The additive factor method: a differential diagnostic tool in hyperactivity and learning disability

Sustained attention and behavioral ratings of attention in struggling readers

Attention is correlated with reading, but the extent to which behavioral ratings and sustained attention relate to reading skills is unclear. We assessed 245 4th and 5th grade struggling readers (mean age = 10.3 years) on behavioral ratings of attention, sustained attention, and reading over a school year. Contributions of behavioral ratings and sustained attention were considered cross-sectionally and longitudinally in the context of other important predictors of reading. Results suggest that sustained measures and behavioral ratings assess distinct, yet overlapping, aspects of attention. Both types of attention accounted for unique variance in comprehension, but not word reading accuracy or fluency, when evaluated cross-sectionally. Results also support the role of behavioral ratings of attention in fluency and in comprehension growth. Findings suggest that multidimensional assessment of attention is useful when considering its relation to reading, and highlights the need to integrate conceptualizations of attention that arise from different theoretical approaches.

Current State and Model for Development of Technology-Based Care for Attention Deficit Hyperactivity Disorder

INTRODUCTION

Care (i.e., evaluation and intervention) delivered through technology is used in many areas of mental health services, including for persons with attention deficit hyperactivity disorder (ADHD). Technology can facilitate care for individuals with ADHD, their parents, and their care providers. The adoption of technological tools for ADHD care requires evidence-based studies to support the transition from development to integration into use in the home, school, or work for persons with the disorder. The initial phase, which is development of technological tools, has begun in earnest; however, the evidence base for many of these tools is lacking. In some instances, the uptake of a piece of technology into home use or clinical practice may be further along than the research to support its use.

METHODS

In this study, we review the current evidence regarding technology for ADHD and also propose a model to evaluate the support for other tools that have yet to be tested.

RESULTS

We propose using the Research Domain Criteria as a framework for evaluating the tools' relationships to dimensions related to ADHD.

CONCLUSION

This article concludes with recommendations for testing new tools that may have promise in improving the evaluation or treatment of persons with ADHD.

Auditory and Visual Continuous Performance Tests

Elementary school children in three grade groups (Grades K/1, 3, and 5/6) completed either the auditory or the visual 1/9 vigilance task from the Gordon Diagnostic System (GDS) as well as subtests from the Wechsler Intelligence Scale for Children–Third Edition and auditory or visual processing subtests from the Woodcock-Johnson Tests of Cognitive Ability–Revised (WJ-R). Teachers rated the children's classroom attentional and self-control behaviors on the Child Behavior Checklist (CBCL) and the Self-Control Observation Scale (SCOS). Although performance on both auditory and visual continuous performance tests (CPTs) improved with age, gender effects were small and limited to the visual CPT. Neither auditory nor visual CPT scores were related to IQ scores. However, auditory CPT scores were related to classroom behaviors as reported by teachers whereas visual CPT scores were related to visual processing.

Differential oscillatory electroencephalogram between attention-deficit/hyperactivity disorder subtypes and typically developing adolescents

BACKGROUND

A neurobiological-based classification of attention-deficit/hyperactivity disorder (ADHD) subtypes has thus far remained elusive. The aim of this study was to use oscillatory changes in the electroencephalogram (EEG) related to informative cue processing, motor preparation, and top-down control to investigate neurophysiological differences between typically developing (TD) adolescents, and those diagnosed with predominantly inattentive (IA) or combined (CB) (associated with symptoms of inattention as well as impulsivity/hyperactivity) subtypes of ADHD.

METHODS

The EEG was recorded from 57 rigorously screened adolescents (12 to 17 years of age; 23 TD, 17 IA, and 17 CB), while they performed a cued flanker task. We examined the oscillatory changes in theta (3-5 Hz), alpha (8-12 Hz), and beta (22-25 Hz) EEG bands after cues that informed participants with which hand they would subsequently be required to respond.

RESULTS

Relative to TD adolescents, the IA group showed significantly less postcue alpha suppression, suggesting diminished processing of the cue in the visual cortex, whereas the CB group showed significantly less beta suppression at the electrode contralateral to the cued response hand, suggesting poor motor planning. Finally, both ADHD subtypes showed weak functional connectivity between frontal theta and posterior alpha, suggesting common top-down control impairment.

CONCLUSIONS

We found both distinct and common task-related neurophysiological impairments in ADHD subtypes. Our results suggest that task-induced changes in EEG oscillations provide an objective measure, which in conjunction with other sources of information might help distinguish between ADHD subtypes and therefore aid in diagnoses and evaluation of treatment.

Rapid automatized naming and immediate memory functions in Chinese children who read English as a second language

This study examined reading performance of 102 Chinese Mandarin-speaking 4th graders in their second language (L2, English) as a function of performance in their first language (L1, Chinese). The results revealed that for Rapid Automatized Naming (RAN) and Rapid Alternating Stimulus (RAS) measures, the mean naming time decreased monotonically in high-achieving, average, and low-achieving readers. RAN and RAS differentiated poor readers from good and average readers but failed to differentiate between good and average readers. RAN deficits occurred in poor readers in both languages. Comparison of memory profiles revealed that patterns varied depending on the mode of stimulus presentation or response. Low-achieving readers performed poorly on a subtest involving visual components only and did relatively better on a subtest involving verbal components only. Poor readers in Chinese also encountered difficulties in learning English as a L2. RAN-character accounted for unique variance in two Chinese reading measures. RAN-letter explained unique variance in English mid-term reading grade. The unique variance captured by the Color Span Subtest 1 (visual-visual) was found in Chinese reading comprehension but not in English reading comprehension. Reading performance in L1 was predictive of reading performance in L2 and vice versa.

Attention impairment in childhood absence epilepsy: an impulsivity problem?

Although attention problems have often been described in children with childhood absence epilepsy (CAE), the use of different methodological approaches, neuropsychological tests, and heterogeneous experimental groups has prevented identification of the selective areas of attention deficit in this population. In this study, we investigated several components of attention in children with CAE using a unique computerized test battery for attention performance. Participants included 24 patients with CAE and 24 controls matched for age and sex. They were tested with a computerized test battery, which included the following tasks: selective attention, impulsivity, focused attention, divided attention, alertness, and vigilance. Compared with healthy controls, patients with CAE made more commission errors in the Go/No-Go task and more omission errors in the divided attention task. Childhood absence epilepsy patients also showed decreased reaction times in measures of selective attention and a great variability of reaction times in alertness and Go/No-Go tasks. Our findings suggest that patients with CAE were impaired in tonic and phasic alertness, divided attention, selective attention, and impulsivity.

