• Teachers' recognition of children with ADHD: Role of subtype and gender

      Moldavsky, Maria; Sayal, Kapil (2013)
      Background: This study investigates the ability of primary school teachers to recognise Attention Deficit/Hyperactivity Disorder (ADHD), and the impact of subtype and child gender on recognition and proposed management. Method: Primary school teachers read one of four types of vignette describing the behaviour of a 9-year-old child: either a boy or a girl with inattentive or combined subtype of ADHD. Teachers were asked about their conceptualisation of the child's difficulties and their thoughts about need for specialist referral and other interventions. Results: Of 496 teachers, 99% identified the presence of a problem. Subtype (combined) of ADHD influenced teachers’ recognition of ADHD and agreement that medication might be helpful. Only 13% of teachers thought that medication might be helpful. Conclusions: Results suggest a need for better teacher awareness about inattentive subtype of ADHD.
    • The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: A systematic review

      Hall, Charlotte L.; Valentine, Althea Z.; Groom, Madeleine J.; Walker, Gemma M.; Sayal, Kapil; Daley, David; Hollis, Chris P. (2016)
      Attention-deficit hyperactivity disorder (ADHD) is typically diagnosed using clinical observation and subjective informant reports. Once children commence ADHD medication, robust monitoring is required to detect partial or non-responses. The extent to which neuropsychological continuous performance tests (CPTs) and objective measures of activity can clinically aid the assessment and titration process in ADHD is not fully understood. This review describes the current evidence base for the use of CPTs and objectively measured activity to support the diagnostic procedure and medication management for children with ADHD. Four databases (PsycINFO, Medline, Allied and Complementary Medicine (AMED), and PsycARTICLES) were systematically searched to understand the current evidence base for (1) the use of CPTs to aid clinical assessment of ADHD; (2) the use of CPTs to aid medication management; and (3) the clinical utility of objective measures of activity in ADHD. Sixty relevant articles were identified. The search revealed six commercially available CPTs that had been reported on for their clinical use. There were mixed findings with regard to the use of CPTs to assess and manage medication, with contrasting evidence on their ability to support clinical decision-making. There was a strong evidence base for the use of objective measures of activity to aid ADHD/non-ADHD group differentiation, which appears sensitive to medication effects and would also benefit from further research on their clinical utility. The findings suggest that combining CPTs and an objective measure of activity may be particularly useful as a clinical tool and worthy of further pursuit.
    • The effects of co-occurring ADHD symptoms on electrophysiological correlates of cognitive control in young people with Tourette syndrome

      Jackson, Georgina M.; Groom, Madeleine J. (2016)
      Efficient cognitive control is implicated in tic control in young people with Tourette syndrome (TS). Attention-deficit/hyperactivity disorder (ADHD) frequently co-occurs with TS and is associated with impaired cognitive control. Young people with TS and ADHD (TS+ADHD) show poorer cognitive control performance than those with TS, but how co-occurring ADHD affects underlying neural activity is unknown. We investigated this issue by examining behavioural and event-related potential (ERP) correlates of cognitive control in young people with these conditions. Participants aged 9-17 with TS (n = 17), TS+ADHD (n = 17), ADHD (n = 11), and unaffected controls (n = 20) performed a visual Go/Nogo task during electroencephalography (EEG) recording. Behavioural performance measures (D-prime, RT, reaction time variability, post-error slowing) and ERP measures (N2, P3, error-related negativity (ERN), error positivity (Pe)) were analysed in a 2 (TS-yes, TS-no) x 2 (ADHD-yes, ADHD-no) factorial analysis to investigate the effects of TS, ADHD, and their interaction. The results of these analyses showed that ADHD was associated with poorer performance and reduced amplitude of all ERPs, reflecting widespread cognitive control impairments. Tourette syndrome was associated with slowed RTs, which might reflect a compensatory slowing of motor output to facilitate tic control. There was no interaction between the TS and ADHD factors for any behavioural or ERP measure, indicating the impairing effects of ADHD on behaviour and electrophysiological markers of cognitive control were present in TS+ADHD and that RT slowing associated with TS was unaffected by co-occurring ADHD symptoms. Copyright © 2015 The British Psychological Society.
    • The incremental validity of a computerised assessment added to clinical rating scales to differentiate adult ADHD from autism spectrum disorder

