A cognitive tool to diagnose predominantly inattentive ADHD behavior

Poor performance on tests of reading comprehension could be the result of weak word-recognition skills, inconsistent attention (ADD), or a combination of the two. Identifying the source of the reading disability (RD) reliably has been difficult because inconsistent attention interferes with reading and weak word recognition skill makes attention wander. The situation is further complicated by the fact that there are no objective diagnostic tests for ADD (Breggin, 1998; Diller, 1998). We proposed a new model of differential diagnosis of ADHD-I/RD and field-tested its utility in two studies. The new diagnostic procedure utilizes intra-individual differences seen in the performance of at-risk learners on tasks related to reading that vary in the degree of sustained attention required for successful performance. The hypothesis is that children whose attention is inconsistent would perform more poorly on tests such as listening comprehension, which require sustained attention, than on tests such as reading comprehension, which are more tolerant of inattention. Such differences will not be seen in the test scores of children who have only a reading disability because their performance on reading tests is determined more by the difficulty level of the tests than by the sensitivity of the tests to attention. The validity of this new model was evaluated by determining the relationship between differences seen in the scores of tests that differ in their attention requirement and the degree of inconsistency in sustained attention as measured by Conners' CPT. The results of the two studies indicate this to be a viable approach. The results of the second study are presented in this report.     

On approximate confidence intervals for measures of concordance

The use ofU-statistics based on rank correlation coefficients in estimating the strength of concordance among a group of rankers is examined for cases where the null hypothesis of random rankings is not tenable. The studentizedU-statistics is asymptotically distribution-free, and the Student-t approximation is used for small and moderate sized samples. An approximate confidence interval is constructed for the strength of concordance. Monte Carlo results indicate that the Student-t approximation can be improved by estimating the degrees of freedom.Research partially supported on ONR Contract N00014-82-K-0207.     

Training raters to assess adult ADHD: reliability of ratings

The standardization of ADHD ratings in adults is important given their differing symptom presentation. The authors investigated the agreement and reliability of rater standardization in a large-scale trial of atomoxetine in adults with ADHD. Training of 91 raters for the investigator-administered ADHD Rating Scale (ADHDRS-IV-Inv) occurred prior to initiation of a large, 31-site atomoxetine trial. Agreement between raters on total scores was established in two ways: (a) by Kappa coefficient (rater agreement for each item with the percentage of raters that had identical item-by-item scores) and (b) intraclass correlation coefficients (reliability). For the ADHDRS-IV-Inv, rater agreement was moderate, and reliability, as measured by Cronbach's alpha, was substantial. The data indicate that clinicians can be trained to reliably evaluate ADHD in adults using the ADHDRS-IV-Inv.     

Assessing ADHD across settings: contributions of behavioral assessment to categorical decision making

Adapted methods of behavioral assessment to assess home and school functioning in a way that maps directly to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., [DSM-IV]; American Psychiatric Association, 1994). The study was conducted in a school-based sample with 5- to 12-year-old children referred to a school intervention team. A multigate set of procedures was used to assign children to one of 3 groups: attention deficit hyperactivity disorder (ADHD), inattentive group; ADHD, combined group; and a non-ADHD control group. The ADHD Rating Scale-IV was used to assess parent and teacher ratings of ADHD symptoms as delineated in DSM-IV. The findings suggest that the use of a fixed cutoff point (i.e., 6 or more symptoms), which is employed in the DSM-IV, is often not the best strategy for making diagnostic decisions. The optimal approach depends on whether diagnostic information is being provided by the parent or teacher and whether the purpose of assessment is to conduct a screening or a diagnostic evaluation. Also, the results indicate that a strategy that aggregates symptoms in the order in which they are accurate in predicting a diagnosis of ADHD is a more effective strategy than the approach used in DSM-IV, which aggregates any combination of a specific number of items. Implications for using methods of behavioral assessment to make diagnostic decisions using DSM-IV criteria are discussed.     

Psychometric properties of an adult ADHD diagnostic interview

Although research has been conducted to support the psychometric properties of rating scales used to assess ADHD in adults, little work has been published examining semi-structured interviews to assess ADHD in adults. The present study examined the test-retest reliability and concurrent validity of the Conners Adult ADHD Diagnostic Interview for Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) in a sample (N = 30) of patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. The findings are discussed in the context of overall issues pertaining to adult ADHD assessment.     

