Prevalence of attention-deficit/hyperactivity disorder (ADHD) in adults, indicating that it is not as rare as previously thought. Global 12-month prevalence rates range from 2.5% to 3.6%. There is significant overlap between clinical anxiety and attention-deficit/hyperactivity disorder (ADHD) in adults, with above-average rates of ADHD among those with clinical anxiety.
Likelihood of Misdiagnosis
Some individuals may present with symptoms consistent with a specific anxiety disorder, while the anxiety may be revealed as secondary to untreated ADHD upon further investigation. Genetic risk factors and neurobiological genesis contributes to comorbidity The overlap can contribute to misdiagnosis. It is a challenge to diagnose comorbid presentation, as well as the high rates of undetected ADHD in adults with anxiety disorders.
Are Present Screening Tools Differentiating Between Anxiety and ADHD?
ADHD is vastly under-detected among adults with clinical anxiety, indicating a need for a screener with well-understood symptom dimensions and good discriminant validity. This paper looked at adults with clinical anxiety and whether there is overlap between their symptoms and attention-deficit/hyperactivity disorder (ADHD).
Overlapping of Symptoms
The study examined the relationship between symptoms of generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), panic disorder (PD), social anxiety disorder (SAD), and attention-deficit/hyperactivity disorder (ADHD). The Adult ADHD Self-Report Scale (ASRS-v1.1) and other relevant measures were used to assess symptoms.
Generalised Anxiety Disorder
For GAD and ADHD, most ASRS-v1.1 items showed significant loadings onto the ADHD factor, while one item loaded significantly onto the GAD factor.
Obsessive Compulsive Disorder
Regarding OCD and ADHD, most ASRS-v1.1 items loaded significantly onto the ADHD factor, except for one item.
Panic Disorder
In the case of PD, all but one ASRS-v1.1 items loaded significantly onto the ADHD factor, while all PDSS items loaded strongly onto their respective factors.
Social Anxiety Disorder and Social Phobia
Similarly, for SAD and ADHD, all ASRS-v1.1 items loaded significantly onto the ADHD factor, while all SPIN items loaded onto their respective social anxiety factor. This analysis provides insights into the overlapping symptoms and potential comorbidities between these mental health conditions and ADHD.
Exploring Adult ADHD Self-Report Scale (ASRS-v1.1)
ASRS-v1.1, comprising 18 questions based on DSM-IV criteria for ADHD. It was specifically developed for adult respondents, with questions framed in a context relevant to adults. The measure demonstrated strong sensitivity and acceptable specificity when scored based on DSM-5 criteria.
The study examines the factor structure of the Adult Self-Report Scale v1.1 (ASRS-v1.1) in individuals with anxiety or related disorders, aiming to determine its suitability for screening ADHD and its discriminant validity within this population. In other words, the study aims to answer questions about the ASRS-v1.1‘s structural validity, the best fitting model, and its discriminant validity in individuals with anxiety or related disorders. The principal diagnosis was based on the most disabling disorder at the time of assessment.
Structural Scrutiny of ASRS-v1.1
- The first-order one-factor model proposes that all 18 items load onto a single factor, reflecting a unitary construct.
- The two-factor model separates inattentive and hyperactive/impulsive symptoms into different factors, consistent with the DSM-IV and DSM-5 models.
- The first-order three-factor model divides the symptoms into inattention, hyperactivity, and impulsivity factors, in line with the DSM-III model. A revised three-factor model reassigns one item, providing a new factor structure.
The study used a tool called the Adult ADHD Self-Report Scale (ASRS-v1.1) to measure ADHD symptoms in 618 adults with clinical anxiety. The results showed that a three-factor model of ADHD (Inattention, Impulsivity, and Hyperactivity) provided a better fit than other models.
Confirmatory factor analysis was used to test these models, and the sample size of 619 exceeded the required 350. The relationships between ADHD symptoms and anxiety/distress were examined using correlational analyses. They discuss the use of exploratory factor analysis to examine the factor structure of combined ADHD and anxiety measures.
Findings
It was found that the ASRS-v1.1 had fair to good discriminant validity against measures of clinical anxiety and distress, but some items within the Hyperactivity factor were more strongly related to anxiety than ADHD. Despite some symptom overlap, the Adult ADHD Self-Report Scale (ASRS-v1.1) was found to be structurally valid and showed fair to good discriminant validity against measures of clinical anxiety and distress. The ASRS-v1.1 may capture non-ADHD symptoms, and further research with comprehensive assessment of ADHD is necessary to examine the specificity and sensitivity of the ASRS-v1.1 in adult populations with anxiety or related disorders.
The three-factor model of Inattention, Impulsivity-r, and Hyperactivity-r demonstrated the best fit, with small differences in AIC values. Standardized factor loadings were significant and similar to the traditional three-factor model, with improved loading for the item “talks excessively” when moved from the Impulsivity to the Hyperactivity factor. ASRS-v1.1 total scores were moderately correlated with PDSS scores and the DASS-21 Anxiety, Stress, and Depression subscales. Correlations between specific factors and SPIN scores were weak and non-significant. EFA of item pools showed mostly appropriate factor loadings. Overall, the findings suggest a complex relationship between ADHD symptoms and anxiety-related disorders, indicating the need for further exploration.
The separation of impulsivity and hyperactivity into distinct factors was supported, suggesting the need for separate consideration in ADHD screening and assessment. The study also noted slightly lower loadings for the best-fitting three-factor model, possibly due to differences in sample diagnostic makeup.
Conclusions
The findings supported the ASRS-v1.1 as a structurally valid tool in anxiety or related disorders populations. Furthermore, the study indicated that the symptom of excessive talking may be better captured within an impulsivity factor rather than hyperactivity. The study suggests that specific items within the ASRS-v1.1 may need to be refined or removed to improve the accuracy of screening for ADHD in the clinical anxiety population. This has implications for screening in clinical anxiety populations, where excessive talking could be an important discriminating factor.
However, clinicians should be cautious when diagnosing ADHD in adults with anxiety, as some symptoms may be due to anxiety rather than ADHD.
Further Research is Needed
Overinflation of ADHD reporting
The ASRS-v1.1, used in the study, may capture non-ADHD symptoms and over inflate ADHD reporting. They recommend future research to comprehensively assess ADHD in adult populations with anxiety disorders, potentially using other screening tools. This study’s findings highlight the need for more accurate assessment and understanding of ADHD in adults with anxiety disorders and across different demographic groups. Differential diagnosis may also be influenced by various forces contributing to false positive cases of ADHD, such as unrealistic expectations of cognitive abilities due to perfectionism or anxiety.
Beyond Traditional Domains
Additionally, they suggest investigating whether ADHD symptoms extend beyond traditional domains, such as emotional regulation, and whether the factor structure of ADHD symptoms differs based on informants and across diverse populations.
Takeaway
The research paper highlights the importance of effective screening tools for detecting ADHD among adults with anxiety disorders due to the high comorbidity between the two conditions. The ASRS-v1.1 total score is deemed to be a useful screening tool for identifying potential ADHD in adults with primary anxiety or related disorders. However, the Hyperactivity factor of the ASRS-v1.1 shows poor specificity against certain clinical anxiety symptoms, indicating a need for further scrutiny of positive screens. The paper suggests that refining or removing non-specific items on the ASRS-v1.1 could improve the tool’s ability to differentiate, thus assisting clinicians in identifying ADHD symptoms in adults with clinical anxiety for more effective treatment planning and decision-making.
The study findings have implications for the assessment and management of ADHD symptoms in adults with clinical anxiety. This differentiation can assist clinicians in better treatment planning and decisions.
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