Esther Sobanski

Emotional lability in children and adolescents with attention deficit hyperactivity disorder (ADHD): Clinical correlates and familial prevalence.

BACKGROUND The goal of this study was to investigate the occurrence, severity and clinical correlates of emotional lability (EL) in children with attention deficit/hyperactivity disorder (ADHD), and to examine factors contributing to EL and familiality of EL in youth with ADHD. METHODS One thousand, one hundred and eighty-six children with ADHD combined type and 1827 siblings (aged 6-18 years) were assessed for symptoms of EL, ADHD, associated psychopathology and comorbid psychiatric disorders with a structured diagnostic interview (PACS) as well as parent and teacher ratings of psychopathology (SDQ; CPRS-R:L; CTRS-R:L). Analyses of variance, regression analyses, chi(2)-tests or loglinear models were applied. RESULTS Mean age and gender-standardized ratings of EL in children with ADHD were >1.5 SD above the mean in normative samples. Severe EL (>75th percentile) was associated with more severe ADHD core symptoms, primarily hyperactive-impulsive symptoms, and more comorbid oppositional defiant, affective and substance use disorders. Age, hyperactive-impulsive, oppositional, and emotional symptoms accounted for 30% of EL variance; hyperactive-impulsive symptoms did not account for EL variance when coexisting oppositional and emotional problems were taken into account, but oppositional symptoms explained 12% of EL variance specifically. Severity of EL in probands increased the severity of EL in siblings, but not the prevalence rates of ADHD or ODD. EL and ADHD does not co-segregate within families. CONCLUSION EL is a frequent clinical problem in children with ADHD. It is associated with increased severity of ADHD core symptoms, particularly hyperactivity-impulsivity, and more symptoms of comorbid psychopathology, primarily symptoms of oppositional defiant disorder (ODD), but also affective symptoms, and substance abuse. EL in ADHD seems to be more closely related to ODD than to ADHD core symptoms, and is only partly explainable by the severity of ADHD core symptoms and associated psychopathology. Although EL symptoms are transmitted within families, EL in children with ADHD does not increase the risk of ADHD and ODD in their siblings.

Psychiatric comorbidity and functional impairment in a clinically referred sample of adults with attention-deficit/hyperactivity disorder (ADHD)

ObjectiveThis exploratory study aims to compare lifetime psychiatric axis-I-comorbidity and psychosocial functioning in a clinically referred sample of adult patients with attention-deficit/hyperactivity disorder (ADHD) with a population-based healthy control group and to examine whether patients with ADHD and lifetime comorbid diagnoses differ from patients with pure ADHD in their functional impairment.MethodSeventy adult patients with ADHD according to DSM-IV criteria and a gender- as well as age-matched population based control group underwent diagnostic evaluations with clinical interviews for ADHD, DSM-IV disorders and demographic information.ResultsThe prevalence of psychiatric lifetime comorbidity was 77.1% in patients with ADHD and thus exceeded the rate in the control group, which was 45.7%. Significantly more patients suffered from depressive episodes, substance related disorders and eating disorders. Compared to the control group adults with ADHD were significantly impaired in a variety of psychosocial functions (education, occupational training). Patients with ADHD and lifetime diagnosis of comorbid psychiatric disorders differed from patients with pure ADHD in their psychosocial functioning only in the percentage of unemployed individuals, which was higher in patients with psychiatric comorbidity.ConclusionAdults with ADHD suffer significantly more often from other psychiatric disorders than individuals of the population-based control group and are impaired in several areas of psychosocial functioning. Poor psychosocial outcome is primarily related to ADHD and not to additional psychiatric disorders. Due to the limited number of assessed patients these results need to be confirmed by studies with larger sample size.

Psychiatric comorbidity in adults with attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a chronic, lifelong disorder with childhood-onset, which seriously impairs the affected adults in a variety of daily living functions like educational and occupational functioning, partnership and parenting.ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. The present overview provides information of comorbid psychiatric disorders in adults with ADHD, underlying associations and clinical implications.

Emotional lability in children and adolescents with Attention Deficit/Hyperactivity Disorder (ADHD): Clinical correlates and familial prevalence