Assessing the process of desensitization therapy: Five practical measures

Assessment of phobic behavior has included self-report, physiological, and in vivobehavioral measures. While self-report measures are convenient, they suffer from subject bias and a low predictive validity. Physiological and in vivobehavioral measures are often too cumbersome to implement in standard clinical practice. The current study investigated the validity of five convenient measures of phobic behavior during the process of desensitization therapy. Responses of 14 clinically phobic patients were compared on phobic and neutral scenes presented within the context of systematic desensitization therapy. Phobic scenes resulted in less clarity of scene visualization, a longer latency to clear scene visualization, higher subjective units of discomfort (SUDs) at clear visualization, a longer latency to relaxation, and higher SUDs at relaxation. The measures seemed to reflect accurately the process and stages of desensitization therapy and showed low to high intercorrelations. The pragmatic value of these measures is discussed, as well as suggestions for future validational research.     

Innovations in Assessing ADHD: Development, Psychometric Properties, and Factor Structure of the ADHD Symptoms Rating Scale (ADHD-SRS)

This research involved the development of a behavior rating scale designed to measure ADHD and the investigation of the scale's psychometric properties and factor structure. This scale, the ADHD Symptoms Rating Scale (ADHD-SRS), was developed for the assessment of ADHD in the school-age (K–12) population. Participants were 1006 children and adolescents (in grades K–12) who were rated by their parents and/or teachers. The results indicate that the ADHD-SRS possesses strong internal consistency reliability and test–retest reliability and moderate cross-informant reliability. The data also suggest that the ADHD-SRS has strong content validity. Convergent validity of this instrument was also high, as demonstrated by correlations with three previously validated behavior rating scales. Significant age and gender differences in ADHD symptoms were found with both the parent and teacher respondent populations. Finally, the factor analysis of the ADHD-SRS suggested a two factor oblique rotation as the best fit for both the parent and the teacher data. After a visual inspection of the items which loaded on each factor, Factor 1 was named Hyperactive-Impulsive and Factor 2 was named Inattention. These two factors, along with the items which loaded on each factor, appear to be remarkably similar to the two categories listed in the DSM-IV for ADHD. Directions for future research, as well as clinical implications and limitations of the research are discussed.     

Assessing social dysfunction: the contributions of laboratory and performance-based measures

Reviewed research studies in which laboratory and performance-based measures were used with success to identify problematic social interaction patterns and social skills deficits associated with poor peer relationships. However, the clinical utility of these measures remains an empirical question. In this article, social competence is conceptualized as an organizational construct, reflecting the child's capacity to integrate behavioral, cognitive, and affective skills to adapt flexibly to diverse social contexts and demands. Correspondingly, performance-based measures of social functioning that include complex social interaction stimuli and require integrative responses appear more likely to demonstrate social validity than measures focused on isolated behaviors or cognitions. Research studies are reviewed that involve observations of children in three types of analogue social situations: play groups, friendship pairs, and social-challenge situations. In addition, studies that have utilized performance-based measures to screen and evaluate children for social skills training programs are reviewed. We conclude that performance-based measures are unlikely to be useful in determining whether a child is experiencing social dysfunction but may enhance the clinical analysis of the nature of the child's social difficulties. We identify gaps in the current knowledge regarding the clinical utility of performance-based measures of social dysfunction, along with directions for future research.     

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.     

Effects of IQ on executive function measures in children with ADHD.

The present study compared children with Attention-Deficit Hyperactivity Disorder (ADHD) and controls on a selected set of clinical measures of executive function (EF). A total of 92 children (51 ADHD, 41 control), ages 6-16, completed measures chosen from a larger neuropsychological battery to illustrate diverse components of the EF construct (planning, inhibitory control, response preparation, memory search). The selected measures were moderately correlated with one another, and moderately correlated with IQ. After controlling for age, sex, presence of learning disability (LD), ADHD, and IQ test version, Full Scale IQ was significantly related to four of the five selected EF measures. A second analysis showed group differences on the EF measures at different IQ levels. After covarying for age, there was a significant multivariate effect for IQ level (average, high average, superior) and a significant multivariate interaction between group (ADHD vs. control) and IQ level. Three of the five selected EF measures showed significant univariate group effects (controls performing better than ADHD) at the average IQ level; however, there were no significant group differences between children with ADHD and controls at high average or superior IQ levels. These results suggest that clinical measures of EF may differ among children with ADHD and controls at average IQ levels, but there is poorer discriminatory power for these measures among children with above average IQ.     

