A conceptual model of child psychopathology: implications for understanding attention deficit hyperactivity disorder and treatment efficacy

Highlights the desirability of using a theoretical framework for guiding the design and evaluation of therapeutic interventions for children with attention deficit hyperactivity disorder (ADHD). A general conceptual model is introduced and used to evaluate ADHD treatment outcome research. Treatments designed to target the substrate level (pharmacological interventions) result in broad, robust improvement in both core and peripheral areas of functioning. Those targeting hypothesized core features of the disorder (i.e., attention, impulsivity-hyperactivity) produce corresponding improvement in core and peripheral outcome measures with the exception of studies employing cognitive-behavior therapy. Those targeting peripheral features of the disorder effect change only in corresponding peripheral areas of functioning. Implications for clinical practice are discussed, and an alternative conceptual model of ADHD is introduced and compared with existing models.     

Utility of a CPT in Diagnosing ADHD among a Representative Sample of High-Risk Children: A Cautionary Study

Continuous performance tests (CPTs) are widely used in the assessment and study of attention deficit hyperactivity disorder (ADHD). Although CPTs have reliably found differences between children with ADHD and normal controls, discriminating between children with ADHD and children with subclinical levels of behavioral or cognitive problems is a more clinically relevant and difficult endeavor. Additionally, most studies use convenience samples from clinical care settings that may not represent the ADHD population as a whole. The current study assessed the utility of a clinically used CPT, the Test of Variables of Attention (TOVA), in distinguishing between children with ADHD and children with subclinical levels of attention/behavior problems. Participants constituted a representative sample of elementary school students at high risk for ADHD, including 116 children with ADHD and 51 subclinical controls. Results found no significant differences between the ADHD and subclinical group on CPT variables, and CPT performance did not reliably predict group membership. Implications of the findings are discussed.     

Utility of a CPT in diagnosing ADHD among a representative sample of high-risk children: a cautionary study.

Continuous performance tests (CPTs) are widely used in the assessment and study of attention deficit hyperactivity disorder (ADHD). Although CPTs have reliably found differences between children with ADHD and normal controls, discriminating between children with ADHD and children with subclinical levels of behavioral or cognitive problems is a more clinically relevant and difficult endeavor. Additionally, most studies use convenience samples from clinical care settings that may not represent the ADHD population as a whole. The current study assessed the utility of a clinically used CPT, the Test of Variables of Attention (TOVA), in distinguishing between children with ADHD and children with subclinical levels of attention/behavior problems. Participants constituted a representative sample of elementary school students at high risk for ADHD, including 116 children with ADHD and 51 subclinical controls. Results found no significant differences between the ADHD and subclinical group on CPT variables, and CPT performance did not reliably predict group membership. Implications of the findings are discussed.     

Attention-Deficit/Hyperactivity Disorder and Behavioral Inhibition: A Meta-Analytic Review of the Stop-signal Paradigm

Deficient behavioral inhibition (BI) processes are considered a core feature of attention deficit/hyperactivity disorder (ADHD). This meta-analytic review is the first to examine the potential influence of a wide range of subject and task variable moderator effects on BI processes--assessed by the stop-signal paradigm--in children with ADHD relative to typically developing children. Results revealed significantly slower mean reaction time (MRT), greater reaction time variability (SDRT), and slower stop-signal reaction time (SSRT) in children with ADHD relative to controls. The non-significant between-group stop-signal delay (SSD) metric, however, suggests that stop-signal reaction time differences reflect a more generalized deficit in attention/cognitive processing rather than behavioral inhibition. Several subject and task variables served as significant moderators for children's mean reaction time.     

Behavioral assessment of impulsivity: a comparison of children with and without attention deficit hyperactivity disorder

We conducted a brief computer-based assessment involving choices of concurrently presented arithmetic problems associated with competing reinforcer dimensions to assess impulsivity (choices controlled primarily by reinforcer immediacy) as well as the relative influence of other dimensions (reinforcer rate, quality, and response effort), with 58 children. Results were compared for children with attention deficit hyperactivity disorder (ADHD) who were and were not receiving medication, and with typically developing children without ADHD. Within-subject and between-groups analyses of the ordinal influence of each of the reinforcer dimensions were conducted using both time- and response-allocation measures. In general, the choices of children with ADHD were most influenced by reinforcer immediacy and quality and least by rate and effort, suggesting impulsivity. The choices of children in the non-ADHD group were most influenced by reinforcer quality, and the influence of immediacy relative to the other dimensions was not statistically significant. Results are discussed with respect to the implications for assessment and treatment of ADHD.     

