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1.  Self-Reported quality of life in adults with attention-deficit/hyperactivity disorder and executive function impairment treated with lisdexamfetamine dimesylate: a randomized, double-blind, multicenter, placebo-controlled, parallel-group study 
BMC Psychiatry  2013;13:253.
Background
This study examined the effects of lisdexamfetamine dimesylate (LDX) on quality of life (QOL) in adults with attention-deficit/hyperactivity disorder (ADHD) and clinically significant executive function deficits (EFD).
Methods
This report highlights QOL findings from a 10-week randomized placebo-controlled trial of LDX (30–70 mg/d) in adults (18–55 years) with ADHD and EFD (Behavior Rating Inventory of EF-Adult, Global Executive Composite [BRIEF-A GEC] ≥65). The primary efficacy measure was the self-reported BRIEF-A; a key secondary measure was self-reported QOL on the Adult ADHD Impact Module (AIM-A). The clinician-completed ADHD Rating Scale version IV (ADHD-RS-IV) with adult prompts and Clinical Global Impressions-Severity (CGI-S) were also employed. The Adult ADHD QoL (AAQoL) was added while the study was in progress. A post hoc analysis examined the subgroup having evaluable results from both AIM-A and AAQoL.
Results
Of 161 randomized (placebo, 81; LDX, 80), 159 were included in the safety population. LDX improved AIM-A multi-item domain scores versus placebo; LS mean difference for Performance and Daily Functioning was 21.6 (ES, 0.93, P<.0001); Impact of Symptoms: Daily Interference was 14.9 (ES, 0.62, P<.0001); Impact of Symptoms: Bother/Concern was 13.5 (ES, 0.57, P=.0003); Relationships/Communication was 7.8 (ES, 0.31, P=.0302); Living With ADHD was 9.1 (ES, 0.79, P<.0001); and General Well-Being was 10.8 (ES, 0.70, P<.0001). AAQoL LS mean difference for total score was 21.0; for subscale: Life Productivity was 21.0; Psychological Health was 12.1; Life Outlook was 12.5; and Relationships was 7.3. In a post hoc analysis of participants with both AIM-A and AAQoL scores, AIM-A multi-item subgroup analysis scores numerically improved with LDX, with smaller difference for Impact of Symptoms: Daily Interference. The safety profile of LDX was consistent with amphetamine use in previous studies.
Conclusions
Overall, adults with ADHD/EFD exhibited self-reported improvement on QOL, using the AIM-A and AAQoL scales in line with medium/large ES; these improvements were paralleled by improvements in EF and ADHD symptoms. The safety profile of LDX was similar to previous studies.
Trial registration
ClinicalTrials.gov, NCT01101022
doi:10.1186/1471-244X-13-253
PMCID: PMC3854089  PMID: 24106804
Lisdexamfetamine dimesylate; LDX; ADHD; Quality of life; Executive function
2.  Does Executive Functioning (EF) Predict Depression in Clinic-Referred Adults?: EF Tests vs. Rating Scales 
Journal of affective disorders  2012;145(2):270-275.
Background
Deficits in executive functioning (EF) are implicated in neurobiological and cognitive-processing theories of depression. EF deficits are also associated with Attention-deficit/hyperactivity disorder (ADHD) in adults, who are also at increased risk for depressive disorders. Given debate about the ecological validity of laboratory measures of EF, we investigated the relationship between depression diagnoses and symptoms and EF as measured by both rating scales and tests in a sample of adults referred for evaluation of adult ADHD.
Method
Data from two groups of adults recruited from an ADHD specialty clinic were analyzed together: Adults diagnosed with ADHD (N=146) and a clinical control group of adults referred for adult ADHD assessment but not diagnosed with the disorder ADHD (N=97). EF was assessed using a rating scale of EF deficits in daily life and a battery of tests tapping various EF constructs. Depression was assessed using current and lifetime SCID diagnoses (major depression, dysthymia) and self-report symptom ratings.
Results
EF as assessed via rating scale predicted depression across measures even when controlling for current anxiety and impairment. Self-Management to Time and Self-Organization and Problem-Solving showed the most robust relationships. EF tests were weakly and inconsistently related to depression measures.
Limitations
Prospective studies are needed to rigorously evaluate EF problems as true risk factors for depressive onset.
Conclusions
EF problems in everyday life were important predictors of depression. Researchers and clinicians should consistently assess for the ADHD-depression comorbidity. Clinicians should consider incorporating strategies to address EF deficits when treating people with depression.
doi:10.1016/j.jad.2012.05.064
PMCID: PMC3519951  PMID: 22858220
executive functioning; depressive disorders; attention-deficit/hyperactivity disorder; ADHD; neuropsychological tests; rating scales
3.  Complex Prospective Memory in Adults with Attention Deficit Hyperactivity Disorder 
PLoS ONE  2013;8(3):e58338.
Objectives
Attention deficit hyperactivity disorder (ADHD) in adults has been associated with disturbances of attention and executive functions. Furthermore, impairments of verbal and figural retrospective memory were reported. However, little is known about the effects of ADHD on prospective memory, the execution of delayed intentions in the future.
