Increased performance uncertainty in children with ADHD? - Elevated post-imperative negative variation (PINV) over the ventrolateral prefrontal cortex

Background: We aimed to investigate the influences of attention deficit/hyperactivity disorder (ADHD) on response evaluation, as reflected by the postimperative negative variation (PINV), a slow event-related potential. Methods: We investigated PINV as an indicator of performance uncertainty in an audio-visual contingent negative variation (CNV) paradigm with an interstimulus interval of 3 seconds. A constant, unilateral, quick motor reaction with either the right or the left thumb was required after an auditory forewarned (S1) visual imperative stimulus (S2). We examined 18 ADHD patients (combined or hyperactive-impulsive subtype) aged between 8 and 14 years and an age-, sex and IQ-matched control group of 19 healthy subjects using 64-channel high-density EEG. A first run was recorded drug-free, a second one under methylphenidate (MPH) medication in the ADHD group. Results: We found a significantly increased negativity of the PINV-component over the ventrolateral prefrontal cortex in ADHD children compared to the healthy control group. PINV amplitude was influenced by movement side, most likely due to the slightly more difficult task when left hand responses were required. After the intake of MPH, PINV amplitudes of ADHD children normalized. Conclusions: We conclude that children with ADHD are likely to be more uncertain about the correctness of their performance and interpret the increased PINV as a hint towards compensatory mechanisms for a deficit in the evaluation of contingencies. Further studies are needed to assess the exact extent to which remainders of eye-movement related potentials contribute to PINV amplitude despite the correction for eye-artifacts

Nine everyday situations, nine different forms of attention

1. ObjectivesThe aim of the present study was to develop a questionnaire for the assessment of everyday attentional capacities in adults: the Everyday Life Attention Scale (ELAS). Its developmental was inspired by multi-component theories of attention and clinical neuropsychology guidelines for the assessment of attention. The items ask about multiple components of attention in nine common everyday situations, including Reading, Movie, Activity, Lecture, Conversation, Assignment, Cooking, Cleaning up, and Driving.2. MethodsTwo validation studies were conducted. Study 1 investigated the factor structure, validity, and reliability of the ELAS in 1206 healthy participants by means of an online survey. Study 2 further investigated the sensitivity of the ELAS in 80 adults with ADHD compared to 80 matched healthy controls and a mixed clinical group of 56 patients diagnosed with other psychiatric disorders. 3. ResultsStudy1: Confirmatory factor analysis supported a situation-specific approach which categorizes everyday attention into nine situation scales. Within each of these nine situations, ratings of sustained, selective, focused, and divided attention as well as motivation constituted reliable subscales. Study 2: We found convincing evidence that adult patients with ADHD have clearly reduced attention scores (with large effect sizes) on all nine situation scales of the ELAS compared to matched healthy controls. Instead, a mixed clinical group of psychiatric patients (including depression and schizophrenia) without ADHD deviated from the healthy sample only on three situations with medium to large effect sizes (Assignment, Cooking, and Cleaning up). Patients with ADHD showed particularly strong attentional difficulties in comparison to both the control and the mixed clinical group regarding Reading, Assignment, Activity, and Conversation. 4. ConclusionsTesting the psychometric properties of the ELAS revealed that attention in everyday life can be reliably measured by situation-specific scales (Study 1) and that these scales are sensitive for attentional difficulties in patients with ADHD (Study 2), particularly for Reading, Assignment, Activity, and Conversation. The ELAS can be used as part of a battery assessment approach or in the context of treatment evaluation.<br/

Nine everyday situations, nine different forms of attention

1. ObjectivesThe aim of the present study was to develop a questionnaire for the assessment of everyday attentional capacities in adults: the Everyday Life Attention Scale (ELAS). Its developmental was inspired by multi-component theories of attention and clinical neuropsychology guidelines for the assessment of attention. The items ask about multiple components of attention in nine common everyday situations, including Reading, Movie, Activity, Lecture, Conversation, Assignment, Cooking, Cleaning up, and Driving.2. MethodsTwo validation studies were conducted. Study 1 investigated the factor structure, validity, and reliability of the ELAS in 1206 healthy participants by means of an online survey. Study 2 further investigated the sensitivity of the ELAS in 80 adults with ADHD compared to 80 matched healthy controls and a mixed clinical group of 56 patients diagnosed with other psychiatric disorders. 3. ResultsStudy1: Confirmatory factor analysis supported a situation-specific approach which categorizes everyday attention into nine situation scales. Within each of these nine situations, ratings of sustained, selective, focused, and divided attention as well as motivation constituted reliable subscales. Study 2: We found convincing evidence that adult patients with ADHD have clearly reduced attention scores (with large effect sizes) on all nine situation scales of the ELAS compared to matched healthy controls. Instead, a mixed clinical group of psychiatric patients (including depression and schizophrenia) without ADHD deviated from the healthy sample only on three situations with medium to large effect sizes (Assignment, Cooking, and Cleaning up). Patients with ADHD showed particularly strong attentional difficulties in comparison to both the control and the mixed clinical group regarding Reading, Assignment, Activity, and Conversation. 4. ConclusionsTesting the psychometric properties of the ELAS revealed that attention in everyday life can be reliably measured by situation-specific scales (Study 1) and that these scales are sensitive for attentional difficulties in patients with ADHD (Study 2), particularly for Reading, Assignment, Activity, and Conversation. The ELAS can be used as part of a battery assessment approach or in the context of treatment evaluation.<br/