Rapid automatized naming and immediate memory functions in Chinese Mandarin-speaking elementary readers

The purpose of this study was to evaluate rapid automatized naming skills (RAN) and immediate memory processes in 243 Chinese Mandarin-speaking elementary readers (ranging from Grade 1 to Grade 5). For RAN subtests, the mean naming time decreased monotonically with grade level in good and average readers, and a similar trajectory was found in poor readers, even though they were generally slower in rapid naming. Regardless of grouping methods (counting all participants or counting good readers only), RAN Character emerged as a significant predictor of various Chinese reading measures. Different from classical findings in English readers indicating that RAN Number was a better correlate of reading than RAN Object, RAN Object outperformed RAN Number and became a significant predictor of Chinese reading speed and spelling, suggesting that the differences in predictive power of RAN tasks may be language specific. Comparison of memory profiles for good, average, and poor readers revealed that the patterns varied depending on mode of stimulus presentation or response. Poor readers performed poorly on subtests involving a visual component and did relatively better on subtests involving verbal cues only, whereas a reversed pattern was shown in the group of good readers. The findings were interpreted to suggest that good and poor Chinese readers may be essentially different in applying visual strategies and verbal mediation during visual-verbal intra- and intermodal processing, and visual skills appear to be particularly important in reading of Chinese.

Shortened conditioned eyeblink response latency in male but not female Wistar-Kyoto hyperactive rats

Reductions in the volume of the cerebellum and impairments in cerebellar-dependent eyeblink conditioning have been observed in attention-deficit/hyperactivity disorder (ADHD). Recently, it was reported that subjects with ADHD as well as male spontaneously hypertensive rats (SHR), a strain that is frequently employed as an animal model in the study of ADHD, exhibit a parallel pattern of timing deficits in eyeblink conditioning. One criticism that has been posed regarding the validity of the SHR strain as an animal model for the study of ADHD is that SHRs are not only hyperactive but also hypertensive. It is conceivable that many of the behavioral characteristics seen in SHRs that seem to parallel the behavioral symptoms of ADHD are not solely due to hyperactivity but instead are the net outcome of the interaction between hyperactivity and hypertension. We used Wistar-Kyoto Hyperactive (WKHA) and Wistar-Kyoto Hypertensive (WKHT) rats (males and females), strains generated from recombinant inbreeding of SHRs and their progenitor strain, Wistar-Kyoto (WKY) rats, to compare eyeblink conditioning in strains that are exclusively hyperactive or hypertensive. We used a long-delay eyeblink conditioning task in which a tone conditioned stimulus was paired with a periorbital stimulation unconditioned stimulus (750-ms delay paradigm). Our results showed that WKHA and WKHT rats exhibited similar rates of conditioned response (CR) acquisition. However, WKHA males displayed shortened CR latencies (early onset and peak latency) in comparison to WKHT males. In contrast, female WKHAs and WKHTs did not differ. In subsequent extinction training, WKHA rats extinguished at similar rates in comparison to WKHT rats. The current results support the hypothesis of a relationship between cerebellar abnormalities and ADHD in an animal model of ADHD-like symptoms that does not also exhibit hypertension, and suggest that cerebellar-related timing deficits are specific to males.

ADHD and DCD: A relationship in need of research

Although the connection between attention deficit hyperactivity disorder (ADHD) and developmental coordination disorder (DCD) has been recognized for several decades, little research has examined the relationship between these two disorders. This paper draws attention to the contribution the cognitive-energetic model (CEM) can make in determining the specific nature of these two disorders. An information processing approach such as the CEM is a useful model to identify specific and overlapping mechanisms that are disrupted in these two disorders. This paper describes the CEM and reviews the research so-far in relation to the model. The CEM has several advantages over other models: First, it predicts which task variables will be independent or may interact, thus enabling the investigator to determine the success/failure of the task manipulation(s) and identify spurious findings. Second, the CEM links energetic factors to task variables and predicts both additive and interactive effects. Third, the CEM enables executive processes such as selective attention, working memory and inhibition to be related to both energetic and lower level processes. Fourth, by employing the CEM in clinical research, taxonomy of deficits can be derived enabling further insight into the nature of the disorders and their specific neuropsychological dysfunction. Suggestions are made for future research into the neuropsychological deficits associated with ADHD and DCD.

Motor preparation, motor execution, attention, and executive functions in attention deficit/hyperactivity disorder (ADHD)

Attention and executive functions were investigated in medicated and unmedicated children with ADHD combined type using a novel selective reaching task. This task involved responding as rapidly as possible to a target while at times having to ignore a distractor. Results indicated that unmedicated children with ADHD showed slow and inaccurate responding. Slow responding reflected problems at the stage of movement preparation but not movement execution. An attentional impairment, rather than a motor planning problem per se, appeared to underlie the slow movement preparation. Inaccurate responding reflected problems with response inhibition and selective attention, impulsivity, set-shifting, and difficulties in maintaining vigilance. Although medicated children with ADHD did not show slow movement preparation, they did show some response inaccuracy, resulting especially from impulsive responding. These findings suggest that ADHD is characterized by slow motor preparation (but not motor execution), and deficits in selective attention, vigilance, and executive functions. Preliminary results suggest that stimulant medication may resolve some of these motor, attentional and executive function deficits.

Modeling attention-deficit/hyperactivity disorder: a critical appraisal of the cognitive-energetic model

A number of theoretical models of attention-deficit/hyperactivity disorder (ADHD) have emerged in recent years that may be used as systematic guides for clinical research. The cognitive-energetic model (CEM) proposes that the overall efficiency of information processing is determined by the interplay of three levels: computational mechanisms of attention, state factors, and management/executive function (EF). The CEM encompasses both top-down and bottom-up processes and draws attention to the fact that ADHD causes defects at all three levels. These include cognitive mechanisms, such as response output; energetic mechanisms, such as activation and effort; and management/EF deficits. Increasing evidence suggests that inhibition deficits associated with ADHD may, at least in part, be explained in terms of an energetic dysfunction. The activation and effort energetic pools appear most relevant to ADHD, being directly related to response organization; however, further testing of CEM is critically dependent on the development of direct measures of these energetic pools. The CEM is a comprehensive model of ADHD but is not without limitations. In particular, further research is required to define more specifically the relationship between process dysfunction and state dysregulation in ADHD.

