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PubMed2000

Do executive function deficits differentiate between adolescents with ADHD and oppositional defiant/conduct disorder? A neuropsychological study using the Six Elements Test and Hayling Sentence Completion Test.

Two neuropsychological measures of executive functions--Six Elements Tests (SET) and Hayling Sentence Completion Test (HSCT)--were administered to 110 adolescents, aged 12-15 years. Participants comprised four groups: Attention Deficit Hyperactivity Disorder (ADHD) only (n = 35). ADHD and Oppositional Defiant Disorder/Conduct Disorder (ODD/CD) (n = 38), ODD/CD only (n = 11), and a normal community control group (n = 26). Results indicated that adolescents with ADHD performed significantly worse on both the SET and HSCT than those without ADHD, whether or not they also had ODD/CD. The adolescents with ADHD and with comorbid ADHD and ODD/CD were significantly more impaired in their ability to generate strategies and to monitor their ongoing behavior compared with age-matched controls and adolescents with ODD/CD only. It is argued that among adolescents with clinically significant levels of externalizing behavior problems, executive function deficits are specific to those with ADHD. The findings support the sensitivity of these two relatively new tests of executive functions and their ecological validity in tapping into everyday situations, which are potentially problematic for individuals with ADHD.

Adolescent↗

PubMed1998

Electroencephalographic and psychometric differences between boys with and without attention-deficit/Hyperactivity disorder (ADHD): a pilot study.

Attention-Deficit/Hyperactivity Disorder (ADHD) is reported to have an incidence of 3-5%, and is associated with a variety of interpersonal, academic, and social problem behaviors. There is controversy as to whether ADHD is a learned behavioral or brain dysfunction. Research has explored a variety of measures to assess behavioral and brain dysfunctions in this population, with no consistent and clearly diagnostic results. We investigated whether a new psychometric and a new electroencephalographic procedure would clearly differentiate ADHD. The psychometric was based on DSM-IV criteria and the EEG measure was based on the assumption that ADHD interferes with cognitive transition from one discrete task to another. Parents of four ADHD boys (ages 8-12) and four age- and interest-matched non-ADHD boys completed the ADHD Symptom Inventory, while their sons' EEG was monitored during viewing of a video and reading of a book. For the ADHD boys, this was repeated a second time, 3 months later, to assess test-retest reliability. Both the psychometric and the EEG measures clearly differentiated the two samples (p's < .01) with no overlap in scores, were reliable over 3 months (r = .87), and were significantly correlated with one another (r = .85). While a small sample size, these robust, related and reliable findings suggest that both the psychometric and the psychophysiological EEG measures deserve further replication and exploration.

Attention Deficit Disorder with Hyperactivity↗

PubMed2003

Relations between Continuous Performance Test performance measures and ADHD behaviors.

The Conners' Continuous Performance Test (CPT) is a neuropsychological task that has repeatedly been shown to differentiate ADHD from normal groups. Several variables may be derived from the Conners' CPT including errors of omission and commission, mean hit reaction time(RT), mean hit RT standard error, d', and beta. What each CPT parameter actually assesses has largely been based upon clinical assumptions and the face validity of each measure (e.g., omission errors measure inattention, commission errors measure impulsivity). This study attempts to examine relations between various CPT variables and phenotypic behaviors so as to better understand the various CPT variables. An epidemiological sample of 817 children was administered the Conners' CPT. Diagnostic interviews were conducted with parents to determine ADHD symptom profiles for all children. Children diagnosed with ADHD had more variable RTs, made more errors of commission and omission, and demonstrated poorer perceptual sensitivity than nondiagnosed children. Regarding specific symptoms, generalized estimating equations (GEE) and ANCOVAs were conducted to determine specific relationships between the 18 DSM-IV ADHD symptoms and 6 CPT parameters. CPT performance measures demonstrated significant relationships to ADHD symptoms but did not demonstrate symptom domain specificity according to a priori assumptions. Overall performance on the two signal detection measures, d' and beta, was highly related to all ADHD symptoms across symptom domains. Further, increased variability in RTs over time was related to most ADHD symptoms. Finally, it appears that at least 1 CPT variable, mean hit RT, is minimally related to ADHD symptoms as a whole, but does demonstrate some specificity in its link with symptoms of hyperactivity.

