When should a university student be allowed academic accommodations for attention-deficit/hyperactivity disorder? A position statement for a unified procedure for use in Brazil

In higher education, reasonable accommodations are increasingly made for students with a wide range of disabilities. However, rigorous assessment is paramount to ensure these students are supported while preventing ineligible students from gaining unfair advantages. In this context, we sought to identify under which circumstances a university student should be allowed academic accommodation for attention-deficit/hyperactivity disorder (ADHD) and to outline an evidence-based policy for use in Brazil based on the global experience. We reviewed the literature to acquire information on what documents are commonly required by disability services before accommodations for ADHD are provided (including detection of malingering) and scrutinized the eligibility criteria of leading universities worldwide. Finally, renowned experts in the field and national stakeholders were consulted. Despite an exhaustive search, we found no international standard for the assessment of students with ADHD who request academic accommodation; even renowned institutions worldwide differ in their approaches to granting accommodations on the grounds of ADHD. Therefore, we propose a unified set of nationwide criteria for Brazilian universities, which could be generalized internationally. Higher education institutions in Brazil and beyond may benefit from adoption of such criteria.

Association Between Stimulant Treatment and Substance Use Through Adolescence Into Early Adulthood.

Importance: Possible associations between stimulant treatment of attention-deficit/hyperactivity disorder (ADHD) and subsequent substance use remain debated and clinically relevant. Objective: To assess the association of stimulant treatment of ADHD with subsequent substance use using the Multimodal Treatment Study of ADHD (MTA), which provides a unique opportunity to test this association while addressing methodologic complexities (principally, multiple dynamic confounding variables). Design, Setting, and Participants: MTA was a multisite study initiated at 6 sites in the US and 1 in Canada as a 14-month randomized clinical trial of medication and behavior therapy for ADHD but transitioned to a longitudinal observational study. Participants were recruited between 1994 and 1996. Multi-informant assessments included comprehensively assessed demographic, clinical (including substance use), and treatment (including stimulant treatment) variables. Children aged 7 to 9 years with rigorously diagnosed DSM-IV combined-type ADHD were repeatedly assessed until a mean age of 25 years. Analysis took place between April 2018 and February 2023. Exposure: Stimulant treatment of ADHD was measured prospectively from baseline for 16 years (10 assessments) initially using parent report followed by young adult report. Main Outcomes and Measures: Frequency of heavy drinking, marijuana use, daily cigarette smoking, and other substance use were confidentially self-reported with a standardized substance use questionnaire. Results: A total of 579 children (mean [SD] age at baseline, 8.5 [0.8] years; 465 [80%] male) were analyzed. Generalized multilevel linear models showed no evidence that current (B [SE] range, -0.62 [0.55] to 0.34 [0.47]) or prior stimulant treatment (B [SE] range, -0.06 [0.26] to 0.70 [0.37]) or their interaction (B [SE] range, -0.49 [0.70] to 0.86 [0.68]) were associated with substance use after adjusting for developmental trends in substance use and age. Marginal structural models adjusting for dynamic confounding by demographic, clinical, and familial factors revealed no evidence that more years of stimulant treatment (B [SE] range, -0.003 [0.01] to 0.04 [0.02]) or continuous, uninterrupted stimulant treatment (B [SE] range, -0.25 [0.33] to -0.03 [0.10]) were associated with adulthood substance use. Findings were the same for substance use disorder as outcome. Conclusions and Relevance: This study found no evidence that stimulant treatment was associated with increased or decreased risk for later frequent use of alcohol, marijuana, cigarette smoking, or other substances used for adolescents and young adults with childhood ADHD. These findings do not appear to result from other factors that might drive treatment over time and findings held even after considering opposing age-related trends in stimulant treatment and substance use.

Systematic Review and Meta-analysis: Screening Tools for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.

OBJECTIVE: This systematic review and meta-analysis aimed to determine the accuracies of a broad range of screening tools for attention-deficit/hyperactivity disorder (ADHD) in children and adolescents, and to compare the diagnostic accuracy of tools between population-based and clinical/high-risk samples, and across reporters. METHOD: MEDLINE, PsycINFO, EMBASE, and PubMed were searched up until February 20, 2020, with no language restrictions. Studies reporting diagnostic accuracy of a screening tool against a diagnosis of ADHD in children and adolescents <18 years of age were eligible for inclusion. Meta-analyses were undertaken to provide pooled estimates of the area under the curve (AUC), and sensitivity and specificity of groups of measures. RESULTS: A total of 75 studies published between 1985 and 2021 reporting on 41 screening tools that were grouped into 4 categories (Achenbach System of Empirically Based Assessment [ASEBA], DSM-IV symptom scales, SDQ, and Other Scales) were retained. The pooled AUC for studies using a combined ADHD symptoms score was 0.82 (95% CI = 0.78-0.86), although this varied considerably across reporters (0.67-0.92) and populations (CI = 0.60-0.95). None of the measures met minimal standards for acceptable sensitivity (0.8) and specificity (0.8). CONCLUSION: Most tools have excellent overall diagnostic accuracy as indicated by the AUC. However, a single measure completed by a single reporter is unlikely to have sufficient sensitivity and specificity for clinical use or population screening.

