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

Association of attention-deficit/hyperactivity disorder symptoms with levels of cigarette smoking in a community sample of adolescents

OBJECTIVE

Research on the association of attention-deficit/hyperactivity disorder (ADHD) with cigarette smoking has primarily occurred within samples of clinically referred youths. This paper reports the association of ADHD symptoms with smoking practices in a community sample of adolescents.

METHOD

Confidential self-report surveys were completed by 1,066 tenth-grade students enrolled in five public high schools who were taking part in a longitudinal study of biobehavioral predictors of adolescent smoking adoption. A well-standardized measure of ADHD inattention and hyperactivity-impulsivity symptoms, as well as demographic and social risk factors, were examined in relation to three levels of cigarette smoking: (1) never having smoked, (2) ever having smoked, and (3) current smoking (having smoked a cigarette within the past 30 days).

RESULTS

Regarding lifetime cigarette use, approximately 43% of students had ever smoked. Among those who had ever smoked, approximately 31% of students were current smokers. Ever having smoked was associated with family (odds ratio [OR] = 2.49, confidence interval [CI] = 1.85, 3.36) and peer smoking (OR = 4.05, CI = 3.07, 5.33) and clinically significant ADHD inattention symptoms (OR = 3.39, CI = 1.53, 7.54). Current smoking was also associated with peer smoking (OR = 2.99, CI = 1.72, 5.20) and clinically significant ADHD inattention symptoms (OR = 2.80, CI = 1.20, 6.56).

CONCLUSION

Clinically significant ADHD symptoms should be taken into account when identifying adolescents at risk to smoke, since those with problematic inattention may be more likely to experiment with smoking and to become regular tobacco users.

The development of impulsivity, fearfulness, and helpfulness during childhood: patterns of consistency and change in the trajectories of boys and girls

BACKGROUND

The objective of the present study was to describe the development of boys and girls during the elementary-school years on three dimensions that conceptually and empirically represent risk for maladjustment.

METHOD

Every year between kindergarten and grade six, teachers rated the impulsivity, fearfulness, and helpfulness dimensions among a sample of 1,865 children representative of kindergarten boys and girls in the province of Quebec (Canada) in 1986-87. A group-based trajectory method was used to 1) identify groups of boys and girls following distinct-level trajectories of behaviours (on each dimension) during the elementary-school years; 2) estimate the proportion of children in each of the identified trajectory groups; and 3) estimate the patterns of consistency and variations in trajectories.

RESULTS

The results indicated that the best models comprised three distinct-level trajectory groups on fearfulness and helpfulness (a low, moderate, and high group) and four distinct-level trajectory groups on impulsivity. The helpfulness and fearfulness trajectory groups were generally more stable than the impulsivity groups. The broad patterns of development were similar across sexes. However, there were more boys on the higher impulsivity trajectories and low helpfulness trajectory, while there were more girls on the high fearfulness trajectory.

CONCLUSION

We found that behavioural consistency over middle childhood varied across trajectory groups and across dimensions, and we identified sex differences in the distribution of children in the different trajectory groups that may reflect gender-specific risks for psychopathology.

Further evidence for the diagnostic continuity between child and adolescent ADHD

OBJECTIVE

To determine if there are differences in the clinical expression and correlates of ADHD between children and adolescents.

METHOD

Subjects were 811 boys and girls aged 6 to 17 with ADHD, and 132 gender- and age-matched controls. Blind raters, using DSM-III-R structured diagnostic interviews and psychometric measures, assessed psychiatric diagnoses, intellectual performance, social disability, and school failure.

RESULTS

Children and adolescents with ADHD had very similar patterns of outcome in multiple domains of assessment, including comorbidity with conduct, mood and anxiety disorders, and school functioning. There was some evidence that the rate of ODD was greater in adolescents compared to children, and that this difference was greater in the control sample.

CONCLUSIONS

These findings document the diagnostic continuity of ADHD between childhood and adolescence and support the inclusion of adolescent samples in ADHD research protocols.

Driving anger and other driving-related behaviors in high and low ADHD symptom college students

This study examined differences between college students with high and low symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). Fifty-nine introductory psychology students completed ADHD diagnostic measures and were compared on measures of driving anger and driving anger expression; accident-related, aggressive, and risky driving behaviors; general anger; and general anger expression. Results indicated high ADHD symptom college students experience more driving anger, display such anger in more hostile/aggressive ways, are more aggressive and risky on the road, experience more crash-related outcomes, are more generally angry, and tend to display anger in socially unacceptable ways. Results are discussed in regard to the understanding and treatment of ADHD.

Attention dysfunction predicts substance involvement in community youths

OBJECTIVE

Cognitive impairments influence alcohol and drug treatment outcomes, though little is known about how neurocognition affects the development of harmful substance use patterns. This study examined the influence of adolescent attention functioning on the development of substance use problems in 66 high-risk youths over an 8-year period.

METHOD

Participants were community youths who were free from any history of substance use disorders, neurological illness, and mood, anxiety, or psychotic disorders at project intake and were administered neuropsychological tests and substance involvement interviews from ages 15 through 23 on average. Substance involvement was assessed by self-report, resource person reports, and randomly sampled toxicology screens.

RESULTS

Attention/executive functioning scores obtained at the intake neuropsychological assessment significantly predicted substance use and dependence symptoms 8 years later, even after controlling for intake substance involvement, gender, education, conduct disorder, family history of substance use disorders, and learning disabilities.

CONCLUSIONS

These results suggest that adolescents with limited attentional abilities, but not necessarily attention-deficit/hyperactivity disorder diagnoses, may be at risk for developing more problematic alcohol and drug involvement. Thus prevention and treatment efforts should target youths with attentional difficulties by using programs that are effective for those with compromised concentration and processing abilities.

ADHD and parental psychological distress: role of demographics, child behavioral characteristics, and parental cognitions

OBJECTIVE

This study aimed to examine the relative roles of demographic, child behavioral, and parental characteristics in understanding the psychological distress suffered by parents of children with attention-deficit/hyperactivity disorder (ADHD). It was hypothesized that a combination of child and parent demographics, severity of child behavioral disturbance, low knowledge of ADHD, causal and controllability attributions internal to the child, along with lower perceived parental control, would be associated with more severe psychological distress, as measured by parenting stress and depression.

