DSM-IV-Defined Inattention and Sluggish Cognitive Tempo: Independent and Interactive Relations to Neuropsychological Factors and Comorbidity

The aim of the present study was to investigate the independent relations of DSM-IV-defined inattention and behaviors characteristic of sluggish cognitive tempo (SCT) to neuropsychological factors and problem behaviors often comorbid with attention deficit/hyperactivity disorder (ADHD). By controlling for symptoms of DSM-IV-defined inattention, unique relations to SCT could be ascertained. Additionally, interactive relations of DSM-IV-defined inattention and SCT were of interest. A community-based sample of school children (N = 209; the higher end of the ADHD-symptom range was oversampled) completed neuropsychological tasks designed to measure executive function (EF), sustained attention, and state regulation. Behavioral symptoms were measured using parental and teacher ratings of the DSM-IV criteria for ADHD and Oppositional Defiant Disorder (ODD). The results showed that these two domains of inattention, DSM-IV-defined inattention and SCT, have neuropsychological processes and comorbid behavioral problems in common. However, when controlling for the overlap, DSM-IV-defined inattention was uniquely related to EF and state regulation, while SCT was uniquely related to sustained attention. In addition, the results showed an interactive relation of DSM-IV-defined inattention and SCT to ODD. Findings from the present study support the notion that DSM-IV-defined inattention constitutes a somewhat heterogeneous condition. Such results can further our theoretical understanding of the neuropsychological impairments and comorbid behavioral problems associated with ADHD symptoms.     

Evaluating the Utility of Sluggish Cognitive Tempo in Discriminating Among <Emphasis Type="Italic">DSM-IV</Emphasis> ADHD Subtypes

The objective of the current study was to evaluate how the inclusion of 3 Sluggish Cognitive Tempo (SCT) symptoms in Attention-Deficit/Hyperactivity Disorder (ADHD) diagnostic criteria influences the external validity of the ADHD subtypes. The sample comprised 228 children (166 boys, 62 girls) ranging in age from 5–18 years who were referred to clinics for attentional, behavioral, and/or learning problems and diagnosed with DSM-IV ADHD (124 Combined type, 81 Inattentive type, 23 Hyperactive-Impulsive type). Parent ratings of ADHD symptoms were obtained using the Emory Combined Rating Scale (ECRS), which assesses symptoms of the common DSM-IV childhood psychiatric disorders. Regression analyses incorporating planned comparisons were conducted to examine how the inclusion of SCT symptoms affects differences among ADHD subtypes on several external validity indicators (i.e., gender, age-of-onset, and overlapping conditions). The regression analyses did not yield any significant differences in gender ratios, mean age-of-onset, or overlapping externalizing or internalizing problems when the ADHD Inattentive type was subdivided into high- versus low-SCT groups. In conclusion, the current results suggest that the inclusion of parent-reported SCT symptoms in the ADHD diagnostic criteria has limited utility for isolating diagnostically meaningful subgroups of the Inattentive type or for enhancing the external validity of the ADHD subtypes in clinic-referred samples.     

Analogue Measures of DSM-IV Mood and Anxiety Disorders Based on Behavior Checklists

Although symptom checklists are commonly used to assess childpsychopathology, confusion arises due to differences between empirically derived checklist syndromes and rationally derived DSM-IV diagnostic categories. This paper explores analogue measures of DSM-IV mood and anxiety disorders created using items from the Youth Self-Report and Child Behavior Checklist (T. M. Achenbach, 1991a, 1991b) that parallel DSM-IV symptoms. In a matched sample of clinically referred and nonreferred adolescents, analogue measures demonstrated expected patterns of age differences, sex differences, and comorbidity. Meeting criteria for an analogue diagnosis was also associated with referral for mental health services and poor social competence. Informant effects are highlighted and the potential benefits and limitations of using existing behavior checklists to assess DSM disorders are discussed. These findings suggest the utility of checklists in identifying analogues of anxiety and mood disorders in children and adolescents.     

