The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study

Calibration of ADHD Assessments Across Studies: A Meta-Analysis Tool

When analyzed separately, data from small studies provide only limited information with limited clinical generalizability, due to small sample size, differing assessments, and limited scope. In this methodological paper we outline a theoretical framework for performing meta-analysis of data obtained from disparate studies using disparate tests, based on calibration of the data from such studies and tests into a unified probability scale. We apply this method to combine the data from five studies examining the diagnostic abilities of different assessments of Attention Deficit/Hyperactivity Disorder (ADHD), including behavioral rating scales and EEG assessments. The studies enrolled a total of 111 subjects, 56 ADHD and 55 controls. Each individual study had a small sample focused on a specific age/gender group, for example 8 boys ages 6-10, and generally had insufficient power to detect statistically significant differences. No gender, or age comparisons were possible within any single study. However, when calibrated and combined, the data resulted in a clear separation between ADHD versus non-ADHD groups in males below the age of 16 (p < 0.001), males above the age of 16, (p = 0.015), females below the age of 16, (p = 0.0014), and females above the age of 16, (p = 0.0022). We conclude that if data from various studies using various tests are made comparable, the resulting combined sample size and the increased diversity of the combined sample lead to increased significance of the statistical tests and allow for cross-sectional comparisons, which are not possible within each individual study.

Severity of adolescent delinquency among boys with and without attention deficit hyperactivity disorder: predictions from early antisocial behavior and peer status

This study evaluated predictors of adolescent delinquency severity (11 to 17 years of age) among a diverse group of preadolescent boys with attention deficit hyperactivity disorder (ADHD; n=100) and age-matched comparison boys (n=75). During childhood, baseline assessments yielded diagnostic information, and naturalistic summer programs provided multimethod measures of overt aggression, covert antisocial behavior (ASB), and peer status. Five years later, multi-informant measures of ASB and delinquency were gathered and independently rated. Baseline ADHD, overt aggression, and peer status were not significantly related to adolescent delinquency severity. Observed noncompliance and an objective measure of covert ASB each independently predicted delinquency. Covert ASB predicted delinquency severity more strongly for comparison boys than for probands.

ADHD and College Students: Exploratory and Confirmatory Factor Structures With Student and Parent Data

Exploratory factor analyses (EFAs) and confirmatory factor analyses (CFAs) were used to investigate the structure of the Student Report Inventory (SRI) and Parent Report Inventory (PRI) of the College Attention-Deficit/Hyperactivity Disorder (ADHD) Response Evaluation. The sample was composed of 1,080 college students and their parents and was stratified by ethnicity, gender, ability level, age, grade, region of residence, and psychoeducational classification status. Results varied according to the information source (self-report vs. parent). EFA uncovered and CFA confirmed 3 distinct and reliable dimensions for student reports: Inattention, Hyperactivity, and Impulsivity. By contrast, EFA and CFA uncovered a reliable 2-dimension structure for the parent-report data. Factor structures replicated across genders (3 factors for the SRI, and 2 factors for the PRI). Results are discussed in terms of the divergence of structures.

Identification and characterization of human NR4A2 polymorphisms in attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is a highly heritable and common disorder thought to arise, in part, from alterations in dopamine function. NR4A2, or Nurr1, is an orphan nuclear receptor implicated in the development of dopaminergic cells of the ventral tegmental area (VTA) and the substantia nigra (SN). Dopaminergic cells of the VTA provide innervation to the prefrontal cortex, believed to be of major importance in the etiology of ADHD, suggesting that NR4A2 is a potential candidate gene for ADHD susceptibility. This study aimed to identify polymorphisms in NR4A2 and test their association to ADHD. Database analysis revealed a CA repeat polymorphism in the 3' UTR of NR4A2 that was confirmed by PCR. SSCP screening revealed a common DeltaC polymorphism, 254 bp 5' to the transcriptional start site. These polymorphisms were tested for an association with ADHD in both a case control study of individuals from the Milwaukee Longitudinal Study of ADHD (103 cases and 66 controls), and in 35 families composed of trios or affected sib pairs (ASP) with ADHD. Functional effects of the promoter polymorphism were tested in vitro. The non-deleted allele was significantly more active in undifferentiated SK-N-MC cells compared to differentiated SK-N-MC and HeLa cells while a trend for increased activity for the DeltaC allele was observed in undifferentiated SK-N-MC cells. Identification of these polymorphisms may aid future candidate gene studies in disorders with altered dopamine signaling, such as schizophrenia Parkinson's disease and ADHD.

Costs of attention deficit-hyperactivity disorder (ADHD) in the US: excess costs of persons with ADHD and their family members in 2000

OBJECTIVE

The objective of this study is to provide a comprehensive estimate of the cost of ADHD by consider ing the healthcare and work loss costs of persons with ADHD, as well as those costs imposed on their family members.

METHODS

Excess per capita healthcare (medical and prescription drug) and work loss (disability and work absence) costs of treated ADHD patients (ages 7 years-44 years) and their family members (under 65 years of age) were calculated using administrative claims data from a single large company; work loss costs are from disability data or imputed for medically related work loss days. Excess costs are the additional costs of patients and their family members over and above those of comparable control individuals. The excess costs of untreated individuals with ADHD and their family members were also estimated. All per capita costs were extrapolated using published prevalence and treatment rates and population data; the prevalence of persons with ADHD was based upon the literature.

RESULTS

The total excess cost of ADHD in the US in 2000 was $31.6 billion. Of this total, $1.6 billion was for the ADHD treatment of patients, $12.1 billion was for all other healthcare costs of persons with ADHD, $14.2 billion was for all other healthcare costs of family members of persons with ADHD, and $3.7 billion was for the work loss cost of adults with ADHD and adult family members of persons with ADHD.

CONCLUSION

The annual cost of ADHD in the US is substantial. Both treated and untreated persons with ADHD, as well as their family members, impose consider able economic burdens on the healthcare system as a result of this condition. While these first estimates of the cost of ADHD to the nation are suggestive of its substantial economic burden, future research needs to refine and build on this analysis, particularly in the context of a model to control for related co-morbidities. Similarly, since these results are based on data from a single company for the period 1996-1998, the analysis should be validated with more representative, current data.