METHOD

One hundred mothers were interviewed and provided ratings of behavioral disturbance, severity of ADHD, knowledge of ADHD, attributions of cause and controllability of ADHD-related behaviors, parenting stress and depression.

RESULTS

Hierarchical regression analyses indicated that the combination of these variables was significantly associated with parental psychological distress, accounting for 24% and 21% of the variance in parenting stress and depression, respectively. Unique contributions were evident for severity of behavioral disturbance and perceived parental control over child behaviors. Child's age, gender, medication status, and maternal education were controlled in the analyses.

CONCLUSION

Results support the view that interventions for ADHD aimed only at child behavior are unlikely to alter long-term outcome.

Attention-deficit/hyperactivity disorder and conduct disorder symptomatology in adolescents with alcohol use disorder

This study tested the hypothesis that attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) comorbidity is associated with substance use and deviance severity in 395 adolescents with alcohol use disorder. Thirty percent of the adolescents had high ADHD symptom counts, and 73% had 3 or more CD symptoms. ADHD-CD was associated with nonalcohol substance use disorder, drinking levels, and CD severity, but in general substance use was not uniquely elevated or problematic among the comorbid cases. In general, CD and CD severity were more important. The findings did not differ between boys and girls, revealing that in a treatment sample of adolescents, ADHD-CD comorbidity may need to be assessed and treated, but it is not broadly indicative of severity.

Child and adolescent psychopathology as risk factors for subsequent tobacco use

A growing body of research suggests that a number of types of psychopathology that occur during childhood and adolescence are also associated with an increased risk for tobacco use. This paper assesses the relationship between several types of child and adolescent psychopathology and subsequent tobacco use. The types of psychopathology that are discussed include 'externalizing' disorders such as conduct problems and attention-deficit/hyperactivity disorder (ADHD), and 'internalizing' disorders such as depression and anxiety disorders. The strongest evidence for connections between child and adolescent psychopathology and subsequent tobacco use is for conduct problems, ADHD, and depression. There is much weaker support for a connection between anxiety disorders and tobacco use. The relationships between conduct problems and ADHD (which frequently co-occur) and subsequent tobacco use are quite robust. Possible explanations of the relationships between conduct problems, ADHD, and tobacco use are presented. There appears to be a bidirectional relationship between depression and tobacco use; i.e., each has a comparable probability of preceding the other. Areas of particular importance are: (a) the effects of various psychopathologies on various aspects of tobacco use; (b) the role of comorbid psychopathologies; (c) identification of protective factors; (d) the effects of moderators (e.g., gender, ethnicity); (e) mechanisms and processes ('active ingredients') associated with various psychopathologies; (f) implications for intervention; and (g) possible cohort effects.

Attention-deficit hyperactivity disorder: critical appraisal of extended treatment studies

We undertook a systematic review of the literature on the long-term treatment of attention-deficit hyperactivity disorder (ADHD). We used systematic strategies to identify randomized treatment studies in which treatment was administered for 12 weeks or more. We included 14 studies involving 1379 subjects. Because of the limited number of high-quality studies and the heterogeneity of outcome measures, we did not perform meta-analysis. We rated 5 studies as adequate for methodological quality. Five studies followed children for more than 26 weeks. Pharmacologic interventions were studied more frequently than non-pharmacologic ones. Six studies permitted evaluation of the effects of combined drug and behavioural intervention. Twenty-five different outcomes were measured using 26 different tests. Stimulant medication appears to reduce ADHD (7 studies), dysfunctional social behaviour (6 studies), and internalizing symptoms (2 studies). Available studies provide little evidence for improved academic performance with stimulants (3 studies). Medications other than stimulants have not been studied extensively (3 studies). Only 1 study showed that combination therapy adds to the effects of medication. Rigorous treatment research among representative samples of ADHD individuals is needed.

A longitudinal study of developmental trajectories to young adult cigarette smoking

This study examined smoking trajectories between adolescence and adulthood in an African American cohort followed prospectively from first grade to age 32. We classified non-smokers, former smokers, current smokers/late adopters (initiated after age 18), and current smokers/early adopters (initiated before age 17). Results show that almost half of the population were currently smoking. Multiple logistic regression analyses showed that non-smokers differed most from the three smoking groups on social integration. Non-smokers were less likely to have left home before the age of 18, to have had more drug use parental supervision as an adolescent, to have moved less, and to attend church more frequently as an adult. Those current smokers who initiated early differed from the non-smokers and also from the former smokers and the current smokers who adopted smoking after the age of 18; they were more likely to be rated as aggressive or both shy and aggressive by their first grade teachers and to have drug problems as adults. Current smokers were less likely to attend church as adults than the non-smokers and former smokers. Neither mother's smoking or lifetime depression was related to smoking. The findings elucidate the contribution of factors over the life course that have an impact on smoking initiation, continuation, and cessation. They highlight the importance of targeting African American children and adolescents for prevention despite the fact that African American youth have the lowest rates of smoking across all ethnic groups. Possible interventions could be aimed at early aggressive behavior, parental supervision and monitoring, and other social integration efforts.

Familial links between attention deficit hyperactivity disorder, conduct disorder, and bipolar disorder

Although family, twin, and adoption studies indicate that attention deficit hyperactivity disorder (ADHD) is a familial condition with a robust genetic component, molecular genetic studies of candidate genes have produced inconsistent findings. One of the challenges to elucidating the genetic architecture of ADHD is its potential genetic heterogeneity. Therefore, efforts are needed to identify etiologically homogeneous subgroups of subjects with ADHD for use in genetic studies. The current article reviews evidence suggesting that parsing ADHD subjects based on comorbidity with conduct and bipolar disorders may yield familial subtypes that are suitable for genetic analyses.

