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

Attention Functioning Among Adolescents With Multiple Learning, Attentional, Behavioral, and Emotional Difficulties

Attention-deficit/hyperactivity disorder (ADHD) is characterized by high levels of inattention, hyperactivity, and impulsivity; however, these symptoms can result from a variety of reasons. To obtain a comprehensive understanding of the various difficulties of individuals with ADHD, especially when co-occurrence difficulties are present, it is essential to combine neuropsychological and subjective assessment tools. In the present field study the authors investigated a group of adolescents with multiple deficits (MD) using neuropsychological and subjective measures. Teachers' ratings verified extremely high levels of symptoms of oppositional behavior, inattention, hyperactivity-impulsivity, social problems, and emotional problems in this group. As expected, MD group participants showed decreased abilities to maintain attention on task for a long period of time, focus attention and effectively inhibit adjacent distractors, and resist conflicting irrelevant information. Importantly, although significant differences in the attention measures were observed at the group level, not all MD participants displayed deviant performance. Thus, we conclude that the heterogeneous group of adolescents with MD comprises individuals with primary attention deficits as well as those with other nonattentional deficits that show equivalent behavioral symptoms. Using neuropsychological tools can be useful in differentiating between different core deficits and in guiding appropriate interventions.

A randomized controlled trial of cognitive behavioral therapy for ADHD in medication-treated adolescents

OBJECTIVE

To test cognitive behavioral therapy (CBT) for persistent attention-deficit hyperactivity disorder (ADHD) symptoms in a sample of medication-treated adolescents.

METHODS

Forty-six adolescents (ages 14-18), with clinically significant ADHD symptoms despite stable medication treatment were randomly assigned to receive CBT for ADHD or wait list control in a cross-over design. Twenty-four were randomized to CBT, 22 to wait list, and 15 crossed-over from wait list to CBT. A blind independent evaluator (IE) rated symptom severity on the ADHD Current Symptom Scale, by adolescent and parent report, and rated each subject using the Clinical Global Impression Severity Scale (CGI), a global measure of distress and impairment. These assessments were performed at baseline, 4-months (post-CBT or post wait list), and 8-months (post-treatment for those originally assigned to the wait list condition and 4-month follow-up for those originally assigned to CBT).

TRIAL REGISTRATION

http://clinicaltrials.gov/show/NCT01019252.

RESULTS

Using all available data, mixed effects modeling, and pooling for the wait list cross-over, participants who received CBT received a mean score 10.93 lower on the IE-rated parent assessment of symptom severity (95% CI: -12.93, -8.93; p < .0001), 5.24 lower on the IE-rated adolescent assessment of symptom severity (95% CI: -7.21, -3.28; p < .0001), and 1.17 lower IE-rated CGI (95% CI: -1.39, -.94; p < .0001). Results were consistent across 100 multiple imputations (all p < .0001). There was a greater proportion of responders after CBT by parent (50% vs. 18%, p = .00) and adolescent (58% vs. 18% p = .02) report.

CONCLUSIONS

This study demonstrates initial efficacy of CBT for adolescents with ADHD who continued to exhibit persistent symptoms despite medications.

Parent-reported symptoms, impairment, helpfulness of treatment, and unmet service needs in a follow-up of outpatient children with attention-deficit/hyperactivity disorder

BACKGROUND

Limited information exists regarding the associations between impairment, symptoms, helpfulness of treatments, and service needs after initial treatment of children with attention-deficit/hyperactivity disorder (ADHD).

AIMS

The aims of this study were to examine persistence rates and associations between parent-reported symptoms, impairment, helpfulness of treatments, and service needs in a retrospective follow-up study of children with ADHD.

METHODS

Parents of 214 children with a mean age of 12.6 years (SD = 2.1) who were diagnosed with ADHD at five child and adolescent mental health clinics (CAMHS) completed questionnaires 1-10 years (mean = 3.7 years, SD = 2.2) after baseline assessment. The response rate was 43.4%. A community comparison group (n = 110) was recruited from the same area.

RESULTS

Approximately two-thirds (60.3%) of the sample fulfilled the DSM-IV symptom criteria of ADHD at follow-up, 84.3% were functionally impaired, and most children (84.7%) were on medication. Inattentive and emotional symptoms were the strongest predictors of impairment across impairment areas. Perceived helpfulness of different treatments varied from 71.8-88.7%, and no significant difference was found between the ADHD sub-groups regarding reported helpfulness. 'Adjustment of the school situation' was the most frequent service need, and approximately half of the parents reported needs for care co-ordination. Children fulfilling the symptom criteria of the ADHD Combined sub-group were most impaired and had most service needs.

CONCLUSIONS

At follow-up, children were highly symptomatic and impaired, despite a high rate of persistent medication treatment. The findings underline the need for more tailored treatment and co-ordinated care over time.

Congruent Validity of the Strengths and Difficulties Questionnaire to Screen for Comorbidities in Children With ADHD

OBJECTIVE

This study aimed to determine whether the Strengths and Difficulties Questionnaire (SDQ) is an effective screening tool for identifying comorbid mental health difficulties in children with ADHD.

METHOD

Parents of children with ADHD (5-13 years) completed the SDQ and the Anxiety Disorders Interview Schedule for DSM-IV-Parent Version (ADIS-C/P-IV). Data from both the measures were compared to determine congruent validity.

RESULTS

Analyses revealed that significant relationships exist between the SDQ total score and the total number of comorbidities on the ADIS-C/P-IV. The SDQ emotional problem and conduct problem scales were significantly related to internalizing and externalizing comorbidities on the ADIS-C/P-IV, respectively.

CONCLUSION

While significant relationships were found between the SDQ and ADIS-C/P-IV across various domains, this relationship was stronger for externalizing comorbidities. Additional screening questions are required to effectively screen for less common internalizing comorbidities in children with ADHD, for example, major depression and panic disorder.

The Development and Use of the Attention Deficit Hyperactivity Disorder-Observational Rating Scale: Factor Analysis and a Preliminary Investigation of Predictive Validity

The Attention Deficit Hyperactivity Disorder- Observational Rating Scale (ADHD-ORS; Deutscher & Fewell, 1996) was developed and used to rate 702 videotapes of 30-month-old, premature, low-birthweight toddlers born at eight medical schools across the nation. Coders were trained to score the 12-item scale according to specific criteria for each of 5 points on the Likert scale. Scores were sub jected to a principal components factor analy sis with varimax and promax rotations. The results support three factors that closely match the three main attributes of the disorder. These factors were identified as inattention, overactivity, and impulsivity. Six-month predic tive validity with selected items from the Child Behavior Checklist was also determined. Implications for use in preschool settings and directions for future research are considered.

