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A Quick Test of Cognitive Speed for Comparing Processing Speed to Differentiate Adult Psychiatric Referrals With and Without Attention-Deficit/Hyperactivity Disorders
Abstract
Objective:
This retrospective study used A Quick Test of Cognitive Speed (AQT) to compare processing speed and efficiency measures by adults with attention-deficit/hyperactivity disorder (ADHD) or non-ADHD psychiatric disorders and healthy controls.
Method:
Color, form, and color-form combination naming tests were administered to 104 adults, ages 17-55 years, referred for psychiatric evaluation of possible ADHD. Thirty healthy adults were controls. Psychiatric intake procedures identified 64 adults with ADHD (ICD-10 and DSM-IV criteria) and 40 with mild psychiatric disorders without ADHD. The study was conducted from 2008 through 2010.
Results:
At intake, color, form, and color-form combination naming times (seconds) were longer and overhead [color-form combination - (color + form)] was larger for patients with ADHD than for non-ADHD patients and controls. In the ADHD group, color and form measures were in the normal range. Color-form combination was in the slower-than-normal speed (60-70 seconds) and overhead, a processing-efficiency measure, in the atypical range (> 10 seconds). In the non-ADHD patient and control groups, all AQT measures were in the normal range. Analysis of variance with post hoc analysis of log-normal values for color, form, and color-form combination and time for overhead indicated significant (Bonferroni P < .01) mean differences between the ADHD and other groups, but not between the non-ADHD and control groups. When using fail criteria for either color-form combination or overhead, the sensitivity for the ADHD group was 89%.
Conclusions:
RESULTS support AQT as a possible complement to psychiatric intake procedures to differentiate adults with ADHD from those with mild psychiatric disorders, and they suggest that a controlled prospective study might be productive.
... In adults with ADHD, tested without medication, perceptual speed (Color, Form) may not be compromised, but there is typically a reduction in cognitive speed (Color-Form) and a larger-than-typical overhead, indicating added shift costs and reduced processing efficiency [10,26,21]. This pattern has been observed to occur in 85% of previously medicated adults with ADHD [10] and in 91-93% of medicationnaïve adults with ADHD [21,26,27]. After treatment with methylphenidate, cognitive speed and shift costs are typically restored to within normal limits [10,26,27]. ...
... This pattern has been observed to occur in 85% of previously medicated adults with ADHD [10] and in 91-93% of medicationnaïve adults with ADHD [21,26,27]. After treatment with methylphenidate, cognitive speed and shift costs are typically restored to within normal limits [10,26,27]. ...
... This was the first study in which the AQT processing speed measures were used to evaluate processing speed and efficiency in a clinical sample of adults with ADHD and comorbid SUD on treatment with methylphenidate, before and after the morning dose of methylphenidate. We expected cognitive speed and processing efficiency to be more severely affected before the morning dose of methylphenidate than previously observed in adults with ADHD without SUD [25][26][27][28]. This expectation was based on the complexity of the physical, psychological or social factors associated with SUD [3,4]. ...
Background: Substance use disorders (SUDs) are common comorbidities of Attention Deficit Hyperactivity Disorder (ADHD). The most commonly prescribed medication for ADHD is methylphenidate. The clinical response to methylphenidate may be monitored against DSM-5 symptomatology, rating scales or interviews.
Aims: To evaluate the use of perceptual and cognitive processing speed measures to monitor methylphenidate effects in adults with ADHD and SUD.
Methods: A Quick Test of Cognitive Speed (AQT) monitored perceptual and cognitive processing speed in 28 adults with ADHD and SUD on treatment with methylphenidate before and after the morning dose.
Results: Twenty-six patients responded on AQT after the morning dose of methylphenidate. One-way ANOVA indicated significant treatment effects for color, form, and color-form combination naming, but not for shift cost values. Before the morning dose of methylphenidate, 92% were identified by cutoff time criteria for longer-than-normal processing times. After the morning dose of methylphenidate, 65% obtained color and form measures in the normal range for age peers. Only 35% obtained color-form processing measures in the normal range. Inter-individual response variability before medication intake was considerably larger than previously reported in studies of adults with ADHD only.
Conclusion: Proportionally, fewer adults with ADHD and SUD exhibited normalization of processing speed than previously observed for adults with ADHD without SUD. A potential clinical implication of the present study is that the AQT test may be used as a tool for dose-adjustment of central stimulants in the treatment of adults with ADHD and SUD.
... Finding reliable, quantifiable measures for dose monitoring has become of increasing interest to psychiatrists and allied health professionals in clinical practice. Several clinical studies suggest that processing-speed measures, as proxy measures of attention, working memory and set shifting, might be incorporated in day-to-day clinical practice to monitor the effects of pharmacological treatment for ADHD in adults [1][2][3][4][5][6][7]. These tests may serve to complement other tests and measures that have been found appropriate for documenting cognitive changes associated with effective treatment of ADHD. ...
... The processing-speed tests (color, form, and color-form) have been used in previous studies of the ADHD symptomatology and of the effects of pharmacological interventions on cognitive speed and processing efficiency [5][6][7][8]. These studies indicated significant statistical differences in the response patterns of adults with ADHD and with psychiatric disorders without ADHD, and neurotypical adolescents and adults [5,6]. ...
... The processing-speed tests (color, form, and color-form) have been used in previous studies of the ADHD symptomatology and of the effects of pharmacological interventions on cognitive speed and processing efficiency [5][6][7][8]. These studies indicated significant statistical differences in the response patterns of adults with ADHD and with psychiatric disorders without ADHD, and neurotypical adolescents and adults [5,6]. Studies have also explored whether the tests might quantify improvements in cognitive speed and processing efficiency (shift cost) as a results of receiving prescribed ADHD medication (Concerta, Ritalin, Medikinet) or immediate-release methylphenidate in controlled, incremental doses (Medikinet IR) [7,8]. ...
... The professional literature offers inconsistent findings regarding the role of comorbid anxiety and depression on executive functioning among adults with and without ADHD (Boonstra et al., 2005;Fuermaier et al., 2019;Holst & Thorell, 2017;Wiig & Nielsen, 2012). Theiling and Petermann (2016) found that adults with ADHD performed significantly lower on working memory and processing speed tasks of the WAIS-IV. ...
... In this study, we tested the differential diagnostic utility of scores on the WAIS-IV WMI and PSI and CTMT trails. A key reason for conducting this study was to help further understanding of inconsistencies reported in the extant literature regarding the role of OPD on executive functioning among adults with and without ADHD (Boonstra et al., 2005;Fuermaier et al., 2019;Holst & Thorell, 2017;Wiig & Nielsen, 2012). In comparing a sample of adults with ADHD, most of whom had comorbid OPD, to a control group, Theiling and Petermann (2016) found adults with ADHD produced significantly lower WMI and PSI scores. ...
In this study, the utility of the Comprehensive Trail Making Test (CTMT) and WAIS-IV working memory (WMI) and processing speed (PSI) indices in assessment of ADHD were examined. Using retrospective analysis of data from two private practices, patients were classified as having ADHD, having another psychiatric disorder, or having comorbid ADHD and other psychiatric disorder. Results indicated that significant differences existed in performance across the three groups [F(6, 246) = 3.38, p = .003; Pillai's Trace = 0.152, partial η2 = 0.076] on CTMT scores (p < .05), WMI scores (p ≤ .001) and PSI scores (p < .05). Logistic regression analyses indicated WMI and CTMT trail 5 scores were individually useful indicators in identifying the presence of ADHD. Analysis also indicated minimal increase in correct classification of presence or absence of ADHD through combining CTMT, WMI, and PSI scores. Clinical implications for neuropsychological assessment and differential diagnosis of ADHD are discussed.
... Accepted manusript Wiig, 2013, Nielsen et al., 2017, Magell et al., 2018, Wiig and Nielsen, 2012. Dose-effect studies further indicated that AQT can identify incremental reductions in colour-form naming and shift costs with controlled increases in methylphenidate IR (Nielsen et al., 2017, Magell et al., 2018. ...