Der Verlauf von Aufmerksamkeitsdefizit-/ Hyperaktivitätsstörungen (ADHS) im Jugend- und Erwachsenenalter

Zusammenfassung. Die Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) ist eine häufige Diagnose im Kindesalter. Die Klassifikationssysteme ICD-10 und DSM-IV erlauben die Diagnose auch im Erwachsenenalter, jedoch unterscheidet sich die Symptomatik von der des Kindesalters. Bei Jugendlichen und Erwachsenen ist mit einer heterogeneren Symptomatik zu rechnen. In großen Studien konnte gezeigt werden, daß die Symptome bei bis zu 30 % der Betroffenen bis ins frühe Erwachsenenalter persistieren können, allerdings leidet ein höherer Prozentsatz weiterhin unter Teilsymptomen mit klinischer Wertigkeit. Insbesondere komorbid auftretende Störungen des Sozialverhaltens, affektive Störungen, psychosoziale Belastungsfaktoren und ADHS in der Familie sind Risikofaktoren für eine Persistenz. Die heterogene Symptomatik im Jugend- und Erwachsenenalter sowie die komorbiden Störungen erfordern ein individuelles therapeutisches Vorgehen mit entwicklungsspezifischen Elementen unter Umständen über mehrere Lebensphasen hinweg.

Adolescent substance use disorders and comorbidity

It is imperative to know what risk factors are more likely to appear during specific developmental stages so that identification and interventions can be used to decrease the risk for future SUD. Continued surveying of risk factors that can occur at any stage in childhood are important to ensure that other risk factors are anticipated and intervened upon as well. Multiple risk factors increase the magnitude of the risk for SUD, and therefore all risk factors should be detected to convert these to protective factors. Screening instruments that can assess risk factors found to increase the risk for substance abuse can be found in examples, such as the Drug Usage Screening Instrument [81] and the Problem-Oriented Screening Instrument for Teenagers. The detection of risk factors by primary care providers is becoming increasingly important. However, other professionals are beginning to recognize that early recognition and treatment can enable a youth to go on to a productive life in other arenas as well. Drug courts and diversion programs are beginning to treat first-time offenders and their families rather than taking the punitive approach. These have proven to be very successful. Primary care physicians also should become familiar with motivational enhancement therapy when confronting a youth with a suspected substance abuse problem [57]. This method has proven to be more effective in getting youth into treatment than the direct, confrontational style, which often puts the youth in a defensive mode. Motivational enhancement therapy includes interventions that are delivered in a neutral and empathetic way. The six components of motivational enhancement therapy (also called FRAMES) include: Feedback on personal impairment Emphasis on personal responsibility Clear advice to change Menu of alternative options Empathy as a counseling style Self-efficacy In this way, a clinician can elicit pros and cons, give advice, provide choices, practice empathy, clarify goals, and remove barriers. This technique allows youth to be less defensive and more proactive. Monti et al. [59] have demonstrated that this technique has been useful in getting youth into treatment. Primary care physicians can use instruments that will assess the possibility of both externalizing (e.g., ADHD) and internalizing (e.g., depression and anxiety) disorders. Examples of this type of instrument are the Auchenbach child behavior checklist, teacher report form, and youth self-report form, which survey symptoms for these disorders [1]. Social anxiety disorder can be detected by asking whether the prelatency child went into new situations willingly and tended to hang back or whether the child had difficulty separating from his or her parents. Other questions to ask are whether the child tended to isolate or was fearful of speaking in front of the class. Of course, any bruising or behavior that suggests exposure to adult-related sexual acts may cause concern for physical or sexual abuse and possible PTSD. However, interest in sex earlier than expected for the age of the child may also indicate the possibility of bipolar disorder. These children have many symptoms of ADHD with a high degree of irritability and may seem boastful or grandiose. They may be "daredevils" with no fear of dangerous consequences. Referral to a specialist is necessary to evaluate these children further. Because substance use at age 14 or 15 years can be predicted by academic and social behavior at ages 7 to 9 years, early detection of poor social skills and learning difficulties is essential [43]. Learning disorders can be uncovered by asking the school to do an evaluation. However, schools having economic problems may not be able to accommodate all requests. A parent may have to pay a private provider to complete this workup because insurance companies seldom pay for educational testing. Learning disorders may go undetected because many school systems opt to use a higher deviation from the full-scale IQ to detect learning problems. For instance, if a student has an IQ of 115, the standard nationally recommended deviation from this IQ to detect a learning disorder is 15. Therefore, any child who scores 100 or less on an achievement test should be considered to have a learning disorder. Some schools prefer to use a deviation of up to 23 so that learning disorders are not detected. Few schools screen for processing problems, including auditory and visual motor processing problems, processing speed, comprehension, and short-term and long-term memory problems. This is extremely important because ADHD can be confused with an auditory processing problem. Stimulants may help this condition, but accommodations must be made to ensure continued success. Early-intervention programs, such as Drug Abuse Resistance Education (DARE), proved to be ineffective because the programs did not target components that have been shown to predict future drug use [54]. One program that has targeted these components, normative beliefs, lifestyle-behavior incongruence, and commitment is the All Stars program [39,40]. A strong initial dosage with booster interventions for at least 2 years is also important [10]. Before a child is diagnosed with oppositional defiant disorder or conduct disorder, every effort should be made to detect any underlying psychiatric disorder that has not been treated and therefore may look like a conduct disorder (e.g., bipolar disorder). Proper psychopharmacologic interventions should be made for psychiatric disorders. If one drug has been ineffective, another untreated psychiatric disorder may be present, and it is always important to tease out what remaining symptoms are present after a therapeutic trial has been tried. It is important to form a team approach so that all risk factors can be approached. Members of the team often include a primary care physician, a child psychologist, the parents, the patient, a teacher, a school counselor, a child psychiatrist, and sometimes a pediatric neurologist. No one member of the treatment team can provide all of the necessary services to prevent the future risk for substance abuse.

Association of DRD4 in children with ADHD and comorbid conduct problems

Recent family and twin study findings suggest that ADHD when comorbid with conduct problems may represent a particularly familial and heritable form of ADHD. Although several independent groups have shown association between the DRD4 7 repeat allele and ADHD, others have failed to replicate this finding. Previous TDT analyses of UK and Eire samples had also been negative. We set out to further examine the role of DRD4 but selecting a subgroup of children with ADHD and comorbid conduct problems. Families were recruited from Manchester, Ireland, Birmingham and London clinics. From these, 67 children who fulfilled diagnostic criteria for ADHD and who displayed conduct disorder symptoms were selected. TDT analysis, which had previously yielded negative results for the total sample, showed evidence of association between DRD4 and "ADHD with conduct problems" (7 repeat allele-24 transmissions, 13 non-transmissions; one-tailed P=0.05). These results provide further support for the role of DRD4 in ADHD. Furthermore, these results when considered together with family and twin study findings, suggest that those children with ADHD and comorbid conduct problems may be particularly informative for molecular genetic studies of ADHD. Further work is needed to examine these phenotype issues.

