Iron deficiency in children with attention-deficit/hyperactivity disorder

BACKGROUND: Iron deficiency causes abnormal dopaminergic neurotransmission and may contribute to the physiopathology of attention-deficit/hyperactivity disorder (ADHD). OBJECTIVE: To evaluate iron deficiency in children with ADHD vs iron deficiency in an age- and sex-matched control group. DESIGN: Controlled group comparison study. SETTING: Child and Adolescent Psychopathology Department in European Pediatric Hospital, Paris, France. PATIENTS: Fifty-three children with ADHD aged 4 to 14 years (mean +/- SD, 9.2 +/- 2.2 years) and 27 controls (mean +/- SD, 9.5 +/- 2.8 years). MAIN OUTCOME MEASURES: Serum ferritin levels evaluating iron stores and Conners' Parent Rating Scale scores measuring severity of ADHD symptoms have been obtained. RESULTS: The mean serum ferritin levels were lower in the children with ADHD (mean +/- SD, 23 +/- 13 ng/mL) than in the controls (mean +/- SD, 44 +/- 22 ng/mL; P < .001). Serum ferritin levels were abnormal (<30 ng/mL) in 84% of children with ADHD and 18% of controls (P < .001). In addition, low serum ferritin levels were correlated with more severe general ADHD symptoms measured with Conners' Parent Rating Scale (Pearson correlation coefficient, r = -0.34; P < .02) and greater cognitive deficits (r = -0.38; P < .01). CONCLUSIONS: These results suggest that low iron stores contribute to ADHD and that ADHD children may benefit from iron supplementation.     

Parent, teacher, child. A trilateral approach to attention deficit disorder

We compared the effectiveness of three instruments in initially diagnosing and monitoring children with attention-deficit disorder with and without hyperactivity (ADD/H). Twenty-one children clinically assessed as having ADD/H and meeting criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, were examined initially and after treatment with methylphenidate hydrochloride and placebo. The following instruments were used: the ADD-H Comprehensive Teacher Rating Scale, the Connors' Parent Rating Scale-Revised, and the Gordon Diagnostic System. The ADD-H Comprehensive Teacher Rating Scale initially classified 67% of the children as having ADD/H and 14% as borderline. The Connors' Parent Rating Scale-Revised identified 71% as having ADD/H, while the Gordon Diagnostic System assessed 52% as having ADD/H and 29% as borderline. With methylphenidate treatment, the mean scores on the ADD-H Comprehensive Teacher Rating Scale displayed an increase in attention span and a decrease in hyperactivity, the Connors' Parent Rating Scale-Revised showed a significant decrease in ADD/H behavior, and the Gordon Diagnostic System mean scores indicated no significant change.     

Parent and teacher rating scales in the evaluation of attention-deficit hyperactivity disorder: contribution to diagnosis and differential diagnosis in clinically referred children

This study evaluated diagnostic utility of parent and teacher ratings in the attention-deficit hyperactivity disorder (ADHD) assessment and differential diagnosis of a clinical sample of children referred for suspected ADHD. Participants were 184 5- to 12-year-old children for whom the following were available: multimethod multi-informant assessment, firm decision regarding presence or absence of ADHD, and parent-completed Child Behavior Checklist and revised 48-item Conners Parent Rating Scale, and teacher-completed Teacher Report Form and 39-item Conners Teacher Rating Scale. Parent ratings of children diagnosed with and without ADHD were generally similar. In contrast, teachers rated students diagnosed with ADHD as displaying higher levels of behavioral difficulties. Discriminant function analyses indicated parent ratings of narrowband measures of ADHD and broadband measures of externalizing symptoms displayed high sensitivity. Teacher ratings outperformed parent ratings when considering sensitivity, specificity, and overall classification accuracy. For clinically recommended cut scores, teacher measures displayed good specificity and positive predictive power. Combining rating scales within informants. did not improve classification accuracy. Combining across parent and teacher measures produced results consistent with teacher ratings. Results support recommendations to include parent and teacher rating scales in ADHD assessment. Scales contributing most to classification accuracy were those designed to assess ADHD. Imperfect performance of rating scales supports recommendations to include other methodologies in diagnosis and differential diagnosis of ADHD.     

