ArticleLiterature Review

Comorbidity in ADHD: Implications for research, practice, and DSM-V

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  • The Reach Institute
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Abstract

Since the introduction of DSM-III/III-R, clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research and future classification approaches. The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria. The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD aggressive subtype, and (2) ADHD, anxious subtype. Additional studies of the frequency of comorbidity and associated factors are greatly needed to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors.

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... The overlapping symptoms between ADHD and comorbid psychopathologies represent challenges for diagnosis and treatment. In children, the main disorders likely to co-occur with ADHD are Oppositional Defiant Disorder (ODD) (50%-60%), Conduct Disorder (CD) (20%-50% in children and 40%-50% in adolescents), depression (16%-26%) and anxiety (10%-40%) disorders, bipolar disorders (11%-75%), tic disorders (20%), obsessive-compulsive disorders (6%-15%), and autism spectrum disorders (65%-80%) [4][5][6][7][8][9][10]. ...
... It seems clear that prevalence rates depend on the different origins of the studied population. Cross-sectional studies, retrospective studies, and follow-up studies have shown that the lifetime probability of having at least one mental illness is up to 80% [10][11][12]. These include both the area of personality disorders and that of mood disorders [13]. ...
... These patients are particularly prone to impulsivity and personality disorders. Some authors Lynskey in 2001, Torok in 2012, Lee in 2011 consider that personality disorders and conduct disorder are confounding factors in the diagnosis of ADHD [10][11][12]. Lee carried out in 2011 a meta-analysis of 27 studies on the subject. He was surprised by the few studies taking these comorbidities into account before concluding that there was an increased risk of substance abuse or dependence in ADHD patients. ...
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Attention Deficit Hyperactivity Disorder (ADHD) accounts for approximately 5% to 10% of mental disorders in childhood and adolescence. Symptoms, or some of them, persist into adulthood. In addition to the core symptoms, other manifestations of mental disorders are often present. These comorbidities increase impairment and complicate treatment, why physicians who treat patients with ADHD need to know a wide variety of comorbid circumstances and must differentiate between symptoms and associated disease. Therefore, the knowledge attention, thoughtfulness and treatment of ADHD and all its associated diseases is crucial to ensure the best possible prognosis. However, the relation is discussed, asking for clinical manifestations of the ADHD or comorbidities of this disorder.
... The overlap between ADHD, externalizing (eg, oppositional defiant disorder or conduct disorder) and internalizing disorders (eg, anxiety disorders or mood disorders) has been reported in multiple studies. 7,[12][13][14] Furthermore, research has highlighted elevated comorbidity rate among neurodevelopmental disorders, for instance ADHD with learning disorders or autism spectrum disorder. 12,13,[15][16][17] Various hypotheses have been proposed to explain comorbidity in ADHD: (1) comorbid disorders are phenotypic variabilities of ADHD rather than representing distinct disorders, (2) each comorbidity represents a separate disorder, (3) comorbid disorders share common risk factors, (4) comorbid disorders represent distinct subtypes within ADHD, (5) ADHD is an early manifestation of the comorbid disorder, (6) ADHD increases the risk for the development of the comorbid disorder. ...
... 7,[12][13][14] Furthermore, research has highlighted elevated comorbidity rate among neurodevelopmental disorders, for instance ADHD with learning disorders or autism spectrum disorder. 12,13,[15][16][17] Various hypotheses have been proposed to explain comorbidity in ADHD: (1) comorbid disorders are phenotypic variabilities of ADHD rather than representing distinct disorders, (2) each comorbidity represents a separate disorder, (3) comorbid disorders share common risk factors, (4) comorbid disorders represent distinct subtypes within ADHD, (5) ADHD is an early manifestation of the comorbid disorder, (6) ADHD increases the risk for the development of the comorbid disorder. 12 ...
Article
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Studies have revealed high rates of neurodevelopmental and psychiatric comorbid conditions among individuals diagnosed with attention-deficit/hyperactivity disorder (ADHD). However, research on this topic in the Arab world has been limited. This study evaluates the medical, neurodevelopmental, and psychiatric comorbidities in children and adolescents diagnosed with ADHD in Dubai, United Arab Emirates (UAE). A total of 428 pediatric patients diagnosed with ADHD were included. Children and adolescents with ADHD had high rates of comorbid disorders. Twenty comorbid conditions were identified. More than 3 quarters of the study sample had at least 1 comorbid disorder. The most common comorbidity among children was autism spectrum disorder, and among adolescents was anxiety disorders. Comprehensive assessments are highly warranted to identify and manage associated comorbid conditions. Further research is needed in exploring the biopsychosocial factors contributing to the elevated rate of comorbidity in children and adolescents with ADHD.
... Regarding this causal relationship, various ideas have emerged. For example, Jensen et al. (1997) suggested that ADHD and comorbid anxiety might be considered a separate ADHD subtype [41]. On the other hand, in two other studies conducted in patients with social anxiety disorder (SAD), it was found that predominantly inattentive type of ADHD was associated with SAD [42, 43•]. ...
... Regarding this causal relationship, various ideas have emerged. For example, Jensen et al. (1997) suggested that ADHD and comorbid anxiety might be considered a separate ADHD subtype [41]. On the other hand, in two other studies conducted in patients with social anxiety disorder (SAD), it was found that predominantly inattentive type of ADHD was associated with SAD [42, 43•]. ...
Article
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Purpose of the Review In this review, we focus on overlapping features of ADHD and anxiety disorders, and will discuss how an anxiety disorder comorbidity leads to diagnostic and treatment challenges in patients with ADHD, in consideration of the accumulated available knowledge. Recent Findings The presence of overlapping symptoms, changes in the diagnostic criteria, and the use of divergent diagnostic tools and informant effects can complicate the diagnosis of this comorbidity. Due to the ongoing debate about the etiology, psychopathology, and diagnostic features of the association between ADHD and anxiety disorders, choosing appropriate treatment options emerges as a challenge. Summary A novel methodology, standardized interview tools, and new statistical analysis methods are needed to define the phenotype of this co-occurrence more clearly. It is important to uncover the developmental nature of this comorbidity with follow-up studies that may explain the etiology and underlying neurobiological basis, and ultimately lead to more effective treatment approaches.
... All eight syndrome scales were either in borderline clinical or clinical range, and their functioning was the most impaired compared to the other groups. Zenglein [30] described similar subgroups with high levels of psychopathological symptoms, which was regarded as a part of the ADHD + anxiety disorders + ODD/CD group proposed by Jensen and colleagues [35]. Emotional dysregulation, defined as deficits in the self-regulation of emotion, has been shown to be associated with comorbidity between internalizing and externalizing disorders [36]. ...
Article
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This study sought to identify subgroups of attention-deficit hyperactivity disorder (ADHD) defined by specific patterns of emotional and behavioral symptoms according to the parent-rated Child Behavior Checklist (CBCL). Our clinical sample comprised 314 children (aged 4 to 15 years) diagnosed with ADHD according to the DSM-5. In addition, comorbid psychiatric disorders, general functioning, and medication status were assessed. Cluster analysis was performed on the CBCL syndrome subscales and yielded a solution with four distinct subgroups. The “High internalizing/externalizing” group displayed an overlap between internalizing and externalizing problems in the CBCL profile. In addition, the “High internalizing/externalizing” group revealed a high rate of comorbid autism spectrum disorder and elevated autistic traits. The “Inattention and internalizing” group revealed a high rate of the predominantly inattentive presentation according to ADHD specifier from the DSM-5. The “Aggression and externalizing” group revealed a high rate of comorbid oppositional defiant disorder and conduct disorder. The “Less psychopathology” group scored low on all syndrome scales. Children with ADHD were subdivided into four distinct subgroups characterized by psychopathological patterns, with and without internalizing and externalizing problems. The overlap between internalizing and externalizing problems may be mediated with emotional dysregulation and associated neurobiological bases.
... A review of epidemiological studies in the Arab region indicated that 15.6% children and adolescents with ADHD also have an anxiety disorder (Farah et al., 2009), however, this figure is likely to be an underestimate given that Arab countries produce only 1% of the worldwide output of peer-reviewed publications in mental health research (Maalouf et al., 2019). It has been suggested that this unique group of children with ADHD and comorbid anxiety disorder may have a different clinical presentation, life course, and response to treatment (Jensen et al., 1997). ...
Article
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Abstract Background Anxiety disorders are among the most common comorbid mental disorders in children and adolescents with attention-deficit hyperactivity disorder (ADHD). While the role of atomoxetine, a non-stimulant medication, is well-established in the management of ADHD symptoms since two decades, there is a dearth of evidence regarding its efficacy in the management of anxiety disorders in children and adolescents with ADHD. Aims We aimed to provide insights into (1) the comparative efficacy of atomoxetine in children and adolescents with comorbid ADHD and anxiety disorders, (2) change in severity of anxiety symptoms based on patients’, parents’, and clinicians’ ratings, (3) tolerability and side effects. Methods We searched PubMed, EMBASE, and PsycINFO for clinical trials that addressed the efficacy of atomoxetine for anxiety symptoms in children and adolescents with ADHD. All published literature was systematically reviewed. Results We included four studies, out of which two specifically addressed comorbid ADHD and anxiety disorder. The studies suggested that atomoxetine did not exacerbate and in fact reduced anxiety symptoms in young patients with comorbid ADHD. Conclusions and implications Overall, atomoxetine demonstrates good efficacy in improving anxiety symptoms in children and adolescents with ADHD. Further studies are needed to shed light on atomoxetine’s efficacy for anxiety subtypes in ADHD.
... Further to this, best evidence suggests ADHD is a heterogeneous condition, known to be highly co-morbid with a range of other conditions (Jarrett and Ollendick 2008;Jensen et al. 2001;Jensen et al. 1997;Nigg 2006). For instance, as many as 81% of people diagnosed with ADHD will also meet criteria for a substance abuse, anxiety, depressive disorder or other mental health concern (McGough et al. 2005). ...
Article
Full-text available
Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, characterized by symptoms of inattention, hyperactivity and or impulsivity. First line treatment is medication; however, medication alone may not provide sufficient functional improvement for some patients, or be universally tolerated. A recent surge in research to treat ADHD using non-pharmacological interventions demands a comprehensive, systematic review of the literature. The aim of this review was to examine the evidence base for psychological treatments for ADHD management in adulthood. A systematic search of PsycINFO, MEDLINE, CINAHL, AMED, PubMed, and EMBASE was undertaken until January 2019 for peer-reviewed articles exploring psychological interventions for adults (18 years with no upper limit) diagnosed with ADHD. A total of 53 papers were identified for inclusion. Collectively, 92% of studies (employing various non-pharmacological interventions) found a variant of significant positive effect on either primary or secondary outcomes associated with ADHD. The strongest empirical support derived from Cognitive Behavioral Therapy interventions. In addition, findings indicated support for the effectiveness of Mindfulness, Dialectical Behavior Therapy and Neurofeedback. Other types of interventions also demonstrated effectiveness; however, support was limited due to lack of available research and methodological rigor. Psychological interventions should be considered a valid and useful addition to clinical practice. Implications and areas for future research are discussed.
... In the case of ADHD, this is unfortunately quite a common situation, affecting approximately one in every two cases (Guidetti & Galli, 2006). The disorders most commonly associated with ADHD are of a behavioural type (Jensen, Martin, & Cantwell, 1997), such as oppositional defiant disorder or conduct disorder. Comorbidity with a learning disability (LD) is also a very frequent finding (DuPaul, Gormley, & Laracy, 2013). ...
