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PubMed2005

Substance abuse in patients with attention-deficit hyperactivity disorder : therapeutic implications.

Attention-deficit hyperactivity disorder (ADHD) is a common disorder in children that frequently persists into adulthood. Studies have found that substance use disorders (SUD) are seen more commonly in those with ADHD than the general population. Although treatment with stimulant medications has been shown to be effective for individuals with ADHD, concern about the use of these agents in this population persists. This review article highlights the research in this area with a focus on the treatment of individuals who present with concomitant ADHD and SUD. Although stimulants can be abused, studies have shown that adolescents who are prescribed stimulants for ADHD have lower rates of SUD than those who are not treated with stimulants. It may be particularly difficult to evaluate adults for the diagnosis of ADHD when SUD is a co-morbid factor. Studies show that 20--30% of adults presenting with SUD have concomitant ADHD and approximately 20--40% of adults with ADHD have histories of SUD. Therefore, it is critical to perform careful diagnostic interviews to discern if patients have either or both of these disorders. Many clinical experts suggest that adults with ADHD and active SUD be treated for the SUD until a period of sobriety persists prior to initiation of specific treatment for ADHD. Since individuals with ADHD and active SUD are more likely to have more severe SUD and a worse prognosis, this approach may not serve many patients, as they relapse prior to obtaining ADHD treatment. Therefore, research has been directed towards determining if the treatment of ADHD with stimulant medications can be safe and effective for the individual with active SUD and concomitant ADHD. An initial trial of methylphenidate in a population of adults with active cocaine dependence and ADHD indicates that this is the case. Individuals with ADHD and SUD can present difficult diagnostic and therapeutic challenges. It appears that the most effective treatment option is to create a programme that uses the most effective treatment modalities available, including both behavioural and medical therapies, along with close supervision and monitoring. Newer medical treatment options of long-acting stimulants and non-stimulants (e.g. atomoxetine) offer effective treatment with a lower risk of abuse potential.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Inner control as an operational mechanism in attention deficit hyperactivity disorder.

Understanding children with attention deficit hyperactivity disorder (ADHD) through a systems theory perspective creates a view of these children as having developed ineffective systems and strategies for acting upon the world. It is proposed that just as a child must develop a system of inner control to become a proficient and independent reader, this same system is necessary for effectively controlling the problematic behaviors associated with ADHD. Speech-language pathologists (SLPs) can encourage the development of this inner control by providing services that foster meaning-based literacy and that enhance visual perception and processing strategies. As SLPs and educators seek to establish and employ embedded literacy activities, they will more effectively meet the needs of their students identified with ADHD.

Attention Deficit Disorder with Hyperactivity↗

PubMed1994

Foods and additives are common causes of the attention deficit hyperactive disorder in children.

The attention deficit hyperactive disorder (ADHD) is a neurophysiologic problem that is detrimental to children and their parents. Despite previous studies on the role of foods, preservatives and artificial colorings in ADHD this issue remains controversial. This investigation evaluated 26 children who meet the criteria for ADHD. Treatment with a multiple item elimination diet showed 19 children (73%) responded favorably, P < .001. On open challenge, all 19 children reacted to many foods, dyes, and/or preservatives. A double-blind placebo controlled food challenge (DBPCFC) was completed in 16 children. There was a significant improvement on placebo days compared with challenge days (P = .003). Atopic children with ADHD had a significantly higher response rate than the nonatopic group. This study demonstrates a beneficial effect of eliminating reactive foods and artificial colors in children with ADHD. Dietary factors may play a significant role in the etiology of the majority of children with ADHD.

Analysis of Variance↗

PubMed2003

Abnormal rhythmic motor response in children with attention-deficit-hyperactivity disorder.