Ferritin and hyperactivity ratings in attention deficit hyperactivity disorder

Background: Iron is a co‐factor of tyrosine hydroxylase which is a critical enzyme in dopamine synthesis. Dopamine has been implicated in the pathophysiology of attention deficit hyperactivity disorder (ADHD). Our objective was to investigate the association of ferritin level with parent and teacher ratings and cognitive measures after controlling for age, sex, ADHD subtype, comorbid conditions, hemoglobin, mean corpuscular volume and reticulocyte distribution width in a large sample. Methods: The study included 713 children and adolescents with ADHD (613 boys; age 7–15 years). Conners' Parent Rating Scale (CPRS) and Conners' Teacher Rating Scale (CTRS) were obtained. In a subgroup of patients we conducted Digit Span, Digit Symbol, Trail‐making Tests as measures of attention and executive functioning. Results: Multiple regression analysis indicated that CPRS Hyperactivity score was significantly associated with ferritin level (B =?0.12; t =?3.1; P < 0.01). Other CPRS and CTRS scores as well as cognitive measures were not associated with ferritin level. Conclusions: Although it is not possible to make an inference on causality in cross‐sectional studies, the results of this largest‐scale cross‐sectional field study to date suggest that lower ferritin level might be associated with parent‐reported hyperactivity after controlling for important confounding factors.     

Methylphenidate in children with seizures and attention-deficit disorder

This study assessed the safety and efficacy of methylphenidate in children with seizures and attention-deficit disorder. Ten children, aged 6 years 10 months to 10 years 10 months, without seizures while receiving a single antiepileptic drug, were evaluated in a double-blind medication-placebo crossover study with methylphenidate hydrochloride was administered at 0.3 mg/kg per dose and given at 8 AM and 12 PM on school days only. The use of methylphenidate was associated with statistically significant improvements on the Conners' Teacher Rating Scale and on the Finger Tapping Task and with trends toward improvement on the Matching Familiar Figures Test and Discriminant Reaction Time tests. No child had seizures during the study period nor subsequently for those who continued receiving psychostimulants. There were no significant changes of epileptiform features or back-ground activity on electroencephalograms and no alterations in antiepileptic drug levels. Methylphenidate may be a safe and effective treatment for certain children with seizures and concurrent attention-deficit disorder.     

Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD

METHODS: Various developmental problems including attention-deficit/hyperactivity disorder (ADHD) have been linked to biological deficiencies in polyunsaturated fatty acids (PUFAs). Additionally, there is evidence that symptoms may be reduced with PUFA supplementation. This study investigated effects of supplementation with PUFAs on symptoms typically associated with ADHD. Because nutrients work synergistically, additional effects of micronutrient supplementation were also investigated. A total of 132 Australian children aged 7 to 12 years with scores > or = 2 SD above the population average on the Conners ADHD Index participated in a randomized, placebo-controlled, double-blind intervention over 15 weeks, taking PUFAs alone, PUFAs + micronutrients, or placebo. Due to unreturned questionnaires, data were only available for 104 children. RESULTS: Significant medium to strong positive treatment effects were found on parent ratings of core ADHD symptoms, inattention, hyperactivity/impulsivity, on the Conners Parent Rating Scale (CPRS) in both PUFA treatment groups compared with the placebo group; no additional effects were found with the micronutrients. After a one-way crossover to active supplements in all groups for a further 15 weeks, these results were replicated in the placebo group, and the treatment groups continued to show significant improvements on CPRS core symptoms. No significant effects were found on Conners Teacher Rating Scales. CONCLUSION: These results add to preliminary findings that ADHD-related problems with inattention, hyperactivity, and impulsivity might respond to treatment with PUFAs and that improvements may continue with supplementation extending to 30 weeks.     

