Plea for a Balanced Conception of AD/HD and Its Diagnosis and Treatment

AD/HD may be overlooked as well as too zealously and concretely overdiagnosed. When this condition is properly identified, it is most fruitfully understood in a balanced manner that is integrated with an appreciation of its inevitable shaping influence on the patient's perceptions, self-experience, and psychodynamic constellation, including central unconscious fantasies. This exploration is necessarily multifaceted: the patient's internal experience of states of distractibility, impulsivity, and hyperactivity, their incorporation in unconscious fantasies, and their employment in the service of both self-punitive urges and defenses against the “unpleasure” (Brenner, 1982) associated with psychic conflicts. Psychoanalysts are in a unique position to grasp these complex relationships. Familiarity with diagnostic issues, the developmental impact of AD/HD, common difficulties such patients present in treatment, and typical countertransference responses will enrich their psychoanalytic work. Interrelationships between AD/HD and the patient's psychic world are presented as they arose in the analysis of a child and an adult.     

AD/HD Symptoms and Conduct Problems: Similarities and Differences in Maternal Perceptions

Several theories attempt to explain the high co-occurrence of Attention Deficit/ Hyperactivity Disorder (AD/HD) and Conduct Problems (CP). A strong possibility is that AD/HD behaviours lead to the development of CP, due to family coercive interaction patterns, maintained through parental false beliefs regarding child problem behaviour. We compared maternal perceptions about AD/HD behaviors and CP, and the possible reactions elicited by such behaviours. The sample consisted of 317 mothers of boys and girls aged 4–6. Four versions of The Parental Account of the Causes of Childhood Problems Questionnaire were used, in which a vignette was ascribed to either a boy or a girl displaying some of the major AD/HD behaviours or CP. The results showed that CP were perceived as significantly more severe than AD/HD behaviours. Moreover, AD/HD behaviours were attributed to biological causes more often than CP, and less strict rearing practices were chosen for AD/HD symptoms. Our findings provide evidence that mothers usually perceive AD/HD behaviours and CP as separate entities and may behave accordingly with their children.     

Semantic Fluency Performance of Patients with Cortical and Subcortical Neurodegenerative Diseases

Previous studies using the Animals Fluency Test have shown that dementia patients with Alzheimer's disease (AD), Huntington's disease (HD), or Parkinson's disease (PD) produce fewer correct words and have smaller semantic cluster sizes than controls or PD patients without dementia (PDND). Although the number of correct words generated by the patients with AD was positively correlated with mental status, cluster size, surprisingly, was not. To increase word output and increase the reliability of estimates of cluster size, semantic fluency was reexamined using the Supermarket Fluency Task. Overall, patients with HD or PD with dementia (PDD) exhibited reduced cluster sizes compared to older controls or PDND patients, but cluster sizes were only marginally reduced for patients with AD. These effects were evident only for female participants, because the cluster sizes for elderly control men were substantially smaller than those of elderly women. For the female patients with AD, cluster size was correlated with mental status, but the relationship was nonlinear. Cluster size was normal for mildly demented patients with AD, but much reduced for moderately or severely demented participants. In contrast to a previous report, in the present study the proportion of category labels generated was increased for patients with HD with dementia but not for patients with AD. This finding questions one line of evidence that semantic memory stores undergo “bottom-up” degradation in AD. Together with previous results, these findings indicate that semantic cluster size reflects efficiency of access to semantic knowledge which is similarly compromised in subcortical and cortical diseases.     

Interval length and time-use by children with AD/HD: a comparison of four models

Predictions made by 4 competing models of time use by children with AD/HD were tested using a computerized version of the Matching Familiar Figures Test in 2 studies. In Study 1 teacher-identified AD/HD children (N = 10) and non-AD/HD controls (N = 10) completed the task under 3 different trial duration conditions (5, 10, and 15 s). In Study 2 the same task was completed by a group of children with a diagnosis of Hyperkinetic Disorder (N = 12) and controls (N = 12). In both studies AD/HD children performed poorly on trials of both 5- and 15-s duration but as well as controls on the 10-s trials. This quadratic function provided support for the State Regulation Deficit model of time use in AD/HD. The value of tailoring the temporal features of learning contexts to the conceptual style of AD/HD children is discussed.     

