Implications of early versus late onset of attention-deficit/hyperactivity disorder symptoms

OBJECTIVE: The current diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) require that symptoms emerge prior to age 7 in order for a formal diagnosis to be considered. However, this age-of-onset criterion (AOC) has recently been questioned on both theoretical and empirical grounds. METHOD: Data from 4 annual waves of interviews with 9- to 16-year-olds from the Great Smoky Mountains Study were analyzed. RESULTS: Confirming previous studies, a majority of youths who had enough symptoms to meet criteria for ADHD were reported to have first exhibited these symptoms prior to age 7. Early onset of ADHD symptoms was associated with worse clinical outcomes in youths with the combined subtype of ADHD but not youths with the inattentive subtype. CONCLUSIONS: Findings support the continued inclusion of the AOC for the assessment of the combined but not necessarily the inattentive subtype of ADHD. Too few youths had a late onset of solely hyperactive-impulsive symptoms to evaluate the AOC for that group. However, regardless of the age of onset, youths who had elevated levels of ADHD symptoms were at increased risk for negative outcomes that may necessitate intervention.     

Comorbidity of adult attention-deficit hyperactivity disorder and bipolar disorder: prevalence and clinical correlates

The aim of this study was to determine the frequency of adult attention deficit hyperactivity disorder (ADHD) comorbidity with lifetime bipolar disorder, and the influence of this comorbidity on various demographic and clinical variables in patients. Patients (n = 159) with a previous diagnosis of bipolar disorder (79 female, 80 male) were included in this study. All patients were interviewed for the presence of current adult and childhood ADHD diagnosis and other axis I psychiatric disorder comorbidities using the structured clinical interview for DSM-IV (SCID) and the Schedule for Affective Disorders and Schizophrenia for School Age Children—Present and Lifetime Version (K-SADS-PL). The subjects also completed a Wender Utah rating scale (WURS-25) and a Current Symptoms Scale for ADHD symptoms. In particular, patients’ clinical characteristics, the age of onset of bipolar disorder, and the number of episodes were noted. Twenty-six of the 159 bipolar patients (16.3%) were diagnosed with adult ADHD, while another subgroup of patients (n = 17, 10.7%) received a diagnosis of childhood ADHD but did not fulfill criteria for adult ADHD. Both of these two subgroups (patients with adult ADHD, and patients with only childhood ADHD) had an earlier age of onset of the disease and a higher number of previous total affective or depressive episodes than those without any lifetime ADHD comorbidity. However only bipolar patients with adult ADHD comorbidity had higher lifetime comorbidity rates for axis I psychiatric disorders, such as panic disorder and alcohol abuse/dependence, compared to patients without lifetime ADHD. Bipolar patients with comorbid adult ADHD did not differ from bipolar patients with comorbid childhood ADHD in terms of any demographic or clinical variables except for adult ADHD scale scores. In conclusion, ADHD is a common comorbidity in bipolar patients, and it adversely affects the course of the disease and disrupts the social adjustment of the patients. Regular monitoring of ADHD will help to prevent problems and complications that could arise in the course of the disease, particularly in patients with early onset bipolar disorder.     

A history of childhood attention‐deficit hyperactivity disorder (ADHD) impacts clinical outcome in adult bipolar patients regardless of current ADHD

Objective: The occurrence of comorbid attention‐deficit hyperactivity disorder (ADHD) might have an impact of the course of the bipolar disorder. Method: Patients with bipolar disorder (n = 159) underwent a comprehensive evaluation with respect to affective symptoms. Independent psychiatrists assessed childhood and current ADHD, and an interview with a parent was undertaken. Results: The prevalence of adult ADHD was 16%. An additional 12% met the criteria for childhood ADHD without meeting criteria for adult ADHD. Both these groups had significantly earlier onset of their first affective episode, more frequent affective episodes (except manic episodes), and more interpersonal violence than the bipolar patients without a history of ADHD. Conclusion: The fact that bipolar patients with a history of childhood ADHD have a different clinical outcome than the pure bipolar group, regardless of whether the ADHD symptoms remained in adulthood or not, suggests that it represent a distinct early‐onset phenotype of bipolar disorder.     