Violent incidents in a forensic adolescent unit: A functional analysis

This paper reports on a survey which identified categorised and measured the relative frequency of specific antecedents before, and the consequences following, violent incidents in an adolescent forensic unit during a two-year period. Retrospective analysis of 219 violent incidents involved the examination of incident forms, nursing-process records and accident reports. Antecedents and precipitating factors were also recorded.

The results demonstrated that the vast majority of incidents were precipitated by several observable antecedents or precipitating factors (186, 85%). Only a small proportion of the violent incidents were preceded by a single risk indicator (21, 9.5%) and a minority were reported to have occurred in the absence of observable antecedents (12, 5.5%). The severity of violent incidents was rated on a four-point scale but no significant correlation was found between category or frequency of antecedent and the violent act itself.

The consequences for the young person following acts of violence were also documented, and the results show that the large majority of incidents were followed by increased staff observation (197, 90.5%). Coercive interventions such as physical restraint (177, 80.8%) or idiosyncratic sanctions (88,40.2%) were commonly recorded. A significant proportion of violent incidents did not appear to be followed by staff intervention, sanction or punishment (80, 36.5%).

Finally, results are considered against research and best practice evidence, and suggestions for further studies are presented. Organisational interventions, strategies for the management of aggression and violence, and a staff training needs analysis are also indicated.

A Randomised Controlled Trial of a Play-Based Intervention to Improve the Social Play Skills of Children with Attention Deficit Hyperactivity Disorder (ADHD)

There is a need for effective interventions to address the social difficulties of children with ADHD. This randomised controlled trial examined the effectiveness of a play-based intervention for improving the social play skills of children with ADHD in peer-to-peer interactions. Children with ADHD (5 to 11 years) were randomised to an intervention-first (n = 15) or waitlist control-first group (n = 14). Participants allocated to the control-first group received the intervention after a 10-week wait period. Children invited a typically-developing playmate and parents of children with ADHD participated. The intervention involved: six clinic play-sessions, weekly home-modules and a one-month home follow up. The Test of Playfulness (ToP) was scored by a blinded rater. Parent reported treatment adherence was used to assess treatment fidelity. Between group statistics were used to compare the change of the intervention-first (10-week intervention period) and control-first (10-week wait period) groups. Once all children had received the intervention, repeated measures ANOVA, post hoc Least Significance Difference tests and Cohen’s-d were used to measure effect. Changes in ToP social items were analysed using Friedman’s ANOVA. Linear regression analyses were used to identify variables that predicted change. The control-first group did not change during the wait period. The change in the intervention-first group was significantly greater than the change in the control-first group (during the wait period). When the data from the two groups were combined, the mean ToP scores of the children with ADHD (n = 29) improved significantly following the intervention, with a large effect from pre to post intervention and from pre intervention to follow up. Children maintained treatment gains at follow up. All ToP social items improved significantly following the intervention. The findings support the use of play involving parent and peer mediated components to enhance the social play skills of children with ADHD.

Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000973617

Cigarette smoking and ADHD: An examination of prognostically relevant smoking behaviors among adolescents and young adults

Attention-deficit/hyperactivity disorder (ADHD) is associated with health risks in adolescence which includes the potential for smoking cigarettes, early smoking initiation, and rapid progression to daily smoking. Much less is known, however, about prognostically relevant smoking behaviors among individuals with childhood ADHD. Further research in this area is important for identifying individuals at pronounced risk for nicotine addiction, and for developing effective interventions for this population. This study examined initiation of cigarette smoking, progression to regular smoking, quantity of use, indicators of tobacco dependence, and quit rates among adolescents and young adults with (n = 364) and without (n = 240) childhood ADHD. Individuals with, versus without, ADHD histories were significantly more likely to become daily smokers independent of conduct disorder (CD). They were also more likely to initiate smoking at younger ages and to progress to regular smoking more quickly. There were no significant group differences in cigarettes smoked per day, Fagerström Test of Nicotine Dependence (FTND), or Nicotine Dependence Syndrome Scale (NDSS) scores or in smoking within 30 min of waking. However, smokers with ADHD reported more intense withdrawal and craving during periods of abstinence than non-ADHD smokers. There were no significant group differences in number of quit attempts. Lastly, there were no significant differences among symptom persisters and desisters in daily smoking and amount. Individuals with ADHD histories are at high risk for persistent smoking given their early onset, rapid course, and abstinence characteristics. Smoking cessation programs may need to be adapted or otherwise intensified for those with ADHD. (PsycINFO Database Record

Diagnosis and Treatment of Attention Deficit Hyperactivity Disorder During Adolescence in the Primary Care Setting: A Concise Review

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder with a worldwide prevalence of about 5% in school-age children. This review is intended to assist primary care providers (PCPs) in diagnosing and treating ADHD in adolescents. PubMed, PsychInfo, and Science Citation Index databases were searched from March 1990 to 2015 with the keywords: ADHD, primary care/pediatrics, and children/adolescents. Abstracts addressing diagnosis and/or treatment with 105 citations were identified including supplementary treatment guidelines/books. Adolescent ADHD presents with significant disturbances in attention, academic performance, and family relationships with unique issues associated with this developmental period. Diagnostic challenges include the variable symptom presentation during adolescence, complex differential diagnosis, and limited training and time for PCPs to conduct thorough evaluations. The evidence base for treatments in adolescence in comparison to those in children or adults with ADHD is relatively weak. Providers should be cognizant of prevention, early identification, and treatment of conditions associated with ADHD that emerge during adolescence such as substance use disorders. Adolescent ADHD management for the PCP is complex, requires further research, and perhaps new primary care psychiatric models, to assist in determining the optimal care for patients at this critical period.

Functional consequences of attention-deficit hyperactivity disorder on children and their families

Attention-deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder with core symptoms that include hyperactivity, impulsiveness, and inattention, and it is the most common psychiatric disorder among children and adolescents. These core symptoms are continuously recognized throughout the day from childhood to adulthood. Furthermore, children with ADHD from childhood to adulthood might also have various comorbid psychiatric disorders. Recently, bipolar disorder and disruptive mood dysregulation disorder, a new clinical issue, have been discussed as comorbid disorders or differential disorders associated with ADHD. Furthermore, comorbid disorders of ADHD are related to quality of life and family burden. Children with ADHD have poorer long-term outcomes than controls with respect to: academic achievement and attainment, occupational rank and job performance, risky sexual practices and early unwanted pregnancies, substance use, relationship difficulties, marital problems, traffic violations, and car accidents. Irritability of children with ADHD has been a key symptom that clinicians and researchers have used to evaluate the developmental condition of children with ADHD. ADHD is sometimes a chronic disorder that occurs over a long period, increasing the family burden of these children (including health-care costs), which will increase with aging for unremitted children with ADHD. Therefore, clinicians should evaluate not only the mental condition of the child but also the family burden. Children with ADHD should be treated during childhood to reduce their clinical symptoms and family burden.