The Nature of Executive Function (EF) Deficits in Daily Life Activities in Adults with ADHD and Their Relationship to Performance on EF Tests

Although attention-deficit/hyperactivity disorder (ADHD) is believed to impair EF, research using EF tests shows such deficits exist in only a minority of those with ADHD. This study hypothesized that this disparity is largely due to the low ecological validity of these EF tests. A 91-item rating scale of EF was constructed based on EF theories and found to represent 5 underlying dimensions: Self-Management to Time, Self-Organization/Problem-Solving, Self-Discipline, Self-Motivation, and Self-Activation/Concentration. Three groups were compared on these scales: Adults with ADHD (N = 146), Clinical control adults not diagnosed with ADHD (N = 97), and a Community control group (N = 109). The ADHD group had more severe EF ratings than did the Clinical group and Community control groups on all 5 scales using both self and other-reported versions. Relationships between the EF scales and tests were low and mostly not significant. Most ADHD adults were clinically impaired on the EF ratings but only a small minority were so on the tests. The EF ratings were more highly associated with measures of deviant behavior (antisocial acts, crime diversity, negative driving outcomes) than the EF tests, most of which were unrelated to such behavior. These results agree with previous research showing that EF tests are largely unrelated to EF ratings and that EF ratings are more strongly associated with impairment in major life activities, in this case deviant or antisocial behavior. Contrary to earlier conclusions based on EF tests, adult ADHD involves substantial problems in EF in daily life.     

The Association Between Sluggish Cognitive Tempo and Academic Functioning in Youth with Attention-Deficit/Hyperactivity Disorder (ADHD)

The purpose of the study was to evaluate the relation between Sluggish Cognitive Tempo (SCT) and academic functioning in a sample of 52 adolescents (40 males, 12 females) with Attention-Deficit/Hyperactivity Disorder (ADHD; M _age?=?13.75). This study builds on prior work by utilizing an empirically-based and psychometrically validated measure of SCT, collecting ratings of SCT from both parents and teachers, and examining associations with multiple domains of academic functioning from both the parent and teacher perspective as well as grade point average (GPA). Both SCT and DSM-IV symptoms of inattention were significantly correlated with domains of academic functioning. Multiple regression analyses demonstrated that the parent-rated SCT Slow subscale predicted overall academic functioning, organizational skills impairment, and homework problems above and beyond ADHD symptoms and child and demographic characteristics known to be associated with academics, including intelligence, academic achievement, and family income. The teacher-rated SCT Low Initiation/Persistence subscale also predicted homework problems and was the only SCT variable to predict school grades above and beyond ADHD symptoms and relevant covariates. Both the SCT Slow and Low Initiation/Persistence subscales include items related to youth seeming apathetic, unmotivated, and lacking initiative, behaviors that are strongly related to ADHD symptoms of inattention but not currently captured by the DSM-IV. Implications of these findings towards supporting the external validity of the SCT construct are discussed along with potential implications for intervention.     

Equivalency for Father and Mother Ratings of the ADHD Symptoms

The study used multiple-group confirmatory factor analysis (CFA) and multiple indicators multiple causes (MIMIC) procedures to examine the measurement and construct equivalencies for father and mother ratings of ADHD symptoms, recoded as binary scores. Fathers (N = 387) and mothers (N = 411) rated their primary school-aged children on the Disruptive Behavior Rating Scale (Barkley & Murphy, 1998). For the multiple-group CFA analyses, the results involving differences in practical fit indices supported full measurement and construct equivalencies, whereas the chi-square difference test showed lack of equivalency in five symptoms for factor loadings, four symptoms for error variance, and the variance and mean scores for the hyperactivity-impulsivity factor. For the MIMIC analyses, six symptoms lacked equivalency for thresholds. These findings extend existing data in this area. The theoretical, psychometric and clinical implications of the findings are discussed.     

Inhibition and working memory in young preschool children with symptoms of ADHD and/or oppositional-defiant disorder

Background: Early symptoms of attention deficit/hyperactivity disorder (ADHD) and oppositional-defiant disorder (ODD) are associated with deficits in cognitive self-regulatory processes or executive functions (EF)s. However, the hypothesis that neurocognitive deficits underlying the two disorders are already evident during early preschool years still has limited empirical support. The present study investigated associations between symptoms of ADHD and/or ODD and two core EFs, inhibition and working memory, in a large nonclinical sample of 3-year old children. Method: Participants were 1045 children (554 boys, age 37–47 months), recruited from the population based Norwegian Mother and Child Cohort Study (MoBa). Relations between behavioral symptoms and measures of inhibition and working memory were studied both categorically and dimensionally. Results: Children with co-occurring symptoms of ADHD and ODD performed at a significantly lower level than typically developing children in 4 out of 5 EF measures. Symptoms of ADHD, both alone and in combination with ODD, were associated with reduced performance on tests of inhibition in the group comparisons. Dimensional analyses showed that performance within both EF domains contributed to variance primarily in ADHD symptom load. The associations between test results and behavioral symptoms remained significant after gender and verbal skills had been controlled. Conclusion: Young preschoolers show the same pattern of relations between EF and behavioral symptoms of ADHD and/or ODD as previously described in older children diagnosed with ADHD and/or ODD. Effect sizes were generally small, indicating that measures of EF have limited clinical utility at this stage in development.     