Executive Functioning in Hyperactive Children as Young Adults: Attention, Inhibition, Response Perseveration, and the Impact of Comorbidity

Tests of several executive functions (EFs) as well as direct observations of symptoms of attention deficit hyperactivity disorder (ADHD) during testing were collected at the young adult follow-up (M = 20 years) on a large sample of hyperactive (H; N = 147) and community control (CC; N = 71) children. The EF tasks included tests of attention, inhibition, and response perseveration. The H group was subdivided into those with and without ADHD (+ or w/o) at follow-up. The H+ADHD group made significantly more inhibition errors than the CC group on a Continuous Performance Test (CPT) and showed more ADHD symptoms while performing the CPT. The H+ADHD group also displayed more ADHD symptoms during a letter cancellation task than did both the hyperactive w/o ADHD and CC groups. Both H groups showed slower reaction times during a Card Playing Task. That subset of hyperactive probands with Conduct Disorder (CD) displayed significantly more perseverative responding on that task than did those without CD, but otherwise it did not differ on any other measures. Current level of anxiety contributed adversely to both CPT commission errors and ADHD behavior during the CPT. Comorbid depression did not contribute to any group differences on these tests. Although developmental improvements were found in both the H and the CC groups in their CPT inattention and inhibition scores since adolescence, the H groups remained distinguishable from the CC groups over this period. We conclude that formerly hyperactive children manifest greater EF deficits at follow-up in the areas of inattention, disinhibition, and slowed reaction time and greater ADHD behavior during testing, but these problems are mostly confined to those with current ADHD. Response perseveration, however, was limited to those hyperactive children with CD by follow-up, consistent with Quay's theory of these two disorders.

History of attention-deficit hyperactivity disorder symptoms and opioid dependence: a controlled study

The co-occurrence of attention-deficit hyperactivity disorder (ADHD) and substance use disorders has received considerable attention in recent clinical and scientific investigations. These two disorders are linked to one another in a variety of ways. The core symptoms of ADHD may be mimicked by the effects of psychoactive substance use, making it difficult to diagnose one disorder in the presence of the other. Individuals with ADHD may demonstrate earlier onset of the substance abuse and a pattern of more frequent or intense use. ADHD symptoms were explored as possible antecedents of opioid dependence. A total of 109 adult opioid-dependent, treatment-seeking male and female outpatients were investigated with an extended clinical semistructured interview to collect sociodemographic, drug-related, and clinical data. The results indicate that ADHD alone does not predispose the development of opioid dependence in our sample. Childhood ADHD symptoms may nevertheless be found more frequently related to school performance problems and difficulties in social adaptation, which was identified in more than half of our population. Patients with ADHD history seemed to experience a drug abuse career with more complications which need to be recognized with focused attention in order to start earlier treatment strategies.

Childhood externalizing behavior: theory and implications

TOPIC

Childhood externalizing behavior

PURPOSE

To analyze the construct of externalizing behavior (aggression, delinquency, and hyperactivity), illustrate the biosocial model of childhood externalizing, and draw clinical implications for nursing research and practice.

SOURCES

A review of the literature based on psychological, psychiatric, and nursing journals.

CONCLUSIONS

A better understanding of childhood externalizing behavior problems and the risk factors underlying them are essential to prevent them. The employment of an integrative biosocial perspective is argued to be important in understanding this behavior.

CASASTART: a community-based, school-centered intervention for high-risk youth

During the past decade, increasing numbers of drug- and alcohol-related delinquency cases have entered the juvenile justice system. The majority of these young people face multiple challenges and risks, yet have few resources to mitigate these risks. This article suggests that the skills, competencies and supports, and protective factors needed to help young people grow into healthy adulthood are not readily available to high-risk youth. We offer lessons from the development, implementation, and institutionalization of one promising model of an evidence-based, community-, and school-centered program for high-risk youth (CASASTART). The experience with this program thus far suggests that program models that encompass a youth development, strength-based, and community-focused approach can intervene successfully with many high-risk youth and their families, reduce use of drugs and alcohol, reduce violent crime, and achieve funding and programmatic stability.

Clinical Pharmacokinetics of Atomoxetine

Atomoxetine (Strattera, a potent and selective inhibitor of the presynaptic norepinephrine transporter, is used clinically for the treatment of attention-deficit hyperactivity disorder (ADHD) in children, adolescents and adults. Atomoxetine has high aqueous solubility and biological membrane permeability that facilitates its rapid and complete absorption after oral administration. Absolute oral bioavailability ranges from 63 to 94%, which is governed by the extent of its first-pass metabolism. Three oxidative metabolic pathways are involved in the systemic clearance of atomoxetine: aromatic ring-hydroxylation, benzylic hydroxylation and N-demethylation. Aromatic ring-hydroxylation results in the formation of the primary oxidative metabolite of atomoxetine, 4-hydroxyatomoxetine, which is subsequently glucuronidated and excreted in urine. The formation of 4-hydroxyatomoxetine is primarily mediated by the polymorphically expressed enzyme cytochrome P450 (CYP) 2D6. This results in two distinct populations of individuals: those exhibiting active metabolic capabilities (CYP2D6 extensive metabolisers) and those exhibiting poor metabolic capabilities (CYP2D6 poor metabolisers) for atomoxetine. The oral bioavailability and clearance of atomoxetine are influenced by the activity of CYP2D6; nonetheless, plasma pharmacokinetic parameters are predictable in extensive and poor metaboliser patients. After single oral dose, atomoxetine reaches maximum plasma concentration within about 1-2 hours of administration. In extensive metabolisers, atomoxetine has a plasma half-life of 5.2 hours, while in poor metabolisers, atomoxetine has a plasma half-life of 21.6 hours. The systemic plasma clearance of atomoxetine is 0.35 and 0.03 L/h/kg in extensive and poor metabolisers, respectively. Correspondingly, the average steady-state plasma concentrations are approximately 10-fold higher in poor metabolisers compared with extensive metabolisers. Upon multiple dosing there is plasma accumulation of atomoxetine in poor metabolisers, but very little accumulation in extensive metabolisers. The volume of distribution is 0.85 L/kg, indicating that atomoxetine is distributed in total body water in both extensive and poor metabolisers. Atomoxetine is highly bound to plasma albumin (approximately 99% bound in plasma). Although steady-state concentrations of atomoxetine in poor metabolisers are higher than those in extensive metabolisers following administration of the same mg/kg/day dosage, the frequency and severity of adverse events are similar regardless of CYP2D6 phenotype.Atomoxetine administration does not inhibit or induce the clearance of other drugs metabolised by CYP enzymes. In extensive metabolisers, potent and selective CYP2D6 inhibitors reduce atomoxetine clearance; however, administration of CYP inhibitors to poor metabolisers has no effect on the steady-state plasma concentrations of atomoxetine.

Effects of two doses of methylphenidate on simulator driving performance in adults with attention deficit hyperactivity disorder

INTRODUCTION

Numerous studies have documented an increased frequency of vehicular crashes, traffic citations, driving performance deficits, and driving-related cognitive impairments in teens and adults with attention deficit hyperactivity disorder.

