternative/complementary pharmacological therapeutic approaches for ADHD are needed. Although the number of publications that study the potential effects of caffeine consumption on ADHD treatment have been accumulating over the last years, and caffeine has recently been used in ADHD research in the context of animal models, an updated evidence-based systematic review on the effects of caffeine on ADHD-like symptoms in animal studies is lacking. To provide insight and value at the preclinical level, a systematic review based on PRISMA guidelines was performed for all publications available up to 1 September 2021. Caffeine treatment increases attention and improves learning, memory, and olfactory discrimination without altering blood pressure and body weight. These results are supported at the neuronal/molecular level. Nonetheless, the role of caffeine in modulating ADHD-like symptoms of hyperactivity and impulsivity is contradictory, raising discrepancies that require further clarification. Our results strengthen the hypothesis that the cognitive effects of caffeine found in animal models could be translated to human ADHD, particularly during adolescence.

Introduction: Attention-deficit/hyperactivity disorder (ADHD) is a chronic health condition presenting with symptoms of hyperactivity, impulsivity, and/or inattention in early childhood, adolescence and adulthood. Many patients will persist with associated symptoms throughout their life and may require long term treatment to maintain adequate control. Objective: The purpose of this article is to review the current literature in regards to diagnosis, treatment, and management of ADHD in the pediatric and adolescent population. Methods: A search was conducted using PubMed, Medline, Ovid, and CINHAL with a focus on studies and reviews in the English language from 2008 – 2013, featuring pediatric/adolescent patients across the ages of 4–17 years using the terms: “management”, “attention-deficit”, “hyperactivity”, and “treatment.” Literature referenced prior to the five-year time frame outlined herein provided foundational information on diagnostics and medications. Discussion: Stimulants, in conjunction with behavioral therapy, are standard first line treatments used in ADHD. While stimulant medications have been shown to be effective in treating symptoms associated with ADHD, there are a variety of concerns that may prevent their use. These concerns are related to adverse consequences, many of which are not supported by concrete evidence. Other pharmacotherapy options such as norepinephrine reuptake inhibitors and selective alpha-2 adrenergic agonists are typically reserved as second line options. The use of novel and emerging complementary therapies will also be explored. Conclusion: Patients diagnosed with ADHD must be thoroughly evaluated when making decisions regarding treatment. Many studies and reviews support the efficacy of pharmacotherapy in treatment of ADHD; however, there is insufficient evidence regarding long-term safety of the medications. Further research is warranted to evaluate current treatment options and associated risks and benefits to guide the clinician in optimal management of these patients.