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

The Comparison of Psychological Factors and Executive Functions of Children with Attention Deficit Hyperactivity Disorder and Cognitive Disengagement Syndrome to ADHD and ADHD Comorbid with Oppositional Defiant Disorder

OBJECTIVE

The study aims to examine family functionality, emotion regulation difficulties, preference for loneliness, social exclusion, internalizing and externalizing disorders, and executive functions in children with Attention Deficit Hyperactivity Disorder (ADHD) and Cognitive Disengagement Syndrome (CDS) and compare with ADHD, and ADHD+ Oppositional Defiant Disorder (ODD).

METHOD

This study included 842 children aged 8-12 years. The subjects were categorized according to DSM-V as ADHD (n = 246), ADHD + ODD (n = 212), ADHD + CDS (n = 176), and Control group (n = 207). The solitude and social exclusion, difficulties in emotion dysregulation and Barkley SCT scales, Child Behavior Checklist, family assessment device, and Central Vital Signs (CNSVS) test were used.

RESULTS

According to the study, children with ADHD + CDS had higher rates of internalizing disorders. They also preferred being alone and experienced more difficulty communicating with their parents and solving problems within the family. Additionally, these children had difficulty recognizing and understanding the emotional reactions of others. The ADHD + ODD group presented a poorer performance on CNSVS domain tests except for the psychomotor speed test than other groups. Also, ADHD + CDS children had the lowest psychomotor speed scores and lower scores on reaction time and cognitive flexibility than pure ADHD children.

CONCLUSION

This study will contribute to the etiology, treatment, and clinical discrimination of ADHD + CDS.

Content, diagnostic, correlational, and genetic similarities between common measures of childhood aggressive behaviors and related psychiatric traits

BACKGROUND

Given the role of childhood aggressive behavior (AGG) in everyday child development, precise and accurate measurement is critical in clinical practice and research. This study aims to quantify agreement among widely used measures of childhood AGG regarding item content, clinical concordance, correlation, and underlying genetic construct.

METHODS

We analyzed data from 1254 Dutch twin pairs (age 8-10 years, 51.1% boys) from a general population sample for whom both parents completed the A-TAC, CBCL, and SDQ at the same occasion.

RESULTS

There was substantial variation in item content among AGG measures, ranging from .00 (i.e., mutually exclusive) to .50 (moderate agreement). Clinical concordance (i.e., do the same children score above a clinical threshold among AGG measures) was very weak to moderate with estimates ranging between .01 and .43 for mother-reports and between .12 and .42 for father-reports. Correlations among scales were weak to strong, ranging from .32 to .70 for mother-reports and from .32 to .64 for father-reports. We found weak to very strong genetic correlations among the measures, with estimates between .65 and .84 for mother-reports and between .30 and .87 for father-reports.

CONCLUSIONS

Our results demonstrated that degree of agreement between measures of AGG depends on the type (i.e., item content, clinical concordance, correlation, genetic correlation) of agreement considered. Because agreement was higher for correlations compared to clinical concordance (i.e., above or below a clinical cutoff), we propose the use of continuous scores to assess AGG, especially for combining data with different measures. Although item content can be different and agreement among observed measures may not be high, the genetic correlations indicate that the underlying genetic liability for childhood AGG is consistent across measures.

Ashwagandha in brain disorders: A review of recent developments

ETHNOPHARMACOLOGICAL RELEVANCE

Withania somnifera (Family: Solanaceae), commonly known as Ashwagandha or Indian ginseng is distributed widely in India, Nepal, China and Yemen. The roots of plant consist of active phytoconstituents mainly withanolides, alkaloids and sitoindosides and are conventionally used for the treatment of multiple brain disorders.

AIM OF THE REVIEW

This review aims to critically assess and summarize the current state and implication of Ashwagandha in brain disorders. We have mainly focussed on the reported neuroactive phytoconstituents, available marketed products, pharmacological studies, mechanism of action and recent patents published related to neuroprotective effects of Ashwagandha in brain disorders.

