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

Equivalent effects of stimulant treatment for attention-deficit hyperactivity disorder during childhood and adolescence

OBJECTIVE

To compare the therapeutic effect size of methylphenidate on attention-deficit hyperactivity disorder (ADHD) during childhood versus adolescence.

METHOD

A retrospective follow-up study of 16 individuals with diagnosed ADHD who completed double-blind, placebo-controlled, crossover studies of methylphenidate 0.3 mg/kg during two separate summer treatment programs. The programs were completed when the subjects were children (aged 8 to 11 years) and adolescents (aged 12 to 14.5 years). Dependent variables include objective measures of academic performance and social behavior and ratings completed by counselors and teachers.

RESULTS

Effect sizes ranged from very large to small, with most effects in the moderate to large range. Across the 12 dependent variables, t tests found that only 3 showed statistically significant changes in effect size from childhood to adolescence. Putative changes in effect sizes can be dismissed for methodological reasons.

CONCLUSION

Stimulant medication is equally effective with children and adolescents with ADHD if they are engaged in similar activities. Treatment providers should rigorously examine environmental causes to problems before prescribing higher doses of stimulants to adolescents with ADHD who exhibit a worsening in functioning.

Diagnostic continuity between child and adolescent ADHD: findings from a longitudinal clinical sample

OBJECTIVE

To determine whether there are differences in the clinical expression and correlates of attention-deficit hyperactivity disorder (ADHD) between children and adolescents.

METHOD

Subjects were 6- to 17-year old Caucasian, non-Hispanic boys with and without ADHD. DSM-III-R structured diagnostic interviews, psychometric measures, and blind raters assessed psychiatric diagnoses, intellectual performance, social disability, school failure, and family functioning.

RESULTS

Children and adolescents with ADHD had an almost identical pattern of correlates in multiple domains of assessment including psychosocial adversity and comorbidity with conduct, mood, and anxiety disorders. Although the rate of substance abuse differed in comparison between child and adolescent subjects, this was independent of ADHD status.

CONCLUSIONS

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

Adolescent substance abuse: a review of the past 10 years

OBJECTIVE

To review and synthesize the recent scientific literature on adolescent substance abuse, covering natural history, epidemiology, etiology, comorbidity, assessment, treatment, and prevention, and to highlight areas for future research.

METHOD

Studies of adolescent substance abuse were reviewed with the focus on substance abuse and dependence rather than substance use.

RESULTS

There has been a sharp recent resurgence in adolescent drug use. Biological factors, including genetic and temperament characteristics, as well as family environment factors, are emerging as important etiological variables. Comorbidity with other psychiatric disorders, particularly with conduct disorder, is frequent and complicates treatment. New assessment instruments are available for clinical and research use. Among treatment modalities, family-based interventions have received the most study.

CONCLUSIONS

The past decade has seen growth in the volume and sophistication of research on adolescent substance abuse and in the conceptualization of this problem. Further research is needed, particularly on the significance of comorbid conditions and on individualized and effective treatment approaches.

Attention-deficit/hyperactivity disorder: a neurodevelopmental approach

TOPIC

Attention-deficit/hyperactivity disorder is frequently overdiagnosed when a complete evaluation by a knowledgeable clinician is not undertaken. Because of the recent negative media campaign regarding psychostimulant medication, it becomes more imperative that a thorough and accurate evaluation be completed before starting children and adolescents on psychostimulant medications.

PURPOSE

To describe the neurodevelopmental perspective in the assessment and treatment of ADHD.

SOURCES

Published literature and clinical experience.

CONCLUSION

It is useful in practice to conceptualize the developmental path of children with ADHD not as disordered but as delayed, and to build on each child's strengths. The neurodevelopmental approach provides the child psychiatric nurse a child-focused framework for assessment and development of individualized interventions.

Classroom-based functional and adjunctive assessments: proactive approaches to intervention selection for adolescents with attention deficit hyperactivity disorder

The present investigation evaluated the utility of classroom-based functional and adjunctive assessments of problem behaviors for 2 adolescents who met diagnostic criteria for attention deficit hyperactivity disorder (ADHD) and comorbid oppositional defiant disorder (ODD). For children with ADHD-ODD, environmental classroom variables, when systematically manipulated by teachers, were related to the occurrence and nonoccurrence of problem behaviors. Classroom interventions derived from information that was obtained during functional and adjunctive assessments and from subsequent analyses resulted in substantial reductions in problem behaviors. Teacher and student consumer satisfaction ratings indicated that the interventions were effective and feasible in the classroom setting.

Peer tutoring for children with attention deficit hyperactivity disorder: effects on classroom behavior and academic performance

We investigated the effects of classwide peer tutoring (CWPT) on the classroom behavior and academic performance of students with attention deficit hyperactivity disorder (ADHD). Typical instructional activities were contrasted with CWPT for 18 children with ADHD and 10 peer comparison students attending first- through fifth-grade general education classes. CWPT led to increases in active engagement in academic tasks along with reductions in off-task behavior for most participants. Of students with ADHD, 50% exhibited improvements in academic performance in math or spelling during CWPT conditions, as measured by a treatment success index. Participating teachers and students reported a high level of satisfaction with intervention procedures. Our results suggest that peer tutoring appears to be an effective strategy for addressing the academic and behavioral difficulties associated with ADHD in general education settings.

