Assessment of Attention in Children with Attention Deficit Hyperactivity Problems in Primary Care Settings

Clinical child psychologists in primary care settings are often asked to evaluate children with suspected attention and learning problems. This paper will review some of the methods and assessments available to child psychologists to enable them to perform this task. Some problems with current practice will be described and some of the newer techniques will be introduced. A research-based understanding of areas of chronic impairment of children with Attention Deficit Hyperactivity Disorder (ADHD) will be discussed, and a new approach to the assessment of both executive functions and attention will be explored. This paper will primarily explore assessment in the primary care setting.     

Processing speed in children with attention deficit/hyperactivity disorder, inattentive type.

Attention Deficit/Hyperactivity Disorder (ADHD) is among the most common and most often reconceptualized neurobehavioral disorders of childhood. In the most recent DSM-IV, a primarily inattentive subtype of ADHD (AD) has again been identified. This study explores the neuropsychological profile of this group of children. Eighty-two children referred for school-related problems participated. Twenty-five met criteria for AD; 52 met criteria for reading disability (RD); 9 were comorbid for RD and AD. AD children performed poorly on measures of information processing speed. Children with comorbid AD/RD were distinguishable from those with RD on speed of processing measures only. Vulnerability to information processing load may be at the root of many of the behavioral manifestations of AD.     

Processing Speed in Children With Attention Deficit/Hyperactivity Disorder,Inattentive Type

Attention Deficit/Hyperactivity Disorder (ADHD) is among the most common and most often reconceptualized neurobehavioral disorders of childhood. In the most recent DSM-IV, a primarily inattentive subtype of ADHD (AD) has again been identified. This study explores the neuropsychological profile of this group of children. Eighty-two children referred for school-related problems participated. Twenty-five met criteria for AD; 52 met criteria for reading disability (RD); 9 were comorbid for RD and AD. AD children performed poorly on measures of information processing speed. Children with comorbid AD/RD were distinguishable from those with RD on speed of processing measures only. Vulnerability to information processing load may be at the root of many of the behavioral manifestations of AD.     

ADHD in college students

OBJECTIVE: According to the American Psychiatric Association, 3% to 7% of the school-age population has ADHD and many children continue to display significant symptoms throughout adolescences and adulthood. Relative to the childhood literature, less is known about ADHD in adults, especially college students with ADHD. The principle purpose of this review articles is to summarize the major research findings concerning ADHD in the college student population with regard to prevalence of symptoms, neuropsychological and psychological functioning. Overall, findings suggest that college students with ADHD are at greater risk for academic and psychological difficulties, and they perform similar to non-ADHD controls on many neuropsychological tasks. These findings are preliminary, however, and are tempered by the small number of studies that have been conducted as well as the methodological limitations of these studies. CONCLUSION: Future research using larger sample sizes, rigorous assessment criteria, and a longitudinal design is needed to better understand the psychological, academic, and neuropsychological functioning of college students with ADHD. Studies are also needed to elucidate the effects of pharmacological and nonpharmacological effects of treatment on the functioning of college students with this disorder.     

ADHD and delinquency--a developmental perspective

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood and adolescence. Until now, it has been unclear whether ADHD by itself constitutes a risk factor for later delinquency or does so only in combination with other disruptive symptoms. This article seeks to give a comprehensive account of the literature to shed light on the developmental pathway from childhood ADHD to adult criminality. Comorbid ADHD and conduct disorder (CD) are significantly related to a range of biological and environmental risk factors such as neurocognitive impairment, high parental psychopathology, poor social functioning, and other comorbid mental disorders, particularly substance abuse, that are described in this review. In addition, the results of treatment studies are presented, with a special focus on the results of the Multimodal Treatment Study of Children with ADHD (MTA). Although treatment programs, including medication and psychosocial treatment, can be very effective in improving the functioning of children with ADHD in the social and academic domains in the short term, there is no conclusive evidence that such treatments lower the risk for developing delinquency in adulthood.     