Methods
The present study compared the performance of 45 adult patients with ADHD not treated with stimulant medication with the performance of 45 matched healthy individuals on a paradigm of complex prospective memory which measured task planning, plan recall, self-initiation and execution. Furthermore, the contribution of other cognitive functions to prospective memory functioning was assessed, including measures of attention, executive functions and memory.
Results
A large-scale impairment could be observed in task planning abilities in patients with ADHD. Only negligible to small effects were found for plan recall, self-initiation and execution. Inhibition was identified to contribute significantly to performance on task planning.
Conclusions
The present findings suggest that four cognitive components contribute to the performance of prospective memory. Impairments of prospective memory mainly emerged from deficient planning abilities in adults with ADHD. Implications on behavioral based intervention strategies are discussed.
doi:10.1371/journal.pone.0058338
PMCID: PMC3590133  PMID: 23484020
4.  Motor regulation problems and pain in adults diagnosed with ADHD 
Background
Most children who are diagnosed with attention deficit-hyperactivity disorder (ADHD) have moderate-to-severe motor problems using the Motor Function Neurological Assessment battery (MFNU). The MFNU focuses on specific muscle adjustment problems associated with ADHD, especially motor inhibition problems and high muscle tone. Here we investigated whether adults with ADHD/hyperkinetic disorder (HKD) have similar motor problems. In our clinical experience, adults with ADHD often complain about back, shoulder, hip, and leg pain. We also investigate reported pain in adults with ADHD.
Methods
Twenty-five adult outpatients diagnosed with ADHD/HKD who were responders to methylphenidate (MPH) were compared to 23 non-ADHD controls on 16 MFNU subtests and using a ‘total score’ (‘TS’) parameter. The MFNU test leader was blinded to group identity. The two groups were also compared using the Pain Drawing and Numerical Pain Rating Scale.
Results
The adult ADHD group had significantly (p < .001) more motor problems (higher TS) than controls. On the muscle regulation subtests, 36–96% of the ADHD group showed ‘moderate’ to ‘severe’ problems compared to 13–52% of the control group, and 80% of the ADHD group reported widespread pain. Highly significant differences were found between the ADHD and control groups for the variables ‘pain level’ (p < .001) and ‘pain location’ (p < .001). Significant correlations were found between TS and ‘pain location’ and between TS and ‘pain level’.
Conclusions
These findings suggest that similar to children with ADHD, adults diagnosed with ADHD also have motor inhibition problems and heightened muscle tone. The presence of significantly higher pain levels and more widespread pain in the ADHD group compared to non-ADHD controls might indicate that pain is a long-term secondary effect of heightened muscle tone and restricted movement that can be demonstrated in children and adults by the MFNU battery.
doi:10.1186/1744-9081-9-18
PMCID: PMC3652792  PMID: 23642255
ADHD; Motor problems; MFNU; Muscular regulation; Tonus; Inhibition; Pain; Adult
5.  When Diagnosing ADHD in Young Adults Emphasize Informant Reports, DSM Items, and Impairment 
Objective
This study examined several questions about the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in young adults using data from a childhood-diagnosed sample of 200 individuals with ADHD (age M = 20.20 years) and 121 demographically similar non-ADHD controls (total N = 321).
Method
We examined the use of self-versus informant ratings of current and childhood functioning and evaluated the diagnostic utility of adult-specific items versus items from the Diagnostic and Statistical Manuel of Mental Disorders (DSM).
Results
Results indicated that although a majority of young adults with a childhood diagnosis of ADHD continued to experience elevated ADHD symptoms (75%) and clinically significant impairment (60%), only 9.6%–19.7% of the childhood ADHD group continued to meet DSM–IV–TR (DSM, 4th ed., text rev.) criteria for ADHD in young adulthood. Parent report was more diagnostically sensitive than self-report. Young adults with ADHD tended to underreport current symptoms, while young adults without ADHD tended to overreport symptoms. There was no significant incremental benefit beyond parent report alone to combining self-report with parent report. Non-DSM-based, adult-specific symptoms of ADHD were significantly correlated with functional impairment and endorsed at slightly higher rates than the DSM-IV-TR symptoms. However, DSM-IV-TR items tended to be more predictive of diagnostic group membership than the non-DSM adult-specific items due to elevated control group item endorsement.
Conclusions
Implications for the assessment and treatment of ADHD in young adults are discussed (i.e., collecting informant reports, lowering the diagnostic threshold, emphasizing impairment, and cautiously interpreting retrospective reports).
doi:10.1037/a0029098
PMCID: PMC3919146  PMID: 22774792
adult ADHD; diagnosis; assessment
6.  Cognitive behaviour therapy in medication-treated adults with ADHD and persistent Symptoms: A randomized controlled trial 
BMC Psychiatry  2011;11:116.
Background
Attention deficit hyperactivity disorder (ADHD) in adulthood is not fully treated by psychopharmacological treatment alone. The main aim of the current study was to evaluate a newly developed cognitive behaviour therapy (CBT) based group programme, the Reasoning and Rehabilitation for ADHD Youths and Adults (R&R2ADHD), using a randomized controlled trial.