Joint consideration of validity indicators embedded in Conners’ Adult ADHD Rating Scales (CAARS)

A decade of research has both illustrated the need for accurate clinical assessment of adult ADHD and brought forward a series of validity indicators assisting this diagnostic process. Several of these indicators have been embedded into Conners’ Adult ADHD Rating Scales (CAARS). As their different theoretical underpinnings offer the opportunity of possible synergy effects, the present study sought to examine whether the item- or index-wise combination of multiple validity indicators benefits classification accuracy. A sample of controls (n = 856) and adults with ADHD (n = 72) answered the CAARS, including the ADHD Credibility Index (ACI) honestly, while a group of instructed simulators (n = 135) completed the instrument as though they had ADHD. First, original CAARS items, which are part of the CAARS Infrequency Index (CII), and items drawn from the ACI were combined into a new CII-ACI-Compound Index. Secondly, existing validity indicators, including suspect T-score elevations and the CII, were considered in combination. Both approaches were evaluated in terms of sensitivity and specificity. The combination of four CII and five ACI items into the CII-ACI-Compound Index yielded a sensitivity between 41 and 51% and an estimated specificity above 87%. Suspect T-score elevations on all three DSM scales emerged as another potentially useful validity indicator with a sensitivity of 45 to 46% and a specificity > 90%. Deeming examinees non-credible whenever two or more validity indicators showed suspect results ensured low false-positive rates ( 11% of misclassified adults with ADHD). Depending on whether high specificity or high sensitivity is prioritized, such combined considerations offer valuable additions to individual validity indicators. High sensitivity provided by “either/or” combinations could prove useful in screening settings, whereas high stakes settings could benefit from “and” combinations

The Plan-a-Day Approach to Measuring Planning Ability in Patients with Schizophrenia

Deficits in executive functioning are closely related to the level of everyday functioning in patients with schizophrenia. However, many existing neuropsychological measures are limited in their ability to predict functional outcome. To contribute towards closing this gap, we developed a computer-based test of planning ability ("Plan-a-Day”) that requires participants to create daily activity schedules in a simulated work setting. Eighty patients diagnosed with schizophrenia were tested with Plan-a-Day and a battery of cognitive ability tests. Plan-a-Day showed satisfactory psychometric properties in terms of consistency, reliability, and construct validity. Compared to other neuropsychological tests used in this study, it also demonstrated incremental validity with regard to the Global Assessment of Functioning. The Plan-a-Day approach, therefore, seems to represent a valid alternative for measuring planning ability in patients with executive function deficits, occupying a middle ground between traditional neuropsychological tests and real-life assessments. (JINS, 2011, 17, 327-335

Everyday Life Attention Scale (ELAS):Normative data of n = 1,874 Dutch participants

The Everyday Life Attention Scale (ELAS) is a sensitive and reliable self-report questionnaire assessing attentional capacities of respondents in nine different situations of daily life. The ELAS has the potential to add relevant information to the clinical evaluation of attention deficits, to guide treatment planning, as well as to evaluate treatment outcome. The present study provides normative data of 1,874 Dutch speaking participants, ranging from 18 to 76 years of age, with mixed levels of education and a roughly equal distribution in gender. Normative data are calculated based on multiple linear regression models for each of the nine ELAS situations. In this article, the ELAS questionnaire as well as norm data are offered free of use. Use of normative ELAS data as presented in this study enables its use in clinical practice and research. Potential applications of the ELAS and future directions are discussed

Non-credible symptom report in the clinical evaluation of adult ADHD:development and initial validation of a new validity index embedded in the Conners' adult ADHD rating scales