The Ecological Validity of Delay Aversion and Response Inhibition as Measures of Impulsivity in AD/HD: A Supplement to the NIMH Multimodal Treatment Study of AD/HD

Impulsivity is a primary symptom of the combined type of Attention Deficit/Hyperactivity Disorder (AD/HD). The Stop Signal Paradigm is premised upon a primary deficit in inhibitory control in AD/HD, whereas the Delay Aversion Hypothesis, by contrast, conceptualizes impulsivity in AD/HD, not as an inability to inhibit a response, but rather as a choice to avoid delay. This study compared the ecological validity of the Stop Signal Task (SST) and Choice-Delay Task (C-DT) measure of delay aversion, with respect to their relative utility in discriminating AD/HD children from normal control participants, and their correlations with classroom observations and with ratings of impulsivity and other core AD/HD symptoms on the Conners and SNAP-IV checklists. The tasks exhibited modest discriminant validity when used individually and excellent discriminant validity when used in combination. The C-DT correlated with teacher ratings of impulsivity, hyperactivity, and conduct problems, and with observations of gross motor activity, physical aggression, and an AD/HD composite score. The SST correlated with the observations only. These results suggest that delay aversion is associated with a broad range of AD/HD characteristics whereas inhibitory failure seems to tap a more discrete dimension of executive control     

Which Executive Functioning Deficits Are Associated With AD/HD,ODD/CD and Comorbid AD/HD+ODD/CD?

This study investigated (1) whether attention deficit/hyperactivity disorder (AD/HD) is associated with executive functioning (EF) deficits while controlling for oppositional defiant disorder/conduct disorder (ODD/CD), (2) whether ODD/CD is associated with EF deficits while controlling for AD/HD, and (3)~whether a combination of AD/HD and ODD/CD is associated with EF deficits (and the possibility that there is no association between EF deficits and AD/HD or ODD/CD in isolation). Subjects were 99~children ages 6–12 years. Three putative domains of EF were investigated using well-validated tests: verbal fluency, working memory, and planning. Independent of ODD/CD, AD/HD was associated with deficits in planning and working memory, but not in verbal fluency. Only teacher rated AD/HD, but not parent rated AD/HD, significantly contributed to the prediction of EF task performance. No EF deficits were associated with ODD/CD. The presence of comorbid AD/HD accounts for the EF deficits in children with comorbid AD/HD+ODD/CD. These results suggest that EF deficits are unique to AD/HD and support the model proposed by R. A. Barkley (1997).     

Loss of Financial Capacity in Alzheimer's Disease: The Role of Working Memory

Recent research has demonstrated that loss of financial capacity is a common consequence of Alzheimer's disease (AD). While progressive cognitive decline is a defining feature of AD, the relationship between such decline and loss of financial capacity in AD remains unclear. Working memory may be strongly associated with financial abilities, as many financial tasks require temporary storage and manipulation of numerical and other data. The present study examined the relationship between financial capacity and working memory in AD patients. Participants included 20 AD patients and 23 cognitively intact older controls. Working memory was conceptualized using Baddeley and colleagues' model, which posits that the three components of the working memory system are the visuospatial sketchpad, phonological loop, and central executive system. The present study examined only the latter two components of working memory. Each participant was administered the Financial Capacity Instrument (FCI), an instrument that directly assesses eight domains of financial activity, and the WAIS-III Working Memory subtests (Digit Span, Arithmetic, Letter–Number Sequencing). AD patients as a group performed significantly below controls on the FCI Total Score and on each of the eight FCI domains and working memory subtests. Within the AD group, measures of the central executive component of working memory (WAIS-III Digits Backward, Arithmetic, and Letter-Number Sequencing tests) showed strong correlations with the FCI domains of basic monetary skills, checkbook management, bank statement management, and bill payment and FCI total score, while a measure of the phonological loop component of working memory (WAIS-III Digits Forward) was not significantly correlated with any FCI domains or with the FCI total score. The results suggest that the multiple domains of financial capacity are primarily correlated with the central executive component of working memory.     