A Call for Research on the Validity of the Age-of-Onset Criterion Application in Older Adults Being Evaluated for ADHD: A Review of the Literature in Clinical and Cognitive Psychology

Roughly 3% of adults aged 50 years or older experience significant symptoms of attention-deficit/hyperactivity disorder (ADHD). They are often diagnosed for the first time in later adulthood, because ADHD is a relatively new diagnosis with only recent awareness of later-life cases, and because many symptomatic adults have high early-life functioning due to supportive environmental and social structures. Current Diagnostic and Statistical Manual of Mental Disorders-5 criteria require evidence of symptom onset prior to age 12, which rests on self-report in older adults for whom ancillary sources are unavailable or unreliable. In this review, we summarize evidence from several bodies of literature which suggest this criterion may be invalid in older adults. The authors hypothesize that demonstrating childhood symptom onset in older adults is not feasible (i.e., no awareness of ADHD prior to 1970; no good current ancillary sources of childhood behaviors), unreliable (i.e., severely flawed retrospective self-report) and unethical (i.e., unreasonable denial of support to people who need it, with demonstrated poor outcomes associated with untreated ADHD in adults). The authors outline additional research that is needed to establish the validity of self-reported childhood symptom onset in this under-studied demographic, including the identification of contextual factors (perhaps unique to late life) that are associated with the emergence of ADHD symptoms in older adulthood; determining the impact of memory biases on recall of childhood symptoms in older adults with ADHD; quantifying self-perception deficits; and investigating the usefulness of executive functioning rating scales to complement diagnostic assessment in older adults.     

Diagnosing adult attention deficit hyperactivity disorder: are late onset and subthreshold diagnoses valid?

OBJECTIVE: Diagnosing attention deficit hyperactivity disorder (ADHD) in adults is difficult when diagnosticians cannot establish an onset before the DSM-IV criterion of age 7 or if the number of symptoms recalled does not achieve DSM's diagnosis threshold. METHOD: The authors addressed the validity of DSM-IV's age-at-onset and symptom threshold criteria by comparing four groups of adults: 127 subjects with full ADHD who met all DSM-IV criteria for childhood-onset ADHD, 79 subjects with late-onset ADHD who met all criteria except the age-at-onset criterion, 41 subjects with subthreshold ADHD who did not meet full symptom criteria for ADHD, and 123 subjects without ADHD who did not meet any criteria. The authors hypothesized that subjects with late-onset and subthreshold ADHD would show patterns of psychiatric comorbidity, functional impairment, and familial transmission similar to those seen in subjects with full ADHD. RESULTS: Subjects with late-onset and full ADHD had similar patterns of psychiatric comorbidity, functional impairment, and familial transmission. Most children with late onset of ADHD (83%) were younger than 12. Subthreshold ADHD was milder and showed a different pattern of familial transmission than the other forms of ADHD. CONCLUSIONS: The data about the clinical features of probands and the pattern of transmission of ADHD among relatives found little evidence for the validity of subthreshold ADHD among such subjects, who reported a lifetime history of some symptoms that never met DSM-IV's threshold for diagnosis. In contrast, the results suggested that late-onset adult ADHD is valid and that DSM-IV's age-at-onset criterion is too stringent.     

Adult attention-deficit hyperactivity disorder in patients with bipolar I disorder in remission: preliminary study

Attention-deficit hyperactivity disorder (ADHD), a syndrome that typically first appears in early childhood, can occur in individuals of all ages. Prospective studies have demonstrated that at least half of children diagnosed as having ADHD continue to suffer the symptoms of this disorder in their adult life with significant impacts on their social status, achievement level and sense of well-being. The purpose of this preliminary study was to determine the rate of ADHD in patients with bipolar disorder (BD) and to examine the effects of comorbid ADHD on several clinical and sociodemographic variables of bipolar patients. Forty-four BD-I patients followed up in psychiatric outpatient clinics in two university hospitals, were assessed for the presence of adult ADHD according to DSM-IV. All patients also completed the Wender Utah Rating Scale for objective evaluation of ADHD. Of 44 patients with BD-I, only seven (15.9%) fulfilled criteria for a diagnosis of adult ADHD. Bipolar disorder-I patients with comorbid ADHD were more likely to be female, and have more affective episodes (especially depressive episodes) than bipolar patients without comorbid ADHD. Age at onset of affective illness was not significantly different between the two groups. In line with results of several previous reports, the present study also showed higher prevalence of ADHD in patients with BD-I than in normal population. A higher number of affective episode in patients with comorbid ADHD may suggest a more severe clinical course of BD in these patients. A larger group of samples is required to clarify the exact association and interaction between these two clinical entities.     