Children with attention-deficit-hyperactivity disorder (ADHD) have difficulties with motor control, inhibition of motor responses, motor flexibility, and motor preparedness. We proposed that motor abnormalities in ADHD might result, at least in part, from an abnormal neuronal oscillatory mechanism necessary for motor temporal regulation. The aim of this study was to assess pacing in children with ADHD, by testing for rhythmic abnormalities of motor activity using a tapping test. Twenty-seven children (21 males, six females; aged 6 to 14 years 6 months; mean age 11 years 4 months, SD 2 years 2 months) diagnosed with ADHD according to DSM-IV clinical criteria, and 33 controls (25 males, eight females; aged 6 to 14 years 6 months; mean 11 years 1 month, SD 2 years 2 months), underwent a finger-tapping test requiring rhythmic responses to frequencies from 1 to 6 Hz. All participants who were treated on a daily basis with methylphenidate (n = 22) were medication-free on the day of the test. Most of the children with ADHD responded at a constant rate regardless of stimulus frequency, a phenomenon only seen in a small number of the controls. This specific error pattern, also seen in Parkinson's disease, has been attributed to an abnormal oscillatory mechanism mediated by dopaminergic fronto-striatal circuitry, which might also be pathophysiologically relevant for ADHD.

Adolescent↗

PubMed2003

Inhibitory control of eye movements during oculomotor countermanding in adults with attention-deficit hyperactivity disorder.

Children with attention-deficit hyperactivity disorder (ADHD) are impulsive, and that impulsiveness can be measured using a countermanding task. Although the overt behaviors of ADHD attenuate with age, it is not clear how well impulsiveness is controlled in adults with ADHD. We tested ADHD adults with an oculomotor countermanding task. The task included two conditions: on 75% of the trials, participants viewed a central fixation marker and then looked to an eccentric target that appeared simultaneous with the disappearance of the fixation marker; on 25% of the trials, a signal was presented at variable delays after target appearance. The signal instructed subjects to stop, or countermand, an eye movement to the target. A correct movement in this case would be to hold gaze at the central fixation location. We expected ADHD participants to be impulsive in their countermanding performance. Additionally, we expected that a visual stop signal at the central fixation location would assist oculomotor countermanding because the signal is presented in the "stop" location, at fixation. To test whether a central stop signal positively biased countermanding, we used a three types of stop signal to instruct the stop: a central visual marker, a peripheral visual signal, and a non-localized sound. All subjects performed best with the central visual stop signal. Subjects with ADHD were less able to countermand eye movements and were influenced more negatively by the non-central signals. Oculomotor countermanding may be useful for quantifying impulsive dysfunction in adults with ADHD especially if a non-central stop signal is applied.

Acoustic Stimulation↗

PubMed1991

Diagnostic efficiency of symptoms for oppositional defiant disorder and attention-deficit hyperactivity disorder.

We examined the diagnostic efficiency of symptoms for experimentally diagnosed oppositional defiant disorder (OD) and attention-deficit hyperactivity disorder (ADHD), and for their differential diagnosis, in a nonreferred sample. More specifically, we used four conditional probability indices--positive predictive power, negative predictive power, sensitivity, and specificity--in an attempt to evaluate the diagnostic efficiency of these symptoms. Teacher ratings of OD and ADHD symptoms were gathered on 102 boys, ages 8 to 12. On average, ADHD symptoms were as useful as OD symptoms as exclusion criteria for OD, while OD symptoms were nearly as effective as ADHD symptoms as inclusion criteria for ADHD. Nonetheless, a number of OD and ADHD symptoms appeared to be useful as both inclusion and exclusion criteria for their respective disorders. These findings illustrate the utility of conditional probability indices in both the diagnosis and differentiation of childhood disorders.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Attention deficit hyperactivity disorder and suicide: a review of possible associations.