Relationship between current quality of life and family of origin dynamics for college students with Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

This study examines the relationship between current quality of life, family of origin relationship dynamics, and the presence of Attention-Deficit/Hyperactivity Disorder (ADHD) in college students.

METHOD

Participants were 37 ADHD undergraduate college students and 59 non-ADHD undergraduate students. Participants completed a background information questionnaire, Quality of Life Questionnaire, Family Environment Scale, and the Family Adaption and Cohesion Scale II.

RESULTS

In comparison to the control group, the ADHD group reported lower quality of life. The ADHD and non-ADHD groups did not differ significantly in reported family of origin relationship dynamics. Family of origin dynamics were highly predictive of current overall quality of life for the ADHD group, but less so for the non-ADHD group.

CONCLUSION

The results of this study suggest that family of origin relationship dynamics deserve further study with respect to how they impact adult quality of life for individuals with ADHD.

Psychopharmacology and aggression. I: A meta-analysis of stimulant effects on overt/covert aggression-related behaviors in ADHD

OBJECTIVE

To determine by meta-analysis the effect size for stimulants on overt and covert aggression-related behaviors in children with attention-deficit/hyperactivity disorder (ADHD), separately from stimulant effects on the core symptoms of ADHD.

METHOD

A review of the literature from 1970 to 2001 revealed 28 studies meeting inclusion/exclusion criteria for meta-analysis. These studies yielded 28 independent effects of overt aggression and 7 independent effects of covert aggression.

RESULTS

The overall weighted mean effect size was 0.84 for overt and 0.69 for covert aggression related behaviors in ADHD. Comorbid conduct disorder is associated with diminishing stimulant effect size for overt aggression.

CONCLUSION

Stimulant effects for aggression-related behaviors in ADHD have effect sizes similar to those for the core symptoms of ADHD.

Four-year follow-up of children with low intelligence and ADHD: a replication

Twenty children with attention deficit hyperactivity disorder (ADHD) and low IQs, who participated in a drug study, were followed up 4.5 years later, when their ages averaged 12.4 years (range: 8-20 years: SD = 2.78). Participants were assessed by their parents and teachers on the Aberrant Behavior Checklist-Community (ABC; Aman & Singh, 1994), on the Child Symptom Inventory (CSI; Gadow & Sprafkin, 1994), and on a structured interview. A majority of children continued to screen positive for ADHD at follow-up, as well as display high rates of comorbid anxiety disorders, tics, and elimination disorders. Educational placement became slightly more restrictive over the follow-up interval. Multiple medication trials (30 in all, among 14 participants) were attempted between initial contact and follow-up. Ratings on the ABC by parents and teachers showed significantly lower scores at follow-up on the Hyperactivity subscale. Relatively few associations were found between initial ratings and follow-up ratings on standardized scales.

Attention and conduct problems in children exposed to family violence

This study examines the impact of family violence on the development of attention and conduct problems in girls and boys. Mothers (n = 287) were interviewed and given diagnostic assessment instruments to measure attention deficit/hyperactivity disorder and conduct disorder in 1 of their children. Six years later, youths were interviewed about their delinquent behavior. Family violence related to attention and conduct problems in girls only. Girls who displayed these problems in childhood were not necessarily at risk for later delinquency. Family violence in childhood had a direct effect on delinquency in girls. Boys who developed attention problems were more likely to show conduct problems that eventually led to adolescent delinquency. Family violence failed to account for problems or delinquency in boys.

Long-term stability of the Child Behavior Checklist in a clinical sample of youth with attention deficit hyperactivity disorder

Evaluated the long-term stability of the Child Behavior Checklist (CBCL) in a longitudinal clinical sample of youth with attention deficit hyperactivity disorder (ADHD), testing the hypothesis that the CBCL scales will show stability over time. Participants were 105 Caucasian, non-Hispanic boys with ADHD between the ages of 6 and 17 assessed at baseline and at a 4-year follow-up. Stability of CBCL scales were computed for dimensional (intraclass correlation coefficients [ICCs], Pearson correlations) and dichotomized scale scores (kappa coefficients and odds ratios [ORs]). Evidence was found for stability of the categorical and dimensional types of scores, as demonstrated by statistically significant stability of the Pearson correlation coefficients, kappas, and ORs. The robust findings obtained from ICCs and kappa coefficients document substantial stability for CBCL scales over time within individuals with ADHD. These results support the informativeness of the CBCL as a useful measure of longitudinal course in clinical samples of youth with ADHD.

Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD)

Clinic-referred teens (ages 12-19) with ADHD and ODD (N = 101) were compared to community control (CC) teens, equated for age and sex, (N = 39) on a variety of psychological tasks assessing executive functioning (EF), temporal reward discounting, and time estimation and reproduction. A factor analysis reduced the EF measures to three dimensions, representing CPF Inattention, Working Memory, and CPT Inhibition. Results indicated that the ADHD group had significantly more CPT Inattention than the CC group. No differences were found for Working Memory or CPT Inhibition. The ADHD group displayed significantly greater temporal discounting of delayed hypothetical monetary rewards relative to immediate ones and manifested more impaired time reproduction, but not time estimation, than did the CC group. Main effects for level of IQ were found only on the Working Memory factor and largely did not interact with the group factor otherwise. The group differences in CPT Inattention, temporal discounting, and time reproduction were not a function of level of comorbid oppositional defiant disorder, delinquency, or anxiety-depression. Results are reasonably consistent with past research on EF and sense of time in children with ADHD and extend these findings to the adolescent age group. Problems with working memory and CPT inhibition found in prior studies of children with ADHD, however, were not evident here, perhaps owing to age-related improvements or insufficient task difficulty.

