Abstract
Background:
Alcohol use disorders (AUDs) are among the most common comorbid psychiatric disorders in patients with adult attention deficit hyperactivity disorder (ADHD), and adult ADHD is an independent risk factor for developing AUD.
Aim:
To study the prevalence of adult ADHD in patients with Alcohol dependence syndrome (ADS).
Materials and Methods:
In total, 177 cases of ADS diagnosed as per International Classification of Diseases-10, Diagnostic Criteria for Research (ICD-10, DCR) were included. The severity of alcohol dependence was estimated by the Severity of Alcohol Dependence Questionnaire (SADQ). The included patients were screened for adult ADHD by the Adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist, and statistical tests were applied.
Results:
Out of 177 patients with ADS, 21 patients screened positive for adult ADHD (11.9%). Greater severity of alcohol dependence among those screened positive for adult ADHD was noted compared to the adult ADHD negative group (P = 0.013). Adult ADHD-positive patients had an earlier age of onset of alcohol consumption (P = 0.020), higher mean duration of alcohol consumption (P < 0.001), and early onset of ADS (P = 0.038). ICD-10 criteria of loss of control, salience, and use despite harmful effects were significantly higher among the adult ADHD-positive group.
Conclusion:
The study findings suggest a significant prevalence of adult ADHD among patients with ADS.
Keywords: Adult ADHD, alcohol dependence syndrome, alcohol use disorder, prevalence
Attention deficit hyperactivity disorder (ADHD) is a disorder with onset in childhood characterized by a persistent pattern of symptoms of developmentally inappropriate and impaired inattention and/or hyperactivity/impulsivity, with difficulties often continuing into adulthood.[1]
Previous longitudinal studies have reported that 45%–60% of children diagnosed with ADHD continued to be symptomatic in adulthood, and 15% met formal diagnostic criteria at the age of 25 years.[2,3] Substance use disorders (SUDs) are among the most common comorbid psychiatric disorders in patients with adult ADHD, and adult ADHD is an independent risk factor for developing SUDs.[4] Recently, studies with improved diagnostic instruments indicate the prevalence of adult ADHD ranging from 10.8% to 40.9% among individuals with SUDs.[5,6,7] A recent meta-analysis reported the prevalence of comorbid ADHD at 23.1% among individuals with SUDs.[5] A study in 2018 reported that comorbid adult ADHD among individuals with alcohol use disorder (AUD) had a lifetime prevalence of 23%,[7] while another study determined that 33% of individuals with AUD had comorbid adult ADHD.[8]
Adults with comorbid Alcohol dependence syndrome (ADS) and ADHD have been noted to have an earlier onset of alcohol dependence, a higher propensity of relapsing, more social problems, more severe alcohol dependence, and more hospital visits than those without ADHD.[9] Studies conducted in the Indian context have reported that individuals diagnosed with adult ADHD had an early onset of alcohol dependence.[10] Other Indian studies also report that among alcohol-dependent individuals, those with ADHD had a significantly higher duration of alcohol use, lesser education, a greater number of jobs held, and had higher severity of alcohol dependence as calculated using Severity of Alcohol Dependence Questionnaire (SADQ) scores.[11] An Indian study in 2019 reported a lower mean age of first exposure to alcohol among those with comorbid ADS and adult ADHD compared to ADS alone.[12] Although there was early exposure to alcohol in subjects with ADHD, the difference was not statistically significant.
There are a few studies indicating research on adult ADHD in India. The prevalence of adult ADHD vis-à-vis the severity of ADS has seldom been studied. Qualitative differences in alcohol dependence [as in the International Classification of Diseases-10 (ICD-10) criteria met for alcohol dependence] in adult ADHD-positive patients and negative patients have been poorly researched. In the present study, we aimed to study the prevalence of adult ADHD in patients with ADS.
MATERIALS AND METHODS
This was designed as an observational cross-sectional study and followed the Consensus-based Checklist for Reporting of Survey Studies (CROSS) guidelines for cross-sectional studies.[13] The sample size was calculated for 80% power of detecting a difference with a 5% level of significance.[14] The minimum required sample calculated was 177 (N = 177). The patients were included in the study over a period of 1.5 years (Jan 2021–Jun 2022), and a convenience sampling approach was used for the study.