Impairment and Distress Judgments of Symptoms Composing Childhood Externalizing and Internalizing Syndromes

The pattern of perceived dysfunction associated with symptoms composing the externalizing childhood disorder syndrome was compared to the pattern characterizing the internalizing syndrome. In Study 1, undergraduate students (N = 205) judged the social impairment, academic/occupational impairment and personal distress associated with symptoms from the child and adolescent psychopathology scale (Lahey et al. 2004) related to externalizing and internalizing syndromes. As predicted, symptoms composing the externalizing syndrome were judged as involving less personal distress and more impairment than those composing the internalizing syndrome. Converging findings emerged in Study 2 when undergraduates (N = 183) judged DSM-IV symptoms composing externalizing and internalizing disorders. This research reveals systematic differences in perceptions of impairment and distress related to the symptoms that compose the externalizing and internalizing syndromes.     

Assessment and DSM-IV Diagnosis of Personality Disorders: A Primer for Counselors

The DSM-IV categorizes 10 personality disorders, long-term patterns of personality traits that result in impairment of social and occupational functioning. The author details steps in the recognition and diagnosis of personality disorders, with emphasis on using the DSM-IV diagnostic framework.     

A Comparison of the Neuropsychological Profiles of the DSM-IV Subtypes of ADHD

Recent research on the DSM-IV subtypes of attention-deficit/hyperactivity disorder (ADHD) has demonstrated that the subtypes differ in demographic characteristics, types of functional impairment, and profiles of comorbidity with other childhood disorders. However, little research has tested whether the subtypes differ in underlying neuropsychological deficits. This study compared the neuropsychological profiles of children without ADHD (n = 82) and children who met symptom criteria for DSM-IV Predominantly Inattentive subtype (ADHD-IA; n = 67), Predominantly Hyperactive Impulsive subtype (ADHD-HI; n = 14), and Combined subtype (ADHD-C; n = 33) in the areas of processing speed, vigilance, and inhibition. We hypothesized that children with elevations of inattention symptoms (ADHD-IA and ADHD-C) would be impaired on measures of vigilance and processing speed, whereas children with significant hyperactivity/impulsivity (ADHD-HI and ADHD-C) would be impaired on measures of inhibition. Contrary to prediction, symptoms of inattention best predicted performance on all dependent measures, and ADHD-IA and ADHD-C children had similar profiles of impairment. In contrast, children with ADHD-HI were not significantly impaired on any dependent measures once subclinical symptoms of inattention were controlled. Our results do not support distinct neuropsychological deficits in ADHD-IA and ADHD-C children, and suggest that symptoms of inattention, rather than symptoms of hyperactivity/impulsivity, are associated with neuropsychological impairment.     

An Evaluation of the Response Modulation Hypothesis in Relation to Attention–Deficit/Hyperactivity Disorder

Several hypotheses related to Newman's (e.g., Patterson & Newman, 1993) response modulation hypothesis were examined among adolescents with attention-deficit/hyperactivity disorder (ADHD; n=18) and normal controls (n=23). Consistent with predictions, youth with ADHD committed more passive avoidance errors (PAEs) than controls during the latter trials of a computerized go/no go task with mixed incentives, and this effect remained significant or marginally significant even after common variance associated with variables that covary with ADHD (i.e., IQ, oppositional-defiant/conduct disorder [ODD/CD] symptoms, anxious/depressed mood) was removed. While a moderate inverse association was observed between PAE frequency and the amount of time spent viewing response feedback following punishment, both categorical (diagnostic) and dimensional analyses of ADHD symptomatology indicated that ADHD and reflection on punishment feedback are uniquely associated with PAE commission. Findings from this study are discussed in relation to models of disinhibition applicable to youth with ADHD.

The adrenergic receptor α-2A gene (ADRA2A) and neuropsychological executive functions as putative endophenotypes for childhood ADHD

There is resurgent interest in the psychiatric literature in endophenotypes, variables thought to more strongly reflect the effects of candidate genes than do manifest disorders. In a sample of 176 children with attention deficit hyperactivity disorder (ADHD) and 52 of their siblings, we examined the validity of several putative endophenotypes for ADHD that represent commonly used clinical measures of multiple cognitive/neuropsychological domains of executive functions (EFs). We review their distributional normality, their relations to ADHD symptoms in probands and unaffected siblings relative to nonADHD controls, and their correlation in siblings. We also tested the EF measures’ associations with the ADRA2A gene and whether they mediated or moderated the associations between ADHD and ADRA2A. Several EF measures showed association with ADRA2A, as well as moderation, but not mediation, of its association with ADHD. Implications of the results for evaluating the validity and utility of putative endophenotype measures and for finding candidate gene effects on ADHD are discussed.     

