Childhood conduct problems, hyperactivity-impulsivity, and inattention as predictors of adult criminal activity

This study reconsiders the relationship of childhood Attention Deficit/Hyperactivity Disorder (ADHD) and childhood conduct problems with adult criminal activity by clarifying the role of the cardinal behaviors associated with the DSM-IV ADHD subtypes (inattention and hyperactivity/impulsivity). Since their childhood (average age 9 years), 230 male and 75 female subjects have been followed prospectively and were interviewed as young adults (average age 26 at follow-up). Early childhood behavior ratings by parents and teachers were examined to determine the role of conduct problems, hyperactivity-impulsivity, and inattention in predicting adult criminal involvement as measured by both official arrest records and self-report. Results show that both hyperactivity-impulsivity and early conduct problems independently, as well as jointly, predict a greater likelihood of having an arrest record for males, but not for females. For male subjects with 10 or more self-reported crimes, both early conduct problems and hyperactivity-impulsivity were significant predictors, both alone and in combination. Therefore, it appears that predominantly the symptoms of hyperactivity-impulsivity, but not inattention, contribute to the risk for criminal involvement over and above the risk associated with early conduct problems alone.     

Common genetic and nonshared environmental factors contribute to the association between socioemotional dispositions and the externalizing factor in children

Background: Childhood behavioral disorders including conduct disorder (CD), oppositional defiant disorder (ODD), and attention‐deficit/hyperactivity disorder (ADHD) often co‐occur. Prior twin research shows that common sets of genetic and environmental factors are associated with these various disorders and they form a latent factor called Externalizing. The developmental propensity model posits that CD develops in part from socioemotional dispositions of Prosociality, Negative Emotionality, and Daring; and recent research has supported the expected genetic and environmental associations between these dispositions and CD. This study examined the developmental propensity model in relation to the broader Externalizing factor that represents the covariance among behavior disorders in children. Methods: Parents of 686 six‐ to twelve‐year‐old twin pairs rated them on symptoms of CD, ADHD, and ODD using the disruptive behavior disorder scale and on Prosociality, Negative Emotionality, and Daring using the Child and Adolescent Dispositions Scale. A latent factor multivariate Cholesky model was used with each disposition latent factor comprised of respective questionnaire items and the Externalizing factor comprised of symptom dimensions of CD, ADHD inattention, ADHD hyperactivity/impulsivity, and ODD. Results: Results supported the hypothesis that the socioemotional dispositions and the Externalizing factor have genetic factors in common, but there was not a single genetic factor associated with all of the constructs. As expected, nonshared environment factors were shared by the dispositions and Externalizing factor but, again, no single nonshared environmental factor was common to all constructs. A shared environmental factor was associated with both Negative Emotionality and Externalizing. Conclusions: The developmental propensity model was supported and appears to extend to the broader externalizing spectrum of childhood disorders. Socioemotional dispositions of prosociality, negative emotionality, and (to a lesser extent) daring may contribute to the covariation among behavioral disorders and perhaps to their comorbid expression through common sets of primarily genetic but also environmental factors.     

Estimates of the validity and utility of unstructured clinical observations of children in the assessment of ADHD

The purpose of this prospective study was to examine the validity and diagnostic utility of unstructured clinic observations of attention deficit hyperactivity disorder (ADHD) behaviors in children. Results showed observations to be related to behavioral ratings of parents but not of teachers. The relationship between observations and parent ratings was stronger for hyperactive-impulsive than inattentive behaviors. The level of agreement between observations and classification of ADHD significantly exceeded chance levels only for parent measures of hyperactivity-impulsivity. Only parent measures predicted a diagnosis of ADHD at a rate that was significantly better than chance. Clinic observations were found to have consistently higher positive predictive power than negative predictive power. Clinical implications are discussed.     