Methods
54 adults with ADHD already receiving psychopharmacological treatment were randomly allocated to an experimental (CBT/MED) treatment condition (n = 27) and a 'treatment as usual' (TAU/MED) control condition (n = 27) that did not receive the CBT intervention. The outcome measures were obtained before treatment (baseline), after treatment and at three month follow-up and included ADHD symptoms and impairments rated by independent assessors, self-reported current ADHD symptoms, and comorbid problems.
Results
The findings suggested medium to large treatment effects for ADHD symptoms, which increased further at three month follow-up. Additionally, comorbid problems also improved at follow-up with large effect sizes.
Conclusions
The findings give support for the effectiveness of R&R2ADHD in reducing ADHD symptoms and comorbid problems, an improving functions associated with impairment. The implications are that the benefits of R&R2ADHD are multifaceted and that combined psychopharmacological and CBT based treatments may add to and improve pharmacological interventions.
Trial registration
ACTRN12611000533998 (http://www.ANZCTR.org.au/ACTRN12611000533998.aspx)
doi:10.1186/1471-244X-11-116
PMCID: PMC3155481  PMID: 21787431
7.  The prevalence and effects of Adult Attention-Deficit/hyperactivity Disorder (ADHD) on the performance of workers: Results from the WHO World Mental Health Survey Initiative 
Objectives
To estimate the prevalence and workplace consequences of adult attention-deficit/hyperactivity disorder (ADHD).
Methods
Ann ADHD screen was administered to 18–44 year-old respondents in ten national surveys in the WHO World Mental Health (WMH) Survey Initiative (n = 7075 in paid or self employment; response rate 45.9–87.7% across countries). Blinded clinical reappraisal interviews were administered in the US to calibrate the screen. Days out of role were measured in the WHO Disability Assessment Schedule (WHO-DAS). Questions were also asked about ADHD treatment.
Results
An average of 3.5% of workers in the ten countries was estimated to meet DSM-IV criteria for adult ADHD (inter-quartile range: 1.3–4.9%). ADHD was more common among males than females and less common among professionals than other workers. ADHD was associated with a statistically significant 22.1 annual days of excess lost role performance compared to otherwise similar respondents without ADHD. No difference in the magnitude of this effect was found by occupation, education, age, gender, or partner status. This effect was most pronounced in Colombia, Italy, Lebanon, and the US. Although only a small minority of workers with ADHD ever received treatment for this condition, higher proportions were treated for comorbid mental-substance disorders.
Conclusions
ADHD is a relatively common condition among working people in the countries studied and is associated with high work impairment in these countries. This impairment, in conjunction with the low treatment rate and the availability of cost-effective therapies, suggests that ADHD would be a good candidate for targeted workplace screening and treatment programs.
Main messages
A high proportion of childhood ADHD persists into adulthood.
An average of 3.5% of workers in nationally representative surveys carried out in 10 countries met criteria for current DSM-IV adult ADHD.
Workers with ADHD have an average 8.4 excess sickness absence days per year and even higher annualized average excess numbers of workdays associated with reduced work quantity (21.7 days) and quality (13.6 days).
Only a small majority of these workers are treated for ADHD despite evidence that such treatment can be quite effective in improving functioning.
Policy implications
ADHD is a good candidate for targeted workplace screening and treatment programs.
Evaluation is needed to determine the extent to which best-practices outreach and treatment interventions would result in improvements in work performance that have a positive return-on-investment from the employer perspective.
doi:10.1136/oem.2007.038448
PMCID: PMC2665789  PMID: 18505771
ADHD; Work loss; Functioning
8.  Preliminary data suggesting the efficacy of attention training for school-aged children with ADHD 
A pilot randomized clinical trial was conducted to examine the initial efficacy of Pay Attention!, an intervention training sustained, selective, alternating, and divided attention, in children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). After a diagnostic and baseline evaluation, school-aged children with ADHD were randomized to receive 16 bi-weekly sessions of Pay Attention! (n = 54) or to a waitlist control group (n = 51). Participants completed an outcome evaluation approximately 12 weeks after their baseline evaluation. Results showed significant treatment effects for parent and clinician ratings of ADHD symptoms, child self-report of ability to focus, and parent ratings of executive functioning. Child performance on neuropsychological tests showed significant treatment-related improvement on strategic planning efficiency, but no treatment effects were observed on other neuropsychological outcomes. Treatment effects were also not observed for teacher ratings of ADHD. These data add to a growing body of literature supporting effects of cognitive training on attention and behavior, however, additional research is warranted.
doi:10.1016/j.dcn.2012.11.004
PMCID: PMC3617931  PMID: 23219490
ADHD; Attention training; Cognitive training; Executive functioning; Intervention
9.  Testing for Neuropsychological Endophenotypes in Siblings Discordant for ADHD 
Biological psychiatry  2007;62(9):991-998.
Objective
Neurocognitive deficits associated with attention deficit-hyperactivity disorder (ADHD) may be useful intermediate endophenotypes for determining specific genetic pathways that contribute to ADHD.
Methods
This study administered 17 measures from prominent neuropsychological theories of ADHD (executive function, processing speed, arousal regulation and motivation/delay aversion) in dizygotic (DZ) twin pairs discordant for ADHD and control twin pairs (ages 8–18) in order to compare performance between twins affected with ADHD (n = 266), their unaffected co-twins (n = 228), and control children from twin pairs without ADHD or learning difficulties (n = 332).