... While this may indicate in part a shared neural basis, the phenotypic differences between these behaviours also suggest the presence of a distinguishing cognitive domain, which we did not capture in our tasks. Nevertheless, the shared neural signatures between ODD/CD and ADHD symptoms indicate a shared neural basis underlying the high comorbidity between ODD/CD and ADHD 41,42 , supporting the idea of unifying ADHD and ODD/CD into a single spectrum disorder 43 . ...
Article
Full-text available
Reinforcement-related cognitive processes, such as reward processing, inhibitory control and social–emotional regulation are critical components of externalising and internalising behaviours. It is unclear to what extent the deficit in each of these processes contributes to individual behavioural symptoms, how their neural substrates give rise to distinct behavioural outcomes and whether neural activation profiles across different reinforcement-related processes might differentiate individual behaviours. We created a statistical framework that enabled us to directly compare functional brain activation during reward anticipation, motor inhibition and viewing emotional faces in the European IMAGEN cohort of 2,000 14-year-old adolescents. We observe significant correlations and modulation of reward anticipation and motor inhibition networks in hyperactivity, impulsivity, inattentive behaviour and conduct symptoms, and we describe neural signatures across cognitive tasks that differentiate these behaviours. We thus characterise shared and distinct functional brain activation patterns underling different externalising symptoms and identify neural stratification markers, while accounting for clinically observed comorbidity. On the basis of the IMAGEN database of 2,000 Caucasian adolescents, Jia et al identify neural patterns of activity during reward anticipation and motor inhibition associated with different externalising symptoms for ADHD and conduct problems.
... De flesta psykiska störningar hos barn såsom depression, ångest, bipolaritet och beteendestörningar förekommer allmänt tillsammans med ADHD. Dessa störningars enskilda samband med inlärningssvårigheter utan effekten av komorbid ADHD är därför svåra att forska i. Eftersom ADHD är så brett sammankopplat med såväl störningar i den neurobiologiska utvecklingen som psykiatriska diagnoser hos barn och unga, bör detta alltid tas i beaktande i differentialdiagnostiken när man utvärderar ett barn med neurologiska och/eller psykiska symtom (20). ...
Article
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Inlärningssvårigheter förekommer hos upp till 5–10 procent av barn och unga och är mer än dubbelt så vanliga bland pojkar. Barn med inlärningssvårigheter uppvisar tecken på psykisk ohälsa oftare än andra barn. Särskilt allmänt förekommer inlärningsproblem tillsammans med någon eller flera neuropsykiatriska diagnoser, såsom ADHD, autismspektret och Tourettes syndrom. Depression och ångest är bara något vanligare hos barn med inlärningssvårigheter, men en ökning av dessa internaliserade störningar kan ses i tonåren hos ungdomar med inlärningssvårigheter, speciellt hos flickor. Beteendestörningar och bipolaritet utan samtidigt förekommande ADHD-diagnos är inte tydligt kopplade till inlärningsproblem. Hos barn med psykotiska symtom är kognitiva brister däremot allmänt förekommande, särskilt hos barn som senare i livet utvecklar schizofreni. Mångprofessionalism i primärvården samt samarbete mellan barnneurologi och barnpsykiatri är viktiga aspekter för att trygga vård och rehabilitering av god kvalitet för barn och unga med fördröjd inlärning och psykiska symtom.
... The finding that children with low writing or math achievement more often have conduct problems can be fully explained by co-occurring ADHD symptoms. This is in line with previous studies (e.g., Willcutt et al., 2013) and with the fact that conduct problems are the most common comorbidity in children with ADHD (Harvey, Breaux, & Lugo-Candelas, 2016;Jensen, Martin, & Cantwell, 1997;Thapar & van Goozen, 2018). Unexpectedly, conduct problems increase with increasing reading achievement when ADHD symptoms are taken into account. ...
... disorder (ODD) (50-60%), conduct disorder (CD) (20-50% in children and 40-50% in adolescents), depression (16-26%) and anxiety (10-40%) disorders, bipolar disorders (11-75%), tic disorders (20%), obsessive-compulsive disorders (6-15%), and autism spectrum disorders (65-80%) (Biederman and Faraone, 2005;Gillberg et al., 2004;Jensen et al., 2001Jensen et al., , 1997aKadesjö and Gillberg, 1999;Reale et al., 2017;TJ et al., 2007). ...
... The finding that children with low writing or math achievement more often have conduct problems can be fully explained by co-occurring ADHD symptoms. This is in line with previous studies (e.g., Willcutt et al., 2013) and with the fact that conduct problems are the most common comorbidity in children with ADHD (Harvey, Breaux, & Lugo-Candelas, 2016;Jensen, Martin, & Cantwell, 1997;Thapar & van Goozen, 2018). Unexpectedly, conduct problems increase with increasing reading achievement when ADHD symptoms are taken into account. ...
Article
Developmental Coordination Disorder (DCD) and Attention Deficit Hyperactivity Disorder (ADHD) often co-occur and are associated with specific learning difficulties. Robust prevalence estimations do not yet exist. We studied how symptoms of DCD and/or ADHD are related to difficulties in reading, writing, and mathematics. Using the data from a large online study with a sample of 3,170 3rd and 4th grade children in Germany, including parent-reported DCD- and ADHD symptoms, we followed two approaches. In the categorical approach, we divided the children into groups with and without DCD and/or ADHD on the basis of cut-offs. The results showed that children without DCD/ADHD have fewer difficulties in all learning domains. Children with only DCD showed less learning difficulties than children with ADHD and the comorbid group. In the continuous approach, we performed a latent profile analysis on the basis of symptoms of fine and gross motor problems, inattention, hyperactivity, impulsivity, and intelligence. This yielded four disability profiles of children with (1) no DCD- or ADHD-symptoms, (2) clinical ADHD-scores and above-average DCD, (3) above-average DCD and inattention, and (4) above-average ADHD. Profiles 2 and 3 appeared related to the lowest learning achievement. Theoretical implications are discussed.
... ADHD has a different clinical profile across the lifespan, for instance children are more likely to present symptoms of hyperactivity (Franke et al., 2018). About 60% of children and 80% of adults with ADHD have some comorbidity (Gillberg et al., 2004;Jensen et al., 1997;Sobanski, 2006), and the comorbidity profile also differs with age. We also observed this here, between our two cohorts of different age-ranges. ...
Article
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Attention-Deficit/Hyperactivity Disorder (ADHD) has been associated with altered brain anatomy in neuroimaging studies. However, small and heterogeneous study samples, and the use of region-of-interest and tissue-specific analyses have limited the consistency and replicability of these effects. We used a data-driven multivariate approach to investigate neuroanatomical features associated with ADHD in two independent cohorts: the Dutch NeuroIMAGE cohort (n=890, 17.2 years) and the Brazilian IMpACT cohort (n=180, 44.2 years). Using independent component analysis of whole-brain morphometry images, 375 neuroanatomical components were assessed for association with ADHD. In both discovery (corrected-p=0.0085) and replication (p=0.032) cohorts, ADHD was associated with reduced volume in frontal lobes, striatum, and their interconnecting white-matter. Current results provide further evidence for the role of the fronto-striatal circuit in ADHD in children, and for the first time show its relevance to ADHD in adults. The fact that the cohorts are from different continents and comprise different age ranges highlights the robustness of the findings.
... Left untreated ADHD may cause significant psychosocial, academic, and long-term negative consequences (2,3). In addition to the impairment directly related to ADHD symptoms, a majority of subjects with ADHD have comorbid psychiatric disorders that warrant clinical attention (4)(5)(6)(7). Comorbidity in ADHD is an important issue with multiple dimensions in terms of clinical practice and research (5,7). It has been reported that there may be significant differences in terms of sociodemographic and clinical characteristics, family history, choice of optimal ADHD treatment, response to treatment and long-term outcome in subjects with and without comorbidity (5,8,9). ...
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Objective: This study aimed to investigate psychiatric comorbidity and sleep problems and their relationships with ADHD presentation, age and gender in a clinical sample of children and adolescents with ADHD. Material and Method: One hundred fifty-four subjects aged 6-17 were included in the study. A semi-structured diagnostic interview was conducted to screen psychiatric disorders. The Child Depression Inventory (CDI), Screen for Child Anxiety Related Emotional Disorders (SCARED) and Children’s Sleep Habits Questionnaire (CSHQ) were used to investigate internalizing difficulties and sleep problems. Results: Overall high rates of comorbid disorders (78%) and sleep problems (97%) were found. ADHD-C was significantly more frequent in males and ADHD-I was more frequent in females (p<0.001). While oppositional defiant disorder (ODD), enuresis and encopresis were more frequent in subjects with ADHD-C (p<0.05), generalized anxiety (GAD) and social anxiety (SAD) disorders were more frequent in subjects with ADHD-I (p<0.05). Females, compared to males, had more frequent diagnoses of depression (p=0.021) and SAD (p=0.03). The majority of subjects (96.7%) scored above the cut off score of 41 in CSHQ (50.51±5.86). The ADHD-C group had significantly higher CSHQ total scores than the ADHD-I group (p<0.05). There was a significant positive correlation between CSHQ total scores and the number of lifetime comorbid diagnoses (p=0.006), self-reported anxiety (p=0.009) and depressive (p=0.004) symptoms. Conclusion: Comorbidity and sleep problems may be common in young people with ADHD and may have complex reciprocal relations with several factors including ADHD presentation, age, and gender. Keywords: ADHD, BMI, children, comorbidity, sleep
... Human Brain, spinal Cord and nervous system under one head is known as Central nervous system. Attention Deficit Hyperactivity Disorder [1] is a complex neuro disorder. A person suffering from ADHD has a relatively slow and different brain development process as compared to normal person. ...
Article
Attention deficit hyperactivity disorder is a mental disorder and after a survey it can be concluded that 5% children and 3% adults are affected by this condition. It can cause learning disability in children which is not tolerable in this learning phase of life. Deep analysis is required of this disease because it is one of the hardest diseases to be diagnosed. The subtle symptoms of this disease are misunderstood most of the time. Most of the children are not properly diagnosed and always get remark by teacher that your child is not performing in class, he is not giving his best effort. Mental disorder is illness which deteriorate the whole life of a person when neglected. ADHD is the most severe and neglected mental disease found in children and in adults. We as a society found it very difficult and shameful to adopt the truth that he or she may be suffering from mental illness that is the main reason this kind of disease never get diagnosed and create difficulties for humans in future. In fact diagnosis of this kind of disease is very difficult to identify due to its very subtle symptoms. Experiment results illustrate the technical aid using the FMRI scans of the brain and unsupervised learning with a decent percentage of prediction accuracy. © 2020, World Academy of Research in Science and Engineering. All rights reserved.
... Вре мя Ин тен сив нос ть Цель Бе седa с ре бен ком 30 ми нут 1 рaз Пост рое ние до ве ри тель ных от но ше ний с ре бен ком с приме не нием aрт терaпевти чес ких ме то дов Тре нинг «Я учусь влaдеть со бой» 35 ми нут 1 рaз По мочь ре бен ку при нять се бя тaким, кaкой он есть, и нaучить его эле ментaм сaмо ко нт ро ля Бе седa с клaсс ным ру ково ди те лем и ре бен ком 20-30 ми нут 1 рaз Познaко мить учи те ля и ре бенкa с «Про фи лем сaмо ко нт роля», a тaкже под писa ние «Ин ди ви дуaльно го до го ворa» Ре ко мендaции ро ди те лям 20 ми нут 1 рaз Знaкомс тво с «Про фи лем сaмо ко нт ро ля», ин фор ми ровaние о тон кос тях вос питa ния ги перaктив но го ре бенкa Ин ди ви дуaльные консультaции 20 ми нут 1 рaз в не де лю Рaзви тие мы шеч но го конт ро ля, сни же ние им пуль сивности у ги перaктив но го ре бенкa Тех ни ки и приемы рaбо ты с деть ми с СДВГ Анaлиз инострaнной ли терaту ры поз во лил нaм сис темaти зи ровaть тех ни ки и приемы рaботы с ги перaктив ны ми деть ми млaдше го школьно го возрaстa (ри су нок 1). Нa ос но ве aнaлизa инострaнной ли терaту ры Bend-er, 2005;Burt, 2007;DuPaul, 2007;Jensen, 2010) былa сис темaти зи ровaнa тех никa рaбо ты с гиперaктив ны ми деть ми млaдше го школь но го возрaстa. ...
