State, trait anxiety and selective attention differences in Attention Deficit Hyperactivity Disorder (ADHD) subtypes

Push-Pull Mechanism of Attention and Emotion in Children with Attention Deficit Hyperactivity Disorder

Background/Objectives: While deficits in executive attention and alerting systems in children with attention deficit hyperactivity disorder (ADHD) are well-documented, findings regarding orienting attention in ADHD have been inconsistent. The current study investigated the mechanism of attentional orienting in children with ADHD by examining their attentional bias towards threatening stimuli. Furthermore, we explored the modulating role of anxiety levels in ADHD on this attentional bias. Methods: In Experiment 1, 20 children with ADHD and 26 typically developing children (TDC) performed a continuous performance task that included task-irrelevant distractions consisting of angry faces and neutral places. In Experiment 2, 21 children with ADHD and 25 TDC performed the same task, but with angry and neutral faces as distractors. To measure children's anxiety levels, the State-Trait Anxiety Inventory was administered before each experiment. Results: In Experiment 1, results revealed no attentional bias effects in children with ADHD, whereas TDC exhibited attentional capture effects by both types of distractors. However, in Experiment 2, ADHD children demonstrated an attentional bias towards angry faces, which revealed a significant positive correlation with their trait anxiety levels (r = 0.61, p < 0.05). Further analyses combining all ADHD children showed that trait anxiety levels in Experiment 2 were significantly higher than those in Experiment 1. Finally, a significant positive correlation was found between anxiety levels and attentional bias towards angry faces in all ADHD children (r = 0.36, p < 0.01). Conclusions: Children with ADHD exhibited atypical attentional-orienting effects to threats, and their levels of trait anxiety appeared to modulate such attentional-orienting mechanisms.

Trait anxiety affects attentional bias to emotional stimuli across time: A growth curve analysis

Many studies have illustrated the close relationship between anxiety disorders and attentional functioning, but the relationship between trait anxiety and attentional bias remains controversial. This study examines the effect of trait anxiety on the time course of attention to emotional stimuli using materials from the International Affective Picture System. Participants with high vs. low trait anxiety (HTA vs. LTA) viewed four categories of pictures simultaneously: dysphoric, threatening, positive, and neutral. Their eye-movements for each emotional stimulus were recorded for static and dynamic analysis. Data were analyzed using a mixed linear model and growth curve analysis. Specifically, the HTA group showed a greater tendency to avoid threatening stimuli and more pupil diameter variation in the early period of stimulus presentation (0–7.9 s). The HTA group also showed a stronger attentional bias toward positive and dysphoric stimuli in the middle and late period of stimulus presentation (7.9–30 s). These results suggest that trait anxiety has a significant temporal effect on attention to emotional stimuli, and that this effect mainly manifests after 7 s. In finding stronger attentional avoidance of threatening stimuli and more changes in neural activity, as well as a stronger attentional bias toward positive stimuli, this study provides novel insights on the relationship between trait anxiety and selective attention.

ADHD-inattentive versus ADHD-Combined subtypes: A severity continuum or two distinct entities? A comprehensive analysis of clinical, cognitive and neuroimaging data

The current study aimed to explore the multimodal differences between the inattentive ADHD (ADHD-I) subtype and the combined ADHD (ADHD-C) subtype. A large sample of medication-naïve children with pure ADHD (i.e., without any comorbidity) (145 with ADHD-I, 132 with ADHD-C) and healthy controls (n = 98) were recruited. A battery of multiple scales and cognitive tests were utilized to assess the clinical and cognitive profiles of each individual. In addition, structural and diffusion magnetic resonance imaging (MRI) were acquired for 120 subjects with ADHD and 85 controls. Regional gray matter volume, white matter volume, and diffusion tensors, e.g., axial diffusivity (AD), were compared among the three groups in a whole-brain voxel-wise manner. Compared with healthy controls, both ADHD groups exhibited elevated levels of behavioral and emotional problems. The ADHD-C group had more behavioral problems and emotional liability, as well as less anxiety, than the ADHD-I group. The two ADHD groups were equally impaired in most cognitive domains, with the exception of sustained attention. Compared with healthy controls, the ADHD-C group showed a high gray matter volume (GMV) in the bilateral thalamus and a high white matter volume in the body of the corpus callosum, while the ADHD-I group presented an elevated GMV mainly in the left precentral gyrus and posterior cingulate cortex. Compared with participants with ADHD-C and healthy controls, subjects with ADHD-I showed increased AD in widespread brain regions. Our study has revealed a distinct, interconnected pattern of behavioral, cognitive, and brain structural characteristics in children with different ADHD subtypes.

