A cognitive tool to diagnose predominantly inattentive ADHD behavior

Poor performance on tests of reading comprehension could be the result of weak word-recognition skills, inconsistent attention (ADD), or a combination of the two. Identifying the source of the reading disability (RD) reliably has been difficult because inconsistent attention interferes with reading and weak word recognition skill makes attention wander. The situation is further complicated by the fact that there are no objective diagnostic tests for ADD (Breggin, 1998; Diller, 1998). We proposed a new model of differential diagnosis of ADHD-I/RD and field-tested its utility in two studies. The new diagnostic procedure utilizes intra-individual differences seen in the performance of at-risk learners on tasks related to reading that vary in the degree of sustained attention required for successful performance. The hypothesis is that children whose attention is inconsistent would perform more poorly on tests such as listening comprehension, which require sustained attention, than on tests such as reading comprehension, which are more tolerant of inattention. Such differences will not be seen in the test scores of children who have only a reading disability because their performance on reading tests is determined more by the difficulty level of the tests than by the sensitivity of the tests to attention. The validity of this new model was evaluated by determining the relationship between differences seen in the scores of tests that differ in their attention requirement and the degree of inconsistency in sustained attention as measured by Conners' CPT. The results of the two studies indicate this to be a viable approach. The results of the second study are presented in this report.     

Differences in cognitive control in children and adolescents with combined and inattentive subtypes of ADHD

The aim of the present study was to investigate the ability of children with attention deficit/hyperactivity disorder-combined subtype (ADHD-C) and predominantly inattentive subtype (ADHD-PI) to direct their attention and to exert cognitive control in a forced attention dichotic listening (DL) task. Twenty-nine, medication-naive participants with ADHD-C, 42 with ADHD-PI, and 40 matched healthy controls (HC) between 9 and 16 years were assessed. In the DL task, two different auditory stimuli (syllables) are presented simultaneously, one in each ear. The participants are asked to report the syllable they hear on each trial with no instruction on focus of attention or to explicitly focus attention and to report either the right- or left-ear syllable. The DL procedure is presumed to reflect different cognitive processes: perception (nonforced condition/NF), attention (forced-right condition/FR), and cognitive control (forced-left condition/FL). As expected, all three groups had normal perception and attention. The children and adolescents with ADHD-PI showed a significant right-ear advantage also during the FL condition, while the children and adolescents in the ADHD-C group showed a no-ear advantage and the HC showed a significant left-ear advantage in the FL condition. This suggests that the ADHD subtypes differ in degree of cognitive control impairment. Our results may have implications for further conceptualization, diagnostics, and treatment of ADHD subtypes.     

Evaluating the endophenotype model of ADHD neuropsychological deficit: results for parents and siblings of children with ADHD combined and inattentive subtypes

Neurogenetic models predict neuropsychological weaknesses in the relatives of children with attention-deficit/ hyperactivity disorder (ADHD). The authors examined executive and regulatory measures in 386 relatives (307 parents, 79 siblings) of children with ADHD combined type, ADHD inattentive type, and controls. Predicted deficits were seen on trailmaking (relatives of ADHD combined type only), stop-signal reaction times (relatives of girls only), and response variability (mothers only) but not on naming or output speed. Effects generally held, even with relatives' ADHD status controlled. A neuropsychologically impaired subgroup of children with ADHD had relatives with clear neuropsychological weaknesses. The authors conclude that a neurogenetic model of ADHD etiology is supportable only for a subset of executive functions and that neuropsychological heterogeneity warrants more examination in ADHD.     

A meta-analytic review of gender differences in ADHD

The present study examined gender differences in ADHD through a meta-analysis. Effect size estimates for the primary symptoms and correlates of ADHD were calculated in an attempt to replicate and extend a previous meta-analysis on gender differences in the disorder. Relatively lenient inclusion criteria were used in order to maximize the number of studies included in the effect sizes. The results indicated that in comparison to ADHD boys, ADHD girls had lower ratings on hyperactivity, inattention, impulsivity, and externalizing problems. In addition, ADHD girls had greater intellectual impairments and more internalizing problems than ADHD boys. Overall, the results of the current meta-analysis indicated general agreement with the previous meta-analysis. The clinical implications of these gender differences and future research considerations are discussed.     