Motivational effects on motor timing in attention-deficit/hyperactivity disorder

OBJECTIVE

This study was designed to clarify whether poor performance of children with attention-deficit/hyperactivity disorder (ADHD) on motor timing tasks reflects a true deficit in the temporal organization of motor output or is due to a lack of intrinsic motivation.

METHOD

Eighteen children with ADHD (age 8-12) were compared with 18 age- and gender-matched normal controls with respect to timing precision, timing variability, and the frequency of extreme under- and overestimations during a 1-second interval production task. Monetary reward, response cost, and no reward were implemented to manipulate motivation.

RESULTS

Children with ADHD produced significantly more inaccurate and more variable time intervals and exhibited a larger number of extreme over- and underestimations than control children. Although all children performed significantly better when monetary incentives were applied, group differences were not eliminated.

CONCLUSIONS

In this study, no evidence was found for a motivational deficit as an explanation for impaired performance on a time production task in ADHD. Rather, results provide clear support for a generic motor timing deficit, probably due to a dysfunctional frontostriatocerebellar network involved in temporal aspects of motor preparation.

Controlled visuomotor preparation deficits in attention-deficit/hyperactivity disorder

To the best of the authors' knowledge, there are no published reports on visuomotor preparation in attention-deficit/hyperactivity disorder (ADHD). This is unfortunate, because research suggests that ADHD is an output-related deficit, and suboptimal execution of tasks may be the result of incomplete visuomotor preparation. The authors compared 19 children with ADHD with 124 healthy and 120 pathological controls in terms of their performance (speed, speed variability, and accuracy) on the finger precuing test, a test measuring (automatic and controlled) visuomotor preparation. The data implied that children with ADHD have an impaired ability to engage in effortful, controlled visuomotor preparation activities. Fast, automatic response preparation was not affected by ADHD. In addition, children with ADHD showed more variability in overall test performance than other children. No group differences were found in response accuracy.

EUNETHYDIS -- searching for valid aetiological candidates of Attention-Deficit Hyperactivity Disorder or Hyperkinetic Disorder

BACKGROUND

To step up research in ADHD, exchange of ideas, working together on key theoretical models and cooperative studies are necessary.

OBJECTIVE

To report about a European approach with strong links to the rest of the world.

METHOD

European Network on Hyperkinetic Disorders (Eunethydis) studies of Attention -- Deficit Hyperactivity Disorder (ADHD) or Hyperkinetic Disorder (HKD) is briefly reviewed in the context of the international effort to discover the aetiology of the disorder.

RESULTS

There are promising neurobiological, neurophysiological and neuropsychological candidates to explain the nature of ADHD/HKD.

CONCLUSION

Eunethydis has shown to be a fruitful platform for ADHD research and has good resources for its further development.

Synaptic gating and ADHD: a biological theory of comorbidity of ADHD and anxiety

To derive a biologically based theory of comorbidity in Attention Deficit Hyperactivity Disorder (ADHD). Theoretical concepts and empirical studies were reviewed to determine whether the behavioral inhibition concept provided an understanding of biological processes involved in comorbidity in ADHD. Empirical studies of ADHD have shown comorbidity of ADHD and anxiety, while studies of behavioral inhibition tend to suggest independent disruptive and anxiety traits. This paradox can be resolved by an understanding of the dynamics of mesolimbic dopamine (DA) systems, where reward and delay of reinforcement are determined by tonic/phasic DA relationships, resulting in impulsive 'fearless' responses when impaired. On the other hand, comorbid anxiety is related to impaired synaptic processes, which selectively gate fear (or aggressive) responses from the amygdala at the accumbens. Monosynaptic convergence between prefrontal, hippocampal, and amygdala projection neurons at the accumbens allows the operation of a synaptic gating mechanism between prefrontal cortex (PFC), hippocampus, and amygdala. Impairment of this mechanism by lowered PFC inhibition allows greater amygdala input, and anxiety-related processes more impact, over the accumbens. In conclusion, a dual theory incorporating long-term tonic/phasic mesolimbic DA relationships and secondly impairment of PFC and hippocampal inputs to synaptic gating of anxiety at the accumbens has implications for comorbidity in ADHD, as well as for possible pharmacological interventions, utilizing either stimulant or axiolytic interventions. The use of DA partial agonists may also be of interest.

A test of the integrity of the components of Baddeley's model of working memory in attention-deficit/hyperactivity disorder (ADHD)

BACKGROUND

The integrity of working memory in attention-deficit/hyperactivity disorder (ADHD) was tested within the framework of Baddeley's model. METHODS-1: Buffers and rehearsal mechanisms were assessed by presenting children with or without ADHD (ages 8 to 15) with 1-7 target letters and a probe after 2-10 s. They decided if the probe was the same (verbal task) or in the same location (spatial task) as any of the targets. RESULTS-1: There was no interaction between group and delay or memory load in either task. METHODS-2: The central executive was assessed on a dual task. RESULTS-2: Although children with ADHD did not differ from controls in simple response time (RT) or in digits recalled, they showed greater decrements in RT when performing the 2 tasks concurrently.

CONCLUSIONS

Findings suggest that children with ADHD (1) do not have generalized impairments in working memory, (2) rehearse verbal and spatial information in the same manner as healthy children, (3) may have an impairment in the central executive component of working memory, which controls ability to divide attention between two tasks.