METHOD

The present study evaluated the effects of two single, acute doses of methylphenidate (10 and 20 mg) and a placebo on the driving performance of 53 adults with ADHD (mean age=37 years, range=18-65) using a virtual reality driving simulator, examiner and self-ratings of simulator performance, and a continuous performance test (CPT) to evaluate attention and inhibition. A double-blind, drug-placebo, within-subjects crossover design was used in which all participants were tested at baseline and then experienced all three drug conditions.

RESULTS

A significant beneficial effect for the high dose of medication was observed on impulsiveness on CPT, variability of steering in the standard driving course, and driving speed during the obstacle course. A beneficial effect of the low dose of medication also was evident on turn signal use during the standard driving course. An apparent practice effect was noted on some of the simulator measures between the baseline and subsequent testing sessions that may have interacted with and thereby obscured drug effects on those measures.

CONCLUSIONS

The results, when placed in the context of prior studies of stimulants on driving performance, continue to recommend their clinical use as one means of reducing the driving risks in ADHD teens and adults.

IMPACT ON INDUSTRY

Given the significantly higher risk of adverse driving outcomes associated with ADHD, industry needs to better screen for ADHD among employees who drive as part of employment so as to improve safety and reduce costs. Use of stimulants to treat the adult ADHD driver may reduce safety risks.

Brain activation gradients in ventrolateral prefrontal cortex related to persistence of ADHD in adolescent boys

OBJECTIVE

To explore the possible role that functional abnormalities of the prefrontal cortex and basal ganglia play in the persistence of attention-deficit/hyperactivity disorder (ADHD) in adolescents aged 15 to 19 years.

METHOD

Ten male adolescents who were diagnosed with ADHD during childhood were grouped into those who continued to meet full diagnostic criteria for DSM-IV ADHD (persisters; n = 5) and those in whom symptoms had remitted sufficiently to warrant a diagnosis of ADHD in partial remission (remitters; n = 5). Persisters, remitters, and five carefully matched controls with no history of ADHD were scanned using functional magnetic resonance imaging while performing a go/no-go task.

RESULTS

Parallel linear trends were found in performance on the go/no-go task and activation of ventrolateral prefrontal cortex, such that persisters made the most commission errors (33%) and showed the greatest activation, remitters made fewer commission errors (24%) and had lower activity, and activation was lowest in controls who made the fewest errors (13%).

CONCLUSIONS

These preliminary results suggest that developmental changes in ADHD symptomatology are associated with functional changes in ventrolateral prefrontal cortex activity.

Significance of childhood conduct problems to later development of conduct disorder among children with ADHD: a prospective follow-up study

This study investigates whether low to moderate levels of childhood oppositional defiant disorder (ODD) and conduct disorder (CD) behaviors contribute to the development of clinically diagnosed CD in adolescence, in children with attention deficit hyperactivity disorder (ADHD). Participants were 207 White boys (ages 6-12) with ADHD free of conduct disorder diagnoses. Parent and teacher ratings were obtained. Participants were assessed at mean age 18 by clinicians blind to childhood status. A non-ADHD group (recruited in adolescence) was also studied. ODD behavior ratings did not predict CD in adolescence, whereas CD behavior ratings did. No single ODD or CD behavior predicted adolescent outcome. ADHD probands with very low ratings (Not at all, Just a little) by parents and teachers on all CD behaviors were still at significantly increased risk for CD in adolescence, compared to non-ADHD controls. The same relationships were found between childhood ODD and CD behaviors, and antisocial personality disorder in adulthood (mean age, 25). We conclude that childhood ADHD is a developmental precursor of later antisocial disorder, even in the absence of comorbid ODD or CD in childhood. However, low levels of CD-type problems are not innocuous, because they predict later CD among children with ADHD without comorbid CD.

Attention deficit hyperactivity disorder and suicide: a review of possible associations

OBJECTIVE

To review the evidence of a possible association between attention deficit hyperactivity disorder (ADHD) and suicide.

DESIGN

We searched the electronic data bases: Medline, Psych LIT, between 1966 and March 2003 looking for articles on ADHD, attention deficit disorder, hyperactivity and suicide.

RESULTS

An association of ADHD and completed suicide was found, especially for younger males. However, the evidence for any direct or independent link was modest with an overall suicide rate from long-term follow-up studies of ADHD of 0.63-0.78%. The estimated relative risk ratio, compared with US national suicide rates (males 5-24 years) is 2.91 (95% confidence interval 1.47-5.7, chi2 = 9.3, d.f. = 1, P = 0.002). ADHD appears to increase the risk of suicide in males via increasing severity of comorbid conditions, particularly conduct disorder (CD) and depression.

CONCLUSION

Identification of those at risk, particularly males with comorbid ADHD, depression and CD, may represent a useful clinical means of reducing completed suicide.

Impact of executive function deficits and attention-deficit/hyperactivity disorder (ADHD) on academic outcomes in children

The association between executive function deficits (EFDs) and functional outcomes were examined among children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Participants were children and adolescents with (n = 259) and without (n = 222) ADHD, as ascertained from pediatric and psychiatric clinics. The authors defined EFD as at least 2 executive function measures impaired. Significantly more children and adolescents with ADHD had EFDs than did control participants. ADHD with EFDs was associated with an increased risk for grade retention and a decrease in academic achievement relative to (a) ADHD alone, (b) controlled socioeconomic status, (c) learning disabilities, and (d) IQ. No differences were noted in social functioning or psychiatric comorbidity. Children and adolescents with ADHD and EFDs were found to be at high risk for significant impairments in academic functioning. These results support screening children with ADHD for EFDs to prevent academic failure.

Multiple marker analysis at the promoter region of the DRD4 gene and ADHD: evidence of linkage and association with the SNP -616

Abnormalities of dopamine neurotransmission have been hypothesized to play an important role in the pathophysiology of attention deficit hyperactivity disorder (ADHD). Support for this has come from numerous association studies on candidate genes including the dopamine D4 receptor gene (DRD4). One of the most replicated associations between ADHD and the dopaminergic system is the 7-repeat allele of the VNTR polymorphism of this gene. A lack of association between this marker and ADHD has also been reported in several investigations. In the absence of a firm link between the number of the VNTR repeats and the function of the gene, we sought to investigate several additional markers at the 5'-end of the gene with potential influence on the expression of the DRD4. We observed a significant over transmission of single nucleotide polymorphism (SNP) (chi(2) = 7.45, P = 0.008, OR = 1.63). In addition, an excess transmission of the A allele of the -521 SNP was observed, although it did not attain statistical significance (chi(2) = 2.14, P = 0.17, OR = 1.25). Linkage disequilibrium (LD) analysis demonstrated a weak level of D' between any of the tested markers implying that this may be a region of high recombination. It also raises the possibility that the new association with ADHD may be independent of the 7-repeat allele. Further analyses, preferably in samples demonstrating association with the VNTR, or in other ethnic groups, are required to confirm these observations.

