Sustained attention and executive functioning performance in attention-deficit/hyperactivity disorder.

The aim of this study was to further refine the cognitive phenotype of attention-deficit/hyperactivity disorder (ADHD), with respect to the ability to sustain attention and executive functioning. Participants were 34 boys with ADHD (combined type) and 28 normal controls. The groups were closely matched for age and IQ. All participants were 12 years of age. Both groups performed a computerized sustained attention task and a response interference task. Measures related to speed, accuracy, and time on task were collected. We found that children with ADHD performed slower, less accurately, more impulsively, and with less stability than controls. Both groups produced more errors with increasing time on task, reflecting reduced vigilance. Importantly, no interaction with time on task was found. The overall pattern of results suggests that measures related to accuracy are more informative than measures related to speed of responding in refining the cognitive phenotype of ADHD.     

Diminished testing benefits in young adults with attention-deficit hyperactivity disorder

Memory retrieval has been shown to enhance the long-term retention of tested material; however, recent research suggests that limiting attention during retrieval can decrease the benefits of testing memory. The present study examined whether testing benefits are reduced in young adults with attention-deficit hyperactivity disorder (ADHD). College students with and without ADHD read three short prose passages, each followed by a free recall test, a restudy period or a distractor task. Two days later participants recalled the passages. Although participants without ADHD did not show a significant benefit of testing over restudying, testing did produce recall benefits relative to not taking a test. These testing benefits were diminished in participants with ADHD, who did not show any advantage of testing over either restudying or no test. The absence of testing benefits in the ADHD group is likely due in part to decreased recall on the initial test. These findings have implications for improving educational practices among individuals with ADHD and also speak to the need to examine individual differences in the effectiveness of testing as a learning strategy.     

Distinguishing sluggish cognitive tempo from attention-deficit/hyperactivity disorder in adults

Researchers who study subtypes of attention-deficit/hyperactivity disorder (ADHD) in children have identified a subset having a sluggish cognitive tempo (SCT) typified by symptoms of daydreaming, mental confusion, sluggish-lethargic behavior, and hypoactivity, among others who differ in many respects from ADHD. No studies have examined the nature and correlates of SCT in adults. This study sought to do so using a general population sample in which those having high levels of SCT symptoms were identified (≥95th percentile) and compared to adults having high levels of ADHD symptoms and adults having both SCT and ADHD symptoms. From a representative sample of 1,249 U.S. adults 18-96 years four groups were created: (a) high levels of SCT but not ADHD (N = 33), (b) high levels of ADHD but not SCT (N = 46), (c) high levels of both SCT and ADHD (N = 39), and (d) the remaining adults as a control group (N = 1,131). As in children, SCT formed a distinct dimension from ADHD symptoms that was unrelated to age, sex, or ethnicity. Adults in both ADHD groups were younger than those with SCT only or control adults. The SCT-only group had less education than the control group, whereas both SCT groups earned less annual income than the control or ADHD-only group. More individuals in the combined group were out of work on disability. In their EF, both SCT groups reported greater difficulties with self-organization and problem solving than controls or the ADHD-only group. Otherwise, the SCT + ADHD group reported significantly greater problems with all other domains of EF than the other groups. But both the SCT-only and ADHD-only groups had significantly more EF difficulties than controls though not differing from each other. A similar pattern was evident on most ratings of psychosocial impairment, except in work and education where SCT was more impairing than ADHD alone and in driving where ADHD was more impairing. SCT contributed unique variance to EF deficits and psychosocial impairment apart from ADHD inattention and hyperactive-impulsive symptoms. Results further suggested that a symptom threshold of 5 or more out of 9 along with a requirement of impairment would result in 5.1% of the population as having SCT. It is concluded that SCT may be a separate disorder from ADHD yet with comorbidity occurring in approximately half of all cases of each. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

School-based intervention for adolescents with attention-deficit/hyperactivity disorder: Effects on academic functioning