Parent-adolescent conflict in teenagers with ADHD and ODD

Eighty-seven male teens (ages 12-18 years) with ADHD/ODD and their parents were compared to 32 male teens and their parents in a community control (CC) group on mother, father, and teen ratings of parent-teen conflict and communication quality, parental self-reports of psychological adjustment, and direct observations of parent-teen problem-solving interactions during a neutral and conflict discussion. Parents and teens in the ADHD/ODD group rated themselves as having significantly more issues involving parent-teen conflict, more anger during these conflict discussions, and more negative communication generally, and used more aggressive conflict tactics with each other than did parents and teens in the CC group. During a neutral discussion, only the ADHD/ODD teens demonstrated more negative behavior. During the conflict discussion, however, the mothers, fathers, and teens in the ADHD/ODD group displayed more negative behavior, and the mothers and teens showed less positive behavior than did participants in the CC group. Differences in conflicts related to sex of parent were evident on only a few measures. Both mother and father self-rated hostility contributed to the level of mother-teen conflict whereas father self-rated hostility and anxiety contributed to father-teen conflict beyond the contribution made by level of teen ODD and ADHD symptoms. Results replicated past studies of mother-child interactions in ADHD/ODD children, extended these results to teens with these disorders, showed that greater conflict also occurs in father-teen interactions, and found that degree of parental hostility, but not ADHD symptoms, further contributed to levels of parent-teen conflict beyond the contribution made by severity of teen ADHD and ODD symptoms.

Attention-deficit hyperactivity disorder and problems in peer relations: predictions from childhood to adolescence

OBJECTIVE

To determine whether childhood attention-deficit hyperactivity disorder (ADHD) and persistence of the disorder are associated with later difficulty in adolescent peer relations.

METHOD

One hundred eleven children with ADHD were interviewed as adolescents and compared with 100 adolescents without an ADHD history (aged 13-18 years). The multi-informant assessment strategy included parents, teachers, and adolescents.

RESULTS

Parents of probands reported fewer close friendships and greater peer rejection compared with the non-ADHD group. Probands reported that their friends were less involved in conventional activities compared with the non-ADHD group. Childhood aggression predicted less self-perceived social competence for probands. The long-term effects of ADHD on social functioning were more pronounced for probands with persistent ADHD or conduct disorder in adolescence.

CONCLUSIONS

Impairments in peer relations for ADHD youths, known to be common in childhood, also exist in adolescence. Given the developmental significance of peer relations, further research into the causes and treatment of poor social functioning in youths with ADHD is recommended.

Dual diagnosis and successful participation of adolescents in substance abuse treatment

A retrospective record review of one year of admissions to a residential adolescent substance abuse treatment program (N = 91) examined the prevalence of comorbid psychiatric disorders and factors associated with successful treatment participation. Psychiatric and substance use disorders (SUD) were diagnosed by DSM-IV criteria. Successful participation was based on multiple factors assessed by the treatment team. Consistent with prior studies, there was considerable comorbidity (63.7%) with both disruptive (Attention Deficit Hyperactivity Disorder [ADHD], 11%; Conduct Disorder [CD], 24%) and other disorders (depression, 24%; adjustment disorder, 7.7%; bipolar disorder, 3.3%). Male gender was negatively associated (OR = 0.23, P = 0.019) with successful participation in univariate analyses, as was ADHD (OR = 0.18, P = 0.007). CD (OR = 0.37, P = 0.053) approached significance. Multivariate analysis reveals ADHD was significant while having CD and being male approached significance. Psychotropic medication use and other diagnoses were not associated with successful participation. It is concluded that further research on the relationship between ADHD, CD, and substance abuse treatment is needed.

Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder

This clinical practice guideline provides evidence-based recommendations for the treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline, the second in a set of policies on this condition, is intended for use by clinicians working in primary care settings. The initiation of treatment requires the accurate establishment of a diagnosis of ADHD; the American Academy of Pediatrics (AAP) clinical practice guideline on diagnosis of children with ADHD(1) provides direction in appropriately diagnosing this disorder. The AAP Committee on Quality Improvement selected a subcommittee composed of primary care and developmental-behavioral pediatricians and other experts in the fields of neurology, psychology, child psychiatry, education, family practice, and epidemiology. The subcommittee partnered with the Agency for Healthcare Research and Quality and the Evidence-based Practice Center at McMaster University, Ontario, Canada, to develop the evidence base of literature on this topic.(2) The resulting systematic review, along with other major studies in this area, was used to formulate recommendations for treatment of children with ADHD. The subcommittee also reviewed the multimodal treatment study of children with ADHD(3) and the Canadian Coordinating Office for Health Technology Assessment report (CCOHTA).(4) Subcommittee decisions were made by consensus where definitive evidence was not available. The subcommittee report underwent extensive review by sections and committees of the AAP as well as by numerous external organizations before approval from the AAP Board of Directors. The guideline contains the following recommendations for the treatment of a child diagnosed with ADHD:

Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design

BACKGROUND

Although attention-deficit hyperactivity disorder (ADHD) and conduct disorder (CD) frequently co-occur, the underlying mechanisms for this comorbidity are not well understood.

AIMS

To examine whether ADHD and conduct problems share common risk factors and whether ADHD+CD is a more heritable variant of ADHD.

METHOD

Questionnaires were sent to 2846 families. Parent-rated data were obtained for 2082 twin pairs and analysed using bivariate genetic analysis and a liability threshold model approach.

RESULTS

The overlap of ADHD and conduct problems was explained by common genetic and non-shared environmental factors influencing both categories. Nevertheless, the two categories appeared to be partly distinct in that additional environmental factors influenced conduct problems. It appeared that ADHD+CD was a genetically more severe variant of ADHD.

CONCLUSIONS

Conduct problems and ADHD share a common genetic aetiology; ADHD+CD appears to be a more severe subtype in terms of genetic loading as well as clinical severity.

The effect of child characteristics on teachers' acceptability of classroom-based behavioral strategies and psychostimulant medication for the treatment of ADHD

Studied the effect of student characteristics on teachers' ratings of treatment acceptability for attention deficit hyperactivity disorder (ADHD). Participants (N = 159) included experienced elementary school teachers who read 1 of 6 vignettes describing a child with symptoms representative of ADHD. Vignettes varied by sex and symptom-subtype classification. However, the number and specific type of symptoms described in the vignettes were consistent across all conditions. Next, teachers read a description of a daily report card (DRC), response cost technique, classroom lottery, and medication and rated their levels of agreement to the items of the Behavioral Intervention Rating Scale (BIRS). Teachers preferred the DRC to all other forms of treatment. However, there was a significant interaction between the type of treatment and sex of the student on the 3 factors (Treatment Acceptability, Treatment Effectiveness, and Timeliness) of the BIRS.

