Authors: I. Graffeo, R. Kumar, D. O'Neill, E. O'Mahony, G. McCarthy, O. Mulligan, D. Adamis

1. Epidemiology of Attention Deficit
Hyperactive symptoms in the mental health
outpatient clinics attendants of
Sligo/Leitrim HSE
12/11/2013

2. Background
ADHD is a mental disorder characterized by either significant difficulties of
inattention or hyperactivity and impulsiveness or a combination of the two.
According to the DSM IV TR, symptoms emerge before 7 years of age,
affecting about 3 to 5% of children globally (Nair at al, 2006).
It is often a chronic disorder (Van Cleave et al, 2008) with 30 to 50 percent of
those individuals diagnosed in childhood continuing to have symptoms
into adulthood (Bàlint at al, 2008).

3. Background
It is estimated that between 2 and 5 percent of adults in general population
live with ADHD (Kooij et al, 2010).
A number of studies (eg Valdizan et al, 2009; Biederman et al, 2000; Langberg
et al, 2008) have found that symptoms of hyperactivity and impulsivity decline
with age, although they persist in some cases and sometimes are the presenting
concerns in adult ADHD, whereas deficits in attention persist and become
more varied in adult cases.

4. Background
Manifestations that characteristically appear in adults are difficulty in
concentrating, poorer memory and short-term memory, disorganization,
difficulties with self-discipline, impulsiveness, low self-esteem, mental
restlessness, frustration and limited social skills.
A number of studies have found that many children with ADHD go
unrecognized and may present in adulthood for the first time (Asherson et al
2007, Kooij et al 2010).

5. Background
The more common symptoms seen during the childhood, such as hyperactivity and
impulsivity, can disappear during the adulthood and they could be replaced by
restlessness, inattention, disorganization, or impaired executive functioning ((Kooij et
al 2010).
Several research found that ADHD is significantly comorbid with a wide range of
other DSM-IV disorders (Jensen at al 1997, 2004 National Comorbidity Survey US,
Kessler at al 2006): like Mood Disorders, Anxiety Disorders, Substance Use Disorders,
Impulse Control Disorders: Intermittent Explosive Disorder, (Biederman et al, 1991;
Pliszka, 1998), Personality disorders, (Kernberg and Yeomans, 2013) and eating
disorders (Fernández-Aranda et al, 2013; Cortese et al, 2013).

6. Background
Undiagnosed or misdiagnosed ADHD can result in ineffective pharmacological
and non-pharmacological treatments which may not improve ADHD-related
symptoms.
In addition there is often a substantial psychosocial and functional decline
associated with undiagnosed and untreated ADHD (Able et al, 2007).

7. Background
o DSM V criteria for ADHD:
People with ADHD show a persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes with functioning or development.
Inattention: Six or more symptoms of inattention for children up to age 16, or
five or more for adolescents 17 and older and adults; symptoms of inattention
have been present for at least 6 months, and they are inappropriate for
developmental level.

8. Background
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Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses
focus, side-tracked).
 Often has trouble organizing tasks and activities.
 Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork
or homework).
 Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork,
eyeglasses, mobile telephones).
 Is often easily distracted
 Is often forgetful in daily activities.

9. Background
Hyperactivity and Impulsivity: Six or more symptoms of hyperactivityimpulsivity for children up to age 16, or five or more for adolescents 17 and
older and adults; symptoms of hyperactivity-impulsivity have been present for
at least 6 months to an extent that is disruptive and inappropriate for the
person’s developmental level.

10. Background
 Often fidgets with or taps hands or feet, or squirms in seat.
 Often leaves seat in situations when remaining seated is expected.
 Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be
limited to feeling restless).
 Often unable to play or take part in leisure activities quietly.
 Is often "on the go" acting as if "driven by a motor".
 Often talks excessively.
 Often blurts out an answer before a question has been completed.
 Often has trouble waiting his/her turn.
 Often interrupts or intrudes on others (e.g., butts into conversations or games)

11. Background
In addition, the following conditions must be met:
 Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
 Several symptoms are present in two or more setting, (e.g., at home, school or work; with
friends or relatives; in other activities).
 There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
school, or work functioning.
 The symptoms do not happen only during the course of schizophrenia or another psychotic
disorder. The symptoms are not better explained by another mental disorder (e.g. Mood
Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder)

12. Background
Based on the types of symptoms, three kinds (presentations) of ADHD can
occur:
1. Combined Presentation: if enough symptoms of both criteria inattention and
hyperactivity-impulsivity were present for the past 6 months
2. Predominantly Inattentive Presentation: if enough symptoms of inattention,
but not hyperactivity-impulsivity, were present for the past six months
3. Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of
hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as
well.

