Sex differences in ADHD: Conference summary

Clinical samples of attention deficit hyperactivity disorder (ADHD) have been dominated by males. Consequently, female manifestations and sex differences have been relatively neglected in the extensive ADHD research. Because ADHD is so common (3% to 5% of school children) and chronic (lifelong in many cases), even a small proportion of females multiplied by such a large base means hundreds of thousands of girls and women with ADHD, a significant public health problem. An NIMH conference concluded that research is needed not only on sex differences related to ADHD, but also on manifestations of ADHD in females as such. Areas of focus should include differences in life course (sex-differential age effects); effects of hormones; effects of ADHD parenting (in utero and postnatal) on the next generation; response to and implications for design of psychosocial treatment; effects of differential comorbidity; normative background sex differences that influence the manifestation of ADHD; differences in development of verbal fluency and social behavior; possible interactions of sex and ethnicity; a prospective study of both sex offspring of ADHD adults; and such methodological issues as appropriate instruments and diagnostic thresholds, power to prevent false negatives, valid impairment measures, validity and reliability of child self-reports, and more inclusive samples (all three subtypes: inattentive, hyperactive-impulsive, and combined).The following participants in the November 16–17, 1994, NIMH Conference on Sex Differences in ADHD may be considered ghost co-authors of the contents in this summary. Special thanks are due to Euthymia Hibbs, Ph.D., co-organizer of the conference; Peter Jensen, M.D., who suggested the successful format; Delores Parron, Ph.D., who gave much helpful advice on the conference arrangements; Emily Areia, Ph.D., who thoroughly critiqued the summary; Joan Cole, who helped abstract the recorded proceedings; and Jose Bauermeister, Ph. D., F. Xavier Castellanos, M.D., Stephen Hinshaw, Ph.D., and Mark Stein, Ph.D., who helped with referencing. Other participants, in alphabetical order, included Russell Barkley, Ph.D.; Joseph Biederman, M.D.; Caryn Carlson, Ph.D.; C. Keith Conners, Ph.D.; Monique Ernst, M.D.; Miranda Gaub; Jay N. Giedd, M.D.; Michael Gordon, Ph.D.; Jeffrey Halperin, Ph. D.; Betsy Hoza, Ph.D.; Hans Huessy, M.D.; Jean King, Ph.D.; Kathleen Kiely; Rachel Klein, Ph.D.; Benjamin Lahey, Ph.D.; Jan Loney, Ph.D.; Elizabeth Lorch, Ph.D.; Spero Manson, Ph.D.; Keith McBurnett, Ph.D.; Richard Milich, Ph.D.; Douglas Novins, M.D.; Daisy Pascualvaca, Ph.D.; Linda Pfiffner, Ph.D.; Jane Steinberg, Ph.D.; James Swanson, Ph.D.; Marcus Thomeer, Ph.D.; Lillie Williams, M.D.; Alan Zametkin, M.D.The opinions expressed herein are the views of the author and conference participants and do not necessarily reflect the official position of the National Institute of Mental Health or any other part of the U.S. Department of Health and Human Services.     

Fundamentalist religion and its effect on mental health

The national self-help group, Fundamentalists Anonymous (F.A.), has focused attention upon mental problems that may be caused or exacerbated by authoritarian religion. In this article we outline assertions about the mental problems caused by membership in fundamentalist religion, illustrate these with two case histories, briefly discuss intervention strategies, and describe conceptual and empirical issues. While former members have presented problems severe enough to warrant professional treatment, a causal link between their symptoms and their religious membership has not yet been established, because there is little empirical work on the subject.An earlier version of this paper was presented at the annual meeting of the American Psychological Association in New York in August 1987.The authors express gratitude to Stephen Strack, Ph.D.; Robert Meagher, Ph.D.; Herman Feifel, Ph.D.; and Ted Schoenberger, M.D., for their helpful comments on previous drafts of this paper.     