ADHD in Swedish 3- to 7-year-old children

OBJECTIVE

To study characteristics of attention-deficit/hyperactivity disorder (ADHD) in a representative group of clinically impaired young children in Sweden with the disorder.

METHOD

One hundred thirty-one children with ADHD (aged 3-7 years) were examined, and their parents were interviewed. Independent parent questionnaire data (Child Behavior Checklist, ADHD Rating Scale-IV, Conners) were collected. For comparison 131 children without ADHD were matched for age, gender, parents' marital status, child's adoption status, and social class.

RESULTS

Children with ADHD had extremely high ADHD symptom levels--on average four to eight times higher than the comparison group. Sociodemographic correlates of ADHD symptoms were more pronounced in parent questionnaire data than in parent interview data, underscoring the importance of diagnostic interview when dealing with clinical issues. Very few of the children with ADHD (6%) appeared "normal" with regard to attention/activity level at clinical examination.

CONCLUSIONS

Clinic children with a diagnosis of DSM-IV ADHD have typical and impairing symptoms already before starting school. The variance of ADHD in this age group appears to be accounted for by primary psychosocial factors only to a limited degree. It would seem reasonable to establish supportive and treatment measures for these young children so that the psychosocial and academic problems shown by so many individuals with ADHD later in their development might be reduced.

Moderators and mediators of long-term adherence to stimulant treatment in children with ADHD

OBJECTIVE

To identify moderators and mediators of long-term adherence to stimulant medication in children with attention-deficit hyperactivity disorder (ADHD).

METHOD

Seventy-one children with ADHD were prescribed methylphenidate, followed prospectively on an annual basis for 3 years, and evaluated for adherence to stimulant treatment. The study occurred in Toronto between 1993 and 1997. Adherents were those who took methylphenidate, or another psychostimulant, for 5 or more days per week throughout the follow-up period, except for "drug holidays." Children who adhered at consecutive evaluations were compared with those who did not. Severity of ADHD, presence of oppositional defiant disorder/conduct disorder, learning difficulties, anxiety, age, family dysfunction, and socioeconomic adversity at baseline were investigated as moderators of adherence. Response to treatment at school, measured at 12 months, was investigated as a mediator of adherence.

RESULTS

Fifty-two percent of children adhered to stimulant treatment for 3 years. Absence of teacher-rated oppositional defiant disorder, more teacher-rated ADHD symptoms, and younger age at baseline predicted adherence.

CONCLUSIONS

Adherence to stimulant medications is a significant factor in the long-term treatment of children with ADHD.

Substance use, substance abuse, and LD among adolescents with a childhood history of ADHD

A clinic-referred sample of 109 children with attention-deficit/hyperactivity disorder (ADHD) was followed into adolescence for the ascertainment of alcohol and other drug use and abuse. Learning disability (reading or math) in childhood was examined as a predictor of adolescent substance use and substance use disorder for alcohol and marijuana. No statistically significant group differences for children with LD versus those without LD emerged even after using different methods to compute LD. IQ/achievement discrepancy scores were similarly not predictive of later use or abuse. However, children with ADHD who had higher IQs and higher levels of academic achievement in childhood were more likely to try cigarettes, to smoke daily, and to have their first drink of alcohol or first cigarette at an early age. Children with ADHD who had higher reading achievement scores were less likely to have later alcohol use disorder. Although these findings are necessarily preliminary, due to the small number of children interviewed, the pattern of results suggests that level of cognitive functioning--rather than discrepancy between IQ and achievement--is important for the prediction of later substance use and abuse, at least in this clinic-referred sample of children with ADHD. Further, different mechanisms of risk related to cognitive functioning may be operating for experimentation with legal drugs such as alcohol and tobacco, regular cigarette smoking, and problematic alcohol use.

Risk factors for adolescent substance abuse

Reviews research on risk factors for adolescent substance use disorders (SUD) and discusses possible relationships between SUDs and learning disabilities (LD). Individual level factors (genetic, biologic, other familial, and psychiatric) emerge as very important in the risk equation, as well as the interaction between individual risk and environmental conditions. Commonalities between SUD risk and LD include prenatal substance exposure, family history of SUD, conduct disorder, social skills deficits, and academic failure; however, further research is needed to establish whether individuals with LD face a specific risk for SUDs, and if so, what the nature of that risk might be.

Factor and latent class analysis of DSM-IVADHD symptoms in a school sample of Brazilian adolescents

OBJECTIVE

To evaluate the validity of the multidimensional construct proposed by DSM-IV for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) in a school sample of young Brazilian adolescents.

METHOD

An instrument including all 18 DSM-IVADHD symptoms was administered to 1,013 students aged 12 to 14 years at 64 state schools by trained research assistants. Each symptom was rated on a Likert scale with five levels of severity (never, almost never, sometimes, frequently, and always).

RESULTS

Using an exploratory factor analytic approach (principal components analysis), two factors were extracted. Factor I (hyperactivity-impulsivity) comprised eight DSM-IV hyperactive-impulsive symptoms with loadings > or =0.40. Factor II (inattention) included also eight DSM-IV symptoms of inattention. The two factors explained 34% of the total variance and had an interfactor correlation of 0.45. Latent class analysis demonstrated similar classes in males and females, but class structures were markedly different from previous analyses of parent report data.

CONCLUSION

The findings support the appropriateness of the multidimensional construct introduced by DSM-IV in the diagnosis of ADHD in a different culture but emphasize the possible impact of different reporters on the results of structural model-testing.

Attention deficit/hyperactivity disorder and substance abuse. Diagnostic and therapeutic considerations

Patterns of association between attention deficit hyperactivity disorder (ADHD) and substance-use disorders are considered. Recent investigations have found that up to 50% of individuals with continuing ADHD symptoms have a substance-use disorder. ADHD appears to represent an independent risk factor for substance abuse. We review clinical challenges posed by the diagnosis of ADHD in substance-abusing populations. Nicotine dependence is also substantially more common among adults with ADHD (40%) than in the general population (26%). While several classes of substances of abuse may ameliorate various symptoms of ADHD, individuals with ADHD may also be vulnerable to substance use because of poor judgment or impulsive behavior in social settings. Evidence is reviewed from genetic studies examining the role of the dopamine D2 (DRD2) gene in the etiology of ADHD. The presence of ADHD may affect the course of adolescent substance abuse in several ways: predicting earlier age of onset, longer duration of substance-use disorder, and progression of alcohol abuse to another drug-use disorder. Individuals with ADHD have been noted to have a shorter interval between the onsets of drug abuse and drug dependence. Such individuals are also at greater risk for treatment failure, as their disruptive behaviors interfere with treatment access and response. Lastly, we review advances in pharmacotherapeutic agents used for treating ADHD and consider the impact of these interventions on comorbid substance-use disorders. We suggest promising areas of focus for clinical research trials targeting the subpopulation of substance abusers with concurrent ADHD.