      Groom, Madeleine J.; Young, Zoe; Hall, Charlotte L.; Gillott, Alinda; Hollis, Chris P. (2016)
      There is a clinical need for objective evidence-based measures that are sensitive and specific to ADHD when compared with other neurodevelopmental disorders. This study evaluated the incremental validity of adding an objective measure of activity and computerised cognitive assessment to clinical rating scales to differentiate adult ADHD from Autism spectrum disorders (ASD). Adults with ADHD (n=33) or ASD (n=25) performed the QbTest, comprising a Continuous Performance Test with motion-tracker to record physical activity. QbTest parameters measuring inattention, impulsivity and hyperactivity were combined to provide a summary score ('QbTotal'). Binary stepwise logistic regression measured the probability of assignment to the ADHD or ASD group based on scores on the Conners Adult ADHD Rating Scale-subscale E (CAARS-E) and Autism Quotient (AQ10) in the first step and then QbTotal added in the second step. The model fit was significant at step 1 (CAARS-E, AQ10) with good group classification accuracy. These predictors were retained and QbTotal was added, resulting in a significant improvement in model fit and group classification accuracy. All predictors were significant. ROC curves indicated superior specificity of QbTotal. The findings present preliminary evidence that adding QbTest to clinical rating scales may improve the differentiation of ADHD and ASD in adults.; Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
    • The relationship between ADHD and obesity: Implications for therapy

      Cortese, Samuele (2014)
      Increasing attention is being paid to the relationship between attention deficit/hyperactivity disorder (ADHD) and obesity. While most available research focused on determining the extent of the association between ADHD and obesity, a few studies have examined the clinical implications of diagnosing/treating ADHD in individuals with obesity. Here, we provide a narrative review of studies addressing the impact of ADHD, or its treatment, in individuals with obesity. Reviewed studies suggest that ADHD impedes the successful treatment of obesity in individuals with comorbid ADHD and obesity. Preliminary evidence also suggests that ADHD treatment might significantly increase the effectiveness of weight management strategies. We discuss the limitations of the reviewed studies and provide suggestions for future research in the field. © 2014 Informa UK, Ltd.
    • Transition between child and adult services for young people with attention-deficit hyperactivity disorder (ADHD): findings from a British national surveillance study

      Sayal, Kapil (2019)
      BACKGROUNDOptimal transition from child to adult services involves continuity, joint care, planning meetings and information transfer; commissioners and service providers therefore need data on how many people require that service. Although attention-deficit hyperactivity disorder (ADHD) frequently persists into adulthood, evidence is limited on these transitions.AimsTo estimate the national incidence of young people taking medication for ADHD that require and complete transition, and to describe the proportion that experienced optimal transition.METHODSurveillance over 12 months using the British Paediatric Surveillance Unit and Child and Adolescent Psychiatry Surveillance System, including baseline notification and follow-up questionnaires.RESULTSQuestionnaire response was 79% at baseline and 82% at follow-up. For those aged 17-19, incident rate (range adjusted for non-response) of transition need was 202-511 per 100 000 people aged 17-19 per year, with successful transition of 38-96 per 100 000 people aged 17-19 per year. Eligible young people with ADHD were mostly male (77%) with a comorbid condition (62%). Half were referred to specialist adult ADHD and 25% to general adult mental health services; 64% had referral accepted but only 22% attended a first appointment. Only 6% met optimal transition criteria.CONCLUSIONSAs inclusion criteria required participants to be on medication, these estimates represent the lower limit of the transition need. Two critical points were apparent: referral acceptance and first appointment attendance. The low rate of successful transition and limited guideline adherence indicates significant need for commissioners and service providers to improve service transition experiences.Declaration of interestNone.
    • The transition from children’s services to adult services for young people with attention deficit hyperactivity disorder: the CATCh-uS mixed-methods study