Confirmation and extension of association of blood lead with attention-deficit/hyperactivity disorder (ADHD) and ADHD symptom domains at population-typical exposure levels

Background:  Recent studies have suggested that child attention-deficit/hyperactivity disorder (ADHD) and its symptom domains are related to blood lead level, even at background exposure levels typical in western countries. However, recent studies disagreed as to whether lead was related to inattention or hyperactivity-impulsivity within the ADHD domain. More definitive evaluation of these questions was sought.
Methods:  Two hundred and thirty-six (236) children aged 6–17 years participated (61 ADHD-Combined type, 47 ADHD Predominantly Inattentive type, 99 non-ADHD control, 29 unclassified borderline, situational, or not otherwise specified (NOS) cases). Formal diagnosis was reliably established by a best estimate procedure based on a semi-structured clinical interview and parent and teacher ratings. Lead was assayed from whole blood using inductively coupled plasma mass spectrometry with a method detection limit of .3 μg/dL.
Results:  Blood lead levels were slightly below United States and Western Europe population exposure averages, with a mean of .73 and a maximum of 2.2 μg/dL. This is the lowest level of blood lead ever studied in relation to ADHD. After statistical control for covariates including IQ and prenatal smoking exposure, blood lead was associated with ADHD-combined type but not inattentive type. Parent and teacher report indicated association of blood lead with Conners cognitive problems, but only teacher report showed effects on DSM-IV inattention symptoms. Blood lead was associated with hyperactivity-impulsivity in parent report regardless of measurement method, whereas teacher report effects depended on child treatment history.
Conclusions:  These findings confirm that in children with typical US population lead exposure, careful identification of children with ADHD also identifies children with slightly elevated blood lead.     

Personality differences in children and adolescents with attention-deficit/hyperactivity disorder, conduct disorder, and controls

BACKGROUND: Differences in personality profiles were examined between children who differed in their co-morbidity of externalizing disorders: attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD). METHODS: 11- and 17-year-old male and female twins from a community sample were categorized as ADHD only, CD only, co-morbid CD-ADHD, and controls (no ADHD or CD) based on threshold and subthreshold CD and ADHD diagnoses assessed with structured interviews. Multivariate analyses were used to identify patterns of personality that differentiate these four diagnostic groups. It was hypothesized that significant differences would be found in the pattern of personality variables between participants in the co-morbid group, compared to the other three groups, and that these differences would hold across developmental periods. RESULTS: As expected, the co-morbid group had a pattern of personality marked by higher Negative Emotionality and lower Constraint than the other diagnostic groups. This pattern was evidenced across gender and age cohort. CONCLUSIONS: An extreme personality profile may represent a liability toward the occurrence of ADHD and CD with more extreme profiles contributing to the occurrence of both disorders among boys and girls. Implications for treatment planning and theoretical development are discussed.     

Language, Social Cognitive Processing, and Behavioral Characteristics of Psychiatrically Disturbed Children with Previously Identified and Unsuspected Language Impairments

This study examined characteristics of social cognitive processing, psychiatric disorder, and behavioral ratings of 380 children aged 7 to 14 years who had been referred consecutively for child psychiatric services with identified and unsuspected language impairments and with normally developing language. The results indicated that children with language impairments generally exhibited greater deficits in social cognitive processing, and particularly emotion decoding and social problem solving, than children who have language that is developing normally. Differences in psychiatric diagnosis and behavior problems were observed only between children with previously identified language impairments and children with normally developing language; children with previously identified language impairments were more likely to be diagnosed as having Attention Deficit Hyperactivity Disorder (ADHD) and to be rated by both parents and teachers as having more severe attentional problems. In addition, teachers rated them as more socially withdrawn. The results suggest that it is important to incorporate measures of both social cognition and language functioning routinely into clinical assessment, something that currently is rarely done.     

Parent-reported symptoms of hyperactivity and attention deficits predict teacher-reported symptoms

The object of the study was to examine whether symptoms of attention problems and hyperactivity reported by parents predicted teacher-reported symptoms in a referred sample of boys with the DSM-III-R diagnosis of Attention-deficit Hyperactivity Disorder (ADHD). Data from 48 boys, 7–12 years, were gathered independently from parents and teachers using the Child Behavior Checklist, Teacher's Report Form and the ADHD Rating Scale. Base rate, positive predictive power and negative predictive power were calculated for each symptom and for clusters of symptoms. The positive predictive power for individual symptoms was reasonably high with a mean score of 80%, while the parent-teacher agreement (measured by phi correlations) was low. Our results indicate that in most children referred because of hyperactivity, inattention and impulsivity, parent reports are sufficient to make a diagnostic evaluation. However, when multiple informants are available, data should be obtained from different sources.     