Response Inhibition in Children With DSM-IV Subtypes of AD/HD and Related Disruptive Disorders: The Role of Reward

The current study had four aims: (a) to replicate previous findings of slow response inhibition in Attention Deficit/Hyperactivity Disorder (AD/HD), (b) to explore whether poor response inhibition in children with AD/HD is a core problem or rather a result of an underlying problem related to reward, (c) to investigate the specificity of poor response inhibition and the role of reward in relation to AD/HD, and (d) to study whether findings would be different for three subtypes of AD/HD. In order to address these issues, a stop paradigm was administered under a reward condition and under a nonreward condition to an AD/HD group (n = 24), an Oppositional Defiant Disorder (ODD)/Conduct Disorder (CD) group (n = 21), a comorbid AD/HD+ODD/ CD group (n = 27), and a normal control (NC) group (n = 41). Firstly, contrary to prediction, none of the Disruptive Behavior Disorder (DBD) groups differed from the NC group with respect to the speed of the inhibition process. Secondly, it was shown that children with AD/HD and children with comorbid AD/HD+ODD/CD, but not children with ODD/CD alone, slowed down more dramatically in the reward condition than normal controls. This finding was interpreted as a strategy to increase the chance of being rewarded in children with AD/HD and children with comorbid AD/HD+ODD/CD, but not in children with pure ODD/CD. Finally, analysis of AD/HD subtypes did not change the main findings of this study.     

Response inhibition in children with DSM-IV subtypes of AD/HD and related disruptive disorders: the role of reward.

The current study had four aims: (a) to replicate previous findings of slow response inhibition in Attention Deficit/Hyperactivity Disorder (AD/HD), (b) to explore whether poor response inhibition in children with AD/HD is a core problem or rather a result of an underlying problem related to reward, (c) to investigate the specificity of poor response inhibition and the role of reward in relation to AD/HD, and (d) to study whether findings would be different for three subtypes of AD/HD. In order to address these issues, a stop paradigm was administered under a reward condition and under a nonreward condition to an AD/HD group (n=24), an Oppositional Defiant Disorder (ODD)/Conduct Disorder (CD) group (n=21), a comorbid AD/HD+ODD/CD group (n=27), and a normal control (NC) group (n=41). Firstly, contrary to prediction, none of the Disruptive Behavior Disorder (DBD) groups differed from the NC group with respect to the speed of the inhibition process. Secondly, it was shown that children with AD/HD and children with comorbid AD/HD+ODD/CD, but not children with ODD/CD alone, slowed down more dramatically in the reward condition than normal controls. This finding was interpreted as a strategy to increase the chance of being rewarded in children with AD/HD and children with comorbid AD/HD+ODD/CD, but not in children with pure ODD/CD. Finally, analysis of AD/HD subtypes did not change the main findings of this study.     

Utility of Behavior Ratings by Examiners During Assessments of Preschool Children With Attention-Deficit/Hyperactivity Disorder

This study examines the clinical utility of behavior ratings made by nonclinician examiners during assessments of preschool children with Attention-Deficit/Hyperactivity Disorder (AD/HD). Matched samples of children with (n = 127) and without (n = 125) AD/HD were utilized to test the internal, convergent, concurrent, and incremental validity of ratings completed by examiners on the Hillside Behavior Rating Scale (HBRS). Results indicated that HBRS ratings were internally consistent, possessed sufficient interrater reliability, and were significantly associated with parent and teacher reports of AD/HD when controlling for age, gender, intelligence, and symptoms of other psychopathology. HBRS ratings also were significantly associated with other measures of functioning, and provided a significant increment in the prediction of impairment over parent and teacher report alone. These findings suggest that behavioral ratings during testing provide a unique source of clinical information that may be useful as a supplement to parent and teacher reports.     

Elementary school students with AD/HD: predictors of academic achievement

Academic underachievement frequently is associated with attention-deficit/hyperactivity disorder (AD/HD); however, the role of variables beyond AD/HD symptoms and cognitive mediators is unknown. Further, whether prediction models vary (a) relative to non-AD/HD students, (b) between math and reading, and (c) based on how achievement is defined has not been examined. Multiple measures (e.g., teacher ratings and behavior observations) were examined as predictors for concurrent achievement outcomes (standardized achievement test scores and report card grades) in math and reading in two samples of 1st through 4th grade children (136 with AD/HD, 53 without AD/HD). Teacher perceptions of academic skills were the strongest predictors of achievement test scores for both groups, while academic skills and enablers accounted for reading report card grades in children with AD/HD but not their normal counterparts. Implications of these findings for school-based assessment and intervention for students with AD/HD are discussed.     

