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PubMed2003

Psychiatric comorbidities in children with attention deficit hyperactivity disorder: implications for management.

Attention deficit hyperactivity disorder (ADHD) is frequently comorbid with a variety of psychiatric disorders. These include oppositional defiant disorder and conduct disorder (CD), as well as affective, anxiety, and tic disorders. ADHD and ADHD with comorbid CD appear to be distinct subtypes; children with ADHD/CD are at higher risk of antisocial personality and substance abuse as adults. Stimulants are often effective treatments for aggressive or antisocial behavior in patients with ADHD, but mood stabilizers or atypical antipsychotics may be used to treat explosive aggressive outbursts. Response to stimulants is not affected by comorbid anxiety, but children with ADHD/anxiety disorder may show greater benefit from psychosocial interventions than those with ADHD alone. The degree of prevalence of major depressive disorder (MDD) and bipolar disorder among children with ADHD is controversial, but a subgroup of severely emotionally labile ADHD children who present serious management issues for the clinician clearly exists. Antidepressants may be used in conjunction with stimulants to treat MDD, while mood stabilizers and atypical antipsychotics are often required to treat manic symptoms or aggression. After resolution of the manic episode, stimulant treatment of the comorbid ADHD may be safely undertaken. Recent research suggests that stimulants can be safely used in children with comorbid ADHD and tic disorders, but the addition of anti-tic agents to stimulants is often necessary. Clinicians who work with patients with ADHD should be prepared to deal with a wide range of emotional and behavioral problems beyond the core symptoms of inattention and impulsivity/hyperactivity.

Attention Deficit Disorder with Hyperactivity↗

PubMed2005

Computerized training of working memory in children with ADHD--a randomized, controlled trial.

OBJECTIVE: Deficits in executive functioning, including working memory (WM) deficits, have been suggested to be important in attention-deficit/hyperactivity disorder (ADHD). During 2002 to 2003, the authors conducted a multicenter, randomized, controlled, double-blind trial to investigate the effect of improving WM by computerized, systematic practice of WM tasks. METHOD: Included in the trial were 53 children with ADHD (9 girls; 15 of 53 inattentive subtype), aged 7 to 12 years, without stimulant medication. The compliance criterion (>20 days of training) was met by 44 subjects, 42 of whom were also evaluated at follow-up 3 months later. Participants were randomly assigned to use either the treatment computer program for training WM or a comparison program. The main outcome measure was the span-board task, a visuospatial WM task that was not part of the training program. RESULTS: For the span-board task, there was a significant treatment effect both post-intervention and at follow-up. In addition, there were significant effects for secondary outcome tasks measuring verbal WM, response inhibition, and complex reasoning. Parent ratings showed significant reduction in symptoms of inattention and hyperactivity/impulsivity, both post-intervention and at follow-up. CONCLUSIONS: This study shows that WM can be improved by training in children with ADHD. This training also improved response inhibition and reasoning and resulted in a reduction of the parent-rated inattentive symptoms of ADHD.

Attention Deficit Disorder with Hyperactivity↗

PubMed1999

Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use disorder.

OBJECTIVE: To assess the risk for substance use disorders (SUD) associated with previous exposure to psychotropic medication in a longitudinal study of boys with attention-deficit/hyperactivity disorder (ADHD). METHODS: The cumulative incidence of SUD throughout adolescence was compared in 56 medicated subjects with ADHD, 19 nonmedicated subjects with ADHD, and 137 non-ADHD control subjects. RESULTS: Unmedicated subjects with ADHD were at a significantly increased risk for any SUD at follow-up compared with non-ADHD control subjects (adjusted OR: 6.3 [1.8-21.6]). Subjects with ADHD medicated at baseline were at a significantly reduced risk for a SUD at follow-up relative to untreated subjects with ADHD (adjusted OR: 0.15 [0.04-0.6]). For each SUD subtype studied, the direction of the effect of exposure to pharmacotherapy was similar to that seen for the any SUD category. CONCLUSIONS: Consistent with findings in untreated ADHD in adults, untreated ADHD was a significant risk factor for SUD in adolescence. In contrast, pharmacotherapy was associated with an 85% reduction in risk for SUD in ADHD youth.

Adolescent↗

PubMed2000

Failure to replicate an association between the catechol-O-methyltransferase polymorphism and attention deficit hyperactivity disorder in a second, independently recruited Israeli cohort.