Children's persistence with methylphenidate therapy: a population-based study

OBJECTIVE

To examine persistence with methylphenidate (MPH) therapy among children and youth in the general population.

METHOD

We conducted a retrospective analysis of longitudinally organized, individual-specific anonymous data from linked prescription and health databases covering the population of British Columbia for 1990 through 1996. No prescriptions being filled for 4 months indicated cessation of one bout of therapy.

RESULTS

Among 16,945 identified MPH patients aged 19 years or under, overall duration of therapy was 584 days, and the average number of prescriptions received was 6.6. One-third of patients received 2 or fewer prescriptions, while 18% followed a chronic, continuous course. Among patients receiving more than 2 prescriptions, 50% of discrete therapy bouts lasted 4 months or less, and one-third of cases had multiple bouts of therapy (range 2 to 6 bouts). Younger age (that is, children aged 0 to 8 years, vs those aged 10 to 19 years), male sex, and receipt of initial prescription from a psychiatrist were associated with greater persistence.

CONCLUSIONS

Enormous variability in persistence with MPH therapy and often-occurring low rates of persistence raises questions about the diligence with which MPH patients are selected, prepared, and followed in the general population. Special attention to the needs of older children and to the needs of girls is required, and discontinuities during children's therapy courses require explication.

Effects of acute nicotine administration on behavioral inhibition in adolescents with attention-deficit/hyperactivity disorder

RATIONALE

Adolescents with attention-deficit/hyperactivity disorder (ADHD) become cigarette smokers at twice the rate of non-ADHD adolescents, and this finding continues into adulthood. Abnormal cognitive/behavioral inhibition is one core cognitive symptom of ADHD, leading to impulsive behavior in people with this disorder. Nicotine, contained in tobacco smoke, is known to improve attention, vigilance, and short-term memory. However, little is known about how nicotine might effect cognitive/behavioral inhibition.

OBJECTIVE

This study tested the hypothesis that acute nicotine administration would improve cognitive/behavioral inhibition in non-smoking adolescents with ADHD.

METHODS

This single-dose, acute, repeated-measures, double blind study in adolescents (13-17 years) with DSM-IV confirmed ADHD assessed the effects of transdermal nicotine, oral methylphenidate, and placebo on inhibition in non-smoking adolescents with ADHD. Dependent measures included tests of cognitive/behavioral inhibition (the stop signal task), cognitive interference control (the Stroop task), and a measure of verbal learning and recognition (the hi-low imagery task).

RESULTS

Results from five subjects indicated that stop signal reaction time (SSRT), an estimate of the speed of inhibiting a response, was significantly (P<0.01) improved following both nicotine and methylphenidate treatment as compared to placebo treatment. Neither "go" reaction time nor accuracy showed any effect of drug. In the Stroop task, another task of cognitive inhibition, nicotine but not methylphenidate significantly (P<0.05) decreased the Stroop effect compared to placebo.

CONCLUSIONS

These results indicate that nicotine administration has measurable positive effects on cognitive/behavioral inhibition in adolescents with ADHD. The size of the effect is at least comparable to methylphenidate. Positive effects of nicotine on inhibitional performance may contribute to higher rates of cigarette use in adolescents with ADHD.

Weekend holidays during methylphenidate use in ADHD children: a randomized clinical trial

OBJECTIVE

The aim of this study was to assess whether weekend drug holidays during methylphenidate (MPH) administration would change the efficacy and tolerability to the medication in male children with Attention-Deficit Hyperactivity Disorder (ADHD).

METHODS

In a 28-day, double-blind study, children with diagnoses of ADHD were randomized to receive BID MPH for 7 days a week (n = 21) or to receive BID MPH on weekdays and a placebo on weekends (n = 19). Parents completed the Conners' Abbreviated Rating Scale (ABRS) to assess ADHD symptoms and the Barkley's Side Effect Rating Scale (SERS) to assess side effects on weekends. Teachers completed the ABRS on each Monday after weekends.

RESULTS

Both groups showed a significant reduction on the ABRS over time as the dose was increased. However, the group difference in the ABRS scores was not statistically significant, either on weekend parent ratings (at the endpoint, p = 0.41; effect size = 0.26) or on teachers' ratings (at the endpoint, p = 0.99; effect size = 0.002). The omission of MPH on weekends was associated with significantly less severity of insomnia (F = 3.96, d.f. = 1, p = 0.05) and a trend for less interference on appetite (F = 3.18, d. f. = 1, p = 0.08).

CONCLUSION

Our findings suggest that weekend holidays during MPH administration reduce the side effects of insomnia and appetite suppression without a significant increase in symptoms, either on weekends or in the first school day after them. Possible explanations for these findings (rate-dependent response or impact of demands of the environment) are discussed in this paper.

Diagnostic performance of the CBCL-Attention Problem Scale as a screening measure in a sample of Brazilian children with ADHD

OBJECTIVE

To evaluate the diagnostic performance of the Attention Problem Scale of the Child Behavior Checklist (CBCL-APS) for the screening of Attention-Deficit/Hyperactivity Disorder (ADHD) in a sample of Brazilian children and adolescents.

METHODS

The CBCL-APS was given to 763 children and adolescents. Child psychiatrists using DSM-IV criteria confirmed the clinical diagnoses. Diagnostic performance was evaluated through Receiver-Operating Characteristic (ROC) curves.

RESULTS

Only moderate areas under the curve (AUC) were found for the general sample (AUC = 0.79; 95% CI = 0.76-0.82), and for the subsample of referred patients (AUC = 0.78; 95% CI = 0.74-0.82). The subsample of patients with ADHD of the combined type presented the largest AUC (AUC = 0.85; 95% CI = 0.82-0.88).

CONCLUSION

Our findings concur with previous studies of different cultures demonstrating adequate diagnostic performance of the CBCL-APS for the screening of ADHD, especially of the combined type.

Genetic and environmental contributions to stability and change of ADHD symptoms between 8 and 13 years of age: a longitudinal twin study

OBJECTIVE

To study the genetic and environmental contributions to stability and change of attention-deficit/hyperactivity disorder (ADHD) symptoms between 8 and 9 and 13 and 14 years of age.

