Attention deficit disorder (ADHD) has been shown to negatively impact cognition across many domains, including attention, inhibition, memory, and general functionality in daily life.1,2 Initially dismissed as a condition to only affect children and adolescents, the recognition of adult ADHD has grown recently in the medical community and general population. Between 2009 and 2018 ADHD diagnoses have increased by 31%3 and many patients continue managing their ADHD symptoms in adulthood. Indeed, following the National Comorbidity Survey Replication, the current estimated prevalence of adults with ADHD in the United States is 4.4%, with the disorder often causing substantial role impairments in the affected population4.
The Difficulty of Diagnosing Adult ADHD
If left untreated, ADHD can have severe emotional and socio-economic consequences5. Despite these adverse effects, adult ADHD remains under-recognized and under-treated6. This might be in part because the diagnostic criteria for ADHD listed in the DSM-IV-TR were developed for children, making it difficult for clinicians to recognize ADHD in adults if the disorder wasn’t already diagnosed in childhood. Indeed, in a survey with 400 primary physicians in the Unites States7, 48% stated they felt uncomfortable diagnosing adult ADHD, and 44% reported a lack of clear diagnostic criteria. A majority (75%) rated the quality and accuracy of existing adult ADHD diagnostic tools as either ‘poor’ or ‘fair’, and 72% felt that ADHD is easier to diagnose in children than in adults. Thus, there is a pressing need for an objective tool to assist with detecting and managing adult ADHD. The following case study demonstrates how BNA™ helps improve your clinics ability to help adults manage ADHD.
The Case
A 28-year-old female reports attention and memory issues. She states she has had difficulty focusing since childhood, but was never diagnosed with a psychiatric condition before. The treating physician recommended a BNA test to assess the cognitive function and screen for potential electrophysiological alterations
Methods
BNA was recorded twice. The first recording reflects the patient’s results at baseline. The second recording was performed one day later after the patient received methylphenidate (Ritalin).
BNA Results & Physician Interpretation
The research physician interpreted the BNA results as following:
BNA Visit 1: The first visit showed a strongly decreased amplitude of the P3b (Z-score >-3.0). The P3b is commonly associated with working memory8 and is often lower in adult ADHD9,10. Also noticeable was the poor behavioral performance affecting the number of correct responses (only 72% accurate), paired with a slow (Z-score +1.9) and variable (Z-score +2.5) reaction time. Those behavioral patterns are also prevalent in untreated ADHD patients11,12. The physician interpreted these results as confirmatory of his supposition that the patient suffers from ADHD, which was undetected during medical screenings in childhood. Thus, the clinician decided to test methylphenidate as a treatment option.
BNA Visit 2: The second visit, conducted the next day and after the intake of methylphenidate, showed a normalization across all scores that previously deviated from the measures of the healthy reference. The P3b amplitude measure (associated with working memory) normalized from a Z-score of <-3 to a score of -0.6. Behaviorally, the patient showed a substantial improvement, reaching 100% correct responses while at the same time becoming faster (Z-score -1.0) and less variable (Z-score +0.8). Given this successful treatment evaluation of methylphenidate, the physician was confident enough to diagnose the patient with adult ADHD and initiate the treatment plan to maintain the induced positive effects on her electrophysiology and performance measures.
Summary Report of the Auditory Oddball Task
Benefits of BNA for Detecting and Managing Adult ADHD
While physicians have typically found diagnosing adult ADHD challenging, the use of BNA can go a long way toward addressing these challenges. BNA provides the following benefits:
- BNA objectively measures the neurophysiology and behavior that can be reflective of our cognitive functioning. This makes BNA an ideal add-on tool for clinical scenarios where standard screenings often remain inconclusive, such as in the diagnosis of adult ADHD.