Preliminary normative data on DSM-IV attention deficit hyperactivity disorder in college students

Identification of attention deficit hyperactivity disorder (ADHD) in adults presents a number of problems because there is no one specific diagnostic test for the condition. Given this challenge, clinicians often struggle between restrictive and exclusionary diagnostic methods or overinclusive acceptance that ADHD is a prevalent and disabling problem. A modified version of the Attention Deficit Hyperactivity Rating Scale was administered to 468 students at a large midwestern university. Analysis of the results suggested that the degree of ADHD symptoms in college students is modest and indicated that cutoff scores of 4 for current symptoms of inattention and hyperactivity-impulsivity would be sufficient to identify a college student as distinct from the norm. Although it would be premature to accept the calculated thresholds completely, clinicians should be aware of these differences when evaluating college students for ADHD.

A prospective study of hyperactive boys with conduct problems and normal boys: adolescent and adult criminality

OBJECTIVE

To examine the relationship between attention deficit disorder with hyperactivity in childhood and criminality in adolescence and adulthood in 89 hyperactive and 87 normal control subjects.

METHOD

In this prospective study, adolescent follow-up intervals ranged from 13 to 21 years and adult follow-up ranged from 18 to 23 years. The official arrest records for all subjects were obtained.

RESULTS

Hyperactive subjects had significantly higher juvenile (46% versus 11%) and adult (21% versus 1%) arrest rates. Juvenile and adult incarceration rates were also significantly higher. Childhood conduct problems predicted later criminality, and serious antisocial behavior in adolescence predicted adult criminality.

CONCLUSIONS

Hyperactive children are at risk for both juvenile and adult criminality. The risk for becoming an adult offender is associated with conduct problems in childhood and serious antisocial behavior (repeat offending) in adolescence. Hyperactive children who do not have conduct problems are not at increased risk for later criminality.

A new self-report scale for assessment of adolescent psychopathology: factor structure, reliability, validity, and diagnostic sensitivity

This paper describes four studies on self-reported problems in 2,243 adolescent males and females, 12 to 17 years of age. In Study 1, principal-axis factoring of 102 items covering 11 problem domains revealed six factors comprising 49.5% of the variance. Study 2 used confirmatory factor analysis of a 64-item reduced set on a new sample of 408 adolescents. Goodness-of-fit indicators suggested that the six-factor model had excellent fit to the data. Study 3 used data from the 2,157 adolescents used in the first two studies. Coefficient alphas ranged from .83 to .92. Median test-retest reliability for the six factors was .86. There was a consistent structure of the correlation matrix across age and gender. Study 4 was a study of criterion validity, using an additional sample of 86 children with attention-deficit hyperactivity disorder (ADHD). Sensitivity and specificity were high, with an overall diagnostic efficiency of 83%. This new self-report scale, the Conners/Wells Adolescent Self-Report of Symptoms (CASS), may provide a useful component of a multimodal assessment of adolescent psychopathology.

The use of qualitative methods in the study of wellness in children with attention deficit hyperactivity disorder

TOPIC

Attention deficit hyperactivity disorder (ADHD) effects on children and families.

PURPOSE

To describe the gaps in current ADHD literature, exploring the role of qualitative research methods to study the health and well-being of children and families with ADHD.

CONCLUSIONS

In light of the difficult problems ADHD children experience and the low efficacy of many medical and psychological treatment, a need exists for understanding the contexts and everyday circumstances under which ADHD children and their families achieve well-being.

Practice parameters for the assessment and treatment of children, adolescents, and adults with attention-deficit/hyperactivity disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters review the literature on children, adolescents, and adults with attention-deficit/hyperactivity disorder (ADHD). There are three types of ADHD: predominantly inattentive, predominantly hyperactive-impulsive, and combined. Together, they occur in as many as 10% of boys and 5% of girls of elementary school age. Prevalence declines with age, although up to 65% of hyperactive children are still symptomatic as adults. Frequency in adults is estimated to be 2% to 7%. Assessment includes clinical interviews and standardized rating scales from parents and teachers. Testing of intelligence and academic achievement usually are required. Comorbidity is common. The cornerstones of treatment are support and education of parents, appropriate school placement, and pharmacology. The primary medications are psychostimulants, but antidepressants and alpha-adrenergic agonists are used in special circumstances. Other treatments such as behavior modification, school consultation, family therapy, and group therapy address remaining symptoms.

Practice parameters for the assessment and treatment of children and adolescents with substance use disorders. American Academy of Child and Adolescent Psychiatry

These practice parameters describe the assessment and treatment of children and adolescents with substance use disorders and are based on scientific evidence regarding diagnosis and effective treatment as well as on the current state of clinical practice. Given the paucity of research on the treatment of substance use disorders in children and adolescents, many of the recommendations are drawn from the adult literature and current clinical practice. These parameters consider risk factors for substance use and related problems, normative use of substances by adolescents, the comorbidity of substance use disorders with other psychiatric disorders, and treatment settings and modalities.