13. Background
Aims of the study:
o To find out the prevalence of ADHD in those adults who attend the mental
health services in Sligo/Leitrim County, Republic of Ireland.
o To understand how many cases of ADHD are undiagnosed in the specific
adult population.
o To investigate what kind of comorbid illnesses with ADHD are present in
this population.

14. Methods
Inclusion of participants:
All patients using Out-Patient Mental Health Services in Sligo/Leitrim County, aged 18-65,
having a minimum of 5 years of education, able to speak, read and write in English language.
Exclusion of participants:
Patients under 18 years of age; patients over 65 years of age; patients admitted in in-patient
units; illiterate patients and/or not able to speak, read and write in English language.
Patients with severe learning disabilities and patients with severe brain injuries and with
amnesic disorders have been excluded.

15. Design
The proposed study will have two phases:
In the first phase all the people who attend the outpatient clinics and day hospital of
the adult mental health services of Sligo/Leitrim County and are eligible for inclusion
have been approached by the researchers for screening tests.
In a second phase those who will be positive in the screening tests will be invited for
more specific tests in a clinic which will be created for this purpose in agreement with
their consultant.

16. Design
First Phase:
Psychiatric patients attending Mental Health Services at Sligo County
(estimated around 2000 attendants) are being contacted in their outpatient
appointment and the purpose of the study is being explained to them by the
researcher.
Those ones who are accepting to take part in the survey are completing the
following two self report questionnaires:

17. Design
First Phase:
o Adult ADHD Self-Report Scale (ASRS): DSM-IV based, 18 questions
regarding symptoms of adult ADHD.
Sensitivity 96.7%
Negative predictive value 96.5%
Specificity 91.1%
Kappa 0.88
Positive predictive value 91.6%
(Kessler et al, 2007; Ramos-Quiroga et al, 2009; Zohar et al, 2010; Ji-Hae Kim et al, 2013)

18. Design
First Phase:
o Wender Utah Rating Scale (WURS): 61 questions answered by the adult
patients recalling their childhood.
Test-retest r = .96
Inter-rater reliability r = .75
Cronbach's alpha = 0.78
(Rossini et al, 1995; Fossati et al, 2001; Wierzbicki, 2005; Marchant et al, 2013)

19. Design
First Phase:
o Demographics: chart number, name, age, gender, marital status, years of
education, highest level of qualification achieved, living circumstances,
housing status, current employment, main occupation.

20. Design
Second Phase:
After this first screening process, any participant who have scored positive in
both of the two scales will be contacted by letter to attend a special clinic
where further testing will happen.
The scales/measurements that will be used at this second stage are:

21. Design
Second Phase:
o Conners’ Adult ADHD Diagnostic Interview for DSM-IV (CAADID): appropriate for
18 and older, divided in 2 parts (Part I – screening interview - and Part II – the only one
administered).
Sensitivity 98.86%
Negative predictive value 94.87%
Specificity 67.68%
Diagnostic precision 91.46%
Positive predictive value 90.77%
Kappa coefficient concordance between the clinical diagnosis and the CAADID is 0.88
(Sparrow et al, 2011; Ramos-Quiroga et al, 2012)

22. Design
Second Phase:
o Mini International Neuropsychiatric Interview (MINI): short
structured diagnostic interview for psychiatric disorders.
Good kappa coefficient, sensitivity, specificity for all diagnoses, inter-rater
and test-retest reliability.
(Lecrubier et al, 1997; Sheehan at al, 1998)

23. Design
Second Phase:
o Millon Clinical Multiaxial Inventory - III (MCMI-III): measure of 24
personality disorders and clinical syndromes for adults undergoing
psychological or psychiatric assessment or treatment, 175 true-false
questions; after the test is scored, it produces 29 scales (24 personality and
clinical scales and 5 scales used to verify how the person approached and
took the test).
Reliability r = .78
(Hsu, 2002; Blais et al, 2003)

24. Design
Second Phase:
o Global Assessment of Functioning (GAF) Scale: present in DSM IV,
single rating scale for evaluating a person’s psychological, social and
occupational functioning on a hypothetical continuum of mental healthillness and ranges from 1, representing the hypothetically sickest individual,
to 100, representing the hypothetically healthiest; divided into 10 equal parts.
Reliability r = .78
(Jones et al, 1995; Startup et al, 2002; Aas, 2010)

25. Design
Second Phase:
Files also will be inspected for a recorded diagnosis of ADHD.

26. Consent
First Phase: written information, verbal consent.
Second Phase: written information, written consent.
For those who were screening positive and the symptoms of ADHD have been
confirmed with detailed testing their consultant will be informed if the
participant agrees to that.
No results of the tests/questionnaires or additional diagnosis will be given
directly to the participants.