Laboratory and performance-based measures of depression in children and adolescents

Reviews laboratory and performance-based measures for the assessment of symptoms and correlates of depression in children and adolescents. First, we briefly review limitations of self-report and other report measures of depression. Next, we describe four laboratory methods, including social interaction tasks, information-processing tasks, measures of psychological deficits and laboratory analogue designs, and sleep studies. We then summarize the specific depressive symptoms measured by each of these methods. Finally, we discuss issues of the validity and utility of these methods.     

Neuropsychological functioning,motor speed,and language processing in boys with and without ADHD

We administered a neuropsychological battery to boys aged 6 to 12 years old diagnosed with attention-deficit hyperactivity disorder (ADHD; n= 51) and to comparison boys of the same age range (n= 31). Boys with ADHD had greater difficulty than comparison youngsters on nonautomated language and motor tasks administered with a fast instructional set and on one of two traditional frontal executive measures (Porteus mazes). When tasks requiring automatic processing were paired with similar tasks requiring greater use of selective attention processes, the latter, controlled processing tasks differentiated groups better than did automated tasks. This differential effect of otherwise similar tasks is interpreted in terms of an output deficit mediated by response organization as detailed in the information processing literature. The ADHD group also exhibited slow gross motor output, measured independently of verbal output. The findings are evaluated in terms of both Luria's (1973) tripartite model of neurocognitive organization and frontal striatal models, with an emphasis on output processes. The observed language deficits could represent frontal lobe processes intricately related to self-monitoring and planning. The utility of controlled processing, self-paced tasks with fast instructional sets in assessing language and motor skills in ADHD is highlighted. This research was supported primarily by National Institute of Mental Health Grant R01 MH45064 awarded to Stephen P. Hinshaw. Joel T. Nigg was partially supported by NIH Research Service Award F31 MH10462-01. The authors wish to thank Deborah P. Waber, Ph.D., of Harvard University for her assistance in scoring the Rey-Osterreith complex design, and Jennifer Ablow, Margaret Kuklinsksi, Jeff Measelle, Teron Park, Cassandra Simmel, and Jennifer Treuting for helping to administer the measures, code the results, and discuss the study. We also acknowledge the enthusiastic participation of the children and families in the summer programs.     

Revolt in the garden of eden: An alternative group model

The most common model used to highlight the significant features of a group revolt has been Freud's primal horde myth. In this essay the utility of this model will be briefly reviewed, then its most apparent limitation will be addressed. To wit, in this model the women play no active part in the revolution. On the other hand, as a model for group behavior the myth of the Garden of Eden preserves much of what is valuable in the primal horde myth, including the oedipal paradigm inherent in the revolution and, at the same time, offers a critical psychological understanding of the very active involvement women do have in groups before, during, and after the revolt. This is the main focus of this essay and will be explored in depth. Concomitant with this exploration, certain commonly observed behaviors of male group members during this critical phase of group life can also be better understood. Furthermore, the Garden of Eden myth highlights other important facets of the group revolt, and these will be noted. Finally a clinical example will be explored that vividly underscores the value of this alternative model.The author is grateful to Thomas Kohut, Ph.D., W. Donald Ross, M.D., and Walter Stone, M.D., for their valuable comments on an earlier version of this paper.     

Support groups for medical caregivers of people with HIV diseases

As we enter the second decade of AIDS, medical caregivers are experiencing stress and burnout as a result of their work with people with HIV diseases. There are common themes to the stress, as well as differences in the experience of stress according to the characteristics of the healthcare setting. Caregiver support groups are a means of reducing this stress by helping medical caregivers cope better, manage difficult cases, normalize their feelings, put understanding and context to their experiences, decrease isolation, and instill meaning in their work. The use of support groups across various medical settings is presented.The author wishes to acknowledge the assistance of Nicholas Covino, Ph.D., Peter Kassel, Psy.D., Randall Paulsen, M.D., Veronica Rempusheski, Ph.D., Dan Silverman, M.D., and Susan Burns Tisdale, R.N., in ongoing research regarding caregiver support groups. The author also wishes to express gratitude to Genya Bernstein, Psy.D., for many editorial contributions.     

