The Role of Neuropsychological Assessment in the Functional Outcomes of Children with ADHD

The value of evidence-based services is now recognized both within clinical communities and by the public at large. Increasingly, neuropsychologists must justify the necessity of often costly and time-consuming neuropsychological assessments in the diagnosis and treatment of common childhood disorders, such as Attention-deficit/Hyperactivity Disorder (ADHD). Published medical guidelines and prominent researchers, however, have argued against the need for formal neuropsychological assessment of ADHD. The present review examines the literature on developmental outcomes in childhood ADHD, with emphasis on the utility of formal neuropsychological assessment among children diagnosed and treated in primary care settings. The review yields three central findings: 1) adherence to published diagnostic guidelines for ADHD is poor among pediatric and primary care physicians; 2) ADHD most often co-exists with other disorders, thus diagnoses made without formal psychometric assessment can be incomplete or incorrect, ultimately increasing treatment costs; and, 3) untreated children with ADHD, and those who have untreated comorbidities, are at greater risk for poor outcomes in social, academic, vocational, and practical settings. The available literature suggests that neuropsychological assessment provides information that can potentially reduce risks for poor outcomes and improve quality of life among children with ADHD. Controlled studies directly examining the impact of neuropsychological assessments in improving outcomes among children with ADHD are needed.     

Attention-Deficit Hyperactivity Disorder: The Medicalization of Misbehavior

During the past decade, there has been an increase in the diagnosis and treatment of Attention-Deficit Hyperactivity Disorder (ADHD). This syndrome, typically diagnosed in childhood, is characterized by inattention, hyperactive motor behavior, and distractibility. Current prevalence rates obtained in various countries generally exceed the 3–5% reported by DSM-IV. Reasons for increased ADHD prevalence include changes in diagnostic standards, overlap between ADHD and other externalizing disorders, nonspecific behavioral criteria, and the rapid effects of stimulant medication on cognitive functioning. However, social, cultural, and economic factors may also contribute to increased diagnosis. ADHD has become a common topic in the lay media. Popular discussions of ADHD may serve as a metaphoric expression of social anxieties, particularly with respect to children. At the same time, ADHD has rapidly become incorporated into a medical model, with emphasis on pharmacological treatment. Reductions in mental health and educational services, as well as economic pressures of managed care, may also contribute to medicalization of behavioral problems. Collaboration between psychologists and primary care physicians can lead to more accurate diagnosis and appropriate treatment of ADHD and related disorders.     

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 control in middle childhood: relations to psychopathological symptoms and threat perception distortions

The present study examined the construct of attention control, which is an important aspect of effortful control, in a sample of non-clinical children aged between 9 and 13 years. Results demonstrated that attention control was associated with a broad range of psychopathological complaints, including symptoms of anxiety, aggression, depression, and ADHD. As predicted, lower levels of attention control were accompanied by higher levels of these symptoms. Further, attention control was also negatively related to threat perception distortions, which indicates that children who display low levels of this regulative temperament factor are more prone to such cognitive biases. Third, when controlling for neuroticism, attention control remained significantly (negatively) associated with symptoms of anxiety, depression (child report only), and ADHD. The correlations between attention control and threat perception distortions largely disappeared when the influence of neuroticism was partialled out. Only the link between attention control and anxious interpretations of ambiguous vignettes survived this correction. Finally, no evidence was found for the hypothesised mediating role of cognitive distortions on the relation between temperament factors and psychopathological symptoms.     

Differences in memory functioning between children with attention-deficit/hyperactivity disorder and/or focal epilepsy

