Review of the New Zealand adult attention-deficit hyperactivity

disorder work by Moffitt et al. (2015)

Jeffrey C. Marck

Institute of Advanced Studies, Australian

National University, Retired

Correspondence to Jeffrey C. Marck, PhD,

Institute of Advanced Studies, Australian

National University, 21 Youssef El-Gendy, Bab

Al Louq, Abdeen, Talaat Harb District, Cairo

Governorate 22368, Egypt.

e-mail: adu66i@r.postjobfree.com

Received: 18 September 2019

Revised: 25 September 2019

Accepted: 1 October 2019

Published: 21 May 2020

Egyptian Journal of Psychiatry 2020,

41:57–60

Despite a prevailing assumption that attention-deficit hyperactivity disorder (ADHD) is a childhood-onset neurodevelopmental disorder, no prospective-longitudinal study has described the childhoods of the adult ADHD population. Unexpectedly, the adult ADHD group did not show tested neurophysiological deficits in childhood or adulthood nor did they show polygenetic risk for childhood ADHD. Findings raise the possibility that adults presenting with the ADHD symptom picture may not have a childhood-onset neurodevelopmental disorder; thus, the disorder’s place in the classification system must be reconsidered, and research must investigate the etiology of adult ADHD. Keywords:

ADHD in prisons, adult ADHD, Moffitt et al. 2015, Nashaat 2015 Egypt J Psychiatr 41:57–60

© 2020 Egyptian Journal of Psychiatry

1110-1105

Moffitt et al. (2015)

The cohort prevalence of attention-deficit

hyperactivity disorder (ADHD) was 6% in

childhood and 3% at the age of 38 years,

corresponding to previous estimates among children and adults. Unexpectedly, childhood and adult

diagnoses comprised virtually nonoverlapping sets of individuals.

In the year following publication of Moffitt and

colleagues, Bonvincini et al. (2016) ‘confirmed the significant role of BAIAP2 and DHA in the etiology of ADHD exclusively in adults.’ Awareness of

ADHD in adults has rapidly increased, and a new

clinical practice has emerged across the world.

Despite this progress, treatment of adult ADHD

in Europe and many other regions of the world is

not yet a common practice, and diagnostic services are often unavailable or restricted to a few specialist centers.

For researchers, these new data are a ‘call to arms’ to study adult-onset ADHD, determine whether and

how to incorporate age at onset into future

diagnostic criteria, and clarify how it emerges from subthreshold ADHD and other neurodevelopmental

anomalies in childhood. The current age-at-onset

criterion for ADHD, although based on the best

data available, may not be correct. We hope that

future research will determine whether and how it

should be modified (Faraone and Biederman, 2016).

Moffitt et al. (2015) reported on a 38-year-old

prospective study of ADHD among 1037 individuals

born from 1972 to 1973 in New Zealand. It is entirely unique, and the world of general practitioners now has deeper insights available into what to expect, who to screen, and the presentation one might expect in

general or other psychiatric practice. Upon

publication of Moffitt and colleagues, many of the world’s ADHD luminaries soon found occasion to

mention it (e.g. Castellanos, 2015; Agnew-Blais

et al., 2016; Asherton et al., 2016; Bonvincini et al., 2016; Faraone and Biederman, 2016; Kennedy et al., 2016; Wakefield, 2016; Clemow et al., 2017, where

Moffitt and colleagues is cited in the first sentence of the authors’ presentation; Geffen and Forster, 2018, where Moffitt and colleagues is cited in the first sentence of the second paragraph; and Murray et al., 2018, where Moffitt and colleagues is cited in the second sentence of the second paragraph). It is

perhaps the study by Moffitt and colleagues and its general reception into the community of adult ADHD researchers which now defines how adult ADHD is

best understood in discussions of adult ADHD

etiologies, diagnosis, and treatment.One of the

Egyptian adult ADHD researchers most suitably

poised to have immediately translated this change of paradigm into changes in best practice died shortly after the publication of Moffitt and colleagues

(Mohamed Nashaat MD). Hence his most recent

citations are from 2015 in his PhD thesis

manuscript (here referred to as Nashaat, 2015),

comprising three in number, and one of them is

Moffitt and colleagues.

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Review article 57

© 2020 Egyptian Journal of Psychiatry Published by Wolters Kluwer - Medknow DOI: 10.4103/ejpsy.ejpsy_32_19

[Downloaded free from http://www.new.ejpsy.eg.net on Tuesday, August 18, 2020, IP: 41.234.180.0] Nashaat (2015) describes study of adult ADHD in 300 consecutive adults (58.3% male, 41.7% female) seeking general psychiatric consultations at the outpatient clinics of the Psychiatry Department of Kasr Alainy Hospitals in Cairo, Egypt.

