ESCAlate – Adaptive treatment approach for adolescents and adults with ADHD: study protocol for a randomized controlled trial

Background: Over the last decade, a wide range of attention-deficit/hyperactivity disorder (ADHD) treatment approaches for adults, including both pharmacological interventions and psychosocial treatments, have been proposed and observed to be efficient. In practice, individual treatment concepts are based on results of clinical studies as well as international guidelines (NICE Guidelines) that recommend a step-by-step treatment approach. Since the evidence supporting this approach is limited, the aim of the present study is to determine an optimal intervention regarding severity levels of ADHD symptomatology conducting a randomized controlled trial. Method: We aim to include 279 ADHD subjects aged between 16 and 45 years. First, participants are randomized to either a face-to-face psychoeducation, telephone assisted self-help (TASH), or a waiting control group (Step 1). All participants assigned to the control group are treated using TASH after a 3-month waiting period. Participants are then allocated to one of three groups, based on their remaining severity level of ADHD symptoms, as (1) full responder, (2) partial responder, or (3) non-responder (Step 2). Full responders receive counseling, partial responders receive either counseling only or counseling and neurofeedback (NF), and non-responders receive either pharmacological treatment only or pharmacological treatment and NF, followed by a 3 month period without intervention. Discussion: The naturalistic sample is one of the study’s advantages, avoiding highly selective inclusion or exclusion criteria. The efficacy of an evidence-based stepped care intervention is explored by primary (reduction of severity of ADHD symptoms) and secondary outcomes (functional outcomes, e.g., quality of life, anger management, enhancement of psychosocial well-being). Predictors of therapeutic response and non-response are being investigated at each step of intervention. Further, sex differences are also being explored. Trial registration: This study is registered by the German Trial Register (reference number: DRKS00008975 ), 23 October 2015

A randomized controlled trial reporting functional outcomes of cognitive-behavioural therapy in medication‑treated adults with ADHD and comorbid psychopathology

Studies assessing psychological treatment of attention deficit hyperactivity disorder (ADHD) in adults are increasingly reported. However, functional outcomes are often neglected in favour of symptom outcomes. We investigated functional outcomes in 95 adults with ADHD who were already treated with medication and randomized to receive treatment as usual (TAU/MED) or psychological treatment (CBT/MED) using a cognitive–behavioural programme, R&R2ADHD, which employs both group and individual modalities. RATE-S functional outcomes associated with ADHD symptoms, social functioning, emotional control and antisocial behaviour were given at baseline, end of treatment and three-month follow-up. The Total composite score of these scales is associated with life satisfaction. In addition, independent evaluator ratings of clinicians who were blind to treatment arm were obtained on the Clinical Global Impression scale at each time point. CBT/MED showed overall (combined outcome at end of treatment and 3-month follow-up) significantly greater functional improvement on all scales. Post-group treatment effects were maintained at follow-up with the exception of emotional control and the Total composite scales, which continued to improve. The largest treatment effect was for the RATE-S Total composite scale, associated with life satisfaction. CGI significantly correlated with all outcomes except for social functioning scale at follow-up. The study provides further evidence for the effectiveness of R&R2ADHD and demonstrates the importance of measuring functional outcomes. The key mechanism associated with improved functional outcomes is likely to be behavioural control