BACKGROUND The goal of this study was to investigate the occurrence, severity and clinical correlates of emotional lability (EL) in children with attention deficit/hyperactivity disorder (ADHD), and to examine factors contributing to EL and familiality of EL in youth with ADHD. METHODS One thousand, one hundred and eighty-six children with ADHD combined type and 1827 siblings (aged 6-18 years) were assessed for symptoms of EL, ADHD, associated psychopathology and comorbid psychiatric disorders with a structured diagnostic interview (PACS) as well as parent and teacher ratings of psychopathology (SDQ; CPRS-R:L; CTRS-R:L). Analyses of variance, regression analyses, chi(2)-tests or loglinear models were applied. RESULTS Mean age and gender-standardized ratings of EL in children with ADHD were >1.5 SD above the mean in normative samples. Severe EL (>75th percentile) was associated with more severe ADHD core symptoms, primarily hyperactive-impulsive symptoms, and more comorbid oppositional defiant, affective and substance use disorders. Age, hyperactive-impulsive, oppositional, and emotional symptoms accounted for 30% of EL variance; hyperactive-impulsive symptoms did not account for EL variance when coexisting oppositional and emotional problems were taken into account, but oppositional symptoms explained 12% of EL variance specifically. Severity of EL in probands increased the severity of EL in siblings, but not the prevalence rates of ADHD or ODD. EL and ADHD does not co-segregate within families. CONCLUSION EL is a frequent clinical problem in children with ADHD. It is associated with increased severity of ADHD core symptoms, particularly hyperactivity-impulsivity, and more symptoms of comorbid psychopathology, primarily symptoms of oppositional defiant disorder (ODD), but also affective symptoms, and substance abuse. EL in ADHD seems to be more closely related to ODD than to ADHD core symptoms, and is only partly explainable by the severity of ADHD core symptoms and associated psychopathology. Although EL symptoms are transmitted within families, EL in children with ADHD does not increase the risk of ADHD and ODD in their siblings.

Structured group psychotherapy in adults with attention deficit hyperactivity disorder: results of an open multicentre study.

Attention deficit hyperactivity disorder (ADHD) is a serious mental disorder that often persists in adulthood. In a pilot study, a structured skills training group program for adult ADHD led to significant symptomatic improvements. The present study evaluated the programs effectiveness, feasibility, and patient acceptability in a multicenter setting. Seventy-two adult ADHD patients were assigned to 13 two-hour weekly sessions at 4 different therapy sites. The therapy was well tolerated and led to significant improvements of ADHD, depressive symptoms, and personal health status (p < 0.001). The factors treatment site and medication did not contribute to the overall improvement. Patients regarded the program topics “behavioral analyses,” “mindfulness,” and “emotion regulation” as the most helpful. In this multicenter study, the therapy program showed therapist-independent effects and seemed to be disorder-specific. This warrants the effort of organizing further controlled studies.

Attention deficit hyperactivity disorder in the European adult population: prevalence, disease awareness, and treatment guidelines

Abstract Background: Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobiological disorder with childhood onset and persistence into adolescence and adulthood. Methods: Our literature review reports scientific publications and guidelines on the treatment of adult ADHD, with a particular focus on European countries, identified by literature searches in Medline and Embase. The final literature search was performed in July 2012, incorporating literature from 1974 to 2012. The primary research parameters were ‘Europe’ (including single European countries), ‘ADHD’, ‘attention deficit disorder’, ‘attention deficit’, ‘attention disorder’, and ‘hyperactivity’. Secondary search parameters were ‘comorbid’, ‘epidemiology’ or ‘prevalence’, ‘disease management’, ‘drug therapy’, or ‘therapy’. The main searches were also limited to adults and English language publications. The papers identified by this literature review were selected for inclusion by consensus of the authors based on clinical relevance. Results: Appropriate resources for the diagnosis and treatment of adult ADHD in Europe are scarce, and many cases go untreated, particularly because of the frequent presence of psychiatric comorbidities. Apart from atomoxetine, and an extended-release form of methylphenidate in Germany, no other medications have been approved for starting treatment in adult ADHD patients in the European Union. However, a variety of stimulant and non-stimulant medications are used off-label, and a number of studies have confirmed that these medications are well tolerated and effective in adult patients with ADHD. Conclusions: Our results emphasize the need for broader access to effective treatments for adult ADHD patients in Europe.

Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial

IMPORTANCE Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with high prevalence in adulthood. There is a recognized need to assess the efficacy of psychotherapy in adult ADHD. OBJECTIVE To evaluate the efficacy of cognitive behavioral group psychotherapy (GPT) compared with individual clinical management (CM) and that of methylphenidate hydrochloride compared with placebo. DESIGN, SETTING, AND PARTICIPANTS Prospective, multicenter, randomized clinical trial of 18- to 58-year-old outpatients with ADHD from 7 German study centers. Patients were recruited between January 2007 and August 2010, treatment was finalized in August 2011, and final follow-up assessments occurred in March 2013. INTERVENTIONS Sessions of GPT and CM were held weekly for the first 12 weeks and monthly thereafter (9 months). Patients received either methylphenidate or placebo for 1 year. MAIN OUTCOMES AND MEASURES The primary outcome was the change in the ADHD Index of the Conners Adult ADHD Rating Scale from baseline to the end of the 3-month intensive treatment (blinded observer ratings). Secondary outcomes included ADHD ratings after 1 year, blinded observer ratings using the Clinical Global Impression Scale, and self-ratings of depression. RESULTS Among 1480 prescreened patients, 518 were assessed for eligibility, 433 were centrally randomized, and 419 were analyzed as randomized. After 3 months, the ADHD Index all-group baseline mean of 20.6 improved to adjusted means of 17.6 for GPT and 16.5 for CM, with no significant difference between groups. Methylphenidate (adjusted mean, 16.2) was superior to placebo (adjusted mean, 17.9) (difference, -1.7; 97.5% CI, -3.0 to -0.4; P = .003). After 1 year, treatment effects remained essentially stable. Descriptive analyses showed that methylphenidate was superior to placebo in patients assigned to GPT (difference, -1.7; 95% CI, -3.2 to -0.1; P = .04) or CM (difference, -1.7; 95% CI, -3.3 to -0.2; P = .03). Regarding depression, no significant differences were found. In contrast, GPT was superior to CM for all visits in the Clinical Global Impression global assessment of effectiveness. CONCLUSION AND RELEVANCE Highly structured group intervention did not outperform individual CM with regard to the primary outcome. Psychological interventions resulted in better outcomes during a 1-year period when combined with methylphenidate as compared with placebo. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN54096201.

