Cognitive Complaints of Adults With Attention Deficit Hyperactivity Disorder

Identification and treatment of individuals with attention-deficit/hyperactivity disorder and substance use disorder: An expert consensus statement

Attention-deficit/hyperactivity disorder (ADHD) often co-occurs with substance use (SU) and/or substance use disorder (SUD). Individuals with concurrent ADHD and SU/SUD can have complex presentations that may complicate diagnosis and treatment. This can be further complicated by the context in which services are delivered. Also, when working with young people and adults with co-existing ADHD and SU/SUD, there is uncertainty among healthcare practitioners on how best to meet their needs. In February 2022, the United Kingdom ADHD Partnership hosted a meeting attended by multidisciplinary experts to address these issues. Following presentations providing attendees with an overview of the literature, group discussions were held synthesizing research evidence and clinical experience. Topics included: (1) A review of substances and reasons for use/misuse; (2) identification, assessment and treatment of illicit SU/SUD in young people and adults with ADHD presenting in community services; and (3) identification, assessment and treatment of ADHD in adults presenting in SU/SUD community and inpatient services. Dis-cussions highlighted inter-service barriers and fragmentation of care. It was concluded that a multimodal and multi-agency approach is needed. The consensus group generated a table of practice recommendations providing guidance on: identification and assessment; pharmacological and psychological treatment; and multi-agency interventions.

Genetic risk for attention-deficit/hyperactivity disorder predicts cognitive decline and development of Alzheimer's disease pathophysiology in cognitively unimpaired older adults

Attention-deficit/hyperactivity disorder (ADHD) persists in older age and is postulated as a risk factor for cognitive impairment and Alzheimer's Disease (AD). However, these findings rely primarily on electronic health records and can present biased estimates of disease prevalence. An obstacle to investigating age-related cognitive decline in ADHD is the absence of large-scale studies following patients with ADHD into older age. Alternatively, this study aimed to determine whether genetic liability for ADHD, as measured by a well-validated ADHD polygenic risk score (ADHD-PRS), is associated with cognitive decline and the development of AD pathophysiology in cognitively unimpaired (CU) older adults. We calculated a weighted ADHD-PRS in 212 CU individuals without a clinical diagnosis of ADHD (55-90 years). These individuals had baseline amyloid-β (Aβ) positron emission tomography, longitudinal cerebrospinal fluid (CSF) phosphorylated tau at threonine 181 (p-tau181), magnetic resonance imaging, and cognitive assessments for up to 6 years. Linear mixed-effects models were used to test the association of ADHD-PRS with cognition and AD biomarkers. Higher ADHD-PRS was associated with greater cognitive decline over 6 years. The combined effect between high ADHD-PRS and brain Aβ deposition on cognitive deterioration was more significant than each individually. Additionally, higher ADHD-PRS was associated with increased CSF p-tau181 levels and frontoparietal atrophy in CU Aβ-positive individuals. Our results suggest that genetic liability for ADHD is associated with cognitive deterioration and the development of AD pathophysiology. Findings were mostly observed in Aβ-positive individuals, suggesting that the genetic liability for ADHD increases susceptibility to the harmful effects of Aβ pathology.

Networks of Neuropsychological Functions in the Clinical Evaluation of Adult ADHD

This study applied network analysis to explore the relations between neuropsychological functions of individuals in the clinical evaluation of attention-deficit/hyperactivity disorder (ADHD) in adulthood. A total of 319 participants from an outpatient referral context, that is, 173 individuals with ADHD (ADHD group) and 146 individuals without ADHD (n-ADHD group), took part in this study and completed a comprehensive neuropsychological assessment. A denser network with stronger global connectivity was observed in the ADHD group compared to the n-ADHD group. The strongest connections were consistent in both networks, that is, the connections between selective attention and vigilance, and connections between processing speed, fluency, and flexibility. Further centrality estimation revealed attention-related variables to have the highest expected influence in both networks. The observed relationships between neuropsychological functions, and the high centrality of attention, may help identify neuropsychological profiles that are specific to ADHD and optimize neuropsychological assessment and treatment planning of individuals with cognitive impairment.

Pilot Study of the Cognitive–Functional Intervention for Adults (Cog-Fun A): A Metacognitive–Functional Tool for Adults With Attention Deficit Hyperactivity Disorder

Importance: Adults with attention deficit hyperactivity disorder (ADHD) often experience chronic challenges in their life roles. There is a need for evidence-based occupational therapy interventions to help enhance their functioning.

