Medication effects on symptoms of attention-deficit/hyperactivity disorder in children with fetal alcohol spectrum disorder

Attention-deficit/hyperactivity disorder (ADHD) may be the most common mental health disorder in children with fetal alcohol spectrum disorders (FASD). Despite this, little information is available regarding the effectiveness of ADHD treatment in this population. This study, conducted within a clinical service, aimed to assess the impact of medication on symptoms of ADHD in children with FASD by determining (a) the extent of change in ADHD symptoms with medication, and (b) whether differences in improvement are seen between symptom domains. Data were extracted from the medical records of 27 children with FASD who had been referred to an ADHD medication service at the Alberta Children's Hospital in Canada. Participants were primarily male and ranged in age from 5 years 6 months to 14 years 5 months. Teacher MTA-SNAP-IV scores were the primary outcome measure. Baseline, best, and change scores across three symptom domains (inattention, hyperactivity/impulsivity, and opposition/defiance) were determined. A total of 41 medication trials was conducted. More children obtained normalized best scores for hyperactivity/impulsivity (n = 18) and opposition/defiance (n = 19) than for inattention (n = 9) across medication trials. These findings suggest that inattention may be less responsive to ADHD medication. Replication in larger samples with a placebo-controlled design is required.     

The structure of adult ADHD

Although DSM‐5 stipulates that symptoms of attention‐deficit hyperactivity disorder (ADHD) are the same for adults as children, clinical observations suggest that adults have more diverse deficits than children in higher‐level executive functioning and emotional control. Previous psychometric analyses to evaluate these observations have been limited in ways addressed in the current study, which analyzes the structure of an expanded set of adult ADHD symptoms in three pooled US samples: a national household sample, a sample of health plan members, and a sample of adults referred for evaluation at an adult ADHD clinic. Exploratory factor analysis found four factors representing executive dysfunction/inattention (including, but not limited to, all the DSM‐5 inattentive symptoms, with non‐DSM symptoms having factor loadings comparable to those of DSM symptoms), hyperactivity, impulsivity, and emotional dyscontrol. Empirically‐derived multivariate symptom profiles were broadly consistent with the DSM‐5 inattentive‐only, hyperactive/impulsive‐only, and combined presentations, but with inattention including executive dysfunction/inattention and hyperactivity‐only limited to hyperactivity without high symptoms of impulsivity. These results show that executive dysfunction is as central as DSM‐5 symptoms to adult ADHD, while emotional dyscontrol is more distinct but nonetheless part of the combined presentation of adult ADHD.     

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.     

The latent structure of attention deficit/hyperactivity disorder in an adult sample

The vast majority of studies that have examined the latent structure of attention deficit/hyperactivity disorder (ADHD) in children and adolescents have concluded that ADHD has a dimensional latent structure. In other words, ADHD symptomatology exists along a continuum and there is no natural boundary or qualitative distinction (i.e., taxon) separating youth with ADHD from those with subclinical inattention or hyperactivity/impulsivity problems. Although adult ADHD appears to be less prevalent than ADHD in youth (which could suggest a more severe adult ADHD taxon), researchers have yet to examine the latent structure of ADHD in adults. The present study used a sample (N = 600) of adults who completed a self-report measure of ADHD symptoms. The taxometric analyses revealed a dimensional latent structure for inattention, hyperactivity/impulsivity, and ADHD. These findings are consistent with previous taxometric studies that examined ADHD in children and adolescents, and with contemporary polygenic and multifactorial models of ADHD.     

Attention-deficit/hyperactivity disorder dimensionality: the reliable ‘g’ and the elusive ‘s’ dimensions

The best structural model for attention-deficit/hyperactivity disorder (ADHD) symptoms remains a matter of debate. The objective of this study is to test the fit and factor reliability of competing models of the dimensional structure of ADHD symptoms in a sample of randomly selected and high-risk children and pre-adolescents from Brazil. Our sample comprised 2512 children aged 6–12 years from 57 schools in Brazil. The ADHD symptoms were assessed using parent report on the development and well-being assessment (DAWBA). Fit indexes from confirmatory factor analysis were used to test unidimensional, correlated, and bifactor models of ADHD, the latter including “g” ADHD and “s” symptom domain factors. Reliability of all models was measured with omega coefficients. A bifactor model with one general factor and three specific factors (inattention, hyperactivity, impulsivity) exhibited the best fit to the data, according to fit indices, as well as the most consistent factor loadings. However, based on omega reliability statistics, the specific inattention, hyperactivity, and impulsivity dimensions provided very little reliable information after accounting for the reliable general ADHD factor. Our study presents some psychometric evidence that ADHD specific (“s”) factors might be unreliable after taking common (“g” factor) variance into account. These results are in accordance with the lack of longitudinal stability among subtypes, the absence of dimension-specific molecular genetic findings and non-specific effects of treatment strategies. Therefore, researchers and clinicians might most effectively rely on the “g” ADHD to characterize ADHD dimensional phenotype, based on currently available symptom items.     

