ADHD and co-occurring mental health conditions in adults
This exciting plenary session was moderated by Professor Martin Katzman (Stress, Trauma, Anxiety, Rehabilitation and Treatment [START] Clinic for Mood and Anxiety Disorders, Canada), who opened the session by highlighting what an interesting time it is in the world of adult ADHD and the important role the audience has in raising awareness of the condition.
The first presentation was by Professor Philip Asherson (Institute of Psychiatry Psychology and Neuroscience, King’s College London, UK) entitled ‘ADHD and co-occurring mental health conditions in adults’. He began by presenting the results from the US National Comorbidity Survey highlighting the high rate of mood disorders, anxiety (including post-traumatic stress disorder) and drug dependence in adults with ADHD.1 He then described the commonly associated features of ADHD that support differential diagnosis: emotional symptoms, developmental traits, education problems and cognitive deficits2 and the common symptoms seen in adults. He outlined the results from the MIRAD project, a study conducted in patients with ADHD with no comorbidities, which showed that pure ADHD is quite symptomatic (compared with patients without ADHD), thus demonstrating that symptoms including fatigue, concentration/forgetfulness, sleep disturbance, irritability and worry are not a result of comorbidities but ADHD itself.3 He noted that affective lability in this patient population was predictive of ADHD and results from anger rating scales showed that patients with ADHD were more angry more often than patients without ADHD.4 He went on to describe the symptoms and impairments of ADHD that can mimic other disorders such as anxiety, depression, personality disorder and bipolar disorder.5
He concluded his presentation by describing the treatment algorithm for adults with chronic mood instability which recommends that chronic trait-like mental health problems (inattention, hyperactivity, impulsivity, emotional dysregulation) should be initially assessed followed by screening for ADHD. The patient ought to then be classified into two categories: 1) those with no ADHD, where an alternative diagnosis should be established and treated accordingly; 2) those with ADHD, with or without psychiatric comorbid disorders. In those without a comorbidity or comorbid personality disorder, pharmacological treatment for ADHD ought to be initiated; in those with significant depression, bipolar disorder or another condition, the comorbid disorder should be treated first in most cases. He also noted that treatment strategies should be reviewed and additional treatments, for example, cognitive behavioural therapy or medication, be considered.6
The second presentation by Professor Roger McIntyre (University of Toronto, Toronto, Canada) entitled ‘Symptom overlap and differential diagnosis’ focused on the phenomenology of symptom overlap. He began by saying that there isn’t a zone of delineation between ADHD and other conditions and that it is important to keep in mind the convergence of cognition, which is central to the conditions of ADHD, bipolar disorder and other impulsive disorders. He described a conceptual framework for the overlap between ADHD and bipolar disorder, describing homotypic versus heterotypic continuity (ADHD early in life and bipolar disorder later in life), topography versus topology (convergence of neurobiology of ADHD and bipolar disorder and the abnormalities in structure and function of ADHD and bipolar disorder with discrete entities which overlap) and symptoms versus domains. He discussed the overlap between phenotypes and introduced the Research Domain Criteria (RDoC) which were developed, for research purposes, as new ways of classifying mental health disorders based on behavioural dimensions and neurobiological measures such as positive and negative valence systems, cognitive symptoms, systems for social processes and arousal/regulatory process7 highlighting that general cognitive functioning is central in bipolar disorder and ADHD. He talked about the dimensional approach to bipolar disorder, describing the manic, mixed and depressive categories of DSM-IV compared with the manic, manic with mixed features, depressive with mixed features, and depressive categories of DSM-5.2,8 He noted that the majority of patients with mood disorders sit in the middle with manic with mixed features and depressive with mixed features, and questioned whether it was these patients that had ADHD with mood disorder, or just ADHD, or whether these symptoms were secondary to ADHD. He went on to report the findings from key studies such as the International Disorders Collaborative project, which measured the mixed features encountered in adult patients with both major depressive disorder (MDD) and bipolar disorder9; the STEP-BD study10; and results from a study which examined anxiety and mixed states.11 He explained that the symptoms of ADHD overlap with binge eating, in areas such as reward functioning, distraction and impulsivity. He concluded his presentation by highlighting that research is increasingly under way, looking at the brain structure of adults with ADHD and mood disorders to examine the overlapping changes.