... Moreover, shift costs remained stable during both the T-PEMF active and sham treatments in the depression group, as shown in the overview of weekly treatment outcomes (see Table 1). Accepted manusript both medication-naïve and previously-medicated patients, some of whom exhibited depression as a comorbidity (Nielsen et al., 2017, Magell et al., 2018, Wiig and Nielsen, 2012. In the depression group, a second clinically relevant observation might be that there was a measurable and incremental increase in cognitive speed (colour-form) after each week of treatment and that a time reduction of 0.74 s in colour-form naming corresponded to an increase of 1 point on the Hamilton 6-item subscale. ...
Objective
We evaluated processing-speed and shift-cost measures in adults with depression or ADHD and monitored the effects of treatment. We hypothesized that cognitive-speed and shift-cost measures might differentiate diagnostic groups.
Methods
Colour, form, and colour-form stimuli were used to measured naming times. The shift cost (s) were calculated as colour-form naming time minus the sum of colour and form naming times. Measurements were done at baseline and endpoint for 42 adults with depression and 42 with ADHD without depression. Patients with depression were treated with Transcranial Pulsed Electromagnetic Fields and patients with ADHD with methylphenidate IR.
Results
During depression treatment, reductions in naming times were recorded weekly. One-way ANOVA indicated statistical between-group differences with effect sizes in the medium range for form and colour-form. In both groups, naming times were longer before than after treatment. For the ADHD group, shift costs exceeded the average-normal range at baseline but were in the average-normal range after stabilization with stimulant medication. For the depression group, shift costs were in the average-normal range at baseline and after treatment. Baseline colour-form naming times predicted reductions in naming times for both groups with the largest effect size and index of forecasting efficiency for the ADHD group.
Conclusions
The cognitive-processing speed (colour-form) and shift-cost measures before treatment proved most sensitive in differentiating patients with depression and ADHD. Reductions in naming times for the depression group were suggested to reflect improved psycho-motor skills rather than improved cognitive control.
... However, the cognitive overhead/shift cost measure was in the atypical range (i.e., > +2 SD/ > 10 s) and larger than average for healthy age peers (i.e., > +/-4s) [4]. This concurred with pro iles of above average-normal cognitive speed/shift cost values that were later reported to occur in 80% or more of adults with attention-de icit disorder with hyperactivity [5][6][7][8][9][10]. ...
... In contrast, the cognitive overhead/shift cost measure was in the atypical/pathological range (i.e., > + 2SD of the mean), as compared to the norms for the age range [4]. The psychiatrist's early hypothesis led to further studies that explored whether larger than average cognitive overhead (shift cost) values might differentiate healthy adults from adults with ADHD diagnoses and psychiatric patients with and without ADHD [5][6][7]. The prevalence of a larger than average cognitive overhead was also compared for medication naïve and previously medicated adults with ADHD diagnosis [5,8,9]. ...
Abstract
This forensic case study follows a young woman with attention-deficit disorder with hyperactivity (ADHD) from early childhood through adolescence and young adulthood. The report of her childhood indicated conflicts between mother and child, physical abuse by a stepparent, frequent changes of school settings and truancy, and unspecified learning disabilities. As a teenager, she was institutionalized in a youth facility with escalating substance use, mood swings, and oppositional defiance disorder. She left school at age 17 to join a group setting with pervasive substance. During this period, she was chronically depressed, had anger attacks, lacked motivation, refused any psychological assistance, and had problems finding work. This culminated in an aggravated assault of a female in an urban public space, after which she was referred to the criminal courts. Based on background evidence of mental illness, including depression with paranoia, the court’s decision was to require hospitalization for observation and in-depth psychiatric evaluation with ambulatory follow-up treatment, as determined by the medical authorities. After the diagnosis of ADHD, the patient was prescribed stimulant medication and referred to a regional psychiatric center for counseling, qualitative evaluations, psychiatric interviews, and psychiatric follow-up with quantitative monitoring of methylphenidate dose effects, using norm-referenced processing-speed measures. Monitoring of treatment effects lasted for a year and a half, during which the medication types, dose amounts, and ingestion times were fine tuned to the patient’s needs, as described in detailed records and protocols. At the beginning of treatment, the patient engaged in daily excessive use of cannabis, amphetamines, and cigarettes. At the end of treatment, the patient used small amounts of cannabis during weekends, smoked a few cigarettes per day, and was actively engaged in a job search. A two-year follow up indicated continued stabilization of mood and AHDH symptomatology, positive social integration, and gainful employment.
... Furthermore, adults with ADHD showed a stronger temporal discounting tendency than adults without ADHD. Previous studies demonstrated that adults with ADHD have a reduced information processing capacity (Roberts et al. 2012) and impairments in working memory (Alderson et al. 2013), speed of information processing (Wiig and Nielsen 2012), vigilance/sustained attention (Tucha et al. 2009(Tucha et al. , 2015, selective attention (Tucha et al. 2008) and arithmetic abilities (Frazier et al. 2004), all which may underly difficulties with understanding financial information. Also, the comorbidities (e.g., depressive disorders or substance dependency) that were present in some of the adults with ADHD might partly explain the differences that were found regarding financial judgment and temporal discounting between adults with and without ADHD. ...
ADHD has a debilitating influence on everyday functioning, including the capability to make financial decisions. The capability to make financial decisions is a multidimensional construct that includes financial knowledge, financial judgment, financial performance and related contextual factors. So far, the majority of studies in adults with ADHD focused on financial performance, while the other aspects of financial capability were less explored. The current study aims to partly bridge this gap by examining the ability of financial judgment in adults with ADHD. Thirty-nine adults with ADHD and 83 adults without ADHD were included. All participants were assessed with the Financial Competence Assessment Inventory (FCAI) and Financial Decision-Making Interview (FDMI) which both assess the four abilities of financial judgment, i.e., understanding, appreciation, reasoning and communication. The results show that adults with ADHD, compared to adults without ADHD, obtained significantly lower scores on understanding (according to the FCAI and FDMI). Furthermore, adults with ADHD showed a significantly lower appreciation, reasoning and communication (according to the FCAI) than adults without ADHD. In conclusion, adults with ADHD have difficulties with financial judgment especially with the ability to understand information that is relevant for a financial situation or transaction. Furthermore, adults with ADHD were found to have problems with appreciating, reasoning and communicating about practical information that partly relates to their own financial situation (as assessed with the FCAI). A careful assessment of financial capability in adults with ADHD, therefore, appears warranted in clinical practice.
... In previous research with "A Quick Test of Cognitive Speed 2" we observed that a large majority (i.e., about 90%) of adults with ADHD exhibited significantly slower cognitive speed and larger shift costs (overhead) during dual-dimension color-form naming than observed among neuro-typical adults [3][4][5]. These characteristics also differentiated adult psychiatric referrals with and without ADHD [6]. The findings suggested that a combination of reduced attention, working memory, set shifting and cognitive control, reflected in longer color-form naming times and larger shift costs (overhead) might characterize adults with ADHD. ...
... Form could stand for the activity required and color could stand for good outcomes. Support for the use of a color-form image comes from evidence of slowed performance with such images among children with attention deficit hyperactivity disorder [65]. These children lack experience of good independently achieved effort-outcome sequences. ...
... RAN is a quickly administered cognitive speed test (e.g. Wiig & Nielsen (2012)) which has also been shown to be sensitive to Alzheimers disease (Palmqvist et al, 2010). Raven's matrices (Raven, 1938;Raven, 2008) were used as a basic non-verbal IQ estimate. ...
Objective:
The aims of the current n200 study were to assess the structural relations between three classes of test variables (i.e. HEARING, COGNITION and aided speech-in-noise OUTCOMES) and to describe the theoretical implications of these relations for the Ease of Language Understanding (ELU) model.
Study sample:
Participants were 200 hard-of-hearing hearing-aid users, with a mean age of 60.8 years. Forty-three percent were females and the mean hearing threshold in the better ear was 37.4 dB HL.
Design:
LEVEL1 factor analyses extracted one factor per test and/or cognitive function based on a priori conceptualizations. The more abstract LEVEL 2 factor analyses were performed separately for the three classes of test variables.