Should there be separate parent and teacher‐based categories of ODD? Evidence from a general population

Objective:  To examine the occurrence of oppositional defiant disorder (ODD) symptoms in a general population of boys and girls, as reported by parents and teachers, and to investigate differences in prevalence estimates, depending on how parents' and teachers' ratings were combined.
Method:  Data were collected from 7007 children (aged 7–9) who participated in The Bergen Child Study (BCS), an ongoing population-based study of children's development and mental health. ODD symptoms were measured by the SNAP-IV (Swanson, Nolan, & Pelham-IV) Oppositional Defiant Disorder sub-scale (SNAP-IV ODD) that was distributed to parents and teachers. Co-occurring symptoms of mental health problems were measured by the Strengths and Difficulties Questionnaire (SDQ).
Results and Conclusion:  Prevalence-estimates of ODD varied considerably depending on how ratings from parents and teachers were combined. Specific ODD symptoms occurred at very different rates depending on the rater and on the gender of the child being rated. Parents and teachers co-identified very few children with ODD. ODD identified by only one informant was associated with high levels of comorbid mental health problems and impairment according to both informants. The results support an informant-specific conceptualization of childhood ODD.     

The Conners' 10-item scale: findings in a total population of Swedish 10–11-year-old children

Aim: To present normative data for the Swedish version of the Conners' 10-item scale, to validate the scale by comparing children with and without attention deficit/hyperactivity disorder (ADHD), to explore the factor structure of this scale and to investigate behavioural characteristics and gender differences among 10- to 11-year-old children, as rated by parents and teachers respectively.
Methods: Parents and teachers rated 509 10- to 11-year-old children (261 boys and 248 girls) from a population-based cohort in a Swedish municipality.
Results: The Conners' 10-item scale discriminated very well between children with and without ADHD. Confirmatory factor analyses confirmed a two-dimensional structure of the scale with items measuring restless/impulsive behaviour in one factor and items measuring emotional lability in another. An ANOVA revealed that parents and teachers reported different behavioural characteristics in boys as compared to girls.
Conclusion: The Conners' 10-item scale is a valid screening instrument for identification of ADHD. The two subscales can be used separately, in addition to the total score, to get a more detailed picture of the child's behaviour. Parents and teachers pay attention to different aspects of problem behaviour in boys and girls. The less disruptive behaviour of girls needs to be highlighted.     

Fetal origins of child non-right-handedness and mental health

Background:  Environmental risk during fetal development for non-right-handedness, an index of brain asymmetry, and its relevance for child mental health is not fully understood.
Methods:  A Swedish population-based prospective pregnancy–offspring cohort was followed-up when children were five years old ( N  =   1714). Prenatal environmental risk exposures were the number of ultrasound examinations and maternal distress during pregnancy. Child mental health, including symptoms of attention deficit hyperactivity disorder (ADHD), language difficulties, and care-seeking for child behavior problems, was assessed via maternal and/or kindergarten teacher's ratings.
Results:  Prenatal exposure to maternal depressive symptoms and critical life events were associated with increased risk of child non-right-handedness and mixed handedness, after adjustment for parity, maternal age, birth outcomes, infant sex, and parental handedness. No association was found between handedness and number of ultrasound examinations. Non-right and mixed-handedness, rather than left-handedness, were associated with increased risk of language difficulties and particularly with ADHD symptoms, after adjustment for current parental ADHD symptoms, current maternal depressive symptoms, birth outcomes, smoking during pregnancy, depressive symptoms and critical life events. Problems were significant enough to prompt mothers to seek care for children's behavioral problems, and parents were more likely to have received advice from the children's kindergarten teachers to seek care.
Conclusions:  This study suggests that mixed-handedness, i.e., reflecting atypical brain laterality, can be a marker of both severity of prenatal exposure to maternal distress and of increased risk of ADHD symptoms in childhood. Our results support the idea that the fetal environment plays a role in subsequent child mental health.     

