By Gloria Arminio Berlinski, MS
Reviewed by Nicole Foubister, MD, Assistant Clinical Professor of Child & Adolescent Psychiatry and Psychiatry, New York University School of Medicine
Strong links exist between addictive use of digital technology and underlying psychiatric disorders, and mounting evidence indicates that attention deficit hyperactivity disorder (ADHD) occurs concurrently with excessive video gaming as well as Internet addiction.1 Newly published studies have specifically explored the association of ADHD symptoms with electronic screen time exposure, internet gaming disorder, and addictive use of social media among university students and older adults.1-3
Higher education students are daily users of electronic devices for both academic activities and recreational time. A researcher at the University of Bordeaux in France, Ilaria Montagni PhD, was the lead author of a 2016 article that described the potential link between high levels of screen time and self-perceived inattention and hyperactivity in graduate students. According to Dr. Montagni, these young adults “spend an average of three hours per day on at least one digital device and they’re frequently exposed to 2 screens, such as laptops and smartphones, at the same time.”
In their cross-sectional study, Dr. Montagni and fellow researchers asked approximately 4,800 French graduate students to self-report their time spent using a smartphone and computer or tablet for working, studying, searching the Internet, social networking, playing video games, or watching television programs or movies. Global information on inattention and hyperactivity over the previous six month period was ascertained through a questionnaire based on the Adult ADHD Self-Report Scale (ASRS-Version 1.1).2
Multivariable ordinal logistic regression analysis showed that increasing screen time exposure was significantly associated with higher levels of self-perceived attention problems and hyperactivity. The authors noted that the correlation seemed to be stronger for the attention deficit domain versus the hyperactivity domain.2 The risk of self-reported ADHD features “steadily increased with increasing levels of screen time exposure categories,” says Dr. Montagni. “As our study was cross-sectional, we cannot rule out that inattention/hyperactivity leads to increased screen time use, but it appears less likely,” she notes.
As to the next steps in research, Dr. Montagni states that “to better understand whether reduction of screen time use would positively affect attention problems and hyperactivity in students.” This is especially important considering the increased diagnosis of previously unrecognized ADHD among college students, she and fellow researchers point out in their report.2 Dr. Montagni and colleagues also call attention to the need for effective interventions and guidelines to promote the healthy use of digital technology among university students.
An article in press by Yen and fellow researchers presents cross-sectional findings on the relationships among ADHD, Internet gaming disorder (IGD), and their common symptoms of impulsivity and hostility.3 After fulfilling recruitment criteria, students from university campuses in Taiwan underwent diagnostic interviews conducted by a psychiatrist based on the DSM-5 IGD criteria and DSM-IV-TR ADHD criteria, and completed the Dickman’s Impulsivity Inventory and Buss-Durkee Hostility Inventory. Study participants included 87 individuals with IGD and 87 controls with no history of IGD, who were matched for gender, educational level, and age.3
Adult ADHD was identified in 34 (39%) IGD-diagnosed participants versus four (5%) individuals in the control group.3 ADHD was found to be associated with IGD, and symptoms of impulsivity and hostility were observed to mediate this association. Yen and fellow authors noted that because young adults with ADHD may use gaming for a sense of achievement and pleasure to escape from their psychosocial difficulties, they may be more susceptible to IGD. Furthermore, they point out that “young adults with both ADHD and IGD had higher IGD severity than those with only IGD did, suggesting that the comorbid IGD and ADHD among young adults result in a vicious cycle.”
Another newly published cross-sectional study, conducted by Schou Andreassen and colleagues, examined whether symptoms of comorbid psychiatric disorders, including ADHD, affect the variance in addictive use of modern online technologies, namely video games and social media. The authors indicate that their investigation is the first to evaluate the relationship between addictive online social networking and ADHD.