METHOD

The sample included 1,480 twin pairs born in Sweden between May 1985 and December 1986. At wave 1 in 1994, when twins were 8-9 years old, 1,106 (75%) of the parents responded to a mailed questionnaire, and at wave 2 when the twins were 13-14 years old, 1,063 (73%) responded. A checklist with 14 items based on the 14 DSM-III-R symptoms for ADHD was completed. Structural equation modeling was used to analyze the data.

RESULTS

A relatively high stability of ADHD symptoms over this 5-year period was found. This continuity was mainly due to the same genetic effects operating at both points in time. Change in symptoms between childhood and early adolescence was to a large extent due to new genetic effects in early adolescence but also due to new nonshared environmental effects that became important during adolescence.

CONCLUSIONS

The genetic stability highlights the importance of the continuing search for genes and endophenotypes of ADHD.

Efficacy of a school-based treatment program for middle school youth with ADHD: pilot data

The effects of a set of behavioral and educational interventions provided in a middle-school-based mental health program on the behavior and academic performance of 7 students diagnosed with attention-deficit/hyperactivity disorder (ADHD) were studied. The treatments included educational, social skills and family interventions designed to target school functioning, peer relations, and family functioning. Dependent measures included parent and teacher ratings of ADHD symptoms, daily functioning, and academic grades. Large effect sizes were found on measures of inattention and school functioning. Grades and measures of family functioning and peer relations yielded small to moderate effect sizes. Description of the procedures is provided and implications for advancing school-based mental health care for adolescents with a diagnosis of ADHD are discussed.

The effect of childhood conduct disorder and cognitive functioning on adolescent substance use

OBJECTIVE

To assess the impact of childhood conduct disorder (CD) and intelligence quotient (IQ) on later substance use in adolescence.

METHODS

Neuropsychological and structured diagnostic evaluations were initially administered to 32 children with disruptive behavior disorder when they were 7-11 years of age. They were then re-evaluated on average 6.7 years later using an array of interviews and rating scales with a focus on substance use.

RESULTS

Early CD and IQ scores together accounted for a significant proportion of the variance in later substance use (R2=.248). In addition, there was a significant CD and Verbal IQ interaction (R2=.164) such that high Verbal IQ was linked to increased substance use in adolescents who had childhood CD.

CONCLUSION

These data indicate that the presence of conduct disorder may interact with high Verbal IQ during childhood in such a way as to predict later adolescent substance use in disruptive behavior disorder populations.

Addressing tobacco among individuals with a mental illness or an addiction

Tobacco dependence among individuals with a mental illness or an addiction is a tremendous problem that goes largely ignored. Studies of genetics, neuroimaging, and nicotinic receptors support a neurobiological link between tobacco use and alcohol dependence, drug dependence, schizophrenia, depression, attention-deficit hyperactivity disorder (ADHD), and anxiety disorders. This paper summarizes the recent literature on this topic and discusses how treatment for tobacco can no longer be ignored in mental-health and addiction-treatment settings. More research is needed as well as a national organized effort to address tobacco in this large segment of smokers.

Aufmerksamkeitsdefizit-/ Hyperaktivitätsstörungen

Zusammenfassung. Hyperkinetische Störungen bzw. die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörungen (ADHS) gehören zu den häufigsten psychischen Auffälligkeiten im Kindesalter. Durch ihre recht hohe Persistenz stellen sie ein beträchtliches Entwicklungsrisiko dar. Es wird der aktuelle Stand der klinischen Forschung zur Epidemiologie, Ätiologie sowie Intervention der ADHS zusammengefasst. Außerdem werden aktuelle Trends vorgestellt, die sich in aktuellen Beiträgen zu neurobiologischen, neuropsychologischen und klinisch-psychologischen Fragestellungen widerspiegeln.

Symptoms defined by parents' and teachers' ratings in attention-deficit hyperactivity disorder: changes with age

OBJECTIVE

To determine whether Child Behavior Checklist/4-18 (CBCL) and Teacher Report Form (TRF) scores of children and adolescents with a first-time diagnosis of attention-deficit hyperactivity disorder (ADHD) are different and whether there is a similar difference in normal control subjects.

METHOD

We analyzed the CBCL and TRF scores of 146 patients (124 boys and 22 girls, aged 6 to 18 years; mean age 11.0 years, SD 3.6). We analyzed the same scores for 274 age and sex-matched control subjects recruited from a nationally representative sample.

RESULTS

Subjects with ADHD had significantly higher CBCL and TRF scores than control subjects. Age was significantly correlated with scores on the CBCL and TRF subscales Social Withdrawal, Somatic Complaints, and Internalization Problems; with scores on the CBCL subscale Attention Problems; and with scores on the TRF subscale Anxiety-Depression. In the group with ADHD, age was negatively correlated with scores on the CBCL and TRF subscale Externalizing Problems and with scores on the TRF subscale Aggressive Behavior. In the control group, the only significant correlation was between age and the CBCL subscale Somatic Complaints score.

CONCLUSIONS

These results indicate that underdiagnosis of ADHD in childhood may cause the emergence of greater internalization problems in adolescence.

Bullied by siblings: association with peer victimisation and behaviour problems in Israeli lower secondary school children

BACKGROUND

The association of bullying victimisation by siblings with a) involvement in bullying at school and b) behaviour problems among lower secondary school children in Israel was investigated.

METHOD

Self-report questionnaires of sibling victimisation, peer bullying experiences and behaviour problems were completed by 921 pupils aged 12-15 (mean age 13.7 years).

RESULTS

Of the sample, 16.2% were directly bullied by their siblings at home and 11.9% were direct victims of bullying by peers at school every week. More than half of victims of bullying by siblings (50.7%) were also involved in bullying behaviour at school compared to only 12.4% of those not victimised by siblings, indicating a strong link between intrafamilial and extrafamilial peer relationships. Children with poor sibling and peer relationships were at a highly increased risk for behaviour problems. Ethnic (Israeli Jewish vs. Arab) and sex differences were small compared to the effects of sibling relationship on behaviour problems.

CONCLUSION

Intervention strategies directed at reducing bullying in school should take into account pupils' experiences of victimisation by siblings at home.

Genetics of adult attention-deficit/hyperactivity disorder

Results of behavioral genetic investigations using family twin and adoption studies converge with those of molecular genetic studies in showing that genes influence susceptibility to'attention-deficit/hyperactivity disorder (ADHD). These finding suggest that genetic mechanisms that predispose individuals to ADHD are complex. It seems likely that the disorder is caused by the combined actions of several genes. It is equally clear that aberrant genes create a vulnerability to the disorder that is not expressed in all environments. The literature about the genetics of adult ADHD is relatively small, but it suggests not only that the persistent form of ADHD is familial, but that it is more familial than the nonpersistent form. More work from twin and molecular genetic studies is needed to determine if the increased familiality of persistent ADHD reflects the actions of genes or of familial environmental causes.