Perceptions of ADHD Among Diagnosed Children and Their Parents: A Systematic Review Using the Common-Sense Model of Illness Representations

Research on children and parents’ experiences of ADHD has grown in recent years, attracting attention to their subjective perception of ADHD as a disorder. Theoretical accounts of illness perception suggest that it is multi-dimensional, consisting of at least five core constructs (see the common-sense model of illness representations or CSM: Leventhal et al., in: Rachman (ed) Medical psychology, Pergamon, New York, vol 2, pp 7–30, 1980, in: Baum, Taylor, Singer (eds) Handbook of psychology and health: social psychological aspects of health, Earlbaum, Hillsdale, vol 4, pp 219–252, 1984). We suggest that the application of CSM in children/adolescents with ADHD and their parents may play an important role in understanding their coping behavior, treatment adherence, and emotional well-being. A systematic search identified 101 eligible studies that investigated the perception of ADHD among diagnosed children/adolescents and their parents. In general, these studies support the existence of the multiple facets of illness representations proposed by the CSM in both diagnosed youngsters and parents indicating substantial variability among both parents and youngsters on each of these facets. The comprehensive assessment of the representations of ADHD indicates imbalance attention to the different representations of ADHD in the literature; disproportional research attention has been paid to the perceived effectiveness of treatment (i.e., treatment control dimension) compared to other illness representations (e.g., timeline, consequence, and coherence), despite research showing their relevance to treatment adherence among other implications. The review identifies the limitation of existing relevant research, needed foci for future studies, specific testable hypotheses, and potential clinical implications of the multifaceted representations of ADHD among youngsters and carers alike.     

Family Impact and Parenting Styles in Families of Children with ADHD

Attention deficit hyperactivity disorder (ADHD) begins in childhood and is characterized by attention deficits, hyperactivity, or impulsiveness that is inconsistent with a child’s developmental level. The effects of ADHD are not limited to the child alone but can affect their familial context, particularly parenting styles. Using data from 68 parents of 6–11-year-old ADHD-diagnosed children, we attempted to identify the predictive variables of two parenting styles: criticism-rejection and permissiveness-indulgence. We analyzed two complex predictive models using structural equation modeling. We hypothesized that family impact variables would mediate the relation between the child’s behavior and parenting. The data showed that the child’s ADHD was only indirectly related to parenting styles, whereas child’s behavior problems had a direct relationship. The results stressed the central role of the child’s behavior on family social life, parents’ marital relationship, and parents’ feelings about their children. These variables mediated the relationship between the children’s disorders and parenting styles. On the other hand, perceived social support had an inverse relationship with this negative family impact, and it even had relevant indirect effects on criticism and permissiveness.     

AULA virtual reality test as an attention measure: Convergent validity with Conners’ Continuous Performance Test

The majority of neuropsychological tests used to evaluate attention processes in children lack ecological validity. The AULA Nesplora (AULA) is a continuous performance test, developed in a virtual setting, very similar to a school classroom. The aim of the present study is to analyze the convergent validity between the AULA and the Continuous Performance Test (CPT) of Conners. The AULA and CPT were administered correlatively to 57 children, aged 6–16 years (26.3% female) with average cognitive ability (IQ mean = 100.56, SD = 10.38) who had a diagnosis of attention deficit/hyperactivity disorder (ADHD) according to DSM-IV-TR criteria. Spearman correlations analyses were conducted among the different variables. Significant correlations were observed between both tests in all the analyzed variables (omissions, commissions, reaction time, and variability of reaction time), including for those measures of the AULA based on different sensorial modalities, presentation of distractors, and task paradigms. Hence, convergent validity between both tests was confirmed. Moreover, the AULA showed differences by gender and correlation to Perceptual Reasoning and Working Memory indexes of the WISC-IV, supporting the relevance of IQ measures in the understanding of cognitive performance in ADHD. In addition, the AULA (but not Conners’ CPT) was able to differentiate between ADHD children with and without pharmacological treatment for a wide range of measures related to inattention, impulsivity, processing speed, motor activity, and quality of attention focus. Additional measures and advantages of the AULA versus Conners’ CPT are discussed.     

Diagnosis and Treatment of Adults With Attention Deficit Hyperactivity Disorder

It is estimated that between 30% and 50% of children diagnosed with attention deficit hyperactivity disorder (ADHD) will continue to exhibit symptomatology that is disruptive throughout their adult lives. Identification and diagnosis of adult ADHD, as well as primary and secondary characteristics and comorbid disorders, are discussed in this article. Counseling strategies are suggested to help clinicians treat adults with ADHD, such as educating the client about the disorder and providing training in attention management techniques, self-management skills, interpersonal and social skills, stress and time management, anger management, and problem-solving skills. Clinicians are encouraged to prepare themselves for understanding, identifying, diagnosing, and treating the adult population with ADHD.     