The inclusion criteria were as follows: male patients aged 18–65 years, who were admitted to the psychiatry department of a tertiary care multispecialty hospital in Pune, India, and were diagnosed with ADS as per International Classification of Diseases-10, Diagnostic Criteria for Research (ICD-10, DCR). Upon admission, patients were screened for signs of alcohol intoxication/withdrawal. In case of alcohol withdrawal, patients were managed with oral/injectable benzodiazepines and forced abstinence. After completion of detoxification, all included patients remained drug-free for a minimum of 1 week prior to their enrollment in the study to ensure no influence of psychoactive medications on the psychometric evaluation. Exclusion criteria were as follows: presence of comorbid psychiatric disorders, including psychotic disorders (F20–F29), mood disorders (F30–34), intellectual disability, Autism spectrum disorder, and neurological disorders (including epilepsy, head injury, and dementia). Patients who had psychosis or mood disorder due to a general medical condition, patients with caffeine and nicotine dependence (F15.2, F17.2), and those who expressed refusal to give informed consent were also excluded. The data were collected from the patients who met the criteria after getting their informed consent and ensuring confidentiality.
Sociodemographic/clinical proforma was completed along with general and systemic examination. Patients were screened for ADS using the Alcohol Use Disorders Identification Test (AUDIT), and the diagnosis was confirmed by ICD-10 criteria. SADQ was utilized to assess the severity of alcohol dependence. Then, adult ADHD was screened by the Adult ADHD Self-Report Scale (ASRS-v1.1) symptom checklist. The scales were self-administered by the patients in the presence of the authors in the ward; doubts if any were cleared by the authors at the time of administration.
Study tools
A semi-structured questionnaire was used to collect relevant sociodemographic and clinical parameters through personal interviews.
Severity of Alcohol Dependence Questionnaire: SADQ is a 20-item clinical screening tool designed to measure the presence and level of alcohol dependence.[15] There is good evidence of construct validity and concurrent validity, and the SADQ score correlates clinically with dependence severity. Cronbach’s alpha ranges between 0.71 and 0.95.[16] It is divided into five sections: physical withdrawal symptoms, affective withdrawal symptoms, craving and relief drinking, typical daily consumption, and reinstatement of dependence after a period of abstinence. Each item is scored on a 4-point scale, giving a possible range of 0–60. A score of over 30 indicates severe alcohol dependence.
Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist: The ASRS-v1.1 Symptom Checklist has been developed by the World Health Organization as a screening test for adult ADHD.[17] The scale is divided into two parts: part A (6 questions) and part B (12 questions). The patient’s symptoms are strongly consistent with ADHD if four or more marks show up in the darker shaded boxes in part A. Part B frequency scores can be used as cues to further enquire into the patient’s symptoms. The six questions contained in part A are the most predictive of adult ADHD. ASRS-v1.1 Symptom Checklist has a high sensitivity for adult ADHD (0.84, 95% CI: 0.76–0.88) making it a good screening tool.[18] It has a high internal consistency (Cronbach’s alpha: 0.88).[19]
For this study, both the SADQ and ASRSv1.1 symptom checklists were translated into Hindi. The Hindi translations were validated using 100 randomly selected normal subjects. Initially, 50 subjects were given the English versions and 50 the Hindi ones. After 1 week, it was reversed. The results did not show any statistically significant difference. Both the rating scales are in the public domain.
Ethical concerns
Institutional ethics committee permission was taken for conducting the study (IEC/2021 dated Jan 9, 2021). Informed consent was obtained from the participants prior to inclusion in the study. Measures were taken so that participation or non-participation in the study would not affect the usual treatment of the patients. If a patient screened positive for ADHD, the same was informed to the treating team, which took further decisions for the management of the patient.
Statistical analysis
The data collected were entered into the Microsoft Excel program and analyzed using Statistical Package for Social Sciences (SPSS) version 25.0.1. Qualitative data variables were expressed using frequency and percentage (%). Quantitative data variables were expressed by mean and standard deviation (SD). The chi-square test was applied to assess the association between categorical variables, such as the presence of ADHD and specific ICD-10 criteria in ADS. Independent samples t-test or analysis of variance (ANOVA) was used to compare mean values of continuous variables across groups (e.g., mean age of onset of alcohol use between ADHD-positive and ADHD-negative groups). Spearman’s rho correlation coefficient was employed to assess the strength and direction of association between ordinal or non-normally distributed variables, such as severity scores on the Severity of Alcohol Dependence Questionnaire (SADQ) and ADHD symptom scores. ANOVA where applicable, was used to compare means across multiple groups (e.g., mild, moderate, and severe dependence categories). The level of statistical significance was kept at P < 0.05 for all the tests.