      Hollis, Chris P.; Sayal, Kapil (2020)
      Background: Attention deficit hyperactivity disorder was previously seen as a childhood developmental disorder, so adult mental health services were not set up to support attention deficit hyperactivity disorder patients who became too old for child services. To our knowledge, this is the first in-depth study of the transition of attention deficit hyperactivity disorder patients from child to adult health services in the UK. Objectives: Our objectives were to explore how many young people with attention deficit hyperactivity disorder are in need of services as an adult, what adult attention deficit hyperactivity disorder services are available and how attention deficit hyperactivity disorder stakeholders experience transition from child to adult services. Design: An interactive mixed-method design was adopted with three study streams: (1) a 12-month surveillance study with 9-month follow-up to find out how many young people required ongoing medication when they were too old for child services (929 surveys completed by children’s clinicians); (2) a mapping study to identify and describe services for young adults with attention deficit hyperactivity disorder (2686 respondents to online surveys for patients and health workers and freedom of information requests to service providers and commissioners); and (3) a qualitative study to explore key stakeholders’ experiences of transition from child to adult services (144 interviews with 64 attention deficit hyperactivity disorder patients, 28 parents and 52 health clinicians; 38 working in child or adult secondary health services and 14 general practitioners). Members of the public advised at each stage of the study. Results: When corrected for non-response and case ascertainment, the annual number of young people with an ongoing need for medication for attention deficit hyperactivity disorder lies between 270 and 599 per 100,000 people aged 17–19 years. Among 315 individuals eligible for transition, 64% were accepted, but only 22% attended their first adult services appointment. Our interactive map describes 294 unique services for adults with attention deficit hyperactivity disorder across the UK, of which 44 are ‘dedicated’ attention deficit hyperactivity disorder services. Few services provide the full range of recommended provision; most focus on diagnosis and medication. Services are unevenly distributed across the UK, with nearly all ‘dedicated’ services being in England. Exploring stakeholders’ experiences revealed how invested the stakeholders are in continuing attention deficit hyperactivity disorder treatment and how the architecture of services affects transition. An association between attention deficit hyperactivity disorder, education and continuance of medication into young adulthood, plus parent involvement and feeling prepared for transition and adult life with attention deficit hyperactivity disorder, influenced investment. However, even with investment, how accessible adult services are, how patient needs fit with the remit of the adult service and the level of patient information available affect transition outcomes. The results also highlight how general practitioners can end up as care co-ordinators during transition by default. Limitations: Transition estimates were based on those who want medication, so these indicate a minimum level of need. Conclusions: Few of those who need ongoing support for attention deficit hyperactivity disorder successfully transfer to adult services, and a small proportion of those who transfer experience optimal transitional care. Adult attention deficit hyperactivity disorder service provision is patchy. Even among ‘dedicated’ services, few provide the whole range of National Institute for Health and Care Excellence-recommended treatments. Future work: We need to evaluate various models of transitional care and adult attention deficit hyperactivity disorder provision, as well as develop and evaluate psychosocial interventions for young people and adults with attention deficit hyperactivity disorder.
    • Transition to adult mental health services for young people with attention deficit/hyperactivity disorder (ADHD): A qualitative analysis of their experiences

      Swift, Katie D.; Marimuttu, Vic; Redstone, Lucy (2013)
      Background: There is little research on the process of transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). More recently, there is growing recognition that Attention Deficit/Hyperactivity Disorder (ADHD) may persist into adulthood requiring services beyond age 18. However, despite National Institute for Health and Clinical Excellence (NICE) Guidance which recommends specialist services for adults with ADHD, there is currently a lack of such services in the UK. The aim of the current study is to explore the experiences of young people with ADHD during transition from CAMHS to AMHS.; Method: Semi-structured qualitative interviews with ADHD patients accessing CAMHS clinics in Nottinghamshire were analysed using thematic analysis.; Results: Ten semi-structured interviews were transcribed and analysed. We found that patients' relationships with their clinician were a key factor in both their reported experience of CAMHS and the transition process. Perceived responsibility of care was also pivotal in how the transition process was viewed. Nature and severity of problems and patients expectations of adult services were also contributing factors in the transition process. The need for continued parental support was openly accepted and thought to be required by the majority of young people with ADHD during transition.; Conclusions: Timely preparation, joint working, good clinician relationships and parental support serve to facilitate the process of transition for young people with ADHD. Nature and severity of problems are perceived to impede or facilitate transition, with predominantly more 'complex presentations' with associated mental health problems more familiar to AMHS (e.g. self-harm, depression) making for smoother transitions to adult services. Transitions to AMHS were more difficult when ADHD was viewed as the main or sole clinical problem. Further exploration of young people's experiences of transition and their engagement with and experience of adult services is required to provide an overall picture of facilitators to successful transition and integration into adult services.;
    • Treatment of ADHD in adults - prevalence of discontinuation and associated factors - results from a cross-sectional analysis of Danish register data