Differentiating between ADHD sub-types on CCPT measures of sustained attention and vigilance

The aim of the study was to test whether sustained attention and vigilance, often considered as the same phenomenon, dissociate on the Conners' Continuous Performance Test, and whether subjects with ADHD-Inattentive type and ADHD-Combined type differ with regard to these measures. Sixty-five healthy controls and 67 subjects with ADHD between 9 and 16 years of age participated in the study. The ADHD-I group performed below control children on Hit Reaction Time Block Change, considered to measure sustained attention and the ADHD-C group scored below controls on Hit Reaction Time Inter-Stimulus-Interval, considered to measure vigilance. Comparing the two clinical groups showed a test by group interaction, with ADHD-I subjects performing below ADHD-C subjects with regard to sustained attention and above ADHD-C subjects with regard to vigilance. Sustained attention on the CCPT correlated specifically with parent and teacher ratings of inattention, but not with ratings of hyperactivity-impulsivity, while vigilance correlated with all symptom ratings.     

Mothers' representations of caregiving and their adult children's representations of attachment: intergenerational concordance and relations to beliefs about mothering

Mothers (N= 35) and their adult children completed questionnaires and were interviewed in order to examine relationships between mothers' caregiving representations and their adult children's attachment representations, and relationships between attachment/caregiving representations and beliefs about mothering. Mothers' and their children's accounts of and present thinking about their past relationship were highly similar, indicating that the two parts develop concordant states of mind regarding their relationship. In contrast, there was no relationship between mothers' and their adult children's beliefs about mothering, suggesting that such beliefs are not simply passed on from generation to generation within families. Attachment/caregiving classification interacted with generation in influencing a belief that biological facts determine maternal behavior, young adults with preoccupied attachment being particularly prone to reject this idea. Attachment/caregiving classification also had a significant effect on participants' tendency to adhere to an idealized conception of mothering, this tendency being associated with a dismissive attachment/caregiving representation.     

Item response theory analyses of adult self-ratings of the ADHD symptoms in the Current Symptoms Scale

The graded response model, which is based on item response theory, was used to evaluate the psychometric properties of adult self-ratings (N = 852) of the attention deficit/hyperactivity disorder inattention, hyperactivity, and impulsivity symptoms presented in the Current Symptoms Scale. This scale has four ordered response categories. The results for the discrimination parameters showed that all symptoms were generally good for discriminating their respective latent traits. For virtually all symptoms, their threshold values showed that they were especially good at representing the appropriate traits from around the mean trait level onward. The item information function values for most symptoms indicated reasonable reliability from approximately the mean trait level onward. All these findings are new and extend existing psychometric information for adult self-ratings of the attention deficit/hyperactivity disorder symptoms in the Current Symptoms Scale.     

The effect of methylphenidate on very low frequency electroencephalography oscillations in adult ADHD

Altered very low-frequency electroencephalographic (VLF-EEG) activity is an endophenotype of ADHD in children and adolescents. We investigated VLF-EEG case-control differences in adult samples and the effects of methylphenidate (MPH). A longitudinal case-control study was conducted examining the effects of MPH on VLF-EEG (.02–0.2 Hz) during a cued continuous performance task. 41 untreated adults with ADHD and 47 controls were assessed, and 21 cases followed up after MPH treatment, with a similar follow-up for 38 controls (mean follow-up = 9.4 months). Cases had enhanced frontal and parietal VLF-EEG and increased omission errors. In the whole sample, increased parietal VLF-EEG correlated with increased omission errors. After controlling for subthreshold comorbid symptoms, VLF-EEG case-control differences and treatment effects remained. Post-treatment, a time by group interaction emerged; VLF-EEG and omission errors reduced to the same level as controls, with decreased inattentive symptoms in cases. Reduced VLF-EEG following MPH treatment provides preliminary evidence that changes in VLF-EEG may relate to MPH treatment effects on ADHD symptoms; and that VLF-EEG may be an intermediate phenotype of ADHD. Further studies of the treatment effect of MPH in larger controlled studies are required to formally evaluate any causal link between MPH, VLF-EEG and ADHD symptoms.