Psychosocial treatments for adults with attention-deficit/hyperactivity disorder

This article discussed some ways in which a history of failure experiences can enhance negative affect and cognitive avoidance and further impair attentional and organizational abilities associated with ADHD. Accordingly,psychosocial interventions have two targets: providing training in organizational and attentional skills while addressing patterns that motivate demand-related distress and avoidance of these skills. The authors conceptualized these interventions as creating the conditions where patients best can use existing abilities and the benefits offered by medication treatment. As rep-resented by a small but growing literature, there are encouraging signs that structured skill-building treatments of this kind offer benefit to adults with ADHD. Further research on these strategies in the context of well-controlled trials is an essential step for helping reduce disability and distress among this cohort of patients.

Driving impairments in teens and adults with attention-deficit/hyperactivity disorder

Available research provides compelling evidence that ADHD is associated with significantly increased risks for various adverse outcomes while driving, including increased traffic citations (particularly speeding), motor vehicle crashes for which the driver is at fault, repeated crash occurrences,and more severe crashes as determined from dollar damage and likelihood of bodily injuries from the crash. Not surprisingly, teens and adults with ADHD are more likely to have their licenses suspended and even fully revoked. Research further suggests that these driving risks cannot be accounted for by the comorbid disorders likely to be associated with ADHD, such as ODD, conduct disorder (CD), depression, or anxiety, or by lower than normal levels of intelligence. Recent attempts to study the processes or mechanisms involved in driving in adults with ADHD offer some explanation of how the disorder conveys such increased risks. Driving can be conceptualized usefully as involving at least three or more dimensions or levels, including basic cognitive abilities necessary for driving (operational), actual skills for maneuvering the vehicle in traffic (tactical), and the more executive, goal-directed aspects of driving(strategic). The findings of studies indicate that ADHD interferes with the basic operational components of driving by means of the impairments it produces in attention, resistance to distraction, response inhibition, slower and more variable reaction time, and the capacity to follow rules that may compete with ongoing sensory information. Accumulating evidence also points to a problem in the tactical level of driving, such that those with ADHDrate themselves and are rated by others as employing less safe driving habits during their normal operation of a vehicle than are adults in community control groups. Although this has been more elusive to demonstrate through the use of simple laboratory-based driving simulators. more modern virtual reality driving platforms offer greater promise in providing more realistic appraisals of driving performance and thus more direct evidence of the problems that occur at the tactical level from the disorder. Research has not examined the impact of ADHD at the higher strategic level or goal-directed aspects of driving. But given the mounting evidence that ADHD adversely affects executive functioning in adults, the author and colleagues anticipate that this level also will be found to be impaired in adults with ADHD. Indeed,it recently has been shown that adults with ADHD overestimate their driving abilities relative to normal adults, a problem that likely can be ascribed to more limited self-awareness and related meta-cognitive abilities for self-evaluation arising from the disorder. Although further research on the driving problems posed by ADHD is in order, sufficient evidence exists to warrant focus on possible treatments that may serve to improve these driving problems and reduce the risk for these adverse outcomes. High on the list of such treatments deserving further research and clinical attention is the use of stimulant medication. The more recent noradrenergic reuptake inhibitor. atomoxetine, also may have some promise in this regard. Studies are underway in the author's driving laboratory to see if this is the case. Meanwhile, adults with ADHD and parents of teens with ADHD should be advised about these heightened risks and encouraged to take steps that may reduce them, including the consideration of more graduated licensing for adolescents with ADHD and the possible use of stimulant medication in teens and adults with ADHD while they are operating a motor vehicle.

Age-dependent expression of attention-deficit/hyperactivity disorder symptoms

The authors' research indicates that most adults with ADHD continue to struggle with substantial number of ADHD symptoms and high levels of dysfunction despite a sizable syndromatic remission. Furthermore, in-attention was more persistent than hyperactivity or impulsivity as children progress throughout adolescence and into early adulthood. These results stress the critical importance of carefully choosing the appropriate definition of remission in longitudinal studies of youth with ADHD and that symptom clusters and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined ADHD subtypes (ie, combined, inattentive., or hyperactive/'impulsive) should be considered separately.

Individual and Contextual Influences on Adolescent Smoking

Cigarette smoking among adolescents remains one of the most important public health challenges. Despite much attention to research on the etiology of smoking, notably the examination of factors that differentiate adolescent smokers from never smokers, much less is known about factors that predict the development of dependence once an adolescent tries smoking. This paper reviews individual and contextual influences on the progression of smoking among adolescents. Highlights include a consideration of multiple levels of influence, from intra-individual factors, such as genetics, demographics, temperament and comorbidities, to social influences, such as families and peers, to the more macro, societal/cultural levels of influence, including advertising and tobacco-related policies. More recent work examining microcontextual influences through the use of Ecological Momentary Assessments is also discussed. Finally, the need to consider both developmental and transdisciplinary approaches to understanding the development of nicotine dependence in adolescents is emphasized.

Screening and diagnostic utility of self-report attention deficit hyperactivity disorder scales in adults

Attention deficit hyperactivity disorder (ADHD) in adults is associated with significant social, legal, occupational, and psychiatric difficulties. The estimated prevalence of ADHD in the adult population is between 0.3% and 5%. Recent interest in the condition in adults has been accompanied by the appearance of a number of readily available scales for screening adults and aiding in the diagnosis of ADHD in this age group. However, there are few published data on the validity and reliability of such measures. We examined the diagnostic and screening utility of three ADHD scales (Adult Rating Scale [ARS], Attention-Deficit Scales for Adults [ADSA], and Symptom Inventory for ADHD) in 82 adults presenting for ADHD evaluation. All three instruments were sensitive to the presence of symptoms in adults with ADHD (correctly identifying 78% to 92% of patients with ADHD), but a high proportion of individuals with non-ADHD diagnoses screened positive (incorrectly identifying between 36% and 67% of non-ADHD patients). Our results suggest that the use of such measures for screening and as an aid in diagnosis should be approached with considerable caution.

Stimulant treatment over five years: adherence, effectiveness, and adverse effects

OBJECTIVE

To evaluate the impact of adherence and medication status on effectiveness and adverse effects of stimulant use in children with attention-deficit/hyperactivity disorder (ADHD) over 5 years.