Results:
The HEARING test variables resulted in two LEVEL 2 factors, which we labelled SENSITIVITY and TEMPORAL FINE STRUCTURE; the COGNITIVE variables in one COGNITION factor only, and OUTCOMES in two factors, NO CONTEXT and CONTEXT. COGNITION predicted the NO CONTEXT factor to a stronger extent than the CONTEXT outcome factor. TEMPORAL FINE STRUCTURE and SENSITIVITY were associated with COGNITION and all three contributed significantly and independently to especially the NO CONTEXT outcome scores (R(2) = 0.40).
Conclusions:
All LEVEL 2 factors are important theoretically as well as for clinical assessment.
... Criterion Measures consisted of: 1) Digit Span Forwards, Digit Span Backwards and Digit Span Sequencing from the Wechsler Adult Intelligence Scale-Fourth Addition, were used to assess auditory-verbal working and short-term memory [34], 2) The Spatial Span Forwards and Spatial Span Backwards from The Cambridge Neuropsychological Testing Automated Battery (CANTAB) was used to assess visual-spatial short-term and working memory [35], 3) The Finger Windows Forwards and Finger Windows Backwards subtest from The Wide Range Assessment of Memory and Learning-Second Edition [36], was used as another measure of visual-spatial short-term and working memory. Near Transfer Measures consisted of: 1) The CANTAB Spatial working memory between errors score was used to assess visual-spatial working memory [35], 2) The CANTAB Pattern Recognition Memory task assessed visual short-term memory [35], 4) A Quick Test of Cognitive Speed was used to measures the speed of naming single dimensions (Color, Form), dualdimension (ColorForm) and overall processing efficiency [CF-(C + F)] in seconds [37]. ...
Objectives:
To determine whether standard-length computerized training enhances working memory (WM), transfers to other cognitive domains and shows sustained effects, when controlling for motivation, engagement, and expectancy.
Methods:
97 post-secondary students (59.8% female) aged 18-35 years with Attention-Deficit/Hyperactivity Disorder, were randomized into standard-length adaptive Cogmed WM training (CWMT; 45-min/session), a shortened-length adaptive version of CWMT (15 min/session) that controlled for motivation, engagement and expectancy of change, or into a no training group (waitlist-control group). All three groups received weekly telephone calls from trained coaches, who supervised the CWMT and were independent from the research team. All were evaluated before and 3 weeks post-training; those in the two CWMT groups were also assessed 3 months post-training. Untrained outcome measures of WM included the WAIS-IV Digit Span (auditory-verbal WM), CANTAB Spatial Span (visual-spatial WM) and WRAML Finger Windows (visual-spatial WM). Transfer-of-training effects included measures of short-term memory, cognitive speed, math and reading fluency, complex reasoning, and ADHD symptoms.
Results:
Performance on 5/7 criterion measures indicated that shortened-length CWMT conferred as much benefit on WM performance as did standard-length training, with both CWMT groups improving more than the waitlist-control group. Only 2 of these findings remained robust after correcting for multiple comparisons. Follow-up analyses revealed that post-training improvements on WM performance were maintained for at least three months. There was no evidence of any transfer effects but the standard-length group showed improvement in task-specific strategy use.
Conclusions:
This study failed to find robust evidence of benefits of standard-length CWMT for improving WM in college students with ADHD and the overall pattern of findings raise questions about the specificity of training effects.
Trial registration:
ClinicalTrials.gov NCT01657721.
... AQT measures are sensitive to small changes in the time used for processing and responding, and have been used to examine, among others, the comparative effects on cognition of Alzheimer's disease and dementia with Lewy bodies and individual responsiveness to Alzheimer's disease's specific medication (Warkentin et al., 2005;Andersson et al., 2007;Warkentin et al., 2008;Palmqvist et al., 2010;Palmqvist, 2011, p. 62). AQT has also proved useful in differentiating adults with and without attention deficit hyperactivity disorders (ADHD; Wiig and Nielsen, 2012). ...
Background
A Quick Test of Cognitive Speed (AQT) is a brief test that can identify cognitive impairment. AQT has been validated in Arabic, English, Greek, Japanese, Norwegian, Spanish, and Swedish. The aim of this study was to develop Italian criterion-referenced norms for AQT.
Methods
AQT consists of three test plates where the patient shall rapidly name (1) the color of 40 blue, red, yellow, or black squares (AQT color), (2) the form of 40 black figures (circles, squares, triangles, or rectangles; AQT form), (3) the color and form of 40 figures (consisting of previous colors and forms; AQT color–form). The AQT test was administered to 121 Italian cognitively healthy primary care patients (age range: 45–90 years). Their mean Mini-Mental State Examination (MMSE) score was 28.8 ± 0.9 points (range 26–30 points). AQT naming times in seconds were used for developing preliminary criterion cut-off times for different age groups.
Results
Age was found to have a significant moderate positive correlation with AQT naming times color (r = 0.65, p < 0.001), form (r = 0.53, p < 0.001), color–form (r = 0.63, p < 0.001) and a moderate negative correlation with MMSE score (r = –0.44, p < 0.001) and AQT naming times differed significantly between younger (45–55 years old), older (56–70 years old), and the oldest (71–90 years old) participants. Years of education correlated positively but weakly with MMSE score (r = 0.27, p = 0.003) and negatively but weakly with AQT color (r = –0.16, p = ns), form (r = –0.24, p = 0.007), and color–form (r = –0.19, p = 0.005). We established preliminary cut-off times for the AQT test based on +1 and +2 standard deviations according to the approach in other languages and settings.
Conclusions
This is the first Italian normative AQT study. Future studies of AQT – a test useful for dementia screening in primary care – will eventually refine cut-off times for normality balancing sensitivity and specificity in cognitive diagnostics.
Attention-Deficit Hyperactivity Disorder (ADHD) is a complex and heterogeneous neurodevelopmental condition for which curative treatments are lacking. Whilst pharmacological treatments are generally effective and safe, there is considerable inter-individual variability among patients regarding treatment response, required dose, and tolerability. Many of the non-pharmacological treatments, which are preferred to drug-treatment by some patients, either lack efficacy for core symptoms or are associated with small effect sizes. No evidence-based decision tools are currently available to allocate pharmacological or psychosocial treatments based on the patient's clinical, environmental, cognitive, genetic, or biological characteristics. We systematically reviewed potential biomarkers that may help in diagnosing ADHD and/or stratifying ADHD into more homogeneous subgroups and/or predict clinical course, treatment response, and long-term outcome across the lifespan. Most work involved exploratory studies with cognitive, actigraphic and EEG diagnostic markers to predict ADHD, along with relatively few studies exploring markers to subtype ADHD and predict response to treatment. There is a critical need for multisite prospective carefully designed experimentally controlled or observational studies to identify biomarkers that index inter-individual variability and/or predict treatment response.
Objectives
Numerous studies showed that adults with attention deficit hyperactivity disorder (ADHD) suffer from impairments in a range of cognitive functions when compared to healthy controls. However, only little is known about the neuropsychological functions when compared to various clinical control groups and whether a distinct neuropsychological profile can be identified for adult ADHD.
Method
This retrospective study examined data of 199 outpatients referred for clinical evaluation of adult ADHD, allocated either to an ADHD group (n = 78) or to one of two clinical comparison groups, depending on whether they show indications (n = 71) or no indications (n = 50) for the presence of psychiatric disorders other than ADHD. All individuals performed a comprehensive neuropsychological test battery.
Results
Data analysis revealed impairments in a range of cognitive functions in a substantial number of patients of all three groups. However, profiles of neuropsychological impairments were similar between groups. Furthermore, significant small- to medium-sized correlations between basic and higher-order cognitive functions were revealed in the ADHD group and the clinical comparison group with indications for psychiatric disorders other than ADHD.
Conclusion
Neuropsychological impairments are prominent in psychiatric outpatients seeking a clinical evaluation of adult ADHD but are not specific for ADHD. It is concluded that neuropsychological test performance may have limited incremental value to support the psychiatric differential diagnosis. Furthermore, a clinical trajectory may need to take into account that deficits in a range of higher-order cognitive functions can be substantially explained by deficits in basic cognitive functions.
Color vision and self-reported visual function in everyday life in young adults with Attention-Deficit/Hyperactivity Disorder (ADHD) were investigated.