Relation of ferritin levels with symptom ratings and cognitive performance in children with attention deficit–hyperactivity disorder

Background: The aim of the present paper was to investigate the relationship between behavioral symptoms and attentional and executive functions and hematological variables related to iron deficiency and anemia, ferritin, hemoglobin, mean corpuscular volume (MCV), and red cell distribution width (RDW) in children and adolescents with attention deficit–hyperactivity disorder (ADHD). Methods: The sample consisted of 52 ADHD children (42 boys, 10 girls; age 7–13 years; mean ± SD, 9.9 ± 2.1 years). Conners Parent and Teacher Rating Scales were obtained. The neuropsychological test battery included Wisconsin Card‐Sorting Test (WCST), Stroop, Continuous Performance Test, Digit Symbol and Digit Span subtests of the Wechsler Intelligence Scale for Children Revised (WISC‐R), and Trail Making Test A and B, which taps abstraction–flexilibity (WCST), sustained attention (CPT), mental tracking and complex attention (WISC‐R Digit Span, Digit Symbol, Trail Making A and B) and interference control (Stroop). Multiple linear regression was used to evaluate the relation of ferritin, hemoglobin, MCV, RDW, age, gender, and presence of comorbidity. Results: While seven children had iron deficiency, none of them was anemic. Lower ferritin levels were associated with higher hyperactivity scores in parental ratings. While performance increased with age for most of the neuropsychological tests utilized, ferritin, hemoglobin, MCV and RDW and gender were not significantly related with cognitive performance in this sample. Conclusions: At least for the present clinical sample, ferritin levels might be related with behavioral but not cognitive measures in ADHD cases.     

Role of dopamine transporter genotype and maternal prenatal smoking in childhood hyperactive-impulsive,inattentive, and oppositional behaviors

OBJECTIVE: To examine the joint effects of a dopamine transporter (DAT) polymorphism and maternal prenatal smoking on childhood hyperactivity-impulsivity and inattentiveness. STUDY DESIGN: A cohort of 161 children was followed prospectively from age 6 months to 60 months. Primary outcomes were the DSM-IV hyperactive-impulsive and inattentive scales of the Conners' Parent Rating Scale Revised-Long Version (CPRS R:L). A secondary outcome was the oppositional scale. Predictors included DAT genotype and maternal report of prenatal smoking. Children homozygous for the 480-bp DAT allele (DAT +/+) were compared with all other children (DAT +/- or -/-). RESULTS: In multivariate analyses, children with both prenatal smoke exposure and the DAT +/+ genotype had significantly elevated hyperactive-impulsive scores (beta, 7.5; SE, 2.9; P<.01) compared with children with no smoke exposure and DAT +/- or -/-. Inattentive scores were not significantly elevated in this group, but oppositional scores were a full standard deviation higher. Neither prenatal smoke exposure alone nor DAT +/+ genotype alone was significantly associated with increased scores. CONCLUSIONS: Child hyperactivity-impulsivity and oppositional behaviors were associated with a DAT polymorphism but only when the child also had exposure to maternal prenatal smoking. This study emphasizes the importance of incorporating environmental cofactors in genetic studies of attention deficit hyperactivity disorder.     

Medium-term outcomes are comparable with short-term outcomes in children with attention deficit hyperactivity disorder treated with stimulant medication

OBJECTIVE: To compare the short- and medium-term effects of psychostimulant medication in children with attention deficit hyperactivity disorder (ADHD). METHODS: Seventy-three children with ADHD participated in a double-blind crossover study of dextroamphetamine (DEX) and methylphenidate (MPH; results previously reported). At the completion of this study, subjects continued to take the preferred stimulant. Subjects were restudied 6-9 months later. The principal outcome measures were the Revised Conners' Parent and Teacher Rating Scales. RESULTS: Fifty-three families (73%) returned the follow-up surveys. At 6-9 months, mean T scores were still significantly lower than the mean at baseline for all factors of both the CPRS-R and CTRS-R (P < 0.01). There were no statistically significant differences between scores at 6-9 months and scores at the completion of the corresponding medication period in the crossover trial. CONCLUSIONS: After 6-9 months treatment with stimulant medication, ratings remained significantly better than at baseline. This suggests that the early benefits of stimulants are sustained for at least 6 months.     