Gestational Smoking and Hypertension as Predictors of Working Memory Functioning in Childhood Attention-Deficit/Hyperactivity Disorder.

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental condition affecting between 5 and 8% of all children and adolescents, characterized by impairing levels of inattention, hyperactivity, and impulsivity. Existing cognitive models of ADHD have placed working memory (WM) deficits at the core of ADHD and suggest that primary WM deficits may also underlie the additional deficits associated with the condition. Although not all children with ADHD show WM deficits, those with such deficits have been found to have worse functional outcomes when compared to their diagnosed peers with typical WM functioning. Even so, contributors to the variability of impaired WM functioning seen within this population remain unknown. In the present study, we examined the association between two known prenatal and perinatal risk factors for impaired cognitive functioning - gestational smoking and hypertension - in three independent samples of children and adolescents with ADHD (samples varied with respect to sample size and WM measurement procedures). Contrary to hypotheses and existing literature, presence of high blood pressure during pregnancy was unexpectedly found to be a positive predictor of offspring WM capacity in one of three samples (a sample of all girls with ADHD). Implications and considerations for future research are discussed.

Early substance use in the pathway from childhood attention-deficit/hyperactivity disorder (ADHD) to young adult substance use: Evidence of statistical mediation and substance specificity.

This study tested whether early and developmentally atypical substance use mediates risk for adult substance use among children with attention-deficit/hyperactivity disorder (ADHD), and whether that risk is substance-specific. Participants were children with ADHD previously enrolled in a randomized controlled trial (RCT), and a demographically similar non-ADHD group, assessed at 2 through 16 years after the original RCT baseline. Self-reports of heavy drinking, marijuana use, daily smoking, and other illicit drug use were collected at follow-ups to establish atypically early and frequent use. Models estimated statistically mediated effects of childhood ADHD on adult substance use via early substance involvement, with planned comparisons to evaluate substance specificity. Results supported the mediation hypothesis, showing that childhood ADHD was associated with more frequent adult substance use via early substance involvement for marijuana, cigarettes, illicit drugs, and to a lesser extent, alcohol. Mediation was not escalated by comorbid childhood conduct disorder or oppositional defiant disorder except for early use of nonmarijuana illicit drugs. Substance-specificity in the mediational pathway was largely absent except for cigarette use, where ADHD-related early smoking most strongly predicted adult daily smoking. Findings from this study provide new evidence that atypically early substance use associated with childhood ADHD signals important cross-drug vulnerability by early adulthood, but cigarette use at a young age is especially associated with increased risk for habitual (daily) smoking specifically. Efforts to prevent, delay, or reduce substance experimentation should occur early and focus on factors relevant to multiple drugs of abuse in this at-risk population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Social status strategy in early adolescent girls: Testosterone and value-based decision making.

There has been strong interest, spanning several disciplines, in understanding adolescence as a developmental period of increased risk-taking behavior. Our goals focus on one line of investigation within this larger developmental risk framework. Specifically, we examined levels of pubertal hormones in girls in relation to their willingness to take greater financial risks to gain social status. To this end, we tested the hypothesis that higher levels of testosterone during the ages of pubertal maturation are associated with a greater willingness to sacrifice money for social admiration. Sixty-three girls ages 10-14 (Mage=12.74) participated in laboratory measures and completed at-home saliva sample collection. The Pubertal Development Scale (PDS) and basal hormone levels (testosterone, estradiol, DHEA) measured pubertal maturation. We made use of a developmentally appropriate version of an Auction Task in which adolescents could take financial risks in order to gain socially motivated outcomes (social status). PDS and testosterone were each associated with overall levels of financial risk taking over the course of the Auction Task. In hierarchical models, PDS and testosterone were predictors of the slope of overbidding over the course of the task. Results provide evidence for the role of testosterone and pubertal maturation in girls' motivations to engage in costly decision making in order to gain social status. Findings contribute to our understanding of the developmental underpinnings of some interesting aspects of adolescent risk behavior.

Prenatal Smoke Exposure Predicts Hyperactive/Impulsive but Not Inattentive ADHD Symptoms in Adolescent and Young Adult Girls.