- BNA can assist in managing adult ADHD by assessing various electrophysiological and behavioral measures known to be altered in ADHD, such as the P3b ERP component9,10, reaction timesand accuracy measures12,13. Thus, using BNA in primary care settings could sensitize standard screenings to detect cognitive alterations caused by CNS conditions, that may otherwise go unnoticed.
- Due to its high sensitivity to subtle electrophysiological changes, BNA can also serve as an objective treatment evaluation tool. In fast- acting agents like methylphenidate, BNA can assess the electrophysiological changes on the same day. This allows physicians to confidently provide their patients with a diagnosis and an effective treatment plan.
References
1. Barkley RA. Major life activity and life outcomes associated with attention-deficit/hyperactivity disorder. Journal of Clinical Psychiatry. 2002;63:10-15. Accessed July 5, 2022. https://www.psychiatrist.com/wp-content/uploads/2021/02/14847_major-life-activity-health-outcomes-associated-attention.pdf
2. Hervey AS, Epstein JN, Curry JF. Neuropsychology of Adults With Attention-Deficit/Hyperactivity Disorder: A Meta-Analytic Review. Neuropsychology. 2004;18(3):485-503. doi:10.1037/0894-4105.18.3.485
3. The Impact of Attention Deficit Hyperactivity Disorder on the Health of America’s Children.; 2019. Accessed August 1, 2022. https://www.bcbs.com/the-health-of-america/health-index
4. Kessler R. The Prevalence and Correlates of Adult ADHD in the United States: Results From the National Comorbidity Survey Replication. American Journal of Psychiatry. 2006;163(4):716. doi:10.1176/appi.ajp.163.4.716
5. Goodman DW. The Consequences of Attention-Deficit/Hyperactivity Disorder in Adults. Journal of Psychiatric Practice. 2007;13(5):318-327. doi:10.1097/01.pra.0000290670.87236.18
6. Ginsberg Y, Quintero J, Anand E, Casillas M, Upadhyaya HP. Underdiagnosis of Attention-Deficit/Hyperactivity Disorder in Adult Patients. The Primary Care Companion For CNS Disorders. 2014;16(3):1-8. doi:10.4088/PCC.13r01600
7. Adler L, Shaw D, Sitt D, Maya E, Ippolito Morrill M. Issues in the diagnosis and treatment of adult ADHD by primary care physicians. Primary Psychiatry. 2009;16(5):57-63.
8. Polich J. Updating P300: An integrative theory of P3a and P3b. Clinical Neurophysiology. 2007;118(10):2128-2148. doi:10.1016/j.clinph.2007.04.019
9. Itagaki S, Yabe H, Mori Y, Ishikawa H, Takanashi Y, Niwa S ichi. Event-related potentials in patients with adult attention-deficit/hyperactivity disorder versus schizophrenia. Psychiatry Research. 2011;189(2):288-291. doi:10.1016/j.psychres.2011.03.005
10. Micoulaud-Franchi JA, Lopez R, Cermolacce M, et al. Sensory Gating Capacity and Attentional Function in Adults With ADHD: A Preliminary Neurophysiological and Neuropsychological Study. J Atten Disord. 2016;19(May):1087054716629716. doi:10.1177/1087054716629716
11. Wiersema JR, Roeyers H. ERP Correlates of Effortful Control in Children with Varying Levels of ADHD Symptoms. Journal of Abnormal Child Psychology. 2009;37(3):327-336. doi:10.1007/s10802-008-9288-7
12. Lazzaro I, Gordon E, Whitmont S, Meares R, Clarke S. The Modulation of Late Component Event Related Potentials by Pre-Stimulus EEG Theta Activity in ADHD. International Journal of Neuroscience. 2001;107(3-4):247-264. doi:10.3109/00207450109150688
13. Wiersema R, van der Meere J, Antrop I, Roeyers H. State Regulation in Adult ADHD: An Event-related Potential Study. Journal of Clinical and Experimental Neuropsychology. 2006;28(7):1113-1126. doi:10.1080/13803390500212896