Parent ADHD and Evidence-Based Treatment for Their Children: Review and Directions for Future Research

One fourth to one half of parents of children with attention-deficit/hyperactivity disorder (ADHD) have ADHD themselves, complicating delivery of evidence-based child behavioral and pharmacological treatments. In this article, we review the literature examining the relation between parent ADHD and outcomes following behavioral and pharmacological treatments for children with ADHD. We also review research that has incorporated treatment of parent ADHD (either alone or in combination with child treatment) with the goal of improving parenting and child outcomes. Finally, we offer recommendations for future research on the relation between parent ADHD and evidence-based treatment outcomes for their children, with the purpose of advancing the science and informing clinical care of these families.     

A comparison of behavioral and attentional functioning in children diagnosed as hyperactive or learning-disabled

The attentional and behavioral functioning of children diagnosed as hyperactive (ADHD), learning-disabled (LD), and hyperactive/learning-disabled were compared, using standardized behavior rating scales across raters and settings, and results from a battery of standardized neuropsychological tests. The ADHD and LD groups were "pure" samples with respect to comorbidity. Multiple discriminant-function analyses on the behavioral and neuropsychological data showed that one variate made clear-cut discriminations among and between each of the three groups. The constructs self-regulation, task accuracy/planning/speed, and aggression differentiated the three groups, while sustained attention did not. The results lend strong support to the validity of ADHD as a diagnostic entity apart from LD, and suggest that poor self-regulation and inhibition of behavior may be the hallmark of 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.     

Referrers' Perceived Utility and Outcomes of Clinical Neuropsychological Assessment in an Adolescent and Young Adult Public Mental Health Service

Despite frequent informal or anecdotal acknowledgement of the usefulness of neuropsychological services within various settings, including mental health settings, few studies have formally investigated the satisfaction, perceived utility, or outcomes associated with such a service. This survey‐based study evaluated referring clinicians’ (n = 35) perceptions of the usefulness and outcomes associated with the provision of clinical neuropsychological assessment and feedback within an adolescent and young adult public mental health service in Melbourne, Australia. The results suggest that referrers perceive the neuropsychological service, including formal neuropsychological assessment report and verbal and written feedbacks, as a highly useful adjunct to their clinical practice. In addition, referrers frequently reported clinically meaningful outcomes in association with the neuropsychological service, including diagnostic changes or additions (11% of clients referred), changes to approaches in treatment (52% of clients referred), and increased or appropriate access to services, education, or work (33% of clients referred). Referrers also reported that almost 60% of neuropsychological assessment reports were forwarded to other services or clinicians involved in the client's care. The findings suggest that mental health settings are likely to benefit from routine inclusion of specialist neuropsychology services. However, future research should also examine client and family perceptions regarding the satisfaction and usefulness of neuropsychological services.     

Assesement of young children

Discusses important issues and problems related to the assessment of young children. A review of the literature identifies major trends in the field of assessment in early childhood education. Authors conclude that with increased emphasis on assessment of young children, there is an increased need to develop teachers' skills in both selection and interpretation of appropriate formal and informal assessment techniques.     

Co-occurring Aggressive and Depressive Symptoms as Related to Overestimations of Competence in Children with Attention-Deficit/Hyperactivity Disorder

Research indicates that on average, children with attention-deficit/hyperactivity disorder (ADHD) overestimate their competence in various domains. ADHD also frequently co-occurs with disorders involving aggressive and depressive symptoms, which themselves seem to influence estimations of self-competence in social, academic, and behavioral domains. In particular, high levels of aggressive behavior are generally associated with overestimations of competence, and high levels of depressive symptoms are related to underestimations of competence. This paper reviews studies of overestimations of competence among children with ADHD and examines the extent to which comorbid aggressive or depressive symptoms may be influencing these estimates. Although significant challenges arise due to limited information regarding comorbidities and problematic methods used to assess overestimations of competence, existing evidence suggests that ADHD may be associated with overestimations of competence over and above co-occurring aggression. As well, studies suggest that comorbid depression may reduce the appearance of overestimations of competence in children with ADHD. Underlying mechanisms (e.g., neuropsychological deficits or self-protection) of overestimations in children with ADHD are discussed, each with particular clinical implications for the assessment and treatment of ADHD. Future research would do well to carefully consider and explicitly describe the comorbid aggressive and depressive characteristics among individuals with ADHD when overestimations of competence are examined.     