The Influence of State and Trait Anxiety on the Achievement of a Virtual Reality Continuous Performance Test in Children and Adolescents with ADHD Symptoms

The three types of presentations of ADHD often co-occur with other disorders, anxiety being one of the most prevalent. For this reason and because there are few studies that have examined the influence of anxiety on attentional activities, this study aims to determine how internalizing difficulties (anxiety levels) can influence performance in a virtual reality continuous performance test. The study used a non-probabilistic clinical sample comprising 68 boys (66%) and 35 girls (34%) aged between 6 and 16 (M = 12.24; SD = 2.45) who had been referred to clinical services for the evaluation of ADHD symptoms. Once informed consent was given, the children were administered the STAI-C scale and a virtual reality continuous performance test by expert researchers. Hierarchical regression models showed that only state anxiety demonstrated significant explanatory power over attentional variables. These findings confirm how important it is for children to feel relaxed when they undergo psychological evaluation tests, as otherwise the individual’s intervention design would be based on biased data. Similarly, the findings also suggested an effect of IQ in the interpretation of continuous performance scores.

Convergent validity, academic correlates and age- and SES-based normative data for the d2 Test of attention in children

The d2, test of attention is one of the most used neuropsychological tests to measure attention in clinical and research settings. To date, no studies have examined neither its convergent and divergent validity in children nor its relationship with academic skills at school age. The aims of the present study were: (1) to examine the convergent and divergent validity of the d2 Test in a non-clinical pediatric population, (2) to explore the relationship between d2 task performance and academic skills (i.e., math, reading and writing abilities) and (3) to develop normative data for Spanish-speaking children (n = 360 8- to 12-year-old children) stratified by age and socioeconomic status (SES). Pearson's correlation and Structural Equation Models (SEM) were used to analyze the d2 Test validity and its relationship with academic skills. A between-subjects factorial MANOVA was used to examine differences among SES (Middle, Low), age (8-10, 11-12), and sex (male, female). Findings revealed a significant relationship between d2 task performance and all attention and executive functions (EF) measures under analysis providing evidence of good convergent validity. Furthermore, SEM results showed that attention has direct effects on math and reading and writing skills. Finally, our study confirms the influence of age and SES on d2 task performance and provides normative data for middle- and low-SES children. These results have important implications for the assessment of attention functions in clinical and research settings in children with typical and atypical development.

Clinical presentations of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents: comparison of neurocognitive performance

This study aimed to compare performance in working memory (WM), processing speed (PRS), and attention measures in children and adolescents with typical development (TD) and with Attention deficit hyperactivity disorder (inattentive [ADHD-I] or combined [ADHD-C]) presentations, and to determine the predictive ability of the measures mentioned to discriminate between ADHD presentations and TD. 260 children and adolescents, 138 with ADHD (70 ADHD-I and 68 ADHD-C) and 122 TD in two age cohorts (8-12 years; 13-16 years), were assessed with WM and PRS indexes of Wechsler Intelligence Scale for Children (WISC-IV) and the d2 attention test. Significant differences between ADHD and TD groups in the WISC-IV GAI scores were found in children but not in adolescents. Children and adolescents with both ADHD presentations performed poorly on the PRS index, while on the WM index only children exhibited difficulties. In the attention test, children with ADHD-C showed more impulsivity and more difficulties for processing speed, concentration and accuracy than ADHD-I and TD. In addition, both ADHD presentations had higher inattention scores than TD. ADHD adolescents performed worse than TD in processing speed, concentration and accuracy. ADHD groups showed more impulsivity and inattention than TD. Digit Span and Symbol Search (WISC-IV) and processing speed and accuracy (d2) successfully classified ADHD and TD in children, but in adolescents, only coding (WISC-IV) and accuracy (d2) successfully classified ADHD presentations and TD. The WISC-IV and d2 yield neuropsychological profiles which reflect age-related cognitive changes and may allow the adaptation of more tailored early interventions for ADHD.

