Joel L. Young

Objective The aim was to develop and test a novel screen of adult ADHD, with a focus on clinical use. We designed a series of three studies to accomplish this aim. Method Study One (n = 155) and Study Two (n = 591) collected data via surveys to conduct exploratory and confirmatory factor analyses respectively. Study Three analyzed the scale's psychometrics in a clinical sample (n = 151). Results Study One and Study Two identified a 10-item scale with a two-factor structure. Study Three found good discriminant validity, sensitivity = 80.0%, specificity = 80.2%, and convergent validity with the Brown Executive Function/Attention Scales, r (131) = .76, p < .001, and the Conner’s Adult ADHD Rating Scales r (131) = .71, p < .001. Conclusion The scale demonstrated effectiveness in screening for ADHD in a psychiatric outpatient population. Its results may be used to identify patients that may benefit from thorough ADHD diagnostic procedures. Keywords: adult ADHD, assessment, decision making

To increase awareness of adult attention-deficit/hyperactivity disorder (ADHD) in the primary care community and to provide guidance for the management of this condition. Despite its increasing prevalence, adult ADHD largely remains underdiagnosed and inappropriately treated in the United States. The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has provided more clear diagnostic criteria for adult ADHD, but a solid framework supporting the transition of ADHD management from pediatric to adult primary care is lacking. We searched PubMed and MEDLINE databases (January 1, 1984-June 1, 2016) using combinations of keywords, including ADHD, adult, diagnosis, prevalence, symptoms, treatment, comorbidity, compliance, and guidelines; international treatment guidelines; and the Diagnostic Interview for Adult ADHD websites to identify relevant clinical studies, reviews, meta-analyses, guidelines, and web-based resources describing updates to the DSM. In total, 143 citations were selected based on their relevance to adult ADHD diagnosis, treatment, major issues, and practice guidelines. The update on diagnostic criteria in the DSM-5 may increase the diagnosis of adult ADHD. There are critical differences between childhood and adult ADHD, and specific considerations should be taken with an adult ADHD diagnosis. Adult ADHD is primarily treated with pharmacotherapy assisted by behavior interventions. Caution should be exercised when using stimulants during pregnancy and the postpartum period. Adult ADHD patients often suffer from unemployment, financial difficulties, and an unsuccessful personal life. Adult-specific guidelines may improve adult ADHD treatment. The successful diagnosis and management of adult ADHD require consideration of many facets including prior medical history and comorbid conditions and use of an individualized, evidence-based treatment approach.

Objective: The purpose of this study was to evaluate the efficacy of once-daily guanfacine extended release (GXR) monotherapy administered either in the morning or evening, using a modified Conners' Parent Rating Scale–Revised: Short Form (CPRS–R:S) assessed three times/day in children with attention-deficit/hyperactivity disorder (ADHD). Methods: This multicenter, double-blind, placebo-controlled study randomized children 6–12 years of age with ADHD into three groups: GXR a.m. (GXR in the morning and placebo in the evening), GXR p.m. (placebo in the morning and GXR in the evening), or twice-daily placebo. The CPRS–R:S, administered in the morning, afternoon, and evening prior to each study visit, was a secondary measure of efficacy. Results: A total of 333 subjects were included in the analysis population (GXR a.m. , n =107; GXR p.m., n =114; placebo, n =112). At visit 10, last observation carried forward (LOCF), subjects receiving GXR demonstrated significantly greater improvement from baseline in the daily mean CPRS–R:S total score, as well as in each of the morning, afternoon, and evening CPRS–R:S assessments, compared with placebo, regardless of the time of GXR administration ( p p <0.003 vs. placebo across all subscales for GXR a.m. and GXR p.m. ). Conclusions: These results provide further support for the demonstrated efficacy of once-daily GXR in reducing ADHD symptoms, and demonstrate that response is consistent throughout the day regardless of the time of administration, with improvement seen in ratings of oppositional as well as of ADHD symptoms.