Validity of the Brown ADD scales: an investigation in a predominantly inattentive ADHD adolescent sample with and without reading disabilities

The Brown ADD Scale for Adolescents is widely used in clinical settings, yet, no published studies have investigated divergent and concurrent validity and specificity and sensitivity to inattentive ADHD symptomatology. Ninety-eight participants (13 to 16 years) were classified as ADHD/I and/or reading disabled (RD) using Kiddie Schedule for Affective Disorder and Schizophrenia (K-SADS), Conners' Rating Scales (CRS-R), and Ontario Child Health Study Scales (OCHSS), WRAT3, and WRMT-R. The results were: 29 ADHD/I; 12 RD, 16 ADHD/I with RD; and, 41 controls. The RD group was included to evaluate specificity. The Brown was administered but not used in classification. The ADHD groups scored higher on the Brown subscales compared with the other two groups. The recommended cutoffs resulted in high rates of false negatives but few false positives; this suggests good specificity but poor sensitivity. There were moderate correlations among the Brown, CRS-R, and OCHSS. The Brown can be useful in screening out ADHD; however, its low sensitivity precludes its usefulness in diagnosing ADHD.     

A review of adult ADHD: a neuropsychological and neuroimaging perspective

Attention-deficit/hyperactivity disorder (ADHD) is a developmental disorder which effects an estimated 3% to 5% of children. Despite estimates that ADHD persists in 30% to 70% of adults having had the disorder in childhood, ADHD in adulthood remains controversial. This report summarizes current thinking in the diagnosis and etiology of adult ADHD. Most theories posit that ADHD is related to anomalies in frontal lobe function and dopaminergic transmission. However, there is debate as to whether ADHD is a unitary disorder with different manifestations, a syndrome, or multiple disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, classifies ADHD into inattention, hyperactivity-impulsivity, and combined subtypes. Although problems with cognition are core ADHD symptoms, self-reporting has not been a reliable predictor of neuropsychological test performance. Nevertheless, we suggest that a performance-based diagnosis, including empirically derived, age-sensitive neuropsychological tests, provides the best hope of dissociating ADHD from psychiatric disorders with similar symptoms. We also describe the promise of new neuroimaging technologies, such as functional magnetic resonance imaging, in elucidating the pathophysiology of ADHD and similar psychiatric disorders.     

Diverse multi-week physical activity programs reduce ADHD symptoms: A systematic review and meta-analysis

ObjectivePhysical activity (PA) has been proposed as an adjunct treatment and secondary prevention intervention for attention-deficit hyperactivity/impulsivity disorder (ADHD) and oppositional defiant disorder (ODD). However, meta-analyses testing effects on symptoms and functional impairment have yielded conflicting results.MethodsA systematic search of eight databases yielded 15 randomized controlled trial and 2 quasi-experimental design studies—including N = 881 youth (M = 9.75 years, 71% male)—that tested the effects of multi-week PA programs on symptoms and impairment of children with [or at-risk for] ADHD and/or ODD.ResultsRandom effects meta-analyses favored PA groups on omnibus ADHD measures (g = −0.42, 95%CI[-0.62;-0.21]), combined ADHD symptoms (g = −0.50, 95%CI[-0.82;-0.17]), inattention (g = −0.41,95%CI[-0.82; 0.00]), and hyperactivity/impulsivity (g = −0.30, 95%CI[-0.56;-0.04]). Heterogeneity was moderate across studies (I² = 49%, 95%CI[12%-to-70%]). Significant differences favored PA programs whether inclusion required diagnosis, programs augmented frontline treatments, and active or passive comparison groups were utilized.ConclusionDiverse PA programs can reduce ADHD symptoms, especially where they intentionally pursue this end.     