Depression and smoking: examining correlates in a subset of depressed patients

OBJECTIVE

The objective of this study was to examine for associations between depression and cigarette smoking.

METHOD

A sample of 92 depressed smokers was compared with a control sample of depressed non-smokers, matched for age, gender and diagnostic variables. Comparisons were made across a range of demographic, depression, family history, developmental factors, anxiety and personality style variables, as well as use of alcohol and illicit drugs.

RESULTS

We failed to find any difference between smokers and non-smokers in history or severity of depression. Cigarette smokers were distinguished principally by greater exposure to aversive experiences in childhood, disordered personality function, greater use of illicit drugs, anxiolytics and alcohol. Logistic regression identified dysfunctional personality 'domains', physical violence in childhood, long-term anxiolytic use and illicit drug use as the most significant predictor set.

CONCLUSIONS

Results favour a model of cigarette smoking and depression as linked by shared early deprivational variables, rather than cigarette smoking causing depression or the converse.

Comorbidity in adults with attention-deficit/hyperactivity disorder

This paper describes the clinical manifestations of attention-deficit/hyperactivity disorder (ADHD) in adulthood, with particular emphasis placed on issues relating to comorbidity. Prospective and retrospective studies are reviewed to evaluate the degree to which adults with ADHD exhibit clinical features that mirror their childhood counterparts with analogous comorbid psychiatric (e.g., antisocial, mood, and anxiety) and/or cognitive (i.e., learning) disorders. We also address the question of whether comorbid disorders in adults represent independent diagnostic entities and whether the presence of psychiatric comorbidity varies as a function of ADHD subtype (i.e., inattentive, hyperactive-impulsive, combined, and residual). As is the case for ADHD in childhood, comorbidity is not uncommon among adults with ADHD. However, the reported prevalence of comorbid conditions among adults with ADHD varies considerably depending upon whether the research used a prospective or retrospective design.

Diagnosis and management of children with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is one of the most prevalent childhood psychiatric disorder which is characterized by three core symptoms of inattention, hyperactivity and impulsivity. It is estimated that 5% to 10% of school aged children suffer from this disorder. This disorder is more common in boys than girls. Comorbidity is a major problem and is present in as many as two thirds of children with ADHD. A multiple modality approach to treatment which combines pharmacotherapy, psycho education, behaviour therapy, environmental changes and social skills training is recommended. The outcome of ADHD is variable and unless properly treated in early years may predispose the child to serious psychopathology in adulthood.

Validity of the parenting scale for parents of children with attention-deficit/hyperactivity disorder

The present study examined the validity of the parenting scale for parents of elementary school-aged children with attention-deficit/hyperactivity disorder (ADHD). Parents from 109 families with children who had been diagnosed with ADHD (106 mothers and 93 fathers) and from 70 families with non-problem children (69 mothers and 59 fathers) completed the parenting scale and reported on their children's behavior problems. Factor analyses revealed two interpretable factors for both mothers and fathers, corresponding to the overreactivity and laxness factors identified in previous studies of the parenting scale. Overreactivity and laxness scores were significantly higher for mothers and fathers of ADHD children than of non-ADHD children; this effect appeared to be accounted for by comorbid aggression and conduct problems among ADHD children. Results support the validity of the parenting scale for use with parents of ADHD children.

The Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in Pediatric Patients

Attention-deficit/hyperactivity disorder (ADHD), characterized by developmentally inappropriate inattentiveness, impulsivity, and hyperactivity, is the most common and thoroughly researched neuropsychiatric disorder affecting children and adolescents. The diagnosis of ADHD requires a comprehensive clinical assessment including a detailed patient history, clinical interview and observation, and a thorough physical examination. A variety of other disorders can masquerade as ADHD or coexist with the disorder. The clinician must recognize environmental influences that may affect the severity of symptoms exhibited in the child or adolescent with ADHD. Clinically, treatment with a stimulant can be expected to result in an immediate, often dramatic, improvement in the core symptoms of ADHD. Studies published over the past 20 years indicate that the symptoms of ADHD, which were originally thought to diminish as a child matured, may persist into adolescence and adulthood. This article is a review of the most recent recommendations and clinical data regarding the diagnosis and management of ADHD in children and adolescents to assist with appropriate and prudent clinical decision making.

Risk factors in childhood that lead to the development of conduct disorder and antisocial personality disorder

With juvenile crime on the rise, understanding and preventing juvenile delinquency is one of the greatest challenges facing mental health professionals today. Recognizing early signs of conduct disorder (CD) can be difficult, but identifying risk factors is an important step in preventing a child's progression to CD or Antisocial Personality Disorder (APD). This paper focuses on various risk factors for CD and APD, such as intrinsic individual differences, psychosocial/environmental factors, genetic and neurochemical factors. Early recognition and intervention may prevent the progression from aggressive and maladaptive behaviors to CD and later APD.

Patterns of remission and symptom decline in conduct disorder: a four-year prospective study of an ADHD sample

OBJECTIVE

To evaluate systematically the longitudinal course of conduct disorder (CD) in a sample of youths with attention-deficit hyperactivity disorder (ADHD) to determine the effects of a persistent course on outcome.

METHOD

One hundred forty children with ADHD and their nuclear families were assessed at baseline and again at 1 and 4 years. Subjects were examined by means of DSM-III-R-based structured interviews. They were also evaluated for cognitive and social functioning. Persistent (exhibiting symptoms of CD at either follow-up) and desistent (symptoms of CD at neither follow-up) cases were identified.