Prior research has shown that attention-deficit/hyperactivity disorder (ADHD) and epilepsy are frequently comorbid and that both disorders are associated with various attention and memory problems. Nonetheless, limited research has been conducted comparing the two disorders in one sample to determine unique versus shared deficits. Hence, we investigated differences in working memory (WM) and short-term and delayed recall between children with ADHD, focal epilepsy of mixed foci, comorbid ADHD/epilepsy and controls. Participants were compared on the Core subtests and the Picture Locations subtest of the Children’s Memory Scale (CMS). Results indicated that children with ADHD displayed intact verbal WM and long-term memory (LTM), as well as intact performance on most aspects of short-term memory (STM). They performed worse than controls on Numbers Forward and Picture Locations, suggesting problems with focused attention and simple span for visual-spatial material. Conversely, children with epilepsy displayed poor focused attention and STM regardless of the modality assessed, which affected encoding into LTM. The only loss over time was found for passages (Stories). WM was intact. Children with comorbid ADHD/epilepsy displayed focused attention and STM/LTM problems consistent with both disorders, having the lowest scores across the four groups. Hence, focused attention and visual-spatial span appear to be affected in both disorders, whereas additional STM/encoding problems are specific to epilepsy. Children with comorbid ADHD/epilepsy have deficits consistent with both disorders, with slight additive effects. This study suggests that attention and memory testing should be a regular part of the evaluation of children with epilepsy and ADHD.     

The Development of Selective Attention in Children With Attention Deficit Hyperactivity Disorder

The influence of age on a selective attention task was studied in a sample of children with and without Attention Deficit Hyperactivity Disorder (ADHD). The impact of methylphenidate (MPH) treatment on selective attention was also investigated in the children with ADHD. Two age groups of children with ADHD and two age groups of control children were tested using a timed computer task. The task consisted of identifying visual target stimuli under various distracter conditions. Distracters varied on the basis of modality (i.e., visual, auditory, or both) and task relevance (i.e., meaningful or irrelevant). Reaction times and accuracy were measured. Children with ADHD were less efficient on the selective attention task than were children without ADHD, and older children were more efficient than younger children in both groups. Children without ADHD were influenced more by the nature of distracters than were children with ADHD. For children with ADHD, MPH improved performance overall.     

Common Grief,Complex Grieving

In this article, the author reflects on the changes during the last 25 years in our understanding of grief and on the emerging new issues in the field of loss and grief studies. He identifies several significant issues, including the implications of violent death for public and private grief, the increased attention upon the family as a mourner, and new ritual patterns emerging out of changes in funeral practices in recent years. The essay concludes by briefly considering a number of issues shaping grief and our care for those who mourn.     

Increased associated movements: influence of attention deficits and movement difficulties

This study was designed to examine whether increased associated movements (AMs) reflect motor difficulties or the symptoms associated with attention disorders. Four groups of male children (N=51) aged 6-8 years participated: Group 1 consisted of 13 children diagnosed with developmental coordination disorder (DCD); Group 2 consisted of 13 children diagnosed with attention deficit hyperactivity disorder (ADHD); Group 3 consisted of 10 children diagnosed with co-occurring DCD and ADHD, and Group 4 was a control sample of 15 children, with no known movement or attention difficulties. Various AM tasks were selected from established assessments and previous research to measure AM severity. The results supported the hypothesis that increased severity of AMs reflect movement difficulties with children in the DCD and DCD/ADHD groups displaying significantly more AMs than children in the ADHD and control groups (p<.001). No differences were found between the ADHD only and control groups (p=.67) or the DCD and DCD/ADHD groups (p=.81) suggesting that AM severity is not influenced by the neurodevelopmental symptoms associated with ADHD.     

Comorbidity of attention Deficit Hyperactivity Disorder and Post-Traumatic Stress Disorder

Attention Deficit Hyperactivity Disorder (ADHD) and Post-Traumatic Stress Disorder (PTSD) show a high degree of comorbidity in traumatized children. Two hypotheses may help explain this relationship: children with ADHD are at higher risk for trauma due to their impulsivity, dangerous behaviors, and parents who may have a genetic predisposition for impairment of their own impulse control; and hyperarousal induced by severe trauma and manifested by hypervigilance and poor concentration may impair attention to create an ADHD-like syndrome. Four illustrative cases are presented, and implications for treatment are discussed.     