Confirming the Factor Structure of Attention Deficit Hyperactivity Disorder Symptoms in Adult, Nonclinical Samples

Three separate models have been proposed to describe the factor structure of attention deficit hyperactivity disorder (ADHD) in the past 20 years. The Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III, 1980) proposed 3 separate factors of inattention, hyperactivity, and impulsivity. The DSM-III-R (1987) proposed a single factor. The DSM-IV (1994) described the disorder as having 2 factors: hyperactivity/impulsivity and inattention. The following 2 studies employed confirmatory factor analysis to compare each of these models and 3 alternative models. University students completed questionnaires that assessed each of the 18 symptoms listed in the DSM-IV for ADHD. The 3-factor model fit the data significantly better than each of the other models in both studies. These findings suggest that a 3-factor model of inattention, hyperactivity, and impulsivity describes adult ADHD symptoms better than current alternatives.     

Using the ASEBA to Screen for Callous Unemotional Traits in Early Childhood: Factor Structure,Temporal Stability,and Utility

This study evaluated a five-item screening measure of Callous Unemotional (CU) traits using items drawn from the Preschool Form of the Achenbach System of Empirically Based Assessment (ASEBA). Using data from the Durham Child Health and Development study (N = 178), confirmatory factor analyses demonstrated that CU items could be distinguished from Attention Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant (ODD) items. The two-year stability (N = 137) of CU (ϕ = .84) was comparable to that of ADHD (ϕ = .79) and ODD (ϕ = .69). Three groups of children were selected based on parent-rated ODD and CU behaviors at the 36-month assessment (N = 37; ODD+CU, N = 7; ODD-only, N = 12; non-ODD, N = 18). Multiple measures of infant temperament predicted group membership with 84% accuracy. Consistent with Frick and Morris’ (Journal of Clinical Child and Adolescent Psychology 33(1):54–68, 2004) hypotheses, ODD+CU and ODD-only children exhibited temperamental profiles in infancy that were consistent with low fear and emotionally dysregulated pathways into conduct problems, respectively.     

Human memory reconsolidation can be explained using the temporal context model

Recent work by Hupbach, Gomez, Hardt, and Nadel (Learning & Memory, 14, 47–53, 2007) and Hupbach, Gomez, and Nadel (Memory, 17, 502–510, 2009) suggests that episodic memory for a previously studied list can be updated to include new items, if participants are reminded of the earlier list just prior to learning a new list. The key finding from the Hupbach studies was an asymmetric pattern of intrusions, whereby participants intruded numerous items from the second list when trying to recall the first list, but not viceversa. Hupbach et al. (2007; 2009) explained this pattern in terms of a cellular reconsolidation process, whereby first-list memory is rendered labile by the reminder and the labile memory is then updated to include items from the second list. Here, we show that the temporal context model of memory, which lacks a cellular reconsolidation process, can account for the asymmetric intrusion effect, using well-established principles of contextual reinstatement and item–context binding.     

Competing Core Processes in Attention-Deficit/Hyperactivity Disorder (ADHD): Do Working Memory Deficiencies Underlie Behavioral Inhibition Deficits?

The current study examined competing predictions of the working memory and behavioral inhibition models of ADHD. Behavioral inhibition was measured using a conventional stop-signal task, and central executive, phonological, and visuospatial working memory components (Baddeley 2007) were assessed in 14 children with ADHD and 13 typically developing (TD) children. Bootstrapped mediation analyses revealed that the visuospatial working memory system and central executive both mediated the relationship between group membership (ADHD, TD) and stop-signal task performance. Conversely, stop-signal task performance mediated the relationship between group membership and central executive processes, but was unable to account for the phonological and visuospatial storage/rehearsal deficits consistently found in children with ADHD. Comparison of effect size estimates for both models suggested that working memory deficits may underlie impaired stop-signal task performance in children with ADHD. The current findings therefore challenge existing models of ADHD that describe behavioral inhibition as a core deficit of the disorder.     