The attention deficit hyperactivity disorder across the lifespan

Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung ist eine im Kindesalter beginnende chronische neurologische Entwicklungsstörung, welche sich durch die Kernsymptome Un-aufmerksamkeit, Hyperaktivität und Impulsivität auszeichnet, und die für die Betroffenen mit erheblichen sozialen und beruflichen Funktionsbeeinträchtigungen einhergeht. Durch die Transition der Erkrankung über die Lebensspanne verändert sich das Erscheinungsbild der ADHS. Zudem ist ein altersabhängiger Rückgang der ADHS-Prävalenz zu verzeichnen (Schrift I, IV). Dennoch berichten auch im höheren Lebensalter noch 2.8% der Befragten von einer ausgeprägten ADHS-Belastung. Nach wie vor ist das Wissen um die ADHS im Senium jedoch begrenzt (Schrift IV). Bislang liegen keine ADHS-spezifischen Skalen für Senioren vor. In der Prüfung zweier für das junge und mittlere Erwachsenalter konzipierter Verfahren, der Selbstbeurteilungsskala ADHS-SB und des Wender-Reimherr- Interviews (WRI), wurden daher an einer Stichprobe von 60- und 99-Jährigen die Einsatzmöglichkeiten dieser Verfahren bei älteren Betroffen untersucht (Schrift V). Beide Verfahren zeigen auch bei Älteren eine gute Konstruktvalidität. Das Ergebnis der Grenzwertoptimierungskurve ist akzeptabel. Unter differentialdiagnostischem Aspekt wurde der Fokus auf die Spezifität gelegt, um vor dem Hintergrund der hohen Symptomüberlappung mit anderen psychiatrischen Störungsbildern Nicht-Betroffene nicht fälschlicherweise als ADHS-Patienten zu klassifizieren. Durch Herabsetzung der Sensitivität kann für den ADHS-SB und den WRI eine Spezifität von 94% bzw. 81% ermittelt werden. Zudem werden altersspezifische Grenzwerte vorgelegt. Demnach können die ADHS-SB sowie das WRI auch im höheren Erwachsenenalter als valide Diagnoseinstrumente zur Unterstützung des klinischen Entscheidungsprozesses eingesetzt werden. Während sich der Einsatz von ADHS-Skalen in der Diagnostik der ADHS bewährt hat, ist hingegen aufgrund der neuropsychologischen Heterogenität der spezifische Einsatz neuropsychologischer Verfahren nicht möglich. Dennoch sind neuropsychologische Verfahren valide, um differentialdiagnostisch ADHS-überlappende kognitive oder mnestische Funkti-onsbeeinträchtigungen zu diskriminieren. Daher wird ein Überblick über gängige neuropsychologische Verfahren bei Erwachsenen und ihre Anwendungsmöglichkeiten gege-ben (Schrift II). ADHS-Symptome sind keine qualitativen, sondern quantitative Merkmale. Erst in Abhän-gigkeit eines bestimmten Schweregrades sind sie krankheitswertig. ADHS-assoziierte Symptome können jedoch bereits unterhalb der diagnostischen Schwelle der Klassifikati-onssysteme einen negativen Einfluss auf den Lebensalltag des Betroffenen haben (Schrift III). Um der Dimensionalität der ADHS-Symptome unabhängig von einem kategorialen Klassifikationssystem Rechnung zu tragen und eine entsprechende Einordnung zu ermöglichen, werden Referenzwerte einer nicht-klinischen Stichprobe vorgelegt (Schrift III). Zur Überprüfung der subjektiven Beeinträchtigung des Störungsbildes über die Lebespanne wurden 296 Ältere (M=69.55 Jahre) ausführlich zu ADHS-assoziierten Symptomen und einhergehenden funktionellen Beeinträchtigungen in der Kindheit, sowohl vor als auch nach dem 50. Lebensjahr befragt. ADHS-Betroffene berichteten von einer hohen intraindi-viduellen Stabilität symptombedingter negativer Einflüsse über die Lebensspanne, sowohl hinsichtlich ihrer individuellen funktionellen Beeinträchtigung als auch der negativen sozi-alen Konsequenzen (Schrift VI). Die Befunde des vorliegenden Kumulus unterstreichen demnach nicht nur die Bedeutung der ADHS als eine lebenslange Erkrankung, sondern auch die klinische Implikation der Notwendigkeit adäquater therapeutischer Angebote für Betroffene aller Altersgruppen. Daher werden Behandlungsansätze für ADHS-Betroffene im jungen und mittleren Lebensalter vorgestellt (Schrift I) und Optionen für Betroffene im höheren Lebensalter diskutiert (Schrift IV).Over the past decade attention deficit hyperactivity disorder (ADHD) has been increasingly identified as an important neurodevelopmental disorder that is evident across the lifespan. ADHD is characterized by the core symptoms of inattention, hyperactivity and impulsivity, and have a complex interplay. It is a childhood onset disorder, associated with a broad range of negative functional outcomes, and persists in up to 60% of individuals into adulthood. However, the transition from young, middle to old age changes the expression of ADHD, and there is an age-dependent-decline (Paper I, IV). Nevertheless, the prevalence of ADHD in seniority is still evident since 2.8% of the older adults are reporting ADHD symptoms associated with significant negative outcomes. But the knowledge about ADHD in older age is still limited, and the older ADHD patients are largely unrecognized due to it typically being viewed as a childhood and middle age disorder (Paper IV). So far, there are also no ADHD-scales specifically in old age to support the diagnostic process. Therefore, the psychometric properties of the ADHD self-rating ADHS-SR and the observer-rating Wender-Reimherr-Interview WRI has been explored for the assessment of ADHD symptoms in old age using a sample of subjects between 60 and 99 years. The study shows, that the psychometric properties of the ADHD-SR and the WRI are adequate. Results of the study provide evidence for construct validity and a good discrimination be-tween Non-ADHD-Patients and ADHD-patients for both the ADHD-SR and the WRI, with a specificity ranging between 81% and 94%. Thus, both measures may also support the di-agnostic process in older adults. While studies provide evidence for the valid use of ADHD-psychometrics, the results of neuropsychological measurements in the assessment of ADHD are mixed. The heteroge-neity in the presentations of ADHD studies suggests differential neuropsychological impairments. The core features of ADHD are also conflated with a number of other clinical syndromes which share some of the symptoms. Hence, results of neuropsychological tests vary within ADHD-subjects and cannot provide ADHD-specific information. Nevertheless, neuropsychological measures have shown some discriminant utility in identifying overlapping cognitive and mnestic impairments that can be used in the diagnostic process. Therefore, an overview of the extant neuropsychological measures for adults and their scope is given (Paper II). ADHD symptoms are not characterized by the quality but by the quantity of their features. The severity of the symptoms is crucial in the diagnosis of the disorder. However ADHD-symptoms below the categorical diagnostic threshold can also cause a significant negative impact on the quality of life (Paper III). For a better understanding of the dimensionality of the ADHD-symptoms and their presentation in the general population, reference values of a non-clinical sample are presented (Paper III). To examine the subjective impairments of ADHD over the lifespan, 296 older adults (M=69.55 years) were assessed regarding their ADHD symptomatology and associated dysfunctions during childhood as well as before and after the age of 50. Older subjects with ADHD describe a high stability of symptom-associated negative influences over their life, regarding both individual dysfunctions and negative social consequences (Paper IV). Findings of the present study do not only underline the impact of ADHD as a chronic disorder, but also highlight the need of an adequate therapy for ADHD subjects of all ages. Therefore treatment options for young and middle age persons (Paper I) as well as seniors are discussed (Paper IV)