We examined the longitudinal associations between prenatal tobacco smoke exposure (PSE) and attention-deficit hyperactivity disorder (ADHD) symptom domains in adolescence and young adulthood. A sample of girls with ADHD combined presentation (N=93), ADHD predominantly inattentive presentation (N=47), and matched comparisons (N= 88) was assessed prospectively. Symptoms of hyperactivity/impulsivity (HI), inattention (IA), and oppositionality (oppositional defiant disorder) were measured via multiple informants 5 (M age =14 years; retention rate =92%) and 10 years (M age =20 years; retention rate =95%) following childhood ascertainment. PSE was captured via maternal self-report. We used linear regressions to examine the prediction from PSE to both HI and IA in adolescence and early adulthood after stringent control of relevant confounding variables. PSE significantly predicted HI during adolescence and young adulthood across multiple informants but did not predict IA at either wave. Symptoms of HI may have partial etiological independence from IA symptoms.

The impact of ADHD persistence, recent cannabis use, and age of regular cannabis use onset on subcortical volume and cortical thickness in young adults.

BACKGROUND: Both Attention Deficit Hyperactivity Disorder (ADHD) and chronic cannabis (CAN) use have been associated with brain structural abnormalities, although little is known about the effects of both in young adults. METHODS: Participants included: those with a childhood diagnosis of ADHD who were CAN users (ADHD_CAN; n=37) and non-users (NU) (ADHD_NU; n=44) and a local normative comparison group (LNCG) who did (LNCG_CAN; n=18) and did not (LNCG_NU; n=21) use CAN regularly. Multiple regressions and MANCOVAs were used to examine the independent and interactive effects of a childhood ADHD diagnosis and CAN group status and age of onset (CUO) on subcortical volumes and cortical thickness. RESULTS: After controlling for age, gender, total brain volume, nicotine use, and past-year binge drinking, childhood ADHD diagnosis did not predict brain structure; however, persistence of ADHD was associated with smaller left precentral/postcentral cortical thickness. Compared to all non-users, CAN users had decreased cortical thickness in right hemisphere superior frontal sulcus, anterior cingulate, and isthmus of cingulate gyrus regions and left hemisphere superior frontal sulcus and precentral gyrus regions. Early cannabis use age of onset (CUO) in those with ADHD predicted greater right hemisphere superior frontal and postcentral cortical thickness. DISCUSSION: Young adults with persistent ADHD demonstrated brain structure abnormalities in regions underlying motor control, working memory and inhibitory control. Further, CAN use was linked with abnormal brain structure in regions with high concentrations of cannabinoid receptors. Additional large-scale longitudinal studies are needed to clarify how substance use impacts neurodevelopment in youth with and without ADHD.

Co-occurring symptoms of attention deficit hyperactivity disorder (ADHD) in a population-based sample of adolescents screened for depression.

BACKGROUND: Depression is common in adolescents, with a gender bias towards girls. Symptoms associated with attention deficit hyperactivity disorder (ADHD) tend to co-occur in depressed adolescents. This may be related to common features between the two symptom domains, but co-occurring ADHD symptoms may also inflate the severity of depression. The present study investigates the frequency and influence of ADHD symptoms co-occurring with depression in a gender balanced population-based sample of Norwegian adolescents. METHODS: A sample of 9614 adolescents (16-19 years) completed a questionnaire including the short version of the Mood and Feelings Questionnaire (sMFQ) and the Adult ADHD Self-Report Scale (ASRS), with items reflecting symptoms associated with depression and ADHD, respectively. The sMFQ sum score was used as a proxy for severity of depression, and adolescents with a score equal to or above the 90th percentile were defined as depressed. A high response on any of the ASRS items was used to define the presence of an ADHD symptom, and the number of high scores was used to indicate severity. RESULTS: ADHD symptoms were frequently reported by the adolescents, with a higher frequency in girls than in boys. The gender differences were, however, minor when the analysis was restricted to the adolescents defined as depressed. Each severe symptom reported on the ASRS contributed significantly to increase the sum score on the sMFQ, and more than 20 % of the adolescents defined as depressed reported six or more symptoms within the ASRS inattention subscale. CONCLUSIONS: The results emphasize the importance of screening for symptoms associated with ADHD when assessing adolescents presenting symptoms indicating depression. Although girls reported higher frequency of symptoms within both domains, the gender bias was dependent on the overall symptom severity. Awareness of co-occurrence of symptoms and gender biases are of importance for both clinical work and future research on mental health and service use in adolescence.

Impact of ADHD and cannabis use on executive functioning in young adults.