... ADHD is a neurobiological disorder that is characterized by symptoms of inattention and of hyperactivity/impulsivity, which may manifest in children and in adults. In children, positive associations have been found between broadly defined quantitative measures of aggression and ADHD and attention problems (Biederman et al. 1991;Jensen et al. 1997;Connor et al. 2010; Bartels et al. 2018, see: https ://www.actio n-eupro ject.eu/ ...
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We present a procedure to simultaneously fit a genetic covariance structure model and a regression model to multivariate data from mono- and dizygotic twin pairs to test for the prediction of a dependent trait by multiple correlated predictors. We applied the model to aggressive behavior as an outcome trait and investigated the prediction of aggression from inattention (InA) and hyperactivity (HA) in two age groups. Predictions were examined in twins with an average age of 10 years (11,345 pairs), and in adult twins with an average age of 30 years (7433 pairs). All phenotypes were assessed by the same, but age-appropriate, instruments in children and adults. Because of the different genetic architecture of aggression, InA and HA, a model was fitted to these data that specified additive and non-additive genetic factors (A and D) plus common and unique environmental (C and E) influences. Given appropriate identifying constraints, this ADCE model is identified in trivariate data. We obtained different results for the prediction of aggression in children, where HA was the more important predictor, and in adults, where InA was the more important predictor. In children, about 36% of the total aggression variance was explained by the genetic and environmental components of HA and InA. Most of this was explained by the genetic components of HA and InA, i.e., 29.7%, with 22.6% due to the genetic component of HA. In adults, about 21% of the aggression variance was explained. Most was this was again explained by the genetic components of InA and HA (16.2%), with 8.6% due to the genetic component of InA.
... In anderen klinischen Studien waren ca. drei Viertel der Kinder von Komorbiditäten betroffen (Jensen, Martin, and Cantwell 1997 (Biederman et al. 1993;Jacob et al. 2007;Jacob et al. 2014 (Biederman et al. 1993;Murphy and Barkley 1996;Barkley et al. 2006;Rösler et al. 2004;Rösler, Retz, et al. 2009). ...
Thesis
Die psychosoziale Komponente spielt bei der ADHS v.a. in der Bewältigung von Erziehungsaufgaben eine erhebliche Rolle, da sowohl die Eltern als auch das Kind von der Störung betroffen sein können. Ziel der vorliegenden Studie war die Untersuchung von Beziehungen und Konfliktpotential in Familien, die von ADHS betroffen sind. Es wurde der Frage nachgegangen, ob eine störungsspezifische Therapie von Müttern mit ADHS und deren Kind, das ebenfalls an ADHS litt, bessere familienspezifische Messwerte erreicht als eine übliche Standardbehandlung. Die Behandlungsgruppe erhielt eine intensive Gruppenpsychotherapie und begleitende Pharmakotherapie mit Methylphenidat, die Kontrollgruppe wiederholte psychiatrische Beratungen, beide Gruppen erhielten zusätzlich ein Mutter-Kind-Training. Die Stichprobe bestand aus 144 Mutter-Kind Paaren mit ADHS, die im Rahmen einer Mutter-Kind Treatment Studie rekrutiert wurden. Es zeigten sich Verbesserungen in den untersuchten familienbezogenen Outcomes (soziales Leben, negative Gefühle gegenüber der Erziehung), nicht aber in allen erfassten Bereichen. Diese Verbesserungen zeigten jedoch keine signifikanten Gruppenunterschiede im Hinblick auf die beiden Studienbehandlungen zur Therapie der ADHS der Mütter (Pharmakotherapie plus Verhaltenstherapie vs. alleinige unspezifische Beratung). Bei Müttern, die ein Krankheitsverständnis für die ADHS, sowie eine Behandlungsmotivation hatten, verbesserte das Mutter-Kind-Training die Outcomes der Kinder, auch wenn die Mutter nur eine unterstützende Beratung erhielt. Die multimodale Therapie der Mütter mit Gruppenpsychotherapie und MPH-Medikation war bezüglich der Symptomreduktion der Mütter effektiv. Jedoch beeinflusste die multimodale Therapie im Vergleich zur unterstützenden psychiatrischen Beratung das externalisierende Verhalten des Kindes nach dem Elterntraining nicht zusätzlich. Deshalb scheint es vielversprechend, Müttern mit ADHS, welche nicht die Möglichkeit einer Medikation oder spezifischen Psychotherapie haben, auch zukünftig Elterntraining anzubieten.
... ‫الخاصة‬ ‫التربية‬ ‫برامج‬ ‫مكتب‬ ‫األمريكية،‬ ‫التعليم‬ ‫وزارة‬ (Anderson, Williams, McGee, & Silva, 1987;Cantwell & Baker, 1991;Dykman, Akerman, & Raney, 1994;Zentall, 1993 (Barkley, 1990;Jensen, Hinshaw, Kraemer, et al., 2001;Jensen, Martin, & Cantwell, 1997 (NIMH, 1999;Swanson, 1992;Waslick & Greenhill, 1997 , 1994;Anderson, et al., 1987;Bird, et al., 1988;Esser, Schmidt, & Woemer, 1990;Pastor & Reuben, 2002;Pelham, Gnagy, Greenslade, & Milich, 1992;Shaffer, et al., 1996;Wolraich, Hannah, Pinock, Baumgaertel, & Brown, 1996 (Barkley, 1998a;Neuwirth, 1994;NIMH, 1999 Abramowitz, et al., 1992;Carlson, et al., 1992;Pelham & Hoza, 1996 (Jadad, Boyle, & Cunningham, 1999;Pelham, et al., 1998 (Hinshaw, et al., 2000) . (Blazer, 1999;Bos, 1999;Bos, Nahmias, & Urban, 1999;Nahmias, 1995;Williams & Carteledge, 1997 ...
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26 ‫سبتمبر‬ 2021 ‫م‬ ‫مقدمة:‬ ‫اآلباء‬ ‫يشاهد‬ ‫البقالة،‬ ‫محل‬ ‫في‬ ‫ذلك‬ ‫كان‬ ‫ربما‬ ‫آخر.‬ ‫أو‬ ‫وقت‬ ‫في‬ ‫التجارب‬ ‫هذه‬ ‫من‬ ‫بواحدة‬ ‫ا‬ ً ‫جميع‬ ‫مررنا‬ ‫لقد‬ ‫"وضع‬ ‫منهم‬ ‫ويطلبون‬ ‫ا‬ ً ‫وتكرار‬ ‫ا‬ ً ‫مرار‬ ‫أطفالهم‬ ‫أسماء‬ ‫ينادون‬ ‫وهم‬ ‫المحبطين‬ ‫أو‬ ‫هذا‬ ‫اذ‬ ‫كان‬ ‫ربما‬ ." ً ‫جانبا‬ ‫ك‬ ‫هناك‬ ً ‫دائم‬ ‫وكان‬ ‫ًا‬ ‫ساكن‬ ‫يجلس‬ ‫أنه‬ ‫يبدو‬ ‫ال‬ ‫طفل‬ ‫مع‬ ‫المدرسة‬ ‫في‬ ‫ا‬ ً ‫موقف‬ ‫ا‬ ً ‫دائم‬ ‫يبدو‬ ً ‫طفًل‬ ‫الحظنا‬ ‫ربما‬ ‫حركة.‬ ‫حالة‬ ‫في‬ ‫ا‬ ‫الفصل‬ ‫في‬ ‫يحلم‬ ‫وكأنه‬-‫من‬ ‫بالملل‬ ‫الطفل‬ ‫يشعر‬ ‫ربما‬ ‫إلنهائه.‬ ‫كافية‬ ‫لفترة‬ ‫نشاط‬ ‫على‬ ‫يركز‬ ‫لن‬ ‫الذي‬ ‫الطالب‬ ‫أن‬ ‫بمجرد‬ ‫يبدو‬ ‫ما‬ ‫على‬ ‫ما،‬ ‫مهمة‬ ‫ي‬ ‫السلوكيات‬ ‫هذه‬ ‫بشأن‬ ‫حيرة‬ ‫في‬ ‫ا‬ ً ‫جميع‬ ‫نحن‬ ‫آخر.‬ ‫شيء‬ ‫إلى‬ ‫االنتقال‬ ‫ويريد‬ ‫بدأ،‬ ‫الصعبة‬. ‫ال‬ ‫االنتباه‬ ‫ونقص‬ ‫الحركة‬ ‫فرط‬ ‫ضطراب‬ (ADHD) ‫الموضوعات‬ ‫أكثر‬ ‫أحد‬ ‫يزال‬ ‫وال‬ ‫الوجوه‬ ‫من‬ ‫العديد‬ ‫و‬ ‫عنها‬ ‫الحديث‬ ‫يتم‬ ‫التي‬ ‫ثت‬ ‫ي‬ ‫التعليم‬ ‫مجال‬ ‫في‬ ‫الجدل‬ ‫ر‬ ‫؛‬ ‫فاألمور‬ ‫األدوية‬ ‫حول‬ ‫الساخنة‬ ‫المناقشات‬ ‫ميزان‬ ‫في‬ ‫معلقة‬ ‫العًلج‬ ‫وخيارات‬ ‫التشخيص‬ ‫وطرق‬ ‫ا‬ ‫عل‬ ‫يجب‬ ‫الذين‬ ‫والبالغون‬ ‫والمراهقون‬ ‫ألطفال‬ ‫حياة‬ ‫والعيش‬ ‫الحالة‬ ‫إدارة‬ ‫يهم‬ ‫يومي‬ ‫أساس‬ ‫على‬ ‫منتجة‬ .
... Attention-deficit/hyperactivity disorder (ADHD) and anxiety disorders are two of the most common and impairing childhood psychological disorders, impacting nearly 10% and 20% of children, respectively (Danielson et al., 2018;Krain et al., 2007). Co-occurrence of ADHD and anxiety symptoms is high; 25 -50% of children with ADHD have a co-occurring anxiety disorder (D'Agati et al., 2019;Jensen et al., 1997). Despite high rates of co-occurrence, little is known about risk and protective factors of co-occurring ADHD and anxiety symptoms. ...
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Symptoms of ADHD and anxiety often co-occur, yet we are limited in our understanding of which children with ADHD symptoms are more likely to develop anxiety symptoms in adolescence. This longitudinal study examined the role of behavioral inhibition (BI) and peer relationships (i.e., peer support and peer victimization) in relation to childhood ADHD and adolescent anxiety symptoms in a community sample, which was oversampled for reactivity. Data were drawn from a larger longitudinal study (N = 291) examining trajectories of BI. For the current analyses, we used behavioral observations of BI at ages 2 and 3, parent report of their child’s ADHD symptoms at age 7, child report of peer support and peer victimization at age 12, and adolescent report of anxiety symptoms at age 15. Using structural equation modeling, results indicated that BI and peer support moderated the relation between ADHD and anxiety symptoms, such that ADHD symptoms predicted later anxiety symptoms only for youth who displayed low BI in toddlerhood and reported experiencing lower levels of peer support in early adolescence. Findings highlight the role of early temperament and peer relationships on the relation between childhood ADHD and adolescent anxiety symptoms, and underscore the importance of evaluating multiple risk factors when examining the development of psychopathology.