MATERIALS AND METHODS

All the information and data was collected on Ashwagandha using keywords "Ashwagandha" along with "Phytoconstituents", "Ayurvedic, Unani and Homeopathy marketed formulation", "Brain disorders", "Mechanism" and "Patents". Following sources were searched for data collection: electronic scientific databases such as Science Direct, Google Scholar, Elsevier, PubMed, Wiley On-line Library, Taylor and Francis, Springer; books such as AYUSH Pharmacopoeia; authentic textbooks and formularies.

RESULTS

Identified neuroprotective phytoconstituents of Ashwagandha are sitoindosides VII-X, withaferin A, withanosides IV, withanols, withanolide A, withanolide B, anaferine, beta-sitosterol, withanolide D with key pharmacological effects in brain disorders mainly anxiety, Alzheimer's, Parkinson's, Schizophrenia, Huntington's disease, dyslexia, depression, autism, addiction, amyotrophic lateral sclerosis, attention deficit hyperactivity disorder and bipolar disorders. The literature survey does not highlight any toxic effects of Ashwagandha. Further, multiple available marketed products and patents recognized its beneficial role in various brain disorders; however, very few data is available on mechanistic pathway and clinical studies of Ashwagandha for various brain disorders is scarce and not promising.

CONCLUSION

The review concludes the results of recent studies on Ashwagandha suggesting its extensive potential as neuroprotective in various brain disorders as supported by preclinical studies, clinical trials and published patents. However vague understanding of the mechanistic pathways involved in imparting the neuroprotective effect of Ashwagandha warrants further study to promote it as a promising drug candidate.

Stress, sensitive periods, and substance abuse

Research on the inter-relationship between drug abuse and social stress has primarily focused on the role of stress exposure during adulthood and more recently, adolescence. Adolescence is a time of heightened reward sensitivity, but it is also a time when earlier life experiences are expressed. Exposure to stress early in postnatal life is associated with an accelerated age of onset for drug use. Lifelong addiction is significantly greater if drug use is initiated during early adolescence. Understanding how developmental changes following stress exposure interact with sensitive periods to unfold over the course of maturation is integral to reducing their later impact on substance use. Arousal levels, gender/sex, inflammation, and the timing of stress exposure play a role in the vulnerability of these circuits. The current review focuses on how early postnatal stress impacts brain development during a sensitive period to increase externalizing and internalizing behaviors in adolescence that include social interactions (aggression; sexual activity), working memory impairment, and depression. How stress effects the developmental trajectories of brain circuits that are associated with addiction are discussed for both clinical and preclinical studies.

[Assessment of comorbidity and social anxiety in adolescents with attention deficit hyperactivity disorder: the SELFIE study]

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) and its comorbidities have an impact on the social anxiety of children and adolescents, but there are practically no studies addressing this topic in adolescence. Our objective was to assess the degree of social anxiety and to analyse the presence of psychiatric comorbidities (PSCs) in adolescents with ADHD.

METHODOLOGY

We conducted a cross-sectional observational study in patients aged 12 to 18 years with a confirmed diagnosis of ADHD (DSM-5). We collected data on the presence and type of PSCs and assessed social anxiety by means of the Social Anxiety Scale for Adolescents (SAS-A).

RESULTS

Forty-six child and adolescent psychiatrists and paediatric neurologists participated in the study and recruited 234 patients. Of the total patients, 68.8% (159) were male and 31.2% (72) female, with a mean age in the sample of 14.9 years (95% CI, 14.6-15.1). The type of ADHD was combined type (C) in 51.7% (121), predominantly inattentive (PI) in 37.2% (87), and predominantly hyperactive-impulsive (PH) in 9% (21). Of all patients, 97.9% (229) received pharmacological therapy: 78.6% (184) methylphenidate, 15% (35) lisdexamfetamine and 4.3% (10) atomoxetine.We found PSCs in 50.4% of the patients (118), of which the most frequent were learning and communication disorders (20.1%, n=47) and anxiety disorders (19.2%, n=45). The patients scored significantly higher in the SAS-A compared to reference values in the healthy population. The scores in the SAS-A were less favourable in adolescents with the PI type compared to those with the PH type (P=.015). The presence of a comorbid anxiety disorder was associated with worst scores in SAS-A (P<.001) showing an increased social anxiety.

CONCLUSION

Adolescents with ADHD classified as PI and those with comorbid anxiety had a higher degree of social anxiety as measured by the SAS-A. This psychological aspect must be identified and controlled in adolescents with ADHD to promote their social adaptation.