Iron deficiency in Indian children with attention deficit hyperactivity disorder

A case control study was conducted at the Child Development and Early Intervention Clinic to determine the body iron status of children with ADHD, and study the correlation between the body iron status and ADHD symptoms. Serum ferritin was measured in newly diagnosed cases with ADHD and compared with that of controls. Correlation was studied between serum ferritin levels and the severity of ADHD symptoms as determined by Conners’ Rating Scale. Serum ferritin was found to be significantly lower in children with ADHD (6.04 ± 3.85 ng/mL) as compared to controls (48.96 ± 41.64 ng/mL, P value<0.001). There was a significant negative correlation between serum ferritin levels and oppositional subscore on Conners’ Rating Scale.     

A comparison of medicated and nonmedicated attention-deficit disordered hyperactive boys.

Sixty boys diagnosed as having attention-deficit disorder with hyperactivity were divided into two equal groups, depending on whether or not they were taking medication for their disorder. These two groups were subdivided equally into younger and older groups, the cutoff being 11.5 years. All subjects were given the Children's Depression Inventory, the Coopersmith Self Esteem Inventory and the Children's Attributional Style Questionnaire. Teachers completed the Child Behaviour Checklist and Conners' Teacher Rating Scale. The results indicated that in the older subjects, the medicated group had lower social self-esteem than the nonmedicated group and in younger subjects the medicated group had higher academic self-esteem than the nonmedicated group. There were no significant differences among the groups with respect to depression; all four groups of subjects were mildly depressed. The younger subjects in general were more inattentive, nervous, impulsive and aggressive; and teachers did not report any less externalising behaviour in those subjects who were on medication. These results were interpreted in the light of findings from previous studies, and the lack of drug effect on externalising behaviour is discussed. Clinical recommendations are made for alleviating depression and improving self-concept by means of cognitive therapy, especially for older medicated ADDH children.     

家长培训合并哌醋甲酯治疗对注意缺陷多动症障碍患儿家庭关系的影响

目的 了解家长培训合并哌醋甲酯治疗对注意缺陷多动障碍（ADHD）患儿家庭关系的干预效果。方法 对59 例ADHD 患儿家长进行为期5 周的家长培训,在培训前后使用Conners 儿童行为问卷（父母用）、ADHD 和对立违抗障碍（ODD）症状分级父母评量表、照料者压力问卷、亲子关系自评量表、儿童自我意识量表等进行评估。结果 和基线相比,培训后Conners 儿童行为问卷总分、品行问题及焦虑因子分下降,ADHD症状分级父母评量表各因子分（注意缺陷、多动、冲动）和对立违抗行为均有下降,照料者压力问卷总分下降,亲子关系自评量表总分、儿童自我意识量表总分以及躯体外貌属性、智力和学校行为因子分提高,以上差异均有统计学意义（P结论 ADHD 患儿家长培训能促进亲子间发展良好关系,减轻家长育儿压力。     

What is measured by the Conners' Teacher Behavior Rating Scale? Replication of factor analysis

The revised 28-item Conners' Teacher Behavior Rating Scale (TBRS) is subjected to factor analysis replication, with a referral sample of 354 children. The factor structure is more clearly defined than in the original normative study, and a primary factor of hyperactivity emerged, accounting for 39% of the variance. Six factors that emerged, all with eigenvalues of 1.00 or more, accounted for 69% of the variance. Hyperactivity and conduct factors, which are consistent over multiple studies, emerged. Items consistent with inattentive, unsociable, and passive behavior also separated into discrete factors. This suggests that using a mixed clinical population produces a clearer delineation of factors, which may provide the basis for subtyping a clinical population. Use of the TBRS as the diagnostic measure in medication studies, and its relationship with the abbreviated Teacher Rating Scale (ATRS), are explored.     