Assessment of post-excitatory long-interval cortical inhibition in adult attention-deficit/hyperactivity disorder

In order to further examine cortical impairment in adult ADHD patients and to test the hypothesis of a disturbed neuronal inhibition in adults with ADHD, late auditory evoked potentials were measured. By using paired-chirp auditory late responses, we compared 15 adults with ADHD with 15 control subjects, focusing on the inhibition elicited by the stimuli. Besides amplitude measurements, a time-frequency phase coherence study using the wavelet phase synchronization stability (WPSS) was performed. ADHD was diagnosed according to DSM-IV criteria. All ADHD subjects were without medication and did not suffer from any further axis I disorder. WPSS analysis revealed impaired auditory inhibition for ADHD patients for interstimulus intervals (ISI) between 500 and 1,100 ms as compared with healthy controls. By analyzing the WPSS in the interval from 80 ms to 220 ms, mean inhibition of the test chirp was found to be 6% in the ADHD group and 38.5% in the control subjects (p = 0.01). Moreover, overall smaller amplitudes in the N100 and P200 waves at all ISI were found (p = 0.04 and p = 0.02). However, reproducibility indices in the amplitude measurements were low, thus supporting the use of the instantaneous phase-based analysis method. The results support the hypothesis of reduced intracortical inhibition as a correlate of disturbed brain function in adults with ADHD. © 2012 Springer-Verlag

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