Promoting Meaning-Making to Help our Patients Grieve: An Exemplar for Genetic Counselors and Other Health Care Professionals

Genetic counselors and other health professionals frequently meet with patients who are grieving a loss. It is thus helpful for medical professionals to be familiar with approaches to bereavement counseling. Grief theory has evolved over the last few decades, from primarily stage theories of grief such as Kübler-Ross’s “five stages of grief” to frameworks that promote more complex and long-term ways to cope with a loss. Herein I present one recent grief theory – meaning-making - and describe how it can be applied to help parents of children with disabilities grieve the loss of the child that they expected. In particular, I describe a scenario that many genetic counselors face - meeting with the parents of a child with Down syndrome. I outline the research done on the reactions, grief and coping experienced by parents in this circumstance, and I present suggestions for encouraging healthy coping and adjustment for parents, based on the meaning-making perspective. The meaning-making theory can also be applied to many of the other losses faced by genetic counseling patients.     

Children with ADHD in Residential Care

Little is known about the characteristics or functioning of children with ADHD in residential care as compared to their non-ADHD peers. This study evaluated data on 538 children with (n = 125) and without (n = 413) ADHD in residential care to determine demographic, mental health, behavioral, and treatment (i.e., medication use) characteristics. Results revealed that both groups presented elevated risks, however, scores for children with ADHD indicated even greater levels of need. Specifically, differences were found between the two groups on demographics (e.g., family reunification status, restrictiveness of prior out-of-home placements), behavior (e.g., attention problems, rule-breaking and aggressive behaviors) and medication status. Findings suggest there is a need for aftercare services to help support families as children transition from care, interventions to address behavior, and medication management through assessment and monitoring.     

Primary Care for the Elderly Bereaved: Recommendations for Medical Education

The aim of this study was to explore the current practices of primary care physicians (PCPs) in providing bereavement care to elderly patients, with implications for medical education. A total of 63 PCPs answered a brief online survey about their typical practices, barriers, comfort level with bereavement, and confidence in their ability to diagnose prolonged grief disorder (PGD). They were recruited through an online newsletter and contacts of one of the authors. The results found that two-thirds of the PCPs do not routinely screen their elderly patients for recent losses, nor do they refer to mental health clinicians when loss is identified. Barriers included not learning of the deaths in patients’ lives and lack of time during clinic visits. Those PCPs who had experienced their own losses were significantly more comfortable in speaking to patients about recent losses and more confident in their ability to diagnose PGD. We recommend bereavement education be incorporated into the medical school curriculum from the outset, utilizing the psychological principle of graded exposure to bereaved individuals.     

Foster Children and ADHD: Anger, Violence, and Institutional Power

This paper explores the ways in which foster children and attention deficit hyperactivity disorder (ADHD) intersect as social and medical categories. Through the method of interpretive biography based on the official case file, this paper shows how the experiences of violence and ADHD become linked in the child's life through the emotion of anger. In this way, it is possible to see how the power dynamics of the medical, educational and welfare systems lock the diagnosis with its embedded meanings into the child's life. It is also possible to see how counter forces like a caring foster family can challenge medical and welfare authorities.     

The impact of stimulants on a clinical measure of attention in children with ADHD.

The effect of stimulant medication on the attentional functioning of 23 children (8-12 yrs) with attention deficit/hyperactivity disorder (ADHD) was investigated. Significant main effects of medication and TEA-Ch subtests were found, however there was no significant interaction. Planned contrasts showed that stimulants improved performance on the sustained attention, but not the selective or divided attention, subtests. Similar to previous studies, the results indicate that stimulants improve sustained attention in children with ADHD. Significant effects of stimulants on selective and divided attention, however, were not as apparent. Therefore, care must be taken when using TEA-Ch subtests to assess performance change subsequent to stimulant administration.     