Enhancing behavioral and social skill functioning in children newly diagnosed with attention-deficit hyperactivity disorder in a pediatric setting

The objective of this study was to evaluate the effectiveness of an 8-week behavioral and social skill (BSS) class for children newly diagnosed with attention-deficit hyperactivity disorder (ADHD) and their parents, initiating stimulant treatment in primary care. The subjects were 100 children, aged 5 to 12 years, recently diagnosed with ADHD and treated with stimulant medication, and their parents or guardians. Eligible families were randomly assigned to an intervention group (IG: n = 59) or control group (CG: n = 41). The BSS function of each child was assessed using DuPaul's ADHD Parent Rating Scale (18-item) and Child Attention Profile (12-item) during blinded baseline and follow-up interviews. Parent discipline practice was assessed using a five-item inventory based on Likert-scale ratings during identical periods. Computerized pharmacy records were used to track psychostimulant use over time. IG children exhibited significantly lower parent-rated ADHD symptoms, whereas IG parents reported significantly better and more consistent discipline practices compared with CG parents across time. No significant differences were found between groups in Child Attention Profile scores across time. Psychostimulant use did not significantly differ between groups across time. BSS training was well accepted and seemed to significantly improve BSS functioning among IG children in the home setting only.     

CONNERS'' TEACHER RATING SCALE IN CHINESE CHILDREN IN HONG KONG

Conners' Teacher's Rating Scale (CTRS) was applied to 914 children, a representative sample of the total population of normal primary school children (age 6-12) in Hong Kong. Both interrater and test-retest reliability were satisfactory. On all the subscales, the scores lay on the high side when compared to results of western countries. When factor analysis was carried out, the main difference from other studies was that the conduct problem factor and hyperactivity factor were combined. There was a very significant sex effect with boys having much higher total and subscales scores of conduct problem, inattention and hyperactivity whereas the girls were rated significantly higher on the subscales of anxiety-tension.     

A randomized, double-blind, placebo-controlled trial of docosahexaenoic acid supplementation in children with attention-deficit/hyperactivity disorder

OBJECTIVE: To determine whether docosahexaenoic acid (DHA) supplementation for 4 months decreases the symptoms of attention-deficit/hyperactivity disorder (ADHD). STUDY DESIGN: Sixty-three 6- to-12-year-old children with ADHD, all receiving effective maintenance therapy with stimulant medication, were assigned randomly, in a double-blind fashion, to receive DHA supplementation (345 mg/d) or placebo for 4 months. Outcome variables included plasma phospholipid fatty acid patterns, scores on laboratory measures of inattention and impulsivity (Test of Variables of Attention, Children's Color Trails test) while not taking stimulant medication, and scores on parental behavioral rating scales (Child Behavior Checklist, Conners' Rating Scale). Differences between groups after 4 months of DHA supplementation or placebo administration were determined by analysis of variance, controlling for age, baseline value of each outcome variable, ethnicity, and ADHD subtype. RESULTS: Plasma phospholipid DHA content of the DHA-supplemented group was 2.6-fold higher at the end of the study than that of the placebo group (4.85 +/- 1.35 vs 1.86 +/- 0.87 mol % of total fatty acids; P <.001). Despite this, there was no statistically significant improvement in any objective or subjective measure of ADHD symptoms. CONCLUSION: A 4-month period of DHA supplementation (345 mg/d) does not decrease symptoms of ADHD.     

Parent SNAP-IV rating of attention-deficit/hyperactivity disorder: accuracy in a clinical sample of ADHD,validity, and reliability in a Brazilian sample