Relationship between motor proficiency, attention, impulse, and activity in children with ADHD

The aim of this study was to investigate the relationship between motor performance, attention deficit, impulsiveness, and hyperactivity in children with attention-deficit--hyperactivity disorder (ADHD). Participants were 42 school-aged children with ADHD (36 males, 6 females; mean age 8 years 2 months, SD 1 year 2 months; range 6 years to 11 years), and 42 age- and sex-matched children without ADHD (mean age 8 years 3 months, SD 1 year 1 month; range 6 years to 11 years). Motor abilities were assessed with the Bruininks-Oseretsky Test of Motor Proficiency. Attention and impulse control were measured with the Gordon Diagnostic System, and assessment of activity level was based on two Activity Level Rating Scales that were completed by parents and teachers. Analysis by t-test revealed a significant difference between children with and without ADHD in fine and gross motor skills, impulse control, and attention. Stepwise regression indicated that attention, impulse control, and parent ratings of activity level were the three best predictors of gross motor skills for children with ADHD, accounting for 55.9% of the variance. Attention and impulse control were the two best predictors of fine motor skills, accounting for 45.7% of the variance. Attention and impulse control were consistently found to be important predictors of both fine and gross motor skills in children with ADHD. However, the fact that activity level was a predictor for gross motor proficiency but not for fine motor tasks suggests that different behavioral processes are involved in fine and gross motor performance to different extents.

Low- and high-level controlled processing in executive motor control tasks in 5-6-year-old children at risk of ADHD

BACKGROUND

The scant research on the characteristics of Attention-Deficit/Hyperactivity Disorder (ADHD) in kindergarten years curtails progress on early assessment of ADHD.

METHOD

By screening a general population sample of 1317 five- to six-year-old children, four groups of children were selected. The performance of 30 children later diagnosed with ADHD was compared with 74 children later diagnosed with 'borderline ADHD' (children exhibiting all ADHD symptoms but without disruptions on two situations), 113 children later diagnosed with other psychopathology, and 126 healthy controls on computerised motor control tasks involving low- and high-level controlled processing. In addition, motor control was compared with movement speed.

RESULTS

The children at risk of ADHD were in general less accurate and more variable in their movements than the children with other psychopathology and healthy controls. Under conditions of high-level controlled processing, the children at risk of ADHD were disproportionately more inaccurate and had a more unstable performance with their preferred hand than the other children. In addition, linear effects were found, with the children at risk of ADHD having the worst performance, followed by the children with 'borderline ADHD', and then both groups of control children. No significant group differences were found in movement speed.

CONCLUSIONS

The main findings are interpreted as evidence for a specific deficit in high-level controlled processing in young children at risk of ADHD, now found in a motor task, rather than a response task. Furthermore, the results support the notion that ADHD represents a dimensional trait. In addition, problems in movement control (the need to allocate attentional capacity) rather than problems in movement speed distinguish children at risk of ADHD from other children. The findings are interpreted as evidence that higher-order executive processes, such as self-control and self-regulation, are already affected early in the development of ADHD.

Neuropsychological evaluation of deficits in executive functioning for ADHD children with or without learning disabilities

This study investigates multiple aspects of executive functioning in children with attention deficit/hyperactivity disorder (ADHD). These areas include attentional components, impulsiveness, planning, and problem solving. The rationale of the study is based on neurophysiological studies that suggest frontal lobe dysfunction in ADHD. As frontal lobe functioning is related to abilities in executive control, ADHD is hypothesised to be associated with deficits in various areas of executive functioning. The specific effect of comorbidity of learning disability (LD) was also investigated. Eighty-three children with ADHD and 29 age-matched controls (age 7-13) participated in the study. A battery of neuropsychological tests was utilized to evaluate specific deficits in speed of processing, selective attention, switching attention, sustained attention, attentional capacity, impulsiveness, planning and problem solving. Findings indicated that children with ADHD have slower verbal responses and sustained attention deficit. Deficits in selective attention and attentional capacity observed were largely related to the presence of LD. No specific deficit associated with ADHD or the comorbidity of LD was identified in switching attention, impulsiveness, planning, and problem solving. These results revealed that ADHD is not associated with a general deficit in executive functioning. Instead, ADHD is related to a specific deficit in regulation for attentional resources. The importance of isolating the deficit related to LDs for examining the specific deficit associated with ADHD is highlighted. Results also emphasised the importance of isolating the effect of lower level of abilities (e.g., speed of processing) and the utilization of specific definition for the examination of executive functions.

Association of ADHD and conduct disorder--brain electrical evidence for the existence of a distinct subtype

BACKGROUND

To evaluate the impact of psychopathological comorbidity with oppositional defiant/conduct disorder (ODD/CD) on brain electrical correlates in children with attention deficit hyperactivity disorder (ADHD) and to study the pathophysiological background of comorbidity of ADHD+ODD/CD.

METHOD

Event-related potentials (ERPs) were recorded during a cued continuous performance test (CPT-A-X) in children (aged 8 to 14 years) with ICD-10 diagnoses of either hyperkinetic disorder (HD; n = 15), hyperkinetic conduct disorder (HCD; n = 16), or ODD/CD (n = 15) and normal children (n = 18). HD/HCD diagnoses in all children were fully concordant with the DSM-IV diagnosis of ADHD-combined type. ERP-microstates, i.e., time segments with stable brain electrical map topography were identified by adaptive segmentation. Their characteristic parameters and behavioral measures were further analyzed.

RESULTS

Children with HD but not comorbid children showed slower and more variable reaction times compared to control children. Children with HD and ODD/CD-only but not comorbid children displayed reduced P3a amplitudes to cues and certain distractors (distractor-X) linked to attentional orienting. Correspondingly, global field power of the cue-CNV microstate related to anticipation and preparation was reduced in HD but not in HCD. Topographical alterations of the HD occurred already in the cue-P2/N2 microstate. In sum, the comorbid group was less deviant than both the HD-group and the ODD/CD-group.

CONCLUSIONS

The findings suggest that HD children (ADHD-combined type without ODD/CD) suffer from a more general deficit (e.g., suboptimal energetical state regulation) including deficits of attentional orienting and response preparation than just a responseinhibitory deficit, backing the hypothesis of an involvement of a dysregulation of the central noradrenergic networks. The results contradict the hypothesis that ADHD+ODD/CD represents an additive co-occurrence of ADHD and ODD/CD and strongly suggest that it represents a separate pathological entity as considered in the ICD-10 classification system, which differs from both HD and ODD/CD-only.