Attention-Deficit Hyperactivity Disorder (ADHD) Symptoms in Children Adopted from Poland and their Atypical Association Patterns: a Bayesian Approach

Although high rates of attention-deficit hyperactivity disorder (ADHD) symptoms have been observed among internationally adopted children, research on these symptoms in Polish adoptees is lacking. Therefore, we examined ADHD symptoms in Polish adoptees and their relationship to pre-adoptive risk factors, that is, time in institutional care, early deprivation, and prenatal alcohol exposure. We further compared the association patterns and gender distribution of ADHD symptoms in children adopted from Poland to those reported in the literature for ADHD symptoms in non-adopted children. Dutch adoptive parents of 121 Polish adoptees (52% boys; M _age = 10.9 years, range 6.2–15.6; M _ageadoption = 3.0 years, range 0.8–6.9) completed questionnaires regarding ADHD symptoms, pre-adoptive risk factors, attachment problems, conduct problems, and executive functioning deficits. Bayesian evaluation of informative hypotheses showed that Polish adoptees had increased levels of ADHD symptoms, compared to Dutch children in the general population. Time in institutional care, early deprivation, and prenatal alcohol exposure were not associated with ADHD symptoms. ADHD symptoms in Polish adoptees were more strongly associated with attachment problems and executive functioning deficits, but less strongly with conduct problems, compared to ADHD symptoms in non-adoptees. Furthermore, ADHD symptoms were more equally distributed among boys and girls than they are in non-adopted children. The findings indicate that Polish adoptees and their adoptive parents need special attention and support. The dissimilarities between ADHD symptoms in Polish adoptees and non-adoptees might indicate a different underlying causal mechanism, which may have important implications for clinical practice.     

The impact of stimulants on a clinical measure of attention in children with ADHD

The effect of stimulant medication on the attentional functioning of 23 children (8–12 yrs) with attention deficit/hyperactivity disorder (ADHD) was investigated. Significant main effects of medication and TEA-Ch subtests were found, however there was no significant interaction. Planned contrasts showed that stimulants improved performance on the sustained attention, but not the selective or divided attention, subtests. Similar to previous studies, the results indicate that stimulants improve sustained attention in children with ADHD. Significant effects of stimulants on selective and divided attention, however, were not as apparent. Therefore, care must be taken when using TEA-Ch subtests to assess performance change subsequent to stimulant administration.     

Computerized stroop test to assess selective attention in children with attention deficit hyperactivity disorder

Research shows abnormal function of the pre-frontal cortex in Attention Deficit Hyperactivity Disorder (ADHD). This cortex is involved in the control of executive functions related to planning and execution of goal-oriented strategies, working memory, inhibitions, cognitive flexibility, and selective attention. Selective attention involves focus on the target stimulus, ignoring competing distractions. The Stroop Test (Stroop, 1935) is usually used to evaluate selective attention. This study investigated whether children with ADHD could exhibit modified performance in the Stroop Test. Using a computerized version of this test (Capovilla, Montiel, Macedo, & Charin, 2005), the study compared the reaction times (RTs) of 62 Brazilian children, between 8 and 12 years of age, 31 of whom were diagnosed with ADHD and sent to psychiatric clinics, and 31 without ADHD studying in regular schools. All children with ADHD satisfied the criteria of the DSM-IV-TR and were evaluated with the Conners Abbreviated Questionnaire (Goyette, Conners, & Ulrich, 1978), completed by parents and teachers. The results revealed that children with ADHD exhibit greater interference in RT than children without ADHD. This corroborated the hypothesis that children with ADHD exhibit a deficit in selective attention, consisting in augmented RTs, as measured by the Computerized Stroop Test.     

The ambiguity of loss affects some,but not all autobiographical memories: redemption and contamination,agency and communion

ABSTRACT

Compared with clear-cut loss by death, ambiguous loss is defined as a loss that is not definite because the person is missing or mentally absent but physically present (e.g., through Alzheimer's disease). We expected the ambiguity of loss to show in psychologically more compromised loss memories and self-defining memories, but not in autobiographical memories in general. Thirty Chinese adults who had lost a parent through death, thirty whose parent had gone missing, and thirty who cared for a demented parent narrated their loss experiences and memories of sad and turning-point events as well as self-defining memories. Individuals with ambiguous loss narrated the loss and a self-defining memory with more contamination and fewer redemption sequences, and only the loss memory with fewer themes of agency and communion than individuals with definite loss, but not in memories of sad and turning point events. Effects of ambiguity of loss were independent of prolonged grief, which in turn independently predicted some of these effects. Thus the ambiguous quality of loss predicts effects on loss memories and self-defining memories independently of psychiatric symptoms.