Are ADHD Symptoms Associated With Delay Aversion or Choice Impulsivity? A General Population Study

ObjectiveThe term delay aversion has been used both to describe a behavioral tendency of greater preference for smaller-immediate over larger-delayed rewards (choice impulsivity) and to refer to a secondary explanatory construct put forward by delay aversion theory. In this study, we examined the association of attention-deficit/hyperactivity disorder (ADHD) symptoms with choice impulsivity and tested the specific hypothesis derived from delay aversion theory.MethodA total of 1,062 children aged 7.90 to 10.90 years (49% girls) made a fixed number of repeated choices between a smaller reward delivered immediately and a larger reward delivered after a delay (choice-delay task), under two conditions (including and excluding a postreward delay). We assessed the unique contribution of each ADHD symptom dimension to the prediction of choice impulsivity and delay aversion, controlling for age (or age and IQ). Sex effects were examined.ResultsInattention ratings uniquely predicted preference for smaller-immediate rewards under both task conditions for both sexes. An index of delay aversion was associated with inattention only in boys; the effect size was small yet significant. Hyperactivity-impulsivity ratings were negatively associated with choice impulsivity in girls in the postreward delay condition, whereas no significant association with hyperactivity-impulsivity ratings was observed in boys. Categorical analyses using groups with high ADHD symptoms yielded similar results.ConclusionsThis is the first study to report a unique association between inattention symptoms and behavioral measures of choice impulsivity and delay aversion. The findings indicate the importance of the primary constitutional processes that underlie choice impulsivity and their potential role in behavioral inattention. Understanding the behavioral and brain processes underlying choice impulsivity may lead to the improved targeting of behavioral and pharmacological interventions.     

Early pathogenic care and the development of ADHD-like symptoms

Early pathogenic care that is characterised by disregard for the child's basic emotional needs can lead to severe global psychosocial and cognitive dysfunction and deviant developmental trajectories of brain maturation. Reactive attachment disorder (RAD) is a developmental disorder associated with early pathogenic care that is characterised by markedly disturbed ways of relating socially in most contexts. In addition to other severe emotional dysfunctions, children suffering from RAD often display a high number of comorbid attention deficit/hyperactivity disorder (ADHD) symptoms such as inattention, impulsivity and hyperactivity. It is not yet clear whether ADHD-like symptoms in children exposed to pathogenic care represent a true comorbidity of ADHD or similarities in behavioural dysfunction with a different neurodevelopmental pathway in terms of a phenocopy. In this review, we summarise the findings on the neurobiological consequences of early pathogenic care. Pathogenic care is considered a form of care by a primary caretaker involving a lack or a loss of expectable care, e.g., by early separation, frequent change in caregivers, institutionalisation or neglect. The reviewed studies suggest that a primary dysfunction of limbic brain circuits after early pathogenic care might lead to an interference by motivational or emotional cues impinging on prefrontal executive functions resulting in behavioural similarities with ADHD. Thus, the complex phenotype observed after early pathogenic care might be best described by a dimensional approach with behavioural and neurobiological similarities to ADHD coinciding to a certain degree as a function of early experience. Based on this evidence, suggestions for the treatment of ADHD-like symptoms in children after adverse early life experiences are provided.     

Methylphenidate response in aggressive and nonaggressive ADHD children: distinctions on laboratory measures of symptoms.

Response to a single, 5-mg dose of methylphenidate was compared in aggressive and nonaggressive attention-deficit hyperactivity disorder (ADHD) children using objective measures of inattention, impulsivity, and activity level. After medication, both ADHD groups had a significant decrease in inattention, whereas impulsivity remained unchanged. Activity level decreased only in the nonaggressive ADHD group. Unmedicated normal controls showed no change on any measure. These results support the hypothesis that aggressive and nonaggressive ADHD children have somewhat different underlying determinants for some of their symptoms. In addition, they suggest that inattention, impulsivity, and overactivity may be mediated by partially distinct neural mechanisms.     