Consequences of Confinement Due to COVID-19 in Spain on Anxiety, Sleep and Executive Functioning of Children and Adolescents with ADHD

The outbreak and the quick expansion of SARS-CoV-2, from December 2019 to today, has forced countries around the world to resolve virus containment measures in order to slow down the contagion curve. Between these measures, the situation of lockdown, and the isolation or limitation of social contact between the citizens, there has been an unknown psychological impact. Certain groups (the elderly, children and teenagers, and the clinical population, for instance) arouse serious fears among professionals due to their greater vulnerability and ignorance regarding the short- and long-term consequences. The main purposes of this work are first of all to evaluate the consequences of the lockdown in children and teenagers diagnosed with attention deficit hyperactivity disorder (ADHD), sleep-related problems, and problems with executive functions. Secondly, we aim to compare the effects produced with respect to the previously mentioned variables with normotypic subjects; that is to say, between a group that was subject to lockdown and another group that was not confined. The findings show that the clinic confined group had high levels of state anxiety and problems with sleep and executive functions; differences could also be seen between the two groups, with the confined ADHD group being more negatively affected in all measured variables.

What Predicts Life Satisfaction in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder (ADHD)? A Study from Parent and Child/Adolescent Perspectives

The aim of this study was to analyze life satisfaction in a sample of 70 children and adolescents (M = 12.21, SD = 2.85) with Attention-Deficit/Hyperactivity Disorder (ADHD), according to parents' and children's/adolescents' reports. In addition, we examined the influence of a series of child/adolescent variables (ADHD presentation, and Conduct Disorder (CD) symptoms, age, gender, and pharmacological support status) on their levels of life satisfaction. Results indicated moderate correlations between children's/adolescents' and parents' perceptions of life satisfaction (r = .40; p < .01), with school being the area with the lowest levels of satisfaction. Also, 44.3% of the sample of parents reported that ADHD drastically interferes negatively in this context. Examining the effects of child/adolescent variables, only the variables age and CD symptoms generated statistically significant differences, showing that as children/adolescents grow up and/or present associate symptoms of CD, perceptions of life satisfaction tend to be more negative. These variables explained 34.5% of the variance of a composite score of life satisfaction, demonstrating a negative effect over the dependent variable. These results might have important implications for diagnosis and intervention in ADHD, as they highlight the relevance of considering life satisfaction as an important aspect to consider in both processes. Further studies must look more deeply into the mechanisms that explain these findings.

Effects of Sleep on the Academic Performance of Children with Attention Deficit and Hyperactivity Disorder

Attention deficit and hyperactivity disorder (ADHD) is commonly associated with disordered or disturbed sleep and the association of sleep problems with ADHD is complex and multidirectional. The purpose of this study was to analyze the relationship between sleep and academic performance, comparing children with ADHD and a control group without ADHD. Academic performance in Spanish, mathematics, and a foreign language (English) was evaluated. Different presentations of ADHD were considered as well as the potential difference between weekday and weekend sleep habits. The sample consisted of 75 children aged 6–12 in primary education. Accelerometry was used to study sleep, and school grades were used to gather information about academic performance. The results showed that ADHD influenced the amount of sleep during weekends, the time getting up at the weekends, weekday sleep efficiency, as well as academic performance. Given the effects that were seen in the variables linked to the weekend, it is necessary to consider a longitudinal design with which to determine if there is a cause and effect relationship.