Maternal pre‐pregnancy obesity and risk for inattention and negative emotionality in children

Objective: This study aimed to replicate and extend previous work showing an association between maternal pre‐pregnancy adiposity and risk for attention deficit hyperactivity disorder (ADHD) symptoms in children. Methods: A Swedish population‐based prospective pregnancy–offspring cohort was followed up when children were 5 years old (N = 1,714). Mothers and kindergarten teachers rated children’s ADHD symptoms, presence and duration of problems, and emotionality. Dichotomized outcomes examined difficulties of clinical relevance (top 15% of the distribution). Analyses adjusted for pregnancy (maternal smoking, depressive symptoms, life events, education, age, family structure), birth outcomes (birth weight, gestational age, infant sex) and concurrent variables (family structure, maternal depressive symptoms, parental ADHD symptoms, and child overweight) in an attempt to rule out confounding. Results: Maternal pre‐pregnancy overweight and obesity predicted high inattention symptom scores and obesity was associated with a two‐fold increase in risk of difficulties with emotion intensity and emotion regulation according to teacher reports. Means of maternal ratings were unrelated to pre‐pregnancy body mass index (BMI). Presence and duration of problems were associated with both maternal over and underweight according to teachers. Conclusions: Despite discrepancies between maternal and teacher reports, these results provide further evidence that maternal pre‐pregnancy overweight and obesity are associated with child inattention symptoms and extend previous work by establishing a link between obesity and emotional difficulties. Maternal adiposity at the time of conception may be instrumental in programming child mental health, as prenatal brain development depends on maternal energy supply. Possible mechanisms include disturbed maternal metabolic function. If maternal pre‐pregnancy obesity is a causal risk factor, the potential for prevention is great.     

Prevalence of Attention-Deficit/Hyperactivity Disorder Symptoms in Preschool-aged Iranian Children

Objective

The aim of this study was to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) symptoms in Iranian preschool children based on evaluations by parents and teachers because a thorough understanding of epidemiologic features of ADHD symptoms in preschool children is important for prevention and management.

Methods

Children between the ages of three and six attending kindergarten participated in this study. For the survey, 37 kindergartens were selected by multistage (stratified cluster random) sampling, consisting of 2213 children with a design effect equal to 1.5. A 19-item observer-rating questionnaire was generated to assess ADHD symptoms in children within the last 6 months. This questionnaire was used by both teachers and parents to assess ADHD behavior in participating children.

Findings

Of 1403 children aged 3–6 years, 362 were classified as having ADHD symptoms according to their parent evaluation [25.8% (23.6–28.1%)] and 239 according to their teachers evaluation [17% (14.1–20.4%)]. Child rank among siblings, mother''s education level, and interest in aggressive television programs were all independent explanatory variables according to parents’ evaluation. Gender, parent education, child rank, single parent and interest in aggressive television programs were all independent explanatory variables according to teachers’ evaluation.

Conclusion

Our findings reveal a large discrepancy in the prevalence of ADHD symptoms in preschool children based on evaluation by parents and teachers. Thus, it seems that the ADHD screening should be performed in multiple settings in order to identify children who need further investigations.     

Are maternal smoking and stress during pregnancy related to ADHD symptoms in children?

BACKGROUND: There are some indications that maternal lifestyle during pregnancy (smoking and stress) contributes to symptoms of ADHD in children. We prospectively studied whether prenatal exposure to maternal smoking and/or stress is associated with ADHD symptoms and diagnostic criteria (according to DSM-IV) in 7-year-olds. METHODS: Nulliparous Scandinavian women were consecutively recruited at their first prenatal health care visit and assessments of smoking and stress were collected at gestational weeks 10, 12, 20, 28, 32, and 36. Children were followed up at 7 years old. We obtained full data for 72% of the sample: ADHD symptoms were rated by 74% of mothers (n=290) and 96% of eligible teachers (n=208). Attrition analyses showed no differences on key variables between participants and non-participants at follow-up. RESULTS: Results of multiple regression analyses showed prenatal exposure to smoking (beta=.16, p<.01) and stress (beta=.18, p<.01) were independently associated with later symptoms of ADHD. Results of logistic regression analyses showed that fulfillment of the diagnostic criteria for ADHD was related to exposure to prenatal stress (beta=.68, p<.01) especially in boys. The results were not confounded by sociodemographic factors or birth outcomes. CONCLUSIONS: This study provides evidence that prenatal exposure to stress and smoking is independently associated with later symptoms of ADHD in human children, particularly for boys. Because stress and smoking are relatively common during pregnancy, and yet preventable, these results are of public health significance.     