... The observed heterogeneity in symptom profiles within disorders (12)(13)(14)(15)(16)(17)(18)(19) has also led to various new definitions of disorder subtypes (20,21). Secondly, there are many possible ways that patients can be comorbid across DSM-5 disorders (22), with studies showing that individuals commonly meet the criteria for multiple disorders (23)(24)(25)(26)(27)(28)(29)(30)(31) and that evolution of disorders across a lifetime is a pervasive phenomenon (28,(32)(33)(34). This misalignment is further exacerbated by an array of mental health assessment tools that are heterogeneous and overlapping, creating a system of diagnosis and evaluation that is poorly standardized and introducing further ambiguity (35,36). ...
Article
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Assessment of mental illness typically relies on a disorder classification system that is considered to be at odds with the vast disorder comorbidity and symptom heterogeneity that exists within and across patients. Patients with the same disorder diagnosis exhibit diverse symptom profiles and comorbidities creating numerous clinical and research challenges. Here we provide a quantitative analysis of the symptom heterogeneity and disorder comorbidity across a sample of 107,349 adult individuals (aged 18–85 years) from 8 English-speaking countries. Data were acquired using the Mental Health Quotient, an anonymous, online, self-report tool that comprehensively evaluates symptom profiles across 10 common mental health disorders. Dissimilarity of symptom profiles within and between disorders was then computed. We found a continuum of symptom prevalence rather than a clear separation of normal and disordered. While 58.7% of those with 5 or more clinically significant symptoms did not map to the diagnostic criteria of any of the 10 DSM-5 disorders studied, those with symptom profiles that mapped to at least one disorder had, on average, 20 clinically significant symptoms. Within this group, the heterogeneity of symptom profiles was almost as high within a disorder label as between 2 disorder labels and not separable from randomly selected groups of individuals with at least one of any of the 10 disorders. Overall, these results quantify the scale of misalignment between clinical symptom profiles and DSM-5 disorder labels and demonstrate that DSM-5 disorder criteria do not separate individuals from random when the complete mental health symptom profile of an individual is considered. Greater emphasis on empirical, disorder agnostic approaches to symptom profiling would help overcome existing challenges with heterogeneity and comorbidity, aiding clinical and research outcomes.
... We considered a linear model of conduct disorder (CD) as a function of attention deficit hyperactivity disorder (ADHD), depression (DEP), their product-term (ADHD × DEP), controlled for by anxiety (ANX) and oppositional defiant disorder (ODD). Previous work has shown comorbidity among these variables (Angold, Costello, & Erkanli, 1999;Jensen, Martin, & Cantwell, 1997). Measures were taken using summary scores of the child behavior checklist (CBCL; Achenbach & Rescorla, 2001). ...
Preprint
We study an EM algorithm for estimating product-term regression models with missing data. The study of such problems in the likelihood tradition has thus far been restricted to an EM algorithm method using full numerical integration. However, under most missing data patterns, we show that this problem can be solved analytically, and numerical approximations are only needed under specific conditions. Thus we propose a hybrid EM algorithm, which uses analytic solutions when available and approximate solutions only when needed. The theoretical framework of our algorithm is described herein, along with two numerical experiments using both simulated and real data. We show that our algorithm confers higher accuracy to the estimation process, relative to the existing full numerical integration method. We conclude with a discussion of applications, extensions, and topics of further research.
... It also negatively affects carers' mental health and family wellbeing [6]. Up to 90% of children with an ADHD diagnosis also display a broader pattern of behaviour problems (e.g., oppositional, disruptive, defiant and challenging behaviours) and often meet the criteria for oppositional defiant disorder (ODD) [7]. This exacerbates the levels of impairment experienced by children with ADHD [8] and presents a major challenge to parents, increasing levels of parenting stress [9] and mental health problems [10]. ...
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Full-text available
Background: n the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waitlist. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children’s health services to implement a remote strategy for recruitment, screening, and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here we present the protocol for Phase 1 of OPTIMA – a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT).
... In children, the main disorders likely to co-occur with ADHD are oppositional defiant disorder (ODD) (50-60%), conduct disorder (CD) (20-50% in children and 40-50% in adolescents), depression (16-26%) and anxiety (10-40%) disorders, bipolar disorders (11-75%), tic disorders (20%), obsessive-compulsive disorders (6-15%), and autism spectrum disorders (65-80%) (Biederman and Faraone, 2005;Gillberg et al., 2004;Jensen et al., 2001Jensen et al., , 1997aKadesjö and Gillberg, 1999;Reale et al., 2017;TJ et al., 2007). ...
Article
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Attention deficit/hyperactivity disorder (ADHD) and anxiety disorders are among the most common psychiatric disorders with a 25% comorbidity rate with each other. ADHD: 650 (34%) had only ADHD, while 1269 (66%) had at least one comorbid psychiatric disorder (learning disorders, 56%; sleep disorders, 23%; oppositional defiant disorder, 20%; anxiety disorders, 12%). Patients with ADHD of combined type and with severe impairment (CGI-S ≥5) were more likely to present comorbidity. But currently the relation is discussed, asking for clinical manifestations of the ADHD or comorbidities of this disorder.
... There is evidence that individuals with an attention-deficit disorder have a markedly increased probability of having one or more additional psychiatric disorders (Biederman, Newcorn, & Sprich, 1991;Jensen, Martin, & Cantwell, 1997). "These comorbid problems contribute further to the significant amount of stress teachers experience when working with ADHD children" (DuPaul & Stoner, 2003, p. 6). ...
Research
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Attention Deficit Hyperactivity Disorder affects about eight to ten percent of the South African population. Teachers are often the first to see hyperactivity and inattentiveness in school. However, teachers are ill trained to recognise ADHD symptoms and how to provide support, and many have misconceptions about the disorder. This study explored mainstream Foundation Phase teachers’ misconceptions, views and classroom implementation strateiges of ADHD. Using a generic qualitative research design, twelve teachers completed an online questionnaire and participated in semi-structured interviews. Thematic content analysis identifed themes. It was found that most teachers had a sound knowledge of ADHD; however, they were ill-informed of all the criteria used in diagnosing or identifying a child with ADHD. The teachers preferred medication as a method of intervention despite their knowing there were other factors which influenced a child’s behaviour. Teachers had misconceptions that all forms of poor behaviour indicate a diagnosis of ADHD, rather than only severe and persistent hyperactivity and inattention. Educational psychologists also need to be mindful of a child that has been referred by a teacher for an assessment because they suspect ADHD, as the teacher might over-emphasise the severity of the child's symptoms. Educational psychologists should conduct workshops and seminars for teachers to dispel their misconceptions of ADHD.
... 12 Indeed, 25-50% of children and 47-53% of adults with ADHD have a comorbid anxiety disorder. [13][14][15] Concerningly, the comorbidity of ADHD and anxiety symptoms has been associated with worse outcomes compared to those with ADHD alone (e.g., more impairment in social skills, more difficulties in navigating peer relationships), and greater treatment costs than ADHD alone. [16][17][18] Thus, identifying factors that could impact the effects of ADHD on anxiety symptoms and vice versa are critical. ...
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Objective: The purpose of this study was to delineate the moderating roles of negative experiences related to the coronavirus disease 2019 (COVID-19) on the association between Attention-Deficit/Hyperactivity Disorder symptoms and anxiety symptoms and internalizing behaviors during Fall 2020.Method: Participants were 200 college students. Using a moderated moderation model, researchers found that attention-deficit/hyperactivity disorder symptoms predicted anxiety symptoms for those who internalized behaviors and experienced COVID-19 more negatively.Results: Results suggested that ADHD symptoms were playing a role in the manifestation of anxiety symptoms during the COVID-19 pandemic and that college students who internalize behaviors experienced worsened ADHD symptoms.Conclusion: Clinical implications underscore the importance of providing mental health resources for students on campus, particularly during the COVID-19 pandemic. Specialized treatment may include help with developing time management skills and teaching interventions such as mindfulness exercises that may help alleviate anxiety and improve attention and concentration.
... ADHD is characterised by symptoms in the domains of inattention and/or hyperactivity-impulsivity and resulting impairment of functioning (American Psychiatric Association, 2013) and is heterogeneous in aetiology, developmental trajectory, and clinical profile (Luo et al., 2019). In 60-80% of cases, ADHD presents with comorbid psychiatric disorders such as oppositional defiant and conduct disorders, autism spectrum disorder, depression, bipolar disorder, borderline personality disorder, anxiety disorders, as well as substance use disorders, sleep disorders, and learning disabilities (Jensen et al., 1997;Ohnishi et al., 2019;Kooij et al., 2012;Katzman et al., 2017;Biederman et al., 1993). ...
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Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder and is associated with structural grey matter differences in the brain. We investigated the genetic background of some of these brain differences in a sample of 899 adults and adolescents consisting of individuals with ADHD and healthy controls. Previous work in an overlapping sample identified three ADHD-related grey matter brain networks located in areas of the superior, middle, and inferior frontal gyrus as well as the cerebellar tonsil and culmen. We associated these brain networks with protein coding genes using a statistical stability selection approach. We identified ten genes, the most promising of which were NR3C2, TRHDE, SCFD1, GNAO1, and UNC5D. These genes are expressed in brain and linked to neuropsychiatric disorders including ADHD. With our results we aid in the growing understanding of the aetiology of ADHD from genes to brain to behaviour.
Chapter
Anxiety disorders (ADs) are one of the most common psychiatric disorders, and various epidemiological studies showed that they are more prevalent than mood, substance use, and impulse control disorders in many countries. ADs determine a great psychosocial impairment, represented by a reduced educational attainment, marital problems, and lower occupational status.
Article
Background: Hyperactivity, inattention, and impulsivity of children with attention deficit hyperactivity disorder (ADHD) increase parenting stress and familial conflict. Among parent-related factors, maternal mental health has been studied in-depth, but studies on paternal factors in this context are scarce. This cross-sectional study was conducted of children with ADHD and their parents in South Korea. We investigated the relationships between ADHD symptom severity of children and the mental health of their mothers and fathers. Methods: The study included 70 children with ADHD and their 140 married heterosexual parents (70 fathers and 70 mothers). Children completed the Child Depression Inventory and State-Anxiety Inventory for children, and their parents completed the Korean ADHD rating scale-IV, Adult ADHD self-report scale, State-Anxiety Inventory, Patient Health Questionnaire-9, and Parental Stress Scale. Results: There was a significant positive correlation between children's ADHD symptoms and maternal anxiety symptom severity, whereby more severe ADHD symptoms were associated with more severe maternal anxiety symptoms. There was also a significant positive correlation between maternal anxiety symptom severity and paternal parenting stress severity, whereby more severe maternal anxiety was associated with more severe paternal parenting stress. A mediation model showed that paternal parenting stress severity was not directly related to children's ADHD symptoms, but the severity of maternal anxiety mediated this relationship. Conclusion: The present study found the importance of mental health in mothers of children with ADHD and the interrelatedness of mental health within families. Future assessments and treatment of children with ADHD should include both the children and their parents.