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).
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.
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.
This study examines (a) how rapid automatized naming (RAN) speed components—articulation time and pause time—predict reading accuracy and reading fluency in Grades 2 and 3, and (b) how RAN components are related to measures of phonological awareness, orthographic knowledge, and speed of processing. Forty-eight children were administered RAN tasks in Grades 1, 2, and 3. Results indicated that pause time was highly correlated with both reading accuracy and reading fluency measures and shared more of its predictive variance with orthographic knowledge than with phonological awareness or speed of processing. In contrast, articulation time was only weakly correlated with the reading measures and was rather independent from any processing skill at any point of measurement.
Compared to the high number of studies that investigated executive functions (EF) in children with attention-deficit/hyperactivity disorder (ADHD), a little is known about the EF performance of adults with ADHD. This study compared 37 adults with ADHD (ADHD(total)) and 32 control participants who were equivalent in age, intelligence quotient (IQ), sex, and years of education, in two domains of EF--set shifting and working memory. Additionally, the ADHD(total) group was subdivided into two subgroups: ADHD patients without comorbidity (ADHD(-), n = 19) and patients with at least one comorbid disorder (ADHD(+), n = 18). Participants fulfilled two measures for set shifting (i.e., the trail making test, TMT and a computerized card sorting test, CKV) and one measure for working memory (i.e., digit span test, DS). Compared to the control group the ADHD(total) group displayed deficits in set shifting and working memory. The differences between the groups were of medium-to-large effect size (TMT: d = 0.48; DS: d = 0.51; CKV: d = 0.74). The subgroup comparison of the ADHD(+) group and the ADHD(-) group revealed a poorer performance in general information processing speed for the ADHD(+) group. With regard to set shifting and working memory, no significant differences could be found between the two subgroups. These results suggest that the deficits of the ADHD(total) group are attributable to ADHD rather than to comorbidity. An influence of comorbidity, however, could not be completely ruled out as there was a trend of a poorer performance in the ADHD(+) group on some of the outcome measures.
The purpose of this study was to examine the possible additive neurocognitive deficits in adults with both attention-deficit/hyperactivity
disorder (ADHD) and serious depressive symptoms. Participants were 54 university students who completed a psycho-educational
assessment. Three groups were examined: a group with comorbid ADHD and elevated depressive symptoms (ADHD + DEP; N = 18); a group with ADHD only (N = 18); and a group with elevated depressive symptoms only (DEP; N = 18). Group differences were examined on a battery of neurocognitive tests. The ADHD + DEP group performed significantly
worse than the other groups on processing speed tasks and delayed recall of conceptual verbal information and significantly
worse than the ADHD group on shifting tasks. Depressive symptom severity was significantly correlated with processing speed,
verbal memory performance, and shifting in the ADHD and ADHD + DEP groups. Results suggest that the co-occurrence of ADHD
and depressive symptoms in adults is associated with additional neurocognitive impairment.
Attention-deficit/hyperactivity disorder (ADHD) is frequently misdiagnosed or undiagnosed in adults. Owing to the relatively recent recognition of adult ADHD as a valid mental disorder and its overlapping symptomatology with other conditions, primary care physicians often fail to screen for ADHD in patients who present with inattention, impulsivity, and hyperactivity. A substantial proportion of adults with ADHD also have psychiatric comorbidities. Physicians need to recognize the ways in which ADHD symptoms are expressed in adults and distinguish them from symptoms of other disorders, including mood, anxiety, and substance abuse disorders.
Attention-deficit hyperactivity disorder (ADHD) is one of the most common neuropsychiatric disorders with childhood onset, having a chronic course associated with high dysfunction and morbidity throughout life. Despite significant advances in our understanding of the neurobiological underpinnings of the disorder, diagnosis of ADHD remains strictly clinical and is based on behavioral symptoms of inattention, impulsivity, and hyperactivity. In this chapter, we review the diagnostic process and current controversies in the diagnosis of ADHD, discuss the clinical presentation of the disorder across the lifespan, and examine the patterns of comorbidity and the longitudinal predictors of outcomes. We conclude by pointing out some of the challenges that need to be addressed in future classifications systems to improve the characterization and validity of the diagnosis of ADHD.
Processing-speed deficits affect reading efficiency, even among individuals who recognize and decode words accurately. Children with ADHD who decode words accurately can still have inefficient reading fluency, leading to a bottleneck in other cognitive processes. This "slowing" in ADHD is associated with deficits in fundamental components of executive function underlying processing speed, including response selection. The purpose of the present study was to deconstruct processing speed in order to determine which components of executive control best explain the "processing" speed deficits related to reading fluency in ADHD. Participants (41 ADHD, 21 controls), ages 9-14 years, screened for language disorders, word reading deficits, and psychiatric disorders, were administered measures of copying speed, processing speed, reading fluency, working memory, reaction time, inhibition, and auditory attention span. Compared to controls, children with ADHD showed reduced oral and silent reading fluency and reduced processing speed-driven primarily by deficits on WISC-IV Coding. In contrast, groups did not differ on copying speed. After controlling for copying speed, sex, severity of ADHD-related symptomatology, and GAI, slowed "processing" speed (i.e., Coding) was significantly associated with verbal span and measures of working memory but not with measures of response control/inhibition, lexical retrieval speed, reaction time, or intrasubject variability. Further, "processing" speed (i.e., Coding, residualized for copying speed) and working memory were significant predictors of oral reading fluency. Abnormalities in working memory and response selection (which are frontally mediated and enter into the output side of processing speed) may play an important role in deficits in reading fluency in ADHD, potentially more than posteriorally mediated problems with orienting of attention or perceiving the stimulus.
There is a great need for quick tests that identify treatment response in Alzheimer's disease (AD) to determine who benefits from the treatment. In this study, A Quick Test of cognitive speed (AQT) was compared with the mini-mental state examination (MMSE) in the evaluation of treatment outcome in AD.
75 patients with mild to moderate AD at a memory clinic were assessed with AQT and the MMSE at a pretreatment visit, at baseline and after 8 weeks of treatment with cholinesterase inhibitors (ChEI) initiated at baseline. Changes in the mean test scores before and after treatment were compared, as well as the number of treatment responders detected by each test, according to a reliable change index (RCI).
After 8 weeks of treatment, the AQT improvement, expressed as a percentage, was significantly greater than that of the MMSE (P = 0.026). According to the RCI, the cut-offs to define a responder were ≥16 seconds improvement on AQT and ≥3 points on the MMSE after 8 weeks. With these cut-offs, both tests falsely classified ≤5% as responders during the pretreatment period. After 8 weeks of treatment, AQT detected significantly more responders than the MMSE (34% compared with 17%; P = 0.024). After 6 months of treatment, the 8-week AQT responders still showed a significantly better treatment response than the AQT nonresponders (22.3 seconds in mean difference; P < 0.001).
AQT detects twice as many treatment responders as the MMSE. It seems that AQT can, already after 8 weeks, identify the AD patients who will continue to benefit from ChEI treatment.
Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe.
The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated.
Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated?
ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group.
Despite the increasing presentation of attention-deficit/hyperactivity disorder (ADHD) in adults, many practitioners remain reluctant to assess individuals for ADHD, in part related to the relative lack of data on the presenting symptoms of ADHD in adulthood. Comorbidity among adults with ADHD is also of great interest due to the high rates of psychiatric comorbidity, which can lead to a more persistent ADHD among adults.
We assessed 107 adults with ADHD of both sexes (51% female; mean +/- SD of 37 +/- 10.4 years) using structured diagnostic interviews. Using DSM-IV symptoms, we determined DSM-IV subtypes. The study was conducted from 1998 to 2003.
Inattentive symptoms were most frequently endorsed (> 90%) in adults with ADHD. Using current symptoms, 62% of adults had the combined subtype, 31% the inattentive only subtype, and 7% the hyperactive/impulsive only subtype. Adults with the combined subtype had relatively more psychiatric comorbidity compared to those with the predominately inattentive subtype. Women were similar to men in the presentation of ADHD.
Adults with ADHD have prominent inattentive symptoms of ADHD, necessitating careful questioning of these symptoms when evaluating these individuals.