Multi-component training interventions such as the Challenging Horizons Program (CHP) improve organization skills and academic functioning of middle school students with attention-deficit/hyperactivity disorder (ADHD); however, few studies have investigated treatment for high school students. We explored the extent to which CHP adapted for high school would improve proximal (e.g., organization skills, homework performance) and distal (e.g., report card grades) academic outcomes through 6-month follow-up relative to a community care (CC) condition. Participants included 186 adolescents who were randomly assigned to CHP (n = 92; 80% male; M age = 15.0; SD = 0.8) or CC (n = 94; 78% male; M age = 15.1; SD = 0.9) with CHP delivered over one school year. Parent, teacher, and self-report ratings of organization skills and academic performance, report card grades, and achievement tests were collected across multiple occasions. Intent-to-treat analyses using hierarchical linear modeling revealed significant improvements of small to medium magnitude (d range = 0.32 to 0.58) for parent-rated organization skills, homework performance, and academic functioning at 6-month follow-up. CHP effect on grades was small, but associated with a less steep decline than that found for CC. No statistically significant effects on teacher or self-report ratings were obtained. CHP appears efficacious for ameliorating organization skills and homework performance deficits exhibited by high school students with ADHD and can protect against decline in report card grades experienced by these students. CHP may require supplementation with academic skills instruction for some students and may need implementation beyond one school year to produce durable effects.     

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.     

Neurocognitive functioning in patients with conversion disorder/functional neurological disorder

Neurocognitive symptoms are common in individuals with somatic symptom and related disorders (SSRD), but little is known about the specific impairments in neurocognitive domains in patients with conversion disorder (CD)/functional neurological disorder (FND). This study examines neurocognitive functioning in patients with CD/FND compared to patients with other SSRD. The sample consisted of 318 patients. Twenty-nine patients were diagnosed with CD/FND, mean age 42.4, standard deviation (SD) = 13.8 years, 79.3% women, and 289 patients had other SSRD (mean age 42.1, SD = 13.3, 60.2% women). Patients completed a neuropsychological test battery that addressed a broad range of neurocognitive domains, including information processing speed, attention and executive functioning. Patients with CD/FND had clinically significant neurocognitive deficits in all neurocognitive domains based on normative data comparison. Patients with CD/FND also performed significantly worse than patients with other SSRD on information processing speed (Digit Symbol Substitution Test (V = .115, p = .035), Stroop Color–Word Test (SCWT) card 1 (V = .190, p = .006), and SCWT card 2 (V = .244, p < .001). No CD/FND vs. other SSRD differences were observed in other neurocognitive domains. These findings indicate the patients with CD/FND perform worse on information processing speed tests compared to patients with other SSRD.     

Gait control in children with attention-deficit/hyperactivity disorder

The current profile of gait control in children with ADHD is incomplete and predominately based on children walking forward at a self-selected pace. There are no studies of potential gait deficits in this clinical population when walking in different directions in combination with varying rates of stepping that are freely selected and entrained to an external stimulus. The purpose of the current study was to address this lack of information by assessing gait of children aged 7–17 years with (n = 17) and without (n = 26) ADHD. Participants walked forward and backward along an electronically instrumented carpet at a self-selected stepping rate and in synchrony to a metronome that dictated an increased and decreased stepping rate. Using repeated measures analysis of covariance (ANCOVA) to assess spatiotemporal gait parameters, results showed that children with ADHD exhibited a significantly exaggerated, toes ‘turned out,’ foot position for all walking conditions compared to typically developing children. When walking backward, children with ADHD produced an increased step width, higher stepping cadence, and increased velocity. Additionally, coefficient of variation ratios indicated that children with ADHD produced greater variability of velocity, cadence, and step time for all walking conditions, and greater variability for stride length when walking at an increased stepping rate. Results were interpreted in terms of clinical significance and practical ramifications that inform rehabilitation specialists in designing therapies that ameliorate the reported gait deficits.     

Separating automatic and intentional inhibitory mechanisms of attention in adults with attention-deficit/hyperactivity disorder

Researchers in the cognitive sciences recognize a fundamental distinction between automatic and intentional mechanisms of inhibitory control. The use of eye-tracking tasks to assess selective attention has led to a better understanding of this distinction in specific populations, such as children with attention-deficit/hyperactivity disorder (ADHD). This study examined automatic and intentional inhibitory control mechanisms in adults with ADHD using a saccadic interference task and a delayed ocular response task. Thirty adults with ADHD were evaluated against 27 comparison adults on measures of inhibitory control. The delayed ocular response task showed that adults with ADHD were less able than comparison adults to inhibit a reflexive saccade toward the sudden appearance of a stimulus in the periphery. However, saccadic interference task performance showed that the ADHD group did not differ significantly from the comparison group on a measure of automatic inhibitory control. These findings suggest a dissociation between automatic and intentional inhibitory deficits in adults with ADHD.     