OBJECTIVE: To review the evidence of a possible association between attention deficit hyperactivity disorder (ADHD) and suicide. DESIGN: We searched the electronic data bases: Medline, Psych LIT, between 1966 and March 2003 looking for articles on ADHD, attention deficit disorder, hyperactivity and suicide. RESULTS: An association of ADHD and completed suicide was found, especially for younger males. However, the evidence for any direct or independent link was modest with an overall suicide rate from long-term follow-up studies of ADHD of 0.63-0.78%. The estimated relative risk ratio, compared with US national suicide rates (males 5-24 years) is 2.91 (95% confidence interval 1.47-5.7, chi2 = 9.3, d.f. = 1, P = 0.002). ADHD appears to increase the risk of suicide in males via increasing severity of comorbid conditions, particularly conduct disorder (CD) and depression. CONCLUSION: Identification of those at risk, particularly males with comorbid ADHD, depression and CD, may represent a useful clinical means of reducing completed suicide.

Adolescent↗

PubMed2006

[Neuropsychological disorders in teenagers with attention deficit hyperactivity disorder].

AIMS: The aim of this study is to report on the neuropsychological aspects of teenage patients with attention deficit hyperactivity disorder (ADHD), namely disorders affecting attention, memory, the executive functions and language. We also discuss how to perform neuropsychological and functional evaluation of the systems involved in attention, by means of haemodynamic (functional magnetic resonance imaging) and neurophysiological (magnetoencephalography) techniques. The comorbidities that most frequently occur in teenage patients with ADHD are also described. DEVELOPMENT: The fundamental symptoms, that is to say, inattention, hyperactivity and impulsiveness, continue to be present in the teenager with ADHD, although with mild variations, and are probably dependent on each individual's own genetic load. The disorders most commonly associated with ADHD are oppositional defiant disorder (33%), conduct disorders (25%), anxiety (25%), learning disabilities (22%) and depression (22%). CONCLUSIONS: During adolescence, patients with ADHD usually suffer disorders that are secondary to their inability to process information efficiently due to the inadequate development of the executive functions. The lack of inhibitory control and a poor capacity to learn from their own mistakes facilitate the appearance of comorbid neuropsychiatric disorders.

Adolescent↗

PubMed2003

Assessment and treatment of attention deficit hyperactivity disorder in children with comorbid psychiatric illness.

PURPOSE OF REVIEW: Attention deficit hyperactivity disorder (ADHD) frequently occurs with a wide variety of comorbid psychiatric disorders such as conduct disorder, depression, mania, anxiety, and learning disabilities. Because the vast majority of children with ADHD are treated in primary care settings, it is important that primary medical doctors be proficient in the diagnosis and initial treatment of children with ADHD and its commonly occurring comorbid disorders. ADHD research is beginning to focus on the treatment of these comorbidly ill children. This review will summarize the recent findings from the psychiatric literature in an attempt to provide the clinician with some initial diagnostic and treatment guidelines for ADHD and its comorbidities. RECENT FINDINGS: The NIMH Multimodal Treatment Study of ADHD found that children with other disruptive behavior disorders plus ADHD respond well to stimulant medications, with behavioral interventions reducing academic and social impairment. Children with anxiety and ADHD are very responsive across multiple dimensions to behavioral and pharmacological ADHD treatments. Much less is known about the impact of depression on ADHD, and significant debate exists surrounding the identification and treatment of bipolar disorder in children with ADHD. Children with learning disabilities respond well to stimulants but often require additional educational supports. New findings suggest that treating ADHD may prevent the development of future psychiatric disorders. SUMMARY: The presence of comorbid illness is associated with significant additional morbidity and complicates the diagnosis, treatment, and prognosis of ADHD. Therefore, it is important to identify and treat any comorbid psychiatric conditions in a child with ADHD.

Antidepressive Agents, Second-Generation↗

PubMed1992

Further evidence for family-genetic risk factors in attention deficit hyperactivity disorder. Patterns of comorbidity in probands and relatives psychiatrically and pediatrically referred samples.