To ensure data completeness, any unclear or incomplete responses were clarified directly with the participants during data collection. This approach minimized the potential for missing information and ensured the accuracy and reliability of the dataset.
RESULTS
A total of 191 approached male patients met the inclusion criteria for the study. Among these approached patients, the reasons for exclusion were >65 years of age (n = 06), acute psychosis/affective episode such that the patient was unable to give consistent responses (n = 08), and premature opt-out from the study due to discharge from the hospital (n = 12). A total of 177 male participants were finally included in the study, which matched the estimated sample size (N = 177). Demographic, social, and alcohol-related details are summarized in Table 1.
Table 1.
Demographic, social, and alcohol-related data
| S. No. | Variables | ASRS v1.1 positive (n=21) | ASRS v1.1 negative (n=156) | Chi-square value | Cramér’s V | P |
|---|---|---|---|---|---|---|
| Age (years) | ≤30 | 4 | 29 | χ2 (3, n=177)=3.41 | 0.139 | 0.333NS |
| 31–40 | 14 | 84 | ||||
| 41–50 | 1 | 33 | ||||
| >50 | 2 | 10 | ||||
| Education status | Primary | 2 | 2 | χ2 (3, n=177)=5.88 | 0.182 | 0.118NS |
| Secondary | 12 | 91 | ||||
| Higher secondary | 6 | 51 | ||||
| Graduation | 1 | 12 | ||||
| Monthly income (rupees) | ≤19,000 | 0 | 3 | χ2 (4, n=177)=0.49 | 0.053 | 0.975NS |
| 20,000–29,000 | 2 | 14 | ||||
| 30,000–39,000 | 8 | 56 | ||||
| 40,000–49,000 | 8 | 63 | ||||
| >50,000 | 3 | 20 | ||||
| Marital Status | Married | 21 | 150 | χ2 (1, n=177)=0.07 | 0.020 | 0.3605NS |
| Unmarried | 0 | 6 | ||||
| Age at first drink (years) | ≤20 | 6 | 17 | χ2 (2, n=177)=7.87 | 0.211 | 0.020* |
| 21–25 | 13 | 88 | ||||
| >25 | 2 | 51 | ||||
| Duration of Consumption (years) | ≤5 | 4 | 2 | χ2 (3, n=177)=20.26 | 0.34 | <0.001** |
| 6–10 | 3 | 48 | ||||
| 11–15 | 9 | 51 | ||||
| >15 | 5 | 55 | ||||
| Age at ADS Diagnosis (years) | ≤5 | 14 | 62 | χ2 (2, n=177)=6.55 | 0.192 | 0.038* |
| 6–10 | 7 | 75 | ||||
| >15 | 0 | 19 | ||||
| Duration of alcohol dependence (years) | ≤5 | 12 | 80 | χ2 (3, n=177)=5.68 | 0.179 | 0.128NS |
| 6–10 | 6 | 52 | ||||
| 11–15 | 0 | 17 | ||||
| >15 | 3 | 7 | ||||
| SADQ score | Mild | 4 | 72 | χ2 (2, n=177)=8.64 | 0.221 | 0.013* |
| Moderate | 12 | 72 | ||||
| Severe | 5 | 12 |
ADS: Alcohol Dependence Syndrome, ASRS: Adult ADHD Self-Report Scale v1.1 Symptom Checklist, NS: Not significant, SADQ: Severity of Alcohol Dependence Questionnaire. Significant P values are highlighted in bold
Out of 177 patients diagnosed with ADS, 21 patients screened positive for adult ADHD (11.9%). The two groups (i.e. adult ADHD positive vs. negative) were statistically similar in respect of mean age (36.10 vs. 37.54 years; P = 0.333), education status (P = 0.118), monthly income (P = 0.975), and marital status (100% married vs. 96.15% married; P = 0.3605). Among adult ADHD-positive patients, the mean age of onset of alcohol consumption was 22.19 years, whereas in the adult ADHD-negative group, it was 23.91 years. The result was statistically significant (P = 0.020), implying earlier age of onset of alcohol consumption among the adult ADHD-positive group.
