Direct assessment of the cognitive correlates of attention deficit disorders with and without hyperactivity

The cognitive functioning of children identified as attention deficit disorder with hyperactivity (ADD/H) was compared to that of children identified as attention deficit disorder without hyperactivity (ADD/WO). Based on information on symptoms supplied by teachers, 20 ADD/H and 15 ADD/ WO children were selected according to DSM-III criteria from a large elementaryschool learning disabilities and behavior disorders population. For comparison purposes, 16 normal children from regular classrooms were also selected. Children from all three groups were evaluated with a battery of cognitive tests. Intelligence test scores differentiated the two ADD groups, with the ADD/H children obtaining significantly lower Full Scale IQ scores than both ADD/WO and control children. In addition, ADD/H children obtained significantly lower Verbal IQ scores than ADD/WO children. Both ADD groups performed more poorly than controls on Spelling and Reading Achievement, and the ADD/WO group performed more poorly on Math Achievement. The two ADD groups took longer to complete six Stroop and rapid naming tasks than the control groups but did not differ among themselves. The ADD/WO group made more errors on a visual matching task than the controls, but neither ADD group differed from controls on the accuracy of the Stroop tasks, rapid naming tasks, measures of receptive and expressive language, visual-motor integration, or sustained visual attention. The differences between the two ADD groups were fewer than expected on the basis of previous research and are more global than specific.The assistance of John Junginger, Jason Walker, and Cynthia Jones at various stages of the project is gratefully acknowledged. Particular thanks are extended to the teachers and staff of Clarke County schools.     

Frontal lobe functions in attention deficit disorder with and without hyperactivity: A review and research report

We review 22 neuropsychological studies of frontal lobe functions in children with attention deficit disorder with and without hyperactivity (ADD/+H,ADD/-H). Some measures presumed to assess frontal lobe dysfunctions were not reliably sensitive to the deficits occurring in either form of ADD. Tests of response inhibition more reliably distinguished ADD/+H from normal children. Where impairments were found on other tests between ADD and normal subjects, they were highly inconsistent across studies and seemed strongly related to age of the subjects and possibly to the version of the test employed. Other methodological differences across studies further contributed to the discrepant reports. The co-morbidity of other disorders, such as learning disabilities (LD) and conduct problems, with ADD may be an additional confounding factor in some, though not all, of these studies. In a separate study, children with ADD/+H (n=12) were then compared on frontal lobe tests to three other groups: ADD/-H (n=12), LD but no ADD (n=11),and normal children (n=12) statistically covarying for differences in conduct problems across groups. Most measures did not distinguish among these groups. Both ADD groups made more omission errors on a Continuous Performance Test (CPT) than the normal group. All three clinical groups performed more poorly on the word and interference portions of the Stroop Test. Thus, while both types of ADD share some apparent similarities in deficits on a few frontal lobe tests in this study, the totality of existing findings suggests an additional problem with perceptual-motor speed and processing in the ADD/-H group.This research was supported by NIMH grant MH41464 and by funds from the Department of Psychiatry, University of Massachusetts Medical Center. The authors are grateful to Judy Tessier and Ellen Mintz-Lennick for their assistance with some of the data collection and scoring. The comments of Virginia Douglas on an earlier draft of this paper are greatly appreciated.     

Agreement of parent and teacher rating scales with comprehensive clinical assessments of attention deficit disorder with hyperactivity

Forty-one clinic-referred children were given the DSM-III diagnosis of attention deficit disorder with hyperactivity (ADD/H) based on structured diagnostic interviews of the child and mother and on two teacher and two parent rating scales. The degree of agreement between diagnostic classification of ADD/H based solely on criterion scores on each rating scale and classification based on the comprehensive clinical assessments that included use of the same rating scaleswas assessed by comparing the ratings of the 41 children with ADD/H to those of 47 clinic-referred children given other diagnoses or no diagnosis. The accuracy of classification was highly similar across scales. Increasing the cutoff score increased the acing true positives. Using the point of intersection of these two curves to choose the optimal cutoff scores resulted in 70–75% accurate classification and 25–30% misclassification of children given clinical diagnoses of ADD/H. This rate of misclassification suggests that rating scales alone should not be used to classify ADD/H for most clinical and research purposes, especially because the method of comparison used in this study favored finding a high degree of correspondence.     

