Shooting the Messenger: The Case of ADHD

Medicating ADHD is a controversial subject that was acutely inflamed in 1995 when high rates of ADHD diagnosis and treatment were documented in southeastern Virginia. Psychologists in southeastern Virginia formed a regional school health coalition to implement and evaluate interventions to address the problem. Other professionals with strong ties to the pharmaceutical industry launched ad hominem attacks on the coalition’s research and work. These attacks contributed to the work being terminated in 2005. In the ensuing years, ADHD drug treatment continued to escalate. Today, the national rate of ADHD diagnosis exceeds all reasonable estimates of the disorder’s true prevalence, with 14 % of American children being diagnosed before reaching young adulthood. Notable key opinion leaders continue to claim that there is no cause for concern, but with a message shift from “the prevalence is not too high” to “high prevalence is not too concerning.” This paper provides an object lesson about how innovative research can be derailed to the detriment of sound medical and mental health care of children when industry interests are threatened. Tenure may be the only option for protecting innovative research from specious attacks. The authors offer a summary of the data on ADHD drug treatments, suggest judicious use of such treatments, and add their voices to others who are once again sounding a cautionary alarm.     

Cigarette Smoking Among Youth with Attention-Deficit/Hyperactivity Disorder: Clinical Phenomenology, Comorbidity, and Genetics

Cigarette smoking and other forms of tobacco use among children and adolescents is a significant public health concern. The negative consequences of prolonged exposure to such substances are numerous, and include higher prevalence rates of cardiopulmonary dysfunction and certain cancers, and may lead to other forms of drug use. Identifying subgroups of youth who may be at greater risk than others to develop a nicotine habit is an important step forward in preventing smoking initiation, and controlling tobacco use. One such subgroup is children with attention-deficit/hyperactivity disorder (ADHD). This is because the prevalence of smoking among these youngsters is nearly twice as high as it is among those who are unaffected with ADHD. However, the etiology of this association is not known. It is possible that a constellation of social, behavioral, and biological factors influences this process, resulting in higher prevalence rates. To further our understanding of this problem, we reviewed each of these factors in relationship to smoking and to ADHD. Using the primary care population as a model, we then discuss clinical research methods that may shed additional light on this topic, as well as the strengths and limitations of current smoking prevention and cessation options for ADHD-affected youth who are assessed and treated in medical settings.     

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.     

ADHD and delinquency--a developmental perspective

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood and adolescence. Until now, it has been unclear whether ADHD by itself constitutes a risk factor for later delinquency or does so only in combination with other disruptive symptoms. This article seeks to give a comprehensive account of the literature to shed light on the developmental pathway from childhood ADHD to adult criminality. Comorbid ADHD and conduct disorder (CD) are significantly related to a range of biological and environmental risk factors such as neurocognitive impairment, high parental psychopathology, poor social functioning, and other comorbid mental disorders, particularly substance abuse, that are described in this review. In addition, the results of treatment studies are presented, with a special focus on the results of the Multimodal Treatment Study of Children with ADHD (MTA). Although treatment programs, including medication and psychosocial treatment, can be very effective in improving the functioning of children with ADHD in the social and academic domains in the short term, there is no conclusive evidence that such treatments lower the risk for developing delinquency in adulthood.     

Informing Evidence-Based Assessment of ADHD in Veterans and Service Members

Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.5% to 5% of the population, and though epidemiological studies of ADHD in veterans and service members are lacking, available evidence suggests that there may be a higher prevalence of ADHD in service members than in the general population. Assessment of ADHD in military populations is complicated by the higher prevalence rates of many other disorders with symptoms that overlap those of ADHD (e.g., posttraumatic stress disorder), making differential diagnosis an important aspect of the evaluation of ADHD. Although the diagnostic interview remains the gold standard for the evaluation and diagnosis of ADHD with adults, several different types of psychological measures have been developed and validated that can aid the evaluation. Future epidemiological research focused on prevalence and comorbidity rates in military samples is warranted to better understand the scope and complexity of the diagnosis. In addition, continued study of diagnostic assessment techniques, including validity testing and neurocognitive performance of veterans and service members with ADHD, particularly postdeployed veterans pursuing higher education, is warranted. This article reviews relevant findings and identifies initial recommendations for clinicians and researchers.     