The practical aspects of diagnosing and managing children with attention deficit hyperactivity disorder

AD/HD is a behaviorally defined disorder with specific behavioral criteria. The most recent definitions decrease heterogeneity by defining subtypes although the current treatments tend to be more generic. The main well-established treatments are stimulant medication and behavior modification, which are most effective when used together.

Educational and occupational outcome of hyperactive boys grown up

OBJECTIVE

Little is known about the adult outcome of attention-deficit hyperactivity disorder (ADHD), a very prevalent childhood disorder that is known to affect deleteriously academic performance and other areas of child functioning. This study represents a third wave of evaluations that examine the long-term educational achievement and occupational rank of children with ADHD.

METHOD

This is a prospective follow-up of white boys of average intelligence whose ADHD was clinically diagnosed according to systematic criteria at an average age of 7 years. Follow-up intervals range from 15 to 21 years (mean, 17 years). At average age 24 years, 85 probands (representing 82% of the childhood cohort) and 73 controls (84%) were directly interviewed by trained clinicians who were blind to group membership.

RESULTS

First, probands completed significantly less formal schooling than controls (about 2 years less, on average). Second, probands had lower-ranking occupational positions than controls. Finally, these disadvantages were not accounted for by adult mental status.

CONCLUSIONS

The present study suggests that childhood ADHD predisposes to specific disadvantages and continues to affect important functional domains unrelated to current psychiatric diagnosis.

Toward a broader definition of the age-of-onset criterion for attention-deficit hyperactivity disorder

OBJECTIVE

To critique the age-of-onset criterion (AOC) for the diagnosis of attention-deficit hyperactivity disorder (ADHD).

METHOD

The specific AOC of 7 years for symptoms producing impairment as part of the diagnostic criteria is examined from historical, empirical, conceptual, and pragmatic perspectives.

RESULTS

No support could be found for the continued use of this criterion for either clinical or research diagnostic purposes. While both empirical and conceptual grounds exist for viewing ADHD as a disorder that typically has its onset of symptoms during childhood, no support exists for the selection of age 7 years for onset of a valid disorder, either for symptom onset or for onset of impairment.

CONCLUSIONS

Several reasons favor dispensing with a precise AOC, either for symptom onset or onset of impairment, not the least of which is that it is scientifically indefensible, poses unwarranted practical problems for the study of older adolescents and adults, and may be arbitrarily discriminatory. Until such time as an empirical justification can be marshaled for a precise AOC for ADHD, the current AOC should be either abandoned or generously broadened to include onset of symptoms during the entire childhood years, in keeping with its conceptualization as a childhood-onset disorder.

Attentional difficulties in middle childhood and psychosocial outcomes in young adulthood

The associations between (dimensionally scored) measures of attentional difficulties at age 8 and psychosocial outcomes at age 18 were examined in a birth cohort of New Zealand children. Increasing attentional difficulties during middle childhood were associated with increased risks of academic failure or difficulties, juvenile offending, and substance use behaviours in young adulthood. However, those with early attentional difficulties were a high-risk group characterised by social disadvantages, early conduct difficulties, lower IQ, and related characteristics. Statistical adjustments showed: (a) that attentional difficulties were related to later academic success even when due allowance was made for potentially confounding factors; and (b) early attentional difficulties were unrelated to later juvenile offending or substance use behaviours after adjustment for confounding. In all cases there was evidence of consistent dose/response relationships between the extent of early attentional difficulties and later academic outcomes, suggesting that these associations were not confined to those with extreme symptoms.

Gender and comorbid psychopathology in adolescents with alcohol dependence

OBJECTIVE

Although several mental disorders have been shown to be common in adolescents with substance use disorders, prior studies have not specifically focused on alcohol dependence and have not had sufficient sample sizes to examine gender effects. This study contrasts mental disorder diagnoses and symptoms between a sample of adolescents with alcohol dependence and a community control sample of adolescents and incorporates gender analyses.

METHOD

Adolescents (aged 14 years 0 months to 18 years 0 months) with alcohol dependence (females: n = 55; males: n = 78) and community-dwelling control adolescents without substance use disorders (females: n = 44; males: n = 42) were assessed by means of a semistructured interview for DSM-III-R.

RESULTS

While cannabis and hallucinogen use disorders were common in the alcohol dependence group, females and males had similar rates. Conduct disorder (CD), oppositional defiant disorder, attention-deficit hyperactivity disorder, major depression (MD), and posttraumatic stress disorder (PTSD) had significantly higher rates in the alcohol dependence than in the community control group. Depression and PTSD symptoms were more strongly associated with alcohol dependence in females than in males. A configural frequency analysis showed that CD and MD tended to occur together in both female and male adolescents with alcohol dependence.

CONCLUSIONS

While alcohol-dependent females and males similarly exhibited more comorbid disorders than control adolescents, gender affects the relationship of alcohol dependence to MD and PTSD. Rather than reflecting distinct types, the comorbid disorders of CD and MD jointly characterize many adolescents with alcohol dependence.

Do attention deficit hyperactivity disorder and major depression share familial risk factors?