Self-Concept and Inattention or Hyperactivity-Impulsivity Symptomatology: The Role of Anxiety

Attention-deficit/hyperactivity disorder (ADHD) has been associated with low levels of self-concept (academic, emotional, social or physical), although this association can differ in the function of the inattention or hyperactivity-impulsivity symptomatology. Furthermore, the relation between ADHD and self-concept can be mediated or moderated by the levels of anxiety. This work is aimed to examine the differential effect of inattention symptomatology and hyperactivity-impulsivity symptomatology on academic, emotional, social and physical self-concept and the mediating or moderating role of anxiety in this relationship. A total of 167 students (70.7% boys and 29.3% girls) aged between 11 and 16 participated in this study. Students' ADHD symptomatology, self-concept in four areas (academic, emotional, social and physical self-concept) and trait anxiety were measured with the State-Trait Anxiety Inventory for Children. The results indicate that trait anxiety mediates the relationship between inattention and emotional, social and physical self-concept but does not moderate this relationship. Trait anxiety does not mediate or moderate the relationship between hyperactivity-impulsivity symptoms and self-concept. When inattention symptomatology increases, academic self-concept decreases directly, but students' emotional, social and physical self-concept decreases indirectly through trait anxiety.

Naming speed as a predictive diagnostic measure in reading and attentional problems

This study aimed to describe and compare naming speed abilities in children diagnosed with either Reading Learning Difficulties (RLD) or Attention Deficit/Hyperactivity Disorder (ADHD), or comorbidity for both (ADHD+RLD). To examine the explanatory power of naming speed and ADHD symptomatology in predicting group associations (while controlling for gender and age), the "Rapid Automatized Naming and Rapid Alternating Stimulus Tests" (RAN/RAS) were utilized. A sample of 101 children (age range = 5-16 years) was divided into four groups: RLD (n = 14), ADHD (n = 28), comorbid (n = 19), and control (n = 40). There were statistically significant differences in RAN/RAS results among the diagnostic groups. Moreover, discriminant analysis revealed that naming speed tasks significantly predicted reading and attentional problems, especially at earlier ages. These results demonstrate the potential usefulness of RAN/RAS in the diagnosis of reading and attentional problems, particularly if the children are aged from 5 to 9.

Short form of the Spanish adaptation of the State-Trait Anxiety Inventory

Background/Objective: The State-Trait Anxiety Inventory (STAI) is one of the assessment instruments that are most widely used by psychologists around the world and is the seventh most broadly used by clinical psychologists in Spain. Although several short forms of the STAI have been developed since its creation, none are available for the Spanish general population. The aim of the present study was to develop and validate a short form of the STAI. Method: To achieve this, we administered the full STAI to 1,157 healthy adults, and 30 patients with generalized anxiety disorder. We conducted a discriminant analysis using such groups. Results: We obtained a selection of four items for state anxiety and four items for trait anxiety and compared it to other short forms through a confirmatory factor analysis. The short form obtained with the discriminant analysis showed the best fit for Spanish samples. Conclusions: these eight items can be used to facilitate the state and trait anxiety assessment.

Attentional control of emotional interference in children with ADHD and typically developing children: An emotional N-back study

Emotional interference control refers to the ability to remain focused on goal-oriented processes when confronted with disrupting but irrelevant emotional stimuli, a process that may be impaired in children and adults with attention deficit/hyperactivity disorder (ADHD). However, emotional interference levels are known to be associated with trait anxiety, and patients with ADHD often display elevated levels of trait anxiety, such as these may have confounded previous findings of decreased emotional interference control in this population. In the present study, male and female 8-13 years old (mean =11.0 years) children with ADHD (n=33) and typically developing (TD) children (n=24) performed a visual emotional working memory (n-back) task with 2 memory loads and three different background pictures (neutral/positive/negative), and trait anxiety measures were obtained. Children with ADHD performed less well, and displayed increased emotional interference in the presence of aversive distractors when compared with TD children. Contrary to our expectations, trait anxiety did not mediate the association between diagnostic group membership and the degree of emotional interference control; however, co-morbid ODD was associated with decreased levels of emotional interference in ADHD. Future research should aim at characterizing the mechanisms subtending decreased emotional interference control in the ADHD population.