Chapter
Comorbid psychiatric disorders are present in the vast majority of adults with ADHD, and ADHD is frequently undiagnosed in people who are in treatment for other disorders. In fact, 50–75% of adults with ADHD suffer from at least another neurodevelopmental or psychiatric condition, and have six times the likelihood to suffer from another disorder throughout the lifespan. People with ADHD are four times more likely to suffer from a mood disorder, three times more likely to develop major depressive disorder, six times more likely to develop dysthymia, and twice as likely to develop a substance dependence. Interestingly, up to 43% of gamblers have a history of childhood ADHD.
Thesis
Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder affecting 3-5% of children. In the UK, three drugs are licensed for its treatment; methylphenidate, dexamfetamine and atomoxetine. There is a lack of evidence on the prescribing of these to UK patients; however the common belief, particularly in the media, is that these drugs are over-prescribed. In addition, ADHD was once considered a condition of childhood alone; however increasing evidence suggests that the condition persists into adulthood in a significant number of patients. Again, there is little data on the use of these medications in older adolescents and young adults. Finally, in recent times, there has been much debate and concern over the safety of these drugs due to a number of spontaneous reports of sudden death in patients taking these medications. In light of these issues, this study had the following objectives; 1) to examine the utilisation of these drugs; 2) to examine prescribing of these medications to older patients; 3) to examine the safety of these medications, in particular the issue of sudden death. This was a pharmacoepidemiological study which mainly utilised data from the General Practice Research Database (GPRD), a computerised database of anonymised patient records from approximately 5% of the UK population. The study showed that 1) prevalence of prescribing of these drugs has increased significantly over the last decade, however the prevalence of prescribing is much lower than prescribing rates reported in other countries; 2) prevalence of prescribing of these drugs decreases dramatically in older patients; 3) no increase in the rate of death or sudden death in patients taking these drugs was detected when compared to mortality rates from the general population.
Article
Background Attention deficit hyperactivity disorder (ADHD), defined by the core symptoms impulsiveness, inattention and motor hyperactivity, is one of the most common neurodevelopmental disorders beginning in early childhood.Objective This article reviews the current state of research on the epidemiology, etiology, diagnostics and therapeutic interventions for ADHD in children and adolescents.MethodsA selective literature search was carried out in PubMed with reference to the German S3 clinical guidelines on ADHD in children, adolescents and adults.Results and conclusionThe epidemiological prevalence of ADHD in children is estimated to be 5.3%. The etiology is complex and heterogeneous and a high percentage of the phenotypic variance can be explained by genetic influences. The challenge of ADHD diagnostics is to exclude differential diagnoses while simultaneously identifying common coexisting psychiatric conditions. Treatment recommendations depend on the severity of symptoms. In severe ADHD pharmacotherapy should be considered as the first line intervention. Psychostimulants (various methylphenidate and amphetamine preparations) and the non-stimulants atomoxetine and guanfacine are approved in Germany for treatment of ADHD in children and adolescents. In milder cases as well as in preschool children, psychosocial interventions (including behavioral psychotherapy) are often sufficient.
Article
Anxiety and irritability symptoms frequently co-occur in children with Attention-Deficit/Hyperactivity Disorder (ADHD). This study aims to investigate whether irritability and anxiety are uniquely associated with performance on measures of cognitive functioning in children with ADHD and whether these associations hold when accounting for confounding variables. Baseline data was used from a randomised controlled trial of cognitive behavioural therapy for anxiety in children with ADHD (N = 219, 8–13 years). Anxiety was assessed using the child- and parent-reported Spence Children’s Anxiety Scale, while irritability was assessed using the parent-reported Affective Reactivity Index. Children completed the National Institutes of Health Toolbox - Cognition Battery. Higher symptoms of anxiety were uniquely associated with performance on the Dimensional Card Change Sort Test (β = −2.75, confidence interval (CI) [−4.97, −.52], p = .02) and the List Sort Working Memory Test (β = −2.57, CI [−4.43, −.70], p = .01), while higher symptoms of irritability were negatively associated with Picture Vocabulary Test (β = −2.00, CI [−3.83, −.16], p = .03). These associations did not survive correction for multiple comparisons. There was little evidence of an association between anxiety or irritability symptoms and cognitive functioning. Frequent co-occurrence of anxiety and irritability suggests clinicians working with children with ADHD should assess co-morbid symptom profiles to inform the provision of optimum care.
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Aim: This study aims to obtain current information on the clinical features of attention deficit hyperactivity disorder cases, comorbid psychiatric disorders and psychiatric drug use. Methods: All patients between the ages of 6 and 18 years who were admitted to our outpatient clinic and diagnosed with attention deficit hyperactivity disorder were included in the study. The files of the patients were examined and their demographic characteristics, symptoms, psychiatric diagnoses and drug profiles were recorded. The pattern of the psychiatric disorders accompanied by attention deficit hyperactivity disorder cases and the differences according to age and gender were analyzed. The differences were determined in patients with psychiatric comorbidity compared to those without. Result: The mean age of the 777 patients included in the study was 11.1±2.94 and 76.6% were boys. 60.9% of attention deficit hyperactivity disorder patients had comorbid psychiatric disorders. The most common psychiatric comorbidities were specific learning disability (23.6%), oppositional defiant disorder (12.9%) and conduct disorder (12.1%). There was no difference between the genders in terms of the incidence of psychiatric comorbidities. The rate of psychiatric comorbidity was significantly higher in adolescents than in children. A psychotropic medication was used in 86.4% of the cases and psychotropic polypharmacy was present in 31.5%. The rate of polypharmacy was significantly higher in the group with psychiatric comorbidity. Conclusion: Attention deficit hyperactivity disorder is frequently accompanied by other psychiatric disorders and the psychiatric comorbidity leads to a more complicated clinical profile. Approximately one-third of attention deficit hyperactivity disorder patients have psychiatric polypharmacy and these patients should be carefully monitored. Primary care physicians who are frequently confronted with attention deficit hyperactivity disorder cases should be careful about psychiatric comorbidities. Keywords: Child psychiatry, attention deficit hyperactivity disorder, mental disorders, Family practice
Article
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Background Anxiety disorders are common comorbidities in children and adolescents with attention-deficit/hyperactivity disorder (ADHD) who are also at a high risk of bullying behavior. However, little is known about the roles of anxiety symptomatology in the relationship between ADHD and bullying behavior. Objective This cross-sectional, clinic-based study aims to investigate the associations between anxiety symptomatology and bullying involvement in youth with ADHD. Method One hundred and eighty children and adolescents with ADHD aged 10–18 years participated in the study. The Screen for Child Anxiety-Related Emotional Disorders (SCARED) was self-rated, and the participants were interviewed with the Revised Olweus Bully/Victim Questionnaire to categorize bullying involvement. Data were analyzed through percentage, nonparametric statistics, chi-squared statistics, and logistic regression analysis. Results Sixty-nine percent of youth with ADHD reported involvement in bullying, of which 33.3%, 8.9%, and 27.2% were classified as victims, bullies, and bully-victims, respectively. The means and 95% confidence intervals of the total SCARED scores showed a significant difference among bullying behavior groups. The highest SCARED scores could be noticed in the victim and bully-victim groups, with the lowest scores observed in the bully group. Youth with ADHD who had comorbid anxiety were 3.51 times more likely to be bullied than those who did not have anxiety. Conclusions A differential effect of anxiety symptomatology on bullying behavior in youth with ADHD was evident. These results highlight the utility of including anxiety in the conceptualization of bullying problems in youth with ADHD to plan successful anti-bullying interventions.
Chapter
Attention-deficit/hyperactivity disorder (ADHD) is a highly heritable and common neurodevelopmental disorder, defined by age-inappropriate levels of inattention, hyperactivity, and impulsivity interfering with the individual functioning, which typically emerges in childhood but persists over the lifespan. The clinical presentation of ADHD is very heterogeneous, as other aspects characterize its phenotype, including emotional dysregulation, mind wandering, and sleep difficulties. Moreover, ADHD symptomatology partially overlaps with that of other conditions and is very frequently associated with other psychiatric disorders. Even though the current systems of classification in psychiatry have been of value in facilitating communication between clinicians and researchers, they failed in establishing the validity of their diagnostic categories beyond the clinical level. In this context, the approach proposed by the National Institute of Mental Health (NIHM) called Research Domain Criteria (R-Do-C) emerged as a useful framework, as it assumes that mental disorders are biological conditions involving brain circuits that implicate specific domains of cognition, emotion, and behavior, which cannot be constrained by the current DSM categories. In this perspective, ADHD should be considered as a dimensional disorder affecting several brain circuits, and its treatment should target all dimensions involved.
Article
Background Baron-Cohen (2002) proposed the Extreme Male Brain Theory (EMB) to suggest that foetal testosterone (FT) (1) is a component of the complex neurobiological aetiology of Autism Spectrum Disorder (ASD) and (2) accounts for its high male prevalence. The theory suggests that ASD is more common in males to an extreme manifestation of psychological maleness due to heightened testosterone exposure in the foetus. Aim To assess the EMB theory by reviewing cohort studies that directly assayed FT levels at 12–24 weeks of gestation in relation to subsequent ASD symptoms, ASD-related cognitions, social outcomes and playstyles prior to adolescence. Method A systematic term to subject heading search was conducted on Web of Science, Embase, PsycINFO, ‘Ovid Medline Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid Medline’, PsycARTICLES Full Text, and ProQuest up to December 2019. Studies that included the extraction of foetal fluid and children of both sexes were assessed in compliance with STROBE guidelines. Additional articles were obtained by reference list screening. Results 22 FT-assay studies (N=2284) containing EMB-associated traits as dependent variables were identified, including ASD symptoms, ASD-related cognition, sociality and playstyles. Their STROBE ratings ranged from 50% to 86.4%. FT significantly accounted for ASD-related traits beyond the child’s sex in 3 of 4 studies. 4 out of 9 papers looking at sexed ASD-related cognitive-styles and 2 of 3 examining social outcomes showed significant FT effect. 2 of 6 found that FT accounted for significant variance in behavioral indices that differ on average between the sexes. Chi-square tests (χ22,N=22=4.46,P<.05) demonstrated that researchers affiliated with Baron-Cohen are significantly more likely to generate results fully supportive of EMB, with 25% (N=3,P<.05) of positive findings produced by independent authors. Homogeneity of data did not account for this. Conclusion The certainty with which FT was established as an agent in sexual differentiation varies by the psychological variable in question, but none of the conclusions were supported by an adequate number of studies. Nevertheless, this review yields the following preliminary conclusions, which can be tested in future research. FT plays a plausible role in driving social and non-social ASD-related cognition as well as ASD symptoms across the sexes. FT accounts for gender differences on eye contact frequency and value-laden proposition use and mediates the narrowing of interest toward systems and exerts sex-specific effects on numerical and language abilities, though these studies require independent replication. The role of FT on the differentiation of play is consistently non-significant. Where an effect exists, it is largely dwarfed by the effect of sex and hence it is equivocal that second trimester FT affects play. Biological implications for sex differences are considered and more lifespan longitudinal amniocentesis studies are suggested to pursue greater clarity in the empirical bases of EMB.
Article
Objective: Among children with ADHD, coexisting psychiatric disorders are common and associated with greater impairment and symptom persistence. Given that temperament traits are easily measured, developmentally stable, and variable among youth with ADHD, temperament profiles may be clinically useful for predicting liability for coexisting psychiatric symptoms in this population. Methods: Eighty-three children with ADHD symptoms participated. Caregivers rated their child’s surgency, negative emotionality, and effortful control, as well as severity of internalizing and externalizing psychiatric symptoms. Hierarchical linear regressions were conducted to estimate associations between temperament traits and psychiatric symptoms, controlling for severity of ADHD. Results: Temperament ratings explained significant variance in psychiatric symptoms above and beyond ADHD symptoms alone. Symptoms of each coexisting psychiatric disorder was associated with a distinct temperament and ADHD symptom profile. Conclusion: Temperament ratings appear to have clinical utility for predicting coexisting psychiatric symptoms in children with elevated ADHD symptoms.