The Relationship of Attention Deficit Hyperactivity Disorder to Crime and Delinquency: A Meta-Analysis

In recent years, criminologists have begun to focus more closely on how certain biosocial and/or neuropsychological factors may influence criminal and delinquent behaviour. One factor that is emerging as a potentially important correlate of such behaviour is Attention Deficit — often combined with hyperactivity — Disorder (ADD and/or ADHD). The results of the growing body of empirical literature assessing this link are, however, inconsistent. The present study subjects this body of research to a ‘meta-analysis' — or, ‘quantitative synthesis' — to establish both the overall effect of ADHD on crime and delinquency and the degree to which this relationship is conditioned by methodological factors across empirical studies. The analyses reveal a fairly strong association between measures of ADHD and criminal/delinquent behaviour. Nevertheless, these effects are not invariant across certain salient methodological characteristics. The implications for criminological theory and correctional policy are discussed.

Cognitive Executive Dysfunction in Children with Mild Sleep-Disordered Breathing

In children, moderate or severe sleep-disordered breathing (SDB) may impair cognitive executive functions (EFs), including working memory, attention, and mental flexibility. The main objective of this study was to assess EFs in children with mild levels of SDB. Subjects for this descriptive study were 12 children (5 girls, 7 boys) aged 8.0 to 11.9 years (M = 9.0 ± 0.85) participating in an ongoing study of the effects of adenotonsillectomy on behavior. Each subject had a nocturnal polysomnogram (PSG) and multiple sleep latency test (MSLT). Mild SDB was considered present if the child’s apnea/hypopnea index (AHI) was ≥ 1 and < 10. Between MSLT nap attempts, each child completed standardized tests of EFs. The sample showed significant impairment of sustained attention and vigilance on a computerized continuous performance test. Children with low mental flexibility scores on the Children’s Category Test (CCT) spent more time in stage 1 sleep (12.2% v. 9.5%, P = 0.028 on PSG) and showed a marginally higher arousal index (9.7 v. 6.5, P = 0.06 on PSG) than children with average or above-average CCT scores. AHI accounted for significant proportion of the variance in CCT scores when 1 outlier was removed (N = 11, Rsq = 0.67, P = 0.002). Mild levels of SDB and associated sleep architecture disruptions may be associated with impairment of EFs in children.

The AD/HD Skills and Strategies Program : A Program for AD/HD Adults in Postsecondary Education

Attention-deficit/hyperactivity disorder (AD/HD) is beginning to be recognized in postsecondary institutions; however, few institutions offer comprehensive programs that provide training in advocacy and study strategies pertinent to the needs of students with this disorder (Richard, 1995). In an effort to address the gap in the literature regarding the treatment of AD/HD adults in postsecondary education, the AD/HD Skills and Strategies Program was developed. The components of this program were carefidly established in accordance with the research literature on the adult form of AD/HD and in keeping with a model of adult AD/HD, proposed by Brown. A two-pronged approach was used to assess the effectiveness of this program. Results and future recommendations are discussed.

Parental ADHD and Depression: Time-Varying Prediction of Offspring Externalizing Psychopathology

Parental attention deficit/hyperactivity disorder (ADHD) and depression are risk factors for negative child outcomes, but given their frequent co-occurrence and variability over time, developmentally sensitive studies are needed. To characterize change in parental ADHD and depression as predictors of change in child ADHD and oppositional defiant disorder (ODD), 230 five- to ten-year-old children with (n = 110) and without (n = 120) ADHD were followed prospectively for 2 years with 90% retention. At baseline and again 2 years later (i.e., Wave 2), parents self-reported their ADHD and depression; parents and teachers also separately rated child ADHD and ODD, as well as broader attention and externalizing problems. Controlling for child sex, race-ethnicity, age, and parental depression, generalized estimating equations revealed that 2-year decreases in parental ADHD significantly predicted reduced child ADHD symptoms, but only among non-ADHD youth. Alternatively, increasing parental depression positively predicted change in teacher-rated ODD symptoms. These findings provide quasi-experimental evidence that parental ADHD and depression may be time-varying risk factors with respect to key dimensions of child externalizing behavior problems. We consider the potential dynamic and reciprocal interrelations among parental ADHD and depression with developmental change in offspring ADHD and ODD. We also discuss implications of parent psychopathology in the development of interventions to reduce the burden of youth ADHD and associated externalizing behavior.

New DSM-5 criteria for ADHD - Does it matter?

OBJECTIVE

The new Diagnostic Statistical Manual (DSM) requires the presence of fewer symptoms to make a diagnosis of adult ADHD while the criteria for diagnosis in childhood are unchanged as compared to previous editions. This study examines the prevalence of adults meeting the revised DSM-5 symptoms cutoff as compared to the previous DSM-IV symptoms cutoff.

METHOD

This study is part of a larger nationwide study that evaluated the use of, and the attitudes toward, ADHD medications by university students. 445 students from four major university faculties were surveyed and filled out questionnaires for our study.

RESULTS

The proportion of participants that met the minimum threshold of six out of nine current symptoms in either of the two DSM-IV symptom domains (inattentive presentation and hyperactive/impulsive presentation) for ADHD was 12.7% while the proportion that met the minimum threshold of five symptoms in either of the DSM-5 symptom domains was 21%.

CONCLUSION

Since the new DSM requires fewer current symptoms for a diagnosis of ADHD, a significant increase (65%) was observed in the number of participants meeting the new cutoff as compared to the old DSM-IV symptoms cutoff. This increase in the number of adults meeting symptoms cutoff may affect the rates of adults diagnosed with ADHD. Using the new criteria may identify more adults with ADHD and fewer diagnoses will be missed. However, meeting the new symptoms cutoff should be considered within the overall clinical context to prevent over-diagnosis.

Attention Deficit-Hyperactivity Disorder

Attention deficit-hyperactivity disorder (ADHD) is a common problem among school-aged children wherein a student exhibits significant difficulties with attention span, impulse control and activity level. Since children with ADHD often display these symptoms on a chronic basis resulting in impaired behavior control and academic productivity, the classroom environment must be modified to enhance their adjustment. Several contingency management procedures for teacher use are briefly discussed in this paper including token reinforcement programs, contingency contracting, response cost, time-out from positive reinforcement and home-based contingency management programs. When used in conjunction with other treatment modalities (e.g. stimulant medication, parent training in behavior modification), these classroom intervention strategies often lead to significant improvements in on-task behavior, work completion, behavioral control and accuracy on academic assignments.