Objective: To determine the preliminary effectiveness of the Cognitive–Functional Intervention for Adults (Cog–Fun A), a metacognitive–functional occupational therapy tool for the improvement of occupational performance (OP) and quality of life (QoL) in adults with ADHD.

Design: One-group pretest–posttest design with a 3-mo follow-up.

Setting: Community setting in Jerusalem, Israel.

Participants: Fourteen adults, ages 18–60 yr, with a valid diagnosis of ADHD and an indication of executive function (EF) impairment.

Intervention: Participants received 15 1-hr weekly sessions that addressed self-awareness of strengths and challenges through education and guided discovery as well as strategy acquisition and implementation within a context of occupational goal attainment.

Outcomes and Measures: The Behavioral Rating Inventory of Executive Function–Adult version, an adult ADHD QoL measure, the Canadian Occupational Performance Measure, and the Self-Regulation Skills Interview were administered.

Results: Twelve participants completed the intervention. Posttreatment scores revealed statistically significant improvements in EF, awareness, OP, and QoL. Gains in QoL showed a modest reduction at the 3-mo follow-up.

Conclusions and Relevance: The Cog–Fun A is a promising intervention for improving OP and QoL among adults with ADHD and should be investigated further.

What This Article Adds: The Cog–Fun A offers an effective nonpharmacological, metacognitive–functional, occupation-centered treatment option for adults with ADHD.

Dendritic and behavioral changes in rats neonatally treated with homocysteine; A proposal as an animal model to study the attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHAD) is a neurobehavioral disorder that affects children and adolescents with a high prevalence. Despite its prevalence and an unclear etiology, previous reports suggest that it is closely related to homocysteine metabolism. Male Sprague Dawley rats were administered with homocysteine from postnatal day (PD) 2 to PD 16. Locomotor activity was evaluated at 35 PD (prepuberal age) and 60 PD (adult age) before and after amphetamine administration. In rats evaluated at both ages, homocysteine induced hyperactivity, and the amphetamine administration reduced hyperactivity significantly at 35 PD, but not at 60 PD. In the social interaction test, homocysteine reduced the number of contacts and increased the latency to the first contact only in rats at 35 PD. Homocysteine also had an effect on short term memory at 35D and 60 PD and long-term memory at 60 PD. Morphological changes were found mainly in the shape of dendritic spines in the prefrontal cortex (PFC-3), dorsal hippocampus (CA1), dentate gyrus (DG) and nucleus accumbens (NAcc), in rats administered neonatally with homocysteine at both ages studied. In prepuberal and adult rats, there was an increase in dendritic length in DG and NAcc, respectively. The dendritic spine morphology also was altered at both ages, mainly decreasing the number of mushroom spines in NAcc and CA1 at 30 PD and in all the areas studied at 60 PD rats. Those areas are associated with the processes of attention, learning and memory that were studied, and those alterations are possibly related to changes observed in the behavioral tests. These behavioral and morphological changes in rats at 35 PD administered with homocysteine could be similar to changes found in children diagnosed with ADHD. Moreover, half to two thirds of children diagnosed with ADHD reach adulthood with this disorder. In this study we found similarities with ADHD, finding alterations in both rats at 35 PD and 60 PD. So, this may be proposed as an animal model to study this disorder present in children, adolescents and adults.

Neuropsychological functioning of individuals at clinical evaluation of adult ADHD

OBJECTIVES

Numerous studies showed that adults with attention deficit hyperactivity disorder (ADHD) suffer from impairments in a range of cognitive functions when compared to healthy controls. However, only little is known about the neuropsychological functions when compared to various clinical control groups and whether a distinct neuropsychological profile can be identified for adult ADHD.

METHOD

This retrospective study examined data of 199 outpatients referred for clinical evaluation of adult ADHD, allocated either to an ADHD group (n = 78) or to one of two clinical comparison groups, depending on whether they show indications (n = 71) or no indications (n = 50) for the presence of psychiatric disorders other than ADHD. All individuals performed a comprehensive neuropsychological test battery.

RESULTS

Data analysis revealed impairments in a range of cognitive functions in a substantial number of patients of all three groups. However, profiles of neuropsychological impairments were similar between groups. Furthermore, significant small- to medium-sized correlations between basic and higher-order cognitive functions were revealed in the ADHD group and the clinical comparison group with indications for psychiatric disorders other than ADHD.