Attention deficit hyperactivity disorder (ADHD) is a developmental syndrome expressed along three domains: inattention, hyperactive-impulsive, and combined type. Both environmental and genetic factors contribute to the etiology of this complex disease. We previously reported an association in 48 ADHD triads (both parents and proband) between the catechol-O-methyl- transferase (COMT) polymorphism (especially the high enzyme activity val allele) and the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) combined category (excluding inattention) of ADHD (however, see erratum, Am. J. Med. Genet. [Neuropsychiatr. Genet.] 96:893). In the current report, we attempted to replicate this finding in an independently recruited group of 70 nuclear families using the haplotype relative risk design. In the current investigation, no evidence for association of the COMT polymorphism and ADHD (or any of the DSM IV subtypes) was observed in either the current cohort or the expanded cohort of 118 Israeli triads. Am. J. Med. Genet. (Neuropsychiatr. Genet.) 96:858-860, 2000.

Attention Deficit Disorder with Hyperactivity↗

PubMed1999

Paired-associate learning in attention-deficit/hyperactivity disorder as a function of hyperactivity-impulsivity and oppositional defiant disorder.

A paired-associate learning (PAL) test was administered to 22 community volunteers without disruptive disorders and 197 children (7.5-13.5 years-old) presenting with the inattentive and combined subtypes of attention-deficit/hyperactivity disorder (ADHD) either in combination with or without oppositional defiant disorder (ODD). Participants were screened for learning disorders. In comparison to non-ADHD participants, children with ADHD achieved worse PAL and made errors rated as more acoustically and less semantically similar to the correct paired associates. These deficits were not related to hyperactivity-impulsivity or comorbid ODD. These results suggest that ADHD children are less competent at PAL and use less efficient learning strategies than their non-ADHD peers.

Adolescent↗

PubMedDate not supplied

Information processing deficits in children with attention-deficit/hyperactivity disorder, inattentive type, and children with reading disability.

We examined the information processing capabilities of children diagnosed with the inattentive subtype of attention-deficit/hyperactivity disorder (ADHD) who had been characterized as having a sluggish cognitive tempo. Children referred for school-related problems (n = 81) and nonreferred community controls (n = 149) participated. Of the referred children, 24 met criteria for ADHD, 42 met criteria for reading disability (RD), and 9 of these were comorbid for RD and ADHD. Children with ADHD differed from those without ADHD on a visual search task but not on an auditory processing task; the reverse was true for children with RD. Decomposition of the visual search task into component operations demonstrated that children in the ADHD group had a slow processing rate that was not attributable to inattention. The children with ADHD were not globally poor at information processing or inattentive, but they demonstrated diminished speed of visual processing.

Attention Deficit Disorder with Hyperactivity↗

PubMed2005

Comparison of DSM-IV symptoms in elementary school-age children with PDD versus clinic and community samples.

This study compares DSM-IV symptoms in children (ages 6 to 12 years) with pervasive developmental disorder (PDD), clinic controls, and community-based samples. Parents/teachers completed the Child Symptom Inventory-4 for four samples: PDD (N = 284/284) and non-PDD psychiatric clinic referrals (N = 189/181) and pupils in regular (N = 385/404) and special (N = 61/60) education classes. The PDD group received higher symptom severity ratings than the regular education group, but was similar to the non-PDD clinic sample. Screening prevalence rates were highest for ADHD, ODD, and generalized anxiety disorder. PDD subtypes exhibited differentially higher rates of psychiatric symptoms. The magnitude of rater and gender differences in symptom severity ratings was modest. Clinic-referred children with PDD exhibit a pattern of psychiatric symptoms highly similar to nonPDD clinic referrals. Although much additional research is needed on comorbidity, these symptoms have important treatment implications.

Anxiety Disorders↗

PubMed2001

Symptom properties as a function of ADHD type: an argument for continued study of sluggish cognitive tempo.