Comorbidity between ADHD and major depression has been reported from both epidemiologic and clinical studies of both children and adults. Our goal was to assess the validity of the association by reviewing family studies of the two disorders. We examined this issue from a genetic epidemiologic perspective by searching the literature for family studies of ADHD children that had assessed depression in relatives and family studies of depressed children that had assessed ADHD in relatives. Family studies of ADHD, family studies of depression, and one population-based family study strongly support the assertion of a familial link between ADHD and depression. ADHD families with antisocial disorders show the greatest risk for depression. However, in the absence of antisocial disorders, ADHD also imparts a familial risk for depression. ADHD and major depression probably share familial risk factors, and the difference between depressed and nondepressed ADHD patients can be attributed to environmental factors. Depression in an ADHD child should not be routinely dismissed as demoralization secondary to ADHD, and depression in mothers of ADHD children should not always be attributed to the stress of living with an ADHD child. The converse statements are equally valid: ADHD in depressed children may not be secondary to depression, and ADHD in the children of depressed mothers may not be a transactional response to the mother's depression.

Influences on adolescent substance dependence: conduct disorder, depression, attention deficit hyperactivity disorder, and gender

OBJECTIVE

In adolescents, conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), and depression are frequently comorbid with substance dependence (SD). We hypothesized that the prevalence and severity of CD, major depressive disorder (MDD), and ADHD would differ by gender, and that these conditions would associate differentially with severity of SD in males and females.

METHODS

We examined these issues, using standardized diagnostic interviews, in 285 male and 82 female adolescents referred for comorbid CD and SD.

RESULTS

Males and females did not differ significantly in severity of substance involvement, MDD, or ADHD, but males had more severe CD. MDD severity was the only variable significantly associated with SD severity for females, while for males, severity of CD combined with MDD and ADHD was significantly associated with SD severity.

CONCLUSIONS

Among referred adolescents, CD, MDD, and ADHD may all be important concomitants of SD in males, while in females, depression may be the primary variable related to SD.

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

OBJECTIVE

Since the introduction of DSM-III/III-R, clinicians and investigators have shown increasing interest in the study of conditions comorbid with attention-deficit hyperactivity disorder (ADHD). Better understanding ADHD comorbidity patterns is needed to guide treatment, research and future classification approaches.

METHOD

The ADHD literature from the past 15 years was reviewed to (1) explore the most prevalent patterns of ADHD comorbidity; (2) examine the correlates and longitudinal predictors of comorbidity; and (3) determine the extent to which comorbid patterns convey unique information concerning ADHD etiology, treatment and outcomes. To identify potential new syndromes, the authors examined comorbid patterns based on eight validational criteria.

RESULTS

The largest available body of literature concerned the comorbidity with ADHD and conduct disorder/aggression, with a substantially smaller amount of data concerning other comorbid conditions. In many areas the literature was sparse, and pertinent questions concerning comorbidity patterns remain unexplored. Nonetheless available data warrant the delineation of two new subclassifications of ADHD: (1) ADHD aggressive subtype, and (2) ADHD, anxious subtype.

CONCLUSIONS

Additional studies of the frequency of comorbidity and associated factors are greatly needed to include studies of differential effects of treatment of children with various comorbid ADHD disorders, as well as of ADHD children who differ on etiological factors.

Long-term follow-up of children with mental retardation/borderline intellectual functioning and ADHD

Fifty-two children (ages 7 to 14 years) with moderate retardation to borderline intellectual functioning were recontacted 12 to 65 months following participation in a double-blind, placebo-controlled trial of methylphenidate (MPH). Sixty-nine percent of subjects continued to be prescribed medication for behavior control at follow-up. While 72% of the sample evidenced improvement, over two-thirds continued to be rated at or above the 98th percentile on the Hyperactivity Index of the Parent Conners. In fact, 22% of subjects had received inpatient psychiatric treatment between the time of the initial MPH trial and follow-up. Finally, subjects with high initial ratings on the Parent Conners Conduct Problems scale were more likely to be suspended from school or receive inpatient psychiatric treatment than subjects with low initial ratings. The results suggested that children with ADHD and mental retardation of borderline intellectual functioning continued to exhibit significant symptoms associated with attention deficit hyperactivity disorder (ADHD) at follow-up and that early conduct problems were predictive of continuing behavioral difficulties.

School-based secondary prevention for children with disruptive behavior: initial outcomes

First through fourth graders from 22 suburban elementary schools were screened for cross-setting disruptive behavior as eligibility criteria for participation in a longitudinal secondary prevention study aimed at reducing the risk for serious externalizing behavioral disorders. Three hundred nine subjects participated in either a multicomponent competence enhancement intervention (MCEI) or an information/attention control (IAC) condition over a 2-year period. Following baseline requirements, initial intervention effects were assessed at the end of intervention Year 1, at the beginning of intervention Year 2 (fall of the next school year), and at the end of intervention Year 2. Multisource assessments were not supportive of the efficacy of the MCEI over the IAC condition. Children in both groups rated themselves as improved over time in terms of increased adaptive skills and decreased school problems and internalizing symptoms. Teacher and parent ratings of externalizing behavior did not yield evidence of positive change, but teachers noted improved problem solving and observers noted a decrease in behavioral interference in both groups over time, possibly as a result of maturation.

Behavioral, situational, and temporal effects of treatment of ADHD with methylphenidate

OBJECTIVE

To determine the behavioral, situational, and temporal effects of 4 months of methylphenidate (MPH) treatment for attention-deficit hyperactivity disorder (ADHD).