To examine the association between adult ADHD status (ASRS v1.1 positive vs. negative) and severity of alcohol dependence (mild, moderate, severe), the chi-square test of independence was conducted. The results revealed a significant association, χ² (2, N = 177) =8.64, P = 0.013, Cramer’s V = 0.22, implying greater severity of alcohol dependence among those screened positive for adult ADHD [Table 2].
Table 2.
Severity of alcohol dependence and adult ADHD
| SADQ Score | Adult ADHD Status |
Total | Expected frequencies |
P | ||
|---|---|---|---|---|---|---|
| ASRS v1.1 Positive | ASRS v1.1 Negative | ASRS v1.1 Positive | ASRS v1.1 Negative | |||
| Mild | 4 | 72 | 76 | 9.02 | 66.98 | 0.013* |
| Moderate | 12 | 72 | 84 | 9.97 | 74.03 | |
| Severe | 5 | 12 | 17 | 2.02 | 14.98 | |
| Total | 21 | 156 | 177 | - | - | |
χ2 (2)=8.64, P=0.013, Cramer’s V=0.22. ADHD: Attention Deficit Hyperactivity Disorder, ASRS: Adult ADHD Self-Report Scale v1.1 Symptom Checklist, SADQ: Severity of Alcohol Dependence Questionnaire. Significant P values are highlighted in bold. Greater severity of alcohol dependence was noted amongst those screened positive for adult ADHD (P=0.013)
To examine the relation between adult ADHD status and duration of alcohol consumption, the chi-square test of independence was performed. The results revealed a significant association between the two variables, χ² (3, N = 177) =20.26, P < 0.001, Cramer’s V = 0.34, indicating that adult ADHD-positive individuals tend to have longer durations of alcohol consumption compared to ADHD-negative individuals [Table 3].
Table 3.
Duration of alcohol consumption and adult ADHD
| Duration of Alcohol consumption (years) | Adult ADHD Status |
Total | Expected frequencies |
P | ||
|---|---|---|---|---|---|---|
| ASRS v1.1 Positive | ASRS v1.1 Negative | ASRS v1.1 Positive | ASRS v1.1 Negative | |||
| ≤5 | 4 | 2 | 6 | 0.71 | 5.29 | <0.001* |
| 6–10 | 3 | 48 | 51 | 6.05 | 44.95 | |
| 11–15 | 9 | 51 | 60 | 7.12 | 52.88 | |
| >15 | 5 | 55 | 60 | 7.12 | 52.88 | |
| Total | 21 | 156 | 177 | - | - | |
χ2 (3)=20.26, P=0.00015, Cramer’s V=0.34. ADHD: Attention Deficit Hyperactivity Disorder, ADS: Alcohol Dependence Syndrome, ASRS: Adult ADHD Self-Report Scale v1.1 Symptom Checklist. Significant P values are highlighted in bold. Adult ADHD positive individuals tend to have longer durations of alcohol consumption compared to ADHD negative individuals (P<0.001).
To examine the association between adult ADHD status and the age at which diagnostic criteria for ADS were met, the Chi-square test of independence was conducted. The results revealed a significant association, χ² (2, N = 177) = 6.55, P = 0.038, Cramer’s V = 0.19, indicating that adult ADHD-positive individuals had a greater likelihood to develop alcohol dependence at an earlier age compared to ADHD-negative individuals [Table 4].
Table 4.
Age of diagnosis of alcohol dependence syndrome and adult ADHD
| Age at diagnosis of ADS (years) | Adult ADHD Status |
Total | Expected frequencies |
P | ||
|---|---|---|---|---|---|---|
| ASRS v1.1 Positive | ASRS v1.1 Negative | ASRS v1.1 Positive | ASRS v1.1 Negative | |||
| 20–30 | 14 | 62 | 76 | 9.02 | 66.98 | P =0.038* |
| 31–40 | 7 | 75 | 82 | 9.73 | 72.27 | |
| >40 | 0 | 19 | 19 | 2.25 | 16.75 | |
| Total | 21 | 156 | 177 | - | - | |
χ2 (2)=6.55, P=0.038, Cramer’s V=0.19. ADHD: Attention Deficit Hyperactivity Disorder, ADS: Alcohol Dependence Syndrome, ASRS: Adult ADHD Self-Report Scale v1.1 Symptom Checklist. Significant P values are highlighted in bold. Adult ADHD-positive individuals had greater likelihood to develop alcohol dependence at an earlier age compared to ADHD-negative individuals (P=0.038)
Even though the mean duration of alcohol dependence was greater in the adult ADHD-positive group (6.81 vs. 5.98 years) the difference was not statistically significant (P = 0.128). ICD-10 criteria of loss of control (66.66% vs. 33.97%; P = 0.0078), salience (28.57% vs. 6.41%; P = 0.003), and use despite harmful effects (28.57% vs. 7.05%; P = 0.006) were significantly higher among the adult ADHD-positive group. There was no statistical difference among craving, withdrawal features, and tolerance [Table 5].