In the final presentation of this plenary session Dr Larry Klassen (Eden Health Care Services, Canada) presented on the topic of ‘Screening and diagnosis of ADHD in adults’. He began by describing the clinical markers which could be suggestive of adult ADHD such as childhood history and a family member diagnosed with ADHD, and the overlapping symptoms of ADHD and comorbidities. He posed the question “Who do you screen?”, and recommended screening all patients with MDD, anxiety and bipolar disorder; those with substance-use disorders (especially those who are receiving methadone); patients with a family history or child with ADHD; adults who are not reaching their full potential; adults with motor vehicle issues; and adults exhibiting symptoms of forgetfulness. He provided the audience with an extremely useful pneumonic for screening for adult ADHD “PDF”: Procrastination, Distractibility, Forgetfulness (Courtesy of Timothy Bilkey). With regard to the screening tools he uses in clinical practice, Dr Klassen described the ADHD Self-Report Scale (ASRS v1.1); Wender-Utah Rating Scale; Barkley Screener; Conners Adult ADHD Rating Scales (CAARS) and noted that there will shortly be a new ASRS v1.2 available. He concluded the presentation by describing two validated diagnostic interviews available to help with diagnosis: the DIVA 2.0 and ACE+.
Professor Roger McIntyre, Professor Philip Asherson and Dr Klassen were then joined by Professor Guy Goodwin and Professor Toni Ramos on stage for a stimulating expert panel discussion moderated by Professor Katzman. Questions from the audience covered topics such as whether there was a risk of mania in patients with ADHD and bipolar disorder treated with psychostimulants; cognitive trajectories in autism spectrum disorders, bipolar disorder and ADHD; ASRS v1.1 versus ASRS v1.2; and the interface between borderline personality disorder and bipolar disorder in ADHD phenotypes.
Professor Katzman: “Be an advocate – we are in a unique position to share and work together to enhance outcomes for those adults that are misdiagnosed.”
Dr Greg Mattingly and the panel
Challenges and complexities of ADHD and co-occurring mental health conditions in children and adolescents
The first speaker at this parallel plenary session was Professor Luis Rohde (Federal University of Rio Grande do Sul, Brazil), who introduced the topic with his short opening presentation entitled ‘Challenges and complexities of ADHD and co-occurring mental health conditions in children and adolescents: Setting the scene’. He highlighted the importance that seminal publications have attached to comorbidity in ADHD. The most commonly reported comorbidities across three international studies were oppositional defiant disorder, anxiety, conduct disorder and depression;12 however, clinical comorbidities, such as type I diabetes and obesity, may also be an issue. Professor Rohde then presented data from three studies that all suggested that ADHD comorbidities may carry the outcome risk for substance use, neuropsychological impairment and traffic accidents. Finally, the audience were reminded that comorbidities should be a consideration when deciding upon a first intervention in the clinic.
In the second talk of the session, ‘ADHD: A highly comorbid condition’, Professor Tobias Banaschewski (Central Institute of Mental Health, Mannheim, Germany) provided an overview of the global prevalence of ADHD, then showed how there has been little change in prevalence estimates over the past 25 years.13 However, at a more local level, prevalence rates can be quite variable, even within countries.14 ADHD comorbidities, however, are reported to occur at similar frequencies between countries and affect individuals at predictable stages of childhood/adolescence.
Professor Banaschewski emphasised that ADHD comorbidities increase in frequency throughout the lifespan and contribute significantly to functional impairment. He highlighted data from two independent longitudinal case-controlled studies that showed an increased lifetime risk of comorbid mood, anxiety, antisocial and addictive disorders compared with controls. A recent meta-analysis also indicated that children with ADHD were 40% more likely to be obese than children without ADHD.15
In summing up, it was shown that ADHD comorbidities can hinder diagnosis, impact on health-related quality of life and on patient mortality.
The next presentation, ‘Managing the more challenging and complex cases’, by Dr Greg Mattingly (Washington University in St Louis, MO, USA) provided an overview of treatment options for children with ADHD and other comorbid conditions. A key theme of the presentation was the optimisation of initial treatments, based on the correct identification of comorbidities at diagnosis. Dr Mattingly emphasised that the presentation of mental health conditions frequently change as the brain matures; in the case of ADHD, cortical maturation is delayed compared with controls, particularly in prefontal regions.