RESULTS

Forty-two percent of CD cases followed a persistent course. Although both persistent and desistent subjects had high rates of antisocial disorders in relatives, increased family conflict and decreased family cohesion were selectively associated with a persistent course. In addition, subjects with persistent symptoms of CD exhibited more impaired ratings on the Aggression and Delinquency subscales of the Child Behavior Checklist, as well as higher rates of bipolar, oppositional defiant, and substance use disorders.

CONCLUSIONS

These findings suggest that the poor prognosis associated with CD is limited to an identifiable subgroup with a persistent course.

Factor structure and criterion validity of secondary school teacher ratings of ADHD and ODD

Attention-Deficit Hyperactivity Disorder (ADHD) is currently viewed as a heterogeneous disorder with two factors: inattention and impulsivity-hyperactivity. This conceptualization of ADHD is based primarily on research with children or samples that mix children and adolescents. To examine if the 2-factor ADHD model is appropriate for adolescents and if the ADHD factors are distinct from Oppositional Defiant Disorder (ODD) in adolescents, teacher rating data were collected for 2 samples of adolescents. The results of a confirmatory factor analysis supported the convergent and divergent validity of a model with separate but correlated factors for inattention, impulsivity-hyperactivity, and defiant behavior. Further evidence of construct validity was found when factor scores were examined relative to the criterion variables of academic performance and rule-breaking behavior. The results support the utility of teacher ratings of ADHD and ODD in the assessment of adolescents, and the applicability of the DSM-IV conceptualization of these disorders to adolescents.

Parenting and family stress treatment outcomes in attention deficit hyperactivity disorder (ADHD): an empirical analysis in the MTA study

Parenting and family stress treatment outcomes in the MTA study were examined. Male and female (579), 7-9-year-old children with combined type Attention Deficit Hyperactivity Disorder (ADHD), were recruited at six sites around the United States and Canada, and randomly assigned to one of four groups: intensive, multi-faceted behavior therapy program alone (Beh); carefully titrated and monitored medication management strategy alone (MedMgt); a well-integrated combination of the two (Comb); or a community comparison group (CC). Treatment occurred over 14 months, and assessments were taken at baseline, 3, 9, and 14 months. Parenting behavior and family stress were assessed using parent-report and child-report inventories. Results showed that Beh alone, MedMgt alone, and Comb produced significantly greater decreases in a parent-rated measure of negative parenting, Negative/Ineffective Discipline, than did standard community treatment. The three MTA treatments did not differ significantly from each other on this domain. No differences were noted among the four groups on positive parenting or on family stress variables. Results are discussed in terms of the theoretical and empirically documented importance of negative parenting in the symptoms, comorbidities and long-term outcomes of ADHD.

Psychosocial treatment strategies in the MTA study: rationale, methods, and critical issues in design and implementation

The Collaborative Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (ADHD), the MTA, is the first multisite, cooperative agreement treatment study of children, and the largest psychiatric/psychological treatment trial ever conducted by the National Institute of Mental Health. It examines the effectiveness of Medication vs. Psychosocial treatment vs. their combination for treatment of ADHD and compares these experimental arms to each other and to routine community care. In a parallel group design, 579 (male and female) ADHD children, aged 7-9 years, 11 months, were randomly assigned to one of the four experimental arms, and then received 14 months of prescribed treatment (or community care) with periodic reassessments. After delineating the theoretical and empirical rationales for Psychosocial treatment of ADHD, we describe the MTA's Psychosocial Treatment strategy applied to all children in two of the four experimental arms (Psychosocial treatment alone; Combined treatment). Psychosocial treatment consisted of three major components: a Parent Training component, a two-part School Intervention component, and a child treatment component anchored in an intensive Summer Treatment Program. Components were selected based on evidence of treatment efficacy and because they address comprehensive symptom targets, settings, comorbidities, and functional domains. We delineate key conceptual and logistical issues faced by clinical researchers in design and implementation of Psychosocial research with examples of how these issues were addressed in the MTA study.

Assessing violence risk among youth

Despite recent declines in the reported rate of juvenile violence, there appears to be increasing public and professional concern about violent behavior among children and adolescents. Media accounts of school shootings and juvenile homicides have prompted a need to develop approaches for systematically assessing violence risk. This article describes the task of assessing general violence risk among youth, and argues that a somewhat different approach is required to assess cases where an identified or identifiable young person may pose a risk to a specifically identified or identifiable target (also referred to as "targeted violence"). Key risk factors for violent behavior among children and adolescents are identified, fundamental principles for conducting an assessment of violence potential in clinical and juvenile justice contexts are outlined, and an approach to assessment when an identified person engages in some communication or behavior of concern that brings him or her to official attention is briefly described.

Attention deficit/hyperactivity disorder: characteristics, interventions and models

An epidemiological study of Attention Deficit/Hyperactivity Disorder (ADHD) suggests that the prevalence may be two to three times higher than the figure of 3-5% often cited. In addition, the data suggest that both underdiagnosis and overdiagnosis occur frequently. Rodent animal models of ADHD, like the Spontaneously Hypertensive Rat (SHR) and other rat models such as those with chemical and radiation-induced brain lesions and cerebellar stunting, and the Coloboma mouse model exhibit clear similarities with several aspects of the human disorder and should prove useful in studying specific traits. Operant behavioral tasks that model learning, short-term memory and simple discriminations are sensitive to ADHD and methylphenidate has been shown to normalize ADHD performance in a short-term memory task. Recent findings challenge not only the current postulate that response inhibition is a unique deficit in ADHD, but also the concepts of ADHD and its treatment, which presume intact perceptual abilities. Time perception deficits may account, in part, for the excessive variability in motor response times on speeded reaction time tasks, motor control problems and motor clumsiness associated with ADHD. The Multimodality Treatment Study of ADHD (MTA) provided data suggesting that pharmacological interventions that included systematic and frequent follow-up with parents and teachers, with or without psychosocial interventions, are superior to psychosocial interventions or standard community care alone. Additionally, the MTA was one of the first studies to demonstrate benefits of multimodal and pharmacological interventions lasting longer than 1 year. Imaging studies have demonstrated differences in brain areas in children with ADHD: anterior corpus callosum, right anterior white matter, and cerebellar volumes are all decreased in children with ADHD and there is less brain asymmetry in ADHD subjects. Additionally, functional imaging studies, coupled with pharmacological manipulations, suggest decreased blood flow and energy utilization in prefrontal cortex and striatum and the dysregulation of catecholamine systems in persons with ADHD.