Reactive and Proactive Aggression Differentially Predict Later Conduct Problems

This study tested whether proactive and reactive aggression were differently predictive of later externalizing problems such as delinquency and DSM-related disruptive behaviors (i.e. oppositional defiant and conduct disorders). It also tested whether these two subtypes of aggressive behaviors interacted in predicting externalizing problems. A community sample of low SES boys participated in the study. Proactive and reactive aggression were rated by teachers when boys were 12 years old. Delinquency, oppositional disorders, and conduct disorders were assessed during mid-adolescence. Proactive but not reactive aggression predicted delinquency and disruptive behaviors. Moreover, high levels of reactive aggression weakened the link between proactive aggression and delinquency. Reactive aggression, however, did not moderate the link between proactive aggression and disruptive behaviors. We conclude that reactive and proactive aggression are two distinct types of aggressive behaviors with different predictive abilities. We also offer tentative explanations to account for the present findings.     

Task-related default mode network modulation and inhibitory control in ADHD: effects of motivation and methylphenidate

Background: Deficits characteristic of attention deficit/hyperactivity disorder (ADHD), including poor attention and inhibitory control, are at least partially alleviated by factors that increase engagement of attention, suggesting a hypodopaminergic reward deficit. Lapses of attention are associated with attenuated deactivation of the default mode network (DMN), a distributed brain system normally deactivated during tasks requiring attention to the external world. Task‐related DMN deactivation has been shown to be attenuated in ADHD relative to controls. We hypothesised that motivational incentives to balance speed against restraint would increase task engagement during an inhibitory control task, enhancing DMN deactivation in ADHD. We also hypothesised that methylphenidate, an indirect dopamine agonist, would tend to normalise abnormal patterns of DMN deactivation. Method: We obtained functional magnetic resonance images from 18 methylphenidate‐responsive children with ADHD (DSM‐IV combined subtype) and 18 pairwise‐matched typically developing children aged 9–15 years while they performed a paced Go/No‐go task. We manipulated motivational incentive to balance response speed against inhibitory control, and tested children with ADHD both on and off methylphenidate. Results: When children with ADHD were off‐methylphenidate and task incentive was low, event‐related DMN deactivation was significantly attenuated compared to controls, but the two groups did not differ under high motivational incentives. The modulation of DMN deactivation by incentive in the children with ADHD, off‐methylphenidate, was statistically significant, and significantly greater than in typically developing children. When children with ADHD were on‐methylphenidate, motivational modulation of event‐related DMN deactivation was abolished, and no attenuation relative to their typically developing peers was apparent in either motivational condition. Conclusions: During an inhibitory control task, children with ADHD exhibit a raised motivational threshold at which task‐relevant stimuli become sufficiently salient to deactivate the DMN. Treatment with methylphenidate normalises this threshold, rendering their pattern of task‐related DMN deactivation indistinguishable from that of typically developing children.     

Sleep habits, parasomnias and associated behaviors in school children with attention deficit hyperactivity disorder (ADHD)

Considerable clinical data support an association between sleep problems and attention deficit hyperactivity disorder (ADHD). We aimed to investigate the sleep habits, associated parasomnias and behavioral symptoms in primary school children with ADHD. Forty primary school children with a clinical diagnosis of ADHD and 40 age-sex-matched healthy community controls were recruited. The Children's Sleep Habits Questionnaire providing information regarding sleep habits and nighttime and daytime symptoms was used. About 22% of children with ADHD (versus 2.9% of the controls) needed their parents to accompany them while going to sleep (p: 0.008). Transitional objects were needed by 8.1% of ADHD children in contrast to 2.9% of controls. Nightmares, overactivity during sleep, habitual snoring, and bed-wetting were significantly higher in the ADHD group. ADHD children needed significantly more time to go to sleep on school days (p < 0.02). Children undergoing evaluation for ADHD should be routinely screened for sleep disturbances.     

Comparison of male adolescent-report of attention-deficit/hyperactivity disorder (ADHD) symptoms across two cultures using latent class and principal components analysis