Efficient execution of perceptual-motor tasks requires rapid voluntary reconfiguration of cognitive task sets as circumstances unfold. Such acts of cognitive control, which are thought to rely on a network of cortical regions in prefrontal and posterior parietal cortex, include voluntary shifts of attention among perceptual inputs or among memory representations, or switches between categorization or stimulus-response mapping rules. A critical unanswered question is whether task set shifts in these different domains are controlled by a common, domain-independent mechanism or by separate, domain-specific mechanisms. Recent studies have implicated a common region of medial superior parietal lobule (mSPL) as a domain-independent source of cognitive control during shifts between perceptual, mnemonic, and rule representations. Here, we use fMRI and event-related multivoxel pattern classification to show that spatial patterns of brain activity within mSPL reliably express which of several domains of cognitive control is at play on a moment-by-moment basis. Critically, these spatiotemporal brain patterns are stable over time within subjects tested several months apart and across a variety of tasks, including shifting visuospatial attention, switching categorization rules, and shifting attention in working memory.
The degree of ADHD-related difficulties - reflecting overall impairment, social functioning, and quality of life - may be perceived differently by adolescent patients, parents and physicians. The primary aim of this study was to investigate ADHD-related difficulties during atomoxetine treatment, as perceived by the three different raters. Secondary objectives focused on effectiveness and tolerability of atomoxetine treatment in a population of adolescent patients with ADHD.
Adolescents with ADHD, aged 12-17 years, received open-label atomoxetine (0.5-1.2 mg/kg/day) up to 24 weeks. ADHD-related difficulties at various times of the day were rated using the Global Impression of Perceived Difficulties (GIPD) instrument. Inter-rater agreement was analyzed using Cohen's Kappa with 95% confidence intervals (95% CI). ADHD-Rating Scale (ADHD-RS) and Clinical Global Impression Severity (GGI-S) scores were assessed by the investigator; and spontaneous adverse events, vital signs and laboratory parameters were collected for tolerability assessments.
159 patients received atomoxetine. Patients' baseline mean GIPD total ratings were significantly lower than parents' and physicians' scores (12.5 [95%CI 11.6;13.5] vs. 17.2 [16.2;18.2] and 18.8 [17.8;19.8]). For all raters, GIPD scores significantly improved over time. Changes were greatest within the first two weeks. Kappa coefficients varied between 0.186 [0.112;0.259] and 0.662 [0.529;0.795], with strongest agreements between parent and physician assessments, and significant improvements of patient/physician agreements over time (based on 95% CIs). ADHD-RS and CGI-S scores significantly improved over the course of the study (based on 95% CIs). Tolerability results were consistent with earlier reports.
ADHD-related difficulties were perceived differently by the raters in this open-label trial, but consistently improved during atomoxetine treatment. The GIPD instrument appeared sensitive to treatment-related change. These primarily quantitative findings may guide future studies to more systematically investigate the clinical and practical relevance of the differences observed. Additionally, in order to further validate these results, placebo- and comparator-controlled trials are recommended as well as inclusion of healthy controls and other patient populations.
Clinical Trial Registry: ClinicalTrials.gov: NCT00191737.
A comprehensive, empirically based review of the published studies addressing neuropsychological performance in adults diagnosed with attention-deficit/hyperactivity disorder (ADHD) was conducted to identify patterns of performance deficits. Findings from 33 published studies were submitted to a meta-analytic procedure producing sample-size-weighted mean effect sizes across test measures. Results suggest that neuropsychological deficits are expressed in adults with ADHD across multiple domains of functioning, with notable impairments in attention, behavioral inhibition, and memory, whereas normal performance is noted in simple reaction time. Theoretical and developmental considerations are discussed, including the role of behavioral inhibition and working memory impairment. Future directions for research based on these findings are highlighted, including further exploration of specific impairments and an emphasis on particular tests and testing conditions.
Performances on Alzheimer's Quick Test color-form naming and Mini-Mental State Examination were compared for 38 adults with Alzheimer's disease and 38 age- and sex-matched normal controls. Group means differed significantly and indicated longer naming times by adults with Alzheimer's disease. The specificity for AQT color-form naming was 97% and sensitivity 97%, i.e., 3% false negatives. The specificity for Mini-Mental State Examination was 100% and sensitivity 84%, i.e., 16% false negatives. These findings, while supporting AQT color-form naming as a screening test for reductions in cognitive speed associated with Alzheimer's disease, are preliminary given the relatively small sample.
In this study, we explored the clinical characteristics, impairment and comorbidity in a sample of 45 adult patients with attention-deficit/hyperactivity disorder (ADHD). The collection of data is based on a naturalistic, retrospective approach using medical records documenting a comprehensive assessment of the patients. The sample was severely impaired in terms of academic achievement, employment and criminality, and had very high levels of comorbidity, especially alcohol and drug abuse, antisocial personality disorder and depression. Despite a high degree of contact with child psychiatric services in childhood, very few were diagnosed with ADHD, and many had a long period of psychiatric treatment as adults before the ADHD diagnosis was made. ADHD is in this sample of adults associated with severe impairment and comorbidity, and the connection between impairment and lack of proper diagnosis and treatment is discussed.
A Quick Test of Cognitive Speed color, form, and color-form naming were administered to 300 normal participants (ages 15-95 years) to explore the effects of age on perceptual (single-dimension naming) and cognitive speed (dual-dimension naming). Naming time means (sec.) were consistent with previous findings. Correlations between age and naming time were low, but significant. Linear regression with age as a factor indicated time increases of 1 sec. per decade for colors and color-form combination naming and of 6 sec. per decade for form naming. Participants were divided into age cohorts, each covering a decade, and naming times were transformed to normalized z scores. The normalized means were similar for color, form, and color-form naming and increased by about 1 SD between ages 15-25 and 75-85 years. The ranges were similar across cohorts, about 2 SD. The findings concur with age patterns for visual-pattern comparison speed, fluid intelligence, and working memory reported by Salthouse in 2004.
Attention-deficit/hyperactivity disorder (ADHD) is hypothesized to be due, in part, to structural defects in brain networks influencing cognitive, affective, and motor behaviors. Although the current literature on fiber tracts is limited in ADHD, gray matter abnormalities suggest that white matter (WM) connections may be altered selectively in neural systems. A prior study (Ashtari et al. 2005), using diffusion tensor magnetic resonance imaging (DT-MRI), showed alterations within the frontal and cerebellar WM in children and adolescents with ADHD. In this study of adults with childhood ADHD, we hypothesized that fiber pathways subserving attention and executive functions (EFs) would be altered. To this end, the cingulum bundle (CB) and superior longitudinal fascicle II (SLF II) were investigated in vivo in 12 adults with childhood ADHD and 17 demographically comparable unaffected controls using DT-MRI. Relative to controls, the fractional anisotropy (FA) values were significantly smaller in both regions of interest in the right hemisphere, in contrast to a control region (the fornix), indicating an alteration of anatomical connections within the attention and EF cerebral systems in adults with childhood ADHD. The demonstration of FA abnormalities in the CB and SLF II in adults with childhood ADHD provides further support for persistent structural abnormalities into adulthood.
Decreased information processing speed (mental slowing) is a known sequelae of many brain disorders, and can be assessed by continuous naming tasks. Functional imaging studies have shown that pause and articulation times in continuous speech are normally associated with different brain regions, but knowledge about such association in dementia is lacking. We therefore tested the hypothesis that perfusion deficits in Alzheimer's disease (AD) are not only associated with slower processing, but also with these speech measures. Using regional cerebral blood flow (rCBF) measurements during the performance of a continuous colour and form-naming task, we found that naming speed was substantially slower in AD patients than in controls. This slower naming was exclusively determined by an increase in mean pause time, and only to a limited extent by articulation time. The increased pause time was uniquely associated with temporo-parietal rCBF reductions of the patients, while articulation was not. By contrast, the rCBF of healthy elderly control subjects was consistently accompanied by substantially shorter articulation and pause times, although the naming measures were not statistically associated with rCBF. These findings suggest that pause time (in contrast to articulation time) may serve as a sensitive measure in the assessment of information processing speed deficits in dementia, by virtue of its close association with brain pathology.