METHOD

Ninety-one children with ADHD were randomly assigned to receive either MPH (titrated to a target dose of 0.7 mg/kg twice a day) or a placebo. Treatment effects were investigated with measures sensitive to various behaviors (core and associated symptoms), situations (home and school), time periods (morning and afternoon, after reaching the target dose, and after 4 months of treatment), and side effects.

RESULTS

MPH treatment improved symptoms of ADHD and oppositional behavior at school, both in the morning and afternoon, but not at home. Side effects (increase in physiological and effective symptoms, lack of weight gain) were significantly more frequent with MPH than with placebo treatment. Benefit was evident after titration, but the onset of some side effects was delayed. Side effects were reported by parents but not by teachers.

CONCLUSIONS

Positive effects of MPH on behavior are evident in the classroom, but with MPH given twice daily, parents do not report that MPH improves behavior at home. Greater impact on home behavior may require three times daily MPH and combined treatments.

Behavioral self-regulation: correlates and 2 year follow-ups for boys at risk for substance abuse

This investigation demonstrated the heuristic construct of behavioral self-regulation (BSR) as a salient component of the liability to substance abuse. Three dimensions of childhood behaviour were employed to create a dimensional model of BSR: inattention, impulsivity/hyperactivity and aggressivity. Multiple measures and multiple informants were employed to develop indices of the three traits in a sample of 10-12 year old sons of substance abusing fathers (high risk (HR); n = 180) and normal controls (low average risk (LAR); n = 200). Informants included mothers, boys and their teachers. The results confirmed the presence of a first-order latent trait of BSR. HR boys had significantly higher scores on BSR than LAR boys. Concurrent validity of the BSR trait scores was supported by significant associations with measures of family dysfunction, deviant peer affiliations and poor school performance. These latter problems are commonly prodromal to substance abuse. Predictive validity of the BSR trait baseline scores (age 10-12 years) was supported at 2 year follow-up by significant associations of BSR scores with magnitude of deviant peer affiliations; trends toward significance were found for family dysfunction and poor school performance. Taken together, these results confirm and extend previous findings which indicate that poor BSR is prodromal to substance abuse.

Child and family factors influencing the clinical referral of children with hyperactivity: a research note

This study examined child and family factors associated with the clinical referral of pervasively hyperactive children. Fourteen children with pervasive hyperactive behaviour problems referred to a London child guidance service were compared with 13 nonreferred pervasively hyperactive children resident in the same geographic area. Child behaviour, parenting, and family life factors were examined as determinants of referral. Preliminary results suggest that both child and parenting factors play an important role in determining whether a child with hyperactivity will be referred for child guidance. The best predictors of clinical referral were a parent's ability to cope with child behaviour, child emotional disturbance, school relationship problems, and parental disciplinary indulgence. Implications of referral bias for research and service planning are discussed.

ADHD is associated with early initiation of cigarette smoking in children and adolescents

OBJECTIVE

The association between attention-deficit hyperactivity disorder (ADHD) and cigarette smoking in children and adolescents was evaluated.

METHOD

Subjects were 6- to 17-year-old boys with DSM-III-R ADHD (n = 128) and non-ADHD comparison boys (n = 109) followed prospectively for 4 years into mid-adolescence. Information on cigarette smoking was obtained in a standardized manner blind to the proband's clinical status. Cox proportional hazard models were used to predict cigarette smoking at follow-up using baseline characteristics as predictors.

RESULTS

ADHD was a significant predictor of cigarette smoking at follow-up into mid-adolescence. Our findings also revealed that ADHD was associated with an early initiation of cigarette smoking. This was the case even after controlling for socioeconomic status, IQ, and psychiatric comorbidity. In addition, among children with ADHD, there was a significant positive association between cigarette smoking and conduct, major depressive, and anxiety disorders.

CONCLUSIONS

ADHD, particularly the comorbid subtype, is a significant risk factor for early initiation of cigarette smoking in children and adolescents. Considering the prevalence and early childhood onset of ADHD, these findings highlight the importance of smoking prevention and cessation programs for children and adolescents with ADHD.

Prevalence and implications of attention-deficit hyperactivity disorder among adolescents in treatment for substance abuse

OBJECTIVE

Attention-deficit hyperactivity disorder (ADHD) is overrepresented among adults and adolescents in treatment for substance abuse. This study was designed to assess the prevalence of ADHD and to elucidate differences among adolescent substance abusers relative to ADHD symptomatology.

METHOD

The Wender Utah Rating Scale and the Self-Evaluation (Teenager's) Self-Report were used to evaluate childhood history of ADHD and current symptoms, respectively, and the Child Attention Problems Scale was completed by treatment program clinicians. A quantitative substance use history and a subjective substance use interview were also administered.

RESULTS

A total of 50% of 14 females and 16 males, ranging in age from 14 to 19, met study criteria for ADHD. ADHD subjects began drug use at an earlier age, had more severe substance abuse, and had a more negative self-image prior to drug use and improved self-image with drug use. They experienced more negative affective responses related to substance use and more drug craving and attentional difficulties in treatment than control subjects.