Timing and force control in boys with attention deficit hyperactivity disorder: subtype differences and the effect of comorbid developmental coordination disorder

This study examined the motor and performance outcomes of boys with subtypes of attention deficit hyperactivity disorder (ADHD) (DSM-IV, [American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th ed., Washington, DC, 1994]). It also examined the differences between boys with a single diagnosis of ADHD versus those who have the dual categorisation of ADHD and developmental coordination disorder (DCD). The participants were 157 boys, aged 7.70-12.98 years recruited from a community sample. Parent report was used to classify 143 boys into either a comparison group or one of the three DSM-IV ADHD subtypes. Participants were given a battery of tests that included the Movement Assessment Battery for Children [Movement Assessment Battery for Children, Psychological Corporation/Harcourt Brace-Jovanovich, New York, 1992], the Wechsler Intelligence Scales for Children--Third Edition [Manual for the Wechsler Intelligence Scale for Children, Psychological Corporation, New York, 1992] and a finger tapping task targeting motor processing, preparation, and execution. Boys with subtypes that included inattentive symptomatology had significant difficulties with timing, force output and showed greater variability in motor outcomes. Boys with the comorbid condition (i.e., ADHD and DCD) had particular difficulty with force control. These outcomes identify a need for increased recognition of the clinical and research implications of the relationship between ADHD and motor dysfunction. This potentially impacts on assessment, intervention, theoretical modelling and the general interpretation of cognitive abilities research with children with ADHD.

Neurocognitive performance of 5- and 6-year-old children who met criteria for attention deficit/hyperactivity disorder at 18 months follow-up: results from a prospective population study

The aim of this prospective study was to examine whether neurocognitive performance of children aged 5-6 years distinguished children who were later diagnosed with attention deficit/hyperactivity disorder(ADHD) or "borderline ADHD" from children without ADHD after adjustment for behavioral measures and to examine the influence of comorbid psychopathology. Out of a general population of 1,317 children, 366 children were selected on the basis of their scores on the Child Behavior Checklist (CBCL). Eighteen months later, the parents were interviewed using a standardized child psychiatric interview: 33 children were classified as ADHD and 75 children as borderline ADHD, and there were 258 children without ADHD. Children with rated ADHD were significantly impaired on measures of visuomotor ability and working memory compared to children without ADHD after adjustment for CBCL results. The performance of borderline ADHD children was in between that of children with and without ADHD. In addition, 4 groups of children were analyzed: 9 ADHD, 24 ADHD with comorbid oppositional defiant disorder/conduct disorder (ODD/CD), 59 ODD/CD, and 274 controls. Children with rated comorbid ADHD and ODD/CD performed significantly worse on these tasks compared to children with rated ODD/CD and control children while they did not differ from ADHD children. Our results imply that neurocognitive measures can contribute to the early identification of ADHD with and without comorbid ODD/CD.

Inhibitory control in children with attention-deficit/hyperactivity disorder: event-related potentials identify the processing component and timing of an impaired right-frontal response-inhibition mechanism

BACKGROUND

A core deficit in inhibitory control may account for a wide range of dysfunctional behaviors in attention-deficit/hyperactivity disorder (ADHD).

METHODS

Event-related potentials were measured in 10 children with ADHD and 10 healthy children during a task specifically involving response inhibition (Stop signal task).

RESULTS

In response to all Stop signals, control participants produced a large negative wave at 200 msec (N200) over right inferior frontal cortex, which was markedly reduced in ADHD children. The N200 amplitude was significantly correlated across subjects with response-inhibition performance. In response to the Go stimuli, ADHD children showed a reduced slow positive wave (250-500 msec) in anticipation of failed inhibitions over right frontal scalp regions.

CONCLUSIONS

ADHD children appear to have an abnormality in an early-latency, right inferior frontal processing component critical to the initiation of normal response-inhibition operations. They also appear to have a right frontal abnormality associated to the covert processing of Go stimuli preceding failed inhibitions. By providing timing and processing component specificity, these results extend the findings of recent functional MRI studies of inhibitory control reporting right frontal abnormalities in ADHD.

Brain mapping of bilateral interactions in attention deficit hyperactivity disorder and control boys

OBJECTIVES

Children with attention deficit hyperactivity disorder (ADHD) are thought to have deficits in attentional control, whereas the status of deficits at visual and pre-motor processing stages is unclear.

METHODS

The timing of such deficits was examined with event-related potential (ERP) microstates (stimulus- and response-related) and continuous force recordings in 15 ADHD and 16 control boys in a choice reaction time task. Unilateral and bilateral stimulus and response conditions were used to assess bilateral interactions at visual, central, and pre-motor stages.

RESULTS

ADHD boys showed poorer performance, particularly in the bilateral conditions. In the visual P1 microstates, they exhibited less suppression of visual evoked potential (VEP) amplitudes but similar speeding of VEP latencies in the bilateral compared to the summed unilateral condition. The central P3 and pre-/post-response microstates were attenuated and topographically altered in ADHD boys. The attenuation was most pronounced in the bilateral condition and was similar for stimulus- and response-related averages. The lateralized readiness potential was also reduced in ADHD boys; this was most pronounced for the left hand responses.

CONCLUSIONS

Brain mapping during uni- and bilateral stimulus and response conditions thus indicates multilevel deficits in ADHD boys affecting visuo-attentional, central, and pre-motor processes.

Neurocognitive functioning in adults with attention-deficit/hyperactivity disorder

The performance of nine adults with attention-deficit/hyperactivity disorder (ADHD) was compared with the performance of 23 normal controls on computerized measures of target orientation, sustained attention, encoding speed, and motor output/response organization to determine the nature of the neurocognitive deficits of adults with ADHD. While the groups' performances on measures of sustained attention and encoding speed did not differ, significant group differences were seen on a task that targeted motor output/response organization. These data suggest that the neurocognitive difficulties of ADHD adults are not related to a primary deficit in sustained attentional functioning. Rather, the deficient information processing in ADHD adults is related to difficulties with motor output/response organization.

Definition and documentation: theory, measurement, and the courts

Definition of terms and the selection criteria for operationalizing the standard of disability are critical to accessing accommodations. The purpose of this article was to examine the research surrounding definitiorns and selection criteria for learning disabilities and attention-deficit/hyperactivity disorder at the postsecondary level. Implications from and for the courts follow a critical analysis of the professional literature. The need for researchers to utilize theory-based models to investigate the multivariate relationships between and within constructs underlying current definitions and eligibility criteria is also disscussed.