The question of whether mood disorders or ADHD should be treated first was also discussed, with some evidence suggesting that early treatment of ADHD can reduce rates of antidepressant resistance.16 The importance of separating the symptoms of pre-pubertal bipolar disorder from those of ADHD was also reviewed. The best differentiating factors, predictive of bipolar disorder over ADHD, were elevated mood, grandiosity, racing thoughts, decreased need for sleep and hypersexuality.17 Results from an 8-year follow‑up study of medication use in pre-adolescent onset bipolar disorder showed that 62.6% received any antimanic medication at any time, 77.4% received medication for ADHD and 64.3% received antidepressants.18 Another study showed that ADHD medication does not affect treatment for bipolar disorder.19
Dr Mattingly went on to show, using pooled data from crossover studies, that responses to ADHD medication vary, and that 13% of children were unresponsive to methylphenidate and amphetamine treatments.20 He highlighted the potential advantages of combination therapy in children who were non-responsive to stimulants and in complex cases.21
Dr Greg Mattingly: “ADHD treatment increases the chances of bipolar disorder treatment working.”
Breaking headlines in ADHD: 2016/17
Review of key publications
This session gave the audience a unique and valuable opportunity to find out which publications from the previous year were considered most impactful by the expert panel members. Key publications were identified and discussed by Professor Tobias Banaschewski, Professor Luis Rohde, Professor David Coghill, Professor Marina Danckaerts, Professor Paulo Mattos and Professor Martin Katzman. The key conclusions from the publications are outlined below.
Journal selections of Professor Tobias Banaschewski
Motor Vehicle Crash Risk Among Adolescents and Young Adults with Attention-Deficit/Hyperactivity Disorder. Curry AE et al. JAMA Pediatr 2017; 171: 756-763.22
- Results from this study show an increased risk of motor vehicle crash risk in adolescents with ADHD, compared with non-ADHD controls. This effect was independent of age, sex, and driving experience. Medication had no effect on crash risk.
Association Between Medication Use for Attention-Deficit/Hyperactivity Disorder and Risk of Motor Vehicle Crashes. Chang Z et al. JAMA Psychiatry 2017; 74: 597-603.23
- This large study followed a US national cohort of over 2 million patients with ADHD over a 10-year period. Inter-individual analyses of motor vehicle crash rate were compared between medicated and non-medicated months using insurance claims data. The rate of crashes was reduced by 38% by medication use, suggesting that around 20% of motor vehicle crashes in adults with ADHD may have been avoided if medication was continued throughout the study period.
Journal selections of Professor Luis Rohde
Educational and Health Outcomes of Children Treated for Attention-Deficit/Hyperactivity Disorder. Fleming M et al. JAMA Pediatr 2017; 171: e170691.24
- This population-based cohort study assessed educational outcomes in 766,244 children attending Scottish schools between 2009 and 2013. Children receiving medication for the treatment of ADHD were compared with children without ADHD, and were found to have poorer outcome measures. These data highlight that even with medication, children with ADHD may be impaired at school.
Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder. Lu Y et al. JAMA Psychiatry 2017; 74: 815-822.25
- Data from Swedish national registers was used to explore the effect of ADHD medication on higher education performance in 930 patients with ADHD. Test scores from periods when patients were taking medication were compared with scores from periods of non-medication. ADHD medication use was associated with significantly higher test scores, although the clinical relevance of the effect size is unclear.
Journal selection of Professor David Coghill
Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. Swanson JM et al. J Child Psychol Psychiatry 2017; 58: 663-678.26
- This paper presents results from the 16-year follow-up of young adults from the Multimodal Treatment Study of Children with ADHD (MTA).27 Key findings included a dose-dependent suppression of growth, and no significant effect on symptoms compared with a local population control group. One limitation of this study was that medication use was only monitored for 10 years, while symptom control was assessed at 12, 14 and 16 years. It is therefore difficult to know if medication was continued at these time points.
Journal selection of Professor Marina Danckaerts
Teenage Parenthood and Birth Rates for Individuals With and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study. Østergaard SD et al. J Am Acad Child Adolesc Psychiatry 2017; 56: 578-584.28
- This Danish historical perspective study examined when in their lifetime patients with ADHD are most likely to become parents. Compared with individuals without ADHD, patients with ADHD were significantly more likely to have children at 12-16 years, and at 17-19 years. Targeted sexual education and contraceptive counselling may be appropriate in these groups.