Sensory-motor deficits in children with developmental coordination disorder, attention deficit hyperactivity disorder and autistic disorder

Children who have been diagnosed with any one developmental disorder are very likely to meet diagnostic criteria for some other developmental disorder. Although comorbidity has long been acknowledged in childhood disorders, little is understood about the mechanisms that are responsible for the high level of comorbidity. In a series of studies, we have investigated the link between sensory-motor deficits and developmental disorders. Poor sensory-motor integration has long been implicated as a cause of motor problems in developmental disorders such as developmental coordination disorder (DCD), and our recent research has also investigated sensory-motor deficits in children with attention deficit hyperactivity disorder (ADHD) and autistic disorder. Based on a critical examination of relevant literature and some of our recent research findings, we argue that the importance of poor sensory-motor functioning in discriminating children with different disorders has been underestimated. Poor sensory-motor coordination appears to be linked to DCD, but not ADHD. Also, sensory-motor deficits in children with DCD and autistic disorder may provide insight into some of the social difficulties found in these groups of children. This research will increase our understanding of why children with one developmental disorder typically also have problems in other areas.     

Child and familial pathways to academic achievement and behavioral adjustment: a prospective six-year study of children with and without ADHD

This longitudinal study examined familial and child predictors of academic achievement and behavioral adjustment. Participants included 115 children with ADHD and 59 normative comparisons. Data analyses spanned three assessment waves from elementary- through secondary-school grades. We evaluated the degree to which child and familial factors present during middle school mediated relationships between childhood ADHD, subsequent academic achievement, and behavioral adjustment during high school. We found that emotional and behavioral well-being of ADHD children during middle school mediated relations between childhood ADHD and adverse academic and behavioral outcomes during high school. In addition, familial factors in middle school years predicted the behavioral adjustment of children in both the ADHD and non-ADHD groups. Academic achievement during high school was strongly associated with previous achievement levels. Our results provide support for tailoring preventive interventions to the unique needs of children with ADHD and their parents at various stages of adolescent development.     

Examining Alternative Explanations of the Covariation of ADHD and Anxiety Symptoms in Children: A Community Study

Attention-deficit hyperactivity disorder (ADHD) is comorbid with a range of other disorders, including anxiety disorders. The aim was to examine different explanations for the covariation of these symptom domains in children according to the framework provided by (Lilienfeld, S. O. Comorbidity between and within childhood externalizing and internalizing disorders: Reflections and directions. Journal of Abnormal Child Psychology, 2003). The covariation of ADHD symptoms and anxiety symptoms were examined over a 12-month period in a community sample of 499 children aged 8-13; 91% were retained at 12-month follow-up. Dimensional assessments were conducted using questionnaires given to children, parents and teachers, with results analyzed via structural equation modeling. Positive associations between ADHD and anxiety symptoms were linked with inattention symptoms, were particularly pronounced for girls, and were linked via temperament and behavioral problems. No support for the hypothesis that ADHD symptoms predicted the development of anxiety symptoms over time or vice versa. ADHD symptoms (particularly inattention) and anxiety symptoms are covarying phenomena that are linked with an irritable temperament and disruptive behavior.     

State of Multicultural Neuropsychological Assessment in Children: Current Research Issues

Scientific attention to cultural considerations in child neuropsychological assessment has not developed parallel to the focus these issues have received in adult and elderly neuropsychological assessment. There are limited data on the presence, magnitude, etiology, and implications of culture-related differences in cognitive test performance among children. This preliminary report reviews the available empirical literature on the current state of multicultural neuropsychological assessment in children. The review identified articles by searching PubMed and PsycINFO databases, and the tables of contents of Developmental Neuropsychology and Child Neuropsychology from 2003-2008. Of the 1,834 abstracts reviewed, ten papers met inclusion criteria for the review. Five studies were completed in America; four of these compared performance between ethnic groups while the fifth examined neighborhood level poverty indicators exclusively within African-American children. Of the five international studies, all established local normative data and/or were exploratory investigations of neuropsychological functions in specific cultural groups, including Taiwanese infants, South African youth, and bilingual British children. Taken together, the results yield important clinical and research data that begin to inform many of the complex and fascinating mechanisms by which ethnic identity and culture impact cognitive development and the neuropsychological assessment of children. A critique of the existing literature and directions for future research are provided.     