Results
ADHD subjects show significant impairment on executive function, processing speed, and response variability measures compared to control subjects. Unaffected cotwins of ADHD subjects are significantly impaired on nearly all the same measures as their ADHD siblings, even when subclinical symptoms of ADHD are controlled.
Conclusion
Executive function, processing speed, and response variability deficits may be useful endophenotypes for genetic studies of ADHD.
doi:10.1016/j.biopsych.2007.04.003
PMCID: PMC2687149  PMID: 17585884
ADHD; endophenotype; genetics; neuropsychology; executive function; processing speed
10.  A controlled study of a simulated workplace laboratory for adults with attention deficit hyperactivity disorder 
Psychiatry research  2012;200(2-3):949-956.
Despite an extant literature documenting that adults with Attention-Deficit/Hyperactivity Disorder (ADHD) are at increased risk for significant difficulties in the workplace, there is little documentation of the underlying factors associated with these impairments. The main aim of this study was to examine specific deficiencies associated with ADHD on workplace performance in a simulated workplace laboratory relative to controls. Participants were 56 non-medicated young adults with DSM-IV ADHD and 63 age and sex matched controls without ADHD. Participants spent 10 hours in a workplace simulation laboratory. Areas assessed included: 1) simulated tasks documented in a government report (SCANS) often required in workplace settings (taxing vigilance; planning; cooperation; attention to detail), 2)observer ratings, and 3)self-reports. Robust findings were found in the statistically significant differences on self-report of ADHD symptoms found between participants with ADHD and controls during all workplace tasks and periods of the workday. Task performance was found to be deficient in a small number of areas and there were few statistically significant differences identified by observer ratings. Symptoms reported by participants with ADHD in the simulation including internal restlessness, intolerance of boredom and difficulty maintaining vigilance were significant and could adversely impact workplace performance over the long-term.
doi:10.1016/j.psychres.2012.04.020
PMCID: PMC3426653  PMID: 22608823
workplace; employment; adult ADHD; self-report
11.  Electrophysiological evidence for abnormal preparatory states and inhibitory processing in adult ADHD 
Background
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder that starts in childhood and frequently persists in adults. Several theories postulate deficits in ADHD that have effects across many executive functions or in more narrowly defined aspects, such as response inhibition. Electrophysiological studies on children, however, indicate that ADHD is not associated with a core deficit of response inhibition, as abnormal inhibitory processing is typically preceded or accompanied by other processing deficits. It is not yet known if this pattern of abnormal processing is evident in adult ADHD.
Methods
The objective of this paper was to investigate event-related potential indices of preparatory states and subsequent response inhibition processing in adults with ADHD. Two cued continuous performance tasks were presented to 21 adults meeting current criteria for adult ADHD and combined type ADHD in childhood, and 20 controls.
Results
The ADHD group exhibited significantly weaker orienting attention to cues, cognitive preparation processes and inhibitory processing. In addition, we observed a strong correlation between the resources allocated to orienting to cues and the strength of the subsequent response strength control processes, suggesting that orienting deficits partly predict and determine response control deficits in ADHD.
Conclusions
These findings closely resemble those previously found in children with ADHD, which indicate that there is not a core response inhibition deficit in ADHD. These findings therefore suggest the possibility of developmental stability into adulthood of the underlying abnormal processes in ADHD.
doi:10.1186/1744-9081-6-66
PMCID: PMC2988695  PMID: 21029446
12.  The FMR1 Premutation and Attention-Deficit Hyperactivity Disorder (ADHD): Evidence for a Complex Inheritance 
Behavior genetics  2011;42(3):415-422.
We recently reported elevated symptoms associated with attention-deficit hyperactivity disorder (ADHD) among adult female carriers of the FMR1 premutation. To gain insight into the contribution of this mutation in the context of polygenes, we examined the proportion of variation in these symptoms due to residual genetic factors after adjustment for the effect of the premutation. To accomplish this, we performed a familial aggregation analysis of ADHD symptoms among 231 females from 82 pedigrees using scores from the Connors Adult ADHD Rating Scales. Results indicate that after accounting for the effect of FMR1, there are significant residual polygenic effects on self-reported symptoms of ADHD, as measured by the ADHD Index (p = 0.0117) and problems with self-concept (p = 0.0110), one specific symptom domain associated with ADHD. For both measures, FMR1 accounts for ~5% of the variance while polygenes account for ~50% of the residual variance, suggesting that the premutation acts in concert with additional genetic loci to influence the severity of ADHD symptoms.
doi:10.1007/s10519-011-9520-z
PMCID: PMC3696489  PMID: 22101959
CGG repeat; Triplet repeat; FMR1; Fragile X syndrome; ADHD; Familial aggregation
13.  Response Time Variability is Related to Parent Ratings of Inattention, Hyperactivity and Executive Function 
Journal of attention disorders  2010;15(7):10.1177/1087054709356379.
Objective:
Individuals with Attention-Deficit/Hyperactivity Disorder (ADHD) are often characterized as inconsistent across many contexts. ADHD is also associated with deficits in executive function. We examined the relationships between response time variability on five brief computer tasks to parents’ ratings of ADHD-related features and executive function in a group of children with a broad range of ADHD symptoms from none to full diagnosis.
