Analysis of Personal and Family Factors in the Persistence of Attention Deficit Hyperactivity Disorder: Results of a Prospective Follow-Up Study in Childhood

Objectives

To study the course of ADHD during childhood and analyze possible personal and family predictor variables of the results.

Method

Sixty-one children with ADHD who were between 6 and 12 years old at the baseline assessment were evaluated 30 months later (mean age at baseline: 8.70 ± 1.97; mean age at follow-up: 10.98 ± 2.19). Status of ADHD in follow-up was identified as persistent (met DSM-IV-TR criteria according to parents’ and teachers’ ratings), contextually persistent (met ADHD criteria according to one informant, and there was functional impairment) and remitted ADHD (with subthreshold clinical symptomatology). Associated psychological disorders of the three groups were analyzed in the follow-up with the Conners'' Rating Scales. The groups were compared on ADHD characteristics (symptoms of ADHD and impairment), child psychopathology, executive functioning (EF; inhibition, working memory) and parenting characteristics (parental stress and discipline styles) at baseline.

Results

At the follow-up, 55.7% of the children continued to meet the DSM-IV-TR criteria for ADHD, 29.5% showed contextual persistence, and 14.8% presented remission of the disorder. The persistent and contextually persistent ADHD groups showed more associated psychological disorders. Inattention, oppositional problems, cognitive problems and impairment at baseline distinguished the remitted ADHD children from the persistent and contextually persistent ADHD children. Moreover, the persistent groups had significantly more emotional liability and higher parental stress than the group in remission, while no differences in EF where found among the groups.

Conclusions

ADHD children continue to present symptoms, as well as comorbid psychological problems, during adolescence and early adulthood. These findings confirm that persistence of ADHD is associated with child psychopathology, parental stress and impairment in childhood.     

Comorbidity and continuity of attention deficit hyperactivity disorder (ADHD) from childhood to adolescence in Turkey

The aim of this study was to examine clinical outcomes, psychiatric comorbidity and neuropsychological characteristics in Turkish adolescents with an attention deficit hyperactivity disorder (ADHD) diagnosis in childhood. A total of 45 children with ADHD diagnosis and 28 children with a psychiatric diagnosis other than ADHD in a 1-year cohort of 7–10-year-olds were reevaluated 6 years later using Schedule for Affective Disorders and Schizophrenia for School-Age Children Present and Lifetime version and Wechsler Intelligence Scale for Children-Revised and Stroop Test TBAG version. This study shows that the clinical outcomes and the comorbidity patterns for ADHD from childhood to adolescence in Turkey are similar to reported rates in the Western countries. In the ADHD group, 75.6 % still has impairing ADHD symptoms and 46.6 % has comorbid psychiatric disorders. The main difference is anxiety disorders being the most common comorbid disorders (37.8 %) in Turkish ADHD youth. These findings stress the high comorbidity associated with ADHD and support the importance of assessment and treatment for ADHD and comorbidities during adolescence.     

Effects of Neurofeedback Training on Performing Bimanual Coordination In-phase and Anti-phase Patterns in Children with ADHD

It is generally accepted that children with attention-deficit/hyperactivity disorder (ADHD) have poor motor control, especially in bimanual coordination tasks. Such children characteristically have impaired fine motor ability, problems with force control, and poor motor coordination. They are at particular risk of loss of motor control and reduced bimanual coordination. We tested whether, compared to a control condition, neurofeedback training (NFT) could improve bimanual coordination among children with ADHD. 20 Children with ADHD (mean age 7.9 years; SD 2.11) were randomly assigned either to NFT or to a control condition. All participants completed a bimanual coordination test at the following time points: baseline, assessment 1, assessment 2, assessment 3, and again 12 session later at posttest. NFT consisted of Sensory Motor Rhythm (SMR) training to achieve increased SMR in C3 and C4, while participants in the control condition were under mock NFT conditions. Bimanual coordination accuracy and consistency improved from baseline to completion of the intervention (significant Time effect), but in the NFT condition (significant time?×?group interaction). Compared to the control condition, the NFT group had fewer errors in both patterns of bimanual coordination (significant Group effect). Among children with ADHD, SMR neurofeedback training (NFT) led to significant improvements in a bimanual coordination task. The SMR NFT thus appears to have the potential to improve and enhance the motor control of ADHD patients.     