CONCLUSIONS

The results support a substantial comorbidity of ADHD among adolescent substance abusers, with indications of drug use for self-medication. Counseling for ADHD and medication may be indicated to improve treatment outcome and future functioning.

Is ADHD a risk factor for psychoactive substance use disorders? Findings from a four-year prospective follow-up study

OBJECTIVE

To evaluate whether attention-deficit hyperactivity disorder (ADHD) is a risk factor for psychoactive substance use disorders (PSUD), attending to issues of psychiatric comorbidity, family history, and adversity.

METHOD

Using assessments from multiple domains, the authors examined 140 ADHD and 120 normal control subjects at baseline and 4 years later. Drug and alcohol abuse and dependence were operationally defined.

RESULTS

No differences were detected in the rates of alcohol or drug abuse or dependence or in the rates of abuse of individual substances between the groups; both ADHD and control probands had a 15% rate of PSUD. Conduct and bipolar disorders predicted PSUD, independently of ADHD status. Family history of substance dependence and antisocial disorders was associated with PSUD in controls but less clearly so in ADHD probands. Family history of ADHD was not associated with risk for PSUD. ADHD probands had a significantly shorter time period between the onsets of abuse and dependence compared with controls (1.2 years versus 3 years, p < .01).

CONCLUSIONS

Adolescents with and without ADHD had a similar risk for PSUD that was mediated by conduct and bipolar disorder. Since the risk for PSUD has been shown to be elevated in adults with ADHD when compared with controls, a sharp increase in PSUD is to be expected in grown-up ADHD children during the transition from adolescence to adulthood.

Attention deficit hyperactivity disorder adults: comorbidities and adaptive impairments

Attention deficit hyperactivity disorder (ADHD) is increasingly recognized as a legitimate adult diagnostic category. Yet the nature of and comorbidities and adaptive impairments associated with adult ADHD have received little scientific investigation. The present study, therefore, compared 172 adults diagnosed with ADHD with 30 adults referred to the same adult ADHD clinic who were not so diagnosed. The ADHD group showed a significantly greater prevalence of oppositional, conduct, and substance abuse disorders, and greater illegal substance use than control adults. Moreover, adults with ADHD displayed greater self-reported psychological maladjustment, more driving risks (speeding violations), and more frequent changes in employment. Significantly more ADHD adults had experienced a suspension of their driver license, had performed poorly, quit, or been fired from their job, and had a history of poorer educational performance and more frequent school disciplinary actions against them than adults without ADHD. Multiple marriages were more likely in the ADHD group as well. Contrary to previous studies, anxiety and mood disorders were not found to be more prevalent in the ADHD than in the control group. Results suggest that ADHD in adults is associated with relatively specific risks for disruptive behavior disorders, school and job performance problems, and driving risks.

Attention problems versus conduct problems as six-year predictors of problem scores in a national sample

OBJECTIVE

To test the extent to which attention problems, the continuation of early comorbid conduct problems, and overall initial problems account for poor outcome scores on the Child Behavior Checklist and related measures 3 and 6 years after initial assessment.

METHOD

The course of attention and conduct problems was investigated in a nationally representative US sample assessed three times over 6 years, using standardized ratings of attention, conduct, and other problems and gender-specific scores for defining deviance.

RESULTS

Subjects deviant on both attention and conduct problems scored significantly higher on behavior problems at outcome than did those deviant on only attention problems or conduct problems. After controlling for initial conduct problems, initial attention problems made little unique contribution to later conduct problems. Predictive patterns were similar across gender and age groups.

CONCLUSIONS

Both boys and girls who show a combination of attention and conduct problems are at particular risk for the persistence of conduct problems.

Hyperactivity and conduct problems as risk factors for adolescent development

OBJECTIVE

To clarify the developmental risk associated with hyperactive behavior, especially the relationship between hyperactive and conduct problems, in a longitudinal epidemiological design.

METHOD

A follow-up study of children who were identified, by parent and teacher ratings in a large community survey of 6- and 7-year-olds, as showing pervasive hyperactivity or conduct problems or the comorbid mixture of both problems or neither problem. They were later investigated, at the age of 16 to 18 years, with detailed interview techniques as well as parental and self-report ratings and cognitive tests.

RESULTS

Hyperactivity was a risk factor for later development, even allowing for the coexistence of conduct problems. Its sequelae included a high likelihood of psychiatric diagnosis, persisting hyperactivity, violence and other antisocial behaviors, and social and peer problems.

CONCLUSIONS

The results suggested a developmental pathway through which hyperactivity raised the likelihood of impaired social adjustment, including the development of psychiatric disorders, independently of the existence of conduct problems.

A clinical and academic outcome study of children attending a day treatment program

OBJECTIVE

To assess the behavioural and academic improvement of children who attended a day treatment program during a defined period of time.

METHOD

Forty-six children admitted consecutively to the project were assessed on admission and discharge using behavioural and academic measures. They also had intelligence and language assessments. The subjects attended the program for one academic year, on the average. The large majority presented with disruptive behaviour disorders and low academic achievement levels.

