Validade dos critérios diagnósticos do transtorno de déficit de atenção e/ou hiperatividade em adultos e seus efeitos na prevalência

Os critérios diagnósticos para o transtorno do déficit de atenção/hiperatividade (TDAH) não foram testados em adultos nos ensaios de campo realizados para embasar sua formulação e publicação no DSM-IV, ainda assim, a soma dos resultados de diversos estudos biológicos e fenotípicos demonstrou que esses critérios transmitiam um construto válido do TDAH em adultos. Por sua vez, os critérios diagnósticos do DSM-5 para aplicação nessa população, apesar das importantes modificações pelas quais passaram, foram muito pouco avaliados até o presente. No primeiro estudo desta tese, testamos a validade de construto dos critérios diagnósticos do TDAH do DSM-5 e estimamos a prevalência de indivíduos com todos os critérios na população adulta. A validade da categoria principal do TDAH foi testada por meio da comparação de elementos avaliados em indivíduos sem TDAH da mesma amostra, e em indivíduos com TDAH de outras amostras. Os elementos testados foram: a) padrão de características clínicas e de comorbidades; b) estrutura fatorial dos sintomas; c) padrão da associação de cada sintoma com prejuízo clínico; d) acurácia do ponto de corte de cinco sintomas para estabelecer o diagnóstico. A categoria principal do DSM-5 demonstrou ser válida, apresentando perfil de comorbidades claramente distinto em relação ao perfil dos indivíduos sem TDAH. Essa categoria também apresentou prevalência e estrutura fatorial semelhantes às encontradas para o TDAH em outras amostras. Os sintomas da categoria principal do TDAH se associaram a prejuízo, e essa associação não foi explicada somente pela presença das comorbidades. No segundo estudo, avaliamos a validade convergente dos “Outros TDAH Especificados” (OS-ADHD) com a categoria principal do TDAH. Três apresentações de OS-ADHD foram observadas na população da coorte: a) uma apresentação em indivíduos que não endossaram a idade de início na infância; b) outra em indivíduos com sintomas subliminares; e c) uma terceira naqueles que não endossaram o critério de pervasividade. Apenas o “OS-ADHD sem o critério idade de início” mostrou-se convergente com a categoria principal do TDAH, pois ambos apresentavam semelhantes perfis clínicos, padrões de comorbidades, invariância de suas estruturas fatoriais, relação de sintomas com as comorbidades, assim como médias do escore de risco poligênico. A prevalência do TDAH encontrada foi de 2,1% quando todos os critérios estavam presentes, de 4,2% para o “Outro TDAH Especificado” sem o critério de idade de início, e de 6,3% para o total das formas válidas. Quando consideramos apenas os casos graves, observamos, respectivamente, prevalências de 1,1%, 1,8% e 2,9%.The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in adults were not tested in field trials for DSM-IV. In spite of this, several biological and phenotypic studies demonstrated that DSM-IV criteria conveyed a valid construct of ADHD for this population. On the other hand, despite presenting important modifications in terms of diagnostic criteria for adults, the DSM-5 criteria remain poorly tested. In the first study of this thesis, we tested the construct validity of the DSM-5 ADHD diagnostic criteria and estimated the resulting prevalence of individuals with full criteria in the adult population. The validity of full criteria ADHD was tested by comparing the features measured in non-ADHD individuals from the same sample, and by comparing these features with results from other samples of adults with ADHD. We tested a) the pattern of clinical characteristics and comorbidities; b) factorial structure; c) the pattern of associations of each symptom to impairment; and d) accuracy of the five symptoms cut-off to diagnose ADHD. Full criteria ADHD demonstrated to be valid, first, because it had a different pattern of comorbidities when compared to the pattern of the non-ADHD subjects. Second, full criteria ADHD had the same factor structure and prevalence rates of the disorder found in other samples. Finally, ADHD symptoms were predictive of impairment independently from the presence of comorbidities. In the second study, we evaluated the convergent validity of Other Specified ADHD presentations (OS-ADHD) with their full criteria validated counterpart. Three persisting and impairing OS-ADHD presentations were observed in the cohort: a) one presentation of individuals not endorsing the age-of-onset in childhood; b) a second presentation of individuals with subthreshold symptoms; and c) a third presentation of those not endorsing the pervasiveness criterion. Only the “OS-ADHD without the age-of-onset criterion” proved to be convergent with the full criteria presentation since both presented similar environmental risk factors, factorial symptoms structure, pattern of comorbidities, as well as similar ADHD polygenic risk scores. The prevalence found was 2.1% for the full criteria ADHD; 4.2% for Other ADHD without positive age-of-onset criterion, and 6.3% when taking together all valid ADHD presentations. When considering only severe cases, the prevalences obtained were 1.1%, 1.8% and 2.9%, respectively