Atomoxetine response in the inattentive and combined subtypes of attention deficit hyperactivity disorder: a retrospective chart review

The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 1994, American Psychiatric Association) describes attention deficit hyperactivity disorder (ADHD) as a heterogeneous disorder; providing diagnostic criteria for three subtypes: hyperactive/impulsive (ADHD/HI), inattentive (ADHD/I), and combined type (ADHD/C). Differences among the subtypes are well defined, but there may be also differences in terms of treatment responses. The aim of this study is to assess the responses of ADHD/I and ADHD/C to atomoxetine treatment. The medical records of the January–June 2012 term, first time referrals to outpatient clinic, were reviewed, and 37 ADHD diagnosed primary school age children (18 ADHD/I, 19 ADHD/C) that were treated with atomoxetine were determined. Thirty-five of them who completed 8 weeks of treatment duration were recruited for the study. The children with an ADHD medication use history in 2 months time prior to onset of treatment and/or the children receiving additional psychopharmacologic treatment to atomoxetine were excluded. Baseline and eighth week assessment, records were evaluated. Efficacy assessments included Turgay DSM-IV ADHD Screening and Rating Scale parent and teacher forms (T-DSM-IV) and Clinical Global Impression Scale-Severity and Improvement subscales. Safety assessments included laboratory and body weight assessments, ECG, heart rate, and blood pressure evaluations (baseline and eighth week) along a scale filled by the parents at the eighth week to review side effects. Atomoxetine was found to be effective in both ADHD/I and ADHD/C groups. Atomoxetine also decreased the opposition defiance subscale scores of T-DSM-IV (both parent and teacher forms), whereas it was not found to make statistically significant difference in the conduct disorder subscale scores. Mean difference in 8-week time in T-DSM-IV hyperactivity subscale and total scores of parent and teacher forms; inattention subscale scores of only parent forms and the CGI- severity subscale scores; differed significantly among the ADHD/I and ADHD/C groups; that ADHD/C types responded better to medication. Results of this study revealed that atomoxetine is effective both in ADHD/I and ADHD/C subtypes. ADHD/C types may be responding better to atomoxetine treatment than the ADHD/I subtypes.     

Stigma in attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a frequently diagnosed disorder in child- and adulthood with a high impact affecting multiple facets of social life. Therefore, patients suffering from ADHD are at high risk to be confronted with stigma, prejudices, and discrimination. A review of the empirical research in the field of ADHD with regard to stigma was performed. The findings of investigations in this field were clustered in different categories, including stigma in children with ADHD, stigma in adults with ADHD, stigma in relatives or in people close to a patient with ADHD, and the influence of stigma on authorities' attitudes toward patients with ADHD. Variables identified to contribute to stigma in ADHD are public's uncertainty concerning the reliability/validity of an ADHD diagnosis and the related diagnostic assessment, public's perceived dangerousness of individuals with ADHD, socio-demographical factors as age, gender, and ethnicity of the respondent or the target individual with ADHD, stigmatization of ADHD treatment, for example public's skepticism toward ADHD medication and disclosure of diagnostic status as well as medication status of the individual with ADHD. The contribution of stigma associated with ADHD can be conceptualized as an underestimated risk factor, affecting treatment adherence, treatment efficacy, symptom aggravation, life satisfaction, and mentally well-being of individuals affected by ADHD. Public as well as health professionals' concepts about ADHD are highly diverse, setting individuals with an ADHD diagnosis at greater risk to get stigmatized.     

Attention-deficit hyperactive disorder presenting with school truancy in an adolescent: a case report

Attention-deficit hyperactive disorder (ADHD) is a psychiatric illness commonly diagnosed during the early years of childhood. In many adolescents with undiagnosed ADHD, presentation may not be entirely similar to that in younger children. These adolescents pose significant challenges to parents and teachers coping with their disability. Often adolescents with behavioural problems are brought to medical attention as a last resort. This case describes an adolescent who presented to a primary care clinic with school truancy. He was initially treated for depression with oppositional defiant disorder and sibling rivalry. Only following a careful detailed history and further investigations was the diagnosis of ADHD made. He showed a positive improvement with the use of methylphenidate for his ADHD and escitalopram for his depression. The success of his management was further supported by the use of behavioural therapy and parenting interventions. There is a need to increase public awareness of ADHD, especially among parents and teachers so that early intervention can be instituted in these children.     