基于时间顺序的多动症共病的概述

多动症是一种常见的行为障碍,它以注意力不集中、多动、行为冲动为主要特征。同时多动症是一组异质性疾病,常与一种或几种精神或非精神障碍相伴发生。以往关于多动症合并症状的研究,大都局限在一个或几个合并症状上,缺乏关于其合并症状的系统认识。基于以往研究,文章以多动症合并症状发生的时间顺序为线索,将其分为前期、同期、后期合并症,并逐一详细介绍。未来应该加强关于多动症患者的纵向研究,以了解症状的发展状况,更好的诊断和治疗多动症。     

Bipolar disorder in children and adolescents

There is increased recognition that bipolar disorder has an early age of onset. The prevalence of bipolar disorder in prepubertal children has not been determined, however the prevalence in adolescence is approximately 1%. Bipolar disorder in children poses a diagnostic challenge since the symptoms may differ from those in late adolescence and adulthood. Comorbid disorders, such as attention-deficit/hyperactivity disorder, further complicate both the diagnosis and course of the disorder. There is increasing evidence of the chronicity and severity of this disorder in youths. Bipolar disorder significantly disrupts a child's psychosocial development including impairments in academic functioning, family functioning, and relationship with peers. Although this disorder has significant morbidity in children and adolescents, there is a paucity of controlled studies to assess the efficacy and safety of mood stabilizers in the treatment of this disorder in youths. The treatment literature consists largely of case studies, retrospective chart reviews, and open-label studies. There is a compelling need for double-blind, placebo-controlled trials to determine whether commonly used medications to treat this disorder are significantly superior to placebo. Since many children in clinical practice require more than one psychotropic medication to adequately manage this disorder, studies of combination treatments are warranted. This review will provide an overview of the literature of bipolar disorder in children and adolescents, including discussion of the prevalence, diagnosis, epidemiology, course of the illness, and treatment issues.     

A Multivariate Predictive Study of Staff OTR Job Satisfaction

Abstract

This paper is a discussion of the experience of adult attention deficit hyperactivity disorder (ADHD). While much is known about the diagnosis and treatment of childhood ADHD, therapists may be less familiar with the clinical signs of adult ADHD and fail to detect and address such deficits in patients. Adult ADHD often affects all occupational domains-work/school, family life, social relationships, and self-organization-often without the person's awareness of the condition. When people with ADHD do not receive a formal diagnosis until adulthood, deficits in the above occupational domains may be severe. The first half of this paper describes (a) clinical presentation; (b) classification; prevalence, adult course, and comorbid conditions; (c) biologic factors; and (d) pharmacologic treatment. The latter half discusses occupational therapy intervention and describes a case study involving a college student.     

Fundamental Movement Skills and Children with Attention-Deficit Hyperactivity Disorder: Peer Comparisons and Stimulant Effects

The purpose of this study was to compare the fundamental movement skills of 22 children with attention-deficit hyperactivity disorder (ADHD), from 6 to 12 years of age, to gender- and age-matched peers without ADHD and assess the effects of stimulant medication on the movement skill performance of the children with ADHD. Repeated measures analyses revealed significant skill differences between children with and without ADHD (p ≤ 0.001). Results from the stimulant medication trials indicated no significant effect of medication on the movement skill patterns of children with ADHD. It is concluded that children with ADHD may be at risk for developmental delays in movement skill performance. Potential factors underlying the movement skill difficulties are discussed, with suggestions for future research.     

How many fidgets in a pretty much: A critique of behavior rating scales for identifying students with ADHD

The school psychologist's role and responsibilities for meeting the needs of students with Attention-Deficit Hyperactivity Disorder (ADHD) have been expanding in recent years. Students with this disorder present refractory problems that may involve the school psychologist in the assessment and diagnosis of ADHD. Rating scales commonly are used, sometimes in conjunction with other techniques, for assessing and diagnosing ADHD. They often are presented as an objective way to quantify the severity of a child's behavior in comparison with a normative standard. Because rating scales have become such an integral component in the identification of children with ADHD, school psychologists should understand the limitations associated with this methodology. In this article we first describe behavior rating scales and difficulties in the use of cutoff scores to identify students as ADHD. Second, we describe how problems with interobserver agreement hamper the validity of rating scales and the subsequent conclusions that can be drawn about students' behavior. Finally, we present recommendations for obtaining more reliable and valid information from rating scales.     

A social relational critique of the biomedical definition and treatment of ADHD; ethical practical and political implications

Attention deficit hyperactivity disorder (ADHD), its existence and treatment, is a contentious matter. The dominant view in medicine considers that ADHD is a psychiatric disorder. My position is to challenge this from a social relational orientation. I explore here a critique of the psychiatric disease model of causation and treatment, particularly the use of medication. A series of prejudices based on a political and social constructionist orientation are offered to address the ethics, politics and practice implications of the practitioner critical of the biomedical model of diagnosis and treatment especially the use of medication. This device is employed in order to invite critical reflection and further debate in a field dominated by the medical and genetic arguments in support of ADHD as a psychiatric disease. The implications of more open debate are explored, together with directions for more politically and ethically informed practice with children and their families.     

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

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

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.     

ADHD and female specific concerns: a review of the literature and clinical implications

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD.     