Parenting in mothers with and without attention-deficit/hyperactivity disorder

The authors examined the impact of maternal attention-deficit/hyperactivity disorder (ADHD) on parenting behaviors. Sixty mothers between the ages of 31 and 50 with (n = 30) and without (n = 30) ADHD and their 8- to 14-year-old children with ADHD completed self-report and laboratory measures of monitoring of child behavior, consistency in parenting, and parenting problem-solving abilities. These parenting behaviors were selected because of their established links to the development of child behavior problems. As predicted, mothers with ADHD were found to be poorer at monitoring child behavior and less consistent disciplinarians compared with mothers without ADHD. There was some evidence to support the prediction that mothers with ADHD were less effective at problem solving about childrearing issues than control mothers. The differences between the 2 groups of mothers persisted after child oppositional and conduct-disordered behavior were controlled. These results indicate that parenting is an area of functioning that requires more attention in adult ADHD research.     

Non-stimulant treatment of attention-deficit/hyperactivity disorder

Stimulants are a highly efficacious and safe treatment for attention-deficit/hyperactivity disorder (ADHD), with 75% to 90% of patients responding well if two different stimulants (amphetamine and methylphenidate) are used. Nonetheless, a subset of ADHD patients will either fail to respond to stimulants or have side effects that preclude their use (tics, severe loss of appetite, marked insomnia). For such patients, there are a number of non-stimulant agents that serve as second-line treatments. Tricyclic antidepressants (TCAs) are the most studied of these drugs. They are superior to placebo in the treatment of ADHD and may reduce abnormal movements in patients with ADHD/tic disorder. TCAs often produce side effects of sedation, dry mouth, and constipation. Bupropion is superior to placebo in the treatment of ADHD and has a more favorable side-effect profile than the TCAs. A new selective norepinephrine reuptake inhibitor, atomoxetine, has been shown to be efficacious in the treatment of ADHD and has recently received an approvable letter from the Food and Drug Administration. The a-agonists clonidine and guanfacine have also been used as alternative agents in ADHD, though the controlled data are more limited. A recent controlled clinical trial suggests a combination of methylphenidate and clonidine has advantages in the treatment of comorbid ADHD and tics over either medication alone. Clinical guidelines for each of these agents, as well as their use in combination with stimulants in comorbid conditions, will be discussed.     

Stimulus-dependent dopamine release in attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is related to an attenuated and dysfunctional dopamine system. Normally, a high extracellular dopamine level yields a tonic dopaminergic input that down-regulates stimuli-evoked phasic dopamine responses through autoreceptors. Abnormally low tonic extracellular dopamine in ADHD up-regulates the autoreceptors so that stimuli-evoked phasic dopamine is boosted. The authors propose that these boosted phasic responses yield hypersensitivity to environmental stimuli in ADHD. Stimuli evoking moderate brain arousal lead to well-functioning performance, whereas either too little or too much stimuli attenuate cognitive performance. Strong, salient stimuli may easily disrupt attention, whereas an environment with impoverished stimuli causes low arousal, which is typically compensated for by hyperactivity. Stochastic resonance is the phenomenon that makes a moderate noise facilitate stimulus discrimination and cognitive performance. Computational modeling shows that more noise is required for stochastic resonance to occur in dopamine-deprived neural systems in ADHD. This prediction is supported by empirical data.     

Parent training for attention-deficit hyperactivity disorder: Its impact on parent functioning

This study examined changes in parent functioning resulting from parental participation in a behavioral parent training (PT) program specifically designed for school-aged children with attention-deficit hyperactivity disorder (ADHD). Relative to wait list controls, subjects who completed the nine-session PT program showed significant posttreatment gains in both child and parent functioning, which were maintained 2 months after treatment. In particular, there were PT-induced reductions in parenting stress and increases in parenting self-esteem, which accompanied parent-reported improvements in the overall severity of their child's ADHD symptoms. In addition to their statistical importance, these findings are discussed in terms of their clinical significance, utilizing methods developed by Jacobson and Truax (1991).This project was supported in part through BRSG grant S07RR05712-19 awarded to Arthur D. Anastopoulos by the Biomedical Research Support Program, Division of Research Resources, National Institutes of Health.     