Methods:
We tested 98 children (mean age 9.9±1.4 yrs; 66 boys) from community clinics on short Tasks of Executive Control (TEC) and the Eriksen Flanker Task, while a parent completed the Conners Parent Rating Scale and Behavior Rating Inventory of Executive Function.
Results:
Variability for two of the TEC tasks explained significant proportions of the variance of all five ADHD-related Conners subscales and several executive function subscales. By contrast, variability on the flanker task or mean response times for any task were not associated with any rating scale.
Conclusions:
The significant dimensional relationships observed between variability measures and parent ratings support the utility of response time variability as an objective measure in ADHD and aspects of executive functioning that is superior to response time means or accuracy measures.
doi:10.1177/1087054709356379
PMCID: PMC3863378  PMID: 20686098
Attention-Deficit/Hyperactivity Disorder; Intra-subject Variability; Rating Scales; Executive Function
14.  Preparatory neural networks are impaired in adults with attention-deficit/hyperactivity disorder during the antisaccade task☆ 
NeuroImage : Clinical  2012;2:63-78.
Adults with attention-deficit/hyperactivity disorder (ADHD) often display executive function impairments, particularly in inhibitory control. The antisaccade task, which measures inhibitory control, requires one to suppress an automatic prosaccade toward a salient visual stimulus and voluntarily make an antisaccade in the opposite direction. ADHD patients not only have longer saccadic reaction times, but also make more direction errors (i.e., a prosaccade was executed toward the stimulus) during antisaccade trials. These deficits may stem from pathology in several brain areas that are important for executive control. Using functional MRI with a rapid event-related design, adults with combined subtype of ADHD (coexistence of attention and hyperactivity problems), who abstained from taking stimulant medication 20 h prior to experiment onset, and age-match controls performed pro- and antisaccade trials that were interleaved with pro- and anti-catch trials (i.e., instruction was presented but no target appeared, requiring no response). This method allowed us to examine brain activation patterns when participants either prepared (during instruction) or executed (after target appearance) correct pro or antisaccades. Behaviorally, ADHD adults displayed several antisaccade deficits, including longer and more variable reaction times and more direction errors, but saccade metrics (i.e., duration, velocity, and amplitude) were normal. When preparing to execute an antisaccade, ADHD adults showed less activation in frontal, supplementary, and parietal eye fields, compared to controls. However, activation in these areas was normal in the ADHD group during the execution of a correct antisaccade. Interestingly, unlike controls, adults with ADHD produced greater activation than controls in dorsolateral prefrontal cortex during antisaccade execution, perhaps as part of compensatory mechanisms to optimize antisaccade production. Overall, these data suggest that the saccade deficits observed in adults with ADHD do not result from an inability to execute a correct antisaccade but rather the failure to properly prepare (i.e., form the appropriate task set) for the antisaccade trial. The data support the view that the executive impairments, including inhibitory control, in ADHD adults are related to poor response preparation.
Highlights
► The neural correlates of inhibitory control in adults with ADHD were examined. ► We used an interleaved pro and antisaccade task simultaneously with functional MRI. ► This enabled the dissociation of automatic versus voluntary control. ► Patients had less activity in fronto-parietal areas during antisaccade preparation. ► Overall, antisaccade deficits in ADHD adults likely arise from poor preparation.
doi:10.1016/j.nicl.2012.10.006
PMCID: PMC3777763  PMID: 24179760
ADHD; Saccade; fMRI; Preparation; Inhibition
15.  Executive Cognitive Dysfunction and ADHD in Cocaine Dependence: Searching for a Common Cognitive Endophenotype for Addictive Disorders 
Background: Cocaine-dependent individuals (CDI) present executive cognitive function (ECF) deficits, but the impact of psychiatric comorbidities such as Attention-Deficit Hyperactivity Disorder (ADHD) on neuropsychological functioning is still poorly understood. The aim of this study was to investigate if CDI with ADHD (CDI + ADHD) would have a distinct pattern of executive functioning when compared with CDI without ADHD (CDI).
Methods: We evaluated 101 adults, including 69 cocaine-dependent subjects (divided in CDI and CDI + ADHD) and 32 controls. ECF domains were assessed with Digits Forward (DF), Digits Backward (DB), Stroop Color Word Test (SCWT), the Wisconsin Card Sorting Test (WCST), and the Frontal Assessment Battery (FAB). DSM-IV criteria for ADHD were used for diagnosis and previous ADHD symptoms (in the childhood) were retrospectively assessed by the Wender-Utah Rating Scale (WURS).
Results: There were no significant differences between CDI + ADHD, CDI, and controls in estimated intellectual quotient (IQ), socioeconomic background, education (in years), and pre-morbid IQ (p > 0.05). SCWT and WCST scores did not differ across groups (p > 0.05). Nevertheless, CDI and CDI + ADHD performed more poorly than controls in total score of the FAB (p < 0.05). Also, CDI + ADHD did worse than CDI on DF (F = 4.756, p = 0.011), DB (F = 8.037, p = 0.001), Conceptualization/FAB (F = 4.635, p = 0.012), and Mental flexibility/FAB (F = 3.678, p = 0.029). We did not find correlations between cocaine-use variables and neuropsychological functioning, but previous ADHD symptoms assessed by WURS were negatively associated with DF (p = 0.016) and with the total score of the FAB (p = 0.017).
