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      Psychiatric comorbid patterns in adults with attention-deficit hyperactivity disorder: Treatment effect and subtypes

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          Abstract

          Psychiatric comorbidities are common in individuals with attention-deficit/hyperactivity disorder (ADHD). In this study, we sought to evaluate the effects of medication and childhood ADHD subtypes on psychiatric comorbidities among adults with ADHD as compared to healthy adult controls. We assessed 121 drug-naïve adults with ADHD, 93 treated adults with ADHD, and 145 healthy controls (age 18–36 years) using semi-structured psychiatric interviews, intelligence tests, and medical records. Drug-naïve adults with ADHD had more comorbidities than treated adults with ADHD and controls. Childhood ADHD-combined subtype, relative to ADHD-inattentive subtype, was associated with higher risks of comorbidities. Current medication treatment was associate with a higher risk for anxiety disorders, and longer treatment duration was associated with lower risks of mood disorders and sleep disorders. Our results indicate that no medication treatment, short treatment duration, and childhood ADHD-combined subtype are associated with increased risks for psychiatric comorbidities among adults with ADHD.

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          Most cited references72

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          Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis.

          In spite of the growing literature about adult attention-deficit hyperactivity disorder (ADHD), relatively little is known about the prevalence and correlates of this disorder. To estimate the prevalence of adult ADHD and to identify its demographic correlates using meta-regression analysis. We used the MEDLINE, PsycLit and EMBASE databases as well as hand-searching to find relevant publications. The pooled prevalence of adult ADHD was 2.5% (95% CI 2.1-3.1). Gender and mean age, interacting with each other, were significantly related to prevalence of ADHD. Meta-regression analysis indicated that the proportion of participants with ADHD decreased with age when men and women were equally represented in the sample. Prevalence of ADHD in adults declines with age in the general population. We think, however, that the unclear validity of DSM-IV diagnostic criteria for this condition can lead to reduced prevalence rates by underestimation of the prevalence of adult ADHD.
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            The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population.

            A self-report screening scale of adult attention-deficit/hyperactivity disorder (ADHD), the World Health Organization (WHO) Adult ADHD Self-Report Scale (ASRS) was developed in conjunction with revision of the WHO Composite International Diagnostic Interview (CIDI). The current report presents data on concordance of the ASRS and of a short-form ASRS screener with blind clinical diagnoses in a community sample. The ASRS includes 18 questions about frequency of recent DSM-IV Criterion A symptoms of adult ADHD. The ASRS screener consists of six out of these 18 questions that were selected based on stepwise logistic regression to optimize concordance with the clinical classification. ASRS responses were compared to blind clinical ratings of DSM-IV adult ADHD in a sample of 154 respondents who previously participated in the US National Comorbidity Survey Replication (NCS-R), oversampling those who reported childhood ADHD and adult persistence. Each ASRS symptom measure was significantly related to the comparable clinical symptom rating, but varied substantially in concordance (Cohen's kappa in the range 0.16-0.81). Optimal scoring to predict clinical syndrome classifications was to sum unweighted dichotomous responses across all 18 ASRS questions. However, because of the wide variation in symptom-level concordance, the unweighted six-question ASRS screener outperformed the unweighted 18-question ASRS in sensitivity (68.7% v. 56.3%), specificity (99.5% v. 98.3%), total classification accuracy (97.9% v. 96.2%), and kappa (0.76 v. 0.58). Clinical calibration in larger samples might show that a weighted version of the 18-question ASRS outperforms the six-question ASRS screener. Until that time, however, the unweighted screener should be preferred to the full ASRS, both in community surveys and in clinical outreach and case-finding initiatives.
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              The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study.

              To determine any long-term effects, 6 and 8 years after childhood enrollment, of the randomly assigned 14-month treatments in the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA; N = 436); to test whether attention-deficit/hyperactivity disorder (ADHD) symptom trajectory through 3 years predicts outcome in subsequent years; and to examine functioning level of the MTA adolescents relative to their non-ADHD peers (local normative comparison group; N = 261). Mixed-effects regression models with planned contrasts at 6 and 8 years tested a wide range of symptom and impairment variables assessed by parent, teacher, and youth report. In nearly every analysis, the originally randomized treatment groups did not differ significantly on repeated measures or newly analyzed variables (e.g., grades earned in school, arrests, psychiatric hospitalizations, other clinically relevant outcomes). Medication use decreased by 62% after the 14-month controlled trial, but adjusting for this did not change the results. ADHD symptom trajectory in the first 3 years predicted 55% of the outcomes. The MTA participants fared worse than the local normative comparison group on 91% of the variables tested. Type or intensity of 14 months of treatment for ADHD in childhood (at age 7.0-9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. Innovative treatment approaches targeting specific areas of adolescent impairment are needed.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Investigation
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: Supervision
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                7 February 2019
                2019
                : 14
                : 2
                : e0211873
                Affiliations
                [1 ] Department of Psychiatry, National Taiwan University and College of Medicine, Taipei, Taiwan
                [2 ] Department of Psychiatry, En Chu Kong Hospital, New Taipei City, Taiwan
                [3 ] Emotion and Development Branch, National Institute of Mental Heath, National Institutes of Health, Department of Health and Human Sevices, Bethesda, MD, United States of America
                [4 ] Beitou Branch, Tri-Service General Hospital, National Medical Defense Center, Taipei, Taiwan
                [5 ] Graduate Institute of Brain and Mind Sciences, College of Medicine, National Taiwan University, Taipei, Taiwan
                [6 ] Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
                QIMR Berghofer Medical Research Institute, AUSTRALIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ‡ These authors are co-first authors on this work.

                Author information
                http://orcid.org/0000-0002-2718-8221
                Article
                PONE-D-18-18344
                10.1371/journal.pone.0211873
                6366698
                30730956
                ec20776f-0cbf-4fff-87ea-3300b73a7ad1
                © 2019 Tsai et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 19 June 2018
                : 22 January 2019
                Page count
                Figures: 0, Tables: 5, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/501100004737, National Health Research Institutes;
                Award ID: NHRI-EX100-10008PI
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100004737, National Health Research Institutes;
                Award ID: NHRI-EX101-10008PI
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100004737, National Health Research Institutes;
                Award ID: NHRI-EX102-10008PI
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/501100004737, National Health Research Institutes;
                Award ID: NHRI-EX103-10008PI
                Award Recipient :
                This work was supported by National Health Research Institute (NHRI-EX100-10008PI, NHRI-EX101-10008PI, NHRI-EX102-10008PI; NHRI-EX103-10008PI), Taiwan. The funders had no role in study design, data collection, decision to publish, or preparation of the manuscript.
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