Table 5.
ICD-10 criteria met for alcohol dependence and adult ADHD
| ICD-10 Criteria met for ADS | ASRS |
Total | Chi-square statistic | Cramér’s V | P | |
|---|---|---|---|---|---|---|
| ASRS Positive | ASRS Negative | |||||
| Craving | 21 | 156 | 177@ | - | - | - |
| Loss of control | 14 | 53 | 67 | χ2 (1, n=177)=7.08 | 0.20 | 0.0078** |
| Withdrawal features | 19 | 148 | 167 | χ2 (1, n=177)=0.10 | 0.024 | 0.752NS |
| Tolerance | 20 | 152 | 172 | χ2 (1, n=177)=0.00 | 0 | 1NS |
| Salience | 6 | 10 | 16 | χ2 (1, n=177)=8.52 | 0.22 | 0.003** |
| Use despite harmful effects | 6 | 11 | 17 | χ2 (1, n=177)=7.55 | 0.21 | 0.006** |
ADS: Alcohol Dependence Syndrome, ASRS: Adult ADHD Self-Report Scale v1.1 Symptom Checklist, ICD: International Classification of Diseases, NS: Not significant. Significant P values are highlighted in bold. @Entire study population had features of craving. ICD-10 criteria of loss of control (P=0.0078), salience (P=0.003), and use despite harmful effects **(P=0.006) were significantly higher amongst adult ADHD positive group
DISCUSSION
This was a cross-sectional observational study designed to study the prevalence of adult ADHD, using the ASRS-v1.1 Symptom Checklist, in patients diagnosed with ADS. The study divided the included population into two groups: adult ADHD positive and negative. The two groups had comparable age distribution, education status, monthly income, and marital status.
Earlier studies have estimated the prevalence of adult ADHD in ADS ranging from 5% to 22%, 20.5%, and 21.1%.[20,21,22] In the Indian context, the prevalence rates vary greatly from 25.6% to 62%.[11,23] In this study, the prevalence of adult ADHD in ADS was estimated to be 11.9%. The findings are similar to some previous studies, which estimated the prevalence to be 7.7%–12%.[24,25] Most previous studies estimate a higher prevalence of adult ADHD in AUD patients. However, these results should be interpreted with caution as in a meta-analysis published in 2023, high heterogeneity was noted in the studies estimating the prevalence of adult ADHD in AUD.[26]
Previous studies have noted that the severity of ADHD symptoms was positively correlated with more severe dependence on alcohol.[27] Similar results have been noted in Indian studies.[11,12] In this study, the SADQ score among adult ADHD-positive patients was significantly higher compared to the adult ADHD-negative group (χ² (2, N = 177) =8.64, P = 0.013, Cramer’s V = 0.22), implying greater severity of alcohol dependence among those screened positive for adult ADHD. This is similar to the findings of the previous studies. We hypothesize that adult ADHD symptoms are positively associated with increased severity of alcohol dependence, as indicated by higher scores on the SADQ.
Earlier studies have reported earlier age of onset of alcohol consumption and earlier age of alcohol dependence in patients with adult ADHD.[20,28] Similar results were noted in studies conducted in Indian settings.[12,29] In the present study, the mean age of onset of alcohol consumption was significantly lower among adult ADHD-positive patients than in the adult ADHD-negative group (22.19 years vs. 23.91 years; P = 0.020). Among adult ADHD-positive patients, the duration of alcohol consumption was significantly higher than in those screened negative for adult ADHD (χ² (3, N = 177) =20.26, P < 0.001, Cramer’s V = 0.34). The age at which the diagnostic criteria for ADS were met was significantly lower in the adult ADHD-positive group than the adult ADHD-negative group (χ² (2, N = 177) =6.55, P = 0.038, Cramer’s V = 0.19). These findings are in consonance with the previous studies. We hypothesize that adults with ADHD are likely to begin alcohol consumption at a younger age and exhibit a faster progression to alcohol dependence compared to those without ADHD.