Approximately 23,500 adults from the Norwegian population who completed an online cross-sectional survey that focused on several addictive behaviors subsequently responded to questionnaires of the Bergen Social Media Addiction Scale and the Game Addiction Scale to evaluate symptoms of digital technology addiction. The ASRS-Version 1.1 was used to assess underlying symptoms of ADHD. Participants ranged in age from 16 to 88 years, with the majority between the ages of 16 and 30 years (41%) and 31 and 45 years (35%).1
Overall, findings suggested that symptoms of psychiatric disorders in adults were correlated with an individual’s addictive social networking and video gaming, after controlling for age, sex, and educational and marital status.1 Results for ADHD, in particular, showed that this disorder explained more of the variance in addictive use of social media than in video games. The authors speculate that features (e.g. beeping, constant updates) of mobile phones, which are typically used for social networking, make individuals who are easily distracted or impulsive more susceptible to excessive or compulsive use of social media.1
Researchers from all three studies described here addressed the limitation of a cross-sectional study design, which prevents any definitive interpretation of causality and directionality of statistically significant relationships.1-2 Schou Andreassen and colleagues make the point that “the identified relationships may very well be the other way around or go in both directions. This should be further investigated using longitudinal study designs.” Investigators emphasize that intervention measures are needed to address the addictive use of technology in adults.1-3
Originally Published: 09/12/2016
By Nancy Gadol
Reviewed by Nicole Foubister, MD, Assistant Clinical Professor of Child & Adolescent Psychiatry and Psychiatry, New York University School of Medicine
Attention deficit hyperactivity disorder (ADHD) can be a tough diagnosis in patients of any age. Its symptoms are often similar to those of several other conditions, including anxiety or other mood disorders.1 ADHD was previously considered to be a childhood disorder, partly because adults were never even asked about symptoms related to the condition. Major US surveys, including the Epidemiologic Catchment Area Study, whose results were published in 1991, and the National Comorbidity Survey of 1994 did not include questions on ADHD symptoms in adults. 2 It is now clear that ADHD can persist into older ages in many patients, affecting functionality in many aspects of life that may lead to interpersonal problems, employment and financial difficulties3 and negatively affecting quality of life by impairing professional, social and emotional well-being. 4
Interest in adult ADHD continues to rise, and an increasing number of adults over age 50 are seeking assessment for the condition for the first time. Most studies on adult ADHD have focused on young adults, and optimal criteria for the diagnosis of ADHD and methods of treatment in older adults have not been systematically researched. However that doesn’t mean that making an accurate diagnosis of ADHD in adults is not worth the time and effort.
"Most adults that I have worked with report a great sense of relief at finally being diagnosed with ADHD. Understanding ADHD has helped my patients put into context decades of frustration with themselves and often with their place in the world,” says Joanna Bornstein, MD, a psychiatrist in private practice in San Francisco who specializes in the diagnosis and treatment of adults with ADHD.
“With treatment, many not only report an improved ability to focus and complete tasks, but, more notably, report a profound shift in their understanding and sense of themselves. For most, this leads to a significant improvement in their quality of life. Refining our tools to identify and treat ADHD in older adults could allow a wider range of patients to find a similar sense of relief, self-understanding and healing,” continues Dr. Bornstein.
Two recent reviews attempt to better define ADHD in older adults by examining studies to date on the prevalence, clinical presentation, diagnosis, and treatment of ADHD in individuals over the age of 50 years. 1,5
Many adults over age 50 who received an ADHD diagnosis as adults were not diagnosed as children, in part because the diagnostic landscape was so different decades ago. Even younger adults may have been overlooked as children, as suggested by findings that 75% of adults in the 18-44-year age range with ADHD were not diagnosed during childhood. 5
The data available from recent studies assessing individuals in various age ranges have found prevalence rates of ADHD in adults ranging from 1% to 6.2%.1 A Dutch study of 1,419 participants aged 55 to 85 years showed that adults 60 to 70 years old reported more ADHD symptoms (4.0%) than adults 71 to 94 years old (1.1%), using the Diagnostic Interview ADHD in adults. 6 This decline in prevalence with age was also noted in the Australian Personality and Total Health (PATH) Through Life Project in which older-age adults (68 to 74 years) reported significantly fewer ADHD symptoms than did middle-aged adults (48 to 52 years), as measured by the World Health Organization adult ADHD Self-Report Scale. 3
Clinical presentation and diagnosis
ADHD may present in one of three ways. Affected individuals may have inattentive type, hyperactive and impulsive type or a combination of both types. In addition, ADHD can present differently over development. For example, motor hyperactivity in children with ADHD can appear as an “inner” hyperactivity in adults, with characteristics such as restlessness, inability to relax, or excessive fidgeting and talking. Impulsivity in adults may be expressed as angry outbursts or making decisions without thinking while inattention may appear as disorganization, forgetfulness or inability to plan and complete tasks. 1
There is no specific test required to diagnose ADHD as part of the DSM-V criteria of 2013. Clinicians use the patients’ self-assessment, rating scales, family observations, and medical or school records to determine if diagnostic criteria are fulfilled. Normal aging, dementia and mild cognitive impairment can exhibit the same attention, behavior, memory and executive function deficits as those of ADHD and need to be considered in the differential diagnosis. Comorbid disorders most often associated with adult ADHD include anxiety disorders, mood disorders, antisocial personality disorder, and substance abuse disorders. 1
ADHD is often a chronic and persistent disorder contributing to symptoms in older adults. Pharmacotherapy and psychotherapy should be adjusted to minimize symptoms and maximize and individual’s capacities. Environmental and behavioral supports are also very useful in optimizing function. Longitudinal studies of ADHD adults into older age may clarify optimal criteria for identifying this condition. David W. Goodman, MD, FAPA, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine and the author of one of the reviews covered in this report succinctly explains:
"It is becoming evident that ADHD is a lifelong disorder extending into later adult years. Given the paucity of research, this will be the next clinical frontier for ADHD.”