The role of socio-economic disadvantage in the development of comorbid emotional and conduct problems in children with ADHD

Previous research shows that, compared to children without ADHD, children with ADHD have worse socio-emotional outcomes and more experience of socio-economic disadvantage. In this study, we explored if and how the increased emotional and behavioural difficulties faced by children with ADHD may be accounted for by their more disadvantaged socio-economic circumstances. Our study, using data from 180 children (149 boys) with ADHD from the Millennium Cohort Study, had two aims. First, to examine the role of socio-economic disadvantage in the trajectories of emotional and conduct problems in children with ADHD at ages 3, 5, 7 and 11 years. Second, to explore the roles of the home environment (household chaos) and parenting (quality of emotional support, quality of the parent-child relationship and harsh parental discipline) in mediating any associations between socio-economic disadvantage and child emotional and conduct problems. Using growth curve models, we found that socio-economic disadvantage was associated with emotional and conduct problems but neither the home environment nor parenting attenuated this association. Lower quality of the parent-child relationship and harsher discipline were associated with more conduct problems. It appears that socio-economic disadvantage and parenting contribute independently to the prediction of comorbid psychopathology in children with ADHD.

The Development of Comorbid Conduct Problems in Children With ADHD: An Example of an Integrative Developmental Psychopathology Perspective

OBJECTIVE

We describe interactions among factors that contribute to the development of conduct problems among children with ADHD.

METHOD

An integrative developmental psychopathology analysis combines various approaches and posits one model of how diverse risk factors operate together to contribute to the development of conduct problems among children with ADHD.

RESULTS

Substantial genetic risk increases covariation between ADHD and conduct problems. Candidate genes are associated with CNS monoaminergic neurotransmission. Subsequent neurodevelopmental impairment interferes with executive function, with impaired verbal working memory playing an important role. Parent/child bi-directional influences exacerbate the risk for conduct problems when ADHD symptoms increase the likelihood of a coercive parenting style. Parent stress in reaction to child comorbid ADHD and conduct problems, and parent attribution for the child's conduct problem behavior, add to the potential for coercion and reduce constructive parent-child interaction that might otherwise enhance the development of verbal working memory.

CONCLUSION

In an integrated manner, these variables increase the risk that a child with ADHD will subsequently develop conduct problems.

Overt versus covert conduct disorder symptoms and the prospective prediction of antisocial personality disorder

Studies have shown strong continuity between conduct disorder (CD) in adolescence and antisocial personality disorder (APD) in adulthood. Researchers have been trying to explain why some adolescents with CD persist into adult APD and others do not. A few studies reported that overt and covert CD symptoms have a differential predictive power for APD, with mixed results. The present study aimed to evaluate the prospective association of overt and covert CD symptoms with APD in a sample of male adolescents with CD (N = 128, mean age = 15.6, SD = 1.6). Participants were recruited at intake in Quebec Youth Centers and reassessed 3 years later (n = 73). CD and ADHD symptoms were assessed at intake with the DISC-R while APD was assessed 3 years later with the SCID-II. Logistic regression results showed that, contrary to previous prospective studies (Lahey, Loeber, Burke, & Applegate, 2005; Washburn et al., 2007), overt (OR = 2.12, 95% CI [1.29, 3.50]) but not covert (OR = 1.04, 95% CI [0.69, 1.56]) symptoms predicted later APD, controlling for ADHD symptoms and socioeconomic status. It is hypothesized that the divergence with previous studies may be explained by the higher mean number and wider range of overt CD symptoms in our sample.