We examined 140 probands with attention deficit hyperactivity disorder, 120 normal controls, and their 822 first-degree relatives using "blind" raters and structured diagnostic interviews. Compared with controls, probands with attention deficit hyperactivity disorder were more likely to have conduct, mood, and anxiety disorders. Compared with relatives of controls, relatives of probands with attention deficit hyperactivity disorder had a higher risk for attention deficit hyperactivity disorder, antisocial disorders, major depressive disorder, substance dependence, and anxiety disorders. Patterns of comorbidity indicate that attention deficit hyperactivity disorder and major depressive disorders may share common familial vulnerabilities, that attention deficit hyperactivity disorder plus conduct disorder may be a distinct subtype, and that attention deficit hyperactivity disorder and anxiety disorders are transmitted independently in families. These results extend previous findings indicating family-genetic influences in attention deficit hyperactivity disorder by using both pediatrically and psychiatrically referred proband samples. The distributions of comorbid illnesses in families provide further validation for subgrouping probands with attention deficit hyperactivity disorder by comorbidity.

Adolescent↗

PubMed2002

Clinical implications of a link between fetal alcohol spectrum disorder and attention-deficit hyperactivity disorder.

OBJECTIVE: To provide an overview of the animal and human research literature on the link between fetal alcohol spectrum disorder (FASD) and attention-deficit hyperactivity disorder (ADHD). METHOD: We conducted a comprehensive literature review that addressed the history of, and current research on, fetal alcohol syndrome (FAS) and FASD, as well as that on ADHD in children. RESULTS: In animal and human research, there is emerging clinical, neuropsychological, and neurochemical evidence of a link between FASD and ADHD. CONCLUSIONS: The evidence of the link between these 2 conditions has implications for clinical management. The clinical quality of ADHD in children with FASD often differs from that of children without FASD. For children with FASD, ADHD is more likely to be the earlier-onset, inattention subtype, with comorbid developmental, psychiatric, and medical conditions. Children with FASD are commonly not mentally retarded but present complex learning disabilities, especially a mixed receptive-expressive language disorder with deficits in social cognition and communication (reminiscent of sensory aphasia and apraxia), working memory problems, and frequently, a mathematics disorder. Comorbid psychiatric conditions include anxiety, mood, conduct, or explosive disorders. As well, cardiac, renal, or skeletal problems are more likely to be present. Because these children have a disturbance in brain neurochemistry, or even brain structure (that is, in the corpus callosum), their response to standard psychostimulant medication can be quite unpredictable.

Animals↗

PubMed1994

Neuropsychiatric and neuropsychological findings in conduct disorder and attention-deficit hyperactivity disorder.

Neuropsychiatric and neuropsychological evaluations were performed in a pilot study of adolescents with DSM-III-R disruptive behavior disorders, including conduct disorder (CD) and attention-deficit hyperactivity disorder (ADHD). The following comparisons were made: 1) CD comorbid with ADHD vs. CD only; 2) all subjects with ADHD vs. all non-ADHD; and 3) all subjects with CD vs. all non-CD. The CD + ADHD group had increased left-sided soft signs compared with the CD group. CD + ADHD subjects significantly underperformed CD subjects on several executive functioning measures, with no differences on Verbal IQ subtests. Results are discrepant with previous findings of deficient verbal functioning in delinquent populations. However, findings may not be generalizable because of sampling limitations.

Adolescent↗

PubMed2004

[Nocturnal polysomnographic study in children with attention deficit hyperactivity disorder].