Time-Based Prospective Memory Performance and Time-Monitoring in Children with ADHD

The current study investigated prospective memory (PM) performance in children with attention deficit/hyperactivity disorder (ADHD) and controls and aimed at exploring possible underlying factors of PM performance. Twenty-two children with ADHD and 39 age- and ability-matched typically developing children performed a computerized time-based PM task. As predicted, children with ADHD had fewer correct PM responses than controls. Neither differences in overall ongoing task performance nor, remarkably, differences in overall frequency and accuracy of time monitoring were found. Exploratory analyses suggest that individual differences in time monitoring in the final interval before target times may be related to PM performance in 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.     

Response inhibition in children with and without ADHD after traumatic brain injury

Children with attention‐deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) show deficient response inhibition. ADHD itself is a common consequence of TBI, known as secondary ADHD (S‐ADHD). Similarity in inhibitory control in children with TBI, S‐ADHD, and ADHD would implicate impaired frontal‐striatal systems; however, it is first necessary to delineate similarities and differences in inhibitory control in these conditions. We compared performance of children with ADHD and those with TBI without pre‐injury ADHD on a stop signal, response inhibition task. Participants were 274 children aged 6–14 years. There were 92 children with ADHD, 103 children with TBI, and 79 typically developing children who served as controls. Among the TBI participants, injury severity ranged from mild to severe. Children with ADHD and TBI showed deficient inhibition. The deficit in children with ADHD was as great as or greater than that in children with TBI, regardless of degree of TBI severity or the presence of S‐ADHD. The finding indicates that TBI results in deficient inhibition regardless of the development of S‐ADHD.     

The Effects of Thematic Importance on Story Recall among Children with Attention Deficit Hyperactivity Disorder and Comparison Children

This study examined the recall of televised stories for younger (4-6 years) and older (7-9 years) children with and without attention deficit hyperactivity disorder (ADHD) under two different viewing conditions (toys present/toys absent). Each child watched two Rugrats television programs, once with toys present and once with toys absent. Immediately after viewing a program, the child completed a free recall of the observed story. Comparison children's recall increased more than ADHD children's as importance level increased, and comparison children recalled more information overall than children with ADHD. When toys were present, children with ADHD retold less coherent stories than comparison children, as indexed by smaller correlations between the story units recalled and the order of these units in the story. In summary, children with ADHD demonstrated multiple difficulties in story comprehension. These findings add to our understanding of the differences in higher-order cognitive processing abilities between children with ADHD and comparison children, and suggest important areas of focus in designing more effective academic interventions for children with ADHD.     

A Playroom Observation Procedure to Assess Children with Mental Retardation and ADHD

Forty-two children (ages 6 to 12 years old) with moderate mental retardation to borderline intellectual functioning were studied in a laboratory playroom setting to determine whether children identified as ADHD (attention deficit hyperactivity disorder) or controls differed on activity and attentional measures. Children with ADHD were further divided into ADHD + conduct problems (ADHD + CD) and ADHD-only subgroups (with an ADHD-combined group comprising children of both subgroups). An interval recording system was used to code observations of independent play and a restricted academic task. Results indicated that the ADHD-combined group was significantly more vocal and engaged in a significantly greater number of toy changes than controls during independent play. Significant group differences were also noted during the restricted academic task, with the ADHD-combined and ADHD + CD groups more off-task and engaging in a greater number of toy touches than controls. Discriminant analyses found independent play measures to predict group membership in 70 percent of cases (ADHD-combined vs. controls), but in only 64 percent of cases using measures from the restricted academic task. No significant findings resulted when the ADHD subjects were further divided into two subgroups. Despite some inconsistent findings, such laboratory-based observations may be of value in the diagnosis of ADHD in children with moderate mental retardation to borderline intellectual functioning.     

Predicting treatment response for childhood attention-deficit/hyperactivity disorder: Introduction of a heuristic model to guide research

Efficacious treatments for childhood attention-deficit/hyperactivity disorder (ADHD) have been clearly documented in the extant literature. However, significant challenges remain in delivering these treatments to the children and families they were developed to benefit. With the aim of better understanding the obstacles that impede delivery of treatments for ADHD, this paper reviews what is known regarding predictors of treatment acceptance, adherence, and success among families of children with ADHD. We identify several gaps in this literature, including the need for a strong, theoretically-driven model that encompasses parental cognitive variables in understanding the treatment experiences of these families.     