Emotion recognition in children and adolescents with attention-deficit/hyperactivity disorder (ADHD)

Children with attention-deficit/hyperactivity disorder (ADHD) are impaired in social adaptation and display deficits in social competence. Deficient emotion recognition has been discussed to underlie these social problems. However, comorbid conduct problems have not been considered in the majority of studies conducted so far, and the influence of medication on emotion recognition has rarely been studied. Here, emotion recognition performance was assessed in children with ADHD without medication compared with children with ADHD under stimulant medication and a matched control group. In order to rule out confounding by externalizing symptoms, children with comorbid conduct problems were excluded. Video clips with neutral faces developing a basic emotion (happiness, sadness, disgust, fear and anger) were presented in order to assess emotion recognition. Results indicated between-group differences neither concerning the number of correctly identified emotions nor concerning reaction times and their standard deviations. Thus, we suggest that ADHD per se is not associated with deficits in emotion recognition.     

Insecure maternal attachment is associated with depression in ADHD children

The objective of this study was to analyze the possible association between maternal attachment style and comorbidity associated with childhood ADHD. We evaluated a total of 103 children with ADHD treated at a Child and Adolescent Mental Health Centre and their mothers. Comorbidity was evaluated using the MINI-KID interview. Maternal attachment was evaluated using the Adult Attachment Questionnaire. We considered child variables that could be associated with the clinical course of ADHD, such as symptom severity, age, gender, evolution time, academic level, and current pharmacological treatment; parental variables, such as the mother’s psychiatric history, current psychopathology, marital status, academic level, income, and employment, were also considered. We found an association between maternal insecure attachment and comorbid depressive disorder in childhood ADHD. An insecure maternal attachment style must be considered in the assessment and treatment of childhood ADHD with comorbid depression.     

The quick delay questionnaire: a measure of delay aversion and discounting in adults

Individuals with ADHD often display an altered response to delay. To date, assessment of this has typically involved neuropsychological testing-however, such tests are designed specifically for children and may not be suitable for adults. They are also relatively time-consuming and expensive. In the current paper, we describe the initial validation of a short questionnaire to assess delay-related behaviour in adults. The Quick Delay Questionnaire (QDQ) is a 10-item scale. The questionnaire was administered to 575 participants from the normal population (ranging in age from 18 to 77 years). Forty of the original sample were selected at random and tested 1 week later. Data on ADHD, anxiety and depression were also collected. There were two five-item scales-(1) delay aversion; and (2) delay discounting. These had internal consistency and had good reliability. Subscales were differentially associated with ADHD, anxiety and depression. The QDQ is a potentially valuable way of assessing response to delay in adults. Further work is required to validate the scale against direct observation and neuropsychological assessment in clinically ascertained samples.     

Dietary patterns and blood fatty acid composition in children with attention-deficit hyperactivity disorder in Taiwan

Nutritional factors may be relative to attention-deficit hyperactive disorder (ADHD), although the pathogenic mechanism is still unknown. Based on the work of others, we hypothesized that children with ADHD have altered dietary patterns and fatty acid metabolism. Therefore, the aim of this study was to evaluate dietary patterns and the blood fatty acid composition in children with ADHD in the Taipei area of Taiwan. The present study found that 58 subjects with ADHD (average age 8.5 years) had significantly higher intakes of iron and vitamin C compared to those of 52 control subjects (average age 7.9 years) (P < 0.05). The blood total protein content in subjects with ADHD was significantly lower than that in control subjects (P < 0.05). On the other hand, children with ADHD had significantly higher blood iron levels compared to the control children (P < 0.05). Additionally, plasma gamma-linolenic acid (18:3 n-6) in children with ADHD was higher than that in control children (P < 0.05). Concerning the composition of other fatty acids in the phospholipid isolated from red blood cell (RBC) membranes, oleic acid (18:1n-9) was significantly higher, whereas nervonic acid (24:1n-9), linoleic acid (18:2n-6), arachidonic acid (20:4n-6), and docosahexaenoic acid (22:6n-3) were significantly lower in subjects with ADHD (P < 0.05). Our results suggest that there were no differences in dietary patterns of these children with ADHD except for the intake of iron and vitamin C; however, the fatty acid composition of phospholipid from RBC membranes in the ADHD children differed from that of the normal children.     