Algorithms↗

PubMed2004

Variations in anxiety and depression as a function of ADHD subtypes defined by DSM-IV: do subtype differences exist or not?

Concerns have been raised about the ability of diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) to distinguish subtypes that are clearly distinct from each other with regard to clinical correlates. One area of concern is that research regarding differences in anxiety and depression as a function of ADHD subtype has produced discrepant findings. This study was designed to systematically evaluate whether the ADHD subtypes differ with regard to level of internalizing symptoms. From a large pool of children referred to an ADHD center based in a pediatric hospital, children were differentiated into three groups: ADHD, Combined Type (ADHD/COM); ADHD, Inattentive Type (ADHD/I); and a non-ADHD, comparison group (COMP). Parent- and child-report measures using both dimensional and categorical methods were used to assess internalizing symptoms. The results indicated that children with ADHD/COM and ADHD/I had similar levels of anxiety and depression. Subtype differences related to parent-reported depression were accounted for by group differences in level of externalizing problems. The results were discussed with regard to their implications for refining the criteria used to differentiate children with ADHD into subtypes.

Adolescent↗

PubMed2006

Potential cognitive, parenting, and developmental mediators of the relationship between ADHD and depression.

The authors investigated the role of parent behavior management and locus of control in mediating the relationships between ADHD (attention-deficit/hyperactivity disorder) and depression in a community sample of 232 children with ADHD and 130 community controls. Results supported the hypothesized path models to depression for older and younger subjects. For older subjects (10 years and older), a cognitive variable, locus of control, partially mediated the relationships between ADHD and parent management and depression. In addition, parent management partially mediated the relationships of ADHD with locus of control and depression. For the younger group (under 8 years old), however, locus of control did not mediate the effects of parent management and ADHD on depression. Consistent with developmental theories, only an environment variable, parent management, explained the relationship between ADHD and depression for this younger group. For children 8-9 years old, both locus of control and parent management partially mediated the ADHD-depression relationship; however, similar to the younger children, locus of control did not mediate the parent management-depression relationships. Implications for designing interventions and prevention strategies for children with ADHD are discussed.

Age Factors↗

PubMed2005

Association of the dopamine transporter (DAT1) 10/10-repeat genotype with ADHD symptoms and response inhibition in a general population sample.

Association between attention-deficit hyperactivity disorder (ADHD) and the 10-repeat allele of the dopamine transporter gene (DAT1) has been reported in independent clinical samples using a categorical clinical definition of ADHD. The present study adopts a quantitative trait loci (QTL) approach to examine the association between DAT1 and a continuous measure of ADHD behaviours in a general-population sample, as well as to explore whether there is an independent association between DAT1 and performance on neuropsychological tests of attention, response inhibition, and working memory. From an epidemiological sample of 872 boys aged 6-11 years, we recruited 58 boys scoring above the 90th percentile for teacher reported ADHD symptoms (SWAN ADHD scale) and 68 boys scoring below 10th percentile for genotyping and neuropsychological testing. A significant association was found between the DAT1 homozygous 10/10-repeat genotype and high-scoring boys (chi(2)square=4.6, P<0.03; odds ratio=2.4, 95% CI 1.1-5.0). Using hierarchical linear regression, a significant independent association was found between the DAT1 10/10-repeat genotype and measures of selective attention and response inhibition after adjusting for age, IQ, and ADHD symptoms. There was no association between DAT1 and any component of working memory. Furthermore, performance on tasks of selective attention although associated with DAT1 was not associated with SWAN ADHD high scores after controlling for age and IQ. In contrast, impairment on tasks that tapped sustained attention and the central executive component of working memory were found in high-scoring boys after adjusting for age and IQ. The results suggest that DAT1 is a QTL for continuously distributed ADHD behaviours in the general population and the cognitive endophenotype of response inhibition.