CONCLUSION

Neuropsychological impairments are prominent in psychiatric outpatients seeking a clinical evaluation of adult ADHD but are not specific for ADHD. It is concluded that neuropsychological test performance may have limited incremental value to support the psychiatric differential diagnosis. Furthermore, a clinical trajectory may need to take into account that deficits in a range of higher-order cognitive functions can be substantially explained by deficits in basic cognitive functions.

Neuropsychological Deficits in Adult ADHD: Evidence for Differential Attentional Impairments, Deficient Executive Functions, and High Self-Reported Functional Impairments

Objective: This study is aimed to investigate neuropsychological deficits in adult ADHD. Method: Neuropsychological deficits in terms of executive functions, divided, selective, and sustained attention, were investigated in a group of adults with ADHD using a series of neuropsychological tests as well as electroencephalography (EEG). Subjective ratings of everyday life attention and memory problems were also collected. Results: Adults with ADHD showed impairments in executive functions, divided attention and sustained attention, compared with adult controls. Performance on selective attention tasks in adults with ADHD was instead no different from control participants' performance. EEG results confirmed neuropsychological findings by showing a selective impairment on P3 event-related potential (ERP) amplitude indicative of sustained attention deficits. Higher subjective ratings of everyday attentional and memory problems were also found in the ADHD group compared with the control group. Conclusion: This pattern of results suggests differential impairments of attentional skills. Impaired executive functions and higher subjective functional impairments were also found.

Mind-wandering and sleepiness in adults with attention-deficit/hyperactivity disorder

Sleepiness and mind-wandering are frequently experienced by patients with attention-deficit/hyperactivity disorder (ADHD), without ever having been jointly explored. We aimed to investigate the co-occurrence of these two phenomena in ADHD adults. Drug-free ADHD adults (n = 25) and healthy controls (n = 28) underwent an online experience sampling of mind-wandering episodes and subjective sleepiness. Participants completed self-reported measures of mind-wandering and sleepiness in daily life. Higher trait of mind-wandering was observed in ADHD patients compared to controls. On the whole sample, self-reported mind-wandering propensity was strongly associated with the severity of inattentive, impulsive and hyperactive symptoms. During the probes, patients reported more frequent episodes of mind-wandering and mind-blanking, and higher sleepiness. Their mind-wandering episodes were less intentional and belonged less frequently to a structured succession of thoughts. In both groups, mind-wandering and mind-blanking were associated with higher sleepiness. On the SART, patients were less accurate than controls. We provide first initial evidence for higher propensity of mind-wandering and mind-blanking using experience sampling in patients with formal ADHD diagnosis. This propensity was associated with sleepiness without negatively impacting attention performances. Mind-wandering and sleepiness have common determinants potentially involved in ADHD pathophysiology. Correlates of mind-blanking in ADHD adults remain to be characterized.

Basic processes as foundations of cognitive impairment in adult ADHD

Attention deficit hyperactivity disorder (ADHD) in adulthood is associated with impairment of multiple aspects of cognition which adversely affect the individual's everyday functioning. However, little is known about how these impairments are intertwined. This study explores whether impairments in basic processes (processing speed and distractibility) in adults with ADHD explain impairments in higher order functions, namely executive functions, memory, and complex attention. Furthermore, it is explored whether pharmacological treatment with methylphenidate (MPH) affects basic processes and higher order functions. A between-subjects design compared patients with ADHD without stimulant drug treatment (N = 55) and patients with ADHD treated with MPH (N = 31) with a healthy control group (N = 80). A neuropsychological test battery assessing basic processes and higher order functions was administered. Hierarchical logistic regression analyses were performed to evaluate the contribution of basic processes to impairments in higher order functions. Patients with ADHD not treated with MPH showed impairments in basic processes and higher order functions compared to controls. The impairments in basic processes explained 41-43% of impairments in executive functions, 27-29% in memory, and 56-74% in complex attention. In patients with ADHD treated with MPH, basic processes were not impaired and did not contribute significantly to impairments of higher order functions. Basic processes may constitute part of the foundation of cognitive impairments in adult ADHD. MPH may improve cognitive performance, presumably through improving basic processes. Applying this information could optimize neuropsychological assessments and inform treatment strategies by targeting basic processes.

Detection of adult attention deficit hyperactivity disorder with cognitive complaint: Experience of a French memory center

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) is a frequent neurodevelopmental mental disorder. It can persist in adulthood and be expressed as a cognitive complaint.