Previous studies have reported the duration of alcohol dependence/abuse to be significantly longer in adult ADHD-positive patients than in controls.[29,30] In the current study, even though the mean duration of alcohol dependence was greater in the adult ADHD-positive group (6.81 vs. 5.98 years), the result was not statistically significant (P = 0.128).
Earlier studies reported that higher ADHD symptom severity was associated with higher odds of non-completion of high school/lower years of education compared with adult ADHD-negative patients. These studies also noted a lower household income and greater unemployment among adult ADHD-positive patients.[11,12,31,32] In the present study, the adult ADHD positive versus negative groups were statistically similar in terms of education status (P = 0.118) and income status (P = 0.975). This can be due to the fact that the majority of the study population was taken from a service hospital, and the participants had a comparable pay structure and educational requirements.
ICD-10 criteria of loss of control (66.66% vs. 33.97%; P = 0.0078), salience (28.57% vs. 6.41%; P = 0.003), and use despite harmful effects (28.57% vs. 7.05%; P = 0.006) were significantly higher among the adult ADHD-positive group. There was no statistical difference among craving, withdrawal features, and tolerance. There are no comparable studies in this regard. We hypothesize that adult ADHD-positive patients exhibit a qualitatively different pattern of alcohol dependence, characterized by a higher likelihood of displaying loss of control, salience, and continued use despite harmful effects, as per ICD-10 criteria, compared to ADHD-negative patients.
The study had several strengths. First, it employed the ASRS-v1.1 Symptom Checklist and SADQ. Very few Indian studies have used the ASRS-v1.1 Symptom Checklist to assess adult ADHD occurrence in ADS. The use of standardized and validated instruments strengthened the robustness of the study. The study employed strict inclusion and exclusion criteria, including age range, gender, and the exclusion of patients with other psychiatric comorbidities, enhancing the internal validity of the findings by reducing potential confounders and ensuring a more homogenous study population. Other possible confounding factors were controlled to enhance the validity of the findings, such as detoxification status, language and cultural adaptation of screening tools, and psychoactive medication use. Finally, the geographical heterogeneity of the study group has made the study firmly representative of the Indian population. This enhances the validity of the study.
The study, however, had its limitations. First, it was a cross-sectional study without a control group and was unable to draw a cause-effect relationship. What we have found are associations that will require testing using longitudinal prospective studies with appropriate comparator groups. Second, only male patients were included in the study. The findings, thus, may not be generalizable to female patients with ADS, and limit the applicability of results across genders. ASRS-v1.1 Symptom Checklist and SADQ are self-reported instruments. Self-reporting can introduce biases such as social desirability bias or recall bias, potentially affecting the validity of the data. Patients with other comorbid psychiatric disorders were excluded. As comorbid psychiatric conditions are common in both ADHD and ADS, excluding these patients may limit the understanding of the full spectrum of ADHD prevalence in ADS. There is a possibility of selection bias as the participants were recruited from a hospital setting, which may have led to the exclusion of individuals with ADS who do not seek hospital-based treatment, limiting the applicability of findings to all individuals with ADS.
CONCLUSION
The prevalence of adult ADHD among alcohol-dependent patients was estimated to be 11.9%. The result is similar to the previous global and Indian studies. Age of first alcohol consumption and age at diagnosis of alcohol dependence syndrome were lower in the adult ADHD group, along with greater duration of consumption of alcohol (both overall and in dependent pattern). Greater severity of alcohol dependence was noted among those screened positive for adult ADHD. This is similar to global and Indian studies.
Ethical statement
This study was approved by the Institutional Ethics Committee (IEC/2021 dated 09 Jan 2021) and conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Informed consent was taken from the patients prior to publishing this article. The participation of the patients was voluntary, and every step was taken to maintain patient’s confidentiality and anonymity. Participation had no bearing on their clinical treatment, and positive adult ADHD screens were communicated promptly to the clinical team.
Authors' contribution
Methodology, formal analysis, investigation, data curation, writing-original draft: RS. Conceptualization, writing-review & editing, supervision: KC. Methodology, writing-review & editing, supervision: VSC.
Data availability statement
The data can be made available upon reasonable request.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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Data Availability Statement
The data can be made available upon reasonable request.