Attention↗

PubMed2002

A decision tree and clinical paths for the assessment and management of children with ADHD.

Attention Deficit/Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder. Children with ADHD are disproportionately represented in pediatric populations characterized by school failure, criminal behavior, and substance abuse. Many children who present with ADHD symptomatology do not receive systematic assessments nor comprehensive treatment that is well coordinated across home and school environments. And yet, evidence suggests that early detection and appropriate treatment can alter the probability of a negative developmental trajectory. The Decision Tree and Clinical Paths for Assessment and Management of ADHD identify the critical components of care through a stepwise decision-making process involving the assessment, diagnosis, treatment, and outcome evaluation of children who present with ADHD symptomatology. Preliminary field testing supports the clinical utility and validity of the ADHD Decision Tree/Paths. In addition, cross-validation comparisons indicate consistency between the ADHD Decision Tree/Paths and recently released ADHD clinical guidelines issued by several national professional organizations.

Attention Deficit Disorder with Hyperactivity↗

PubMed2004

Visuo-spatial working memory span: a sensitive measure of cognitive deficits in children with ADHD.

Working memory (WM) has been hypothesised to be impaired in attention-deficit/hyperactivity disorder (ADHD). However, there are few studies reported on tests measuring visuo-spatial WM (VSWM) in ADHD. Some of these studies used paradigms including episodic memory, others only used low memory loads. In the present study we used a VSWM test that has not been used previously in ADHD research. The sensitivity of the VSWM test and a choice reaction time (CRT) test was evaluated in a pilot study by comparing them to two commonly used tests in ADHD-research; the Continuous Performance Test (CPT) and a Go/no-go test, in children with and without ADHD. The groups differed significantly in performance on the VSWM test (P < .01) and CRT (P < .05) but not on the CPT (P > .1) or on the Go/no-go test (P > .1). The results from the VSWM and CRT tests were replicated in a larger sample of participants (80 boys; 27 boys with ADHD and 53 controls, mean age 11.4 years). The difference between the groups was significant for both the VSWM test (P < .01) and the CRT test (P < .01). The effect size (ES) of the VSWM test was 1.34. There was a significant age-by-group interaction on the VSWM test, with larger group differences for the older children (P < .01). Our results show that the VSWM test is a sensitive measure of cognitive deficits in ADHD and it supports the hypothesis that deficits in VSWM is a major component of ADHD.

Adolescent↗

PubMed2006

Interference effects in a numerical Stroop paradigm in 9- to 12-year-old children with ADHD-C.

Attention deficit hyperactivity disorder (ADHD) is characterized by deficient self-regulation, poor attentional control, and poor response inhibition. To date, however, the extent to which these deficits affect basic interference control remains a matter of controversy. Secondly, ADHD has been reported to be associated with arithmetic deficits. It remains unclear whether such deficits are a secondary consequence of the above-mentioned characteristics of ADHD or whether basic numerical magnitude representations are also affected. In the present study we attempted to investigate these issues using a basic numerical interference paradigm. Nine- to twelve-year-old children with ADHD-C (attention-deficit hyperactivity-disorder combined type) and control children without ADHD (each n = 16) were presented with two digits of possibly different physical sizes (e.g., 3 7). This numerical Stroop task requires subjects to make a magnitude classification concerning either the physical or the numerical stimulus dimension. The irrelevant dimension can be congruent (same response), incongruent (different response), or neutral (no response association). Children with ADHD-C performed worse than control children in most analyses. The most important finding was a significant interaction of congruity effects with group in the numerical comparison task. Children with ADHD-C tended to show larger congruity and interference effects than controls, and these were not attributable to a speed-accuracy trade-off. The results might reflect differential processing speeds, or a different degree of automatic activation of physical and numerical magnitudes in children with and without ADHD-C. Alternative explanations, such as insufficient inhibition of selective (domain-specific) attention are also discussed.