Preprint
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Background: In the UK, children with high levels of hyperactivity, impulsivity and inattention referred to clinical services with possible attention-deficit/hyperactivity disorder (ADHD) often wait a long time for specialist diagnostic assessment. Parent training (PT) has the potential to support parents during this difficult period, especially regarding the management of challenging and disruptive behaviours that often accompany ADHD. However, traditional face-to-face PT is costly and difficult to organise in a timely way. We have created a low-cost, easily accessible PT programme delivered via a phone app, Structured E-Parenting Support (STEPS), to address this problem. The overall OPTIMA programme will evaluate the efficacy and cost-effectiveness of STEPS as a way of helping parents manage their children behaviour while on the waiting list. To ensure the timely and efficient evaluation of STEPS in OPTIMA, we have worked with children’s health services to implement a remote strategy for recruitment, screening, and assessment of recently referred families. Part of this strategy is incorporated into routine clinical practice and part is OPTIMA specific. Here we present the protocol for Phase 1 of OPTIMA – a study of the feasibility of this remote strategy, as a basis for a large-scale STEPS randomised controlled trial (RCT). Methods: This is a single arm observational feasibility study. Parents of up to 100 children aged 5-11 years with high levels of hyperactivity/impulsivity, inattention and challenging behaviour who are waiting for assessment in one of five UK child and adolescent mental health or behavioural services. Recruitment, consenting and data collection will occur remotely. The primary outcome will be the rate at which the families, who meet inclusion criteria, agree in principle to take part in a full STEPS RCT. Secondary outcomes include acceptability of remote consenting and online data collection procedures; the feasibility of collecting teacher data remotely within the required timeframe, and technical difficulties with completing online questionnaires. All parents in the study will receive access to STEPS. Discussion: Establishing the feasibility of our remote recruitment, consenting and assessment strategy is a pre-requisite for the full trial of OPTIMA. It can also provide a model for future trials conducted remotely. Trial registration: N/A
Article
Personen met aandachtstekortstoornis met hyperactiviteit (ADHD) hebben een grotere kans om minder goede (levens)beslissingen te nemen en om risicovolle activiteiten te ondernemen dan personen zonder ADHD. Mogelijk komt dit doordat de kenmerken van ADHD van invloed zijn op het besluitvormingsproces. Hoewel beslissingsproblematiek reeds uitgebreid is onderzocht bij kinderen en adolescenten met ADHD, is er nog relatief weinig bekend over de besluitvorming van volwassenen met ADHD. Om die reden was het doel van dit literatuuronderzoek de aard en omvang van eventuele tekorten in het besluitvormingsproces van volwassenen met ADHD vast te stellen. Hiertoe is de bestaande literatuur, waarin de prestatie van volwassenen met ADHD op beslissingstaken werd vergeleken met de prestatie van een gezonde controlegroep, systematisch doorzocht, waartoe de databases PsycINFO, MEDLINE en PubMed zijn geraadpleegd. In totaal werden er 31 studies geïncludeerd. In de meerderheid van de studies (i.e. 55 %) weken de prestaties van volwassenen met ADHD af op een of meer van de gebruikte beslissingstaken in vergelijking met de controlegroep(en). Dit literatuuronderzoek levert daarmee voorzichtig bewijs voor het bestaan van verschillen in het besluitvormingsproces tussen gezonde individuen en volwassenen met ADHD. De grote inconsistentie in de bevindingen wordt deels verklaard door de verscheidenheid aan domeinen van besluitvorming die werden onderzocht, de comorbide stoornissen van de participanten en het medicatiegebruik in de ADHD-groepen. Het literatuuronderzoek besluit met een bespreking van de implicaties die de bevindingen hebben voor theorieën over de onderliggende mechanismen van ADHD.
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1 Attention deficit hyperactivity disorder (ADHD) accounts for approximately 5 to 10% of 2 mental disorders in childhood and adolescence. Symptoms, or some of them, persist into 3 adulthood. In addition to the core symptoms, other manifestations of mental disorders are 4 often present. These comorbidities increase impairment and complicate treatment, why 5 physicians who treat patients with ADHD need to know a wide variety of comorbid 6 circumstances and must differentiate between symptoms and associated disease. Therefore, 7 the knowledge attention, thoughtfulness and treatment of ADHD and all its associated 8 diseases is crucial to ensure the best possible prognosis. However, the relation is discussed, 9 asking for clinical manifestations of the ADHD or comorbidities of this disorder. 10 11
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Many studies have proven that parental stress was associated with childhood mental disorders and disabilities, and in recent years, studies have shown that parents of children with neurodevelopmental disorders (NDDs) experience more parenting stress than parents of typically developing children. Parents living with a child with ADHD experienced stress as they struggled to cope with the child's symptoms amidst the stigmatizing attitudes from family and community members. The chapter tried to explore various factors related with parental stress and ADHD such as quality of life, parental rating of ADHD symptoms and related issues, treatment outcome, marital life, and mental health. One of the important factors contributing to stress is stigma, and the chapter also attempted to explore the link between parental stress and stigma, especially related to ADHD and its interventions. The chapter emphasized the role of mindfulness training for treating ADHD and parental stress while pointing out the methodological limitations.
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Chapter
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ADHD diagnoses increase discontinuously by a child's school starting age, with young‐for‐grade students having much higher ADHD diagnostic rates. Whether these higher rates reflect over‐diagnosis or under‐diagnosis remains unknown. To decompose this diagnostic discrepancy, we exploit differences in parent and teacher pre‐diagnostic assessments within a regression discontinuity strategy based on school starting age. We show that being young‐for‐grade or male generates over‐assessment of symptoms specifically from teacher assessment. However, under‐assessments of the oldest students in a grade, especially the oldest females, account for a large part of the observed school starting age assessment gap. We argue that this difference by sex and higher school starting age effects in lower‐income schools may exacerbate known gaps in educational attainment by gender and socioeconomic status. Importantly, we fail to find evidence that teachers who receive special education training make such errors.
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We examined 140 probands with attention deficit hyperactivity disorder, 120 normal controls, and their 822 first-degree relatives using "blind" raters and structured diagnostic interviews. Compared with controls, probands with attention deficit hyperactivity disorder were more likely to have conduct, mood, and anxiety disorders. Compared with relatives of controls, relatives of probands with attention deficit hyperactivity disorder had a higher risk for attention deficit hyperactivity disorder, antisocial disorders, major depressive disorder, substance dependence, and anxiety disorders. Patterns of comorbidity indicate that attention deficit hyperactivity disorder and major depressive disorders may share common familial vulnerabilities, that attention deficit hyperactivity disorder plus conduct disorder may be a distinct subtype, and that attention deficit hyperactivity disorder and anxiety disorders are transmitted independently in families. These results extend previous findings indicating family-genetic influences in attention deficit hyperactivity disorder by using both pediatrically and psychiatrically referred proband samples. The distributions of comorbid illnesses in families provide further validation for subgrouping probands with attention deficit hyperactivity disorder by comorbidity.
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This study evaluated the effectiveness of eight weeks of intensive behavioral treatment in normalizing the classroom behavior of 28 children with attention deficit disorder with hyperactivity (ADDH). Using blind classroom observers, treatment efficacy was examined for full normalization, partial normalization, and the rate of hyperactive children classified as being like normals. Evidence for normalization was scarce. With treatment, there was no significant change in the percentage of hyperactive children classified as normal. Some normalization gains were found at midtreatment but were not sustained. Attention, activity, and impulsivity, the primary features of ADDH, were not normalized. Aggression, however, was consistently and fully normalized. The modification of aggression does not appear to remedy hyperactive behaviors. The clinical meaningfulness of treatment was minimal; the hyperactive children remained deviant in many aspects of classroom conduct.
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This study examined the issue as to whether or not children carefully diagnosed as having either attention deficit disorder with hyperactivity (ADDH) or without hyperactivity (ADDnoH) could be distinguished on selected cognitive, academic, rapid naming, and behavioral measures. Employing a previously validated multimodal, multi-informant diagnostic process that results in reliable clinical diagnoses, 10 ADDH and 10 ADDnoH children were examined. While no significant differences in cognitive ability were noted between groups, significant underachievement was found in the children diagnosed as ADDnoH, particularly in mathematics achievement. The ADDnoH children were also significantly slower on rapid naming tasks than the ADDH children. Further, 60% of the ADDnoH children had a codiagnosis of a developmental reading or arithmetic disorder while none of the ADDH children received such a codiagnosis. Conversely, 40% of the ADDH children had a codiagnosis of conduct disorder and were rated by their parent as significantly more motorically active, impulsive, and deviant in the demonstration of age-appropriate social skills. These findings are discussed as they relate to the notion that children with attention deficit disorder may suffer from a right hemispheric syndrome. (J Child Neurol 1991;6(Suppl):S35-S41).
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• We investigated the prevalence of DSM-III disorders in 792 children aged 11 years from the general population and found an overall prevalence of disorder of 17.6% with a sex ratio (boys-girls) of 1.7:1. The most prevalent disorders were attention deficit, oppositional, and separation anxiety disorders, and the least prevalent were depression and social phobia. Conduct disorder, overanxious disorder, and simple phobia had intermediate prevalences. Pervasive disorders, reported by more than one source, had an overall prevalence of 7.3%. Examination of background behavioral data disclosed that children identified at 11 years as having multiple disorders had a history of behavior problems since 5 years of age on parent and teacher reports. Fifty-five percent of the disorders occurred in combination with one or more other disorders, and 45% as a single disorder.
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Apparent comorbidity may arise as an artifact of conceptual or diagnostic models that impute inappropriate boundaries between disorders. To draw firm conclusions about comorbidity, each disorder must be clearly distinguishable from others. Few behavioral or emotional disorders of childhood have been validated as separate diagnostic entities that can be reliably distinguished from one another. Rather than accepting reports of comorbidity at face value, we need to understand how particular conceptual and diagnostic schemas affect the perceived relations among disorders. Categorical and quantitative models offer potentially complementary approaches to differentiating between disorders more effectively, a process that is essential for improving our knowledge of etiology and our assessment of the risks and benefits of particular psychopharmacological interventions.