Prevalence of Attention-Deficit/Hyperactivity Disorder Symptoms in 4- to 17-Year-Old Children in the General Population

The purposes of this study were (a) to estimate the prevalence of Attention-Deficit/Hyperactivity Disorder (AD/HD) symptoms in the general preschool and school population; and (b) to analyze the influence of gender, age, and socioeconomic status (SES) variables on AD/HD symptoms. Out of the 80,000 preschool and schoolchildren living in Manizales, Colombia, a random sample of 540 children was selected. Two gender, three age (4- to 5-year olds, 6- to 11 -year olds, and 12- to 17-year olds), and three SES (low, middle, and high) groups were used. The 18 DSM-IV symptoms corresponding to AD/HD Criterion A were assessed on a scale of 0 (never) to 3 (almost always). All three demographic variables established statistically significant differences: AD/HD symptoms were more frequent in 6-to 11-year-old, low-SES, male participants. DSM-IV Criterion A for AD/HD was fulfilled by 19.8% of the boys and 12.3% of the girls. However, this difference was marginally significant only in the AD/HD Subtype I: Combined. It was concluded that demographic variables are significant correlates of the AD/HD diagnosis. The prevalence found in this study was higher than usually reported, even though only the symptomatic DSM-IV AD/HD criterion was analyzed. We failed to confirm the assumed AD/HD gender ratio.     

Effects of Reward and Response Cost on Response Inhibition in AD/HD, Disruptive, Anxious, and Normal Children

In previous research, children with attention deficit/hyperactivity disorder (AD/HD) have demonstrated impaired response inhibition on the stop paradigm. In this study we examined whether this impairment in fact reflects a motivational deficit. Four groups of children (age range 7–13 years) participated in the study: 14 AD/HD children, 21 normal controls, 14 disruptive children, and 14 anxious children. The psychopathological groups were recruited from special educational services and mental health outpatient clinics. Parent, teacher, and child questionnaires were used to select children with pervasive disorders. Normal controls attended regular classes and scored low on all questionnaires. Children were tested once with reward contingencies and once with response cost contingencies in a randomized cross-over design. We hypothesized that if a motivational deficit underlies poor response inhibition in AD/HD children, this deficit will be remedied by response contingencies. Despite the presence of response contingencies, AD/HD children showed poor response inhibition compared with normal controls. Findings argue against a motivational explanation for the response inhibition deficit in AD/HD children     

Do adapted vignettes improve medical decision‐making capacity for individuals with Alzheimer's disease?

Medical decision‐making capacity (MDC) is known to decline in individuals with Alzheimer's disease (AD). The vignette method uses hypothetical information as a prerequisite for measuring the capacity to make well‐informed decisions to clinical trials. Our aim was to investigate if adapted vignettes can help individuals with mild AD to assimilate information, make decisions and express them in an understandable way, compared to corresponding decisions based on linguistically more demanding vignettes, as measured by the Swedish Linguistic Instrument for Medical Decision‐making (LIMD). Two vignettes from LIMD were altered linguistically with the aim to facilitate understanding for individuals with AD. An experimental within‐subject design was used to study the influence on MDC of readability (original/adapted vignettes) and content (two different clinical trials). We included 24 patients with mild AD in this prospective study, which read all four vignettes along with a few other tests. This allowed us to investigate the association between MDC and cognitive function. Adapted vignettes did not yield significant differences regarding MDC as compared with original vignettes using a two‐way repeated measures analysis of variance. A difference was found between the two clinical trials where LIMD score was significantly higher for Kidney disease than hypertension vignettes. Our results indicate that adapted vignettes may not improve MDC for individuals with mild AD. MDC was affected by which clinical trial the vignettes regarded, which implies that other factors affecting MDC need to be investigated, like length of text and vocabulary used.     

Implicit and explicit memory performance in children with attention deficit/hyperactivity disorder

The present investigation examined implicit and explicit memory in 20 children diagnosed with attention deficit/hyperactivity disorder (AD/HD) and 20 matched controls. Consistent with previous research, children with AD/HD performed more poorly than controls on an explicit test of long‐term memory for pictures. New results were that (a) there was no deficit on an implicit memory test for equivalent material and that (b) the observed deficit in explicit memory operated over and above any effects of depression/anxiety. Another finding to emerge was that AD/HD children had greater difficulty than controls in identifying pictures of objects that were presented in an unusual form, either rotated or degraded. Overall, the pattern of results is interpreted in terms of deficient effortful/resource‐intensive processes in AD/HD but intact automatic processes.     