      Daley, David (2020)
      BACKGROUNDA growing number of adults are receiving pharmacological treatment for ADHD but a sizable proportion also discontinues or have gaps in treatment. The primary aims of this study were to identify how many patients treated for ADHD in adulthood, have at least one event of discontinuation in treatment and to identify possible associated variables.METHODSWithin the Danish population aged 18-60 years on the 1st of January 2013, we identified the number of individuals who had been prescribed ADHD-medication at least once during the 1st of January 2002-31st of December 2013 using Danish register data. Among those who filed more than one prescription, treatment discontinuation was defined as having more than 211 days between two prescriptions. In crude and adjusted logistic regression analysis, we explored potential associations to discontinuation for variables such as gender and age at treatment initiation.RESULTSIn a population, if N = 3,165,844 individuals, n = 42,892 had received at least one prescription for ADHD medication. Among those with more than one prescription (N = 38,289), 29.4% had discontinued their treatment at least once, according to our definition of treatment discontinuation. ADHD treatment discontinuation was associated with being male, unemployment, lower educational attainment, receiving incapacity benefits and younger age at treatment initiation (p < 0.001).CONCLUSIONSA large proportion of individuals treated for ADHD had at least one discontinuation of treatment according to our definition. Although the present study does not allow for investigating the direction of these effects, nor whether some patients later resumed treatment, having at least one discontinuation was associated with a range of variables relating to e.g. age and gender, and provides an emerging profile for clinicians of patients more likely to discontinue.
    • Use of services and associated costs for young adults with childhood hyperactivity/conduct problems: 20-year follow-up

      Sayal, Kapil (2014)
      BACKGROUND: Although childhood hyperactivity and conduct problems are associated with difficulties in adulthood, little is known about later service use or public expenditure costs in the UK. AIMS: To describe the use of services and calculate recent (past 6 months) and early adulthood (since the age of 18 years) public expenditure costs incurred by young adults who had hyperactivity and/or conduct problems during childhood. METHOD: A 20-year follow-up of a community sample of 6- to 7-year-old boys (n = 83) with hyperactivity only, conduct problems only, mixed hyperactivity and conduct problems, and no behaviour problems (control). Information was obtained about service use; recent (past 6 months), and early adulthood (since age 18 years) public expenditure costs were calculated. METHOD: A 20-year follow-up of a community sample of 6- to 7-year-old boys (n = 83) with hyperactivity only, conduct problems only, mixed hyperactivity and conduct problems, and no behaviour problems (control). Information was obtained about service use; recent (past 6 months), and early adulthood (since age 18 years) public expenditure costs were calculated. RESULTS: High levels of childhood conduct problems were associated with a two- to threefold increase in early adulthood costs, mainly driven by criminal justice contacts. Although the mixed problems group had the highest recent costs in terms of receipt of benefits and health and social care, they had the lowest criminal justice costs. CONCLUSIONS: High levels of early childhood conduct problems are particularly associated with increased health, social care and criminal justice costs in adulthood.Copyright Royal College of Psychiatrists.
    • The validity of the SNAP-IV in children displaying ADHD symptoms

      Hall, Charlotte L.; Guo, Boliang; Valentine, Althea Z.; Groom, Madeleine J.; Daley, David; Sayal, Kapil; Hollis, Chris P. (2020)
      The Swanson, Nolan, and Pelham Rating Scale (SNAP-IV) is a widely used scale that measures the core symptoms of attention deficit hyperactivity disorder (ADHD). However, there are contradictory findings regarding factor structure. Factor structure and measurement equivalence/invariance analysis on parent and teacher SNAP-IV for children referred for an ADHD assessment ( N = 250; 6-17 years), revealed a two-factor structure provided the best fit. SNAP-IV scores were also compared with clinician diagnosis of ADHD and research diagnoses of ADHD and hyperkinetic disorder. Parent ratings of inattention and hyperactivity/impulsivity were good predictors of research but not clinician diagnosis. For teacher ratings, only hyperactivity/impulsivity scores were associated with research and clinician diagnosis. SNAP-IV scores showed high sensitivity but low specificity to clinician diagnosis. The SNAP-IV is a valid outcome measure for use in randomized controlled trials and clinical settings, and is best used as a screening rather than a diagnostic tool for ADHD. (PsycInfo Database Record (c) 2020 APA, all rights reserved) (Source: journal abstract)
    • The validity of the Strengths and Difficulties Questionnaire (SDQ) for children with ADHD symptoms