Sociometric status of clinic-referred children with Attention Deficit Disorders with and without Hyperactivity

Peer sociometric nominations of clinic-referred children given the diagnosis of Attention) Deficit Disorder with Hyperactivity (ADD/H) or Attention Deficit Disorder without Hyperactivity (ADD/WO) were compared to one another and to those of normal control children. Only children with ADD diagnoses in the absence of other major diagnoses were included. Both children with ADD/H (n=16) and ADD/WO (n=11) received significantly fewer liked most nominations, more liked least nominations, and lower social preference scores than normal control (n=45) children. These results confirm previous findings of social deficits in children with ADD/H, even when codiagnoses are excluded. In addition, they support the validity of the diagnostic category of ADD/WO by demonstrating that the ADD/WO behavior pattern is apparently psychopathological in being associated with peer unpopularity after codiagnoses are excluded. When larger groups including all codiagnoses (primarily Conduct Disorder) of children with ADD/H (n=36) and ADD/WO (n=20) were compared, identical patterns of peer unpopularity were found, except that children with ADD/H also were significantly more likely to be nominated as a child who fights most.     

Assessing Psychiatric Symptoms in Youth Affected by HIV: Comparing a Brief Self-Administered Rating Scale with a Structured Diagnostic Interview

Brief psychiatric assessment tools are needed for evaluating children affected by HIV for emotional and behavioral problems. We compared a self-administered symptom rating scale (CASI-4R) to a semi-structured diagnostic interview (DICA-P) in 136 U.S. children affected by HIV. Agreement and performance measures for the two instruments were computed for attention deficit hyperactivity disorder, depression, anxiety, and disruptive behavior. Correlations and regression analyses were conducted to compare the two instruments, and to evaluate their associations with social, academic, and global function. Higher CASI-4R symptom severity scores were associated with DICA diagnoses (p?<?0.02 for all disorders). Agreement (κ) between DICA diagnoses and CASI-4R Clinical Cutoffs (which incorporated symptoms and impairment) was low to moderate (0.19–0.40 for all disorders). Thirty-two percent of cases with a DICA diagnosis were identified by the CASI-4R Clinical Cutoff (sensitivity), yet over 90% of DICA-negative cases were negative by the CASI-4R (specificity). Sensitivity was higher using CASI-4R Severity Score thresholds based on median scores compared to the DICA diagnoses. The presence and severity of psychiatric symptoms and impairment were associated with poorer academic, social, and global function. The CASI-4R symptom checklist can be used to inexpensively screen youth affected by HIV for emotional and behavioral problems, although it is important that there be appropriate mental health evaluation follow-up.     

Separate verbal memory and naming deficits in attention deficit disorder and reading disability

In this study, verbal memory and naming abilities were investigated in reading disabled (RD) and control children who were characterized according to the presence or absence of attention deficit disorder (ADD). Results indicate that deficits in learning and memory for recently acquired information occur as a function of ADD rather than RD while deficits in naming are specific to RD rather than ADD. We conclude that ADD is a major source of additional and separate cognitive morbidity in RD children.     

Attention deficit disorder in reading-disabled twins: Evidence for a genetic etiology

In order to assess the genetic etiology of attention deficit hyperactivity disorder (ADHD), the basic regression model for the analysis of selected twin data (DeFries & Fulker, 1985, 1988) was fitted to questionnaire data (DICA: Diagnostic Interview for Children and Adolescents; Herjanic, Campbell, & Reich, 1982) for 37 identical and 37 fraternal twin pairs tested in the Colorado Reading Project. Results of this analysis suggest that ADHD is highly heritable. Moreover, adjusting DICA scores for either IQ or reading performance differences did not substantially change parameter estimates. In future analyses of larger data sets, distinguishing between possible subtypes of attentional problems (e.g., ADD with or without hyperactivity) may facilitate tests of more searching etiological questions.This work was supported in part by program project and center grants from NICHD (HD-11681 and HD-27802) to J. C. DeFries. This report was prepared while J. Gillis was supported by NIMH training grant MH-16880, and J. Gilger was supported by a Fellowship in Developmental Psychobiology through the University of Colorado (MH-15442). B. Pennington was also supported by NIMH grants MH-38820 and MH-45916. The invaluable contributions of staff members and families who participated in the Colorado Reading Project are gratefully acknowledged. We also acknowledge the expert editorial assistance of the late Rebecca G. Miles.     