Identifying ADHD Symptoms Most Associated with Impairment in Early Childhood, Middle Childhood, and Adolescence Using Teacher Report

The purpose of this study was to examine the relationships between ADHD symptoms and impairment within a sample that includes children in early childhood (n = 250), middle childhood (n = 269) and adolescence (i.e., high school; n = 269). Nested multivariate regression analyses were used to examine the extent to which each ADHD symptom dimension (inattention and hyperactivity/impulsivity) is most associated with impairment in academic, social, and behavioral functioning within and across three developmental levels. Results indicated for academic impairment, inattention is more predictive than hyperactivity/impulsivity at all ages. For social functioning, both with peers and teachers, hyperactivity/impulsivity is more predictive than inattention but only for early childhood students; at the high school level, inattention is a significant predictor of social impairment. For behavioral functioning in the classroom, the pattern is mixed across dimensions and ages with HI decreasing in predictive utility across the three age groups and IA increasing in predictive utility. Forward stepwise regression was used to determine which of the 18 ADHD symptom items are most associated with impairment within and across developmental levels. Findings indicate that the symptoms that were most predictive of impairment varied by age group and by domain of impairment. Implications for assessment are discussed.

Management of ADHD in children and adolescents: clinical audit in a South African setting

OBJECTIVES

Attention deficit hyperactivity disorder (ADHD) is common, yet under-recognised and undertreated, particularly in low socio-economic settings. Little is known about compliance to evidence- based guidelines in low- and middle-income countries, and no clinical audits have been published in Africa. We undertook to measure compliance in a South African setting using the National Institute for Clinical Excellence (NICE) guidelines for ADHD as the gold standard to compare compliance and socio-demographic characteristics between two treatment locations in Cape Town and to generate an audit checklist for standardising care.

METHODS

The study used a sample of 100 randomly selected cases of school-age patients diagnosed with ADHD, at the Division of Child & Adolescent Psychiatry, Red Cross War Memorial Children's Hospital and University of Cape Town, South Africa. Fifty cases each from a central and a peripheral clinic location were reviewed retrospectively using audit tools, including 17 audit standards derived from NICE guidelines. We defined compliance as "good" with ≥80%, "fair" with 50-79%, and "poor" with <50% adherence.

RESULTS

Compliance was low, with only four audit standards rated as "good". Physical monitoring was especially poor. The central group received more treatment options and relatively safer monitoring.

CONCLUSIONS

We recommend introducing structured protocols followed by re-auditing to improve service delivery, and present a checklist for use in future audit cycles.

Naturalistic Pharmacotherapy Compliance among Pediatric Patients with Attention Deficit/Hyperactivity Disorder: a Study Based on Three-Year Nationwide Data

We examined short- and long-term medication compliance among youth with attention-deficit hyperactivity disorder (ADHD), using data from the National Health Insurance database in Korea. Of the 5,699,202 6-14-year-old youth in 2008, we chose those with at least 1 medical claim containing an ICD-10 code for diagnosis of ADHD (F90.0) and no prescription for ADHD within the previous 365 days. We tracked the data every 6 months between 2008 and 2011, to determine treatment compliance among newly diagnosed, medicated patients. Further, we checked every 1 month of the 6 months after treatment commencement. Treatment continuity for each patient was calculated by sequentially counting the continuous prescriptions. For measuring compliance, we applied the medication possession ratio (MPR) as 0.6, 0.7, and 0.8, and the gap method as 15- and 30-days' intervals. There were 15,133 subjects; 11,934 (78.86%) were boys. Overall 6-month treatment compliance was 59.0%, 47.3%, 39.9%, 34.1%, 28.6%, and 23.1%. Monthly drop-out rates within the first 6 months were 20.6%, 6.5%, 4.7%, 3.7%, 3.0%, and 2.5%, respectively. When applying MPR more strictly or shorter gap days, treatment compliance lessened. This is the first nationwide report on 36-month treatment compliance of the whole population of 6-14-year-olds with ADHD. We found the beginning of the treatment, especially the first month, to be a critical period in pharmacotherapy. These results also suggest the importance of setting appropriate treatment adherence standards for patients with ADHD, considering the chronic course of ADHD.

Developmental brain trajectories in children with ADHD and controls: a longitudinal neuroimaging study

BACKGROUND

The symptom profile and neuropsychological functioning of individuals with Attention Deficit/Hyperactivity Disorder (ADHD), change as they enter adolescence. It is unclear whether variation in brain structure and function parallels these changes, and also whether deviations from typical brain development trajectories are associated with differential outcomes. This paper describes the Neuroimaging of the Children's Attention Project (NICAP), a comprehensive longitudinal multimodal neuroimaging study. Primary aims are to determine how brain structure and function change with age in ADHD, and whether different trajectories of brain development are associated with variations in outcomes including diagnostic persistence, and academic, cognitive, social and mental health outcomes.

METHODS/DESIGN

NICAP is a multimodal neuroimaging study in a community-based cohort of children with and without ADHD. Approximately 100 children with ADHD and 100 typically developing controls will be scanned at a mean age of 10 years (range; 9-11years) and will be re-scanned at two 18-month intervals (ages 11.5 and 13 years respectively). Assessments include a structured diagnostic interview, parent and teacher questionnaires, direct child cognitive/executive functioning assessment and magnetic resonance imaging (MRI). MRI acquisition techniques, collected at a single site, have been selected to provide optimized information concerning structural and functional brain development.

DISCUSSION

This study will allow us to address the primary aims by describing the neurobiological development of ADHD and elucidating brain features associated with differential clinical/behavioral outcomes. NICAP data will also be explored to assess the impact of sex, ADHD presentation, ADHD severity, comorbidities and medication use on brain development trajectories. Establishing which brain regions are associated with differential clinical outcomes, may allow us to improve predictions about the course of ADHD.

A Review of Impact of Tobacco Use on Patients with Co-occurring Psychiatric Disorders

Consumption of tobacco has been a worldwide problem over the past few decades due to the highly prevalent tobacco-attributable complications. Tobacco use has also been found to be more prevalent in patients with psychiatric disorders. Therefore, we conducted this review about the impact of tobacco use on co-occurring psychiatric disorders. Various facets of this interaction between tobacco use among those with co-occurring psychiatric disorders have been explored. It has been found that people with psychiatric disorders have a higher chance of currently smoking tobacco and lesser chance of cessation. Tobacco use and mental disorders continue to share a complex relationship that has been further evolving after the change in the pattern of tobacco use and also the advent of newer modalities of treatment. However, at the same time, it is believed that cessation of smoking may lead to improvement in the symptoms of mental illness.

Neurocognitive and Behavioral Predictors of Math Performance in Children With and Without ADHD

OBJECTIVE

This study examined neurocognitive and behavioral predictors of math performance in children with and without ADHD.

METHOD

Neurocognitive and behavioral variables were examined as predictors of (a) standardized mathematics achievement scores, (b) productivity on an analog math task, and (c) accuracy on an analog math task.

RESULTS

Children with ADHD had lower achievement scores but did not significantly differ from controls on math productivity or accuracy. N-back accuracy and parent-rated attention predicted math achievement. N-back accuracy and observed attention predicted math productivity. Alerting scores on the attentional network task predicted math accuracy. Mediation analyses indicated that n-back accuracy significantly mediated the relationship between diagnostic group and math achievement.