INTRODUCTION: The main symptoms of attention deficit hyperactivity disorder (ADHD) are attention deficit, hyperactivity and impulsivity. Its prevalence lies between 3 and 5% in schoolchildren. Children with ADHD can present a high prevalence rate of comorbidity. A timely diagnosis and treatment can modify the educational and psychosocial development of most of these children. A number of subjective reports (especially from parents) describe sleep disorders. The objective verification of these disorders and the exact nature of the sleep problems are still to be determined and the purpose of this study is to deal with these issues. PATIENTS AND METHODS: We studied a sample of 48 children (9 females and 39 males) with a mean age of 8 (SD: 2.59) who met DSM IV criteria. They were submitted to a general exploration as well as a neurological exploration, including their patient record, and then they were evaluated using the DSM IV, which was carried out by parents and teachers (in order to evaluate two different environments), and a nocturnal polysomnographic study. In the sample there were 26 children with predominant attention deficit type ADHD (ADHD/AD); 4 children with predominant hyperactivity impulsivity type ADHD (ADHD/H); and 18 children with combined type ADHD (ADHD/C). RESULTS: The most frequently diagnosed subtype is the attention deficit subtype. The sleep architecture of children with ADHD presents the most consistent differences as compared to normal children in an increase in the percentage of phase 3 of sleep and, consequently, an increase in the percentage of slow sleep. Epileptiform type paroxysms were observed in 16.7% of the children who presented symptoms of ADHD. The number of epileptiform paroxysms is more usual in the attention deficit subtype. CONCLUSIONS: The increase in phase 3 may be related to the alterations in noradrenaline and dopamine transmission present in children who suffer from ADHD. Some children with ADHD can have a region of the brain with intense epileptic activity, which does not trigger epileptic seizures but gives rise to behavioural disorders, learning disorders and language problems.

Adolescent↗

PubMed2003

High-dose methylphenidate treatment of attention deficit hyperactivity disorder in a preschooler.

Although attention deficit hyperactivity disorder is thought to be present in preschoolers, there are no clear guidelines for dosing stimulant medications in this population. This is a case of a 4-year-old boy who was given 108 mg/day extended-release methylphenidate (OROS) MPH) (6.1 mg/kg/day) by his caregiver with notable behavioral improvement. However, weight loss incurred due to the anorexic side effect of the medication led the clinician to decrease his dose to 72 mg/day OROS MPH (3.7 mg/kg/day). The case highlights that some young children with attention deficit hyperactivity disorder treated with MPH may require higher doses than would be predicted by weight-based dosing. An increased frequency of side effects associated with high doses of MPH necessitates that the clinician balance the positive behavioral response of the medication with adverse side effects in determining ideal dose.

Attention Deficit Disorder with Hyperactivity↗

PubMed2006

The cognitive genetics of attention deficit hyperactivity disorder (ADHD): sustained attention as a candidate phenotype.

Here we describe the application of cognitive genetics to the study of attention deficit hyperactivity disorder (ADHD). Cognitive genetics owes much to the pioneering work of cognitive neuropsychologists such as John Marshall, whose careful observations of cognitive dissociations between brain-lesioned patients greatly advanced the theoretical understanding of normal cognitive function. These theories have in turn helped to constrain linkages between candidate genes and cognitive processes and thus help to drive the relatively new field of cognitive genetics in a hypothesis-driven fashion. We examined the relationship between sustained attention deficits in ADHD and genetic variation in a catecholamine-related gene, dopamine beta hydroxylase (DbetaH). DBH encodes the enzyme that converts dopamine to noradrenaline and is crucial to catecholamine regulation. A polymorphism with the DBH gene has been associated with ADHD. In fifty-two children with ADHD, we examined whether variation in the Taq I DBH gene polymorphism was related to sustained attention performance. Participants performed the Sustained Attention to Response Test (SART). Performance on the SART discriminates ADHD from control children, and in imaging work, is associated with right frontoparietal activation. A significant effect of DBH genotype was found on SART performance measures. Children possessing two copies of the ADHD-associated risk allele (A2) had significantly poorer sustained attention than those ADHD children who did not possess this allele or a non-genotyped control group. The DBH gene may contribute to the susceptibility for ADHD, in part because of its varying effects on the development of brain mechanisms mediating sustained attention.

Adolescent↗

PubMed2004

Impaired habituation in children with attention deficit hyperactivity disorder.