To estimate the prevalence and workplace consequences of adult attention-deficit/hyperactivity disorder (ADHD).
An ADHD screen was administered to 18-44-year-old respondents in 10 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 USA to calibrate the screen. Days out of role were measured using the WHO Disability Assessment Schedule (WHO-DAS). Questions were also asked about ADHD treatment.
An average of 3.5% of workers in the 10 countries were 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 USA. Although only a small minority of workers with ADHD ever received treatment for this condition, higher proportions were treated for comorbid mental/substance disorders.
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.
Diagnosing attention deficit hyperactivity disorder (ADHD) in adults is difficult when diagnosticians cannot establish onset prior to the DSM-IV criterion of age 7 or if the number of symptoms does not achieve the DSM threshold for diagnosis. Previous work has assessed the validity of such diagnoses based on psychiatric co-morbidity, family history and neuropsychological functions but none of these studies have used personality as a validation criterion.
We compared four groups of adults: (1) full ADHD subjects who met all DSM-IV criteria for childhood-onset ADHD; (2) late-onset subjects who met all criteria except the age at onset criterion, (3) subthreshold subjects who did not meet full symptom criteria and (4) non-ADHD subjects who did not meet any of the above criteria. Diagnoses were made by using the Structured Clinical Interview for DSM-IV (SCID) and the Temperament and Character Inventory (TCI) was used to assess personality traits.
We found that full ADHD and late-onset ADHD showed similar personality profiles with significant deviations on all TCI scales except reward dependence and self-transcendence. By contrast, subthreshold cases only showed deviations on novelty seeking and self-directiveness.
These data call into question the stringent age of onset of ADHD symptom criteria for adults when making retrospective diagnoses of ADHD. Subthreshold ADHD seems to be a milder form of the disorder that is consistent with dimensional views of the disorder.
Recent years have seen tremendous advances in understanding and treating Attention-Deficit/Hyperactivity Disorder (ADHD). Now in a revised and expanded third edition, this authoritative handbook brings the field up to date with current, practical information on nearly every aspect of the disorder. Drawing on his own and others' ongoing, influential research - and the wisdom gleaned from decades of front-line clinical experience - Russell A. Barkley provides insights and tools for professionals working with children, adolescents, or adults. Part I presents foundational knowledge about the nature and developmental course of ADHD and its neurological, genetic, and environmental underpinnings. The symptoms and subtypes of the disorder are discussed, as are associated cognitive and developmental challenges and psychiatric comorbidities. In Parts II and III, Barkley is joined by other leading experts who offer state-of-the-art guidelines for clinical management. Assessment instruments and procedures are described in detail, with expanded coverage of adult assessment. Treatment chapters then review the full array of available approaches - parent training programs, family-focused intervention for teens, school- and classroom-based approaches, psychological counseling, and pharmacotherapy - integrating findings from hundreds of new studies. The volume also addresses such developments as once-daily sustained delivery systems for stimulant medications and a new medication, atomoxetine. Of special note, a new chapter has been added on combined therapies. Chapters in the third edition now conclude with user-friendly Key Clinical Points. This comprehensive volume is intended for a broad range of professionals, including child and adult clinical psychologists and psychiatrists, school psychologists, and pediatricians. It serves as a scholarly yet accessible text for graduate-level courses. Note: Practitioners wishing to implement the assessment and treatment recommendations in the Handbook are advised to purchase the companion Workbook, which contains a complete set of forms, questionnaires, and handouts, in a large-size format with permission to photocopy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(jacket)
(
This reprinted article originally appeared in the Journal of Experimental Psychology,
1935, Vol 18, 643–662. The following abstract of the original article appeared in PA, Vol 10:1863.) In this study pairs of conflicting stimuli, both being inherent aspects of the same symbols, were presented simultaneously (a name of one color printed in the ink of another color—a word stimulus and a color stimulus). The difference in time for reading the words printed in colors and the same words printed in black is the measure of the interference of color stimuli on reading words. The difference in the time for naming the colors in which the words are printed and the same colors printed in squares is the measure of the interference of conflicting word stimuli on naming colors. The interference of conflicting color stimuli on the time for reading 100 words (each word naming a color unlike the ink-color of its print) caused an increase of 2.3 sec or 5.6% over the normal time for reading the same words printed in black. This increase is not reliable, but the interference of conflicting word stimuli on the time for naming 100 colors (each color being the print of a word which names another color) caused an increase of 47.0 sec or 74.3% of the normal time for naming colors printed in squares.… (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We evaluated the hypotheses that A Quick Test of Cognitive Speed (AQT) single- and dual-dimension naming speed measures would differentiate normal adults and adults with ADHD before medication and that there would be no differences between groups after stabilization with medication.
Thirty adults with ADHD, aged 18-43, were evaluated with the AQT color (C), form (F) and color-form combination (CF) naming tests before and after medication with methylphenidate. Thirty age- and sex-matched normal adults served as controls.
Among adults with ADHD, pre-medication naming times (s) for C, F, and CF were significantly longer and overhead [CF - (C + F)] significantly larger than post-medication. Before medication, C, F and CF naming and processing efficiency (overhead) (s) differed significantly between ADHD adults and controls. After medication, there were no significant differences between groups. When we used fail criteria for dual-dimension naming (> 60 s) and overhead (processing efficiency) (> + 6 s) together the sensitivity was 93% and specificity 100%.
Within the study limitations, findings suggest that the processing-speed and efficiency measures in AQT may be used to screen adults for executive dysfunction and reduced cognitive control associated with ADHD.
Color-form naming in A Quick Test of Cognitive Speed (AQT) is used to assess processing speed on three rapid automatic naming tasks, two of which measure single-dimension and the third of which measures dual-dimension naming speed. These tests have been used to identify changes in processing speed associated with normal aging. The present study evaluated whether a simple additive model could explain the normally expected relation between scores on measures of single- and dual-dimension naming speed. The AQT color (C), form (F), and color-form (CF) naming tests were administered individually to 270 adults (ages 18 to 70 yr.). Paired-sample t tests mean comparisons of C+F and CF naming times for the total group and for three age cohorts (ages 18 to 34, 35 to 54, and 55 to 70), each with 90 adults, indicated significant mean differences between these processing-speed measures for the total group and for the 18- to 34- and 35- to 54-year age cohorts. Thus, a simple additive model does not explain the relationship between single- and dual-dimension naming speed across ages. To provide a better description, an additive model with "overhead" (a measure of processing efficiency) was proposed and norm-referenced for using the AQT tests to assess normal and atypical ranges for dual-dimension processing efficiency (overhead). ANOVA with post hoc analysis (Scheffé) compared AQT C + F, CF, and overhead means across age cohorts. The results indicated significant mean differences for the CF and overhead measures, but not for the C+F measure. Normative ranges for typical overhead sizes were established for each age cohort. In clinical practice, an overhead larger than typical or normal for a given age would suggest executive dysfunction, involving attention, visual working memory, and set shifting.
The present study aims to gain insight into the clinical presentation (viz., self-reported complaints and neuropsychological functioning) of adults referred for an attention-deficit hyperactivity disorder (ADHD) diagnosis. The investigation evaluated group differences between an ADHD and a non-ADHD sample (n = 30 and n = 42, respectively), all of which had been clinically referred for multidisciplinary assessment of ADHD. Forty-two percent of all referred patients were diagnosed with adult ADHD. Adults with ADHD made significantly more errors on a verbal learning task than the non-ADHD control group, which could indicate an impairment of the self-monitoring function in adult ADHD. The ADHD group reported more problems than the control group in the domains of executive functioning but not in the domains of attention and hyperactivity. More attention should be paid to executive complaints and functioning (present and past) when referring adults suspected of ADHD for multidisciplinary assessment. Also, characteristics that are thought to be striking symptoms of adult ADHD, such as problems with concentration and hyperactive behavior, are in fact not distinctive symptoms of ADHD at all.