CONCLUSION

Neurocognition, rather than behavior, may account for the deficits in math achievement exhibited by many children with ADHD.

Deficits in Verbal Working Memory among College Students with Attention-Deficit/Hyperactivity Disorder Traits: An Event-related Potential Study

Objective

This study investigated verbal working memory in college students with traits of attention-deficit/hyperactivity disorder (ADHD) using event-related potentials and the 2-back task.

Methods

Based on scores on the Adult ADHD Self-Report Scale and Conners’ Adult ADHD Rating Scale, participants were assigned to the normal control (n=28) or ADHD-trait (n=29) group. The 2-back task, which was administered to evaluate working memory, consists of a congruent condition, under which the current stimulus is the same as the one presented two trials earlier, and an incongruent condition, under which the current stimulus is not the same as the one presented two trials earlier. The numbers 1, 2, 3, and 4 were used as stimuli.

Results

On the 2-back task, the ADHD-trait group committed significantly more errors in response to congruent stimuli and showed a smaller P300 amplitude than did the control group.

Conclusion

These results indicate that college students with ADHD traits have deficits in verbal working memory, possibly due to difficulties in memory updating or attentional allocation.

Review of international clinical guidelines for adolescents on transition to Adult Mental Health Services and adults with attention-deficit hyperactivity disorder and their application to an irish context

OBJECTIVES

To review the available clinical guidelines from Canada, North America, Europe and the United Kingdom for the diagnosis and management of attention-deficit hyperactivity disorder (ADHD) for adolescents previously diagnosed in Child and Adolescent Mental Health Services (CAMHS) on transition to Adult Mental Health Services (AMHS) and for adults presenting with a diagnostic query re-ADHD. This article seeks to apply the available guidelines to an Irish context.

METHOD

Various clinical guidelines and consensus statements were identified by a literature search of PubMed, incorporating literature from the past 10 years from English speaking countries and inclusion of any additional guidelines of clinical relevance. A clinical guideline with specific reference for Irish clinicians was proposed for the diagnosis and management of adults presenting for the first time with a diagnostic query re-ADHD and also to include those young adults previously diagnosed in CAMHS on transition to AMHS.

CONCLUSIONS

ADHD is a lifelong disorder, which if undiagnosed or untreated can lead to significant impairment resulting in a high economic cost for society. Stimulant medication is a first-line treatment option for adults with ADHD; however, some formulations are unlicensed in Ireland. Recent licensing of Atomoxetine, for both adolescents on transition and for adults with newly diagnosed ADHD is a welcome development. Third-line agents are rarely prescribed due to their side effect profiles and are prescribed off-label: It is important to establish clinical guidelines for an Irish context incorporating a biopsychosocial approach. Further discussion amongst clinicians and stakeholders is needed to plan service development.

A four-year follow-up controlled study of stress response and symptom persistence in Brazilian children and adolescents with attention deficit disorder and hyperactivity (ADHD)

This study evaluated children and adolescents with Attention Deficit Disorder andHyperactivity Disorder (ADHD), reassessing them at a four-year follow-up. Their cortisol response to a stress stimulus was measured twice. ADHD symptom persistence, development of comorbidities, and psychostimulant usage were also reassessed. The initial sample consisted of 38 ADHD patients and 38 healthy controls, age ranging 6-14. At the follow-up, there were 37 ADHD patients and 22 healthy controls, age ranging 10-18. ADHD was classified as persistent if the patients fulfilled all DSM IV criteria for syndromic or subthreshold or had functional impairment. Salivary cortisol samples were collected prior to the application of a cognitive stressor (Continuous Performance Test - CPT), and at three time intervals afterwards at baseline and at the follow-up. Their reassessment showed that 75% had persistent symptoms, psychiatric comorbidities (oppositional defiant and behavioral disorders), functional and academic impairement. Only seven patients were on medication. The ADHD group's cortisol levels were lower than those measured four years earlier, but cortisol concentrations were similar for both ADHD and control groups at the four-year follow-up. The cortisol results suggest that HPA axis reactivity could be a marker differentiating ADHD from ADHD with comorbidities.

Impact of Attention-Deficit Hyperactivity Disorder on School Performance: What are the Effects of Medication?

Attention-deficit hyperactivity disorder (ADHD) affects an estimated 5-7 % of schoolchildren worldwide. School functioning and academic achievement are frequently impaired by ADHD and represent one of the main reasons children start ADHD medication. Multiple potential causal pathways exist between ADHD and impaired school performance. In this review, we decompose school performance into three components and assess the impact of ADHD and its treatments on academic performance (assessed by grade point average [GPA], time on-task, percentage of work completed as well as percent completed correctly), academic skills (as measured by achievement tests and cognitive measures), and academic enablers (such as study skills, motivation, engagement, classroom behavior and interpersonal skills). Most studies examined only the short-term effects of medication on school performance. In these, ADHD medications have been observed to improve some aspects of school performance, with the largest impact on measures of academic performance such as seatwork productivity and on-task performance. In a subset of children, these benefits may translate into detectable improvements in GPA and achievement testing. However, limited data exists to support whether these changes are sustained over years. Optimizing medication effects requires periodic reassessment of school performance, necessitating a collaborative effort involving patients, parents, school staff and prescribers. Even with systematic reassessment, behavioral-based treatments and additional school-based services may be needed to maximize academic performance for the many youth with ADHD and prominent impairments in school performance.

Familial influences on the full range of variability in attention and activity levels during adolescence: A longitudinal twin study

To investigate familial influences on the full range of variability in attention and activity across adolescence, we collected maternal ratings of 339 twin pairs at ages 12, 14, and 16, and estimated the transmitted and new familial influences on attention and activity as measured by the Strengths and Weaknesses of Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior Scale. Familial influences were substantial for both traits across adolescence: genetic influences accounted for 54%-73% (attention) and 31%-73% (activity) of the total variance, and shared environmental influences accounted for 0%-22% of the attention variance and 13%-57% of the activity variance. The longitudinal stability of individual differences in attention and activity was largely accounted for by familial influences transmitted from previous ages. Innovations over adolescence were also partially attributable to familial influences. Studying the full range of variability in attention and activity may facilitate our understanding of attention-deficit/hyperactivity disorder's etiology and intervention.

A Randomized, Placebo-Controlled Trial of Guanfacine Extended Release in Adolescents With Attention-Deficit/Hyperactivity Disorder

OBJECTIVE

Despite the continuity of attention-deficit/hyperactivity disorder (ADHD) into adolescence, little is known regarding use of nonstimulants to treat ADHD in adolescents. This phase 3 trial evaluated the safety and efficacy of guanfacine extended release (GXR) in adolescents with ADHD.