A guide to the treatment of adults with ADHD

While child and adolescent physicians are familiar with the treatment of attention-deficit/hyperac-tivity disorder (ADHD), many adult physicians have had little experience with the disorder. It is difficult to develop clinical skills in the management of residual adult manifestations of developmental disorders without clinical experience with their presentation in childhood. Adult patients are increasingly seeking treatment for the symptoms of ADHD, and physicians need practice guidelines. Adult ADHD often presents differently from childhood ADHD. Because adult ADHD can be comorbid with other disorders and has symptoms similar to those of other disorders, it is important to understand differential diagnoses. Physicians should work with patients to provide feedback about their symptoms, to educate them about ADHD, and to set treatment goals. Treatment for ADHD in adults should include a medication trial, restructuring of the patient's environment to make it more compatible with the symptoms of ADHD, and ongoing supportive management to address any residual impairment and to facilitate functional and developmental improvements.     

Clinical presentations of adult patients with ADHD

Attention-deficit/hyperactivity disorder (ADHD) persists into adulthood in an increasingly recognized number of individuals with childhood onset. The symptoms of adult ADHD are similar to the restlessness, distractibility, and impulsivity central to childhood ADHD, but expression of symptoms changes as the individual matures. A childhood history of ADHD is requisite for a diagnosis of adult ADHD, although full DSM-IV criteria for the childhood disorder need not be met as long as significant symptoms and impairment occurred. Three case reports described here illustrate the migration of symptoms and the use of retrospective reporting and rating scales to determine a diagnosis of adult ADHD. These reports also stress the high probability of comorbid disorders and family aggregation of ADHD, as well as the likelihood that the adult with ADHD has developed coping mechanisms to compensate for his or her impairment.     

Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder

BACKGROUND: Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS: To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD: We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS: Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS: Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder.     

Lifespan attention deficit/hyperactivity disorder and borderline personality disorder symptoms in female patients: a latent class approach

Attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are frequently comorbid. To contribute to a better understanding of the associations regularly found between ADHD and BPD, on the one hand, and the developmental pathways for these disorders, on the other hand, latent class analyses (LCA) were undertaken to identify classes differing in profiles of childhood symptoms of ADHD and adult symptoms of ADHD and BPD. Diagnostic interviews with 103 female outpatients meeting the criteria for ADHD and/or BPD were used to assess current DSM-IV symptoms; childhood symptoms of ADHD were assessed in parent interviews. The latent classes were examined in relation to the DSM-IV conceptualizations of ADHD and BPD. And relations between childhood and adult classes were examined to hypothesize about developmental trajectories. LCA revealed an optimal solution with four distinct symptom profiles: only ADHD symptoms; BPD symptoms and only ADHD symptoms of hyperactivity; BPD symptoms and ADHD symptoms of inattention and hyperactivity; BPD symptoms and ADHD symptoms of inattention, hyperactivity and impulsivity. All patients with BPD had some ADHD symptoms in both adulthood and childhood. Hyperactivity was least discriminative of adult classes. Adult hyperactivity was not always preceded by childhood hyperactivity; some cases of comorbid ADHD and BPD symptoms were not preceded by significant childhood ADHD symptoms; and some cases of predominantly BPD symptoms could be traced back to combined symptoms of ADHD in childhood. The results underline the importance of taking ADHD diagnoses into account with BPD. ADHD classification subtypes may not be permanent over time, and different developmental pathways to adult ADHD and BPD should therefore be investigated.     

Reliabilität und Validität der Wender-Utah-Rating-Scale-Kurzform

The diagnosis of adult attention deficit/hyperactivity disorder (ADHD) requires the retrospective assessment of ADHD symptoms in childhood. The Wender Utah Rating Scale (WURS) is helpful in detecting ADHD-associated symptomatology in childhood. A German short version (WURS-k) of this instrument has been made available recently. In the present study, we investigated the validity of the WURS-k. In a population of 63 adult ADHD patients (according to ICD-10 and DSM-IV criteria) and 1,303 male controls, ROC analysis indicated a sensitivity of 85% and specificity of 76% at a cutoff of 30 points. In ADHD patients, seven individual factors explained 70.3% of the variance. The highest diagnostic precision was demonstrated using the WURS-k total score. The seven extracted factors of the WURS-k did not differ in diagnostic value. Significant correlations were found between impulsivity according to Eysenck's Impulsivity Questionnaire (EIQ) and excitability, aggression, emotional lability, and satisfaction on the Freiburg Personality Inventory (FPI-R) in ADHD patients. Concerning a 30-50% persistence of ADHD symptomatology in adults, these correlations underline the diagnostic validity of the WURS-k. The scale manifested excellent internal consistency (alpha=0.91) and a split-half correlation of r(12)=0.85.     

DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls

OBJECTIVE: To compare the prevalence of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) to those with attention deficit hyperactivity disorder (ADHD) and normal community controls (CC). METHODS: To optimize generalizeability, subjects with PEA-BP and ADHD were consecutively ascertained from outpatient pediatric and psychiatric sites, and CC subjects were obtained from a random survey. All 268 subjects (93 with PEA-BP, 81 with ADHD, and 94 CC) received comprehensive, blind, baseline research assessments of mothers about their children and of children about themselves. PEA-BP was defined by DSM-IV mania with elation and/or grandiosity as one criterion to ensure that subjects had one of the two cardinal symptoms of mania and to avoid diagnosing mania only by criteria that overlapped with those for ADHD. RESULTS: Five symptoms (i.e., elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality) provided the best discrimination of PEA-BP subjects from ADHD and CC controls. These five symptoms are also mania-specific in DSM-IV (i.e., they do not overlap with DSM-IV symptoms for ADHD). Irritability, hyperactivity, accelerated speech, and distractibility were very frequent in both PEA-BP and ADHD groups and therefore were not useful for differential diagnosis. Concurrent elation and irritability occurred in 87.1% of subjects with PEA-BP. Data on suicidality, psychosis, mixed mania, and continuous rapid cycling were also provided. CONCLUSION: Unlike late teenage/adult onset bipolar disorder, even subjects with PEA-BP selected for DSM-IV mania with cardinal symptoms have high rates of comorbid DSM-IV ADHD. High rates of concurrent elation and irritability were similar to those in adult mania.     

Assessing attention-deficit/hyperactivity disorder in adults: focus on rating scales

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults can be a challenging process because it includes making judgments based on clinical interviews, rating scale results, informant ratings, and objective supporting evidence. The patient evaluation should gather information on the severity and frequency of symptoms, the establishment of childhood onset of symptoms, the chronicity and pervasiveness of symptoms, and the impact of symptoms on major life activities. Some of the rating scales being used in the adult population are the Conners' Adult ADHD Rating Scales, the Brown Attention-Deficit Disorder Scale for Adults, the Wender Utah Rating Scale, the ADHD Rating Scale and ADHD Rating Scale-IV, the Current Symptoms Scale, and the recently-developed Adult ADHD Self-Report Scale-v1.1 Symptom Checklist. More research is needed to establish the usefulness of self-administered rating scales compared with investigator-administered scales in the assessment and diagnosis of adult ADHD.     

Does bipolar disorder exist in children? A selected review.

Although there is increasing recognition that a substantial proportion of patients with bipolar disorder (BD) experience an onset of illness in adolescence, significant controversy remains over the validity of the diagnosis in very young children. In careful studies of adult patients dating from Kraepelin, first mood episodes not uncommonly occurred during adolescence. Some of these early-onset patients experienced subthreshold mood disturbances or predisposing temperaments earlier in childhood. Earlier onsets of BD have been reported in more recent clinical and community samples of children. Several factors possibly contributed to these earlier onsets, including exposure to psychotropics, bias in favour of a mood rather than a psychotic diagnosis, and recognition of softer-spectrum BDs. However, the validity of the diagnosis of BD in impulsive, irritable, labile, or behaviourally dysregulated children remains to be proven. Studies of high-risk children of well-characterized parents with BD have demonstrated that BD most often debuts as a depressive episode in mid to late adolescence and that activated episodes are rare prior to age 12 years. Some children manifest antecedent nonspecific psychopathology in early childhood. Therefore, as currently diagnosed, BD does not manifest as such typically until at least adolescence.     

Subtyping obsessive-compulsive disorder: clinical and immunological findings in child and adult onset

It has been suggested that certain kinds of childhood OCD with specific clinical, biological and immunological characteristics may form a subgroup of OCD. We study the presence of these characteristics in child onset OCD and propose that the disorder be considered as a subtype of adult OCD. Forty adult patients with OCD were divided in two groups according to time of disease onset: 18 early onset and 21 late. Both sets were compared with a control group of 14 psychiatric patients. Child onset OCD was associated with higher mean ASLO titers, higher frequencies of history of tic disorders and tonsillitis in childhood and compulsive symptoms. No differences were found in D8/17 antibody titers or in other autoimmune parameters. The findings suggest that child onset OCD can be considered as a subgroup of adult OCD, although more specific biological markers are needed to identify it.     