Sluggish Cognitive Tempo Symptoms Contribute to Heterogeneity in Adult Attention-Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD) persists into adulthood in over 50% of cases, although its associated symptom profiles, comorbid problems, and neuropsychological deficits change substantially across development. Sluggish cognitive tempo (SCT) symptoms may contribute to associations between ADHD and comorbid problems and may partially explain the substantial heterogeneity observed in its correlates. 349 adults aged 18–38 years (M = 23.2, SD = 4.5, 54.7% male, 61.03% with ADHD) completed a multi-informant diagnostic procedure and a comprehensive neuropsychological battery. Adults with ADHD (n = 213) were retained for analyses. Latent class analyses (LCA) revealed three profiles of SCT symptoms among those with ADHD, which we classified as minimal, moderate, or severe SCT. Multiple analysis of covariance (MANCOVA) revealed significant differences among these profiles, which remained when controlling for persistence of ADHD symptoms and sex. In general, adults with ADHD combined with SCT symptoms (moderate and severe) had significantly more symptoms of anxiety, depression, and persistent inattention, and had more severe professional and relational impairment compared to ADHD adults without SCT. Compared to those with moderate or minimal SCT symptoms, the severe SCT group had the most symptoms of depression and internalizing disorders, and the most impairment in the domain of daily responsibility. No significant differences based on externalizing symptoms emerged when controlling for sex and persistence of inattention symptoms, suggesting the moderate and severe SCT groups do not simply reflect more symptoms. Moreover, follow-up mediation analyses revealed that SCT might at least partially explain the heterogeneity in ADHD. Findings have implications for refinement of etiological conceptualization, assessment methods, and intervention strategies.     

The Use of the Devereux Scales of Mental Disorders in the Assessment of Attention-Deficit/Hyperactivity Disorder and Conduct Disorder

The present study was designed to gather validity data on the Devereux Scales of Mental Disorders (DSMD) for distinguishing among children and adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD; N = 32), Conduct Disorder (CD; N = 34), or no clinical diagnosis (NC; N = 65). Three types of indicators were compared: (a) DSMD scale, composite, and total scores, (b) the number of ADHD or CD-related items endorsed, and (c) diagnostic efficiency statistics (e.g., sensitivity, positive and negative predictive power). The clinical groups did not differ significantly from each other, but both were significantly higher than the NC group on all DSMD scales. Moreover, there were significant differences between the ADHD and the CD groups on the number of respective ADHD and CD-related items endorsed. A cut-off of seven to eight items yielded the best discrimination between the two diagnostic groups. Diagnostic efficiency statistics indicate that the DSMD may be effective at differentiating between similar disruptive behavior disorders.     

Models of child–parent attachment in attention deficit hyperactivity disorder: Links to executive functions

This study explored multiple attachment relationships and examined four conceptual models of child–mother/father attachment—monotropy, hierarchy, independence, integration—to explain executive functioning (EF) in attention deficit hyperactivity disorder (ADHD) versus typical development (TD; n = 50 each; age: M = 11.45, SD = .50). Significant ADHD versus TD differences emerged on all EF measures and on distribution into four clusters (secure attachment to both parents, neither parent, only father, only mother). For both groups, results supported two attachment models: (a) monotropy: child–mother attachment predicted all EF measures; child–father attachment predicted none and (b) integration: clusters differed significantly on all EF measures. Children with ADHD comprised ～74% of the high‐risk cluster (concordant insecure attachment, highest EF difficulties). Discussion focused on unique risk/protective roles played by each parental attachment for understanding EF in children with ADHD or TD.     

Equivalence of mother and father ratings of ADHD in children

Obtaining data from multiple informants provides a more comprehensive diagnostic picture in the assessment of attention deficit hyperactivity disorder (ADHD). Differences in symptom ratings have been observed between parent- and teacher-report scales, though less information is available regarding differences between mothers and fathers. To address this gap, this study examines the rater agreement between mothers and fathers on the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV) ADHD Symptom Rating Scale (DSM-ADHD-SRS). The participants consisted of 337 children diagnosed with ADHD who underwent comprehensive neuropsychological assessment. Confirmatory factor analysis indicates that a three-factor model comprising inattention, hyperactivity, and impulsivity symptoms provides the best fit for both mothers’ and fathers’ ratings. Mothers provided higher mean ratings for the inattention scale. These results suggest that the factor structure for the DSM-ADHD-SRS is the same, regardless of parent gender. However, symptoms of inattention may vary depending upon which parent completes the ratings. This discrepancy could lead to differences in diagnostic impressions in clinical evaluations.