METHOD

This 13-week, multicenter, randomized, double-blind, placebo-controlled trial evaluated once-daily GXR (1-7 mg per day) in adolescents with ADHD aged 13 to 17 years. The primary endpoint was the change from baseline in the ADHD Rating Scale-IV (ADHD-RS-IV) total score; key secondary endpoints included scores from the Clinical Global Impressions-Severity of Illness (CGI-S), and Learning and School domain and Family domain scores from the Weiss Functional Impairment Rating Scale-Parent Report (WFIRS-P) at week 13.

RESULTS

A total of 314 participants were randomized (GXR, n = 157; placebo, n = 157). The majority of participants received optimal doses of 3, 4, 5, or 6 mg (30 [22.9%], 26 [19.8%], 27 [20.6%], or 24 [18.3%] participants, respectively), with 46.5% of participants receiving an optimal dose above the currently approved maximum dose limit of 4 mg. Participants receiving GXR showed improvement in ADHD-RS-IV total score compared with placebo (least-squares mean score change, -24.55 [GXR] versus -18.53 [placebo]; effect size, 0.52; p <.001). More participants on GXR also showed significant improvement in CGI-S scores compared with placebo (50.6% versus 36.1%; p = .010). There was no statistically significant difference between treatments at week 13 in the 2 WFIRS-P domains. Most treatment-emergent adverse events were mild to moderate, with sedation-related events reported most commonly.

CONCLUSION

GXR was associated with statistically significant improvements in ADHD symptoms in adolescents. GXR was well tolerated, with no new safety signals reported.

CLINICAL TRIAL REGISTRATION INFORMATION

Dose-Optimization in Adolescents Aged 13-17 Diagnosed With Attention-Deficit/Hyperactivity Disorder (ADHD) Using Extended-Release Guanfacine HCl; http://ClinicalTrials.gov/; NCT01081132.

Change over time in adolescent and friend alcohol use: Differential associations for youth with and without childhood attention-deficit/hyperactivity disorder (ADHD)

Individuals with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for experiencing alcohol-related problems by adulthood. However, few studies have examined contextual factors that may contribute to this risk. The current study examined 1 widely investigated social-contextual risk factor, friend alcohol use, in a sample of adolescents with and without a history of ADHD. One hundred and 59 adolescents (14-17 years old) with childhood ADHD and 117 demographically similar youth without ADHD were interviewed annually in the Pittsburgh ADHD Longitudinal Study. Adolescents reported the frequency of their own alcohol use in the prior 12 months and the number of friends who used alcohol regularly or occasionally (perceived friend alcohol use). Multiple-group parallel process models indicated that increases in friend alcohol use were more strongly associated with increases in adolescent alcohol use over time for individuals with ADHD (r = .15, SE = 0.04; 95% confidence interval [CI] = [0.08, 0.22]) than for those without ADHD (r = .06, SE = 0.03; 95% CI [0.00, 0.11]). These results suggest that social factors are an important part of escalating alcohol use among adolescents with ADHD histories, and they highlight the possibility that interventions focused on the peer context could be important for these at-risk youth. Additional social network research on adolescent alcohol use within the larger context of other relationships (e.g., family and romantic relationships) is indicated.

A 4-Year Follow-Up Study of Attention-Deficit Hyperactivity Symptoms, Comorbidities, and Psychostimulant Use in a Brazilian Sample of Children and Adolescents with Attention-Deficit/Hyperactivity Disorder

The aim of this study was to evaluate symptom persistence in attention-deficit/hyperactivity disorder (ADHD), the development of comorbidities, and psychostimulant usage patterns. Follow-up studies were conducted in 37 patients with ADHD and 22 healthy controls, aged 10 and 18, 4 years after their first assessment. The ADHD was rated as persistent if participants met all DSM-IV criteria for syndromic or sub-threshold persistence, or had functional impairments (functional persistence). Of the 37 ADHD patients we reevaluated, 75% had persistent symptoms, and psychiatric comorbidities with additional functional impairments and academic problems were more common than in controls. These follow-up findings show a high comorbidity associated with ADHD and support the importance of evaluation and treatment for ADHD and comorbidities throughout life.

A Review of Peer Relationships and Friendships in Youth With ADHD

OBJECTIVE

The purpose of this essay is to examine peer relationships in youth with ADHD and to review current peer functioning interventions.

METHOD

The studies included in this review were identified using the following search terms: "attention-deficit/hyperactivity disorder," "ADHD," "peer relationships," "friendships," "social skills," "intervention," and "treatment." Other than a few seminal studies published prior to 2000, studies included were published between 2000 and 2012.

RESULTS/DISCUSSION

Background information regarding peer relationship difficulties and specific social skills deficits of youth with ADHD is reviewed and current social skills and friendship intervention programs are examined. Future directions also are provided.

Self-image profile in children and adolescents with attention deficit/ hyperactivity disorder and the quality of life in their parents

OBJECTIVE

We explored the impact of clinical response to treatment for Attention Deficit/Hyperactivity Disorder (ADHD) in children and adolescents on the subsequent changes in their self-image profile, the quality of life of their parents, and its effect on socio-demographic variables.

METHOD

Conners Rating Scales for Parents (CPRS-R) and for Teachers (CTRS-R) completed at the time of entry to the service were repeated to measure clinical response to treatment; the Self-image Profiles for Children (SIP-C) and Adolescents (SIP-A), the World Health Organization Quality of Life (WHOQoL) questionnaire and postcode data were used to evaluate other domains.

RESULTS

Data was collected for 53 boys (84%) and 10 girls (16%) with current mean age 11.5 years. Four-fifths (51/63) received pharmacological treatment and all parents were offered group parent training program. The only subscale in CPRS-R to show significance was the ADHD Index. The CTRS-R demonstrated statistically significant improvement (p < 0.01) in most subscales. On the Self-image Profile, children reported themselves as more Kind (p < 0.012), more Helpful (p < 0.038) and less Bossy (p < 0.047). Comparison of pre- and post-treatment scores on QoL revealed no significant changes; however, correlations of QoL responses against CPRS post-treatment revealed significant negative relationships in a number of instances. Parents living in less deprived areas felt their lives were more meaningful and less likely felt negatively about themselves (p = 0.04, N = 26, rho = 0.405).

CONCLUSION

Clinical improvement in ADHD symptoms was positively correlated with some improvement in the Self-image Profile of children and adolescents, but its impact on the QoL in parents was limited.