Neuropsychological Functioning and Attachment Representations in Early School Age as Predictors of ADHD Symptoms in Late Adolescence

This study aimed to examine relations between parent and child attachment representations and neuropsychological functions at age 8, as well as relations between these constructs and ADHD symptoms over a 10-year period. A community-based sample of 105 children (52 boys) participated. Measures of attachment representations and a range of neuropsychological functions were collected at age 8. Parents rated emotion dysregulation and ADHD symptoms at age 8 and ADHD symptoms again at age 18. Significant, although modest, relations were found between disorganized attachment and some aspects of neuropsychological functioning in childhood. When studying outcomes in late adolescence and controlling for early ADHD symptom levels, spatial working memory and disorganized attachment remained significant in relation to both ADHD symptom domains, and one measure of inhibition remained significant for hyperactivity/impulsivity. When examining independent effects, spatial working memory and disorganized attachment were related to inattention, whereas spatial working memory and dysregulation of happiness/exuberance were related to hyperactivity/impulsivity. Our findings showing that disorganized attachment is longitudinally related to ADHD symptoms over and above the influence of both neuropsychological functioning and early ADHD symptom levels highlights the importance of including measures of attachment representations when trying to understand the development of ADHD symptoms. If replicated in more “at-risk” samples, these findings could also suggest that parent–child attachment should be taken into consideration when children are referred for assessment and treatment of ADHD.     

Group Psychological Intervention for Children with Hyperactivity Disorder

ADHD is a broad psychiatric disorder that affects children of normal or near-normal intelligence. It is characterized by inattention, hyperactivity, and age-inappropriate impulsivity, and it is often accompanied by learning difficulties, behavioral, emotional, and interpersonal problems. On the other hand, hyperactive tendencies in children with ADHD exhibit ADHD-like behaviors such as lack of self-control, inattention, hyperactivity, and emotional impulsivity. However, because their symptoms are less severe, they do not meet the diagnostic criteria for ADHD but are ADHD or at risk of developing ADHD. The purpose of this study is to alleviate and reduce children’s hyperactivity symptoms by investigating the current situation of the children studied, and systematically intervening and educating children with ADHD through psychological group intervention. Research data shows that ADHD is most commonly diagnosed in school-age children, and in 70%–80% of children with ADHD, symptoms persist into adolescence and 30% into adulthood. Through the use of group psychological intervention in the experiment, the prevalence rate of children with hyperactivity disorder tendency has been effectively reduced. This shows that group psychological intervention training has a significant effect on improving hyperactivity symptoms in children with ADHD tendency.     

Disturbed sleep in children born extremely preterm is associated with behavioural and emotional symptoms

AimTo determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms.MethodEPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age.ResultsExtremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1–5% of variance).ConclusionChildren born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population.     

Specificity of inattention, impulsivity, and hyperactivity to the diagnosis of attention-deficit hyperactivity disorder.

Children with attention-deficit hyperactivity disorder (ADHD) were compared with non-ADHD psychiatric patients and normal controls on objective measures of inattention, impulsivity, and hyperactivity to determine the specificity of these symptoms to ADHD. Inattention and impulsivity were assessed using a continuous performance test, and activity was measured using solid state actigraphs. Both patient groups were inattentive relative to normals, but were indistinguishable from each other. However, the ADHD group was more active than both non-ADHD patients and normals, who did not differ from each other. These data suggest that inattention may be a nonspecific symptom of child psychiatric disorder. However, ADHD may be uniquely characterized by overactivity.     

Neurofeedback in ADHD: a single-blind randomized controlled trial

Neurofeedback treatment has been demonstrated to reduce inattention, impulsivity and hyperactivity in children with attention deficit/hyperactivity disorder (ADHD). However, previous studies did not adequately control confounding variables or did not employ a randomized reinforcer-controlled design. This study addresses those methodological shortcomings by comparing the effects of the following two matched biofeedback training variants on the primary symptoms of ADHD: EEG neurofeedback (NF) aiming at theta/beta ratio reduction and EMG biofeedback (BF) aiming at forehead muscle relaxation. Thirty-five children with ADHD (26 boys, 9 girls; 6–14 years old) were randomly assigned to either the therapy group (NF; n = 18) or the control group (BF; n = 17). Treatment for both groups consisted of 30 sessions. Pre- and post-treatment assessment consisted of psychophysiological measures, behavioural rating scales completed by parents and teachers, as well as psychometric measures. Training effectively reduced theta/beta ratios and EMG levels in the NF and BF groups, respectively. Parents reported significant reductions in primary ADHD symptoms, and inattention improvements in the NF group were higher compared to the control intervention (BF, d _corr = −.94). NF training also improved attention and reaction times on the psychometric measures. The results indicate that NF effectively reduced inattention symptoms on parent rating scales and reaction time in neuropsychological tests. However, regarding hyperactivity and impulsivity symptoms, the results imply that non-specific factors, such as behavioural contingencies, self-efficacy, structured learning environment and feed-forward processes, may also contribute to the positive behavioural effects induced by neurofeedback training.     