Conclusion: CDI + ADHD presented more pronounced executive alterations than CDI and CDI exhibited poorer cognitive functioning than controls. Pre-existing ADHD symptoms may have a significant negative impact on executive dysfunction in CDI. It remains to be investigated by future studies if symptoms such as impulsivity or a pre-existing ECF dysfunction could represent underlying cognitive endophenotypes that would substantially increase the risk for acquiring addictive disorders.
doi:10.3389/fpsyt.2013.00126
PMCID: PMC3801150  PMID: 24155725
executive dysfunction; ADHD; cocaine; addiction; impulsivity; prefrontal cortex
16.  Mindfulness and Attention Deficit Hyperactivity Disorder 
Journal of clinical psychology  2009;65(10):1087-1098.
Attention Deficit Hyperactivity Disorder (ADHD) is a disorder characterized by attentional difficulties. Mindfulness is a receptive attention to present experience. Both ADHD and mindfulness are associated with attention and personality. This study tests whether individuals with ADHD have lower mindfulness scores than controls and, if true, whether personality contributes to these differences. 105 adults (half with ADHD) were assessed for mindfulness, using the Kentucky Inventory of Mindfulness Skills, and personality, using the Tridimensional Character Inventory. Individuals with ADHD report themselves as less mindful than non-ADHD controls and more novelty-seeking, less self-directed, and more self-transcendent. Mindfulness is negatively associated with ADHD and positively associated with self-directedness and self-transcendence. Analyses of subscales of mindfulness suggest that ADHD is associated most with the ‘Acting in Awareness’ dimension perhaps due to shared items reflecting attentional variability. The current findings support that a large portion of variability in trait mindfulness can be explained by ADHD status and personality traits of self-directedness and self-transcendence. It further suggests that interventions that increase mindfulness might improve symptoms of ADHD and increase self-directedness and/or self-transcendence.
doi:10.1002/jclp.20618
PMCID: PMC2827240  PMID: 19681107
novelty-seeking; self-directedness; self-transcendence; attention; temperament
17.  The Utility of Attention-Deficit/Hyperactivity Disorder Screening Instruments in Individuals Seeking Treatment for Substance Use Disorders 
The Journal of clinical psychiatry  2012;73(11):e1372-e1378.
Objective
Several screening tools for attention-deficit/hyperactivity disorder (ADHD) have been validated in non–substance-abusing populations, but limited data are available regarding their utility in adults with current substance use disorders. The aim of this study was to determine the sensitivity, specificity, and positive and negative predictive values of 3 commonly used ADHD screening instruments in cocaine-dependent individuals.
Method
Adults seeking treatment for cocaine dependence (N = 102) were administered 3 self-report instruments between May 2009 and April 2011: the Conners Adult ADHD Rating Scale (CAARS), the Wender Utah Rating Scale (WURS), and the Adult ADHD Self-Report Scale-Version 1.1 (ASRS-V1.1). They then met with master’s-level clinicians who administered the Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID). With the CAADID serving as the gold standard, the validity of the screening instruments was determined, both singly and in combination.
Results
Twenty-five (25%) of the 102 patients met DSM-IV criteria for ADHD or ADHD not otherwise specified (NOS) based on the CAADID. Kappa scores determining agreement between the screening tools and the CAADID (with ADHD NOS labeled as ADHD or labeled as not ADHD) ranged from 0.37 to 0.69. Sensitivity scores for the broadest range of ADHD cases were 80.0%, 87.5%, and 60.9% for the CAARS, WURS, and ASRS-V1.1, respectively. Positive predictive value was highest for the CAARS, at 74.1%, and negative predictive value was highest for the WURS, at 95.1%. The highest sensitivity (96.0%) was found with coadministration of the WURS and CAARS.
Conclusion
While all of the screening instruments were found to have adequate sensitivity and specificity, the CAARS outperformed the other instruments in regard to agreement with the CAADID and positive predictive values. However, the WURS, with the highest sensitivity in regard to the broadest range of ADHD cases, may be the single best instrument for preliminary screening purposes. Further, because the ASRS-V1.1 is the simplest and shortest instrument to administer, it may have advantages when a large number of patients need to be screened.
doi:10.4088/JCP.12m07895
PMCID: PMC3627386  PMID: 23218166
18.  Neuropsychological Outcome in Adolescents/Young Adults with Childhood ADHD: Profiles of Persisters, Remitters and Controls 
Background
This study examined neuropsychological functioning in a longitudinal sample of adolescents/young adults with ADHD and controls as a function of the persistence of ADHD. We hypothesized that measures of executive processes would parallel adolescent clinical status, with ADHD-Persisters, but not Remitters, differing significantly from Controls. In contrast, Persisters and Remitters were hypothesized to perform similarly, and different from Controls, on tasks requiring less effortful processing.
Methods
Ninety-eight participants diagnosed with ADHD in childhood were reevaluated approximately 10 years later. Eighty-five never-ADHD controls similar in age, IQ, and sex distribution served as a comparison group. Participants were administered a psychiatric interview and neuropsychological test battery.