Exploratory Eye Movements to Pictures in Childhood-Onset Schizophrenia and Attention-Deficit/Hyperactivity Disorder (ADHD)

We investigated exploratory eye movements to thematic pictures in schizophrenic, attention-deficit/hyperactivity disorder (ADHD), and normal children. For each picture, children were asked three questions varying in amount of structure. We tested if schizophrenic children would stare or scan extensively and if their scan patterns were differentially affected by the question. Time spent viewing relevant and irrelevant regions, fixation duration (an estimate of processing rate), and distance between fixations (an estimate of breadth of attention) were measured. ADHD children showed a trend toward shorter fixations than normals on the question requiring the most detailed analysis. Schizophrenic children looked at fewer relevant, but not more irrelevant, regions than normals. They showed a tendency to stare more when asked to decide what was happening but not when asked to attend to specific regions. Thus, lower levels of visual attention (e.g., basic control of eye movements) were intact in schizophrenic children. In contrast, they had difficulty with top-down control of selective attention in the service of self-guided behavior.     

Interventions to Address the Academic Impairment of Children and Adolescents with ADHD

There exists a strong link between ADHD and academic underachievement. Both the core behavioral symptoms of ADHD and associated executive functioning deficits likely contribute to academic impairment. Current evidence-based approaches to the treatment of ADHD (i.e., stimulant medication, clinical behavior therapy and classroom behavioral interventions) have demonstrated a robust impact on behavioral variables such as attention and disruptive behavior within classroom analogue settings; however, their efficacy in improving academic outcomes is much less clear. Although surprisingly few treatment outcome studies of ADHD have attempted to incorporate interventions that specifically target academic outcomes, the studies that are available suggest that these interventions may be beneficial. The state of the treatment literature for addressing academic impairment in children and adolescents with ADHD will be reviewed herein, as well as limitations of current research, and directions for future research.     

Methylphenidate improves some but not all measures of ATTENTION,as measured by the TEA-Ch in medication-naïve children with ADHD

The Test of Everyday Attention for Children (TEA-Ch) is a reliable neuropsychological assessment of attention control in children. Methylphenidate (MPH) is an effective treatment to improve attentional difficulties in children with attention deficit/hyperactivity disorder (ADHD). Previous studies investigating the effects of MPH on attention performance of children with ADHD have produced mixed results and prior MPH usage may have confounded these results. No previous study has tested the effects of MPH on the entire TEA-Ch battery. This study investigated the effects of MPH on attention performance using the entire TEA-Ch in 51 medication-naïve children with ADHD compared with 35 nonmedicated typically developing children. All children were tested at baseline and after 6 weeks: The children with ADHD were medication-naïve at baseline, received MPH for 6 weeks and were tested whilst on medication at the second testing session. A beneficial effect of MPH administration was found on at least one subtest of each of the three forms of attention (selective, sustained, and attentional control) assessed by the TEA-Ch, independent of practice effects. MPH aided performance on the TEA-Ch tasks that were inherently nonarousing and that might require top-down control of attention. It is recommended that the TEA-Ch measures—Sky Search Count (selective attention),Score! (sustained attention), Creature Counting Time Taken for older children (attentional control), and Same Worlds (attentional control) be prioritized for use in future pharmacological studies using MPH.     

正念冥想在ADHD儿童干预中的应用

正念冥想是有意识、非评判地将注意集中于当下经验的方法。近年来,正念冥想作为一种潜在的方法被引进到ADHD儿童干预领域。因为ADHD儿童的特异性,为了增加正念冥想方案对ADHD儿童的适切性,研究者从练习设置、奖励系统、解释方式和家长纳入几个方面对标准的正念减压训练方案做了改编。越来越多的研究证据表明,正念冥想训练能有效地减轻ADHD儿童的核心缺陷、改善其内外化症状和亲子关系。本文通过对已有相关实证研究的分析认为这些积极的影响可能与ADHD儿童的执行功能与去中心化等心理功能的改善有关,而大脑相关区域激活模式的变化和结构的积极改变可能是正念冥想影响ADHD儿童的神经基础。文章也提出已有研究在内容和方法学上的不足及其以后的探究方向。     

RD,ADHD, and their comorbidity from a dual route perspective

In order to achieve further insight into the comorbidity of reading disorder (RD) and attention deficit/hyperactivity disorder (ADHD), lexical processing and rapid naming were studied in RD and ADHD. The Dual Route Cascaded model postulates that lexical processing contains two parallel processes: lexical route processing and sublexical route processing. An orthographic decision task and a phonological decision task were used to measure lexical and sublexical route processing, respectively. In addition, a rapid naming task was used to compare 27 children with RD, 18 children with ADHD, 20 children with ADHD+RD, and 29 controls. RD and ADHD shared impairments in accuracy of orthographic and phonological decision making as well as in rapid naming, which suggest that RD and ADHD may be overlapping disorders that share deficits in both lexical route and sublexical route processing. RD was dissociated from ADHD by being slower in both orthographical and phonological decision making that indicates unique deficits in RD on lexical and sublexical speed.