Combined Psychophysiological Assessment of ADHD: A Pilot Study of Bayesian Probability Approach Illustrated by Appraisal of ADHD in Female College Students

Manifestations of ADHD are observed at both psychological and physiological levels and assessed via various psychometric, EEG, and imaging tests. However, no test is 100% accurate in its assessment of ADHD. This study introduces a stochastic assessment combining psychometric tests with previously reported (Consistency Index) and newly developed (Alpha Blockade Index) EEG-based physiological markers of ADHD. The assessment utilizes classical Bayesian inference to refine after each step the probability of ADHD of each individual. In a pilot study involving six college females with ADHD and six matched controls, the assessment achieved correct classification for all ADHD and non-ADHD participants. In comparison, the classification of ADHD versus non-ADHD participants was < 85% for any one of the tests separately. The procedure significantly improved the score separation between ADHD versus non-ADHD groups. The final average probabilities for ADHD were 76% for the ADHD group and 8% for the control group. These probabilities correlated (r = .87) with the Brown ADD scale and (r = .84) with the ADHD-Symptom Inventory used for the screening of the participants. We conclude that, although each separate test was not completely accurate, a combination of several tests classified correctly all ADHD and all non-ADHD participants. The application of the proposed assessment is not limited to the specific tests used in this study--the assessment represents a general paradigm capable of accommodating a variety of ADHD tests into a single diagnostic assessment.     

Salivary melatonin rhythm as a marker of the circadian system in healthy children and those with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. Problems with sleep structure, efficiency, and timing have been reported in some, but not all, studies on ADHD children. As the sleep-wake cycle belongs to circadian rhythms, the timekeeping circadian system might be involved in ADHD. To assess whether the circadian system of ADHD children differs from that of controls, the rhythm of the pineal hormone melatonin was used as a reliable marker of the system. Saliva from 34 ADHD and 43 control 6- to 12-yr-old children was sampled at 2-h intervals throughout the entire 24-h cycle, and the melatonin profiles of the ADHD and control children were compared. The nocturnal melatonin peaks of the ADHD and control group did not differ significantly. The high nocturnal interindividual variability of the peaks seen in adulthood was present already in the studied children. The 24-h melatonin profiles of all the ADHD subjects did not differ significantly from those of the control subjects. Categorization of subjects according to age, into groups of 6- to 7-yr-old (9 ADHD, 5 control), 8- to 9-yr-old (16 ADHD, 26 control), and 10- to 12-yr-old (9 ADHD, 12 control) children, revealed significant differences between the ADHD and control group in the melatonin rhythm waveform, but not in nocturnal melatonin peaks; the peaks were about the same in both groups and did not change significantly with increasing age. In the oldest, but not in the younger, children, the melatonin signal duration in the ADHD group was shorter than in the control group. The difference might be due to the fact that whereas in the control group both the evening melatonin onset and the morning offset phase delayed in the oldest children relative to those in the youngest children, in the ADHD group only the onset, but not the offset, phase delayed with increasing age. The data may indicate subtle differences between the circadian system of ADHD and control children during development.     