Inconsistent alertness and orientation (sluggishness, drowsiness, daydreaming) were reported to accompany Attention Deficit Disorder (ADD) without Hyperactivity in DSM-III. Such Sluggish Cognitive Tempo items were tested in the DSM-IV Field Trial for ADHD, but were discarded from the Inattention symptom list because of poor negative predictive power. Using 692 children referred to a pediatric subspecialty clinic for ADHD, Sluggish Tempo items were re-evaluated. When Hyperactivity-Impulsivity was absent (i.e., using only cases of Inattentive Type plus clinic controls), Sluggish Tempo items showed substantially improved utility as symptoms of Inattention. Factor analyses distinguished a Sluggish Tempo factor from an Inattention factor. When DSM-IV ADHD types were compared, Inattentive Type was uniquely elevated on Sluggish Tempo. These findings suggest that (a) Sluggish Tempo items are adequate symptoms for Inattentive Type, or (b) Sluggish Tempo may distinguish two subtypes of Inattentive Type. Either conclusion is incompatible with ADHD nosology in DSM-IV.

Adolescent↗

PubMed1998

Familial subtypes of attention deficit hyperactivity disorder: a 4-year follow-up study of children from antisocial-ADHD families.

ADHD is a familial disorder with high rates of comorbidity with conduct disorder in childhood and antisocial personality and substance use disorders in adulthood. A growing literature suggests that ADHD with antisocial comorbidity may be nosologically distinct from other forms of ADHD. Previously, we proposed a family-based stratification that defined Antisocial families as those with either conduct disorder or antisocial personality disorder in the probands or relatives. To provide predictive validity for that stratification, we assessed psychopathology in these families 4 years after their initial assessment. Results show that the probands and siblings from Antisocial families had higher rates of psychopathology during the 4-year follow-up period compared with siblings from Non-antisocial and control families. They also had more deviant ratings on the Child Behavior Checklist (especially for anxious/depressed, delinquent, and aggressive behavior). We found fewer group differences in the academic, psychosocial, and intellectual correlates of ADHD. These results confirm and extend previous work indicating that Antisocial ADHD may be a nosologically and clinically meaningful subform of ADHD.

Adolescent↗

PubMedDate not supplied

[Atomoxetine safety and efficacy in children with attention deficit/hyperactivity disorder (ADHD): initial phase of 10-week treatment in a relapse prevention study with a Spanish sample].

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) appears to be associated to problems with regulation of cortical dopaminergic/noradrenergic function. The purpose of this work is to present efficacy and safety data from 10-week open label treatment with atomoxetine, a highly selective norepinephrine reuptake inhibitor, in a Spanish sample of children and adolescents with ADHD participating in a double-blinded, placebo-controlled, multinational study on relapse prevention. PATIENTS AND METHODS: Sub-analysis of data in 36 children and adolescents aged 6 to 15 years, with diagnosis of ADHD (DSM-IV) included in Spain, receiving open-label treatment with atomoxetine for 10 weeks and assessed using ADHD-RS, CGI-ADHD-S, CPRS-R:S, CTRS-R:S y CHQ-PF50. RESULTS: After 10 weeks of treatment with atomoxetine, statistically significant reductions in ADHD-RS, CGI-ADHD-S, CPRS-R:S and CTRS-R:S scores were obtained in both subtypes; 87.5 % of inattentive patients and 82.14 % of patients with combined subtype were responders. No recurrences were observed. No serious adverse event-driven discontinuations occurred, and no statistically significant changes in blood pressure, but a mild increase in heart rate (p < 0.0001) were observed. CONCLUSIONS: In general, atomoxetine was well tolerated and effective in the open phase in Spanish patients, both for inattentive and combined subtypes. Atomoxetine appears as a non-stimulant therapeutic alternative for the treatment of ADHD.

Adolescent↗

PubMed1995

Affective comorbidity in children and adolescents with attention deficit hyperactivity disorder.

Recent research examining comorbidity associated with attention deficit hyperactivity disorder (ADHD) has raised the possibility of the existence of subtypes of the disorder. If this is the case, delineating subgroups is clinically imperative. Two hundred seventy nonrepetitive, consecutively admitted children and adolescent inpatients received structured diagnostic interviews (Schedule for Affective Disorders and Schizophrenia in School Aged Children). Twenty-eight percent of these children met the criteria for ADHD. Of those children with an ADHD diagnosis, 68% also met the criteria for an affective disorder. Thirty-six percent met the full criteria for major depression disorder. Eight percent met the criteria for an affective psychosis and 22% were diagnosed with bipolar disorder. There was a significant overlap between ADHD and bipolar disorder, suggesting the possibility of a lack of specificity in the diagnostic instruments used in this population. The results support the clinical necessity of carefully assessing for occult affective illness in all children and adolescents with attention deficit disorder.