In previous studies, children with both Attention-Deficit Hyperactivity Disorder (ADHD) and a Reading Disorder were found to have more difficulties with processing speed, working memory, and timed as opposed to non-timed executive functioning (EF) measures when compared with those with either disorder alone. The current study found that older adolescents and adults with both disorders also had more difficulties on processing speed and working memory measures than individuals who only had ADHD. There were no differences among non-timed EF scores. These results add support to the premise that common underlying features may be contributing to the high co-morbidity between these disorders and associated cognitive weaknesses.
Attention deficit hyperactivity disorder (ADHD) in medication-naïve children has been associated with reduced activation in inferior/medial prefrontal, striatal and parieto-temporal cortices during inhibitory control and attention allocation. Functional magnetic resonance imaging (fMRI) studies in adult ADHD, however, have been inconsistent and confounded by medication-history and the need for a retrospective diagnosis of childhood ADHD. We used fMRI combined with a Simon task that measured interference inhibition and controlled for and co-measured attention allocation to compare brain function in 11 medication-naïve adults with persistent inattentive/hyperactive behaviours, followed up from childhood ADHD, and 15 age-matched controls. Despite comparable task performance, patients showed reduced activation compared to controls in left orbital/medial frontal cortex and striatum during interference inhibition and in left lateral inferior/dorsolateral prefrontal cortex during attention allocation. Whole-brain regression analyses within patients showed a negative correlation between symptom severity and fronto-striatal, temporo-parietal and cerebellar brain activation. The findings demonstrate that the typical fronto-striatal dysfunction observed in children with ADHD during interference inhibition and attention allocation is also observed in adults grown up from childhood ADHD with persistent symptoms. Furthermore, they show that functional deficits in adult ADHD are not related to chronic stimulant medication given that this sample was medication-naive.
In the cognitive theories of Attention Deficit Hyperactivity Disorder (ADHD) impaired behavioral adjustment has been linked to a deficit in learning to detect regularities or irregularities in the environment. In the neural level, the P3 component of event-related potential (ERP) is modulated by stimulus probability and has been suggested to index activation of the ventral attention network, which constitutes the reorienting system of the human brain. To explore the cortical basis of late positive ERP components and the engagement of the ventral attentional pathway in ADHD, we used ERP recordings complemented by spatiotemporally sensitive magnetoencephalography (MEG) measurements. We followed the activation evoked by frequent Go and infrequent NoGo stimuli in 10 ADHD adults and 13 control subjects. In the ERP recordings, a prominent positive deflection was detected after the infrequent visual stimuli (late positive component, LPC) in both subject groups. In ADHD adults the difference between the responses evoked by infrequent NoGo and frequent Go stimuli was markedly reduced compared to the control group during the LPC. The MEG recordings revealed that the activation detected during the LPC was localized bilaterally in the posterior temporal cortex. Activation of the left and right temporal regions was enhanced after infrequent NoGo stimuli in both subject groups. In ADHD adults, however, the effect of stimulus frequency was less pronounced. We suggest that the activation in the superior temporal cortices during the LPC reflects the action of ventral attention network. The engagement of this stimulus-driven reorienting system is defective in ADHD.
To assess the effect of atomoxetine on ADHD-related executive functions over a 6-month period using the Brown Attention-Deficit Disorder Scale (BADDS) for Adults, a normed, 40-item, self-report scale in a randomized, double-blind, placebo-controlled clinical trial.
In a randomized, double-blind clinical trial, adults with ADHD received either atomoxetine 25 to 100 mg/day or placebo for 6 months. Patients completed the BADDS to report their current daily functioning in 5 clusters of ADHD-related impairments of executive functioning: (1) Organizing and Activating to Work; (2) Focusing for Tasks; (3) Regulating Alertness and Effort; (4) Modulating Emotions; and (5) Utilizing Working Memory.
Mean scores were significantly more improved in the atomoxetine group compared to the placebo group: total score, -27.0 versus -19.0 (p < .001); all 5 cluster scores, p < .01.
Once-daily atomoxetine can improve executive function impairments in adults with ADHD as assessed by the BADDS.
To explore the longitudinal stability of measures of cognition during treatment with acetylcholinesterase inhibitors (AchEI) in patients with Alzheimer's disease (AD).
Cognitive status was measured in a cohort of 60 patients at 6 months after initiation of treatment with AchEI (baseline) and after an additional 6 months of treatment (endpoint). A Quick Test of Cognitive Speed (AQT), Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and MMSE were administered concurrently.
Correlations (rho) between age and AQT processing speed were non-significant, but were significant for ADAS-Cog and Mini Mental State Examination (MMSE). AQT and ADAS-Cog means did not differ significantly between baseline and endpoint. There was a small, significant reduction in MMSE point scores. Measures of stability (Spearman's rho) were moderate-to-high for all tests. Means for subgroups did not differ as a function of medication type.
AQT processing speed, ADAS-Cog, and MMSE measures proved stable during the second 6 months of treatment with AChEI.
This randomized, double-blind, placebo-controlled, 6-month trial examined the efficacy and safety of once-daily morning-dosed atomoxetine in adult patients with attention-deficit/hyperactivity disorder (ADHD) and the efficacy of atomoxetine in ameliorating symptoms through the evening hours. Patients received once-daily atomoxetine (n = 250) or placebo (n = 251) in the morning for approximately 6 months. The efficacy measures included the Adult ADHD Investigator Symptom Rating Scale (AISRS), Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version, Clinical Global Impressions-ADHD-Severity of Illness, and Adult ADHD Quality of Life Scale. Overall, 94 patients randomized to atomoxetine and 112 patients randomized to placebo completed the study. On the AISRS total score, Conners' Adult ADHD Rating Scale-Investigator Rated: Screening Version evening index total score, Clinical Global Impressions-ADHD-Severity of Illness score, and Adult ADHD Quality of Life Scale total score, atomoxetine was statistically superior to placebo at the 10-week and 6-month time points. From the visitwise analysis, the mean (SD) AISRS total scores for atomoxetine decreased from 38.2 (7.5) at baseline to 21.4 (12.3) at the 6-month end point compared with 38.6 (7.0) to 25.8 (13.2) for placebo (P = 0.035). Nausea, dry mouth, fatigue, decreased appetite, urinary hesitation, and erectile dysfunction were the treatment-emergent adverse events reported significantly more often with atomoxetine. Discontinuations due to adverse events were 17.2% and 5.6% for atomoxetine and placebo, respectively (P < 0.001). Once-daily morning-dosed atomoxetine is efficacious for treating ADHD in adults when measured 10 weeks and 6 months after initiating treatment. Atomoxetine demonstrated significant efficacy that continued into the evening. Adverse events were similar to previous trials.
The objective of the study was to determine the prevalence and comorbidity of persisting attention-deficit hyperactivity disorder (ADHD) in adult psychiatric outpatients. Consecutive patients, first visits excluded, at a general psychiatric outpatient clinic were offered a screening for childhood ADHD with the Wender Utah Rating Scale (WURS). One hundred and forty-one patients out of 398 (35%) completed and returned the scale. Patients above or near cut-off for ADHD (n=57) were offered an extensive clinical evaluation with psychiatric as well as neuropsychological examination. The attrition was analysed regarding age, sex and clinical diagnoses. Out of the screened sample, 40% had scores indicating possible childhood ADHD. These 57 patients were invited to the clinical part of the study, but 10 declined assessment, leaving 47 (37 women and 10 men) who were actually examined. Thirty of these (21 women and nine men) met diagnostic criteria for ADHD at the time of examination. Among the patients with ADHD, affective disorders were the most common psychiatric diagnoses. The rate of alcohol and/or substance abuse, as noted in the medical records, was also high in the ADHD group. In the WURS-screened group, 22% (30 patients assessed as part of this study and one person with ADHD previously clinically diagnosed) were shown to have persisting ADHD. Therefore, it is clearly relevant for psychiatrists working in general adult psychiatry to have ADHD in mind as a diagnostic option, either as the patient's main problem or as a functional impairment predisposing for other psychiatric disorders.
The goal of this study was to investigate the effect of methylphenidate (MPH) on response interference, as measured by the Stoop Color and Word Test, in children with attention deficit hyperactivity disorder (ADHD). Response interference is a core component of response inhibition that has been shown to be impaired in children with ADHD.