Gap Effect Abnormalities during a Visually Guided Pro-Saccade Task in Children with Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that starts in early childhood and has a comprehensive impact on psychosocial activity and education as well as general health across the lifespan. Despite its prevalence, the current diagnostic criteria for ADHD are debated. Saccadic eye movements are easy to quantify and may be a quantitative biomarker for a wide variety of neurological and psychiatric disorders, including ADHD. The goal of this study was to examine whether children with ADHD exhibit abnormalities during a visually guided pro-saccadic eye-movement and to clarify the neurophysiological mechanisms associated with their behavioral impairments. Thirty-seven children with ADHD (aged 5–11 years) and 88 typically developing (TD) children (aged 5–11 years) were asked to perform a simple saccadic eye-movement task in which step and gap conditions were randomly interleaved. We evaluated the gap effect, which is the difference in the reaction time between the two conditions. Children with ADHD had a significantly longer reaction time than TD children (p < 0.01) and the gap effect was markedly attenuated (p < 0.01). These results suggest that the measurement of saccadic eye movements may provide a novel method for evaluating the behavioral symptoms and clinical features of ADHD, and that the gap effect is a potential biomarker for the diagnosis of ADHD in early childhood.     

Parental efficacy and child behavior in a community sample of children with and without attention-deficit hyperactivity disorder (ADHD)

Most studies of attention-deficit hyperactivity disorder (ADHD) youth have obtained data from the perspective of either children or parents, but not both simultaneously. The purpose of this study was to examine child and parent perspectives on parenting in a large community-based sample of children with and without ADHD. We identified children in grades 4?C6 and their parents through surveys administered to a random sample of public schools. We used multivariable logistic regression to determine independent associations between child and parent characteristics and the presence of ADHD while controlling for covariates and clustering by school. Sufficient data were achieved for 2,509 child/parent dyads. Ten percent of youths (n?=?240) had been diagnosed with ADHD. Compared with those without ADHD, those with ADHD were more commonly male (67.9 vs. 48.0?%, p?<?.001) and age 12 or over (16.3 vs. 10.3?%). After adjusting for covariates and clustering, compared to children without ADHD, children with ADHD were significantly more likely to report lower self-regulation (OR?=?0.68, 95?% CI?=?0.53, 0.88) and higher levels of rebelliousness (OR?=?2.00, 95?% CI?=?1.52, 2.69). Compared with parents whose children did not have ADHD, parents of children with ADHD rated their overall parental efficacy substantially lower (OR?=?0.23, 95?% CI?=?0.15, 0.33). However, child assessment of parenting style was similar by ADHD. Despite the internal challenges community-based youth with ADHD face, many parents of ADHD youth exhibit valuable parental skills from the perspective of their children. Feedback of this information to parents may improve parental self-efficacy, which is known to be positively associated with improved ADHD outcomes.     

Attention-Related Eye Vergence Measured in Children with Attention Deficit Hyperactivity Disorder

Recent evidence shows a novel role for eye vergence in orienting attention in adult subjects. Here we investigated whether such modulation in eye vergence by attention is present in children and whether it is altered in children with ADHD compared to control subjects. We therefore measured the angle of eye vergence in children previously diagnosed with ADHD while performing a cue task and compared the results to those from age-matched controls. We observed a strong modulation in the angle of vergence in the control group and a weak modulation in the ADHD group. In addition, in the control group the modulation in eye vergence was different between the informative cue and uninformative cue condition. This difference was less noticeable in the ADHD group. Our study supports the observation of deficient binocular vision in ADHD children. We argue that the observed disruption in vergence modulation in ADHD children is manifest of altered cognitive processing of sensory information. Our work may provide new insights into attention disorders, like ADHD.     

Salivary Melatonin Rhythm as a Marker of the Circadian System in Healthy Children and Those With Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. Problems with sleep structure, efficiency, and timing have been reported in some, but not all, studies on ADHD children. As the sleep-wake cycle belongs to circadian rhythms, the timekeeping circadian system might be involved in ADHD. To assess whether the circadian system of ADHD children differs from that of controls, the rhythm of the pineal hormone melatonin was used as a reliable marker of the system. Saliva from 34 ADHD and 43 control 6- to 12-yr-old children was sampled at 2-h intervals throughout the entire 24-h cycle, and the melatonin profiles of the ADHD and control children were compared. The nocturnal melatonin peaks of the ADHD and control group did not differ significantly. The high nocturnal interindividual variability of the peaks seen in adulthood was present already in the studied children. The 24-h melatonin profiles of all the ADHD subjects did not differ significantly from those of the control subjects. Categorization of subjects according to age, into groups of 6- to 7-yr-old (9 ADHD, 5 control), 8- to 9-yr-old (16 ADHD, 26 control), and 10- to 12-yr-old (9 ADHD, 12 control) children, revealed significant differences between the ADHD and control group in the melatonin rhythm waveform, but not in nocturnal melatonin peaks; the peaks were about the same in both groups and did not change significantly with increasing age. In the oldest, but not in the younger, children, the melatonin signal duration in the ADHD group was shorter than in the control group. The difference might be due to the fact that whereas in the control group both the evening melatonin onset and the morning offset phase delayed in the oldest children relative to those in the youngest children, in the ADHD group only the onset, but not the offset, phase delayed with increasing age. The data may indicate subtle differences between the circadian system of ADHD and control children during development. (Author correspondence: sumova@biomed.cas.cz)     