Overt Versus Covert Conduct Disorder Symptoms and the Prospective Prediction of Antisocial Personality Disorder

Studies have shown strong continuity between conduct disorder (CD) in adolescence and antisocial personality disorder (APD) in adulthood. Researchers have been trying to explain why some adolescents with CD persist into adult APD and others do not. A few studies reported that overt and covert CD symptoms have a differential predictive power for APD, with mixed results. The present study aimed to evaluate the prospective association of overt and covert CD symptoms with APD in a sample of male adolescents with CD (N = 128, mean age = 15.6, SD = 1.6). Participants were recruited at intake in Quebec Youth Centers and reassessed 3 years later (n = 73). CD and ADHD symptoms were assessed at intake with the DISC-R while APD was assessed 3 years later with the SCID-II. Logistic regression results showed that, contrary to previous prospective studies (Lahey, Loeber, Burke, & Applegate, 2005; Washburn et al., 2007), overt (OR = 2.12, 95% CI [1.29, 3.50]) but not covert (OR = 1.04, 95% CI [0.69, 1.56]) symptoms predicted later APD, controlling for ADHD symptoms and socioeconomic status. It is hypothesized that the divergence with previous studies may be explained by the higher mean number and wider range of overt CD symptoms in our sample.

The Children's Attention Project: a community-based longitudinal study of children with ADHD and non-ADHD controls

BACKGROUND

Attention-Deficit/Hyperactivity Disorder (ADHD) affects approximately 5% of children worldwide and results in significant impairments in daily functioning. Few community-ascertained samples of children with ADHD have been studied prospectively to identify factors associated with differential outcomes. The Children's Attention Project is the first such study in Australia, examining the mental health, social, academic and quality of life outcomes for children with diagnostically-confirmed ADHD compared to non-ADHD controls. The study aims to map the course of ADHD symptoms over time and to identify risk and protective factors associated with differential outcomes.

METHODS/DESIGN

The sample for this prospective longitudinal study is being recruited across 43 socio-economically diverse primary schools across Melbourne, Australia. All children in Grade 1, the second year of formal schooling (6-8 years), are screened for ADHD symptoms using independent parent and teacher reports on the Conners' 3 ADHD index (~N = 5260). Children screening positive for ADHD by both parent and teacher report, and a matched sample (gender, school) screening negative, are invited to participate in the longitudinal study. At baseline this involves parent completion of the NIMH Diagnostic Interview Schedule for Children IV (DISC-IV) to confirm likely ADHD diagnostic status and identify other mental health difficulties, direct child assessments (cognitive, academic, language and executive functioning; height and weight) and questionnaires for parents and teachers assessing outcomes, as well as a broad range of risk and protective factors (child, parent/family, teacher/school, and socio-economic factors). Families will be initially followed up for 3 years.

DISCUSSION

This study is the first Australian longitudinal study of children with ADHD and one of the first community-based longitudinal studies of diagnostically confirmed children with ADHD. The study's examination of a broad range of risk and protective factors and ADHD-related outcomes has the potential to inform novel strategies for intervention and prevention.

Relations between parent psychopathology, family functioning, and adolescent problems in substance-abusing families: disaggregating the effects of parent gender

The present study: (1) examined relations between parent psychopathology and adolescent internalizing problems, externalizing problems, and substance use in substance-abusing families; and (2) tested family functioning problems as mediators of these relations. Structural equation modeling was used to estimate the independent effects of parent psychopathology and family functioning problems by parent gender. Participants included 242 parents in treatment for substance abuse and/or dependence and 59 of their coparents (16.9% in treatment for substance-abuse/dependence) from middle income households (SES: M = 4.7; SD = 2.1). Ratings were obtained for 325 adolescents (48% female; 27.8% non-Caucasian) between the ages of 10 and 18 years (M = 13.5 years; SD = 2.5 years). Parent psychopathology, family functioning problems, and adolescent problems were assessed with parent and coparent ratings on the Symptom Checklist (SCL-90)/Brief Symptom Inventory (BSI), the Family Relationship Measure, and the Child Behavior Checklist, respectively. Results indicated that maternal psychopathology was directly related to adolescent internalizing problems and substance use, but maternal perceptions of family functioning problems failed to mediate relations between maternal psychopathology and adolescent problems. By contrast, paternal perceptions of family functioning problems uniquely mediated relations between paternal psychopathology and adolescent externalizing problems. Findings underscore the importance of examining how mothers and fathers may differentially impact adolescent problems in substance-abusing families.

The role of conduct disorder in the association between ADHD and alcohol use (disorder). Results from the Netherlands Mental Health Survey and Incidence Study-2

BACKGROUND

Much is unclear about the association between attention-deficit/hyperactivity disorder (ADHD) and alcohol use (disorder). Research on this subject is hindered by the role of conduct disorder (CD). We investigate whether (1) childhood ADHD is associated with higher prevalence and earlier onset of alcohol initiation, regular alcohol use and alcohol use disorder (AUD) (2) CD mediates or modifies this association.