The Use of Psychostimulants in Pervasive Developmental Disorders

Many children with Pervasive Developmental Disorders (PDD) display problematic behaviors similar to those seen in children with Attention Deficit Hyperactivity Disorder (ADHD). This paper will look at the controversy concerning diagnosing comorbid ADHD in children who meet criteria for PDD and review the existing literature examining the efficacy of stimulants in these particular set of behaviors or symptom clusters (hyperactivity, impulsivity and inattention). The potential drawbacks of using stimulants in a population of children and adolescents who exhibit symptoms of PDD and ADHD will be discussed. Finally, this review will also attempt to define potential areas of future research to examine the utility of the psychostimulants in children and adolescents with PDD and symptoms of ADHD.     

The negative attribution processes of mothers of children with attention deficit/hyperactivity disorder

The objective of this study was to investigate the attribution processes of mothers regarding children's prosocial behaviors, inattention, and hyperactivity/impulsivity (symptoms of attention deficit/hyperactivity disorder, ADHD) using two paradigms. The first paradigm involved multidimensional attributions. The second paradigm concerned making attributions of children's identical behaviors based on information such as consensus, distinctiveness, and consistency. The participants were 64 mothers of children with ADHD (7–13 years old) and 64 mothers with typical/normal children (7–12 years old). The results showed that mothers of typical children exhibited positive attribution styles or person attributions whereas mothers of children with ADHD exhibited negative attribution styles. Mothers of children with ADHD tended to make personal attributions of children's negative behaviors (e.g., inattention and hyperactivity/impulsivity; HI) but made situational attributions of prosocial behaviors. The results of this study can be used in future studies of the effects of intervention on children with ADHD or in studies related to neurophysiology.     

Autism severity as a predictor of inattention and impulsivity in toddlers

Abstract

Objective: Evaluate how severity of autism spectrum disorder (ASD) symptoms predicts attention-deficit/hyperactivity disorder (ADHD) symptoms in atypically developing toddlers.

Method: Parents/caregivers of 2300 atypically developing toddlers’ ages 18–37 months were assessed about their children’s behaviours using the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) Part 1 and the inattention/impulsivity subscale of the BISCUIT-Part 2.

Results: ASD symptom severity was positively and significantly correlated with inattention/impulsivity, indicating that children with more severe symptoms of ASD tended to have higher scores on the measure of inattention/impulsivity, R²?=?0.49, F (1, 2298)?=?2234.72, p?<?0.001. Additionally, ASD symptom severity significantly predicted inattention/impulsivity, β?=?0.70, t (2298)?=?47.27, p?<?0.001.

Conclusions: ASD symptom severity predicts rates of ADHD symptoms in atypically developing toddlers. The implications of these findings are discussed in the context of other research.     

Factor structure and cultural factors of disruptive behaviour disorders symptoms in Italian children.

OBJECTIVE: Poor parent and teacher awareness for attention-deficit/hyperactivity disorder (ADHD) and the scepticism of many clinicians on the prevalence of the disorder, make Italy an interesting environment in which to verify neuropsychological constructs generated in a predominantly Northern American cultural contest. The aim of the study was to verify, by factor confirmatory analysis, the empirical validity of the DSM constructs underlying the diagnostic criteria for developmental disruptive behaviour disorders in Italian school-age children. METHODS: Scores for DSM-IV inattention and hyperactivity/impulsivity, for oppositional defiant disorder (ODD) and for conduct disorder (CD) symptoms in 6-12 years old Italian children were analysed from 1575 parent and 1085 teacher forms of the disruptive behaviour disorders questionnaires collected in four different Italian regions. RESULTS: Reliability indicates high internal consistencies for both parent and teacher rating of inattention, hyperactivity/impulsivity, and oppositionality, but not for conduct problems. In accordance with the literature, a relatively low inter-rater convergent and discriminant validity correlation was observed comparing measures obtained by between parents and teachers. Confirmatory factor analysis of both parent and teacher data showed a better fit for a four-factor model, indicating a factor structure in accordance with the DSM-IV taxonomy. When completed by parents and teachers of clinically assessed ADHD, dyslexic or normal children, the disruptive behavioural disorder questionnaires showed a significant predictive diagnostic value. CONCLUSION: Although an informant variance higher that dimensional (trait) variance was observed, the study provides support for DSM-IV taxonomy for developmental disruptive disorders, showing construct validity of ADHD. ODD and CD could also be distinguished from each other.     