How do children with and without ADHD talk about frustration?: Use of a novel emotion narrative recall task

Children with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotional reactivity and regulation. The current study examines differences in the emotional reactivity and regulation of children with and without ADHD in the context of their real-life experiences of negative emotion using a novel ecologically valid methodology. Eighty-three 8–12-year-old children (46 ADHD, 38 non-ADHD) participated in the study. Children completed the negative emotion narrative recall task, a novel task whereby children provided a narrative recall of a real-life event where they experienced negative emotion. ANCOVA indicated children with ADHD recalled significantly more overall frustration and intense frustration than children without ADHD. Children with ADHD exhibiting more negative emotional reactivity while recalling negative emotions than children without ADHD. The current study suggests that children with ADHD are uniquely impacted by negative emotional experiences and represents an important step in understanding the emotional reactivity and regulation of children with ADHD.     

Effect of EEG Biofeedback on Cognitive Flexibility in Children with Attention Deficit Hyperactivity Disorder With and Without Epilepsy

Attention deficit hyperactivity disorder (ADHD) is one of the most common developmental disorders in school-aged children. Symptoms consistent with ADHD have been observed in 8–77 % of children with epilepsy. Researchers have been motivated to search for alternative forms of treatment because 30 % of patients with ADHD cannot be treated by psychostimulants. Several studies support the use of a multimodal treatment approach that includes neurofeedback (NF) for the long-term management of ADHD. These studies have shown that NF provides a sustained effect, even without concurrent treatment with stimulants. We aimed to assess cognitive flexibility in ADHD children with and without temporal lobe epilepsy (TLE), and to evaluate the effects of NF on cognitive flexibility in these groups of children. We prospectively evaluated 69 patients with ADHD aged 9–12 years. The control group was 26 ADHD children without TLE who received no treatment. The first experimental group comprised 18 children with ADHD. The second experimental group comprised 25 age-matched ADHD children with TLE. This group was further divided in two subgroups. One subgroup comprised those with mesial temporal lobe epilepsy (16 patients, 9 with hippocampal sclerosis and 7 with hippocampal atrophy), and the other with lateral temporal lobe epilepsy (9 patients, 5 with temporal lobe dysplasia, 3 with temporal lobe cysts, and 1 with a temporal lobe cavernoma). We treated their ADHD by conducting 30 sessions of EEG NF. Reaction time and error rates on the Trail Making Test Part B were compared before and after treatment, and significant differences were found for all groups of patients except those who had mesial temporal lobe epilepsy with hippocampal atrophy. Our results demonstrate that in most cases, NF can be considered an alternative treatment option for ADHD children even if they have TLE. Additional studies are needed to confirm our results.     

Characteristics of attention in children with attention deficit hyperactivity disorder (an analytical review)

The information concerning specific features of different attention components (alertness, sustention and selectivity) in children with attention deficit hyperactivity disorder (ADHD) is analyzed and systematized. According to the data reviewed, behavioral and attention problems described as ADHD are not homogeneous. Literature analysis of attention characteristics in children with ADHD shows that different components can be disrupted if ADHD is diagnosed as inattentive or combined subtype, but the main deficit in this case is that of selective voluntary attention. In case of hyperactivity/impulsivity subtype of ADHD, attention is impaired mainly in its brain activation components.