27. Analysis of the data
The collected data are being anonymized and are being entered in a spreadsheet
software for analysis.
The first research question (point prevalence) will be answered as a ratio or
percentage (number of cases divided by total screened population) multiplied by a
hundred.
The second research question (undiagnosed cases of ADHD) will be answered as
percentage and in absolute numbers. This will be happen by reviewing the participants’
files for any reference in previously diagnosed ADHD.
The third research question (comorbidity) will be investigated with DSM-IV
diagnoses Axis I (psychiatric diagnoses from MINI scale) and Axis II (personality
disorders from MCMI-III).

28. Analysis of the data
Secondary analyses of the data:
o Agreement between the scales WURS and ASRS calculated with the Cohen’s
kappa coefficient.

29. Analysis of the data
o 300 consecutive patients analysed:
242 included (80.7%)
58 excluded (19.3%)
o Reason for exclusion:
36 refused (12%)
17 over 65 (5.7%)
5 learning disability (1.6%)

30. Analysis of the data
Statistics regarding the included subjects (242)
o Age: calculated on 222 pts (20 missing)
minimum 18
maximum 65
mean 41.20
std. deviation 12.445

31. Analysis of the data
o Gender: calculated on 241 pts (1 missing)
males 120 (49.8%)
females 121 (50.2%)

32. Analysis of the data
o Highest level of education achieved: calculated on 235 pts (7 missing)
junior certificate 31 (13.2%)
postgraduate degree 17 (7.2%)
leaving certificate 68 (28.9%)
other 56 (23.8%)
university degree 26 (11.1%)
none 11 (4.7%)
vocational diploma 17 (7.2%)
IT degree 9 (3.8%)

33. Analysis of the data
o Living Circumstances: calculated on 241 pts (1 missing)
alone 69 (28.6%)
with your own family 90 (37.3%)
with parents 46 (19.1%)
with others 36 (14.9%)

34. Analysis of the data
o Housing status: calculated on 215 pts (27 missing)
owner 103 (47.9%)
rented 112 (52.1%)

35. Analysis of the data
o Current employment status: calculated on 238 pts (4 missing)
currently employed 91 (38.2%)
unemployed 111 (46.6%)
retired 20 (8.4%)
student 16 (6.7%)

36. Analysis of the data
o Marital status: calculated on 240 pts (2 missing)
single 132 (54.6%)
married 64 (26.5%)
divorced 9 (3.8%)
co-habiting 21 (8.8%)
separated 11 (4.6%)
widowed 3 (1.3%)

37. Analysis of the data
o Diagnosis with both scales: calculated on 237 pts (5 missing)
negative 194 (81.9%)
positive 43 (18.1%)

38. Analysis of the data
o Agreement between the scales:
Total n = 242
Valid n = 237 (97.9%)
ASRS- WURS- 113 (47.7%)
ASRS+ WURS- 45 (19%)
ASRS- WURS+ 36 (15.2%)
ASRS+ WURS+ 43 (18.1%)
P = 0.001
Kappa = .252
Missing n = 5 (2.1%)

39. Analysis of the data
o Age and WURS’ score do not have normal distribution
Spearman’s rho = - .205

40. Analysis of the data

41. Analysis of the data
o Correlation between Education and ADHD:
Chi squared = 2.9
df = 7
P = .9
o Correlation between Employment and ADHD:
Chi squared = 2.22
df = 3
P = .53

42. Analysis of the data
o Correlation between Education and ADHD:
N = 230
Chi squared = 2.9
df = 7
P = .9
o Correlation between Employment and ADHD:
N = 233
Chi squared = 2.22
df = 3
P = .53

43. Provisional Conclusions and Critics
18.1% of the psychiatric population analysed is positive for both ASRS and
WURS.
o Scales seem to be valid
o More cases in psychiatric population than general adult population as previous
studies have already shown (10 – 20%, Fones et al, 2000; Kesler et al, 2010)
o Undiagnosed cases in child population?

44. Provisional Conclusions and Critics
Labile agreement between ASRS and WURS.
o Because the different age span considered?
o To consider a different scoring system for the scales?
o Need to reconsider and analyse the scales’ validity?

45. Provisional Conclusions and Critics
Social functioning, in terms of level of education achieved and
employment status, does not significantly differ from the considered
psychiatric population.
…any other observation?

46. Thank you…