Symptom variations in ADHD: importance of context, development and comorbidity

Attention-deficit hyperactivity (ADHD) is a common disorder in school-aged children and is associated with significant impairment in social and academic functioning. Its recognition is based on congruent information from different sources, because most ADHD children and adolescents are not completely aware of impairments caused by inattention and/or hyperactivity/impulsivity. Fluctuations in symptom expression may complicate the diagnosis: during clinical examination or tests sessions, ADHD symptoms may be less severe than usual or completely absent. This review examines variations in ADHD symptoms due to environmental context, internal state, circadian factors, development, psychiatric comorbidity and discusses their clinical relevance. Generally, ADHD symptoms are pervasive and identified in different areas of functioning. Despite their chronicity, they show a relative context-dependency. An unfamiliar environment or situation may lessen symptoms. The same happens in dual relations or in calm settings, when the child receives attention and positive reinforcement from the adult. On the contrary, the classroom situation with its high stimulation level (noise, visual distractors, large class size) is likely to reveal or accentuate instability, impulsivity and inattention. Independently from objective symptom fluctuations, the impact of ADHD symptoms, and their consequences on self-esteem may also vary with the degree of environmental mismatch. Recent research in experimental psychology also draws attention to the motivational state of ADHD children: preference for immediate gratification and delay aversion may explain why most of them show satisfactory attentional capacities in certain activities (for instance video games or TV), while showing impairment in school work or in other effortful tasks. The diagnosis of the full ADHD syndrome requires significant impact on functioning in at least two areas. Some children with "situational" ADHD are impaired either in school setting or exclusively at home. Manuzza et al. report long-term outcome of "situational" versus "pervasive" ADHD. School-ADHD, in opposition to home-ADHD shows similarities with the full blown syndrome, as regards proportion of anti-social personality disorder, psycho-social functioning and academic/professional achievements. Moderate seasonal variations have also been identified with less ADHD symptoms in August. This result is likely to reflect a better fit between individual characteristics and environmental demands during school holidays rather than neurobiological changes, as there are no convincing arguments for seasonal fluctuations of serotoninergic tone in ADHD. Another cause for variations in ADHD symptom expression may be the co-occurrence of a mood disorder. Relationships between early-onset mania and ADHD are discussed. The appropriate definition of prepubertal mania is still in debate; its recognition is hindered by symptom overlap and high level of comorbid conditions. Chronic emotional dysregulation with irritability and frequent temper tantrums, sometimes viewed as characteristics of early-onset mania, might reflect a--possibly severe--sub-type of ADHD rather than a prodrome of bipolarity. A marked cyclicity of symptoms, with periodic accentuation of ADHD and mood symptoms, requires careful monitoring and systematic analysis of comorbid conditions. Clarification of the complex interrelations between ADHD and bipolar disorder will be obtained from long-term studies.     

Modulation of attention-deficit/hyperactivity disorder symptoms by short- and long-acting methylphenidate over the course of a day

The purpose of this study was to investigate whether a long-acting methylphenidate formulation (MPH-ret) is as effective as two doses of immediate-release methylphenidate (MPH-IR) in reducing attention-deficit/hyperactivity disorder (ADHD) symptoms including inattention, impulsivity, and hyperactivity during the course of the day. Two groups of children (n=18 each) with ADHD aged between 8 and 12 years completed a continuous performance test in combination with a motion-tracking system four times a day within 8 hours. Inattention (standard deviation of reaction time), impulsivity (commission error rate), and hyperactivity (path length of the headband) were simultaneously measured. We included a control group (n=20) to rule out circadian fluctuations of attentional performance and motor activity. We observed a postlunch dip in attentional performance and an increasing trend of motor activity throughout the day whereas impulsivity remained stable in controls. The MPH-ret and MPH-IR groups had comparable treatment effects on measures of hyperactivity and inattention and normalized participant performance to control levels. In contrast, MPH-IR seems to have an advantage over MPH-ret in impulsivity treatments. Thus, our data suggest that it is crucial to assess the different domains of ADHD symptoms precisely over the course of a day to determine the optimal titration and stimulant formulation for a person with ADHD.