Journal selection of Professor Paulo Mattos
Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. Groenman AP et al. J Am Acad Child Adolesc Psychiatry 2017; 56: 556-569.29
- The aim of this meta-analysis was to assess the risk of developing substance-use disorders in patients with ADHD and other mental health problems. A total of 37 studies were assessed and indicated that patients with ADHD have increased risk for alcohol, tobacco and drug addiction. Similar results were found for patients with oppositional defiant disorder, conflict disorder and depression.
Journal selections of Professor Martin Katzman
Association of Risk of Suicide Attempts With Methylphenidate Treatment. Man KKC et al. JAMA Psychiatry 2017; doi: 10.1001/jamapsychiatry.2017.2183.30
- The relative risk of suicide attempt in patients receiving treatment with methylphenidate was compared with periods of non-treatment in this population-based, self-controlled study. A total of 25,629 patients were assessed over the 5-year study period. Incidence of suicide attempt was higher in the period immediately before onset of methylphenidate treatment. No causal relationship between methylphenidate treatment and suicide attempt was found.
Psychiatric Comorbidities Modify the Association Between Childhood ADHD and Risk for Suicidality: A Population-Based Longitudinal Study. Yoshimasu K et al. J Atten Disord 2017; 1087054717718264.31
- This population-based birth cohort study assessed the influence of comorbidities on adult suicide risk following childhood ADHD. Patients with ADHD and generalised anxiety disorder had a 2-fold elevated risk of suicidality compared with ADHD-alone. Comorbid substance use disorder and hypomanic episode disorder also increased suicide risk synergistically.
Professor Katzman: “Comorbidity is important in defining the trajectory to suicide.”
ADHD: a family affair
Professor Marina Danckaerts (University of Leuven, Belgium) got the final plenary sessions under way with her presentation entitled ‘ADHD: a family affair’. The interactions between a child’s ADHD symptoms, their parents’ behaviours and the family unit were explored, and the potential impact on treatments assessed.
Results from large studies of twins in Sweden have revealed an increased risk of ADHD in siblings, but not cousins of individuals with ADHD.32 Similarly, meta-analysis of twin studies have estimated the heritability of clinically diagnosed ADHD to be 88% overall, and 72% in adults.33 These studies confirm a strong genetic component in the heritability of ADHD, but also show that other factors must also play a role.
Professor Danckaerts went on to present results from a meta-analysis of twin and adoption studies (n=490) which examined internalising and externalising psychopathology prior to adulthood, where results showed that shared environment accounted for 10-19% of the variance within conduct disorder, oppositional defiant disorder, anxiety, depression; however, ADHD appeared to be largely genetic origin.34 She then discussed the results from a population study in Sweden which estimated the heritability of ADHD as 89% with non-shared environment accounting for 11% of the variance.32
The role of evocative correlation in predicting future ADHD was highlighted. This is when the child elicits parental reactions that further increase the risk of ADHD.35 It was also shown that genetic influences of ADHD are highest in low-risk environments (when parental involvement is high).36
The problems affecting families with a child with ADHD were examined; these were shown to have significant impact on measures of quality of life. It was also demonstrated that short-term ADHD prognosis can be influenced by the family, with high levels of warmth and involvement correlating with attenuation of symptoms, and the development of comorbid symptoms associated with parental aggression, maternal depression or inconsistent parenting.37
In conclusion, Professor Danckaerts advocated early intervention and treatment of both children and parents with symptoms of ADHD. Parenting interventions for adults with ADHD may also provide benefits to the family unit, but should be tailored to the individual’s needs and abilities.
Greg Mattingly returned to the stage to deliver an informative talk on ‘The clinical challenges of genetics, neurology and environmental context’. During the presentation, he addressed areas in which clinical outcomes may be improved by changes in clinical practice, covering diagnosis, transition management and optimisation of medication.
The complex aetiology of ADHD means that symptoms often differ between patients, and there are several areas of impairment that could potentially be addressed.
Treatment persistence was identified as a key concern, particularly in adolescents. Results from several studies have shown a drop-off in ADHD medication adherence over this period.38-40
From his own clinical experience, Dr Mattingly identified the following factors as important in improving compliance and persistence to ADHD treatments:
- active case management
- once-daily education
- shared decision-making
- rapport with the treatment provider.