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Made psychiatric and intellectual assessments of 140 children with attention deficit hyperactivity disorder (ADHD), 120 normal controls, and their 303 siblings. The index children were White, non-Hispanic boys. ADHD children were more likely to have had learning disabilities, repeated grades, been placed in special classes, and received academic tutoring. They also did worse on the Wechsler Intelligence Scale for Children—Revised (WISC—R). Among ADHD probands, comorbid conduct, major depressive, and anxiety disorders predicted school placement more than school failure or WISC—R scores. However, the neuropsychological disability of all ADHD children could not be attributed to comorbid disorders because those without comorbidity had more school failure and lower WISC—R scores than normal controls. Intellectual impairment was also increased among siblings of ADHD children. This provides converging evidence that the ADHD syndrome is familial. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Reviews childhood disorder studies describing the meaning and significance of comorbid psychiatric disorders in children and adolescents. Data on the prevalence of disorders in children and adolescents sets the stage for discussing the more specific forms of psychopathology that are seen in boys vs girls at various ages. The authors focus on conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder (ADHD), anxiety disorders, and depressive disorders. The stability of these forms of psychopathology over the course of children's development are examined. Patterns of comborbidity are explored, and what is known/not known about the predictors and outcomes of various comorbid conditions is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Abstract The present study reports the results of a prospective, 8–year follow-up study of 100 hyperactive and 60 normal children followed from childhood into adolescence. Ratings of child behavior problems and family conflicts as well as direct observations of mother-child interactions were taken in childhood and again at adolescent follow-up. At outcome, hyperactives continued to have more conduct and learning problems and to be more hyperactive, inattentive, and impulsive than controls. Hyperactives were also rated by their mothers as having more numerous and intense family conflicts than the normal controls, although the adolescents in both groups did not differ in their own ratings of these conflicts. Observations of mother-adolescent interactions at outcome found the hyperactive dyads displaying more negative and controlling behaviors and less positive and facilitating behaviors towards each other than in the normal dyads. These interaction patterns were significantly related to similar patterns in mother-child interactions observed 8 years earlier. Mothers of hyperactives also reported more personal psychological distress than normal mothers at outcome. Further analyses of subgroups of hyperactives at outcome, formed on the presence or absence of ADHD and oppositional defiant disorder (ODD), indicated that the presence of ODD accounted for most of the differences between hyperactives and normals on the interaction measures, ratings of home conflicts, and ratings of maternal psychological distress. Results suggest that the development and maintenance of ODD into adolescence in hyperactive children is strongly associated with aggression and negative parent-child interactions in childhood.
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A comprehensive chart review of 66 hyperactive patients, who were followed prospectively for 15 years at five-year intervals, identified four subgroups in the developmental course of antisocial behavior in adulthood: those who never presented with antisocial problems, those with continuing antisocial problems from childhood to adulthood, those who showed initial antisocial behavior that did not continue, and those who exhibited antisocial behavior initially and in adolescence, but not in adulthood.
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In the course of a prospective longitudinal study, we examined age of onset of behavior problems in a group of boys and girls identified with attention deficit disorder (ADD) at age 11. Onset occurred during the preschool years, by the first year of schooling, or by the end of the second year of school Onset was strongly related to informant source at age 11, pattern of comorbidity of disorder at age 11, and developmental language, perceptual motor, and IQ measures. Onset by the first year of schooling was particularly related to poor reading skills. By age 15, nearly three-quarters of those with onset of problems before age 6 had one or more DSM-III disorders.
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It has been suggested that children with attention deficit disorder-hyperactivity (ADDH) are likely to show allergic disorders, and that both ADDH and allergic disorders may share a common biological background. In a large sample of children from the general population we found no association between parent, teacher, and self-reports of ADDH behaviors and a history of allergic disorders (asthma, eczema, rhinitis, and urticaria) at ages 9 or 13 years. Similarly, reports of ADDH behaviors at age 13 years were not related to level of atopic responsiveness by skin test or serum IgE levels. Our findings call into question the hypothesis that there is a relationship between ADDH and allergic disorder.
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DSM-III-R provides a unidimensional definition of attention deficit-hyperactivity disorder (ADHD), based on the assumption that inattention, impulsivity, and motor hyperactivity are unitary aspects of the same dimension. The definition of undifferentiated attention deficit disorder (UADD), however, contradicts this assumption by treating inattention as a separate dimension. The present study evaluated these assumptions empirically. A cluster analysis of three factors derived from factor analyses of teacher ratings of ADD symptoms and a broader list of ADD symptoms produced three distinct clusters: patients without ADD, those with both inattention and hyperactivity, and a group that exhibited inattention and sluggish tempo but not hyperactivity. The association was very strong between the empirically derived clusters and clinical DSM-III diagnoses of ADD with and without hyperactivity. These findings do not support the DSM-III-R unidimensional definition of ADHD.
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The distinguishing and overlapping features of attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) are discussed. Conclusions regarding comorbidity, treatment efficacy, and long-term outcome can be influenced by several factors, including diagnostic procedures and sample characteristics. The need to distinguish between referred and non-referred samples is particularly crucial when considering treatment and comorbidity issues. The efficacy of psychosocial and pharmacological treatments in ADHD and CD children is reviewed as are the few studies of psychostimulant medication in co-morbid youngsters. Suggestions regarding treatment planning and recommendations for treatment and research are described.
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Blends the commentaries from T. A. Brown and D. H. Barlow, K. T. Mueser et al, M. T. Shea et al, P. C. Kendall et al, H. Abikoff and R. G. Klein, and S. P. Hinshaw (see PA, Vol 80:13821, 13794, 14471, 13663, 13603, and 13616, respectively). Included is a discussion of various definitions of comorbidity, the merits and demerits of a hierarchical diagnostic system, and consideration of the extent, patterning, and nature of comorbidity. Directive comments with reference to future intervention planning mention both assessment (distinguishing overlapping constructs) and treatment (sequencing and treatment manuals) issues.
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Although comorbidity with specific learning disabilities is less frequent than commonly reported, externalizing behavior disorders--particularly attention-deficit hyperactivity disorder (ADHD)--often overlap with various indices of academic underachievement during childhood. Furthermore, by adolescence, delinquency is clearly associated with school failure. Because the link between behavioral and learning problems often appears before formal schooling, and because the co-morbid problems predict a negative course, early intervention is a necessity. Controlled treatment investigations with youngsters who show these combined problems are rare, and such studies present a host of methodologic and practical problems. I discuss issues surrounding multimodality treatment programs and the potential for long-term interventions to break cycles of school failure and externalizing behavior.
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Monozygotic and dizygotic twin pairs, in which at least one member of each pair is reading disabled (RD), were assessed for attention-deficit hyperactivity disorder (ADHD). Within pair cross-concordances of the RD and ADHD qualitative diagnoses for monozygotic twins were larger than for dizygotic twins, although not significantly so (p less than 0.10). Thus, the data suggest that RD and ADHD may be primarily genetically independent. However, trends in the data and subtype analyses suggest that in some cases RD and ADHD may occur together because of a shared genetic etiology and that a genetically mediated comorbid subtype may exist.
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Prior studies suggest that the birth of a new baby causes a modest but reliable drop in marital satisfaction. The present study replicates and extends this finding in couples with children at medical risk and probes the mechanisms behind this effect. Longitudinal data on marital satisfaction, family structure, infant illness and temperament, and family life events were collected at prenatal, 6, 12, and 18 month periods. Family structural burdens and family stress burdens had a significant negative effect on marital satisfaction. Child-related burdens were less reliably related. Results are discussed in the context of stress and coping as well as developmental psychopathology.
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One hundred seven preadolescent children who meet criteria for attention-deficit hyperactivity disorder (ADHD) were further diagnosed by structured interview with regard to oppositional defiant disorder, conduct disorder, and overanxious disorder (ANX). The ADHD population was subdivided into those with and without a comorbid ANX, and the two ADHD groups were compared with each other and a control group in terms of teacher ratings, behavioral observations during an academic task, and the Inhibition version of the Continuous Performance Test. The results suggested that ADHD/ANX children may be less impulsive and/or hyperactive than those children with ADHD alone though they remain more impaired than controls. There was also a trend for the comorbid group to show fewer conduct disorder symptoms. The implications of comorbidity for the study of both ADHD and ANX are discussed.
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Epidemiological data show that the co-occurrence of two or more supposedly separate child (and adult) psychiatric conditions far exceeds that expected by chance (clinic data cannot be used for this determination). The importance of comorbidity is shown and it is noted that it is not dealt with optimally in either DSM-III-R or ICD-9. Artifacts in the detection of comorbidity are considered in terms of referral and screening/surveillance biases. Apparent comorbidity may also arise from various nosological considerations; these include the use of categories where dimensions might be more appropriate, overlapping diagnostic criteria, artificial subdivision of syndromes, one disorder representing an early manifestation of the other, and one disorder being part of the other. Possible explanations of true comorbidity are discussed with respect to shared and overlapping risk factors, the comorbid pattern constituting a distinct meaningful syndrome, and one disorder creating an increased risk for the other. Some possible means of investigating each of these possibilities are noted.
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We examined the role of attention deficit hyperactivity disorder (ADHD) in juvenile delinquency. Forty-two incarcerated male delinquents participated. Thirty of these youths met the criterion for conduct disorder (CD), only while 12 met the criterion for CD and ADHD. The results indicated that the latter group were arrested at an earlier age and had more total arrests than those in the former group; however, they did not have more criminal charges against them. The role of intellectual and academic skills in these findings was considered. It appears that ADHD has an important additive influence on the development and persistence of juvenile delinquency. Implications for the behavior therapist are discussed.
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Follow-up studies of children with attention deficit hyperactive disorder show that they continue to have problems with restlessness, over-activity, impulsive behaviour and inattention, often resulting in serious academic, social and emotional problems in adolescence. Outcome in adulthood generally falls into three groups: fairly normal outcome, persistent attentional, social, emotional and impulse problems, and serious psychiatric and/or social pathology. Factors affecting outcome include characteristics related to the child (for example, health, temperament, IQ) and characteristics of the family (for example, socioeconomic status, emotional and psychological aspects of the family, family composition and structure, and the larger social and physical environment.
Article
This study examined the issue as to whether or not children carefully diagnosed as having either attention deficit disorder with hyperactivity (ADDH) or without hyperactivity (ADDnoH) could be distinguished on selected cognitive, academic, rapid naming, and behavioral measures. Employing a previously validated multimodal, multi-informant diagnostic process that results in reliable clinical diagnoses, 10 ADDH and 10 ADDnoH children were examined. While no significant differences in cognitive ability were noted between groups, significant underachievement was found in the children diagnosed as ADDnoH, particularly in mathematics achievement. The ADDnoH children were also significantly slower on rapid naming tasks than the ADDH children. Further, 60% of the ADDnoH children had a codiagnosis of a developmental reading or arithmetic disorder while none of the ADDH children received such a codiagnosis. Conversely, 40% of the ADDH children had a codiagnosis of conduct disorder and were rated by their parent as significantly more motorically active, impulsive, and deviant in the demonstration of age-appropriate social skills. These findings are discussed as they relate to the notion that children with attention deficit disorder may suffer from a right hemispheric syndrome.
Article
In this report, we examine the interrelationships between attention deficit disorder (ADD), learning disabilities (LD), and conduct and oppositional disorders (COD). We indicate that it is reasonable to consider ADD as a distinct entity, frequently co-occurring with LD on the one hand, and COD on the other. The first section reviews the interrelationships between ADD and LD. Here we focus on definitional issues, trace the historical antecedents of ADD and LD, examine the prevalence of ADD and LD, and review studies designed to differentiate cognitive from attentional mechanisms in children with ADD, LD, or both. In the next section, we review the evidence linking ADD with COD, a distinction blurred in earlier investigations by problems with referral bias. More recent studies suggest that the antecedents, clinical characteristics, and prognosis may differ in children with ADD alone compared to those with ADD in association with COD.
Article
This study used an adoption design to investigate the relationships among genetic background, environmental factors, and clinical outcome of attention deficit/hyperactivity, aggressivity, and adult antisocial personality (ASP) in a sample of 283 male adoptees. A biologic parent adjudged to be delinquent or to have an adult criminal conviction predicted increased attention deficit/hyperactivity in the adopted away sons, as well as increased adult ASP diagnosis. Aggressivity in the adoptee was predicted by attention deficit/hyperactivity, and aggressivity in turn predicted increased adult ASP. Environmental factors of socioeconomic status (SES), and psychiatric problems in adoptive family members correlated significantly with various clinical outcomes of aggressivity, attention deficit/hyperactivity, and ASP. The results suggest that attention deficit/hyperactivity should be considered a syndrome that has a variety of correlated behaviors, such as aggressivity, and that each of these correlated behaviors is influenced by different genetic and environmental factors and their interactions. Depending on the mix of factors, adult ASP can be one of the outcomes.