ObjectiveTo investigate the psychometric properties of the short or multimodal treatment study version of the Swanson, Nolan, and Pelham, Version IV (SNAP-IV) scale, which measures attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms.MethodsParticipants were 765 parents of children from 4 to 16 years old (641 non-attention-deficit/hyperactivity disorder and 124 attention-deficit/hyperactivity disorder children) from Belo Horizonte, Brazil, who reported sociodemographic characteristics and answered the SNAP-IV. Parents of the clinical sample also underwent the K-SADS-PL interview.ResultsAge was significantly associated with SNAP-IV hyperactivity-impulsivity problems (r = ?0.14), but not with inattention or oppositional defiant disorder. Sex was a significant influence on attention-deficit/hyperactivity disorder and oppositional defiant disorder severity (all p < 0.001), with boys showing higher scores in the full sample, but not within the attention-deficit/hyperactivity disorder group. Exploratory and confirmatory factor analysis supports a three-factor structure of the SNAP-IV scale. Moderate-to-strong correlations were found between SNAP-IV and K-SADS-PL measures. All SNAP-IV scales showed very high internal consistency coefficients (all above 0.91). SNAP-IV inattention scores were the most predictive of attention-deficit/hyperactivity disorder diagnosis (AUC: 0.877 for the averaging rating method and the raw sum method, and 0.874 for the symptom presence/absence method).ConclusionThe parent SNAP-IV showed good psychometric properties in a Brazilian school and clinical sample.
     

深圳市小学儿童注意力缺陷多动障碍流行病学调查

目的：调查深圳市小学儿童注意力缺陷多动障碍（ADHD）的患病情况和行为问题。方法：采用Conners行为量表对深圳市小学1~6年级10553名学生的家长、教师进行问卷调查,对经问卷调查为ADHD行为阳性的儿童进一步采用美国精神病学会的精神障碍诊断和统计手册第 4版（DSM-Ⅳ）进行诊断。结果家长问卷和教师问卷均填写完整、合格的为 8193份。纳入研究对象年龄为7~13岁。由家长问卷量表得到ADHD行为发生率为 7.60%,由教师问卷量表得到ADHD行为发生率为5.59%。依据DSM-Ⅳ诊断ADHD 442例,总患病率为 5.39%;7～13岁各年龄组间患病率差异有统计学意义（χ2=21.613,P<0.05）,其中7～9岁各年龄组患病率较高,均在6%以上;男童患病率显著高于女童（6.65% vs 3.12%,P<0.05）。冲动多动问题（79.6%）、学习问题（60.6%）和品行问题（52.0%）是ADHD儿童较突出的行为问题,其中女童学习问题显著高于男童（83.5% vs 54.7%,P<0.01）。结论：深圳市小学儿童ADHD患病率为 5.39%,其中7~9岁儿童患病率较高;男童患病率显著高于女童;冲动多动问题、学习问题和品行问题是ADHD儿童常见的行为问题。     

Child and Parent Perceptions of the Upsettingness of Major Life Events

An adaptation of the Coddington Social Readjustment Rating Scale for use with first-grade children was administered to 164 first-graders and their parents. Parents indicated whether each event occurred and both parents and their children rated the upsettingness to the child. Parent ratings of stress are significantly higher than child ratings for specific events and a composite stress measure. Parent and child composite scores correlated 0.21 when the number of events was controlled. Implications for research on life events and childhood stress are discussed.     

Attention deficit hyperactivity disorder: does cognitive behavioral therapy improve home behavior?

This study evaluates the effectiveness of cognitive behavioral therapy (CBT) in improving the home behavior of children with attention deficit hyperactivity disorder (ADHD). Twenty-five boys (age 7 to 13) with a diagnosis of ADHD were randomized to a CBT or supportive therapy control group. Outcome measures included parent and teacher ratings of the child on the Behavior Problem Checklist-Attention Problem Subscale (BPC-AP), and the Self-Control Rating Scale (SCRS), parent ratings on the Modified Werry Weiss Activity Scale, and child ratings on the Piers Harris Self-Concept Scale and Matching Familiar Figures Task. Data were analyzed using a two-way analysis of variance for main effects. A significant improvement favoring CBT was found on the Werry Weiss Scale, which measures the parent's perception of the child's hyperactivity in the home, and the child's rating of his/her self-esteem on the Piers Harris Self-Concept Scale. Other outcome measures did not demonstrate statistical differences. This research provides support for the use of CBT in children with ADHD. CBT was found to improve the parent's perception of the child's hyperactivity in the home as well as the child's self-esteem.