Results were presented from a linguistic study that assessed physician-patient interview transcripts for qualitative and quantitative aspects that correlated with patient satisfaction. It was found that overall visit length had little correlation with patient satisfaction.41 Several gaps in treatment were identified, including inadequate use of ADHD rating scales, and use of inconsistent assessment questions. Examples of identified problems that negatively impacted on the patient’s experience included:41
- focusing too heavily on school and deficits
- failure to stress the importance of adherence and persistence
- exclusion of children from the discussion.
Dr Mattingly concluded his talk by discussing the importance of optimising symptom reduction across the lifespan by adjusting treatments in response to changes in ADHD presentation.
The final speaker was Professor David Coghill (University of Melbourne, Australia) who gave an inspiring overview of the successful Dundee ADHD Clinical Care Pathway (DACCP) project entitled ‘Sustaining optimal management of ADHD’.
ADHD can be relatively easy to treat; however, achieving sustained benefit in patients with ADHD can be difficult. Although most parents report satisfaction with their child’s ADHD treatment, many still experience considerable behavioural challenges across the day.42
The aim of the DACCP project was to emulate the sustained, long-term improvements in ADHD symptoms seen in the MTA study.43,44 An important outcome from the MTA studies was that the standard of care must be maintained over time for treatment benefits to be sustained.
Two key elements of the DACCP design were:
- the inclusion of an intensive 4-week dose titration protocol, focused on symptom reduction and optimisation of treatment
- delivery by trained nurses
- treatment started with a stimulant
- ongoing dose adjustments informed by standardised outcome measures and teacher consultations.
Professor Coghill discussed some results from DACCP, where mean SNAP/ADHD-RS-IV score decreased from 2.5 at baseline, to 0.7 at the end of titration, and to 0.8 at the most recent visit. The mean duration of treatment was 43 months (range 1-119 months), and the mean dose of methylphenidate was 52 mg/day.45 Rates of remission in DACCP were 44% pre-change and 67% post-change.
Potential modifications to the DACCP approach that would allow its application to adult populations were suggested. These included using expanded DSM-5 prompts when rating symptoms, and adopting different approaches to the management of comorbidities.
Professor Coghill: “Standardise your approach, measure specific outcomes, and keep it up! Persist!”
- Kessler RC, Adler L, Barkley R, Biederman J, Conners CK, Demler O, Faraone SV, Greenhill LL, Howes MJ, Secnik K, Spencer T, Ustun TB, Walters EE, Zaslavsky AM. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2006; 163: 716-723.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. eds. 2013.
- Skirrow C, Asherson P. Emotional lability, comorbidity and impairment in adults with attention-deficit hyperactivity disorder. J Affect Disord 2013; 147: 80-86.
- Skirrow C, Ebner-Priemer U, Reinhard I, Malliaris Y, Kuntsi J, Asherson P. Everyday emotional experience of adults with attention deficit hyperactivity disorder: evidence for reactive and endogenous emotional lability. Psychol Med 2014; 44(16): 3571-3583.
- Asherson P, Buitelaar J, Faraone SV, Rohde LA. Adult attention-deficit hyperactivity disorder: key conceptual issues. Lancet Psychiatry 2016; 3: 568-578.
- UK Adult ADHD Network. Handbook for attention deficit hyperactivity disorder in adults. eds. Springer, 2013.
- National Institute of Mental Health. Research Domain Criteria (RDoC). Available at: www.nimh.nih.gov/research-priorities/rdoc/research-domain-criteria-matrix.shtml. Last updated 2017.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. eds. Washington, DC: IV-TR. American Psychiatric Association, 2004.
- McIntyre RS, Soczynska JK, Cha DS, Woldeyohannes HO, Dale RS, Alsuwaidan MT, Gallaugher LA, Mansur RB, Muzina DJ, Carvalho A, Kennedy SH. The prevalence and illness characteristics of DSM-5-defined “mixed feature specifier” in adults with major depressive disorder and bipolar disorder: Results from the International Mood Disorders Collaborative Project. J Affect Disord 2015; 172: 259-264.
- Goldberg JF, Perlis RH, Bowden CL, Thase ME, Miklowitz DJ, Marangell LB, Calabrese JR, Nierenberg AA, Sachs GS. Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP-BD. Am J Psychiatry 2009; 166: 173-181.
- MacKinnon DF, Zandi PP, Gershon ES, Nurnberger JI, Jr., DePaulo JR, Jr. Association of rapid mood switching with panic disorder and familial panic risk in familial bipolar disorder. Am J Psychiatry 2003; 160: 1696-1698.