Establishing a Link Between Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder and Childhood Physical Abuse

Attention deficit disorder and attention deficit/hyperactivity disorders (ADD/ADHD) are found in approximately 5% to 10% of school-aged children. This study examined whether childhood physical abuse was associated with ADD/ADHD. Data were derived from a population-based sample of 13,054 adults from the 2005 Canadian Community Health Survey. We used logistical regression analysis in 2 models, both of which had ADD/ADHD as the criterion variable. There were 7 times higher odds of ADD/ADHD among those who reported they had been abused after controlling for several potential mediating factors, including age, race, gender, and 3 other types of adverse childhood experiences (parental divorce, parental addictions, and long-term parental unemployment) in comparison to those who were not abused. The results of this analysis show a strong link between childhood abuse and ADD/ADHD, an association that requires further study.     

Visual attention and academic performance in children with developmental disabilities and behavioural attention deficits

Despite well‐documented attention deficits in children with intellectual and developmental disabilities (IDD), distinctions across types of attention problems and their association with academic attainment has not been fully explored. This study examines visual attention capacities and inattentive/hyperactive behaviours in 77 children aged 4 to 11 years with IDD and elevated behavioural attention difficulties. Children with autism spectrum disorder (ASD; n = 23), Down syndrome (DS; n = 22), and non‐specific intellectual disability (NSID; n = 32) completed computerized visual search and vigilance paradigms. In addition, parents and teachers completed rating scales of inattention and hyperactivity. Concurrent associations between attention abilities and early literacy and numeracy skills were also examined. Children completed measures of receptive vocabulary, phonological abilities and cardinality skills. As expected, the results indicated that all groups had relatively comparable levels of inattentive/hyperactive behaviours as rated by parents and teachers. However, the extent of visual attention deficits varied as a result of group; namely children with DS had poorer visual search and vigilance abilities than children with ASD and NSID. Further, significant associations between visual attention difficulties and poorer literacy and numeracy skills were observed, regardless of group. Collectively the findings demonstrate that in children with IDD who present with homogenous behavioural attention difficulties, at the cognitive level, subtle profiles of attentional problems can be delineated.     

Self-Reported Delinquency,neuropsychological deficit,and history of attention deficit disorder

This study was designed to evaluate the possibility that a pattern of cognitive deficit is associated with delinquent behavior, while avoiding some of the methodological problems of previous research. The Self- Report Early Delinquency instrument and a research battery of neuropsychological tests were administered blindly to an unselected cohort of 678 13- year- olds. Because the diagnosis of attention deficit disorder (ADD) was found at markedly elevated rates in the backgrounds of these delinquents, the possibility was examined that the neuropsychological deficits of delinquents might be limited to delinquents with histories of ADD. Although delinquents with past ADD were more cognitively impaired than non-ADD delinquents, both groups scored significantly below nondelinquents on verbal, visuospatial, and visualmotor integration skills. In addition, ADD delinquents scored poorly on memory abilities. Subjects with ADD who had not developed delinquent behavior were not as cognitively impaired as ADD delinquents, suggesting that it is the specific comorbidity of ADD and delinquency that bears neuropsychological study.This work was supported by USPHS Grant 1 R23 MH-42723-01 from the Antisocial and Violent Behavior Branch of the National Institute of Mental Health. The Dunedin Multidisciplinary Health and Development Research Unit is supported by the Medical Research Council of New Zealand. Appreciation is expressed for the methodological advice of Prof. Sarnoff A. Mednick, and for the data collection efforts of Mrs. Pat Brasch, Mrs. Kathleen Campbell, Mr. Rich Poulton, and the psychometrists who administered the WISC-R.     