METHOD

Seventy-nine of 91 participants in a 12-month randomized controlled trial of methylphenidate and parent groups enrolled in a follow-up study. Adherence to stimulants, treatment response, and adverse effects were evaluated annually for 5 years. Changes in teacher-reported symptoms and parent-reported adverse effects were compared at 2, 3, 4, and 5 years for 3 groups: adherents, nonadherents on medication, or nonadherents off medication. Controlling for age, gender, and baseline severity, adherence status and medication status were evaluated as correlates of teacher-reported ADHD symptom scores at each year using multiple regression analyses.

RESULTS

At 2 years, adherents (n = 41) showed greater improvement in teacher-reported symptoms than those off medication (n = 16) and equivalent response to nonadherents on stimulants (n = 16) (p =.02). At 5 years, adherents (n = 16) showed greater improvement in teacher-reported symptoms than nonadherents on stimulants (n = 15) and those off medication (n = 14) (p =.04). At year 2 medication status (beta = 4.67 [0.40-8.95, p =.033]) and at year 5 adherence status (beta = 7.23 [3.01-11.44, p =.001]) correlated with higher teacher-reported symptom scores. Clinically significant adverse effects were present for 5 years, most commonly loss of appetite.

CONCLUSIONS

Psychostimulants improve ADHD symptoms for up to 5 years, but adverse effects persist.

Long-term use of stimulants in children with attention deficit hyperactivity disorder: safety, efficacy, and long-term outcome

The purpose of this review is to summarize existing data on the long-term safety and efficacy of stimulant treatment, and how long-term stimulant treatment of children with attention deficit hyperactivity disorder (ADHD) affects their outcome. Existing controlled studies of children with ADHD treated and untreated with stimulants, as well as long-term prospective follow-up studies, are reviewed. Children with ADHD treated with stimulants for as long as 2 years continue to benefit from the treatment, with improvements observed in ADHD symptoms, comorbid oppositional defiant disorder, and academic and social functioning, with no significant problems of tolerance or adverse effects. Long-term, prospective follow-up studies into adulthood show that stimulant treatment in childhood has slight benefits regarding social skills and self-esteem. Long-term adverse effects from stimulant treatment in childhood regarding adult height or future substance abuse have not been supported by existing studies.

Heritability of attention problems in children: longitudinal results from a study of twins, age 3 to 12

BACKGROUND

Twin studies of childhood behavior problems support the conclusion that individual differences in impulsivity, hyperactivity, and inattention are largely due to genetic influences. Non-genetic variation is due to environmental influences that are unique to the individual, and possibly to rater contrast effects. In the present longitudinal twin study, we report on the size of genetic and environmental effects on individual differences in attention problems at ages 3, 7, 10 and 12 years.

METHODS

Mothers were asked to complete the CBCL for their twin offspring when the children were 3 (n = 11,938), 7 (n = 10,657), 10 (n = 6,192), and 12 years old (n = 3,124). We focus on the Overactivity (OA) scale in the Child Behavior Checklist (CBCL/2-3), and on the Attention Problem (AP) scale of the CBCL/4-18. The data were analyzed using longitudinal structural equation modeling.

RESULTS

Broad heritability of OA and AP is estimated at nearly 75%, at each age. A contrast effect was observed at age 3 only. The results revealed less stability of OA at age 3 to AP at age 7 (r = .40), compared to the stability from AP at age 7 and beyond (r = .70). Genetic effects explained between 76% and 92% of the covariance between OA and AP.

CONCLUSIONS

OA and AP are highly heritable at all ages in both genders. The same set of genes appears to be expressed in boys and girls. The size of genetic and environmental contributions remains the same across the ages studied. Stability in OA and AP is accounted for by genetic influences. Children who do not display OA or AP at a given age are unlikely to develop these problems at a subsequent age.

ADHD and reading disability in male adults: is there a connection?

The present study examined the comorbidity between attention-deficit/hyperactivity disorder (ADHD) and reading disability (RD) in male adults. Participants were 120 men, of whom 24 were classified as having ADHD. The basis for the diagnosis was two self-report scales validated by interviews and background data. An extensive battery was used to assess phonological abilities and various aspects of reading skills. No differences were obtained between adults with and without ADHD on measures of either phonological processing skills or word decoding, indicating a low comorbidity with RD. This finding was valid even when different criteria were used to diagnose RD. However, the two groups differed in reading comprehension, with individuals with ADHD performing poorly in tests of reading comprehension. These results are compatible with the view that reading comprehension involves many of the higher cognitive control functions assumed to be impaired in ADHD. However, these attentional control functions are not critical to word recognition, which is determined by a more encapsulated phonological processing module. The pattern of associations between ADHD and RD observed in the present study is explained with reference to the differential attentional demands of the two aspects of reading.

Impact of methylphenidate delivery profiles on driving performance of adolescents with attention-deficit/hyperactivity disorder: a pilot study

OBJECTIVE

Adolescents with attention-deficit/hyperactivity disorder (ADHD) are at high risk for driving accidents. One dose of methylphenidate (MPH) improves simulator driving performances of ADHD-diagnosed adolescents at 1.5 hours post-dose. However, little is known about the effects of different MPH delivery profiles on driving performance throughout the day.

METHOD

This randomized, crossover, single-blind study compared osmotic, controlled-release oral system (OROS) MPH (Concerta) given q.d. to immediate-release MPH (Ritalin) given in equal doses t.i.d. on driving performance among six male ADHD-diagnosed adolescent drivers aged 16 to 19 years. Under each treatment condition, participants were maintained on their medication dosage for 7 days, then drove a sophisticated driving simulator at 2 p.m., 5 p.m., 8 p.m., and 11 p.m. The primary outcome measure was each participant's computer-quantified Impaired Driving Score (IDS).

RESULTS

IDS worsened in the evenings for participants receiving MPH t.i.d. but remained stable when they received once-daily OROS MPH. Participants performed significantly better when receiving OROS MPH q.d. compared with MPH t.i.d. (F = 9.3, df = 1, p =.004). When MPH was given t.i.d., IDS significantly worsened beginning at 8 p.m. compared to OROS MPH (p =.01).

CONCLUSIONS

Participants demonstrated significantly less variability and better driving performance when receiving OROS MPH q.d. compared to MPH t.i.d., particularly in the evenings.

Effect of methylphenidate on time perception in children with attention-deficit/hyperactivity disorder

The effects of methylphenidate (MPH) on performance of a time-production task were studied in 17 children with attention-deficit/hyperactivity disorder who participated in 1 test session on and 1 off MPH. Participants held a response lever down for at least 10 but no longer than 14 s. Administration of MPH had no effect on the number of correct responses or on the mean duration of lever holds. MPH administration significantly decreased timing response variability, increased holds of 10- to 11-s duration, and decreased lever holds of extremely short durations. These results indicate that administration of MPH resulted in more precise timing performance without changing the mean duration of lever holds, suggesting an enhancement in working memory.