Risky decision-making in children with and without ADHD: A prospective study

Learning from past decisions can enhance successful decision-making. It is unclear whether difficulties in learning from experience may contribute to risky decision-making, which may be altered among individuals with attention-deficit/hyperactivity disorder (ADHD). This study follows 192 children with and without ADHD aged 5 to 10 years for approximately 2.5 years and examines their risky decision-making using the Balloon Emotional Learning Task (BELT), a computerized assessment of sequential risky decision-making in which participants pump up a series of virtual balloons for points. The BELT contains three task conditions: one with a variable explosion point, one with a stable and early explosion point, and one with a stable and late explosion point. These conditions may be learned via experience on the task. Contrary to expectations, ADHD status was not found to be related to greater risk-taking on the BELT, and among younger children ADHD status is in fact associated with reduced risk-taking. In addition, the typically-developing children without ADHD showed significant learning-related gains on both stable task conditions. However, the children with ADHD demonstrated learning on the condition with a stable and early explosion point, but not on the condition with the stable and late explosion point, in which more pumps are required before learning when the balloon will explode. Learning during decision-making may be more difficult for children with ADHD. Because adapting to changing environmental demands requires the use of feedback to guide future behavior, negative outcomes associated with childhood ADHD may partially reflect difficulties in learning from experience.     

Classroom observations of students with and without ADHD: Differences across types of engagement

The current study examined the behaviors related to academic engagement exhibited by students with ADHD during instruction in math and reading. A total of 155 students (92 ADHD, 63 recruited controls) in grades 1 through 4 participated in the study. Results revealed that students with ADHD exhibited statistically significant lower rates of academic engagement and higher rates of off-task behaviors than recruited controls and randomly selected peer comparisons. Specifically, students with ADHD exhibited statistically significant lower rates of passive academic engagement (PET) than recruited controls and peer comparisons; however no group differences were found with regard to active engaged time (AET). In addition, students with ADHD exhibited lower rates of AET than PET, a finding observed among both recruited controls and randomly selected peer comparisons. Implications for research and practice are discussed.     

ADHD and female specific concerns: a review of the literature and clinical implications

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD.     

Telemedicine and adherence to national guidelines for ADHD evaluation: A case study

The pilot project evaluated a telemedicine clinic's adherence to American Academy of Pediatrics (AAP) guidelines for attention-deficit/hyperactivity disorder (ADHD) evaluation. Real-time videoconferencing linked the patients, the families, and the specialty mental health team. The ADHD Telemedicine Clinic adherence to AAP guidelines was tracked using chart data. The study included 22 patients (Mean age = 9.3 years, SD = 2.3 years) participating in 69 telemedicine visits across 13 different school-related sites. The ADHD Telemedicine Clinic reached extremely high adherence rates across the AAP evaluation guidelines for ADHD, ranging from 95-100% across the six guidelines. No factor inherent to the telemedicine service delivery mechanism impeded adherence to national guidelines for ADHD evaluation. Telemedicine-based outreach had the greatest impact on AAP Guideline #4, stating that information should be obtained from the child's academic setting. The school-based telemedicine clinic allowed increased communication across the school and specialty mental health systems and facilitated greater input across child, parent, school personnel, and mental health professionals. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

A Review of Factors that Promote Resilience in Youth with ADHD and ADHD Symptoms

The vast majority of research on youth with ADHD has focused on risk factors and describing the types of impairment individuals with ADHD experience. However, functional outcomes associated with ADHD are heterogeneous, and although many youth with ADHD experience significant negative outcomes (e.g., school dropout), some are successful in multiple domains of functioning (e.g., pursue and graduate college). There is a growing body of literature supporting the existence of factors that protect youth with ADHD from experiencing negative outcomes, but there is no published synthesis of this literature. Accordingly, the goals of this review are to conceptualize risk–resilience in the context of ADHD using a developmental psychopathology framework and to systematically review and critique evidence for promotive and protective factors in the context of ADHD. The literature search focused specifically on resilience in the context of ADHD symptoms or an ADHD diagnosis and identified 21 studies, including clinic, school, and community samples. Findings of promotive and/or protective factors are summarized across individual, family, and social–community systems. Overall, we know very little of the buffering processes for these youth, given that the study of promotive and protective factors in ADHD is in its infancy. The strongest evidence to date was found for social- and family-level systems. Specifically, multiple longitudinal studies support social acceptance as a protective factor, buffering against negative outcomes such as poor academic performance and comorbid depressive symptoms for youth with ADHD. There was also compelling evidence supporting positive parenting as a promotive factor. In terms of individual-level factors, positive or modest self-perceptions of competence were identified as a promotive factor in multiple studies. Future directions for research that will catalyze the study of resilience with ADHD are provided, and the potential for targeting protective mechanisms with intervention and prevention is discussed.