- Coghill D, Rohde LA, Banaschewski T. Attention-deficit/hyperactivity disorder in: Banaschewski T, Rohde LA eds. Biological Child Psychiatry. Recent Trends and Developments. Karger, 2008: 1-20.
- Polanczyk GV, Willcutt EG, Salum GA, Kieling C, Rohde LA. ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. Int J Epidemiol 2014; 43: 434-442.
- Visser SN, Danielson ML, Bitsko RH, Holbrook JR, Kogan MD, Ghandour RM, Perou R, Blumberg SJ. Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003-2011. J Am Acad Child Adolesc Psychiatry 2014; 53: 34-46.
- Cortese S, Moreira-Maia CR, St Fleur D, Morcillo-Penalver C, Rohde LA, Faraone SV. Association Between ADHD and Obesity: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016; 173: 34-43.
- Chen MH, Pan TL, Hsu JW, Huang KL, Su TP, Li CT, Lin WC, Tsai SJ, Chang WH, Chen TJ, Bai YM. Attention-deficit hyperactivity disorder comorbidity and antidepressant resistance among patients with major depression: A nationwide longitudinal study. Eur Neuropsychopharmacol 2016; 26: 1760-1767.
- Geller B, Zimerman B, Williams M, Delbello MP, Frazier J, Beringer L. Phenomenology of prepubertal and early adolescent bipolar disorder: examples of elated mood, grandiose behaviors, decreased need for sleep, racing thoughts and hypersexuality. J Child Adolesc Psychopharmacol 2002; 12: 3-9.
- Geller B, Tillman R, Bolhofner K, Zimerman B. Pharmacological and non-drug treatment of child bipolar I disorder during prospective eight-year follow-up. Bipolar Disord 2010; 12: 164-171.
- Findling RL, Landbloom RL, Szegedi A, Koppenhaver J, Braat S, Zhu Q, Mackle M, Chang K, Mathews M. Asenapine for the Acute Treatment of Pediatric Manic or Mixed Episode of Bipolar I Disorder. J Am Acad Child Adolesc Psychiatry 2015; 54: 1032-1041.
- Arnold LE. Methylphenidate vs amphetamine: comparative review. J Atten Disord 2000; 3: 200-211.
- Cutler AJ, Brams M, Bukstein O, Mattingly G, McBurnett K, White C, Rubin J. Response/remission with guanfacine extended-release and psychostimulants in children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 2014; 53: 1092-1101.
- Curry AE, Metzger KB, Pfeiffer MR, Elliott MR, Winston FK, Power TJ. Motor Vehicle Crash Risk Among Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr 2017; 171: 756-763.
- Chang Z, Quinn PD, Hur K, Gibbons RD, Sjolander A, Larsson H, D’Onofrio BM. Association Between Medication Use for Attention-Deficit/Hyperactivity Disorder and Risk of Motor Vehicle Crashes. JAMA Psychiatry 2017; 74: 597-603.
- Fleming M, Fitton CA, Steiner MFC, McLay JS, Clark D, King A, Mackay DF, Pell JP. Educational and Health Outcomes of Children Treated for Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr 2017; 171: e170691.
- Lu Y, Sjolander A, Cederlof M, D’Onofrio BM, Almqvist C, Larsson H, Lichtenstein P. Association Between Medication Use and Performance on Higher Education Entrance Tests in Individuals With Attention-Deficit/Hyperactivity Disorder. JAMA Psychiatry 2017; 74: 815-822.
- Swanson JM, Arnold LE, Molina BSG, Sibley MH, Hechtman LT, Hinshaw SP, Abikoff HB, Stehli A, Owens EB, Mitchell JT, Nichols Q, Howard A, Greenhill LL, Hoza B, Newcorn JH, Jensen PS, Vitiello B, Wigal T, Epstein JN, Tamm L et al. Young adult outcomes in the follow-up of the multimodal treatment study of attention-deficit/hyperactivity disorder: symptom persistence, source discrepancy, and height suppression. J Child Psychol Psychiatry 2017; 58: 663-678.
- MTA Cooperative Group. Moderators and mediators of treatment response for children with attention-deficit/hyperactivity disorder: the Multimodal Treatment Study of children with Attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56: 1088-1096.