Attention↗

PubMed2005

Utility of a CPT in diagnosing ADHD among a representative sample of high-risk children: a cautionary study.

Continuous performance tests (CPTs) are widely used in the assessment and study of attention deficit hyperactivity disorder (ADHD). Although CPTs have reliably found differences between children with ADHD and normal controls, discriminating between children with ADHD and children with subclinical levels of behavioral or cognitive problems is a more clinically relevant and difficult endeavor. Additionally, most studies use convenience samples from clinical care settings that may not represent the ADHD population as a whole. The current study assessed the utility of a clinically used CPT, the Test of Variables of Attention (TOVA), in distinguishing between children with ADHD and children with subclinical levels of attention/behavior problems. Participants constituted a representative sample of elementary school students at high risk for ADHD, including 116 children with ADHD and 51 subclinical controls. Results found no significant differences between the ADHD and subclinical group on CPT variables, and CPT performance did not reliably predict group membership. Implications of the findings are discussed.

Attention↗

PubMed1996

Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study.

OBJECTIVE: To evaluate the predictors of persistence and the timing of remission of attention-deficit hyperactivity disorder (ADHD). METHOD: Subjects were 6- to 17-year old Caucasian, non-Hispanic boys with and without ADHD. DSM-III-R structured diagnostic interviews and blind raters were used to examine psychiatric diagnoses, cognitive achievement, social, school, and family functioning at a 4-year follow-up assessment. RESULTS: At the 4-year follow-up assessment, 85% of children with ADHD continued to have the disorder and 15% remitted. Of those who remitted, half did so in childhood and the other half in adolescence. Predictors of persistence were familiality of ADHD, psychosocial adversity, and comorbidity with conduct, mood, and anxiety disorders. CONCLUSIONS: The findings prospectively confirm that the majority of children with ADHD will continue to express the disorder 4 years later. For a minority of children, ADHD was a transient disorder that remits early in development. In addition, we have shown that persistence of ADHD is predictable. Familiality, adversity, and psychiatric comorbidity may be clinically useful predictors of which children with ADHD are at risk for a persistent disorder.

Achievement↗

PubMed1997

Gender differences in ADHD: a meta-analysis and critical review.

OBJECTIVE: To quantitatively review and critically evaluate literature examining gender differences in attention-deficit hyperactivity disorder (ADHD). METHOD: A meta-analysis of relevant research based on 18 studies meeting inclusion criteria was performed. Domains evaluated included primary symptomatology, intellectual and academic functioning, comorbid behavior problems, social behavior, and family variables. RESULTS: Gender differences were not found in impulsivity, academic performance, social functioning fine motor skills, parental education, or parental depression. However, compared with ADHD boys, ADHD girls displayed greater intellectual impairment, lower levels of hyperactivity, and lower rates of other externalizing behaviors; it was not possible to evaluate the extent to which referral bias affected these findings. Some gender differences were clearly mediated by the effects of referral source; among children with ADHD identified from nonreferred populations, girls with ADHD displayed lower levels of inattention, internalizing behavior, and peer aggression than boys with ADHD, while girls and boys with ADHD identified from clinic-referred samples displayed similar levels of impairment on these variables. CONCLUSIONS: The need for future research examining gender differences in ADHD is strongly indicated, with attention to methodological limitations of the current literature, including the potential confounding effects of referral bias, comorbidity, developmental patterns, diagnostic procedures, and rater source.

Adolescent↗

PubMed1999

Evaluation of ADHD typology in three contrasting samples: a latent class approach.