The patients completed Adult ADHD Self-Report

Scale-v.1.1, and 72 of those patients (56.9% male, 43.1% female) were ‘definite’ cases of adult ADHD

by DSM-5 criteria, resulting in a 24% rate of affliction among those patients who had presented to that clinic with issues. Comorbidity was present in all 72 cases: 41.7% bipolar I disorder, 25.0% substance use disorder

(SUD), 15.3%major depressive disorder (MDD), 9.7%

anxiety disorder, and 8.3% obsessive-compulsive

disorder (OCD); these were the primary diagnoses

in an overall pattern of two-thirds of the patients having two or more comorbidities. Moffitt and

colleagues, in their prospective study, found a large number of adult cases without comorbidity, and it can be assumed that Nashaat would have found such cases in such proportions in a 38-year-old prospective study from birth of Egyptian patients. However, he was

dealing with adults experiencing issues sufficient to seek consultation, and thus, a different kind of cross- section was involved.

The results of Nashaat (2015) showed that something on the order of 25% of that facility’s Egyptian

adults presenting with concerns may be afflicted and that SUD is not the first place to go looking when wondering who might have adult ADHD comorbidity,

which would be bipolar I disorder. In Nashaat’s

sample at least, the common SUD/ADHD equation

is associated with SUD as a self-medication for

adult ADHD and the figures that result when

mainly patients with SUD are screened for

ADHD, commonly in the context of evaluating

criminal offenders or patients presenting with

behavior issues.

So where might Egypt now turn One would want to

start with the best evidence about general community ADHD morbidity and comorbidity worldwide. In

those massive literature studies, there is the

persistent finding that human populations generally see 6% of their children afflicted and 3% of their adults. What is known about Egypt suggests a

similar pattern.

Alkhateeb and Alhadidi (2016) have recently noted

how short the list of Arab ADHD studies seems to be. Beyond Nashaat, I find few English reports on the

topic of adult ADHD in Egypt or Arab countries in

general, just as Alkhateeb and Alhadidi have indicated. Moreover, even wealthy nations have often paid little attention to adult ADHD. Sweden, for instance, only recently emerged from an older pattern where there was little diagnostic or treatment activity.

For the moment and for some years into the future, the questions of who to screen and how to evaluate findings will first involve familiarity with the New Zealand research summarized in Moffitt and

colleagues. In that study, ‘[a]s expected, the adult ADHD group showed 3% prevalence . . .

Unexpectedly . . . 90% of adult ADHD cases

lacked a history of childhood ADHD.’ So just as

SUD may not be the first place to go looking for

adult ADHD comorbidity, patients with childhood

ADHD histories are not the first place to go looking for afflicted adults either.

‘If this finding is replicated, then the disorder’s place in the classification system must be reconsidered, and research must investigate the etiology of [adult]

ADHD’ (Moffitt et al., 2015), which is a rather

modest pronouncement on the part of those authors. It would take 38 years to replicate their study. Perhaps other such studies are underway.

However, ‘he who hesitates is lost’ and, in light of Moffitt and colleagues, practitioners are in possession of evidence which beckons one toward a new path more or less immediately. Moreover, there are discussions in Moffitt and colleagues describing what would

constitute more powerful presentations or refutations of their main or indicative findings. Supporting

physiological evidence emerged in the next year.

Bonvincini et al. (2016) ‘confirmed the significant role of BAIAP2 and DHA in the etiology of

ADHD exclusively in adults.’

One would hope that the world community of adult

ADHD specialists is not going to be slow to bring

Moffitt and colleagues to the attention of sentencing, incarceration, and parole practitioners.

Adult ADHD diagnosis is neither extremely old (c.f., e.g. Biederman et al., 1993 for the idiom of that period) nor is the search for the afflicted all that it might be at this time (and, thus, such measured forays into adult ADHD diagnosis as Nashaat, 2015.

Nashaat’s (2015) sample was a different kind of sample than that of Moffitt and colleagues and produced

somewhat different results in that Moffitt’s group found the following:

58 Egyptian Journal of Psychiatry, Vol. 41 No. 2, May-August 2020

[Downloaded free from http://www.new.ejpsy.eg.net on Tuesday, August 18, 2020, IP: 41.234.180.0] Ubiquitous comorbidity for adults with ADHD has

been reported before (Kessler et al., 2006), suggesting the hypothesis that ADHD symptoms in adults in their thirties might be the psychiatric equivalent of fever, a syndrome that accompanies many different illnesses and is diagnostically nonspecific, but signals treatment need. However, 55% of adult ADHD cases had no

other concurrent diagnosis at age 38; the ADHD

symptom picture can present alone in adults.

Nashaat (2015) found no adult patients with ADHD

without comorbidity which may be a result of screening individuals presenting with issues, underrepresenting the afflicted who suffer solely from adult ADHD, and such persons perhaps make life adjustments of varying levels of suitability and more rarely seek treatment. One place to go looking for undiagnosed persons who create social, administrative, and institutional costs would be prisons, as their inmates’ criminal conduct is often so impulsive, incomprehensible, and self- defeating owing to adult ADHD. Such is

accompanied by a high level of SUD and its ADHD

self-medication effect when the main substance

involved is methamphetamine. The world is in the

awkward position of imprisoning many people for

illegal methamphetamine use or sales only to end up deciding to treat some of them with methamphetamine once they are diagnosed with adult ADHD in prison, in the case of those prisons which are screening for and treating adult ADHD (cf. Young et al., 2017 for related issues). Moreover, in the case in Egypt, one might imagine, where the cost of methamphetamine

alternatives might be considered prohibitive.

