Mary V. Solanto

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).

Development of a New Psychosocial Treatment for Adult ADHD

Objective: The purpose of this study was to assess the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills. Method: Thirty adults diagnosed with ADHD completed an 8- or 12-week program designed to target impairments in time management, organization, and planning skills. Treatment efficacy was measured using pre- and posttreatment self-report standardized measures (CAARS-S:L & Brown ADD Scales). Results: General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale (p < .001) as well as improvement on the Brown ADD Scales (p < .001). Conclusion: The findings indicate that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (J. of Att. Dis. 2008; 11(6) 728-736)

Research Forum on Psychological Treatment of Adults With ADHD

Background: A literature search found five empirical studies of psychological treatment for adults with ADHD, out of 1,419 articles on ADHD in adults. Practice guidelines to date all recommend multimodal intervention, given that a significant number of patients cannot tolerate, do not respond to, or fail to reach optimal outcomes with medication alone. Method: This article provides a literature review and the recommendations of a forum of experts in the psychological treatment of adults with ADHD. Results: Empirical studies of brief, structured, and short-term psychological interventions for adults with ADHD to date demonstrate moderate to large effect sizes. Methodological challenges include selection of control groups, broad-based measures of outcome, and the need for larger samples. Conclusion: Psychological treatment may play a critical role in the management of adults with ADHD who are motivated and developmentally ready to acquire new skills as symptoms remit. (J. of Att. Dis. 2008; 11(6) 642-651)

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

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).

Stimulant Drug Response in the Predominantly Inattentive and Combined Subtypes of Attention-Deficit/Hyperactivity Disorder

OBJECTIVEnThis 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.nnnMETHODnThe 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.nnnRESULTSnTwenty-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.nnnCONCLUSIONSnResults support the clinical utility of MPH in the treatment of the PI subtype and provide no evidence of differences in response between the subtypes.

Social Functioning in Predominantly Inattentive and Combined Subtypes of Children With ADHD

Objective: The objective of this study was to compare the social functioning of children with the Combined (CB) and Predominantly Inattentive (PI) subtypes of Attention Deficit/Hyperactivity Disorder (ADHD), controlling for comorbidity and medication-status, which may have confounded the results of previous research. Method: Parents and teachers of rigorously diagnosed unmedicated children with PI or CB subtypes of ADHD, and typical comparison children, rated them on the multidimensional Social Skills Rating Scale (SSRS). Results: After co-varying for oppositionality and anxiety, social impairment was substantial and equivalent in both ADHD groups whether rated by parent or teacher. In addition, when rated by teacher, the nature of the deficits varied by subtype: Children with PI were impaired in assertiveness, whereas children with CB were deficient in self-control. These findings indicate that AD/HD subtypes differ in the nature of their social dysfunction independent of comorbidity and highlight the need for interventions to target their divergent needs.

The utility of self-report measures and the continuous performance test in the diagnosis of ADHD in adults.

BACKGROUNDnAttention-deficit/hyperactivity disorder (ADHD) occurs in as many as 4 percent of adults yet it is often not recognized in clinical settings because the presenting symptoms may resemble those seen in other disorders or because symptoms may be masked by commonly comorbid conditions such as anxiety and depression.nnnOBJECTIVEnThe purpose of this study was to examine the diagnostic utility of instruments commonly used in the assessment of adults presenting with symptoms of ADHD.nnnMETHODSnWe reviewed several widely used self-report and laboratory measures and empirically examined the utility of the Brown Attention-Deficit Disorder Scale for Adults (Brown ADD Scale) and the Conners Continuous Performance Test (CPT) in differentially identifying adults with ADHD and those with other Axis I disorders.nnnRESULTSnNinety-three adults who self-referred to the ADHD program for adults at a university medical center participated in the study. Of these, 44 had ADHD combined subtype (ADHD-CB), and 26 had ADHD, predominantly inattentive subtype (ADHD-IA). Thirty-three non-ADHD adults diagnosed with Axis I mood or anxiety disorders comprised an Other Psychiatric group. Rates of comorbid disorders, including substance abuse, in the ADHD groups were typical of those reported in the adult ADHD literature. Data on the Brown ADD Scale and on the CPT were available for subsets of 61 and 46 participants, respectively. Analyses showed that the ADHD-CB, ADHD-IA, and Other Psychiatric groups all received mean scores in the clinical range on the Brown ADD Scale, with a trend toward even higher elevations in the two ADHD groups. Among 12 CPT variables assessed for the three groups, the mean scores on only two variables for the ADHD-IA group were clinically elevated. Neither the Brown ADD Scale nor CPT scores evinced sufficient sensitivity and specificity to qualify them to assist in differential diagnosis of ADHD vis-a-vis other, predominantly internalizing, psychiatric disorders.nnnCONCLUSIONnThe results indicate a need for closer examination of executive and adaptive functioning in adults with ADHD compared with those with internalizing disorders in order to identify features that could assist in differential diagnosis.

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.

Bipolar disorder and comorbid attention deficit hyperactivity disorder. A distinct clinical phenotype? Clinical characteristics and temperamental traits1

Abstract 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.

Managing ADHD across the Lifespan in the Primary Care Setting

Abstract 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 Organizations 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.