Comments on Adult ADHD and its Familial Associations: Neuropsychological Profiles and Psychiatric Comorbidities

Dear Editor,

I appreciate Makkar et al. for their significant research on the enduring nature of childhood ADHD diagnoses and their associated cognitive factors among families. This is a vital domain for comprehending the persistence of mental health difficulties from childhood into adulthood. The study’s conclusion that 36.7% of first-degree relatives exhibited symptoms of ADHD is noteworthy. Furthermore, the impacted relatives had significant cognitive impairments, especially in planning (100%), sustained attention (81.8%), and working memory (81.8%). This substantiates a genetic and neurocognitive correlation, aligning with other genetic studies.^1,2 The authors’ implementation of structured neuropsychological profiling, including the NIMHANS battery and approved screening instruments, enhances the study’s methodology.

However, several study limitations and methodological constraints may have influenced the article’s overall applicability and the precision of its conclusions. The study’s exclusive concentration on male participants (n = 30) restricts the capacity for sex-based comparisons. This represents a considerable constraint, considering the increasing evidence that adult ADHD in females is frequently underdiagnosed, manifests through various compensatory cognitive strategies, and displays a unique neuropsychological profile, especially in attention and executive function. ³ The manifestation of ADHD is influenced by both genetic factors and unique environmental conditions, so utilizing a single-gender reference group obstructs the effective differentiation of these influences. ¹ Therefore, subsequent studies would benefit from equitable recruitment of both genders and clear classification by sex.

A subsequent limitation arises from the absence of treatment-history control, despite the recognized variability in neuropsychological performance among medicated, unmedicated, and previously treated groups, particularly regarding sustained attention, response inhibition, and planning capabilities. ⁴ The omission of treatment exposure may artificially enhance or obscure familial cognitive connections. Therefore, subsequent research ought to include treatment-oriented subgroup classification and multivariate correction.

From a statistical standpoint, despite the authors’ recognition of non-normal data, the study employed parametric group comparisons, namely t tests and ANOVA, executed using SPSS. This method may not yield the most precise modeling of skewed neuropsychological performance distributions.

Previous observational reporting standards indicate that regression-normative comparisons or generalized linear models more effectively capture neurocognitive variation than mean-based parametric inference in small analytical cohorts. ⁵

Another limitation is the study’s dependence on screening-only ADHD classification for relatives, lacking confirmatory formal diagnostic interviews (e.g., DIVA-5 or MINI), which heightens the likelihood of misclassification, particularly in analytical family-aggregation estimations. ² The study notably lacks functional behavioral or occupational outcome measures, hence constraining the applicability of cognitive deficits to practical clinical or public health recommendations. Given that dynamic executive performance is contingent upon specific tasks, further research may incorporate driving performance indicators, computerized continuous performance tests, eye-tracking biomarkers, or simulator-based attention tasks to enhance ecological validity.^6,7

To strengthen the effectiveness and impact of ADHD research, future studies should:

Increase sample sizes and include mixed-gender participants to enhance generalizability;

Carefully document and control for treatment exposure as a neurocognitive variable;

Incorporate structured clinical diagnostic interviews to identify positive cases;

Utilize regression-normative modeling instead of relying solely on mean-based parametric comparisons;

Integrate objective functional attention or behavioral outcome indicators to enable the conversion of neuropsychological impairments into actionable policy or clinical screening guidelines.

This article provides preliminary data about the cognitive load of family ADHD; however, future research, including larger, sex-balanced, confounder-controlled, and function-linked approaches, could greatly enhance its clinical and public health significance.