Accuracy of drawing in a dual-task and resistance-to-distraction study: motor or attention deficit?

To determine whether manual incoordination is caused by attention deficit or not, we used an accuracy drawing task as a primary task in dual-task and resistance-to-distraction studies, and examined if thus measured attention could differentiate inattention (IA) and combined (CO) subtypes of ADHD. The secondary tasks and distractions failed to lower the primary task performance in IA, CO and control groups. We also compared the impairment scores of the accuracy drawing tasks from the Movement Assessment Battery for Children [Henderson, S. E., & Sugden, D. A. (1992). Movement assessment battery for children. London: Psychological Corporation.] between the groups with attention deficit hyperactivity disorder (ADHD) and/or developmental coordination disorder-inaccurate drawing type (DCD-ID). There were no group differences in the impairment score between the control and the ADHD groups, and between ADHD and ADHD plus DCD-ID groups. We concluded that inaccurate drawing is not caused by attention deficit, but that it is a manifestation of a motor deficit as a separate entity from attention deficit.     

Reported prevalence of attentional difficulties in a general sample of college students

The present study investigated the self-reported prevalence of attention-deficit hyperactivity disorder (ADHD)symptoms in 770 college students using the Adult Rating Scale and the Wender Utah Rating Scale. Psychometric properties of these scales were explored. The study also investigated the performance of students with ADHD symptoms, relative to students without ADHD symptoms, on a battery of neuropsychological tasks. Results revealed that 7 and 8% of the students reported significant symptoms (i.e., 1.5 SD above the mean) on the Adult Rating Scale and the Wender Utah Rating scale, respectively, and 2.5% reported significant symptoms on both the Adult Rating Scale and the Wender Utah Rating Scale. Using more stringent criteria (two standard deviations), fewer (i.e, 4, 3.8%, and 0.5%) subjects reported significant symptoms associated with ADHD. Between-group differences were found on one of the neuropsychological tasks. The construct validity of the rating scales was supported. Limitations and implications for future research are advanced.Presented at the International Neuropsychological Society's Sixteenth European Conference, Angers, France, June 1994, and the Annual Convention of the American Psychological Association, Los Angeles, CA, August 1994.     

Values interpretation: A new model for hospital ministry

The importance of values in clinical settings is a topic of increasing discussion in the medical literature, but the nature of values and the process of interpreting them have received little attention. The hospital chaplain or religious professional is an underused resource in addressing values issues. This paper summarizes the current models of the hospital chaplaincy in historical context, and then develops a new model drawn from the disciplines of pastoral care and clinical medical ethics in order to address problems involving values in clinical settings. The model construes the chaplain as values interpreter who provides both consultation and liaison functions in clinical situations. We present a clinical case to illustrate the role of the values interpreter. We conclude that the religious professional can make an important contribution to both clinical decision making and medical education through such a model.The authors thank Don S. Browning, Ph.D., and Thomas H. Jobe, M.D., for their critical readings of earlier versions of this paper.     

Attentional WM is not necessarily specifically related with fluid intelligence: the case of smart children with ADHD symptoms

Executive functions and, in particular, Attentional (active) Working Memory (WM) have been associated with fluid intelligence. The association contrasts with the hypothesis that children with ADHD exhibit problems with WM tasks requiring controlled attention and may have a good fluid intelligence. This paper examines whether children who are intelligent but present ADHD symptoms fail in attentional WM tasks. The latter result would be problematic for theories assuming the generality of a strict relationship between intelligence and WM. To study these issues, a battery of tests was administered to a group of 58 children who all displayed symptoms of ADHD. All children were between the age of 8 and 11 years, and were described by their teachers as smart. Children were compared to a control group matched for age, schooling, and gender. The battery included a test of fluid intelligence (Raven’s Coloured Matrices), and a series of visuospatial WM tasks. Results showed that children with ADHD were high in intelligence but significantly lower than the controls in WM tasks requiring high attentional control, whereas there was no difference in WM tasks requiring low attentional control. Furthermore, only high attentional control WM tasks were significantly related to Raven’s performance in the control group, whereas all WM tasks were similarly related in the ADHD group. It is concluded that performance in high attentional control WM tasks may be related to fluid intelligence, but also to a specific control component that is independent of intelligence and is poor in children with ADHD.     