RESULTS

There was a significant improvement reported by the parents in externalizing (P < 0.001) and internalizing (P < 0.05) behaviour. The subjects also gained one academic year, but their levels continued to be low in terms of percentiles. Measures of academic improvement showed significant associations with cognitive measures only (subscales of Wechsler Intelligence Scale for Children-Revised [WISC-R] and Clinical Evaluation of Language Fundamentals-Revised [CELF-R]).

CONCLUSION

A day treatment and school program is an effective modality for treatment and remediation of children with severe psychiatric disorders. The academic underachievement may be resistant to remediation within the limited period of attendance in such a program.

Families of children with attention deficit hyperactivity disorder: a review

OBJECTIVES

1) To review the evidence of attention deficit hyperactivity disorder (ADHD) and other conditions in family members (siblings and parents) of children with ADHD and determine the importance of genetic and environmental factors in this condition. 2) To describe the prospective 10-year follow-up of 65 families with ADHD children and 43 families of matched normal controls. 3) To review various studies that have looked at parent-child interactions with ADHD children on and off stimulant medication, and such interactions over time. The paper thus provides an overview of family pathology and functioning of families of ADHD children over time.

METHOD

The paper outlines twin, sibling, family and adoption studies with regard to possible genetic and environmental factors in ADHD. It also presents data of a prospective 10-year follow-up of 65 families with ADHD children and 43 families of normal controls. This family study evaluated sociocultural factors, child rearing practices, health of family members and relationships, as well as the parental view of the child's functioning over time.

RESULTS

A review of the literature suggests that ADHD has a strong genetic component, but that environmental factors also play an important role. Families of children with ADHD have more problems than families of normal controls, but these problems improve as the child with ADHD grows up and leaves home. Families of ADHD subjects can appreciate positive as well as negative changes in their children over time. Generally, family interactions with children with ADHD are problematic but improve when the child is on medication and when the child becomes an adult.

CONCLUSIONS

This condition has strong genetic underpinnings; therefore, diagnosing and treating family members (parents and siblings) as well as the child with ADHD is important in improving parent-child interactions and better long-term outcome for the child and his or her family.

Pemoline therapy in college students with attention deficit hyperactivity disorder: a retrospective study

Pemoline, a dopamine agonist, is effective in children with attention deficit hyperactivity disorder (ADHD), but its efficacy in adults is unknown. The authors studied the efficacy and safety of pemoline, using retrospective chart review of treated students with ADHD over a 2-year period. Forty students met diagnostic and treatment criteria; pemoline was associated with much improved or very much improved Clinical Global Impression symptoms scores in 70% of the students during a treatment period of 14 or more days. Severity of illness scores dropped from 4.11 to 3.01 between baseline and subsequent evaluation. Nine evaluable patients had adverse events, most commonly headaches, insomnia, and decreased appetite. Five additional students, who failed to meet the treatment-duration criterion, terminated because of severe initial insomnia. The authors concluded that pemoline is effective and safe in students with ADHD and has a lower abuse potential than methylphenidate and dextroamphetamine, the other two widely used, structurally dissimilar compounds, but controlled studies may be necessary before any final conclusions are reached.

National trends in the use of stimulant medication for attention deficit hyperactivity disorder

OBJECTIVE

To document the use of stimulant medication in the different states and territories of Australia in 1993 and trends in use of stimulant medication in Western Australia and New South Wales from 1988 to 1993.

METHODOLOGY

Health authorities in the states and territories of Australia were contacted and requested to provided data on total numbers, patient gender, date of birth, postcode and type of stimulant medication prescribed to estimate the prevalence of use of stimulant medication in Australia.

RESULTS

Despite variation in the data obtained from each health authority there is a significant difference in the rates of use of stimulant medication between states and territories in Australia, and a significant increase in use between 1988 and 1993 in Western Australia and New South Wales.

CONCLUSIONS

These trends should continue to be closely monitored and the possibility of establishing national prescription guidelines considered.

A sequential analysis of the mother-adolescent interactions of ADHD, ADHD/ODD, and normal teenagers during neutral and conflict discussions

The sequential interactions of three groups of teenagers conversing with their mothers during both neutral and conflict discussion situations were evaluated. Groups consisted of (1) attention deficit hyperactivity disorder (ADHD) alone (n = 21), (2) ADHD with comorbid oppositional defiant disorder (ADHD/ODD; n = 40), and (3) a community control group of adolescents (n = 49). All groups had been followed concurrently for the past 8 to 10 years before being reevaluated in this study. Results indicated that (1) teens and parents in all groups interacted in a tightly linked manner, with the behavior of each member being significantly related only to the immediate antecedent behavior of the other; (2) mothers in all groups were more likely than teens to initiate positive behaviors; (3) teen interactions could be characterized as tit-for-tat while mothers could be typified as be-nice-and-forgive; (4) mother-teen dyads in the ADHD/ODD group displayed significantly higher rates of conflict behaviors than dyads in the other two groups, who did not differ significantly from each other on most measures; and (5) mothers in the ADHD/ODD group responded in a manner similar to their teens (greater negativity) and less like that of mothers in the other groups. The majority of conflict between ADHD children and their parents seemed due to comorbid ODD and such ODD is a family, not just a teen, characteristic.

Psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder

OBJECTIVE

To conduct a retrospective follow-up study of psychosocial adjustment and educational outcome in adolescents with a childhood diagnosis of attention deficit disorder (ADD) and a group of clinical controls.