OBJECTIVE: To identify subtypes of attention-deficit/hyperactivity disorder (ADHD) and characterize them as either categorical or continuous; to investigate familial resemblance for ADHD among sibling pairs; and to test the robustness of all results by using contrasting data sets. METHOD: Latent class analysis was applied to the ADHD symptom profiles obtained from parents or best informant about their offspring in 3 samples: a population-based set of female adolescent twins (724 monozygotic pairs, 594 dizygotic pairs) and male (N = 425) and female (N = 430) child and adolescent offspring ascertained from high-risk alcoholic families. RESULTS: Latent class analysis revealed 2 categories of clinically significant ADHD which were replicated in all 3 study groups: a subtype with high endorsements of ADHD inattention symptoms and a second combined type with high endorsements of both inattention and hyperactivity-impulsivity items. Both appeared to be continuous across all 3 data groups. The high-risk families contained a class in which members heavily endorsed the ADHD "fidget" item but not other ADHD items. A large proportion of the monozygotic sibs (80%) versus a smaller proportion of dizygotic sibs (52%) were assigned to the same latent class. Among the high-risk children and adolescents, 51% of the female and 41% of the male siblings were concordant for class membership. CONCLUSIONS: The pattern of latent classes suggested that ADHD consists of an inattentive and a combined subtype, within each of which lies a dimensional domain. These analyses further support that genetic factors are significant determinants of latent class membership.

Adolescent↗

PubMed1999

Response to methylphenidate in children with ADHD and comorbid anxiety.

OBJECTIVE: To determine whether comorbid anxiety alters response to methylphenidate (MPH) in children with attention-deficit hyperactivity disorder (ADHD). METHOD: Ninety-one children with ADHD were assessed for anxiety. Children were randomly assigned to receive MPH or placebo, titrated to a dose of 0.7 mg/kg, while side effects were minimized. Measures of side effects and behavioral response were obtained from parents and teachers before treatment, after titration to optimal dose, and after 4 months of treatment. These measures, dose of drug, and rate of adherence to assigned medication assignment were compared for nonanxious (ADHD- ANX) and anxious ADHD children (ADHD+ ANX). RESULTS: Rates of adherence to original medication assignment did not differ between the groups. ADHD+ ANX on both MPH and placebo titrated to a lower dose at the end of titration, although the dose of drug did not differ among the groups after 4 months of treatment. No differential response to MPH between ADHD+ ANX and ADHD- ANX was noted at end-titration or at 4 months on any side effect or behavioral measures. CONCLUSIONS: Comorbid anxiety does not appear to influence development of side effects or behavioral response to MPH when dose is titrated as in standard clinical practice.

Anxiety Disorders↗

PubMed1999

Are stimulants overprescribed? Treatment of ADHD in four U.S. communities.

OBJECTIVE: To address rising concerns about the possible overdiagnosis of attention-deficit hyperactivity disorder (ADHD) and overtreatment with stimulants. To date, almost no studies have examined ADHD in unbiased community-based studies, ascertaining both the prevalence of the diagnosis within nonreferred populations and the extent to which various treatments (i.e., stimulant medication, mental health treatments, and educational interventions) are used. METHOD: As a part of the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study, the authors examined epidemiological survey data obtained from 1,285 children and their parents across 4 U.S. communities. Analyses examined the frequency of children's ADHD diagnosis, the extent to which medications were prescribed, as well as the provision of other services (e.g., psychosocial treatments, school-based educational interventions). RESULTS: Findings indicated that 5.1% of children met full DSM-III-RADHD criteria across the pooled sample. Only 12.5% of children meeting ADHD criteria had been treated with stimulants during the previous 12 months. Some children who had been prescribed stimulants did not meet full ADHD diagnostic criteria, but these children manifested high levels of ADHD symptoms, suggesting that the medication had been appropriately prescribed. Children with ADHD were generally more likely to receive mental health counseling and/or school-based interventions than medication. CONCLUSIONS: Medication treatments are often not used in treating ADHD children identified in the community, suggesting the need for better education of parents, physicians, and mental health professionals about the effectiveness of these treatments. On the basis of these data it cannot be concluded that substantial "overtreatment" with stimulants is occurring across communities in general.

Adolescent↗

PubMed2001

Symptom profiles in children with ADHD: effects of comorbidity and gender.