Despite the overall high degree of response to pharmacotherapy, consensus is lacking on how to judge clinical response or define optimal treatment/remission when treating adults with attention-deficit/hyperactivity disorder (ADHD). This study examined clinical response and symptomatic remission in analyses of 2 studies of lisdexamfetamine dimesylate (LDX) in adults with ADHD. In a 4-week, double-blind, forced-dose trial, adults with ADHD were randomized to LDX 30, 50, and 70 mg/day (mg/d) or placebo. In a second, open-label, follow-up trial, adults entering from the 4-week study were titrated to an “optimal” LDX dose (30 mg/d [n=44], 50 mg/d [n=112], and 70 mg/d [n=171]) over 4 weeks, and maintained for 11 additional months. The ADHD Rating Scale IV (ADHD-RS-IV) with adult prompts and the Clinical Global Impressions-Improvement (CGI-I) scale assessed efficacy. Clinical response was defined, post hoc, as ≥30% reduction from baseline in ADHD-RS-IV and CGI-I rating of 1 or 2; symptomatic remission was defined as ADHD-RS-IV total score ≤18. Log rank analysis examined overall significance among the treatment groups in time to response or remission. Four hundred and fourteen participants in the 4-week study and 345 in the open-label, extension study were included in the efficacy populations. All LDX groups improved by ADHD-RS-IV and CGI-I scores in both studies. In the 4-week study (n=414), 69.3% responded and 45.5% achieved remission with LDX (all doses); 37.1% responded and 16.1% achieved remission with placebo; time (95% CI) to median clinical response (all LDX doses) was 15.0 (15.0, 17.0) days and to remission was 31.0 (28.0, 37.0) days (P<.0001 overall). In the open-label study, with LDX (all doses), 313 (95.7%) and 278 (85.0%) of 327 participants with evaluable maintenance-phase data met criteria for response and remission, respectively. Of participants who completed dose optimization, 75.2% remained responders and 65.7% remained in remission in the 12-month study. Overall, 285 (82.6%) and 227 (65.8%) of 345 participants were responders and remitters, respectively, at their final visits. In the long-term study, with open-label, dose-optimized LDX treatment, most adults with ADHD achieved clinical response and/or symptomatic remission; almost two-thirds maintained symptomatic remission over the remaining 11 months. Clinical Trial Numbers: NCT00334880 and NCT01070394 Clinical Trial Registry: clinicaltrials.gov http://www.clinicaltrials.gov/show/NCT00334880 http://www.clinicaltrials.gov/ct2/show/NCT01070394?term=NCT01070394&rank=1

Fatigue is commonly reported in the primary care setting; however, its cause is often unclear. This article presents 3 cases involving patients with chronic fatigue syndrome who responded poorly to treatment. After clinical evaluation, all patients were found to meet criteria for attention-deficit/hyperactivity disorder (ADHD) and underwent a standard regimen of a psychostimulant medication. After treatment with psychostimulants, the 3 patients reported improved symptoms of fatigue and pain, and cognitive and core ADHD symptoms. These cases suggest that ADHD and chronic fatigue syndrome (and possibly fibromyalgia) share a common underlying mechanism. This article presents a model suggesting that over time, ADHD (predominantly inattentive type) develops into a syndrome of chronic fatigue and pain. These cases indicate that fatigue may be an important presenting symptom of adult ADHD. These cases also suggest the need for additional research to determine the prevalence of ADHD in patients who present with fatigue, and, in those meeting criteria for ADHD, the responsiveness of fatigue to psychostimulant treatment.

Objectives. To explore factors underlying the onset of delusional parasitosis; a condition in which an individual has a fixed, false belief that he/she is infested with insects.Case Description. MJ is a 57-year-old female who presents with symptoms of fatigue and AD/HD. Upon treatment with extended release mixed amphetamine salts, the patient displayed symptoms of delusional parasitosis. After eventual discontinuation of this medication, her delusions resolved.Comments. In order to maintain confidentiality, all identifying information was removed. To this end, please note that MJ is a fictitious name.

Objectives: Atomoxetine (ATX) once daily was compared with placebo (PBO) in adults with attention-deficit/hyperactivity disorder (ADHD) at 12 and 24 weeks. Methods: Patients were randomized to PBO (n = 234) or ATX (60-100 mg; n = 268) for 24 weeks following a 2-week on-label (40 mg for 3 days then 80 mg) or slow (40 mg for 7 days then 80 mg) titration. After 24 weeks, PBO patients were rerandomized to either ATX titration strategy. Efficacy measures included the Conners' Adult ADHD Rating Scale Total ADHD Symptoms score, Clinical Global Impression-ADHD-Severity, Montgomery-Asberg Depression Rating Scale, and State-Trait Anxiety Inventory. General and titration safety measures and tolerability were evaluated. Results: Conners' Adult ADHD Rating Scale Total ADHD Symptoms score reduction was greater with ATX over PBO at 12 weeks (−14.33 vs −10.05; P < 0.001) and 24 weeks (−16.43 vs −8.65; P < 0.001; effect size, 0.57). Response (25% decrease on Conners' Adult ADHD Rating Scale Total ADHD Symptoms) was greater for ATX (68%) than PBO (42%; P < 0.001) at 24 weeks. Clinical Global Impression-ADHD-Severity improvement was greater for ATX over PBO at 8 and 24 weeks (P < 0.001; effect sizes, 0.45 and 0.46, respectively). There were no significant changes in depressive or anxiety measures for either group. Discontinuation due to an adverse event was greater for on-label versus slow titration, although the rate of patients experiencing adverse events were comparable. Common adverse events included dry mouth, nausea, and decreased appetite. Conclusions: Atomoxetine demonstrated significant improvement in ADHD symptoms at 12 and 24 weeks over PBO. Adverse events overall and for on-label or slow titration to ATX were similar and consistent with previous adult ATX studies.

*Corresponding author. E-mail address: jyoung@rcbm.net (J. Young).