Results
Those with childhood ADHD demonstrated broad neuropsychological deficits relative to Controls. When the group with childhood ADHD was subdivided based on adolescent ADHD status, compared to Controls, both Persisters and Remitters showed deficient perceptual sensitivity and response variability, and increased ankle movements recorded by a solid-state actigraph. Only Persisters differed from controls on several measures of more effortful executive processes.
Conclusions
Findings provide preliminary support to the hypothesis that ADHD is associated with early-appearing and enduring subcortical dysfunction, while recovery over the course of development is associated with improvements in executive control functions.
doi:10.1111/j.1469-7610.2008.01926.x
PMCID: PMC2646044  PMID: 18573145
19.  Disentangling weak coherence and executive dysfunction: planning drawing in autism and attention-deficit/hyperactivity disorder. 
A tendency to focus on details at the expense of configural information, 'weak coherence', has been proposed as a cognitive style in autism. In the present study we tested whether weak coherence might be the result of executive dysfunction, by testing clinical groups known to show deficits on tests of executive control. Boys with autism spectrum disorders (ASD) were compared with age- and intelligence quotient (IQ)-matched boys with attention-deficit/hyperactivity disorder (ADHD), and typically developing (TD) boys, on a drawing task requiring planning for the inclusion of a new element. Weak coherence was measured through analysis of drawing style. In line with the predictions made, the ASD group was more detail-focused in their drawings than were either ADHD or TD boys. The ASD and ADHD groups both showed planning impairments, which were more severe in the former group. Poor planning did not, however, predict detail-focus, and scores on the two aspects of the task were unrelated in the clinical groups. These findings indicate that weak coherence may indeed be a cognitive style specific to autism and unrelated to cognitive deficits in frontal functions.
doi:10.1098/rstb.2002.1204
PMCID: PMC1693126  PMID: 12639335
20.  The Latent Structure of Attention Deficit/Hyperactivity Disorder in an Adult Sample 
Journal of Psychiatric Research  2012;46(6):782-789.
The vast majority of studies that have examined the latent structure of attention deficit/hyperactivity disorder (ADHD) in children and adolescents have concluded that ADHD has a dimensional latent structure. In other words, ADHD symptomatology exists along a continuum and there is no natural boundary or qualitative distinction (i.e., taxon) separating youth with ADHD from those with subclinical inattention or hyperactivity/impulsivity problems. Although adult ADHD appears to be less prevalent than ADHD in youth (which could suggest a more severe adult ADHD taxon), researchers have yet to examine the latent structure of ADHD in adults. The present study used a sample (N = 600) of adults who completed a self-report measure of ADHD symptoms. The taxometric analyses revealed a dimensional latent structure for inattention, hyperactivity/impulsivity, and ADHD. These findings are consistent with previous taxometric studies that examined ADHD in children and adolescents, and with contemporary polygenic and multifactorial models of ADHD.
doi:10.1016/j.jpsychires.2012.03.010
PMCID: PMC3359405  PMID: 22480749
ADHD; taxometric analysis; latent structure
21.  Women with Childhood ADHD: Comparisons by Diagnostic Group and Gender 
This study compared adult women with childhood ADHD to adult women without childhood ADHD and to adult men with childhood ADHD. The participants, all from a larger longitudinal study, included 30 women and 30 men (approximately age 23 to 24) with childhood ADHD, and 27 women without ADHD. Women with childhood ADHD were matched to comparison women on age, ethnicity, and parental education, and to men with childhood ADHD on age, ethnicity, and IQ. Self- and parent-reports of internalizing, interpersonal, academic, and job impairment, as well as substance use and delinquency indicated group differences on measures of self-esteem, interpersonal and vocational functioning, as well as substance use. Follow-up planned comparison tests revealed that almost all of these differences emerged by diagnostic status, and not by gender. This study adds to research on the negative adult outcomes of ADHD and demonstrates that the outcomes of men and women with childhood ADHD are relatively similar.
doi:10.1007/s10862-011-9247-4
PMCID: PMC3251258  PMID: 22228922
ADHD; Gender
22.  Attention Network Test in adults with ADHD - the impact of affective fluctuations 
Background
The Attention Network Test (ANT) generates measures of different aspects of attention/executive function. In the present study we investigated whether adults with ADHD performed different from controls on measures of accuracy, variability and vigilance as well as the control network. Secondly, we studied subgroups of adults with ADHD, expecting impairment on measures of the alerting and control networks in a subgroup with additional symptoms of affective fluctuations.
Methods
A group of 114 adults (ADHD n = 58; controls n = 56) performed the ANT and completed the Adult ADHD Rating Scale (ASRS) and the Mood Disorder Questionnaire (MDQ). The latter was used to define affective fluctuations.
Results
The sex distribution was similar in the two groups, but the ADHD group was significantly older (p = .005) and their score on a test of intellectual function (WASI) significantly lower than in the control group (p = .007). The two groups were not significantly different on measures of the three attention networks, but the ADHD group was generally less accurate (p = .001) and showed a higher variability through the task (p = .033).
