Molina BS, Flory K, Hinshaw SP, Greiner AR, Arnold LE, Swanson JM, Hechtman L, Jensen PS, Vitiello B, Hoza B, Pelham WE, Elliott GR, Wells KC, Abikoff HB, Gibbons RD, Marcus S, Conners CK, Epstein JN, Greenhill LL, March JS, Newcorn JH, Severe JB, Wigal T.

The Multimodal Treatment Study of Children with ADHD (MTA) was a National Institute of Mental health (NIMH) cooperative agreement randomized clinical trial involving six clinical sites.J Am Acad Child Adolesc Psychiatry. 2007 Aug; 46(8):1028-1040.

OBJECTIVE: To compare delinquent behavior and early substance use between the children in the Multimodal Treatment Study of Children with ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36 months post randomization and to test whether these outcomes were predicted by e andomly assigned treatments and subsequent self-selected prescribed medications.

METHOD: Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.

RESULTS: Relative to local normative comparison group, MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001). Children randomized to intensive behavior therapy reported less 24-month substance use than other MTA children (p = .02). Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or ubstance use. By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use.

CONCLUSIONS: Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention-deficit/hyperactivity disorder enter adolescence.

2. Diagnosing ADHD in adults with substance use disorder: DSM-IV criteria and differential diagnosis.

Levin FR, Upadhyaya HP. New York State Psychiatric Institute and Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, USA.

J Clin Psychiatry. 2007 Jul; 68(7):e18.

Individuals with ADHD have a high rate of comorbid psychiatric disorders, especially substance use disorders. Similarly, ADHD is overrepresented in the SUD population. This high rate of comorbidity can make ADHD difficult to diagnose and treat. Comorbid SUD in individuals with ADHD can have a negative impact on course of illness and quality of life. The stringent DSM-IV criteria for ADHD may make diagnosing ADHD in adults difficult, which may lead to an underdiagnosis of ADHD in the adult population.

This may be especially true for patients with SUD, because cognitive deficits associated with substance abuse can hinder their ability to recall ADHD symptoms for appropriate diagnostic purposes. On the other hand, SUD symptoms may mimic ADHD symptoms, which can lead to an verdiagnosis of ADHD in the SUD population. If proper attention is paid to age-appropriate symptoms of ADHD, and careful longitudinal data are obtained from patients presenting with ADHD or SUD, proper treatment can be given to patients with these comorbid disorders.

3. Comorbidity of Adult ADHD and Bipolar Disorder Still Unclear

Lexa W Lee

American Psychiatric Association 2007 Annual Meeting: New Research Session: NR 90. Presented May 21, 2007.

The comorbidity of adult attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) is not well established by existing studies, according to findings of a new literature review presented at the American Psychiatric Association 2007 Annual Meeting, in San Diego, California. While there is considerable symptom overlap between the 2 conditions and frequent reports that they coexist, their concurrent diagnosis remains controversial. Researchers led by Aliza Wingo, MD, a psychiatrist at Emory University in Atlanta, Georgia, carried out a systematic literature review to examine rates of comorbidity and investigate the diagnostic validity of adult ADHD/BPD. They concluded that the comorbidity of adult ADHD and BPD has been insufficiently studied.

"The diagnostic validity of adult ADHD/BPD as a true comorbidity is not well established based on this equivocal and insufficient literature," the authors write. "More studies are generally needed to clarify the diagnostic validity and treatment approach."

Symptom Overlap Adult ADHD has a prevalence rate of 4.4%, while BPD has a lifetime prevalence of 1.3% to 1.6%, the authors note. In the study presented ere, Dr. Wingo and colleagues conducted a search of medical and psychiatric databases (Medline, Embase, PsycInfo, and Cochrane), using the keywords manic, ipolar, attention deficit hyperactivity, adult. Articles published before March 30, 2007 were included, and bibliographies were cross-referenced. Exclusion criteria were ediatric-only subjects, childhood-only ADHD, articles that addressed either BPD or ADHD but not both, review articles, case reports, letters to the editor, and book chapters.

Out of 262 citations, 12 met 5 inclusion criteria: 7 studies on the rates of comorbidity; 4 studies on symptomatology; 3 on the course of illness; 2 on heredity; and 1 examining treatment response. No eligible study looked at biomarkers. Three studies of BPD reported comorbid adult ADHD rates of 9.5% to 21.2%, while 4 studies of adult ADHD reported comorbid BPD rates of 5.1% to 47.1%.