Motor control and state regulation in children with ADHD: a cardiac response study

The goal of the current study was to investigate whether poor motor control in children with Attention-Deficit Hyperactivity Disorder (ADHD) was associated with a state regulation deficit. For this purpose, 28 ADHD and 22 healthy children carried out two Go No-Go tests: one with a fast stimulus presentation rate, and the other with a slow stimulus presentation rate. Groups were compared on RT performance and on specific cardiac measures, reflecting arousal, motor activation/inhibition, and effort allocation. No group difference in the arousal measure (mean heart rate) was found. Further, groups did not differ with respect to response inhibition: in both the fast and slow condition, ADHD children made comparable numbers of errors of commission to the control group, and the groups did not differ with respect to the heart rate deceleration after the onset of the No-Go signal, reflecting motor inhibition. Group differences were found with respect to motor activation and effort allocation in the condition with a slow presentation rate. In this condition: (1) ADHD children reacted more slowly to Go signals than control children, suggesting poor motor activation; (2) the heart rate deceleration before the onset of Go signals, which is believed to reflect motor preparation, was less pronounced in the ADHD children; (3) after Go signals, where a response was given, the cardiac shift from deceleration to acceleration, indicating response initiation, was delayed in ADHD children; and (4) ADHD children had greater heart rate variability (0.10 Hz component) than the control group, indicating that less effort was allocated. No group differences in motor activation and effort allocation were found in the condition with a fast presentation rate of stimuli. We conclude, therefore, that a slow presentation rate of stimuli brings the ADHD child in a non-optimal activation state.

Synchronization, anticipation, and consistency in motor timing of children with dimensionally defined attention deficit hyperactivity behaviour

We tested the hypothesis that children with hyperactive behaviour are impaired in the temporal organization of their motor output. The performance of 11 boys, scoring above a cut-off on standard scales of overactivity and inattention, was compared to that of controls in progressively more complex Motor-timing tasks. The tasks administered required self-paced and externally paced Sensorimotor Synchronization and Sensorimotor Anticipation. Deficits at a perceptual level were investigated with a Time-discrimination task. As hypothesized, we found that hyperactive children had no deficits in their perception of time but were impaired in timing their motor output. Hyperactive children were more inconsistent than controls in maintaining a freely chosen tapping rhythm, in synchronizing and in anticipating their motor response to external visual stimulation.

Attention-deficit hyperactivity disorder and developmental right-hemisphere syndrome: congruence and incongruence of cognitive and behavioral aspects of attention

We studied clinical aspects of attention in three groups: children with developmental right-hemisphere syndrome and attention-deficit hyperactivity disorder (ADHD), children with ADHD only, and normal controls. The three groups (N = 54) were case-matched for age, sex, IQ, hand dominance, and socioeconomic status. ADHD was diagnosed clinically using the Diagnostic and Statistical Manual of Mental Disorders-III-Revised criteria and the Conners' Abbreviated Teacher Questionnaire. Additional aspects of attention and behavior were measured by the Child Behavior Checklist, a low-cognitive-load continuous performance task, and the visual target cancellation test (paper and pencil). Although the Child Behavior Checklist profile of attentional deficits in the two clinical groups was similar, we found that the developmental right-hemisphere syndrome group was more severely impaired on parameters of attention measured by the continuous performance task and visual target cancellation test than the children with ADHD. We conclude that the profile of attentional deficits in developmental right-hemisphere syndrome is different than that seen in children with ADHD only, possibly reflecting disparate neurologic underpinnings for the two syndromes.

Methylphenidate does not modify the impact of response frequency or stimulus sequence on performance and event-related potentials of children with attention deficit hyperactivity disorder

Twenty-six children with attention deficit/hyperactivity disorder (ADHD) participated in a double-blind trial consisting of 2 consecutive weeks each of placebo and methylphenidate (M = 26.92 mg/day = 0.78 mg/kg/day). As expected, stimulant therapy resulted in moderate weight loss, increased somatic complaints, and teacher and parent reports of reduced inattentiveness, aggression, and oppositionality. In both phases of the trial, patients were tested in a choice reaction time task assessing two aspects of the task that presumably affect response selection: response frequency (ratio of targets/nontargets = 25/75 vs. 50/50) and stimulus sequence (alternations vs. repetitions). Both manipulations yielded expected results on performance and event-related potentials (ERPs). Stimulant treatment increased accuracy and speed among younger children and curtailed variability of reaction time for the sample as a whole. However, methylphenidate did not affect ERPs. In combination, the results imply that the enhancement of performance by methylphenidate does not involve the demands of response selection examined in this study.

Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration

The psychostimulants, D-amphetamine (D-AMP) and methylphenidate (MPH), are widely used to treat attention-deficit hyperactivity disorder (ADHD) in both children and adults. The purpose of this paper is to integrate results of basic and clinical research with stimulants in order to enhance understanding of the neuropharmacological mechanisms of therapeutic action of these drugs. Neurochemical, neurophysiological and neuroimaging studies in animals reveal that the facilitative effects of stimulants on locomotor activity, reinforcement processes, and rate-dependency are mediated by dopaminergic effects at the nucleus accumbens, whereas effects on delayed responding and working memory are mediated by noradrenergic afferents from the locus coeruleus (LC) to prefrontal cortex (PFC). Enhancing effects of the stimulants on attention and stimulus control of behavior are mediated by both dopaminergic and noradrenergic systems. In humans, stimulants appear to exert rate-dependent effects on activity levels, and primarily enhance the motor output, rather than stimulus evaluation stages of information-processing. Similarity of response of individuals with and without ADHD suggests that the stimulants do not target a specific neurobiological deficit in ADHD, but rather exert compensatory effects. Integration of evidence from pre-clinical and clinical research suggests that these effects may involve stimulation of pre-synaptic inhibitory autoreceptors, resulting in reduced activity in dopaminergic and noradrenergic pathways. The implications of these and other hypotheses for further pre-clinical and clinical research are discussed.