ADHD in DSM-5 : a field trial in a large, representative sample of 18- to 19-year-old adults

Background. The DSM criteria for adult attention-deficit/hyperactivity disorder (ADHD) have not been tested in American Psychiatric Association (APA) field trials for either DSM-IV or DSM-5. This study aimed to assess: (a) the prevalence of ADHD according to DSM-5 criteria; (b) the factor solution that provides the best fit for ADHD symptoms; (c) the symptoms with the highest predictive value for clinical impairment; and (d) the best symptomatic threshold for each ADHD dimension (inattention and hyperactivity/impulsivity). Method. Trained psychologists evaluated 4000 young adults from the 1993 Pelotas Birth Cohort Study with an instrument covering all DSM-5 ADHD criteria. A series of confirmatory factor analyses (CFAs) tested the best factor structure. Complex logistic regressions assessed differential contributions of each symptom to clinical impairment. Receiver-operating characteristic (ROC) analyses tested which would be the best symptomatic cut-off in the number of symptoms for predicting impairment. Results. The prevalence of DSM-5 ADHD was 3.55% [95% confidence interval (CI) 2.98–4.12]. The estimated prevalence of DSM-IV ADHD was 2.8%. CFA revealed that a bifactor model with a single general factor and two specific factors provided the best fit for DSM-5 symptoms. Inattentive symptoms continued to be the most important predictors of impairment in adults. The best cut-offs were five symptoms of inattention and four symptoms of hyperactivity/ impulsivity. Conclusions. Our results, combined with previous findings, suggest a 27% increase in the expected prevalence of ADHD among young adults, comparing DSM-IV to DSM-5 criteria. The DSM-5 symptomatic organization derived a similar factor structure for adults as DSM-IV symptoms. Data using DSM-5 criteria support lowering the symptomatic threshold for diagnosing ADHD in adults

Reduced fronto-striatal volume in attention-deficit/hyperactivity disorder in two cohorts across the lifespan

Attention-Deficit/Hyperactivity Disorder (ADHD) has been associated with altered brain anatomy in neuroimaging studies. However, small and heterogeneous study samples, and the use of region-of-interest and tissue-specific analyses have limited the consistency and replicability of these effects. We used a data-driven multivariate approach to investigate neuroanatomical features associated with ADHD in two independent cohorts: the Dutch NeuroIMAGE cohort (n = 890, 17.2 years) and the Brazilian IMpACT cohort (n = 180, 44.2 years). Using independent component analysis of whole-brain morphometry images, 375 neuroanatomical components were assessed for association with ADHD. In both discovery (corrected-p = 0.0085) and replication (p = 0.032) cohorts, ADHD was associated with reduced volume in frontal lobes, striatum, and their interconnecting white-matter. Current results provide further evidence for the role of the fronto-striatal circuit in ADHD in children, and for the first time show its relevance to ADHD in adults. The fact that the cohorts are from different continents and comprise different age ranges highlights the robustness of the findings

Impact of COVID-19 on cardiovascular testing in the United States versus the rest of the world

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis. Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection

Transtornos externalizantes em adultos com TDAH

Objetivos: O transtorno de déficit de atenção/hiperatividade (TDAH), o transtorno de conduta (TC) e o transtorno opositor desafiante (TOD) frequentemente ocorrem juntos na infância. No entanto, a existência e importância destes transtornos na vida adulta ainda é motivo de discussão. Este estudo tem como objetivo avaliar a extensão do impacto da história de TOD e TC na saúde mental global de indivíduos com TDAH persistente. Visa também avaliar a relação desses achados com o modelo de desinibição comportamental, considerando os perfis de desenvolvimento neurológico, personalidade e comorbidades. Métodos: Os pacientes foram selecionados consecutivamente a partir de uma amostra de conveniência no ambulatório de pesquisa do TDAH em adultos do Hospital de Clínicas de Porto Alegre (n=458). O grupo controle foi composto de voluntários doadores de sangue no Hemocentro do mesmo hospital (n=121). Os diagnósticos foram realizados com base nos critérios do DSM-IV, sendo os sujeitos avaliados para o TDAH e o TOD através do K-SADS-E; para o TC e o transtorno de personalidade anti-social através do MINI; e através do SCID para as demais comorbidades. A gravidade do TDAH foi avaliada utilizando o SNAP, e a personalidade avaliada com o TCI (Cloninger). Na análise foram comparados os pacientes com TDAH e os controles. No caso das variáveis com diferenças significativas, comparamos três grupos: TDAH sem história de TC ou de TOD (n=178); TDAH com história de TOD (sem TC) (n=184) e TDAH com história de TC (com ou sem TOD) (n=96). Resultados: Pacientes com TDAH apresentaram um perfil mais grave na comparação com os controles em diversas variáveis, incluindo todas as comorbidades. Internamente ao grupo com TDAH, uma história positiva de TC (e, em grau menor, de TOD) associou-se a maior gravidade e a um perfil mais externalizador. Conclusão: Uma história positiva de TOD e TC na infância ou adolescência associa-se a um impacto negativo na saúde mental de sujeitos com TDAH persistente, reforçando o valor preditivo destes transtornos para a saúde mental do adulto. Estes achados sugerem uma ligação entre déficits do desenvolvimento, características de personalidade, e desdobramentos de psicopatologias, que é consistente com o conceito de cascada de desinibição comportamental.Objective: Attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are frequently co-occurring disorders in children and adolescents. However, their clinical status among adults is disputed. This study analyzes how the clinical presentation of persistent ADHD might be influenced by a childhood or adolescence history of CD and ODD, and how these findings fit in the behavioral disinhibition framework. Methods: Patients were ascertained in an ADHD outpatient clinic. Diagnoses were based on the DSM-IV criteria and all subjects were evaluated using the KSADS- E for ADHD and ODD, MINI for CD/ASPD, SCID-I for other comorbidities, SNAP-IV for ADHD severity and Cloninger’s Temperament and Character Inventory (TCI) for personality. We compared patients with ADHD (n= 458) with controls (n=121). For those variables with significant differences, we compared three groups of patients: ADHD without history of CD or ODD (n=178); ADHD + history of ODD (without CD) (n=184) and ADHD + history of CD (with or without ODD) (n=96). Results: Patients with ADHD presented a worse profile than controls in several variables, including a higher frequency of all comorbidities. Within the ADHD group, a history of CD (and to a lower extent ODD) is associated with a more severe and externalizing profile. Conclusion: A history of CD and ODD entail a significant negative mental health impact on persistent ADHD, reinforcing the predictive validity of these entities in adulthood mental health. These findings suggest a link among neurodevelopmental deficits, personality characteristics, and unfolding of psychopathology consistent with the behavioral disinhibition cascade

O polimorfismo 5-HTTLPR e o transtorno de déficit de atenção e hiperatividade (TDAH) em adultos

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The neurodevelopmental nature of attentiondeficit hyperactivity disorder in adults

Background Population studies have suggested that most adults with attention-deficit hyperactivity disorder (ADHD) did not have the disorder in childhood, challenging the neurodevelopmental conceptualisation of ADHD. Arbitrary definitions of age at onset and lack of defined trajectories were accounted for the findings. Aims The objective of this study was to assess the proportion of individuals presenting with either a neurodevelopmental trajectory or late-onset disorder, and to assess risk factors associated with them. Method Data of 4676 individuals from the 1993 Pelotas birth cohort at 11, 15, 18 and 22 years of age were used. Polythetic and latent class mixed model analyses were performed to define ADHD trajectories from childhood to adulthood, and characterise the neurodevelopmental or late-onset courses. Regression models were applied to assess factors associated with different trajectories. Results Classical polythetic analyses showed that 67% of those with ADHD at 22 years of age had a neurodevelopmental course of the disorder. Latent class mixed model analysis indicated that 78% of adults with ADHD had a trajectory of persistent symptoms, more common in males. The remaining adults with ADHD had an ascending symptom trajectory that occurred after puberty, with late-onset ADHD associated with female gender and higher IQ. Conclusions Both polythetic and latent trajectories analyses provided empirical evidence supporting that the large majority of adults with ADHD had a neurodevelopmental disorder