Methodological Issues in the Assessment of Medication Effects in Children Diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is one of the most commonly diagnosed disorders in school-aged children and is usually treated with stimulant medications, including methylphenidate (MPH; Ritalin®, Ritalin-LA®, Concerta®, Metadate®, or Focalin®) and other drug compounds (e.g., Adderall®, Adderall-XR®, or Dexedrine). Assessment of school behavior and performance is a critical component in determining the safety and efficacy of these medications. This paper reviews methodological issues in assessing drug effects in school settings by considering features of the independent variable (the medication), the dependent variables (the endpoints selected for assessment), and the design (the structure of the assessment). In addition, we consider recent conceptual advances in understanding the behavioral mechanisms of action of drugs used to treat ADHD that may influence the structure and interpretation of medication assessments.     

Clinical,neuropsychological and structural convergences and divergences between Attention Deficit/Hyperactivity Disorder and Borderline Personality Disorder: A systematic review

Attention Deficit/Hyperactivity Disorder (ADHD) symptoms overlap with Borderline Personality Disorder (BPD). Since ADHD presents earlier than BPD, ADHD might be either a risk factor or a prodromal stage in the development of BPD or in the reinforcement of its symptoms. However, despite the similar phenomenological origin of the two disorders, ADHD and BPD patients often present discrete profiles. The present study reviews literature data of the clinical, neuropsychological and structural convergences and divergences of ADHD and BPD. A total of 185 studies were identified that address the association of ADHD and BPD and relate to clinical, neuropsychological and structural parameters. The total number of articles included was 45. ADHD exhibits a more outwardly expressed symptomatology, with difficulties in inhibition control and dysfunction in ventrolateral prefrontal regions. BPD presents a more mixed picture of externalizing and interrelating clinical features with emotionally conditioned cognitive disturbances and dysfunction in the orbitofrontal and dorsolateral prefrontal regions. When considering the three abovementioned parameters there is no unique clear-cut point that can differentiate the two disorders in a definitive way. Both disorders share impulsivity, emotional dysregulation, deficits in attention and decision making, brain volume reductions and connectivity impairments in prefrontal and limbic areas.     

Rationale and principles for early intervention with young children at risk for anxiety disorders

Anxiety disorders are one of the most prevalent categories of disorder among adults and children. Children of parents with anxiety disorders are known to be at higher risk for anxiety disorders themselves, with manifestations of this risk often appearing in toddlerhood or early childhood. Yet because affected parents are often unskilled in anxiety management, they often have difficulty in helping their young children learn to manage anxiety. Literature on the course of anxiety disorders through childhood and on effective cognitive-behavioral interventions suggests that preventive interventions even with very young children could potentially be of benefit in mitigating the course of these often debilitating disorders. This paper outlines the rationale for offering early or preventive interventions to preschool-age children at risk and their parents and discusses means of identifying children to target for intervention and the importance of parental involvement. Drawing upon the literature on parental factors in childhood anxiety disorders as well as on effective intervention strategies with preschool-age children, it delineates principles for intervention with parents and effective components of intervention with youngsters in this age range.     

Die Bedeutung der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung für die Entstehung und Prognose von Störungen des Sozialverhaltens im Kindes- und Jugendalter

Attention Deficit/Hyperactivity Disorder (ADHD) and Conduct Disorder (CD) are two of the most common neurobehavioral disorders of childhood. Despite of their high comorbidity rate both disorders can be reliably differentiated. Especially the comorbid condition is associated with a poor outcome and some of the affected children develop an Antisocial Personality Disorder. This article summarizes diagnostic criteria and epidemiological data of both disorders and emphasises the role of ADHD in the aetiology and pathogenesis of antisocial behavior. ADHD seems to have a negative impact particular in children of the early-starter subtype of CD. Findings from genetic, psychophysiological and neuroimaging studies emphasise the relevance of biological risk factors in the etiological models and developmental pathways of antisocial behavior. We present so far unpublished data of children with ADHD and ADHD/disruptive behavior disorders which indicate group-specific neurocognitive impairments in the comorbid condition. ADHD and CD seem to constitute a synergistic and interactive relationship in that each disorder aggravates the other. Recent findings point to a “true hybrid” of ADHD/CD. Considering the negative outcome of the comorbid condition, several findings suggest that high-quality treatments may have considerable impact on restoring ADHD children to better functioning.