Interior experience within analytic process

In this paper, I consider the feeling of interiority as it evolves within the treatment relationship. A capacity to access and sustain one's interiority reflects a sense of personal solidity within which the validity of subjective process and privacy is taken for granted. When this capacity is relatively undeveloped, individuals rely on the “other”; (including the analyst) to help them contact, elaborate, or manage their affective experience. Quite paradoxically, the analyst's active investigation of dynamic or intersubjective process may obfuscate rather than clarify this core difficulty. I suggest two alternative approaches to the treatment situation that stand in some tension and yet also complement each other. One emphasizes the “active”; investigation of dynamic and dyadic process, wherein the analyst works interpretively and/or around relational issues. The other is organized around the “interior”; dimension of the treatment experience, emphasizing the patient's need to develop or manage her affective process in the relative absence of input from the analyst. Two clinical situations are described, the first illustrating the use of silence with a patient whose difficulties involved affect articulation, and the second involving a patient whose need for affect regulation made her highly dependent on the analyst for soothing.     

Emotion Regulation and Parenting in AD/HD and Comparison Boys: Linkages with Social Behaviors and Peer Preference

Children's emotion regulation strategies and parenting responses in a family task that elicited frustration are investigated by, comparing core attention-deficit/hyperactivity disorder (AD/HD) symptomatology, emotional reactivity, and emotional regulation in the prediction of social behaviors and peer social preference. Participants were boys, ages 6–12 years, either with AD/HD (n = 45) or without problem behaviors (comparison; n = 34). A high-aggressive subgroup of AD/HD boys showed a significantly less constructive pattern of emotional coping than did both a low-aggressive AD/HD subgroup of boys and nondiagnosed comparison boys, who did not differ. With statistical control of core AD/HD symptomatology, noncompliance in a naturalistic summer camp was predicted by boys' overall emotion regulation and three specific strategies (emotional accommodation, problem solving, negative responses) during the parent–child interaction. Emotional accommodation and negative responses to the frustration task also marginally predicted social preference at the camp. These emotion regulation variables outperformed emotional reactivity in predicting such outcomes. Some emotion-related parenting behaviors were associated with child coping in the task. We discuss the relationship of emotion regulation to core AD/HD symptomatology and emotional reactivity, and the role of parents' behaviors in influencing children's emotional responses.     

AD/HD,Psychoanalysis, and Neuroscience: A Survey of Recent Findings and Their Applications

Research findings and review articles in the neurosciences relevant to AD/HD are surveyed. Summaries of results in the areas of attention and executive control, learning, and neural plasticity and memory suggest that, as hypothesized, AD/HD is an apt field for the interdigitation of psychoanalysis, neuroscience, and cognitive psychology. Two case reports of adult AD/HD patients demonstrate the intricacy of the clinical picture.     

The Benefits of Goal Adjustment Capacities for Well‐Being Among Women With Breast Cancer: Potential Mechanisms of Action

Breast cancer can seriously disrupt a person's important life goals. As such, the ability to adjust one's goals may be critical for well‐being. The present study investigated the relationships between disengagement/reengagement capacity and well‐being among women with breast cancer, as well as several potential mechanisms (intrusive thoughts, life purpose, and physical activity) that could explain these relationships. The sample consisted of 230 women with early‐stage (n = 172) or late‐stage (n = 58) breast cancer, who were followed prospectively for 8 months. Well‐being measures consisted of global mental health, perceived physical health, positive/negative affect, and sleep efficiency. Disengagement capacity did not predict any outcome variable. In contrast, reengagement capacity prospectively predicted changes in global mental health, positive affect, negative affect, sleep efficiency, life purpose, and physical activity. Life purpose mediated the prospective relationship between reengagement capacity and multiple aspects of well‐being. The relationships between purpose and positive/negative affect were reciprocal over time. Results also suggested that physical activity is not a mediator, but is in fact a result of the effect of reengagement capacity on well‐being. The results demonstrate that reengagement capacity is important for well‐being among women with breast cancer.