As attention-deficit/hyperactivity disorder (ADHD) is a feasible target for individuals aiming to procure stimulant medication or accommodations, there is a high clinical need for accurate assessment of adult ADHD. Proven falsifiability of commonly used diagnostic instruments is therefore of concern. The present study aimed to develop a new, ADHD-specific infrequency index to aid the detection of non-credible self-report. Disorder-specific adaptations of four detection strategies were embedded into the Conners’ Adult ADHD Rating Scales (CAARS) and tested for infrequency among credible neurotypical controls (n = 1001) and credible adults with ADHD (n = 100). The new index’ ability to detect instructed simulators (n = 242) and non-credible adults with ADHD (n = 22) was subsequently examined using ROC analyses. Applying a conservative cut-off score, the new index identified 30% of participants instructed to simulate ADHD while retaining a specificity of 98%. Items assessing supposed symptoms of ADHD proved most useful in distinguishing genuine patients with ADHD from simulators, whereas inquiries into unusual symptom combinations produced a small effect. The CAARS Infrequency Index (CII) outperformed the new infrequency index in terms of sensitivity (46%), but not overall classification accuracy as determined in ROC analyses. Neither the new infrequency index nor the CII detected non-credible adults diagnosed with ADHD with adequate accuracy. In contrast, both infrequency indices showed high classification accuracy when used to detect symptom over-report. Findings support the new indices’ utility as an adjunct measure in uncovering feigned ADHD, while underscoring the need to differentiate general over-reporting from specific forms of feigning. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00702-021-02318-y

Metacognition in adult ADHD:Subjective and objective perspectives on self-awareness of cognitive functioning

Although attention deficit hyperactivity disorder (ADHD) in adulthood is associated with marked cognitive impairment, research on metacognition in adult ADHD is scarce. Deficits in metacognition may have a negative impact on treatment adherence, functional outcomes, and everyday life. This study explores metacognition, specifically self-awareness of cognitive performance, in adults with ADHD by combining objective and subjective assessments. Forty-seven patients with ADHD and 47 control individuals completed a neuropsychological assessment battery including tests for attention, executive functions and memory (objective assessment), as well as questionnaires for cognitive functioning and symptom severity (subjective assessment; self- and informant-report). Participants evaluated their test performance of the objective assessment after test completion by selecting a percentile rank which was subtracted from their normed test result, yielding a discrepancy score. Compared to controls, adults with ADHD showed impairments in attention (medium effects) and memory (small and medium effects), but not in executive functions. The discrepancy scores between self-evaluation and cognitive performance revealed deficits in self-awareness of attentional functions (small effects), but not in executive functions and memory in patients with ADHD compared to controls. Discrepancy scores between self- and informant-reports of cognitive functioning revealed no significant differences. Adults with ADHD show impairments in metacognition in attentional functions, but may have intact metacognitive abilities in other domains. Patients with ADHD tend to overestimate their abilities, especially in attentional functions. Subjective and objective measures of metacognition may not correspond, highlighting the need for clinicians to not solely rely on patients’ self-report in their assessment. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at (10.1007/s00702-020-02293-w)

Metacognition, psychopathology and daily functioning in adult ADHD

Objective: Previous research indicated that adults with ADHD may have deficits in metacognition, yet the evidence base is scarce. This study aims to explore the existence and nature of metacognitive deficits in adults with ADHD, how psychopathology (such as inattention and depression) may affect metacognition and whether metacognition may impact daily functioning in adults with ADHD.Method: Forty-six adult patients with ADHD and 46 controls completed questionnaires for metacognition, psychopathology and daily functioning (subjective assessment; self- and informant report). Participants performed two attention tests in a neuropsychological assessment. After test completion, participants were asked to evaluate their performance with the help of a visual aid and this self-evaluation of test performance was compared with their actual test performance (objective assessment).Results: Patients with ADHD reported large deficits in knowledge of cognition and medium deficits in regulation of cognition compared to controls. Self-evaluation of cognitive test performance revealed no significant deficits. Regression analyses revealed that psychopathology may explain a part of the variation in metacognition. Further regressions indicated that metacognition may account for a significant and meaningful proportion of variance in daily functioning, both self-rated and informant-rated.Conclusions: Current findings of compromised metacognitive functioning of adults with ADHD suggest that clinicians may not want to rely on patients' self-reports in the clinical assessment. Inattention predicted impairments in metacognition, pointing toward the importance of attention for awareness and metacognition. Finally, we recommend that metacognition is addressed in the treatment trajectory of patients with ADHD, given that aspects of metacognition were directly linked to impairments in daily functioning as rated by participants and their relatives