- Ostergaard SD, Dalsgaard S, Faraone SV, Munk-Olsen T, Laursen TM. Teenage Parenthood and Birth Rates for Individuals With and Without Attention-Deficit/Hyperactivity Disorder: A Nationwide Cohort Study. J Am Acad Child Adolesc Psychiatry 2017; 56: 578-584.
- Groenman AP, Janssen TWP, Oosterlaan J. Childhood Psychiatric Disorders as Risk Factor for Subsequent Substance Abuse: A Meta-Analysis. J Am Acad Child Adolesc Psychiatry 2017; 56: 556-569.
- Man KKC, Coghill D, Chan EW, Lau WCY, Hollis C, Liddle E, Banaschewski T, McCarthy S, Neubert A, Sayal K, Ip P, Schuemie MJ, Sturkenboom MCJM, Sonuga-Barke E, Buitelaar J, Carucci S, Zuddas A, Kovshoff H, Garas P, Nagy P et al. Association of Risk of Suicide Attempts With Methylphenidate Treatment. JAMA Psychiatry 2017; doi: 10.1001/jamapsychiatry.2017.2183.
- Yoshimasu K, Barbaresi WJ, Colligan RC, Voigt RG, Killian JM, Weaver AL, Katusic SK. Psychiatric Comorbidities Modify the Association Between Childhood ADHD and Risk for Suicidality: A Population-Based Longitudinal Study. J Atten Disord 2017; 1087054717718264.
- Chen Q, Brikell I, Lichtenstein P, Serlachius E, Kuja-Halkola R, Sandin S, Larsson H. Familial aggregation of attention-deficit/hyperactivity disorder. J Child Psychol Psychiatry 2017; 58: 231-239.
- Larsson H, Chang Z, D’Onofrio BM, Lichtenstein P. The heritability of clinically diagnosed attention deficit hyperactivity disorder across the lifespan. Psychol Med 2014; 44: 2223-2229.
- Burt SA. Rethinking environment contributions to child and adolescent psychopathology: a meta-analysis of shared environmental influences. Psychol Bull 2009; 135(4): 608-637.
- Harold GT, Leve LD, Barrett D, Elam K, Neiderhiser JM, Natsuaki MN, Shaw DS, Reiss D, Thapar A. Biological and rearing mother influences on child ADHD symptoms: revisiting the developmental interface between nature and nurture. J Child Psychol Psychiatry 2013; 54: 1038-1046.
- Nikolas MA, Klump KL, Burt SA. Parental involvement moderates etiological influences on attention deficit hyperactivity disorder behaviors in child twins. Child Dev 2015; 86: 224-240.
- Deault LC. A systematic review of parenting in relation to the development of comorbidities and functional impairments in children with attention-deficit/hyperactivity disorder (ADHD). Child Psychiatry Hum Dev 2010; 41: 168-192.
- McCarthy S, Wilton L, Murray ML, Hodgkins P, Asherson P, Wong IC. Persistence of pharmacological treatment into adulthood, in UK primary care, for ADHD patients who started treatment in childhood or adolescence. BMC Psychiatry 2012; 12: 219.
- Burcu M, Zito JM, Metcalfe L, Underwood H, Safer DJ. Trends in Stimulant Medication Use in Commercially Insured Youths and Adults, 2010-2014. JAMA Psychiatry 2016; 73: 992-993.
- Lachaine J, Beauchemin C, Sasane R, Hodgkins PS. Treatment patterns, adherence, and persistence in ADHD: a Canadian perspective. Postgrad Med 2012; 124: 139-148.
- Mattingly G, Surman CB, Mao AR, Eagan CA, Onofrey M, Lerner M. Improving Communication in ADHD Care: Results from In-office Linguistic Research. CNS Spectr 2011; 16: 85-94.
- Coghill D, Soutullo C, d’Aubuisson C, Preuss U, Lindback T, Silverberg M, Buitelaar J. Impact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey. Child Adolesc Psychiatry Ment Health 2008; 2: 31.
- MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry 1999; 56: 1073-1086.
- MTA Cooperative Group. National Institute of Mental Health Multimodal Treatment Study of ADHD follow-up: changes in effectiveness and growth after the end of treatment. Pediatrics 2004; 113: 762-769.
- Coghill D, Seth S. Effective management of attention-deficit/hyperactivity disorder (ADHD) through structured re-assessment: the Dundee ADHD Clinical Care Pathway. Child Adolesc Psychiatry Ment Health 2015; 9: 52.