Eating pathology among adolescent girls with attention-deficit/hyperactivity disorder

The authors investigated prospectively assessed eating pathology (body image dissatisfaction and bulimia nervosa symptoms) among an ethnically and socioeconomically diverse sample of adolescent girls with attention-deficit/hyperactivity disorder-combined type (ADHD-C; n=93), ADHD-inattentive type (ADHD-I; n=47), and a comparison group (n=88). The sample, initially ages 6-12 years, participated in a 5-year longitudinal study (92% retention rate). After statistical control of relevant covariates, girls with ADHD-C at baseline showed more eating pathology at follow-up than did comparison girls; girls with ADHD-I were intermediate between these two groups. Baseline impulsivity symptoms, as opposed to hyperactivity and inattention, best predicted adolescent eating pathology. With statistical control of ADHD, baseline peer rejection and parent- child relationship problems also predicted adolescent eating pathology. The association between punitive parenting in childhood and pathological eating behaviors in adolescence was stronger for girls with ADHD than for comparison girls. Results are discussed in terms of the expansion of longitudinal research on ADHD to include female-relevant domains of impairment, such as eating pathology.     

Predictors of physical aggression in children with attention-deficit/hyperactivity disorder

The present investigation examined factors that predict physical aggression in children with attention-deficit/hyperactivity disorder (ADHD). Stepwise, multiple regression-analyses were used to examine predictors of children's physical aggression as rated by parents at a 1-year follow-up point and by teachers at both 1- and 2-year follow-up points. Early parent and teacher ratings of verbal aggression (ie, cursing, teasing, and threatening) accounted for the greatest proportion of the variance in physical aggression ratings obtained at follow-up. None of the other predictor variables, including early ratings of physical aggression and ADHD behaviors, contributed significant additional variance beyond that accounted for by early verbal aggression ratings. Temporal and cross-informant analyses revealed that the relationship between verbal aggression and later physical aggression was situation-specific for teacher ratings but not parent ratings. Although physical aggression may emerge early in development, these data suggest that verbal aggression represents a stable, temperamental characteristic that may be of greater value than early physical aggression for predicting later physically aggressive acts.     

Trait mechanisms in youth with and without attention-deficit/hyperactivity disorder

Relations of temperament and personality traits within children and adolescents with ADHD and non-ADHD controls were examined. A two-process structure was hypothesized involving top-down effortful and bottom-up reactive response tendencies. Top-down processes were hypothesized to relate to inattentive ADHD symptoms, whereas bottom-up processes were hypothesized to relate to hyperactive–impulsive ADHD symptoms. Each hypothesis was tested in a sample of 179 children age 7–13 (113 boys; 107 ADHD) and then replicated in 184 adolescents age 14–17 (109 boys; 87 ADHD). All families completed a multistage diagnostic process. Youth completed laboratory measures of cognitive control, and parents completed trait ratings. Traits examined in the current study included effortful control, reactive control, resiliency, negative emotionality, neuroticism, extraversion, openness, agreeableness, and conscientiousness. Correlational relations among traits were inconclusive, but external correlations with cognitive tasks and ADHD symptoms were interpretable within the hypothesized two-process framework. Results provide partial support for a distinction between effortful and reactive traits and suggest this distinction is useful in relation to understanding ADHD.     

A psychoanalytic perspective on attention-deficit/hyperactivity disorder

Psychoanalysts have tended to view the diagnosis of AD/HD either with skepticism or as a contraindication to analytic treatment. The author reviews the history of this puzzling diagnostic entity, which is estimated to account for up to fifty percent of child referrals, and suggests that a psychoanalytic perspective on the underlying disturbance in ego functioning helps to clarify the nature of the symptom picture. Whatever the etiology, which may be compound, she suggests that psychoanalytic treatment, most often in conjunction with psychopharmacological therapy, can address the core disturbance in ego integration that creates the familiar triad of inattention, impulsivity, and hyperactivity.