Two studies assessed symptomatology, including symptom overlap, suicide attempts, violence, and other comorbid psychiatric illnesses. Four studies assessed course of illness, including age of onset, number of mood episodes, and severity. Together, these indicated that the course of illness of ADHD/BPD appears to be more severe than BPD alone, given higher lifetime episodes of mania, suicide attempts, more violence and legal problems, an earlier onset of bipolar disorder, and a higher risk for onset of addiction in adolescence. Only 1 study each assessed family history and treatment response.

The research team concluded that the comorbidity of adult ADHD and BPD has been insufficiently studied, with more emphasis on comorbidity rate and course, but little about phenomenology, family history, or treatment. BPD appears somewhat more likely to be diagnosable in adult ADHD than vice versa. It is still not clear whether these are 2 separate illnesses or 1 illness with a broad manifestation of emotional and cognitive symptoms, they note. Dr. Wingo commented, "If you give bipolar patients stimulants or selective antidepressants, they have a risk of mania or rapid cycling. We recommend treating their symptoms until they stabilize, and then you can evaluate whether they have adult ADHD. If they do, then you can use selective antidepressants before trying to stimulate."

ADHD "Protobipolar?"
"Sometimes there is confusion and overlap between adult ADHD and BPD, particularly if the BPD is relatively mild," said Dr. Robert Guynn, professor of psychiatry at the University of Texas-Houston Medical School. "In children, there is an interest in diagnosing BPD as early as possible. Some of the kids we are now calling ADHD may prove to be 'protobipolar.' At the same time, there is no reason why the 2 [conditions] couldn’t occur together. This needs ongoing research."

4. Are Girls with ADHD at Risk for Eating Disorders? Results from a Controlled,
Five-Year Prospective Study.

Biederman J, Ball SW, Monuteaux MC, Surman CB, Johnson JL, Zeitlin S. From the *Clinical and Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, Boston, MA; †Department of Psychiatry, Harvard Medical School, Boston, MA.

J Dev Behav Pediatr. 2007 Aug;28(4):302-307.

OBJECTIVE: To evaluate the association between attention-deficit/hyperactivity disorder (ADHD) and eating disorders in a large adolescent population of girls with and without ADHD.

METHOD: We estimated the incidence of lifetime eating disorders (either anorexia or bulimia nervosa) using Cox proportional hazard survival models. Comparisons between ADHD girls with and without eating disorders were then made on measures of comorbidity, course of ADHD, and growth and puberty.

RESULTS: ADHD girls were 3.6 times more likely to meet criteria for an eating disorder throughout the follow-up period compared to control females. Girls with eating disorders had significantly higher rates of major depression, anxiety disorders, and disruptive behavior disorder compared to ADHD girls without eating disorders. Girls with ADHD and eating disorders had a significantly earlier mean age at menarche than other ADHD girls. No other differences in correlates of DHD were detected between ADHD girls with and without eating disorders.

CONCLUSIONS: ADHD significantly increases the risk of eating disorders. The presence of an eating disorder in girls with ADHD heightens the risk of additional morbidity and dysfunction.

5. Personality Characteristics Associated with Persistent ADHD in Late Adolescence.

Miller CJ, Miller SR, Newcorn JH, Halperin JM. Department of Psychology, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, N9B 3P4, Canada, cjmiller@uwindsor.ca.

J Abnorm Child Psychol. 2007 Aug 15; [Epub ahead of print]

This study focused on the personality characteristics associated with Attention-deficit/Hyperactivity disorder (ADHD) in a longitudinal sample of youth, with a particular focus on differences between those with and without persisting ADHD symptoms. Participants with ADHD (n = 90) were initially evaluated when they were 7-11 years old, and re-assessed at 16-22 years of age. Matched control subjects (n = 80) were recruited at the time of the follow-up evaluation. At follow-up, the Kiddie-SADS-PL, a semi-structured psychiatric interview, and the NEO-PI, a self-report personality inventory, were administered.

Data were analyzed using multivariate analyses of variance (MANOVA). Results indicate that childhood ADHD is associated with lower scores on the NEO Conscientiousness subscale in adolescents/young adults-irrespective of the degree of ADHD persistence.

In contrast, ratings of Neuroticism and Agreeableness appear to be more closely linked to adolescent status; those with persisting symptoms only exhibited increased Neuroticism and decreased Agreeableness. These results suggest that ADHD, and the degree to which symptoms persist into adolescence, may be closely linked to personality structure.