Originally Published: 02/24/2016
Study suggests CPAP benefit in epilepsy patients with OSA
by Kristina Fiore, Deputy Managing Editor, MedPage Today December 03, 2017
Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
WASHINGTON -- Treating obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) may lower the risk of seizures in patients with epilepsy, researchers reported here.
In a single-center study of patients treated at the Cleveland Clinic, a larger proportion of epilepsy patients with OSA who had CPAP therapy reported at least a 50% reduction in seizures from baseline at 1 year compared with those who weren't treated, and with those who didn't have OSA (63% versus 14% and 44%), according to Thapanee Somboon, MD, of the Cleveland Clinic, and colleagues, in a poster presentation at the American Epilepsy Society meeting.
Somboon said few clinicians screen their epilepsy patients for this condition. "Neurologists don't often ask their epilepsy patients about sleep, but sleep affects everything," she told MedPage Today.
At the same time, "many people with epilepsy don't realize they have sleep apnea," she noted. "Being diagnosed is the first step towards getting effective treatment and potentially decreasing the risk of seizures."
The study results suggest that it's "important to screen every epilepsy patient [for OSA] with just a small, simple question: do you snore at night? Do you have apnea at night?" If the answer is yes, a neurologist can order polysomnography, and depending on the results and recommendations, can prescribe CPAP, she said.
In patients with epilepsy, a lack of quality sleep is tied to an increased risk for seizures. Antiepileptic drugs (AEDs) may also increase the risk of OSA, because the drugs relax upper respiratory muscles and may cause weight gain, another risk factor for OSA, the researchers said.
Somboon's group looked at records for 197 patients with epilepsy who'd had polysomnography for some sleep complaint at the Cleveland Clinic from 1997 to 2015. A total of 122 of them had OSA, while 75 did not. Of those with OSA, 73 used CPAP and 49 did not.
At baseline, those without OSA were younger, more likely to be female, and had a lower BMI than those who used CPAP and those who had untreated OSA.
In addition to the finding that more epilepsy patients with treated OSA had at least a 50% reduction in seizures from baseline, more of them also achieved "treatment success." defined as no seizure activity continued from baseline, or at least a 50% reduction from baseline in seizure activity.
This outcome occurred in 85% of those who were treated, in 55% of those who were untreated, and 65% of those who didn't have OSA (P<0.001 and P=0.007, respectively), she reported.
After adjusting for baseline seizure freedom and AED standardized dose, CPAP-treated OSA patients remained more likely to achieve treatment success than untreated OSA (OR 9.58, 95% CI 3.05 to 30.2, P<0.001) and those without OSA (OR 3.66, 95% CI 1.39 to 9.63, P=0.009), she said.
Although Somboon's group didn't see any statistically significant differences between groups at 3 or 5 years, she said there was a trend in favor of CPAP treatment. "We can't talk about significance because the number of patients is too small, since we lost a lot of them due to the retrospective nature of the study," she explained.
She said further studies that are ongoing have looked at CPAP adherence, and preliminary results show that patients who achieve treatment success have very good adherence.
Somboon noted that in addition to CPAP, there are several other treatments for OSA, including weight loss, taking a decongestant, wearing a special mouth guard to bed, and having surgery. CPAP is the most effective treatment for people with moderate to severe OSA, she said.