Hot and Cool Executive Functions in Children with Attention-Deficit/Hyperactivity Disorder and Comorbid Oppositional Defiant Disorder

While neuropsychological deficits in both "hot" and "cool" executive functions (EFs) have been documented among individuals with attention-deficit/hyperactivity disorder (ADHD), these EF deficits are not universal across all individuals with this diagnosis. One potential moderator of executive dysfunction may be the presence of comorbid oppositional defiant disorder (ODD). This study examined the association between "hot" and "cool" EFs and comorbid ODD in children with ADHD. Thirty-three children with ADHD and comorbid ODD (ADHD+ODD), 67 with ADHD without ODD (ADHD-ODD), and 30 typically developing controls participated. Children were 7-12 years of age. "Cool" EFs were assessed with a spatial span task and a card sorting test. "Hot" EFs were assessed using a delay discounting task and a gambling task. ADHD-ODD and ADHD+ODD groups performed more poorly on "cool" EF tasks than controls, but did not differ from each other. Furthermore, the number of ADHD symptoms, but not ODD symptoms, was associated with "cool" EF scores. The three groups did not differ on "hot" EF tasks and the number of ADHD or ODD symptoms was unrelated to "hot" EF scores. In sum, children with ADHD presented with "cool" EF deficits which appear to be unrelated to ODD comorbidity. However, "hot" EF deficits were not present among children with ADHD, irrespective of comorbid ODD status.

Adult attention-deficit/hyperactivity disorder: Associations between subtype and lifetime substance use - a clinical study

ADHD is the one of the most prevalent childhood disorders and has been associated with impairments persisting into adulthood. Specifically, childhood ADHD is an independent clinical risk factor for the development of later substance use disorders (SUD). Moreover, adults who meet diagnostic criteria for ADHD have shown high rates of comorbid SUDs. Few studies, however, have reported on the relationship between ADHD subtypes and SUD in adult samples. The purpose of this study was to characterize a clinical sample of adults with ADHD and to identify possible associations between ADHD subtypes, lifetime substance use, and if ADHD subtypes may be preferentially associated with specific substances of abuse. We recruited 413 adult ADHD patients, performed an evaluation of their ADHD and conducted an interview on their use of psychotropic substances. Complete data was obtained for 349 patients. Lifetime substance abuse or dependence was 26% and occasional use was 57% in this sample. The inattentive subtype was significantly less likely to abuse or be dependent on cocaine than the combined subtype. Our findings underscore the high rate of comorbidity between substance use and ADHD in adults. The more frequent abuse/dependence of cocaine by adult patients with hyperactive-impulsive symptoms should be kept in mind when treating this patient group.

Using Sibling Designs to Understand Neurodevelopmental Disorders: From Genes and Environments to Prevention Programming

Neurodevelopmental disorders represent a broad class of childhood neurological conditions that have a significant bearing on the wellbeing of children, families, and communities. In this review, we draw on evidence from two common and widely studied neurodevelopmental disorders-autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD)-to demonstrate the utility of genetically informed sibling designs in uncovering the nature and pathogenesis of these conditions. Specifically, we examine how twin, recurrence risk, and infant prospective tracking studies have contributed to our understanding of genetic and environmental liabilities towards neurodevelopmental morbidity through their impact on neurocognitive processes and structural/functional neuroanatomy. It is suggested that the siblings of children with ASD and ADHD are at risk not only of clinically elevated problems in these areas, but also of subthreshold symptoms and/or subtle impairments in various neurocognitive skills and other domains of psychosocial health. Finally, we close with a discussion on the practical relevance of sibling designs and how these might be used in the service of early screening, prevention, and intervention efforts that aim to alleviate the negative downstream consequences associated with disorders of neurodevelopment.

Analysis of personal and family factors in the persistence of attention deficit hyperactivity disorder: results of a prospective follow-up study in childhood

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Developmental progression to early adult binge drinking and marijuana use from worsening versus stable trajectories of adolescent attention deficit/hyperactivity disorder and delinquency

AIMS

To examine the association between developmental trajectories of inattention, hyperactivity-impulsivity and delinquency through childhood and adolescence (ages 8-16 years) and subsequent binge drinking and marijuana use in early adulthood (age 21 years).

DESIGN

Prospective naturalistic follow-up of children with attention deficit/hyperactivity disorder (ADHD) previously enrolled in a randomized controlled trial (RCT). Treatment-phase assessments occurred at 3, 9 and 14 months after randomization; follow-up assessments occurred at 24 months, 36 months, and 6, 8 and 12 years after randomization.

SETTING

Secondary analysis of data from the Multimodal Treatment Study of ADHD (MTA), a multi-site RCT comparing the effects of careful medication management, intensive behavior therapy, their combination, and referral to usual community care.

PARTICIPANTS

A total of 579 children with DSM-IV ADHD combined type, aged 7.0 and 9.9 years at baseline (mean = 8.5, SD = 0.80).

MEASUREMENTS

Ratings of inattention, hyperactivity-impulsivity and delinquency were collected from multiple informants at baseline and through the 8-year follow-up. Self-reports of binge drinking and marijuana use were collected at the 12-year follow-up (mean age 21 years).

FINDINGS

Trajectories of worsening inattention symptoms and delinquency (and less apparent improvement in hyperactivity-impulsivity) were associated with higher rates of early adult binge drinking and marijuana use, compared with trajectories of stable or improving symptoms and delinquency (of 24 comparisons, all P-values <0.05), even when symptom levels in stable trajectories were high.

CONCLUSIONS

Worsening inattention symptoms and delinquency during adolescence are were associated with higher levels of early adult substance use; this pattern may reflect a developmental course of vulnerability to elevated substance use in early adulthood.

Overview of Attention Deficit Hyperactivity Disorder in Young Children

Attention deficit hyperactivity disorder (ADHD) is a complex disorder, which can be seen as a disorder of life time, developing in preschool years and manifesting symptoms (full and/or partial) throughout the adulthood; therefore, it is not surprising that there are no simple solutions. The aim of this paper is to provide a short and concise review which can be used to inform affected children and adults; family members of affected children and adults, and other medical, paramedical, non-medical, and educational professionals about the disorder. This paper has also tried to look into the process of how ADHD develops; what are the associated problems; and how many other children and adults are affected by such problems all over the world basically to understand ADHD more precisely in order to develop a better medical and or non-medical multimodal intervention plan. If preschool teachers and clinicians are aware of what the research tells us about ADHD, the varying theories of its cause, and which areas need further research, the knowledge will assist them in supporting the families of children with ADHD. By including information in this review about the connection between biological behavior, it is hoped that preschool teachers and clinicians at all levels will feel more confident about explaining to parents of ADHD children, and older ADHD children themselves about the probable causes of ADHD.

ADHD symptoms and academic adjustment to college: the role of parenting style

OBJECTIVE

The primary aim of this study was to examine relationships among parenting style, symptoms of ADHD, and academic adjustment in college students. Specifically, we investigated whether parenting style may act as a buffer in the negative relationship between ADHD symptoms and academic adjustment.

METHOD

Participants were 200 undergraduate students attending a large public university. Questionnaires measuring their ADHD symptoms, parent's parenting style, and academic adjustment were completed.