Inhibitory dysfunction in hyperactive boys

Recent evidence suggests that the main deficit in childhood hyperactivity is in frontal lobe-mediated self-regulative functions such as inhibitory control. Hyperactives have consistently been shown to perform poorly on the stop task, which is a laboratory measurement of inhibitory control. This study was aimed at extending knowledge about inhibitory processes involved in the hyperactive's performance on this task. For this purpose, the performance of 11 pervasive hyperactives was compared to the performance of normal children on two stop tasks which differed from each other in the contingency of timing of the stop signal. In Stop1 stop signals were internally related, i.e. presented at time intervals after onset of the response stimulus, whereas in Stop2 stop signals were externally related, i.e. presented at time intervals related to the subject's own go-process. Both tasks were modifications of the classical stop task in modality of the stop signal visual instead of auditory and in event rate, which was half-shortened. The aim of this study was: (a) to replicate the findings of deficient inhibitory functions in hyperactive children in the stop task in spite of modifications in modality and event rate; and (b) to elucidate (dis)similarities of stopping processes or of group differences in these stopping processes triggered by stop delays related either to external or to internal processes. Hyperactive children were less efficient than controls in inhibiting their motor response in both versions of the stop task. independent of whether the stop signals were externally or internally related. Furthermore, the go-process of the hyperactives was more variable and erratic in both tasks. Thus, the results strengthen the effectiveness of stop tasks in distinguishing hyperactive from normal children.

Neuroelectric mapping reveals precursor of stop failures in children with attention deficits

Children with attention deficit disorders (ADD) may have specific problems with response inhibition in the STOP task. This task requires that subjects stop responses to a primary task if a second signal follows. However, it is unclear whether these problems reflect an impairment of the stopping process per se, whether they are related to reduced frontal lobe activation and whether they are confined to severe and pervasive forms of ADD. In 11 ADD and nine control children, 32 channel event-related EEG potentials (ERPs) were recorded in a STOP and a delayed GO task. Mapping revealed that both tasks evoked a similar sequence of neuroelectric microstates, i.e. of time segments with stable map topography. Adaptive segmentation identified the transition between these microstates. Reliable group differences were found in several microstates and in both tasks despite matched performance. In the GO task, ADD children had topographically altered P2/N2 microstates and attenuated P300-type microstates. In the STOP task, a topographically altered N1 microstate which coincided with the onset of the stop signal preceded the stop failures of ADD children. The timing of this microstate is too early to reflect deficits in actual stop signal processing and instead suggests altered initial orienting of attention to the primary signal in ADD children. Imaging with low resolution tomography (LORETA) during this microstate to stop failures indicated mainly posterior activation for both groups and increased rather than reduced frontal activation in ADD children. For a later microstate (P550), LORETA indicated strong frontal activation after successful stopping, but no group differences. The results suggest that information processing of ADD children deviates during activation of posterior mechanisms which may be related to the orienting of attention and which precedes and partly determines inhibitory control problems in ADD.

Neuromotor functioning in children with Tourette syndrome with and without attention deficit hyperactivity disorder

Neuromotor function was assessed in 94 children of normal intelligence with Tourette syndrome, Tourette syndrome and attention-deficit hyperactivity disorder (ADHD), or ADHD only, using the Physical and Neurological Examination of Subtle Signs (PANESS). Time to complete six motor movements was analyzed separately by side (left and right) and complexity (simple and patterned). All groups performed faster on their preferred, dominant side. Although all groups took longer to complete patterned versus simple movements, the group with ADHD had a larger discrepancy for complexity than the other two groups. The speed for simple and patterned tasks was at or faster than age expectations for 54% of tasks in the group with Tourette syndrome but only 15% of tasks in the other two groups. More children in the group with Tourette syndrome (76%) than the groups with Tourette syndrome with ADHD (54%) or ADHD (54%) or ADHD only (65%) performed movements within normal time limits for age. Findings suggest that Tourette syndrome is not associated with motor slowing.

The overlap of attention deficit hyperactivity disorder with other common mental disorders

OBJECTIVE

The literature on the overlap (co-morbidity) of attention deficit hyperactivity disorder (ADHD) with conduct disorder, specific learning disability, and anxiety disorders was reviewed to examine: (i) the evidence for ADHD being a syndrome distinct from the other conditions; and (ii) the evidence for co-morbid patterns representing meaningful subtypes of ADHD.

METHODOLOGY

Narrative review of the literature.

CONCLUSIONS

Conduct disorder is distinguished from ADHD by prognosis, patterns of association and familial aggregation. Pure' disorders are uncommon, however, and there is little evidence to support a distinct co-morbid subtype. There are few data that reliably distinguish ADHD from specific learning disabilities, but there are weaknesses in research to date. A specific ADHD+learning disabled subtype may exist, but as yet the implications for treatment are not known. Attention deficit hyperactivity disorder is distinguished from anxiety by symptom discrimination, factor analysis, patterns of association, familial aggregation and treatment response. There is evidence for a distinct ADHD+anxiety subtype.

Changing a response set in normal development and in ADHD children with and without tics

The current study was designed to provide a rigorous investigation of the locus of task-inappropriate (impulsive) responding in ADHD children with and without tics. For this purpose we used a variant of Sternberg's (1969) response bias task. The task measures a set of mental operations, namely, preparing a planned response, carrying out or stopping a planned response, and preparing to execute an alternative response. In the first study, we determined the effect of age in a normal sample. As expected, task performance improved as a function of age. Younger children had problems changing a response set. In the second experiment, we compared ADHD children with and without tics with normal children. Unexpectedly, the noticeable task inefficiency of the patient groups was not related to (a) a hasty scan of the display, (b) an inability to change response set, or (c) a speed-accuracy trade-off. Implications for and a discussion about the response inhibition hypothesis in ADHD are discussed.