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Attention deficit hyperactivity disorder is a heterogeneous disorder of unknown etiology. Little is known about the comorbidity of this disorder with disorders other than conduct. Therefore, the authors made a systematic search of the psychiatric and psychological literature for empirical studies dealing with the comorbidity of attention deficit hyperactivity disorder with other disorders. The search terms included hyperactivity, hyperkinesis, attention deficit disorder, and attention deficit hyperactivity disorder, cross-referenced with antisocial disorder (aggression, conduct disorder, antisocial disorder), depression (depression, mania, depressive disorder, bipolar), anxiety (anxiety disorder, anxiety), learning problems (learning, learning disability, academic achievement), substance abuse (alcoholism, drug abuse), mental retardation, and Tourette's disorder. The literature supports considerable comorbidity of attention deficit hyperactivity disorder with conduct disorder, oppositional defiant disorder, mood disorders, anxiety disorders, learning disabilities, and other disorders, such as mental retardation, Tourette's syndrome, and borderline personality disorder. Subgroups of children with attention deficit hyperactivity disorder might be delineated on the basis of the disorder's comorbidity with other disorders. These subgroups may have differing risk factors, clinical courses, and pharmacological responses. Thus, their proper identification may lead to refinements in preventive and treatment strategies. Investigation of these issues should help to clarify the etiology, course, and outcome of attention deficit hyperactivity disorder.
Article
The present study reports the results of a prospective, 8-year follow-up study of 100 hyperactive and 60 normal children followed from childhood into adolescence. Ratings of child behavior problems and family conflicts as well as direct observations of mother-child interactions were taken in childhood and again at adolescent follow-up. At outcome, hyperactives continued to have more conduct and learning problems and to be more hyperactive, inattentive, and impulsive than controls. Hyperactives were also rated by their mothers as having more numerous and intense family conflicts than the normal controls, although the adolescents in both groups did not differ in their own ratings of these conflicts. Observations of mother-adolescent interactions at outcome found the hyperactive dyads displaying more negative and controlling behaviors and less positive and facilitating behaviors towards each other than in the normal dyads. These interaction patterns were significantly related to similar patterns in mother-child interactions observed 8 years earlier. Mothers of hyperactives also reported more personal psychological distress than normal mothers at outcome. Further analyses of subgroups of hyperactives at outcome, formed on the presence or absence of ADHD and oppositional defiant disorder (ODD), indicated that the presence of ODD accounted for most of the differences between hyperactives and normals on the interaction measures, ratings of home conflicts, and ratings of maternal psychological distress. Results suggest that the development and maintenance of ODD into adolescence in hyperactive children is strongly associated with aggression and negative parent-child interactions in childhood.
Article
Reports of adolescent outcome in attention deficit hyperactivity disorder have uniformly indicated high rates of behavioral problems including cognitive impairment. Dysfunction is markedly reduced in adulthood, but the pattern of outcome remains unchanged except for failure to document cognitive deficits. In adulthood, dysfunction is characterized by antisocial personality and substance (nonalcohol) use disorders. These are in turn associated with criminality. The little existing information on girls with attention deficit hyperactivity disorder does not suggest a worse outcome than for boys. Attempts to identify the children most likely to have a poor outcome have been largely unsuccessful.
Article
With the use of family study methods and assessments by "blinded" raters, we tested hypotheses about patterns of familial association between DSM-III attention deficit disorder (ADD) and affective disorders (AFFs) among first-degree relatives of clinically referred children and adolescents with ADD (73 probands, 264 relatives) and normal controls (26 probands, 92 relatives). Among the 73 ADD probands, 24 (33%) met criteria for AFFs (major depression, n = 15 [21%]; bipolar disorder, n = 8 [11%]; and dysthymia, n = 1 [1%]). After stratification of the ADD sample into those with AFFs (ADD + AFF) and those without AFF (ADD), familial risk analyses revealed the following: (1) the relatives of each ADD proband subgroup were at significantly greater risk for ADD than were relatives of normal controls; (2) the age-corrected morbidity risk for ADD was not significantly different between relatives of ADD and ADD + AFF (27% vs 22%); however, these two risks were significantly greater than the risk to relatives of normal controls (5%); (3) the risk for any AFF (bipolar disorder, major depressive disorder, or dysthymia) was not significantly different between relatives of ADD probands and ADD + AFF probands (28% and 25%), but these two risks were significantly greater than the risk to relatives of normal controls (4%); (4) ADD and AFFs did not cosegregate within families; and (5) there was no evidence for nonrandom mating. These findings are consistent with the hypothesis that ADD and AFFs may share common familial vulnerabilities.
Article
This article describes a longitudinal analysis of the behavior of a birth cohort of 435 boys. 4 groups were defined at age 13 on the basis of both self-reported delinquent behavior and professional diagnosis of Attention Deficit Disorder: ADD + delinquent, ADD only, delinquent only, and nondisordered. Biennial correlates of delinquency (antisocial behavior problems, verbal intelligence, reading difficulty, and family adversity) were traced across childhood. The ADD + delinquent boys consistently fared the worst on the assessments of family adversity, verbal intelligence, and reading. Their antisocial behavior began before school age, escalated at school entry, and persisted into adolescence. The ADD-only boys had normal family, intelligence, and reading scores, and showed only mild antisocial behavior in middle childhood. The delinquent-only boys showed no early risk from family, low intelligence, or reading deficit, and remained relatively free of conduct problems until they initiated delinquency at age 13. Persistence of criminal offending beyond adolescence is predicted for the ADD + delinquent boys.
Article
The psychiatric outcome is reported for a large sample of hyperactive children (N = 123), meeting research diagnostic criteria, and normal control children (N = 66) followed prospectively over an 8-year period into adolescence. Over 80% of the hyperactives were attention deficit hyperactivity disorder (ADHD) and 60% had either oppositional defiant disorder and/or conduct disorder at outcome. Rates of antisocial acts were considerably higher among hyperactives than normals, as were cigarette and marijuana use and negative academic outcomes. The presence of conduct disorder accounted for much though not all of these outcomes. Family status of hyperactives was much less stable over time than in the normal subjects. The use of research criteria for diagnosing children as hyperactive identifies a pattern of behavioral symptoms that is highly stable over time and associated with considerably greater risk for family disturbance and negative academic and social outcomes in adolescence than has been previously reported.
Article
We investigated the prevalence of DSM-III disorders in 792 children aged 11 years from the general population and found an overall prevalence of disorder of 17.6% with a sex ratio (boys-girls) of 1.7:1. The most prevalent disorders were attention deficit, oppositional, and separation anxiety disorders, and the least prevalent were depression and social phobia. Conduct disorder, overanxious disorder, and simple phobia had intermediate prevalences. Pervasive disorders, reported by more than one source, had an overall prevalence of 7.3%. Examination of background behavioral data disclosed that children identified at 11 years as having multiple disorders had a history of behavior problems since 5 years of age on parent and teacher reports. Fifty-five percent of the disorders occurred in combination with one or more other disorders, and 45% as a single disorder.
Article
Data on perinatal and early childhood somatic and psychological risk factors of a random sample of children were gathered in early to middle childhood and employed to examine the long-term risk of emotional and behavioral problems of late childhood and adolescence. 3 issues were addressed: First, can syndromic specificity of such effects be identified on scaled and diagnostic measures of syndromes? Second, are these effects attributable to excess risk of low-income children for both perinatal and later childhood problems? Third, are the intervening mechanisms identifiable as intellectual impairment, vulnerability to poor health, poor maternal caretaking, maternal rejection, or maternal stress associated with marital problems? Findings indicated that elevated risk was present for all syndromes, both at the scale level and at the diagnostic level. None of the examined intervening mechanisms fully accounted for the effects of early risks.
Article
The effect of the comorbidity of overanxious disorder (ANX) in attention deficit hyperactivity disorder (ADHD) on laboratory measures of behavior, cognition, and stimulant response was examined. Seventy-nine children who met DSM-III-R criteria for ADHD were tested further for an oppositional defiant disorder (ODD), conduct disorder (CD), or ANX. Subjects with comorbid ANX showed less impulsiveness on a laboratory measure of behavior and had longer, sluggish reaction times on the Memory Scanning Test than those without ANX. ADHD subjects with comorbid ANX were less frequently diagnosed as CD. Forty-three of the subjects completed a double-blind trial of methylphenidate; subjects with comorbid anxiety had a significantly poorer response to the stimulant than those without anxiety, while the comorbidity of ODD or CD did not affect stimulant response. The results suggest that ADHD with comorbid ANX may represent children with primary anxiety who develop secondary inattentiveness, or they may represent a different subtype of ADHD, perhaps similar to the condition of attention deficit disorder without hyperactivity under DSM-III.
Article
Differences between 37 aggressive and 37 nonaggressive children with attention deficit hyperactivity disorder (ADHD) were evaluated as was their response to two doses of methylphenidate (0.3 and 0.5 mg/kg) using a multimethod battery of behavior ratings, laboratory tests, and direct observations. Aggressive ADHD children differed little from nonaggressive ADHD children except that nonaggressives displayed more problems with inattentiveness at school than aggressives while mothers of aggressives reported more symptoms of psychopathology in themselves than mothers of nonaggressives. In their drug responding, aggressives and nonaggressives were quite similar. The few exceptions were on measures of conduct, on which the aggressives were initially rated as more extreme and subsequently showed the greater degree of improvement from medication than nonaggressives. Results replicated those of a previous study and further indicate that aggressive and nonaggressive ADHD children share a common disorder of ADHD but aggressives have more impaired family situations.
Article
Eight-year and two-year longitudinal analyses of prevalence and risk factors for adult and adolescent psychopathology were carried out for a random sample of 776 children drawn from households in New York State. A 17.7% prevalence rate for one or more DSM-III disorders was estimated. In general, the risk factors studied were more related to externalizing than internalizing diagnoses. Risk factors assessed over 8-year and 2-year intervals were very similar.
Article
Data from the Ontario Child Health Study were used to examine the prevalence and selected correlates of conduct disorder, hyperactivity, emotional disorder, and somatization in children 4 to 16 years of age by informant (parent and teacher for children 4 to 11, and parent and youth for children 12 to 16). The results indicate that the prevalence and pattern of correlates of the individual disorders differ in important ways by informant. This suggests that we need to understand the factors that influence assessments provided by informants from different contexts (e.g., parents and teachers) before combining information from them to arrive at singular classifications.
Article
This study was designed to evaluate the possibility that a pattern of cognitive deficit is associated with delinquent behavior, while avoiding some of the methodological problems of previous research. The Self-Report Early Delinquency instrument and a research battery of neuropsychological tests were administered blindly to an unselected cohort of 678 13-year-olds. Because the diagnosis of attention deficit disorder (ADD) was found at markedly elevated rates in the backgrounds of these delinquents, the possibility was examined that the neuropsychological deficits of delinquents might be limited to delinquents with histories of ADD. Although delinquents with past ADD were more cognitively impaired than non-ADD delinquents, both groups scored significantly below nondelinquents on verbal, visuospatial, and visual-motor integration skills. In addition, ADD delinquents scored poorly on memory abilities. Subjects with ADD who had not developed delinquent behavior were not as cognitively impaired as ADD delinquents, suggesting that it is the specific comorbidity of ADD and delinquency that bears neuropsychological study.