Further evidence for a low body weight in male children and adolescents with Asperger's disorder

Abstract The study explores the common clinical impression and previously reported finding by Hebebrand et al. (7) of reduced body weight in male children and adolescents with Aspergers disorder (AD). Body weight and height of 36 consecutively admitted male patients with AD were retrospectively assessed for the calculation of body mass indices (BMI, kg/m2). The BMIs were transformed to percentile ranks and plotted into BMI-centiles representative for the German population. In addition, comorbid psychopathology was assessed to explore a possible relationship between associated psychopathology and body weight. The mean BMI-centile of all patients was 34.7 ± 31.8 and, thus, differed significantly from the mean centile of an age- and gender-matched psychiatric control group, which was 52.7 ± 28.3. Thirteen patients had a BMI below the 10th centile and five even below the third. Three of the latter presented with disturbed eating behaviour. Altogether four patients showed disturbed eating behaviour. They had a significantly lower mean BMI-centile than the rest of the group. The BMI-centiles of patients with other additional psychopathology did not differ significantly from the mean percentile of the whole cohort. The results clearly show an increased risk for underweight and disturbed eating behaviour in patients with Aspergers disorder which should be evaluated in further studies.

Impulsivity and Aggression in Female BPD and ADHD Patients: Association with ACC Glutamate and GABA Concentrations

Borderline personality disorder (BPD) and attention-deficit-hyperactivity disorder (ADHD) are both characterized by high impulsivity and difficulties in controlling anger and aggression. In BPD, comorbid ADHD may further increase impulsivity. For both disorders, altered MR spectroscopy levels of the neurotransmitters glutamate and GABA as well as some correlations with impulsivity were previously reported. The objective of this study was to investigate the neurotransmitters glutamate and GABA in relation to impulsivity and aggression as expressed in the anterior cingulate cortex (ACC) in groups of female patients with BPD and ADHD, respectively. Associations of glutamate and GABA levels with further BPD (symptom severity) and ADHD aspects (hyperactivity and inattention) were exploratively evaluated. 1H MR spectra were acquired at 3T to determine glutamate to total creatine ratios (Glu/tCr) and GABA levels from the ACC in a BPD group (n=26), an ADHD group (n=22), and a healthy control (HC) group (n=30); all participants were females. Both patient groups showed higher scores on self-reported impulsivity, anger, and aggression compared with HCs. ACC GABA levels were significantly lower in ADHD than HC. Although measures of impulsivity were positively related to glutamate and negatively to GABA, for aggression only a negative correlation with GABA could be demonstrated. These data provide human in vivo evidence for the role of ACC Glu/tCr and GABA in impulsivity and aggression. If distinct associations of Glu/tCr and GABA for BPD and ADHD can be confirmed in future studies, this might yield implications for more specific pharmacological treatments.

Impulsivity in relation to stress in patients with borderline personality disorder with and without co-occurring attention-deficit/hyperactivity disorder: an exploratory study.

Abstract Impulsivity is regarded as a key feature in borderline personality disorder (BPD). However, discrepancies in previous research indicate that the role of impulsivity in BPD is not yet fully understood. For example, state-dependent impulsivity in individuals with BPD may be related to co-occurring psychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD) and to emotional states. We assessed self-reports of trait and state impulsivity and response inhibition before and after an experimental stress induction in 15 patients with BPD without ADHD, 15 patients with BPD and ADHD, 15 patients with ADHD, and 15 healthy participants. The patients in both BPD subgroups reported a stress-dependent increase of state impulsivity, which was not observed in the other groups. Response inhibition was impaired in the patients with BPD and ADHD but not in those without ADHD compared with the healthy participants. We suggest that stress levels and co-occurring ADHD should receive attention in future studies on impulsivity in BPD.