METHODS

Groups included male and female subjects aged 14 to 18 years at time of follow-up with childhood diagnosis of ADD (cases; n = 48) versus other neurodevelopmental disorders (clinical controls; n = 37). Cases were also subdivided based on the presence of conduct disorder (CD) at follow-up. All groups were compared on measures of academic performance, self-esteem, behavior, alcohol and substance use, and adaptive functioning.

RESULTS

Cases had significantly lower academic performance and poorer social, emotional, and adaptive functioning than clinical controls. Cases with CD had significantly lower academic performance, greater externalizing behaviors and emotional difficulties, and lower adaptive functioning than cases without CD. Cases with CD fared worse than clinical controls on self-report measures of behavior, socialization skills, and alcohol and substance use.

CONCLUSIONS

These academic and psychosocial problems in adolescents with a childhood diagnosis of ADD suggest potential long-term ramifications for vocational and psychological functioning into adulthood. In addition, the presence of CD in some of these cases during adolescence appears to further increase the risk for maladaptive outcome.

Predictors of persistence and remission of ADHD into adolescence: results from a four-year prospective follow-up study

OBJECTIVE

To evaluate the predictors of persistence and the timing of remission of attention-deficit hyperactivity disorder (ADHD).

METHOD

Subjects were 6- to 17-year old Caucasian, non-Hispanic boys with and without ADHD. DSM-III-R structured diagnostic interviews and blind raters were used to examine psychiatric diagnoses, cognitive achievement, social, school, and family functioning at a 4-year follow-up assessment.

RESULTS

At the 4-year follow-up assessment, 85% of children with ADHD continued to have the disorder and 15% remitted. Of those who remitted, half did so in childhood and the other half in adolescence. Predictors of persistence were familiality of ADHD, psychosocial adversity, and comorbidity with conduct, mood, and anxiety disorders.

CONCLUSIONS

The findings prospectively confirm that the majority of children with ADHD will continue to express the disorder 4 years later. For a minority of children, ADHD was a transient disorder that remits early in development. In addition, we have shown that persistence of ADHD is predictable. Familiality, adversity, and psychiatric comorbidity may be clinically useful predictors of which children with ADHD are at risk for a persistent disorder.

Effect of concentration problems on the malleability of children's aggressive and shy behaviors

OBJECTIVE

Previous research has demonstrated the central role of early childhood concentration problems in the development of aggression and other maladaptive behaviors. The present study investigated the moderating effect of concentration problems on the impact of a classroom-based preventive intervention directed at aggressive and shy behaviors in an epidemiologically defined sample of 1,084 urban first-grade children.

METHOD

Concentration problems, aggressive behavior, and shy behavior were assessed by a structured teacher interview (the Teacher Observation of Classroom Adaptation-Revised) in the fall and spring of first grade.

RESULTS

Children with high ratings on concentration problems in the fall had higher levels of teacher-rated aggressive and shy behavior in the spring than did children without such problems. The intervention reduced aggressive and shy behavior in children regardless of fall concentration level. Boys, but not girls, in the intervention condition with high concentration problems had higher levels of spring aggression than those without such problems, but they also showed the greatest reductions in aggressive behavior from fall to spring.

CONCLUSIONS

These results suggest that aggressive behavior is malleable in children with concentration problems, provide further evidence on the etiological significance of concentration problems for the development of maladaptive behavior, and highlight the importance of directly targeting concentration problems to maximize preventive intervention impact.

Developmental change in attention-deficit hyperactivity disorder in boys: a four-year longitudinal study

One hundred six clinic-referred boys meeting criteria for DSM-III-R attention-deficit hyperactivity disorder (ADHD) (mean age 9.4 years) were assessed annually for 4 years using structured interviews of multiple informants. Hyperactivity-impulsivity symptoms declined with increasing age, but inattention symptoms did not. Rather, inattention declined only from the first to the second assessment and remained stable thereafter in boys of all ages. The rate of decline in hyperactivity-impulsivity symptoms was independent of the amount and type of treatment received. Boys who still met criteria for ADHD in Years 3 and 4 were significantly younger, more hyperactive-impulsive, and more likely to exhibit conduct disorder in Year 1 than boys who no longer met criteria in Years 3 and 4.

Salivary cortisol responses and the risk for substance abuse in prepubertal boys

Investigations of adults with a psychoactive substance use disorder (PSUD) or antisocial behavior have reported diminished secretion of the adrenal "stress" hormone, cortisol. Consequently, we determined whether prepubertal sons of PSUD fathers, at high risk for later PSUD, differed from controls on salivary cortisol concentrations before, and after, an anticipated stressor. The roles of problematic behavioral disposition and state anxiety in the cortisol responses were also examined. A significant risk-group x time interaction for salivary cortisol concentrations was found, with high-risk boys secreting less salivary cortisol than controls when anticipating the task. High-risk boys also had significantly higher scores for aggressive delinquency and impulsivity that wholly accounted for the risk-group x time effect on salivary cortisol. Thus, cortisol hyporesponsivity was associated with the dysregulated behaviors prevalent among high-risk boys. The results suggest that cortisol hyporesponsivity could be a "marker" for later antisociality and PSUD.