RESULTS

Results indicated small but significant moderation effects for authoritarian parenting and authoritative parenting on the relationship between ADHD symptoms and academic adjustment.

CONCLUSION

Although research has revealed that different parenting styles may relate to different outcomes in children with ADHD, for young adults, the effects of parenting on academic adjustment may be diluted. Future research should investigate variables that may be more salient predictors of functional outcomes for this population, such as organizational skills.

The efficacy of atomoxetine for the treatment of children and adolescents with attention-deficit/hyperactivity disorder: a comprehensive review of over a decade of clinical research

Atomoxetine was first licensed to treat attention-deficit/hyperactivity disorder (ADHD) in children and adolescents in the US in 2002. The aim of this paper is to comprehensively review subsequent publications addressing the efficacy of atomoxetine in 6- to 18-year-olds with ADHD. We identified 125 eligible papers using a predefined search strategy. Overall, these papers demonstrate that atomoxetine is an effective treatment for the core ADHD symptoms (effect sizes 0.6-1.3, vs. placebo, at 6-18 weeks), and improves functional outcomes and quality of life, in various pediatric populations with ADHD (i.e., males/females, patients with co-morbidities, children/adolescents, and with/without prior exposure to other ADHD medications). Initial responses to atomoxetine may be apparent within 1 week of treatment, but can take longer (median 23 days in a 6-week study; n=72). Responses often build gradually over time, and may not be robust until after 3 months. A pooled analysis of six randomized placebo-controlled trials (n=618) indicated that responses at 4 weeks may predict response at 6-9 weeks, although another pooled analysis of open-label data (n=338) suggests that the probability of a robust response to atomoxetine [≥40% decrease in ADHD-Rating Scale (ADHD-RS) scores] may continue to increase beyond 6-9 weeks. Atomoxetine may demonstrate similar efficacy to methylphenidate, particularly immediate-release methylphenidate, although randomized controlled trials are generally limited by short durations (3-12 weeks). In conclusion, notwithstanding these positive findings, before initiating treatment with atomoxetine, it is important that the clinician sets appropriate expectations for the patient and their family with regard to the likelihood of a gradual response, which often builds over time.

Toward quality care in ADHD: defining the goals of treatment

OBJECTIVE

Therapeutic goals for chronic mental disorders like major depressive disorder (MDD) and schizophrenia have evolved in parallel with the growing medical knowledge about the course and treatment of these disorders. Although the knowledge base regarding the clinical course of ADHD, a chronic psychiatric disorder, has evolved beyond symptomatic improvement and short-term treatment response, long-term goals, such as functional remission, have not yet been clearly defined.

METHOD

A PubMed literature search was conducted to investigate the therapeutic goals of pharmacologic treatment referenced in the published literature from January 1998 through February 2010 using the following commonly used ADHD treatments as keywords: amphetamine, methylphenidate, atomoxetine, lisdexamfetamine, guanfacine, and clonidine. This search was then combined with an additional search that included the following outcome keywords: remission, relapse, remit, response, normal, normalization, recovery, and effectiveness.

RESULTS

Our search identified 102 publications. The majority (88.2% [90/102]) of these contained predefined criteria for treatment response. Predefined criteria for normalization and remission and/or relapse were presented in 4.9% (5/102), 12.7% (13/102), and 3.9% (4/102) of publications, respectively. There was a lack of consistency between the instruments used to measure outcomes as well as the criteria used to define treatment response, normalization, and remission as well as relapse.

CONCLUSION

The therapeutic goals in treating ADHD should address optimal treatment outcomes that go beyond modest reductions of ADHD symptoms to include syndromatic, symptomatic, and functional remission. Future work should focus on reliable and valid tools to measure these outcomes in the clinical trial setting.

Association of attention-deficit/hyperactivity disorder and conduct disorder with early tobacco and alcohol use

BACKGROUND

The association of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) with tobacco and alcohol use has not been assessed in a young adolescent sample representative of the U.S. population.

METHODS

Data are from the 2000-2004 National Health and Nutrition Examination Survey, a cross-sectional sample representative of the U.S. population. Participants were age 12-15 years (N=2517). Exposure variables included diagnosis of ADHD and CD, and counts of ADHD and CD symptoms based on caregiver responses to the Diagnostic Interview Schedule for Children. Primary outcomes were adolescent-report of any use of tobacco or alcohol and age of initiating use. Multivariate logistic regression and Cox proportional hazard models were conducted.

RESULTS

Adolescents with ADHD+CD diagnoses had a 3- to 5-fold increased likelihood of using tobacco and alcohol and initiated use at a younger age compared to those with neither disorder. Having ADHD alone was associated with an increased likelihood of tobacco use but not alcohol use. Hyperactive-impulsive symptom counts were not independently associated with any outcome, while every one symptom increase in inattention increased the likelihood of tobacco and alcohol use by 8-10%. Although participants with a diagnosis of CD alone (compared to those without ADHD or CD) did not have a higher likelihood of tobacco or alcohol use, for every one symptom increase in CD symptoms the odds of tobacco use increased by 31%.

CONCLUSIONS

ADHD and CD diagnoses and symptomatology are linked to higher risk for a range of tobacco and alcohol use outcomes among young adolescents in the U.S.

ADHD and Marijuana-Use Expectancies in Young Adulthood

OBJECTIVE

This study examined mean level differences in marijuana expectancies and the differential associations between expectancies and marijuana use for individuals with and without a history of Attention-Deficit/Hyperactivity Disorder (ADHD).

BACKGROUND

Substance-use expectancies are a widely studied risk factor for alcohol and other drug use. The relations between marijuana-use expectancies and self-reported marijuana use have not been examined in young adults with ADHD, a population shown to be at risk for marijuana use.

METHOD

Participants were 306 (190 ADHD and 116 non-ADHD) young adults (M age = 20.06, SD = 2.03) from the Pittsburgh ADHD Longitudinal Study (PALS) who provided data about marijuana use and marijuana-use expectancies.

RESULTS

Individuals in the ADHD group reported lower levels of social enhancement, tension reduction, and cognitive and behavioral-impairment expectancies compared to individuals in the non-ADHD group. Positive and negative marijuana-use expectancies were associated with marijuana use frequency in the whole sample and statistically significant ADHD group by expectancy interactions were found. Sexual-enhancement expectancies were more strongly associated with marijuana use frequency among individuals with ADHD histories while cognitive behavioral-impairment expectancies were more strongly associated with marijuana use frequency among individuals without ADHD.

CONCLUSIONS

Marijuana-use expectancies may be acquired, and operate differently, for individuals with and without ADHD histories. Although future research is needed to test this speculation, these differences may be associated with ADHD-related difficulties in higher order cognitive processes that affect the encoding and utilization of expectations regarding marijuana's effects.