A clinic-referred sample of school-aged children with a confirmed Diagnostic and Statistical Manual of Mental Disorders (4th ed.) diagnosis of ADHD and good reading skills (n = 31) completed the Stroop Color and Word Test in an acute, randomized, placebo-controlled, crossover trial with three single fixed doses of MPH.
MPH did not improve response interference on the Stroop Color and Word Test but did significantly improve color naming and word naming abilities.
Response interference, as measured by the Stroop Color and Word Test, is not improved by MPH in children with ADHD. In addition, findings demonstrate strongly positive MPH effects on the highly effortful process of color naming, which has previously been demonstrated as impaired in children with ADHD. MPH was also shown to have a positive but smaller effect on word naming speed.
Rapid automatic naming tasks are clinical tools for probing brain functions that underlie normal cognition. To compare performance for various stimuli in normal subjects and assess the effect of aging, we administered six single-dimension stimuli (color, form, number, letter, animal, and object) and five dual-dimension stimuli (color-form, color-number, color-letter, color-animal, and color-object) to 144 normal volunteers who ranged in age from 15 to 85 years. Rapid automatic naming times for letters and numbers were significantly less than for forms, animals, and objects. Rapid automatic naming times for color-number and color-letter stimuli were significantly less than for color-form, color-animal, or color-object stimuli. Age correlated significantly with rapid automatic naming time for each single-dimension stimulus and for color-form, color-number, color-animal, and color-object stimuli. Linear regression showed that rapid automatic naming times increased with age for aggregated color stimuli, aggregated single-dimension stimuli, and aggregated dual-dimension stimuli. This age effect persisted in subgroups less than 60 years of age and greater than 60 years of age. We conclude that normal performance time is dependent on the task, with letter and number stimuli eliciting most rapid responses, and that most rapid automatic naming times increase with age.
To determine the empirical evidence for deficits in working memory (WM) processes in children and adolescents with attention-deficit/hyperactivity disorder (ADHD).
Exploratory meta-analytic procedures were used to investigate whether children with ADHD exhibit WM impairments. Twenty-six empirical research studies published from 1997 to December, 2003 (subsequent to a previous review) met our inclusion criteria. WM measures were categorized according to both modality (verbal, spatial) and type of processing required (storage versus storage/manipulation).
Children with ADHD exhibited deficits in multiple components of WM that were independent of comorbidity with language learning disorders and weaknesses in general intellectual ability. Overall effect sizes for spatial storage (effect size = 0.85, CI = 0.62 - 1.08) and spatial central executive WM (effect size = 1.06, confidence interval = 0.72-1.39) were greater than those obtained for verbal storage (effect size = 0.47, confidence interval = 0.36-0.59) and verbal central executive WM (effect size = 0.43, confidence interval = 0.24-0.62).
Evidence of WM impairments in children with ADHD supports recent theoretical models implicating WM processes in ADHD. Future research is needed to more clearly delineate the nature, severity, and specificity of the impairments to ADHD.
Despite growing interest in adult attention-deficit/hyperactivity disorder (ADHD), little is known about predictors of persistence of childhood cases into adulthood.
A retrospective assessment of childhood ADHD, childhood risk factors, and a screen for adult ADHD were included in a sample of 3197 18-44 year old respondents in the National Comorbidity Survey Replication (NCS-R). Blinded adult ADHD clinical reappraisal interviews were administered to a sub-sample of respondents. Multiple imputation (MI) was used to estimate adult persistence of childhood ADHD. Logistic regression was used to study retrospectively reported childhood predictors of persistence. Potential predictors included socio-demographics, childhood ADHD severity, childhood adversity, traumatic life experiences, and comorbid DSM-IV child-adolescent disorders (anxiety, mood, impulse-control, and substance disorders).
Blinded clinical interviews classified 36.3% of respondents with retrospectively assessed childhood ADHD as meeting DSM-IV criteria for current ADHD. Childhood ADHD severity and childhood treatment significantly predicted persistence. Controlling for severity and excluding treatment, none of the other variables significantly predicted persistence even though they were significantly associated with childhood ADHD.
No modifiable risk factors were found for adult persistence of ADHD. Further research, ideally based on prospective general population samples, is needed to search for modifiable determinants of adult persistence of ADHD.
One of the most prominent neuropsychologic theories of attention-deficit/hyperactivity disorder (ADHD) suggests that its symptoms arise from a primary deficit in executive functions (EF), defined as neurocognitive processes that maintain an appropriate problem-solving set to attain a later goal. To examine the validity of the EF theory, we conducted a meta-analysis of 83 studies that administered EF measures to groups with ADHD (total N = 3734) and without ADHD (N = 2969). Groups with ADHD exhibited significant impairment on all EF tasks. Effect sizes for all measures fell in the medium range (.46-.69), but the strongest and most consistent effects were obtained on measures of response inhibition, vigilance, working memory, and planning. Weaknesses in EF were significant in both clinic-referred and community samples and were not explained by group differences in intelligence, academic achievement, or symptoms of other disorders. ADHD is associated with significant weaknesses in several key EF domains. However, moderate effect sizes and lack of universality of EF deficits among individuals with ADHD suggest that EF weaknesses are neither necessary nor sufficient to cause all cases of ADHD. Difficulties with EF appear to be one important component of the complex neuropsychology of ADHD.
Although individuals with attention deficit-hyperactivity disorder (ADHD) commonly exhibit deficits in executive functions that greatly increase the morbidity of the disorder, all available information on the subject is cross sectional.
Males (n = 85) 9-22 years with ADHD followed over 7 years into young adulthood were assessed on measures of sustained attention/vigilance, planning and organization, response inhibition, set shifting and categorization, selective attention and visual scanning, verbal and visual learning, and memory. A binary definition of executive function deficits (EFDs) was defined based on a subject manifesting at least two abnormal tests 1.5 standard deviations from controls.
The majority of subjects maintained EFDs over time (kappa: 0.41, P < 0.001; sensitivity: 55%, specificity: 85%, positive predictive value: 69%, and negative predictive value: 75%).
Considering the morbidity of EFDs, these findings stress the importance of their early recognition for prevention and early intervention strategies. EFDs are stable over time.
The purpose of this article is to investigate how patients with dementia with Lewy bodies (DLB) perform on A Quick Test for Cognitive Speed (AQT) compared with patients with Alzheimer's disease (AD) and age- and sex-matched controls and to see whether this test might be helpful in distinguishing DLB from AD at comparable cognitive levels. Twenty-three patients with DLB, 18 patients with AD, and 24 controls were included. The time in seconds to complete the AQT was recorded for the 3 independent study groups according to standard directives. The DLB patients had significantly longer reading times than the AD patients at equivalent and relatively high Mini-Mental State Examination levels. We suggest that slow performance on the AQT at relatively high Mini-Mental State Examination levels could be one way of distinguishing DLB from AD. This may have clinical implications for treatment as well as for understanding the neuropathological properties of the disease.
We investigated the relation between cognitive processing speed and structural properties of white matter pathways via convergent imaging studies in healthy and brain-injured groups. Voxel-based morphometry (VBM) was applied to diffusion tensor imaging data from thirty-nine young healthy subjects in order to investigate the relation between processing speed, as assessed with the Digit-Symbol subtest from WAIS-III, and fractional anisotropy, an index of microstructural organization of white matter. Digit-Symbol performance was positively correlated with fractional anisotropy of white matter in the parietal and temporal lobes bilaterally and in the left middle frontal gyrus. Fiber tractography indicated that these regions are consistent with the trajectories of the superior and inferior longitudinal fasciculi. In a second investigation, we assessed the effect of white matter damage on processing speed using voxel-based lesion-symptom mapping (VLSM) analysis of data from seventy-two patients with left-hemisphere strokes. Lesions in left parietal white matter, together with cortical lesions in supramarginal and angular gyri were associated with impaired performance. These findings suggest that cognitive processing speed, as assessed by the Digit-Symbol test, is closely related to the structural integrity of white matter tracts associated with parietal and temporal cortices and left middle frontal gyrus. Further, fiber tractography applied to VBM results and the patient findings suggest that the superior longitudinal fasciculus, a major tract subserving fronto-parietal integration, makes a prominent contribution to processing speed.
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