Neuropsychological functioning, motor speed, and language processing in boys with and without ADHD

We administered a neuropsychological battery to boys aged 6 to 12 years old diagnosed with attention-deficit hyperactivity disorder (ADHD; n = 51) and to comparison boys of the same age range (n = 31). Boys with ADHD had greater difficulty than comparison youngsters on nonautomated language and motor tasks administered with a fast instructional set and on one of two traditional frontal executive measures (Porteus mazes). When tasks requiring automatic processing were paired with similar tasks requiring greater use of selective attention processes, the latter, controlled processing tasks differentiated groups better than did automated tasks. This differential effect of otherwise similar tasks is interpreted in terms of an output deficit mediated by response organization as detailed in the information processing literature. The ADHD group also exhibited slow gross motor output, measured independently of verbal output. The findings are evaluated in terms of both Luria's (1973) tripartite model of neurocognitive organization and frontal striatal models, with an emphasis on output processes. The observed language deficits could represent frontal lobe processes intricately related to self-monitoring and planning. The utility of controlled processing, self-paced tasks with fast instructional sets in assessing language and motor skills in ADHD is highlighted.

Spatial orienting and focused attention in attention deficit hyperactivity disorder

Seventeen children with attention deficit disorder (ADHD) and 10 normal controls performed two tasks while event-related potentials were recorded. ADHD subjects took part in two more sessions under methylphenidate (MP) or placebo. In the spatial orienting task, invalidly cued targets elicited a longer reaction time (RT) and a P3 that was longer in latency and greater in amplitude than did validly cued targets. Performance was similar for both groups, but the early portion of P3 (300-400 ms) was lower in amplitude for invalidly cued targets in ADHD subjects. MP increased accuracy without affecting RT and shortened P3 peak latency and increased the amplitude of its early portion. In the focused attention task, accuracy was greater for controls and MP, but there were no RT differences. Attended stimuli elicited greater amplitude P1, N1, and P3 than did nonattended stimuli, but these measures were unaffected by diagnosis or medication.

Information processing in patients with early and continuously-treated phenylketonuria

A total of 33 patients with early and continuously-treated phenylketonuria (PKU) between 7 and 16 years of age and 33 matched controls participated in a study examining perceptual, central, and response-related mechanisms of information processing. The specific mechanisms studied were: perceptual filtering, memory search, response selection, response execution, and motor presetting. In addition, groups were compared on mean intelligence level and task oriented behaviour. The performance of the PKU patients practically matched that of the controls on all three tasks, suggesting that PKU patients who are continuously maintained on a well-controlled phenylalanine-restricted diet are not impaired in the elementary mechanisms of information processing. Furthermore, groups did not differ in mean IQ or task-oriented behaviour.

CONCLUSION

These results underline the importance of continued, well-controlled dietary treatment. Further studies are recommended to obtain a more complete evaluation of the potential of PKU patients under these stricter dietary treatment conditions.

Visuospatial attentional shifts and choice responses of adults and ADHD and non-ADHD children

18 adults, 17 ADHD children, and 18 non-ADHD children performed a choice-response task on which the spatial location of a target was sometimes compatible and sometimes incompatible with priming cues that varied between 50 and 1000 msec. Children's response latencies differed from adults' response latencies as a function of the delay between priming cue and target onset. A cost-benefit analysis indicated that valid stimulus cues facilitated performance and invalid stimulus cues impeded performance similarly for the three groups. Choice-response errors following invalid cues did not differ between ADHD and non-ADHD children; however, adults made more choice errors than children at 150-msec. and 300-msec. delay intervals. Developmental factors that may underlie differences between children's and adults' response speed and response accuracy are discussed.

Effects of closed-head injury on attentional processes: generality of Sternberg's additive factor method

The present study examined the generality of Shum, McFarland, Bain, and Humphreys' (1990) findings that closed-head injury (CHI) selectively impairs different processes of attention (operationalized in terms of stages of information processing) depending on the severity of, and the time since, injury. The procedure of Shum et al. was based on Sternberg's additive factor method (AFM), with the mode of information processing involved being a physical-directional matching of visual stimuli. The present study followed a similar procedure except that a name-matching task was used. This task was administered to 16 first-year psychology students and two groups of CHI patients (viz., severe short-term (SS) and severe long-term (SL)) with matched control groups. The results obtained replicated the study by Shum in that the SS group was found to be impaired on the identification and response-selection stages of information processing whereas the SL group was found to be impaired only on the response-selection stage. The present study confirms that the AFM is not limited to one specific mode of information process and strengthens the validity of the conclusions made by Shum et al. regarding the effects of CHI on attention.

A comparison of neuropsychological test profiles of children with attention deficit-hyperactivity disorder and/or learning disorder

The study compared 8-year-old children with pure attention deficit-hyperactivity disorder (ADHD) (n = 21), specific learning disorder (LD) (n = 12), and both (ADHD + LD) (n = 27) on a comprehensive set of neuropsychological measures. The tests were mainly derived from a new neuropsychological instrument, the Neuropsychological Assessment of Children. The children with ADHD were specifically impaired in the control and inhibition of impulses; the children with LD were impaired in phonological awareness, verbal memory span, and storytelling, as well as in verbal IQ. Children with both showed all of these deficiencies; they also had more pervasive attention problems and more visual-motor problems than the two other groups. All groups exhibited impaired performance in tasks of visual-motor precision and name retrieval. The latter finding may involve two different mechanisms, one related to linguistic impairment and possibly contributing to reading and spelling problems, and the other related to attentional problems.

A motor presetting study in hyperactive, learning disabled and control children

Motor presetting was investigated in hyperactive children, learning disabled children and normal controls. The reaction time of the hyperactive group was more sensitive to increases in interstimulus interval (event rate) than was that of the learning disabled and the controls. This finding indicates that hyperactive children have difficulty with motor presetting.

The dimension of focussed attention: relationship to behavior and cognitive functioning in children

A sample of 73 nonreferred school children were administered a newly developed Visual Focussed-attention Test along with other measures of attentional, cognitive, and behavioral functioning. Internal reliability and construct validity for the test were established. Children were then divided into underfocussed (distractible, n = 6), normofocussed (n = 38), and overfocussed (n = 5) groups based upon their test scores. The three groups did not differ with regard to age, intellectual functioning, or academic achievement. However, the underfocussed and overfocussed groups contained a greater proportion of behaviorally disturbed children than the normofocussed group. Underfocussed children, as a group, were rated higher than normofocussed, but not higher than overfocussed children on the Hyperactivity factor of the Conners Teacher Questionnaire. The significance of these focussed attention deficits is reviewed in relation to the more familiar concepts of distractibility and hyperactivity.