Adolescent↗

PubMed2000

Attention-deficit disorder and conduct disorder in girls: evidence for a familial subtype.

BACKGROUND: The frequent comorbidity between attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) raises the possibility that ADHD+CD is a distinct and separate condition. METHODS: We tested hypotheses about patterns of familial association between ADHD, CD, oppositional defiant disorder (ODD) and adult antisocial personality disorder (ASPD). Using family study methodology in a sample of girls, we found 11 children with diagnoses of ADHD+ CD, 39 with ADHD+ODD, and 90 with ADHD only. These were compared with 122 non-ADHD, non-CD control probands. Familial risk analysis was utilized. RESULTS: Relatives of each ADHD proband subgroup were at significantly greater risk for ADHD, and the relatives of ADHD-only subjects were at a greater risk of ODD than relatives of control subjects. Also, rates of CD were elevated among relatives of ADHD+CD probands only, and the coaggregation of ADHD and the antisocial disorders could not be accounted for by marriages between ADHD and antisocial spouses. Both ADHD and antisocial disorders occurred in the same relatives more often than expected by chance. CONCLUSIONS: These findings suggest that ADHD with and without antisocial disorders may be etiologically distinct disorders and provide evidence for the nosologic validity of ICD-10 hyperkinetic conduct disorder.

Adolescent↗

PubMed1996

Validity of DSM-IV ADHD predominantly inattentive and combined types: relationship to previous DSM diagnoses/subtype differences.

UNLABELLED: Since 1980, three different diagnostic nomenclatures have been published regarding attention-deficit hyperactivity disorder (ADHD). These changing conceptualizations and diagnostic criteria have generated considerable confusion. OBJECTIVE: To examine the multidimensional DSM-IV ADHD criteria in relation to how children and adolescents with a previous DSM-III ADD diagnosis or a DSM-III-R ADHD diagnosis are diagnosed according to DSM-IV criteria. METHOD: Children whose original diagnoses were according to DSM-III and DSM-III-R criteria received retrospective diagnoses according to DSM-IV criteria. RESULTS: Predominantly inattentive (n = 30) and combined types (n = 26) were compared on their previous DSM-III and DSM-III-R diagnoses and on demographic, behavioral, cognitive, and comorbidity variables. Predominantly inattentive and combined type diagnoses corresponded with DSM-III ADD/WO and ADD/H diagnoses, respectively. The DSM-III-R ADHD diagnosis did not correspond with either DSM-IV subtype. Children with the combined type diagnosis had more externalizing codiagnoses, and their parents reported more externalizing, delinquent, and aggressive behaviors. Children with the predominantly inattentive type had more math learning disability codiagnoses. CONCLUSION: Results support a multidimensional conceptualization of ADHD. There exists close correspondence between the DSM-III ADD/WO type and the DSM-IV predominantly inattentive type and between the DSM-III ADD/H type and the DSM-IV combined type.

Achievement↗

PubMed2001

Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design.

BACKGROUND: Although attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) frequently co-occur, the underlying mechanisms for this comorbidity are not well understood. AIMS: To examine whether ADHD and conduct problems share common risk factors and whether ADHD+CD is a more heritable variant of ADHD. METHOD: Questionnaires were sent to 2846 families. Parent-rated data were obtained for 2082 twin pairs and analysed using bivariate genetic analysis and a liability threshold model approach. RESULTS: The overlap of ADHD and conduct problems was explained by common genetic and non-shared environmental factors influencing both categories. Nevertheless, the two categories appeared to be partly distinct in that additional environmental factors influenced conduct problems. It appeared that ADHD+CD was a genetically more severe variant of ADHD. CONCLUSIONS: Conduct problems and ADHD share a common genetic aetiology; ADHD+CD appears to be a more severe subtype in terms of genetic loading as well as clinical severity.

Adolescent↗

PubMed2001

The effect of child characteristics on teachers' acceptability of classroom-based behavioral strategies and psychostimulant medication for the treatment of ADHD.