Spiritual and emotional determinants of health

Within our present health care system, there is a growing movement that argues that our perceptions of health and illness are in need of change. This change includes redefining what we mean by health in terms of the whole person—the emotional, social, and spiritual dimensions of our being, as well as the physical. An increasing number of health professionals and social scientists believe our concepts of health and illness must consider all these aspects of life. It is believed that the quality of life may be enhanced by such perceptions of health, which include social and spiritual factors. Using data from the 1985 Akron Area Survey—The Subjective Quality of Life in the Akron Area—this study explores the effects of spiritual well-being and emotional well-being on health satisfaction. Results indicate that emotional and spiritual factors do significantly contribute to the subjective evaluation of health, especially for individuals who are physically limited.An earlier draft of this paper was presented at the joint session of the Association for the Sociology of Religion and the American Sociological Association, August 20, 1986. The author would like to thank Margaret Poloma, Ph.D., The University of Akron, and Mark Tausig, Ph.D., The University of Akron, for their helpful comments.     

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.     

Enhancing Criterion-Related Validity Through Bottom-Up Contextualization of Personality Inventories: The Construction of an Ecological Conscientiousness Scale for Ph.D. Candidates

In this article the concept of “ecological personality scales” is introduced. These are contextualized inventories with a high ecological validity. They are developed in a bottom-up or qualitative way and combine a relatively high trait specificity with a relatively high situational specificity. An ecological Conscientiousness or time management scale for Ph.D. candidates was developed. It significantly predicted Ph.D. performance criteria and showed incremental validity beyond Big Five (Study 1) and narrow trait and frame-of-reference scales (Study 2). These findings suggest that an ecological approach may contribute to further improving the criterion validity of personality measures.     

Treatment of alcoholic couples in outpatient group therapy

This paper summarizes special issues that group leaders are likely to encounter when adapting their skills to outpatient group therapy with alcoholic couples. More specifically, the paper: (a) discusses the advantages of treating alcoholic couples in a group as opposed to individual couple's therapy; (b) outlines the parameters of a couples group with alcoholic members that differentiate it from working with other kinds of couples in group; and (c) provides guidelines and techniques for tackling some of the specific kinds of problems and situations that arise.This paper was presented at the Annual Meeting of the American Group Psychotherapy Association, New York City, February, 1985.The author wishes to acknowledge the contribution of Geraldine Alpert, Ph.D., whose thoughtful comments and discussion helped to crystallize the concepts presented.     

Must a hermeneutical psychoanalysis exclude science?

The work on this article was made possible in part by a grant to all three authors from the Social Sciences and Humanities Research Council of Canada (410-91-0422) and a St. Paul University research award. All three authors contributed equally to the text. An earlier version of this article was presented at the Division of Psychoanalysis of the American Psychological Association annual meeting, August 1990. We are grateful to James Pambrun, Ph.D., Ted O'Grady, and Bertram P. Karon, Ph.D. for their advice and encouragement. Correspondence concerning this article should be addressed to Paul Rigby, St. Paul University, 223 Main St. E., Ottawa, Ont, Canada K1S 1C4.     

Relating lab to life: Decrements in attention over time predict math productivity among children with ADHD