METHODS

We conducted a descriptive study in a French memory center concerning patients seen over a period of two years. All patients for whom the final diagnosis was ADHD were included. All patients benefited from standard neuropsychological tests and a psychiatric specific consultation.

RESULTS

Thirteen patients were included with an average age of 50.2±19 years. Main complaints related to memory, attention, focusing and organizational functioning. These difficulties had negative social, professional and academic consequences. ADHD history in descendants was noted in 46% of patients. More than 20% of subjects had motor, verbal or mental restlessness. Neuropsychological assessment highlighted impaired performances in executive functions (38%), sustained attention (67%), divided attention (45%), working memory (46%) and information processing speed (75%). A psychiatric history or comorbidities were present in 85% of patients, mostly of the anxio-depressive type. The more prevalent presentations of ADHD were the combined (38%) and inattentive (38%) types.

DISCUSSION

Adult ADHD can masquerade as a cognitive impairment, including a stable cognitive complaint from infancy to old age. Inattentive, hyperactive and impulsive symptoms change with time and become more internalized (such as concentration difficulties or mental restlessness). No neuropsychological pattern has been reported but fluctuating deficits in sustained, divided attention, working memory and information processing speed are frequently observed in adult ADHD. A specific psychiatric expertise is essential in diagnosis and care for ADHD and its commonly associated psychiatric comorbidities.

Increased Beta Activity Links to Impaired Emotional Control in ADHD Adults With High IQ

OBJECTIVE

The present study investigated the neuropathology of everyday-life executive function (EF) deficits in adults with ADHD with high IQ.

METHOD

Forty adults with ADHD with an IQ ≥ 120 and 40 controls were recruited. Ecological EFs were measured, and eyes-closed Electroencephalograph (EEG) signals were recorded during a resting-state condition; EEG power and correlations with impaired EFs were analyzed.

RESULTS

Compared with controls, the ADHD group showed higher scores on all clusters of EF. The ADHD group showed globally increased theta, globally decreased alpha, and increased central beta activity. In the ADHD group, central beta power was significantly related to emotional control ratings, while no such correlation was evident in the control group.

CONCLUSION

The results suggest that resting-state beta activity might be involved in the neuropathology of emotional control in adults with ADHD with high IQ.

Remittance or persistence of attention deficit-hyperactivity disorder (ADHD) and its impact on recidivism in risky driving behaviors

OBJECTIVE

Recent data regarding the persistence or remittance of attention deficit-hyperactivity disorder (ADHD) diagnosis into adulthood raise the question of its possible role in crucial public health issues, including road safety, especially when neurocognitive capacities are challenged.

METHODS

The study included 611 participants with serious traffic violations. The Spanish version of the Mini International Neuropsychiatric Interview (M.I.N.I.) was used to assess psychopathology. They were grouped into 3 diagnostic conditions: non-ADHD, persistent ADHD (ADHD-P), and remittent ADHD (ADHD-R). Several risky driving behaviors were analyzed.

RESULTS

Although participants with ADHD have more driving violations relative to non-ADHD, ADHD-R, and ADHD-P drivers have similar profiles. ADHD-R and ADHD-P drivers are more prone to perform risky and recidivistic behaviors relative to non-ADHD counterparts (P = .044 and P = .047, respectively); ADHD-R and ADHD-P participants are statistically comparable in this proneness (P = .772).

CONCLUSION

These results suggest that the underlying core deficits of ADHD-attention and other executive disabilities-persist despite the fact that some people no longer reach the threshold for clinical diagnosis.

What Predicts a Good Adolescent to Adult Transition in ADHD? The Role of Self-Reported Resilience

OBJECTIVE

ADHD is a disorder associated with impairment and comorbid psychiatric problems in young adulthood; therefore, factors that may imply a more favorable outcome among adolescents with ADHD are of interest.

METHOD

This study used a longitudinal design to assess whether adolescent personal resilience characteristics during adolescence protected against psychosocial impairment, depression, and anxiety 3 years later. Self-reported protective factors were used as baseline measures in the assessment of 190 clinically referred adolescents with ADHD. A semi-structured diagnostic interview was performed at the follow-up.

RESULTS

In a group of youth with ADHD, personal resilience characteristics were associated with better psychosocial functioning in young adulthood, and less depression and anxiety.

CONCLUSION

Although further research is needed, these results indicate that personal resilience characteristics may be protective factors in the transitional period from adolescence to early adulthood.