BACKGROUND: The goal of this study is to gauge the consistency of Attention Deficit/Hyperactivity Disorder (ADHD) latent class models that are generated by different informants such as adolescents and parents. The consistency of adolescent-derived latent classes from two different samples was assessed and these results were then compared to the class structure generated by parent-report ADHD information. METHODS: Self-reported DSM-IV Criterion A ADHD symptoms of 497 adolescent males from a population-based twin study in the state of Missouri (USA) were subjected to principal components and latent class analysis, and findings were compared to previous results obtained from identical analyses using an adolescent sample from Porto Alegre, Brazil (N = 483). RESULTS: The bi-dimensional structure of self-reported ADHD symptoms was similar for both male adolescent groups, but explained less than 40% of the symptom variance in either sample. Two factors, one with loadings on inattention symptoms only and the other with loadings on hyperactive-impulsive symptoms only, were identified in the Missouri sample. Specific ADHD latent classes did not replicate well across the Missouri and Brazilian samples, and both groups were characterized by the presence of several combined symptom classes but few inattentive or hyperactive-impulsive classes. CONCLUSIONS: While adolescent-report information across two different cultures can at least in part reproduce the two-factor structure of ADHD, results from latent class analysis suggest that adolescent reporting on their own symptoms is markedly different from the type of information parents provide about ADHD symptoms in their offspring. The current findings indicate that if male adolescents endorse any ADHD symptoms there is a tendency for them to report combined type problems.     

Parent and teacher mental health ratings of children using primary-care services: interrater agreement and implications for mental health screening.

OBJECTIVE: To examine interrater agreement when screening for child mental health problems during primary-care visits. METHODS: Children aged 5 to 10 (n = 227) and one of their parents were systematically recruited from the waiting rooms of 15 primary-care sites located in Baltimore, Md; Washington, DC; and rural New York from 2002 to 2005. The parent and teacher of the child completed the Strengths and Difficulties Questionnaire to measure the child's emotions, behaviors, and functional impairment. RESULTS: Parents and teachers identified a similar proportion of children as having high symptoms (25% vs 23%) and high impairment (27% vs 32%) but rarely agreed in their assessments of specific children. Parent ratings alone missed 52% of children rated by teachers as having both high symptoms and high impairment (kappa = 0.15). Only 6% of these discrepant visits were for mental health problems, making it unlikely that teacher reports would have been solicited. CONCLUSIONS: Parent reports failed to detect half of school-aged children considered to be seriously disturbed by their teachers. Efforts to improve detection of mental health problems by using screening tools in primary care may require algorithms that help providers judge when to solicit teacher reports and how to interpret conflicting information from parents and teachers.     

Behavioural and learning problems in schoolchildren related to cognitive test data

Aim : To assess cognitive functions in children who were reported by their teachers and parents to exhibit learning and/or behavioural problems, especially in the field of attention. Method : In connection with the scheduled school health examination in grade 4 in one municipality, 591 children were screened through questionnaires and interviews with the parents and teachers. Those with positive rating scores were subjected to further cognitive assessments, including the WISC III. A cluster analysis based on cognitive data was performed. Results : One third (175 children) of the population obtained a positive rating score, indicating significant behavioural and/or learning problems. Of these, 144 children were assessed. Cluster analysis revealed six clusters. Within these clusters, two large groups were identified: one group displayed generally low cognitive abilities and one group was dominated by attention deficit symptoms.
Conclusion : We found a surprisingly high number of positive rating scores in the cohort (30%). This could be explained, on the one hand, by known developmental disorders, such as mental retardation and learning disabilities, ADHD (Attention Deficit Hyperactivity Disorder) and pervasive developmental disorders, and, on the other hand, by prevalent milder cognitive dysfunctions that, in combination with inappropriate demands, seemed to lead to overt behavioural problems.     

ERPs associated with monitoring and evaluation of monetary reward and punishment in children with ADHD

Background: Several models of attention‐deficit hyperactivity disorder (ADHD) propose abnormalities in the response to behavioural contingencies. Using event‐related potentials (ERPs), the present study investigated the monitoring and subsequent evaluation of performance feedback resulting in either reward or punishment in children with ADHD (N = 18) and normal controls (N = 18) aged 8 to 12 years. Methods: Children performed a time production task, in which visual performance feedback was given after each response. To manipulate its motivational salience, feedback was coupled with monetary gains, losses or no incentives. Results: Performance feedback signalling omitted gains as well as omitted losses evoked a feedback‐related negativity (FRN) in control children. The FRN, however, was entirely absent in children with ADHD in all conditions. Moreover, while losses elicited enhanced amplitudes of the late positive potential (LPP) in controls, omitted rewards had this effect in ADHD. Conclusions: The lack of modulation of the FRN by contingencies in ADHD suggests deficient detection of environmental cues as a function of their motivational significance. LPP findings suggest diminished response to punishment, but oversensitivity to the loss of desired rewards. These findings suggest that children with ADHD have problems assigning relative motivational significance to outcomes of their actions.