Pragmatic aspects of communication and language comprehension in groups of children differentiated by teacher ratings of inattention and hyperactivity

Children with attention‐deficit hyperactivity disorder (ADHD) experience pragmatic language deficits, but it is not known whether these difficulties are primarily associated with high levels of inattention, hyperactivity, or both. We investigated pragmatic aspects of communication and language comprehension in relation to poor attention and/or high hyperactivity in a nondiagnosed population of 7‐ to 11‐year olds. Classroom teachers rated their pupils' attention and hyperactivity/impulsivity on the ADD‐H Comprehensive Teacher Rating scale (ACTeRS). Three groups were formed: children with poor attention and low hyperactivity (poor attention group), children with good attention and high hyperactivity (high hyperactivity group), and children with both poor attention and high hyperactivity (poor attention/high hyperactivity group). Their performance was compared with that of same‐age controls in two studies: Study 1 (N = 94) investigated the comprehension of figurative language in and out of context and Study 2 (N = 100) investigated the pragmatic aspects of communication using the Children's Communication Checklist – Second Edition. Two groups, the poor attention and the poor attention/high hyperactivity groups, were impaired in both their comprehension of figurative language and their communication skills. The high hyperactivity group was impaired in their comprehension of figurative language but they did not exhibit communication impairments. The findings extend work with clinical populations of children with ADHD: even in a nondiagnosed sample of children, poor attention and elevated levels of hyperactivity are associated with pragmatic language weaknesses.     

Developmental changes of parental-reported sleep disturbance symptoms in children with attention deficit disorder

The primary goal of this retrospective study was to assess parental report of current sleep disorders in school-aged attention deficit disorder (ADD) children, as well as recalled sleep problems from when the children were infants (0–12 months) and toddlers (1–3 years). Results of a sleep questionnaire completed by mothers of 48 ADD children and a comparison group of 30 patients with school problems indicate that ADD children were perceived to have significantly more sleep problems and that these problems had onset in infancy. Specific items in the questionnaire which were increased included latency to sleep onset of more than 30 min at least 3 nights per week, fatigue upon awakening, and recall of nightmares. Pediatric clinicians should be alert to possible sleep disorders in children suspected of attention disorders and should consider sleep hygiene measures as a component of treatment.     

Overanxious disorder: An examination of developmental differences

Differences between a clinical sample of younger (ages 5 to 11) and older (ages 12 to 19) children meeting DSM-III criteria for overanxious disorder (OAD) were examined. Younger and older children were compared in terms of (1) the rates of OAD diagnoses occurring in the two age groups, (2) sociodemographic characteristics, (3) symptom expression, (4) association with other forms of maladjustment, and (5) self-reported anxiety and depression. The prevalence of OAD diagnoses and sociodemographic characteristics did not differ. Although younger and older OAD children showed similar rates of most specific DSM-III OAD symptoms, older children presented with a higher total number of overanxious symptoms than younger children. Older children more frequently exhibited a concurrent major depression or simple phobia, whereas younger OAD children more commonly had coexisting separation anxiety or attention deficit disorders. Older OAD children reported significantly higher levels of anxiety and depression on self-report measures. Findings indicated that the expression of OAD varies by developmental level.     

Processing Speed Weakness in Children and Adolescents with Non-Hyperactive but Inattentive ADHD (ADD)