Prevalence of Smoking in Anxiety Disorders Uncomplicated by Comorbid Alcohol or Substance Abuse

This study examined the point prevalence of smoking in patients with anxiety disorders who do not have comorbid alcohol or substance abuse or dependence (ASAD). In a retrospective chart review, the smoking status of 581 patients with anxiety disorders was assessed. Patients, ages 18–65, were seeking treatment for anxiety disorders at an outpatient clinic that specialized in anxiety and related disorders. All participants were interviewed using the Anxiety Disorders Interview Schedule—IV, during which their smoking status was assessed. The prevalence of smoking across all anxiety disorders was 14.8%, which is much lower than found in the general population (23.3%; CDC, 2002) and even lower than previous estimates in individuals with comorbid anxiety and ASAD. Individuals with panic disorder and generalized anxiety disorder had the highest prevalence of smoking, although these rates were still considerably lower than those found in previous studies of smokers with anxiety disorders. Reasons for lower prevalence estimates are discussed.     

ADHD in college students

OBJECTIVE: According to the American Psychiatric Association, 3% to 7% of the school-age population has ADHD and many children continue to display significant symptoms throughout adolescences and adulthood. Relative to the childhood literature, less is known about ADHD in adults, especially college students with ADHD. The principle purpose of this review articles is to summarize the major research findings concerning ADHD in the college student population with regard to prevalence of symptoms, neuropsychological and psychological functioning. Overall, findings suggest that college students with ADHD are at greater risk for academic and psychological difficulties, and they perform similar to non-ADHD controls on many neuropsychological tasks. These findings are preliminary, however, and are tempered by the small number of studies that have been conducted as well as the methodological limitations of these studies. CONCLUSION: Future research using larger sample sizes, rigorous assessment criteria, and a longitudinal design is needed to better understand the psychological, academic, and neuropsychological functioning of college students with ADHD. Studies are also needed to elucidate the effects of pharmacological and nonpharmacological effects of treatment on the functioning of college students with this disorder.     

Exploration of the Factor Structure of ADHD in Adolescence through Self,Parent, and Teacher Reports of Symptomatology

Factor analytic studies of attention-deficit/hyperactivity disorder (ADHD) in children and adults have shown that second-order and bifactor models better represent ADHD symptoms than two- or three-factor models, yet there is far less evidence for a bestfitting model of ADHD in adolescence. Thus, the current study examined the factor structure of ADHD in adolescence and further evaluated the external validity of the best fitting model. Participants were 588 adolescents (22 % female; 366 with a childhood ADHD diagnosis; mean age 15.9 years) from the 8-year assessment of the Multimodal Treatment Study of Children with ADHD (MTA). ADHD symptoms were assessed via adolescent self-report, parent report, and teacher report on the SNAP-IV scale. Potential factor structures for the 18 symptoms of ADHD were tested for each informant, which included traditional one-factor, two-factor, and three-factor models of ADHD, as well as second-order factor (specific factors loading onto general factor) and bifactor (items loading onto both specific and general factors) models. Unique associations between external criteria and the identified factors of each informant’s best fitting model were examined. Although several of the proposed models exhibited good fit, the second-order two-factor model best accounted for ADHD in adolescence according to self-report and parent report, and the second-order three-factor model was optimal according to teacher report. Several key measurement issues emerged for the hierarchical bifactor models, such as numerous Heywood cases and out-of-bound parameter estimates, which rendered them unfit as optimal representations of ADHD in adolescence. These findings and the implications of the best fitting model of ADHD in adolescence suggest that a possible reorganization of this disorder may eventually aid clinicians in the accurate diagnosis of ADHD in adolescents.     

The national institutes of health attention-deficit/hyperactivity disorder consensus statement: implications for practitioners and scientists

Although the concept of pharmacotherapy for attention-deficit/hyperactivity disorder (ADHD) was first introduced more than 60 years ago, treatment of this disorder remains more controversial than ever. It is hoped, however, that the recent Consensus Development Conference (CDC) Statement on the diagnosis and treatment of ADHD will not only help answer some of the questions surrounding management of this disorder, but also lend needed scientific weight to debate in this area. While more research in ADHD is needed, the CDC participants pointed to a solid body of evidence showing that careful medication management can result in noticeable improvement in several measures, with little risk of adverse events.     

Perceptions of attention deficit hyperactivity disorder and its treatment among children and adolescents

Little is known about how children and adolescents conceptualize psychiatric disorders and psychiatric treatment. In the current study, children and adolescents diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) were interviewed about their understanding of ADHD and the medication used to treat their disorder. The participants were all taking Ritalin and ranged in age from 5 to 16 years. With increasing age, children improved in their ability to name their condition and the medication. Latency-aged children often did not perceive Ritalin as helpful while adolescents recognized some value in taking medication. Some of the adolescents were also able to describe medication side effects. The implications of these findings for patient education are discussed.