Psychometric properties of the Conners-3 and Conners Early Childhood Indexes in a Spanish school population

Ba#ckground/Obje#ctive: To examine the psychometric properties of the Conners 3 ADHD Index (Conners 3 AI) and the Conners Early Children Global Index (Conners ECGI) parents' form (PF) and teachers' form (TF) in Spanish schoolers. Method: Two-phase cross-sectional study. In the first phase, information was gathered from teachers (n = 1,796) and parents (n = 882) of 4-5 and 10-11 year-old children. In the second phase (n = 196), children at risk of ADHD and controls were individually assessed. Results: The results confirmed the two-factor structure of the Conners 3 ADHD Index, which contains hyperactive-impulsive and inattentive symptoms, and the two-factor structure of the Conners ECGI PF, consisting of emotional lability and restless-impulsive symptoms. In contrast with the original version, the Conners ECGI TF presented an additional inattentive factor. Moderate-to-high rates of evidence of convergent validity with Child Behavior Checklist and Kiddie-Schedule for Affective Disorders & Schizophrenia, and evidence of external validity (academic achievement) were found. Scores were significantly higher in boys than in girls, for both indexes. Raw scores corresponding to clinical T-scores were higher than the original version. Conclusions: The Conners indexes may be considered reliable and valid instruments for detecting ADHD symptoms in Spanish populations.

Attention Deficit/Hyperactivity Disorder (ADHD) Diagnosis: An Activation-Executive Model

Attention deficit with, or without, hyperactivity and impulsivity (ADHD) is categorized as neuro-developmental disorder. ADHD is a common disorder in childhood and one of the most frequent conditions affecting school ages. This disorder is characterized by a persistent behavioral pattern associated with inattention, over-activity (or hyperactivity), and difficulty in controlling impulses. Current research suggests the existence of certain patterns of cortical activation and executive control, which could more objectively identify ADHD. Through the use of a risk and resilience model, this research aimed to analyze the interaction between brain activation variables (nirHEG and Q-EEG) and executive variables (Continuous performance test -CPT-) in subjects with ADHD. The study involved 499 children, 175 females (35.1%) and 324 males (64.91%); aged from 6 to 16 years (M = 11.22, SD = 1.43). Two hundred and fifty six of the children had been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and 243 were without ADHD. For the analysis of this objective, a causal model was designed to include the following different measures of task-execution: CPT TOVA (omissions, commissions, response time, variability, D prime and the ADHD Index); electrical activity (using Q-EEG); and blood-flow oxygenation activity (using nirHEG). The causal model was tested by means of structural equation modeling (SEM). The model that had been constructed was based upon three general assumptions: (1) There are different causal models for children with ADHD and those without ADHD; (2) The activation measures influence students' executive performance; and (3) There are measurable structural differences between the ADHD and control group models (executive and activation). In general, the results showed that: (a) activation measures influence executive patterns differently, (b) the relationship between activation variables (nirHEG and Q-EEG) depends on the brain zone being studied, (c) both groups showed important differences in variables correlation, with a good fit in each model (with and without ADHD). Lastly, the results were analyzed with a view to the diagnosis procedure. Therefore, we discuss the implications for future research.

Substance use in young adults with ADHD: Comorbidity and symptoms of inattention and hyperactivity/impulsivity

Young adults with attention deficit hyperactivity disorder (ADHD) are at high risk of substance use (SU). The aims of the current study were: 1) to examine the use of alcohol, tobacco, marijuana and other illegal drugs by adults with and without ADHD; 2) to compare the oppositional, conduct, anxiety, depression, sleep and antisocial personality symptoms of ADHD adults with SU and ADHD adults without SU; 3) to examine the ability of ADHD symptoms and conduct problems to predict SU. A total of 93 young adults, 43 without ADHD and 50 with a childhood diagnosis of ADHD, who were part of the Spanish sample of the Multicenter ADHD Genetics (IMAGE) study, collaborated in a follow-up evaluation 10.1 years later. ADHD participants were divided into two groups based on the presence or absence of SU. Statistically significant differences were found between young adults with and without ADHD in their use of tobacco, marijuana and alcohol. A statistically significant association was also shown between externalization problems and a greater risk of SU. Conduct problems, to a greater degree than ADHD symptoms, affect SU in ADHD adults.