DSM-IV-TR defines ADHD-Predominantly Inattentive as allowing up to five symptoms of hyperactivity/impulsivity, while theories of the inattentive type usually assume a group that is hypoactive and characterized by processing speed and cognitive interference deficits. In a community-recruited sample of 572 children and adolescents, a pure inattentive subtype of ADHD (ADD) was defined as those who met DSM-IV-TR criteria for ADHD-PI but had two or fewer hyperactive/impulsive symptoms. Processing and output speeds of those with ADD were compared to those identified with DSM-IV-TR ADHD combined type and non-ADHD controls. These results were then contrasted with those found when DSM-IV-TR defined ADHD-PI was compared with ADHD-C and controls. Processing and output speed were assessed with the Trailmaking A and B and the Stroop Naming Tests. Cognitive interference control was assessed with the interference score from the Stroop Task. Slower cognitive interference speed was found in the ADD vs. ADHD-C and controls comparisons, but not the ADHD-PI versus ADHD-C and controls comparisons. On output speed measures, ADD exhibited the slowest performance, significantly different from controls and the effect size for the set-shifting speed contrast (Trailmaking B) was double that of the ADHD-PI vs. control comparison. ADHD-Inattentive type as defined by the DSM-IV-TR is a heterogeneous condition with a meaningful proportion of those affected exhibiting virtually no hyperactive/impulsive symptoms. This subgroup may represent a distinct inattentive condition characterized by poor cognitive interference control and slow processing or output speed.     

The effects of background illumination and stimulant medication on smooth pursuit eye movements of hyperactive children

Problems with visual information processing have been reported in children with the diagnosis of attention deficit disorder with hyperactivity (ADD H), and deficits in oculomotor control have been posited as an important factor in this phenomenon. To assess aspects of oculomotor performance, smooth pursuit eye movements (PEMs) were recorded electrooculographically in 20 ADD H and 20 age-matched control children and computer-analyzed for discrete (velocity arrests) and global (root mean square error) disruptions. The effects of stimulant medication (methylphenidate), together with manipulations designed to influence behavioral (attention) and physiological (cerebellar) processes involved in PEM performance, were examined. The tracking patterns of nonmedicated ADD H children contained significantly more discrete aberrations on baseline conditions. Although no single experimental manipulation significantly improved tracking performance in ADD H children, combining all experimental conditions did normalize PEMs in these subjects. Slight improvements in PEM performance in association with medication correlated positively with does of madication of with medication-related improvments of behavior. In light of these data, arguments are presented in supported of (a) hyporousal as a contributing factor underlying oculomotor difficulties in ADD H children and (b) subcortical involbment in PEM dysfunction.This research was funded in part by grants from The Hospital for Sick Children Foundation and the Ontario Mental Health Foundation (RTP). The authors thank Susan Anthony, Dr. Pamela M. Cooper, Stella Cowley, Dr. Kathy Margittai, and Ralph Nevins for technical assistance, Martin Gillett for computer programming, Dr. Phil Firestone and the staff of the University of Ottawa Child Study Centre, and Dr. B. Lena of the Family and Child Unit, Ottawa General Hospital, for subject referral.     

Health anxiety and hypochondriasis in the light of DSM-5

Background: In the DSM-5, the diagnosis of hypochondriasis was replaced by two new diagnositic entities: somatic symptom disorder (SSD) and illness anxiety disorder (IAD). Both diagnoses share high health anxiety as a common criterion, but additonal somatic symptoms are only required for SSD but not IAD. Design: Our aim was to provide empirical evidence for the validity of these new diagnoses using data from a case–control study of highly health-anxious (n = 96), depressed (n = 52), and healthy (n = 52) individuals. Results: The individuals originally diagnosed as DSM-IV hypochondriasis predominantly met criteria for SSD (74%) and rarely for IAD (26%). Individuals with SSD were more impaired, had more often comorbid panic and generalized anxiety disorders, and had more medical consultations as those with IAD. Yet, no significant differences were found between SSD and IAD with regard to levels of health anxiety, other hypochondriacial characteristics, illness behavior, somatic symptom attributions, and physical concerns, whereas both groups differed significantly from clinical and healthy controls in all of these variables. Conclusion: These results do not support the proposed splitting of health anxiety/hypochondriasis into two diagnoses. Further validation studies with larger samples and additional control groups are warranted to prove the validity of the new diagnoses.     