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) and cannabis use are each associated with specific cognitive deficits. Few studies have investigated the neurocognitive profile of individuals with both an ADHD history and regular cannabis use. The greatest cognitive impairment is expected among ADHD Cannabis Users compared to those with ADHD-only, Cannabis use-only, or neither. METHODS: Young adults (24.2 ± 1.2 years) with a childhood ADHD diagnosis who did (n=42) and did not (n=45) report past year ≥ monthly cannabis use were compared on neuropsychological measures to a local normative comparison group (LNCG) who did (n=20) and did not (n=21) report past year regular cannabis use. Age, gender, IQ, socioeconomic status, and past year alcohol and smoking were statistical covariates. RESULTS: The ADHD group performed worse than LNCG on verbal memory, processing speed, cognitive interference, decision-making, working memory, and response inhibition. No significant effects for cannabis use emerged. Interactions between ADHD and cannabis were non-significant. Exploratory analyses revealed that individuals who began using cannabis regularly before age 16 (n=27) may have poorer executive functioning (i.e., decision-making, working memory, and response inhibition), than users who began later (n=32); replication is warranted with a larger sample. CONCLUSIONS: A childhood diagnosis of ADHD, but not cannabis use in adulthood, was associated with executive dysfunction. Earlier initiation of cannabis use may be linked to poor cognitive outcomes and a significantly greater proportion of the ADHD group began using cannabis before age 16. Regular cannabis use starting after age 16 may not be sufficient to aggravate longstanding cognitive deficits characteristic of ADHD.

Perinatal problems and psychiatric comorbidity among children with ADHD.

Among two large, independent samples of girls with attention-deficit/hyperactivity disorder (ADHD), we examined associations between specific (maternal gestational smoking and drug use, early labor, low birth weight, and infant breathing problems at birth) and cumulative prenatal and perinatal risk factors and psychiatric comorbidity during childhood. Data from the (a) Multimodal Treatment Study of Children with ADHD, a randomized clinical trial with 579 children aged 7 to 9.9 years with combined-type ADHD, and the (b) Berkeley Girls ADHD Longitudinal Sample, a naturalistic study of 140 girls with ADHD (93 combined-type and 47 inattentive-type) who were first seen when they were 6 to 12 years old, were analyzed separately. In each sample, perinatal risk factors were assessed retrospectively by maternal report, and current childhood psychiatric comorbidity was assessed using maternal report on the Diagnostic Interview Schedule for Children. Consistent findings across these two studies show that infant breathing problems, early labor, and total perinatal problems predicted childhood comorbid depression but not comorbid anxiety or externalizing disorders. These associations remained significant, in both samples, with control of family socioeconomic status (SES) and maternal symptoms of ADHD and depression. Results attenuated slightly with control of the number of child comorbidities plus SES and maternal symptoms. Accumulating evidence suggests that perinatal risk factors are important precursors of childhood psychiatric comorbidity and that the association between these risk factors and detrimental psychiatric outcomes cannot be explained by maternal psychiatric symptoms or SES during childhood.

Peer rejection and friendships in children with Attention-Deficit/Hyperactivity Disorder: contributions to long-term outcomes.

Even after evidence-based treatment, Attention-Deficit/Hyperactivity Disorder (ADHD) is associated with poor long-term outcomes. These outcomes may be partly explained by difficulties in peer functioning, which are common among children with ADHD and which do not respond optimally to standard ADHD treatments. We examined whether peer rejection and lack of dyadic friendships experienced by children with ADHD after treatment contribute to long-term emotional and behavioral problems and global impairment, and whether having a reciprocal friend buffers the negative effects of peer rejection. Children with Combined type ADHD (N = 300) enrolled in the Multimodal Treatment Study of Children with ADHD (MTA) were followed for 8 years. Peer rejection and dyadic friendships were measured with sociometric assessments after the active treatment period (14 or 24 months after baseline; M ages 9.7 and 10.5 years, respectively). Outcomes included delinquency, depression, anxiety, substance use, and general impairment at 6 and 8 years after baseline (Mean ages 14.9 and 16.8 years, respectively). With inclusion of key covariates, including demographics, symptoms of ADHD, ODD, and CD, and level of the outcome variable at 24 months, peer rejection predicted cigarette smoking, delinquency, anxiety, and global impairment at 6 years and global impairment at 8 years after baseline. Having a reciprocal friend was not, however, uniquely predictive of any outcomes and did not reduce the negative effects of peer rejection. Evaluating and addressing peer rejection in treatment planning may be necessary to improve long-term outcomes in children with ADHD.

The role of children's ethnicity in the relationship between teacher ratings of attention-deficit/hyperactivity disorder and observed classroom behavior.

Significant ethnic differences have been consistently documented on attention-deficit/hyperactivity disorder (ADHD) teacher rating scales. Whether these ethnic differences result from a teacher rating bias or reflect actual classroom behavior patterns is unknown. Ethnic differences between Caucasian and African American (AA) elementary schoolchildren on teacher ratings and codings of observed classroom behavior were examined with latent variables. In structural equation models, correlations between teacher ratings and observed classroom behavior suggested nonbiased teacher ratings of AA schoolchildren with diagnosed ADHD. Ethnic differences were documented for both teacher ratings of ADHD and classroom behavior. Differences in classroom behavior were attenuated when the behavior of an average child in the classroom was taken into account. Multiple explanations for this pattern of results are discussed.