A child’s ability to sustain attention over time (AOT) is critical in attention-deficit/hyperactivity disorder (ADHD), yet no prior work has examined the extent to which a child’s decrement in AOT on laboratory tasks relates to clinically-relevant behavior. The goal of this study is to provide initial evidence for the criterion validity of laboratory assessments of AOT. A total of 20 children with ADHD (7–12 years of age) who were enrolled in a summer treatment program completed two lab attention tasks (a continuous performance task and a self-paced choice discrimination task) and math seatwork. Analyses focused on relations between attention task parameters and math productivity. Individual differences in overall attention (OA) measures (averaged across time) accounted for 23% of the variance in math productivity, supporting the criterion validity of lab measures of attention. The criterion validity was enhanced by consideration of changes in AOT. Performance on all laboratory attention measures deteriorated as time-on-task increased, and individual differences in the decrement in AOT accounted for 40% of the variance in math productivity. The only variable to uniquely predict math productivity was from the self-paced choice discrimination task. This study suggests that attention tasks in the lab do predict a clinically-relevant target behavior in children with ADHD, supporting their use as a means to study attention processes in a controlled environment. Furthermore, this prediction is improved when attention is examined as a function of time-on-task and when the attentional demands are consistent between lab and life contexts.     

A cognitive footprint in archival data: Generalizing the dilution effect from laboratory to field settings

This paper delineates a bridging strategy for generalizing a theoretical proposition about human judgment from laboratory to field settings. This strategy encompasses experimental and archival methods, emphasizing each method’s complementary rather than competitive advantage. Basic experiments that use generic tasks and settings, and novice subjects, contribute empirical tests that maximize internal validity. Given a target area in the “real world” for generalizing the proposition, applied experiments that use tasks and settings with greater mundane realism, and professional subjects from the target area, contribute replicating tests that balance internal and external validity. As a complement to experimentation, archival research adds value by testing observable implications of the proposition in field settings. We relate the bridging strategy to judgment research on the dilution effect (i.e., the presence of nondiagnostic cues, when processed with diagnostic cues, causes judges to under-weigh the diagnostic cues) in psychology and applied areas. Finally, we contribute an archival data analysis that uncovers indirect evidence, or a cognitive footprint, of the dilution effect in a professional judgment setting where social and economic mechanisms potentially discipline systematic error.     

Adult attention-deficit/hyperactivity disorder: neuropsychological correlates and clinical presentation

We compared the neuropsychological test performance of adult ADHD patients to the neurocognitive profiles of control subjects recruited from the general population. We administered a neuropsychological test battery consisting of measures considered sensitive to either orbitofrontal or dorsolateral-prefrontal (DLPF) dysfunction. Orbitofrontal hypoarousal is associated with behavioral disinhibition and a relative indifference to punishment. The DLPF region may function as a central executive system. Indeed, DLPF dysfunction may underlie many of the cardinal symptoms associated with ADHD. We tested the following hypotheses: (1) adult subjects meeting DSM-IV criteria for ADHD, predominantly hyperactive-impulsive type, would display neuropsychological deficits on tasks sensitive to orbitofrontal dysfunction; (2) adult subjects meeting DSM-IV criteria for ADHD, predominantly inattentive type, would perform poorly on measures sensitive to DLPF dysfunction; and (3) adult subjects meeting DSM-IV criteria for ADHD, combined type, would exhibit performance deficits on orbitofrontal measures and on DLPF tasks. Results partially confirmed our hypotheses. Subtyping ADHD patients revealed important group differences. Distinct neurocognitive and clinical profiles were observed.     

Discriminant validity of the Conners’ scales for ADHD subtypes

Differential diagnosis and treatment of children with Attention-Deficit/Hyperactivity Disorder (ADHD) remains difficult and controversial, particularly when children present with concomitant academic and behavior problems. Describing a sample of 184 chil-dren referred for evaluation in a university-affiliated outpatient pediatric clinic, this study subsequently examined the discriminant validity of the Conners’ parent and teacher rating scales for ADHD subtypes with and without comorbid conditions. Although discriminant analyses suggest several Conners’ subscales help differentiate subtypes, multimethod evaluations using a variety of data sources are necessary for accurate identification and classification of the disorder with and without comorbid conditions. These data were previously reported at the 107^th Annual Convention of the American Psychological Association, Boston, Massachusetts. The authors express gratitude to Ross D. Crosby, Ph.D., Director of Biomedical Statistics and Methodology at the Neuropsychiatrie Research Institute, for his pre-submission review of the article.