The significance was only retained for the accuracy measure when age and IQ scores were controlled for. Within the ADHD group, individuals reporting affective fluctuations (n = 22) were slower (p = .015) and obtained a lower score on the alerting network (p = .018) and a higher score on the conflict network (p = .023) than those without these symptoms. The significance was retained for the alerting network (p = .011), but not the conflict network (p = .061) when we controlled for the total ASRS and IQ scores.
Discussion
Adults with ADHD were characterized by impairment on accuracy and variability measures calculated from the ANT. Within the ADHD group, adults reporting affective fluctuations seemed to be more alert (i.e., less impacted by alerting cues), but slower and more distracted by conflicting stimuli than the subgroup without such fluctuations. The results suggest that the two ADHD subgroups are characterized by distinct patterns of attentional problems, and that the symptoms assessed by MDQ contribute to the cognitive heterogeneity characterizing groups of individuals with ADHD.
doi:10.1186/1744-9081-7-27
PMCID: PMC3168400  PMID: 21794128
23.  PROCESS EXAMINATION OF EXECUTIVE FUNCTION IN ADHD: SEX AND SUBTYPE EFFECTS 
The Clinical neuropsychologist  2008;22(5):826-841.
To examine effects of group (Attention-Deficit/Hyperactivity Disorder [ADHD] versus Typically Developing [TD]), sex, and ADHD subtype on “process/optional” measures of executive functioning, children (n = 123; 54 ADHD, 69 TD) aged 8−16 completed subtests from the D-KEFS. No group, sex, or ADHD subtype effects were found on optional measures from the Trail Making, Color–Word Interference, and Tower tests. A significant interaction was found for Verbal Fluency Total Repetition Errors; boys with Combined/Hyperactive-Impulsive (ADHD-C/HI) type ADHD performed better than ADHD-C/HI girls, whereas girls with Inattentive type ADHD (ADHD-I) performed better than ADHDI boys. Overall, children with ADHD did not differ from TD on most optional measures from the D-KEFS. When sex and ADHD subtype were considered, children with the subtype of ADHD less common for sex were at greater risk for poorer performance.
doi:10.1080/13854040701563583
PMCID: PMC2575661  PMID: 18609314
Process approach; ADHD; Executive function; D-KEFS
24.  Adherence with Electronic Monitoring and Symptoms in Children with Attention Deficit Hyperactivity Disorder 
Psychiatry Investigation  2012;9(3):263-268.
Objective
The primary aim of this study was to compare electronic monitoring with other measures of adherence to Osmotic-controlled Release Oral delivery System methylphenidate in children with attention-deficit hyperactivity disorder (ADHD). The secondary aim was to analyze the relationships between adherence and clinical factors, including ADHD symptoms.
Methods
Thirty-nine children diagnosed with ADHD were monitored for adherence to medication over the course of eight weeks. Medication adherence was assessed using the Medication Event Monitoring System (MEMS), which is a bottle cap with a microprocessor that records all instances and times that the bottle is opened; patient self-report; clinician rating; and pill count. Information, including demographic and clinical characteristics, symptom rating scale, and psychological test results, were also collected. The relationships between adherence and clinical factors, including ADHD rating scores of baseline and of the changes, were assessed.
Results
The rate of non-adherence measured by the MEMS was found to be 46.2%, which was considerably higher than those of the patient self-report (17.9%), clinician rating (31.7%), and pill count (12.8%) of non-adherence. The rate of adherence measured by the MEMS was not significantly associated with baseline symptom severity or symptom changes over the eight weeks, although non-adherent group showed more severe baseline symptoms and inferior improvement.
Conclusion
Adherence as measured by the MEMS showed a discrepancy with other measures of adherence in patients with ADHD. The symptom severity and level of improvement were not related to adherence with MEMS. Further studies are needed to evaluate the variables that may impact medication adherence in children with ADHD.
doi:10.4306/pi.2012.9.3.263
PMCID: PMC3440476  PMID: 22993526
Attention-deficit hyperactivity disorder; Adherence; Medication Event Monitoring System; Symptoms
25.  Visual function and color vision in adults with Attention-Deficit/Hyperactivity Disorder 
Journal of Optometry  2013;7(1):22-36.
Purpose
Color vision and self-reported visual function in everyday life in young adults with Attention-Deficit/Hyperactivity Disorder (ADHD) were investigated.
Method
Participants were 30 young adults with ADHD and 30 controls matched for age and gender. They were tested individually and completed the Visual Activities Questionnaire (VAQ), Farnsworth-Munsell 100 Hue Test (FMT) and A Quick Test of Cognitive Speed (AQT).
Results
The ADHD group reported significantly more problems in 4 of 8 areas on the VAQ: depth perception, peripheral vision, visual search and visual processing speed. Further analyses of VAQ items revealed that the ADHD group endorsed more visual problems associated with driving than controls. Color perception difficulties on the FMT were restricted to the blue spectrum in the ADHD group. FMT and AQT results revealed slower processing of visual stimuli in the ADHD group.
Conclusion
A comprehensive investigation of mechanisms underlying visual function and color vision in adults with ADHD is warranted, along with the potential impact of these visual problems on driving performance.
doi:10.1016/j.optom.2013.07.001
PMCID: PMC3938738  PMID: 24646898
Visual function; Adults with ADHD; Color vision; ADHD; Función visual; Adultos con TDAH; Visión de color; TDAH

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