Taking the message to prison system administrators Although women constitute approximately half of the adults diagnosed with ADHD, they do not have

anything like the rates of male offences and

incarceration. Afflicted women’s symptomologies are more associated with inattention than the

impulsiveness, aggression, and diminished executive functioning of males. So the following speaks only to the more distressing situation with respect to males. As many as half of the incarcerated males may have adult ADHD in some nations. World prison systems

have long been aware that many of their inmates

experience something like adult ADHD, and some

prison systems have implemented stimulant or

atomoxetine therapies for such offenders. Results

seem buried in the gray literatures. Little mention of results of such trials or operating procedures seems available through English language academic sources, including journals concerned with prison

administration. However, Usher et al. (2013) provide an example of what is found when prisoners are

screened:

Previous research has shown that a significant

percentage of offenders are affected by adult

ADHD and its related symptoms; however, it is

unknown the extent to which this disorder affects

federal inmates in Canada and the impact ADHD has

on key correctional outcomes. Four hundred and

ninety-seven male federal offenders were assessed at intake over a 14-month period using the Adult

ADHD Self-Report Scale. Approximately 16.5%

scored in the highest range, which is consistent

with the clinical threshold for diagnosis for the

disorder; a further 25.2% reported subthreshold

symptoms in the moderate range. ADHD

symptoms were found to be associated with

unstable job history, presence of a learning

disability, lower educational attainment, substance abuse, higher criminal risk and need levels, and

other mental health problems. ADHD symptoms

were also found to predict institutional misconduct. Additionally, offenders with high levels of ADHD

symptomatology fared more poorly on release to the community. Implications for institutional behavior management and the need for additional resources

and adapted interventions are discussed (The Usher and colleagues research was conducted using DSM-

IV, as DSM-5 was published at about the same time

as Usher and colleagues was completed and published. DSM-5 would have moved more patients into the

‘highest’ and ‘moderate’ range.)

Egypt’s rates of incarceration (traditionally about 80 prisoners per 100 000 total population) are on par with Germany, Switzerland, and the Netherlands, and for such populations, it is often noted that something less than half of such inmates, but rarely less than 30%, are incarcerated for the typical sorts of impulsive

misconduct or aggression related to ‘ADHD

crimes.’ Forethought is impaired and impulsivity

is high.

Possibly this will interest the Egyptian law

enforcement and incarcerations systems over time if such information can find a certain level of

prominence in their occupational literatures.

Perhaps it already has. In the meantime, it would

be useful to screen and then treat afflicted newer and older prisoners and parolees for ADHD to

demonstrate to criminal justice stakeholders the

efficacy of such remedies as exist and their

Review of the New Zealand adult ADHD Marck 59

[Downloaded free from http://www.new.ejpsy.eg.net on Tuesday, August 18, 2020, IP: 41.234.180.0] cost–benefit equations. It might open doors for more and quicker paroles if treated prisoners are responding as might be expected with reduced offending

while initially incarcerated.

Conclusion

Moffitt et al. (2015) provide the world’s treatment and incarceration specialists with a solid point of reference in making sense of adult ADHD etiologies and

interventions and will continue to do so for a very long time even while those authors’ own

recommendations for further enquiry are addressed

(see also Faraone and Biederman, 2016 for some

initial observations). Meanwhile, the world of adult diagnosis and treatment goes on and on as if

practitioners do not know what to do. ‘This

situation is remarkable given the strong evidence

base for safe and effective treatment’ (Asherton

et al., 2016). With the publication of the findings of Moffitt and colleagues, there is no reason for Arab and other nations to wait for further evidence when

translating existing information into action with

respect to adult screening and treatment in general practice and in its criminal justice systems.

National and local incarceration and parole systems should be invited to employ screening and

pharmacological interventions (Scott et al. 2016)

using proven treatments to enrich the lives of the afflicted and reduce disease burden costs to the

society. Young et al. (2015) note that populations in male youth prisons have five times the ADHD

prevalence as the general population and that there is a tenfold factor in male adult prisons. Ibrahim et al.

(2014) and and Scott et al. (2016) observe that the psychiatric health of prisoners typically declines rather than improves. Research seems far ahead of best

practice across most incarceration systems

internationally. Those jurisdictions which come to implement remedial interventions might best report simply and clearly on the extent to which net system costs contract when best practice is implemented so as to entice more jurisdictions to follow suit. On another front, general psychiatric practitioners might find they have a new tool kit for improving outcomes for a

substantial portion of their adult patients if they would screen more or all of them for ADHD, which

takes little time, and then treat the afflicted.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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