Use of self-ratings in the assessment of symptoms of attention deficit hyperactivity disorder in adults

OBJECTIVE: The purpose of this research was to determine if adults can provide a true rating of their own childhood and current symptoms of attention deficit hyperactivity disorder (ADHD). METHOD: The authors conducted two studies. In study 1, 50 adult subjects completed a questionnaire assessing their ADHD symptoms in childhood. In addition, a parent of each subject completed a questionnaire rating the subject's childhood ADHD symptoms. In study 2, 100 adult subjects completed a questionnaire rating their own current ADHD symptoms. The subject's partner also completed a questionnaire rating the subject's current ADHD symptoms. The correlation between subject and observer ratings was measured in each study. Inattentive symptoms, hyperactive-impulsive symptoms, and total symptoms were analyzed. RESULTS: Good correlations were found between subject and observer scores in both studies. CONCLUSIONS: The diagnosis of ADHD in adults relies on an accurate recall of childhood behavior and an accurate account of current behavior. The results of this study suggest that adults can give a true account of their childhood and current symptoms of ADHD.     

Clinical features of hereditary dentatorubropallidoluysian atrophy

Hereditary dentatorubropallidoluysian atrophy (DRPLA) is an inherited disease with an autosomal dominant trait. Its cardinal symptoms are myoclonus, epileptic seizures, ataxia, choreoathetosis, and dementia. The age of onset ranges from childhood to senescence. There is a particular correlation between the age at onset and clinical symptoms; progressive myoclonus epilepsy is a characteristic feature of DRPLA patients with juvenile onset, whereas those with late adult onset manifest cerebellar ataxia and choreoathetosis usually without myoclonus with or without epilepsy. The clinical forms of DRPLA may be classified into three subtypes: juvenile, early adult and late adult type.     

Current issues and trends in the diagnosis and treatment of adults with ADHD

Attention-deficit/hyperactivity disorder (ADHD) has been commonly thought of as a childhood disorder that diminished over time. It is one of the most common developmental disorders and it is estimated that ADHD affects 5-10% of children. Two-thirds of children with ADHD will continue to have symptoms of ADHD that persist throughout adolescence. Longitudinal studies have demonstrated that symptoms of ADHD can also remain in adulthood, affecting 4.4% of the adult population. However, diagnosing adults with ADHD can prove difficult because they often find that their symptoms are egosyntonic. In addition, the development of comorbid conditions, such as anxiety, depression, personality disorders or substance abuse, can often overshadow underlying ADHD symptoms. Nonetheless, treatments such as stimulant and nonstimulant medication (e.g., atomoxetine), and cognitive-behavior therapy have been effective in treating adults with ADHD. This article reviews the prevalence of adults with ADHD, followed by a discussion of the neurobiological and genetic underpinnings of the disorder. Issues regarding the diagnosis and treatment of ADHD are also addressed.     

A prepubertal and early adolescent bipolar disorder-I phenotype: review of phenomenology and longitudinal course

Objective: Phenomenology, assessment, longitudinal, and psychosocial findings from an ongoing, controlled, prospective study of 93 subjects with a prepubertal and early adolescent bipolar disorder phenotype (PEA‐BP) will be reviewed. Methods: Unlike adult‐onset bipolar disorder, for which there were over 50 years of systematic investigations, there were a paucity of rigorous data and much controversy and skepticism about the existence and characteristics of prepubertal‐onset mania. With this background, issues to address for investigation of child‐onset mania included the following: (i) What to do about the differentiation of mania from attention‐deficit hyperactivity disorder (ADHD). (ii) How to deal with the ubiquity of irritability as a presenting symptom in multiple child psychiatry disorders. (iii) Development of a research instrument to assess prepubertal manifestations of adult mania (i.e. children do not ‘max out’ credit cards or have four marriages). (iv) How to distinguish normal childhood happiness and expansiveness from pathologically impairing elated mood and grandiosity. Results: To address these issues, a PEA‐BP phenotype was defined as DSM‐IV mania with elated mood and/or grandiosity as one inclusion criterion. This criterion ensured that the diagnosis of mania was not made using only criteria that overlapped with those for ADHD, and that subjects had at least one of the two cardinal symptoms of mania (i.e. elated mood and grandiose behaviors). Subjects were aged 10.9 years (SD = 2.6) and age of onset of the current episode at baseline was 7.3 years (SD = 3.5). Validation of PEA‐BP was shown by reliable assessment, 6‐month stability, and 1‐ and 2‐year diagnostic longitudinal outcome. PEA‐BP resembled the severest form of adult‐onset mania by presenting with a chronic, mixed mania, psychotic, continuously (ultradian) cycling picture. Conclusion: Counterintuitively, typical 7‐year‐old children with PEA‐BP were more severely ill than typical 27 year olds with adult‐onset mania. Moreover, longitudinal data strongly supported differentiation of PEA‐BP from ADHD.