      Hall, Charlotte L.; Guo, Boliang; Valentine, Althea Z.; Groom, Madeleine J.; Daley, David; Sayal, Kapil (2019)
      BACKGROUND: The Strengths and Difficulties Questionnaire (SDQ) is widely used to assess child and adolescent mental health problems. However, the factor structure of the SDQ is subject to debate and there is limited evidence investigating measurement equivalence invariance (ME/I) between treatment groups, informants, and across time. METHOD: A randomised controlled trial (RCT) recruited 250 participants (6-17 years) who had been referred for an attention deficit hyperactivity disorder (ADHD) assessment. Participants and their clinician either received or did not receive a QbTest report (computer task measuring attention, impulsivity and activity). Parents and teachers completed the SDQ at baseline and 6-months later. This study aimed to understand the factor structure of the SDQ in a clinic referred ADHD sample, and validate the scale as a screening/diagnostic aide and as a measure of treatment outcome both in clinical and research settings. Exploratory Structural Equation Modelling (ESEM) was performed to examine the factor structure, and ME/I was assessed between treatment groups, informants, and time points. The criterion validity of the SDQ predictive algorithm for ADHD was compared with clinician and research diagnoses using logistic regression and tests of diagnostic accuracy. RESULTS: A 5-factor structure provided the best fit with strong factorial invariance between treatment groups and across time points, but not across informants (parent and teacher ratings). SDQ ratings of 'probable' hyperactivity disorder were good predictors of clinical (OR = 10.20, 95%CI 2.18-48.71,p = 0.003) and research diagnoses of ADHD (OR = 6.82, 95%CI 1.95-23.84,p = 0.003), and research diagnoses of Hyperkinetic disorder (OR = 4.02, 95%CI 1.13-14.25,p = 0.031). Further examination of the SDQ hyperactivity 'probable' rating showed good specificity (84.5%-74.5%) but poor sensitivity (45.0-42.5%) for ADHD. CONCLUSION: The findings indicate the SDQ is a valid outcome measure for use in RCTs and clinical settings. However, care should be taken when using the SDQ predictive algorithm to screen for ADHD in clinically referred samples.
    • What is the effect of stimulus complexity on attention to repeating and changing information in autism?

      Arora, Iti; Bellato, Alessio; Kochhar, Puja; Hollis, Chris P.; Groom, Madeleine J. (2021)
      Slower habituation to repeating stimuli characterises Autism, but it is not known whether this is driven by difficulties with information processing or an attentional bias towards sameness. We conducted eye-tracking and presented looming geometrical shapes, clocks with moving arms and smiling faces, as two separate streams of stimuli (one repeating and one changing), to 7-15 years old children and adolescents (n = 103) with Autism, ADHD or co-occurring Autism+ADHD, and neurotypical children (Study-1); and to neurotypical children (n = 64) with varying levels of autistic traits (Study-2). Across both studies, autistic features were associated with longer looks to the repeating stimulus, and shorter looks to the changing stimulus, but only for more complex stimuli, indicating greater difficulty in processing complex or unpredictable information.
    • What is the health and well-being burden for patients living with a child with ADHD in the United Kingdom?

      Daley, David (2020)
      Objective: To explore the burden associated with childhood ADHD in a large observational study. Methods: We recruited familes with at least one child (6-18 years) with ADHD via 15 NHS trusts in the UK, and collected data from all family members. We made careful adjustments to ensure a like-for-like comparison with two different control groups, and explored the impact of controlling for a positive parental/carer ADHD screen, employment, and relationship status. Results: We found significant negative impacts of childhood ADHD on parents'/carers' hours and quality of sleep, satisfaction with leisure time, and health-related quality of life (measured by the EuroQol-5D [EQ-5D]). We found a decrement in life satisfaction, mental well-being (as measured by the Short-Warwick Edinburgh Mental Well-Being Scale [S-WEMWBS]), and satisfaction with intimate relationships, but this was not always robust across the different control groups. We did not find any decrement in satisfaction with health, self-reported health status, or satisfaction with income. Conclusion: The study quantifies the impact on the health and well-being of parents living with a child with ADHD using a survey of families attending ADHD clinics in the United Kingdom.
    • WITHDRAWN: Electrophysiological correlates of reinforcement learning in young people with Tourette syndrome with and without co-occurring ADHD symptoms

      Jackson, Georgina M.; Groom, Madeleine J. (2016)
      The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.ijdevneu.2016.04.006. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
    • The World Federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder

      Daley, David; Hollis, Chris P. (2021)
      BACKGROUNDMisconceptions about ADHD stigmatize affected people, reduce credibility of providers, and prevent/delay treatment. To challenge misconceptions, we curated findings with strong evidence base.METHODSWe reviewed studies with more than 2,000 participants or meta-analyses from five or more studies or 2,000 or more participants. We excluded meta-analyses that did not assess publication bias, except for meta-analyses of prevalence. For network meta-analyses we required comparison adjusted funnel plots. We excluded treatment studies with waiting-list or treatment as usual controls. From this literature, we extracted evidence-based assertions about the disorder.RESULTSWe generated 208 empirically supported statements about ADHD. The status of the included statements as empirically supported is approved by 79 authors from 27 countries and 6 continents. The contents of the manuscript are endorsed by 362 people who have read this document and agree with its contents.CONCLUSIONSMany findings in ADHD are supported by meta-analysis. These allow for firm statements about the nature, course, outcome causes, and treatments for disorders that are useful for reducing misconceptions and stigma.