Studied the effect of student characteristics on teachers' ratings of treatment acceptability for attention deficit hyperactivity disorder (ADHD). Participants (N = 159) included experienced elementary school teachers who read 1 of 6 vignettes describing a child with symptoms representative of ADHD. Vignettes varied by sex and symptom-subtype classification. However, the number and specific type of symptoms described in the vignettes were consistent across all conditions. Next, teachers read a description of a daily report card (DRC), response cost technique, classroom lottery, and medication and rated their levels of agreement to the items of the Behavioral Intervention Rating Scale (BIRS). Teachers preferred the DRC to all other forms of treatment. However, there was a significant interaction between the type of treatment and sex of the student on the 3 factors (Treatment Acceptability, Treatment Effectiveness, and Timeliness) of the BIRS.

Adolescent↗

PubMed2005

Family-based association study of DAT1 and DRD4 polymorphism in Korean children with ADHD.

Although the etiology of Attention Deficit/Hyperactivity Disorder (ADHD) is not well understood, evidence from the family and twin studies suggest that ADHD is familial and highly heritable. The aim of the study was to test whether dopamine transporter gene (DAT1) and dopamine receptor D4 gene (DRD4) polymorphisms are in linkage disequilibrium with ADHD in Korean children, using a family-based association study. One hundred and twenty-six trios were studied and 87% of probands were boys (mean age=8.2 years, mean IQ=104). ADHD not otherwise specified (NOS) was the most common subtype and comorbidity rates were low. Descriptive analysis and the TDT test were the primary analyses. In exploratory analyses, logistic regression and QTDT were performed. The 10-repeat allele and 4-repeat allele were the most frequent for DAT1 and DRD4. TDT test for DAT1 and DRD4 did not show preferential transmission. Based on logistic regression and QTDT, the 5-repeat allele of DRD4 may confer protection for hyperactive-impulsivity symptom severity compared to the 4-repeat allele. The negative TDT finding between DAT1 and DRD4 VNTR polymorphisms and ADHD should be interpreted with caution; partly due to lack of power caused by low heterozygosity in the study population. Future studies are necessary to test the hypothesis generated in this study that the 5-repeat allele of DRD4 is protective for hyperactive-impulsivity symptom severity compared to the 4-repeat allele.

Analysis of Variance↗

PubMed2004

Adolescents with attention-deficit/hyperactivity disorder: an overview of empirically based treatments.

The author first presents an overview of attention-deficit/hyperactivity disorder (ADHD) as it presents in adolescents. He reviews what is known about the predominantly inattentive subtype in adolescents, the persistence of symptoms into this developmental phase, and comorbid disorders in adolescent patients with ADHD. The author then reviews treatments for adolescents with ADHD for which there is some empirical support in the scientific literature. He first discusses common assumptions concerning the treatment of ADHD and evidence for or against these assumptions. Information on therapies that have been shown to be ineffective or the benefit of which is unproven are then described. These include cognitive-behavioral therapy and social skills training. The author then presents an overview of what is known about the medication treatment of ADHD and discusses how this information is applicable to adolescents with the disorder. Four main classes of drugs are discussed: stimulants, noradrenergic reuptake inhibitors, tricyclic antidepressants, and antihypertensive agents. The author then reviews the use of several psychosocial interventions, including contingency management strategies, parent training in behavior management methods, and teacher training in classroom management, and discusses how these strategies can best be used for adolescents with ADHD. The author then discusses the use of combined treatment with psychosocial interventions and medication. Finally, information on the use of physical exercise as therapy for adolescents with ADHD is discussed.

Adolescent↗

PubMed1995

Clinical correlates of enuresis in ADHD and non-ADHD children.

Enuresis and attention deficit hyperactivity disorder (ADHD) are common childhood disorders that often co-occur. Although each has been linked to neurodevelopmental immaturity and increased risk for psychopathology, the clinical correlates of enuresis remain unclear. Subjects were 140 6-17-year-old boys with DSM-III-R ADHD and 120 non-ADHD controls. Information on enuresis and psychiatric diagnoses was obtained in a standardized manner blind to the child's clinical status. Our results show that (1) enuresis did not increase the risk for psychopathology in children with or without ADHD; (2) enuresis was not associated with psychosocial adversity or developmental immaturity; (3) enuresis was associated with increased risk for learning disability, impaired intellectual functioning, and impaired school achievement in normal control children but not in children with ADHD; and (4) the same pattern of findings was obtained after stratifying children with enuresis by primary versus secondary and by nocturnal versus diurnal subtypes. These results suggest that the clinical implications of enuresis may differ for ADHD and non-ADHD children.

Adolescent↗