Psychiatric and Psychological Morbidity as a Function of Adaptive Disability in Preschool Children with Aggressive and Hyperactive-Impulsive-Inattentive Behavior

Children with high levels of aggressive-hyperactive-impulsive-inattentive behavior (AHII; n = 154) were subdivided into those with (n = 38) and without (n = 116) adaptive disability (+AD/–AD) defined as a discrepancy between expected versus actual adaptive functioning. They were compared to each other and a control group of 47 normal children. Both AHII groups were more likely to have attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder than control children; more symptoms of general psychopathology; greater social skills deficits; more parental problems; and lower levels of academic achievement skills. Compared to AHII – AD children, AHII + AD children had (1) more conduct disorder; (2) greater inattention and aggression symptoms; (3) more social problems, less academic competence, and poorer self-control at school; (4) more severe and pervasive behavior problems across multiple home and school settings; and (5) parents with poorer child management practices. Thus, adaptive disability has utility as a marker for more severe and pervasive impairments in AHII children.     

Convergence of clinically derived diagnoses and parent checklists among inpatient children

The extent to which parent rating scales differentiated children according to DSM III diagnoses was examined. A total of 113 psychiatric inpatient boys (ages 6–11) were rated by their mothers or maternal figures on the Child Behavior Checklist (CBCL) and the Behavior Problem Checklist (BPC). Children with DSM III diagnoses of conduct disorder or depression were compared to children without these diagnoses. Externalizing and internalizing scales of the parent checklists and additional measures of child aggression and depression differentiated children according to major diagnoses. The use of parent checklists to classify children indicated a high level of sensitivity for both CBCL and BPC scales for diagnosing conduct disorder and depression. However, specificity of the subscales, particularly for the CBCL, was relatively low, indicating a high rate of false positives. The need for further work that extends the range of diagnosis, that examines subtypes of disorders, and that increases the specificity of the measures for diagnostic purposes is discussed.Completion of this project was supported by a Research Scientist Development Award (MH00353) and a grant (MH35408) from the National Institute of Mental Health, and by a Clinical Research Center Grant for the Study of Affective Disorders (5 P50 MH30915) from the National Institute of Mental Health. The authors are grateful to Elaine Meyer, Karen Esveldt-Dawson, Antoinette Rodgers, and the clinical research team and staff of the Child Psychiatric Treatment Service.     

Neuropsychological profiles of children with depressive and anxiety disorders

The neuropsychological functioning of 56 children and young adolescents with diagnoses of unipolar depression (n = 17), anxiety disorder (n = 19), or comorbid anxiety/depressive disorder (n = 20) was examined. The neuropsychological profiles of the three groups were parallel, but not equal in level of performance. The three groups displayed similar patterns of performance with profiles suggesting diminished attention abilities. The groups, however, were not equal in level of performance. While subjects with an anxiety or a depressive disorder were similar in level of performance, subjects with a comorbid anxiety/depressive disorder generally performed worse than those with either an anxiety or depressive disorder alone. There was no significant evidence of asymmetrical cerebral dysfunction in any of the diagnostic groups. Results are discussed in relation to adult models of psychopathology with an emphasis on the importance of considering developmental factors when formulating models of childhood psychopathology.     

Anxious Solitude and Clinical Disorder in Middle Childhood: Bridging Developmental and Clinical Approaches to Childhood Social Anxiety

It was hypothesized that children identified by their peers at school as anxious solitary would report more symptoms of social anxiety disorder on a self report questionnaire and, on the basis of child and parent clinical interviews, receive more diagnoses of social anxiety disorder and additional anxiety and mood disorders. Participants were 192 children drawn from a community sample of 688 children attending public elementary schools. Half of these children were selected because they were identified as anxious solitary by peers and the other half were demographically-matched controls. 192 children provided self reports of social anxiety disorder symptoms on a questionnaire, and 76 of these children and their parent participated in clinical interviews. Results indicate that children identified by their peers as anxious solitary in the fall of 4th grade, compared to control children, were significantly more likely to receive diagnoses of social anxiety disorder, specific phobia, and selective mutism based on parent clinical interviews. Additionally, there was a tendency for these children to be diagnosed with generalized anxiety disorder and post traumatic stress disorder based on parent clinical interviews. Furthermore, children who had been identified as anxious solitary at any time in the 3rd or 4th grades were more likely than control children to report symptoms of social anxiety disorder that fell in the clinical range and to receive diagnoses of social anxiety disorder and dysthymia (both trends) and major depression (a significant effect) according to parental clinical interview.