Motivational Influences on Cigarette Smoking

Cigarette smoking is a leading cause of mortality and morbidity and a particularly common and intractable addictive disorder. Research shows that nicotine is a sine qua non of tobacco addiction and that it produces the hallmark effects of addictive drugs: sensitization, tolerance, physical dependence, and euphoria/elation. Research on the development of smoking reveals that although smoking prevalence has declined from a peak in the mid-1990s, close to 30% of twelfth graders still smoke. Smoking in adolescents is related to development of physical dependence, ethnicity, impulsivity, affective disorder, and peer influences. However, which of these exerts the greatest causal effects is unknown, and their influence no doubt varies across individuals and across development. Once dependence on tobacco smoking is established, evidence suggests that tobacco motivation is strongly influenced by a reduction in withdrawal symptoms, an expectation of stress reduction, and conditioned reinforcement. Nicotine motivation may also be influenced by modulation in stimulus incentive value.

The Relation Between Parental Coping Styles and Parent-Child Interactions Before and After Treatment for Children With ADHD and Oppositional Behavior

This study examined the relation between parental coping styles, discipline, and child behavior before and after participating in a parent training program for parents of children with Attention-Deficit/Hyperactivity Disorder (ADHD) and oppositional behavior. For mothers, use of more maladaptive and less adaptive coping styles was related to more self-reported lax and overreactive discipline, more observed coercive parenting, and more observed child misbehavior prior to parent training. No significant relations were found for mothers following parent training after controlling for pretreatment variables. For fathers, use of more maladaptive and less adaptive coping styles was related to self-reported lax discipline before and after parent training. Contrary to prediction, fathers who reported less seeking support and adaptive-focused coping showed the most improvement in their children's behavior. Most results remained significant after controlling for self-reported depression. Implications for improving parent training research and programs were discussed.

Young adult follow-up of hyperactive children: antisocial activities and drug use

BACKGROUND

Hyperactive/ADHD children are believed to be a greater risk for adolescent and young adult antisocial activity and drug use/abuse, particularly that subset having comorbid conduct problems/disorder.

METHOD

We report on the lifetime antisocial activities and illegal drug use self-reported at young adult follow-up (mean age 20-21 years; 13+ year follow-up) for a large sample of hyperactive (H; N = 147) and community control (CC; N = 73) children. Parent reports of childhood hyperactivity and conduct problems at study entry, parent and self-reports of ADHD and conduct disorder at adolescence, and parent reports of ADHD at young adulthood are examined for their contribution to antisocial behavior and drug use at adulthood.

RESULTS

More of the H group committed a variety of antisocial acts and had been arrested for doing so (corroborated through official arrest records) than did the CC group. The H group also committed a higher frequency of property theft, disorderly conduct, assault with fists, carrying a concealed weapon, and illegal drug possession, as well as more arrests. These activities reduced to two dimensions corresponding to predatory-overt and drug-related antisocial conduct. The H group differed from the CC group only on the latter dimension. Childhood, adolescent, and adult ADHD predicted higher drug-related activities, as did childhood conduct problems. The H group with conduct disorder (CD) reported greater use of most substances than did the H only or CC groups, who did not differ from each other. Severity of teen ADHD and especially lifetime CD predicted use of hard drugs while just lifetime CD predicted marijuana/LSD use. Teen drug use seemed to potentiate increased drug-related antisocial activities beyond the contribution made by teen CD.

CONCLUSIONS

Hyperactive children are at greater risk for antisocial activities and arrests by young adulthood that appear to be principally associated with illegal drug possession, use, and sale. Those having CD, however, appear to engage in greater and more diverse substance use.

Adolescents with attention-deficit/hyperactivity disorder: an overview of empirically based treatments

The author first presents an overview of attention-deficit/hyperactivity disorder (ADHD) as it presents in adolescents. He reviews what is known about the predominantly inattentive subtype in adolescents, the persistence of symptoms into this developmental phase, and comorbid disorders in adolescent patients with ADHD. The author then reviews treatments for adolescents with ADHD for which there is some empirical support in the scientific literature. He first discusses common assumptions concerning the treatment of ADHD and evidence for or against these assumptions. Information on therapies that have been shown to be ineffective or the benefit of which is unproven are then described. These include cognitive-behavioral therapy and social skills training. The author then presents an overview of what is known about the medication treatment of ADHD and discusses how this information is applicable to adolescents with the disorder. Four main classes of drugs are discussed: stimulants, noradrenergic reuptake inhibitors, tricyclic antidepressants, and antihypertensive agents. The author then reviews the use of several psychosocial interventions, including contingency management strategies, parent training in behavior management methods, and teacher training in classroom management, and discusses how these strategies can best be used for adolescents with ADHD. The author then discusses the use of combined treatment with psychosocial interventions and medication. Finally, information on the use of physical exercise as therapy for adolescents with ADHD is discussed.

The prevalence of dyslexia and AD/HD in a sample of forensic psychiatric rapists

The prevalence of dyslexia and attention deficit/hyperactivity disorder (AD/HD) (DSM-IV) is markedly increased among those who are sentenced for criminal offences. The aim of the study was to identify developmental disabilities, dyslexia and AD/HD among severely disturbed men in forensic psychiatric care, and to study the co-occurrence of such disabilities, with the objective to discuss the importance of the diagnoses in forensic psychiatry. The participants were 10 males who had committed rape on adult women, and included two murder-rapists, one of which had murdered more than one victim (i.e. a serial murderer). All had been assigned to special long-term forensic psychiatric care, based predominantly on a psychodynamic ground. In order to be identified as having dyslexia, a participant's performance on at least three out of four tests of academic skills had to be markedly below the expected level (more than two stanine steps), given the participant's non-verbal intellectual capacity and considering the length of his education. AD/HD was investigated by studying the participants' forensic psychiatric files and by a clinical interview. Seven of the 10 participants met the DSM-IV criteria for dyslexia, and six of them met the DSM-IV criteria for AD/HD. Four participants had AD/HD and dyslexia, three had AD/HD but no dyslexia, and two had dyslexia but no AD/HD. Only one participant had neither dyslexia nor AD/HD. The participants with dyslexia performed well in tests assessing non-verbal reasoning, visuo-spatial capacity and visual memory. Although the generalization of the results from 10 rapists is severely limited, the results indicate the importance of assessing dyslexia as well as AD/HD in people who are admitted for forensic psychiatric assessment. The lack of correct diagnoses may negatively influence the choice of appropriate forensic psychiatric care. Early assessment of those disorders might have a positive influence on the psychological development and socialization process in people with dyslexia and/or AD/HD.