OBJECTIVE: To examine ratings and objective measures of attention-deficit/hyperactivity disorder (ADHD) symptoms to assess whether ADHD children with and without comorbid conditions have equally high levels of core symptoms and whether symptom profiles differ as a function of comorbidity and gender. METHOD: Four hundred ninety-eight children from the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder (MTA) were divided into comorbid groups based on the parent Diagnostic Interview Schedule for Children and assessed via parents' and teachers' Swanson, Nolan, and Pelham (SNAP) ratings and a continuous performance test (CPT). Comorbidity and gender effects were examined using analyses of covariance controlled for age and site. RESULTS: CPT inattention, impulsivity, and dyscontrol errors were high in all ADHD groups. Children with ADHD + oppositional defiant or conduct disorder were rated as more impulsive than inattentive, while children with ADHD + anxiety disorders (ANX) were relatively more inattentive than impulsive. Girls were less impaired than boys on most ratings and several CPT indices, particularly impulsivity, and girls with ADHD + ANX made fewer CPT impulsivity errors than girls with ADHD-only. CONCLUSIONS: Children with ADHD have high levels of core symptoms as measured by rating scales and CPT, irrespective of comorbidity. However, there are important differences in symptomatology as a function of comorbidity and gender.

Analysis of Variance↗

PubMed2001

Oculomotor abnormalities in boys with tourette syndrome with and without ADHD.

OBJECTIVE: To assess saccadic eye movements in boys with Tourette syndrome (TS) with and without attention-deficit hyperactivity disorder (ADHD), comparing performance with that of an age-matched group of male controls. METHOD: Three different saccade tasks (prosaccades, antisaccades, and memory-guided saccades) were used to examine functions necessary for the planning and execution of eye movements, including motor response preparation, response inhibition, and working memory. The study included 14 boys with TS without ADHD (TS-only), 11 boys with TS and ADHD (TS+ADHD), and 10 male controls. RESULTS: Latency of prosaccades was prolonged in boys with TS (both with and without ADHD) compared with controls. Variability in prosaccade latency was greater in the groups of boys with TS+ADHD compared with both the TS-only and control groups. Response inhibition errors on both the antisaccade task (directional errors) and memory-guided saccade task (anticipatory errors) were increased in boys with TS+ADHD compared with those with TS-only. There were no significant differences among the three groups in accuracy of memory-guided saccades. CONCLUSIONS: Oculomotor findings suggest that TS is associated with delay in initiation of motor response as evidenced by excessive latency on prosaccades. Signs of impaired response inhibition and variability in motor response appear to be associated with the presence of ADHD.

Attention Deficit Disorder with Hyperactivity↗

PubMed2003

Correlates of comorbid psychopathology in children with ADHD.

OBJECTIVE: To investigate correlates of internalizing and externalizing psychopathology in a clinical sample of children with attention-deficit/hyperactivity disorder (ADHD). METHOD: Parent and teacher Child Behavior Checklists were administered to 300 children with ADHD to ascertain comorbid symptoms. Based on previous research, a seven-step hierarchical regression analysis was developed. Six hierarchical regression analyses were conducted with either parent or teacher Child Behavior Checklist aggression, delinquency, or anxious/depressive comorbid symptoms as dependent measures. RESULTS: Controlling for (1) variables known to increase risk for ADHD child psychopathology and (2) estimated duration of ADHD, our results suggest that the presence of comorbid symptoms is influenced by age of onset. An early age of onset of ADHD was correlated with a greater rate of parent-reported child aggressive symptoms, and a later age of onset was correlated with a greater rate of parent-reported child anxious/depressive symptoms. Elevated levels of comorbid externalizing and internalizing symptoms are associated with greater ADHD symptom severity. CONCLUSIONS: Comorbid externalizing and internalizing symptoms are correlated with age of ADHD onset and are related to the severity of clinical presentation in a referred sample of children with ADHD.

Age of Onset↗