OBJECTIVE: To investigate whether children with attention deficit hyperactivity disorder show impaired habituation to peripheral stimuli. METHOD: We compared the Troxler effect (the ability to habituate to a peripheral visual stimulus when presented with a competing central visual stimulus) in groups of 23 children with attention deficit hyperactivity disorder and 15 controls matched for age, gender, and IQ. RESULTS: Regression analyses revealed a statistically significant effect of diagnosis on fading (P = 0.03), with attention deficit hyperactivity disorder subjects taking longer to fade to a peripheral stimulus than controls. Additional analyses revealed a significant interaction between diagnosis and visual field; control subjects showed similar fading times to stimuli presented in the right and left visual fields (13.25 vs. 12.96 seconds), while the attention deficit hyperactivity disorder group showed much slower fading in the right than in the left visual field (18.64 vs. 15.00 seconds). CONCLUSIONS: Our results suggest that children with attention deficit hyperactivity disorder have impaired visual habituation. The findings provide evidence of frontal dysfunction in attention deficit hyperactivity disorder and suggest that impaired habituation contributes to off-task behavior in children with the disorder.

Attention Deficit Disorder with Hyperactivity↗

PubMed2006

The impact of attention deficit hyperactivity disorders on brainstem dysfunction in nocturnal enuresis.

PURPOSE: In a specialized university setting the prevalence of attention deficit hyperactivity disorder in general and particularly the inattentive subtype attention deficit hyperactivity disorder of the predominantly inattentive subtype is highly increased. We replicated previous research findings that enuresis is associated with a brainstem deficit and investigated the impact of attention deficit hyperactivity disorder on this brainstem deficit in enuresis. MATERIALS AND METHODS: Electromyography recorded startle eye blink modification with and without attentional modulation was used to measure brainstem functioning in 158 children between 6 and 12 years old. Performance in 3 enuresis groups, including children with enuresis, enuresis plus attention deficit hyperactivity disorder of the predominantly inattentive subtype and enuresis plus attention deficit hyperactivity disorder combined, respectively, was compared with that in normally developing controls and in children with attention deficit hyperactivity disorder subtypes without enuresis. RESULTS: In an automatic attentional task the enuresis groups showed decreased brainstem inhibition compared to that in the control and attention deficit hyperactivity disorder groups (p <0.006). In a controlled attentional task children with and without enuresis who had attention deficit hyperactivity disorder of the predominantly inattentive subtype were unable to show attentional modulation in all age groups (p <0.02). CONCLUSIONS: Startle eye blink modification research reveals a brainstem inhibition deficit in children with enuresis, which could explain why they are unable to remain dry at night. When additional attention is allocated to specific trials in the task, children with attention deficit hyperactivity disorder of the predominantly inattentive subtype fail to optimize sensory gating. With respect to enuresis, this could result in an identification problem of bladder signals, leading to an inadequate or absent arousal effect in attention deficit hyperactivity disorder of the predominantly inattentive subtype.

Attention Deficit Disorder with Hyperactivity↗

PubMed2002

Epileptiform abnormalities in children with attention-deficit-hyperactivity disorder.

The proportion of children with attention-deficit-hyperactivity disorder and epileptiform abnormalities is compared with an historic control group of normal school-aged children. The medical records of 655 children 5-16 years of age referred to a single pediatric neurologist (M.S.) from January 1991 to December 1999 with school problems, behavior problems, or hyperactivity were retrospectively reviewed. Clinical criteria for attention-deficit-hyperactivity disorder were satisfied in 476 of these children. An electroencephalogram was obtained from 347 patients and coded as epileptiform in 6.1 +/- 1.3%, which is significantly higher (chi-square test, P < 0.025) than the prevalence rate of 3.5 +/- 0.6% observed in a study of 3,726 normal school-aged children. The epileptiform abnormality was present only with activation procedures in six of our patients (hyperventilation [n = 2] and photic stimulation [n = 4]). Only three of the 21 children with epileptiform abnormalities developed a seizure disorder in our cohort. We conclude that the prevalence rate of epileptiform abnormalities is greater in children with attention-deficit-hyperactivity disorder compared with that observed in normal school-aged children when hyperventilation and photic stimulation are used. However, the clinical utility of routine electroencephalography in the diagnosis of a comorbid seizure disorder in children with attention-deficit-hyperactivity disorder is limited.

Attention Deficit Disorder with Hyperactivity↗