METHODS

Data were derived from the baseline assessment of the Netherlands Mental Health Survey and Incidence Study-2, a general population study. ADHD and CD were assessed among respondents aged 18-44 (n=3309). ADHD, CD, and alcohol use (disorder) were assessed using the Composite International Diagnostic Interview 3.0.

RESULTS

Lifetime prevalence was 2.9% for ADHD, 5.6% for CD, 94.3% for alcohol initiation, 85.7% for regular alcohol use and 19.0% for AUD; mean ages of onset were 6.7, 11.5, 14.8, 16.7 and 19.2 years, respectively. After correction for gender and age, ADHD was associated with a higher prevalence of all three stages of alcohol use, but not with earlier onset of these stages. The association between ADHD and prevalence of AUD was fully explained by a mediating role of CD. CD did not modify the associations between ADHD and prevalence and onset of alcohol use (disorder).

CONCLUSIONS

The mediating role of CD in the association between ADHD and AUD suggests a developmental pathway from ADHD to CD and subsequent AUD. Early interventions in children with ADHD may prevent CD and subsequent onset of AUD.

The lifetime impact of attention deficit hyperactivity disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

BACKGROUND

The aim of the study was to present nationally representative data on the lifetime independent association between attention deficit hyperactivity disorder (ADHD) and psychiatric co-morbidity, correlates, quality of life and treatment seeking in the USA.

METHOD

Data were derived from a large national sample of the US population. Face-to-face surveys of more than 34 000 adults aged 18 years and older residing in households were conducted during the 2004-2005 period. Diagnoses of ADHD, Axis I and II disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version.

RESULTS

ADHD was associated independently of the effects of other psychiatric co-morbidity with increased risk of bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder, specific phobia, and narcissistic, histrionic, borderline, antisocial and schizotypal personality disorders. A lifetime history of ADHD was also associated with increased risk of engaging in behaviors reflecting lack of planning and deficient inhibitory control, with high rates of adverse events, lower perceived health, social support and higher perceived stress. Fewer than half of individuals with ADHD had ever sought treatment, and about one-quarter had ever received medication. The average age of first treatment contact was 18.40 years.

CONCLUSIONS

ADHD is common and associated with a broad range of psychiatric disorders, impulsive behaviors, greater number of traumas, lower quality of life, perceived social support and social functioning, even after adjusting for additional co-morbidity. When treatment is sought, it is often in late adolescence or early adulthood, suggesting the need to improve diagnosis and treatment of ADHD.

The utility of home problem pervasiveness and severity in classifying children identified with attention-deficit/hyperactivity disorder

Given the propensity for clinical assessment of Attention-Deficit/Hyperactivity Disorder (ADHD) to focus on core behavioral symptoms, the current study examined how well other predictors classified children who were diagnosed with ADHD by licensed practitioners. Participants were 91 children (39 ADHD-identified, 52 without ADHD), aged 8 to 13 years. In addition to significantly more ADHD symptoms, the ADHD-identified group exhibited significantly more externalizing problems and internalizing symptoms, less adaptive functioning, and greater problem pervasiveness and severity. Binary logistic regression analyses indicated that problem pervasiveness and severity significantly predicted diagnostic group membership when controlling for other predictors, and pervasiveness added unique variance beyond measures of core ADHD symptoms. Diagnostic utility analyses showed measurement of problem pervasiveness and severity to be a useful tool in the identification of ADHD. Findings provide support for the practical use of a parent-report measure of impairment in the home as part of evidence-based assessment of ADHD.

Prospective association of childhood attention-deficit/hyperactivity disorder (ADHD) and substance use and abuse/dependence: a meta-analytic review

Given the clinical and public health significance of substance disorders and the need to identify their early risk factors, we examined the association of childhood attention-deficit/hyperactivity disorder (ADHD) with substance use (nicotine, alcohol, marijuana) and abuse/dependence outcomes (nicotine, alcohol, marijuana, cocaine, other). To strengthen a potential causal inference, we meta-analyzed longitudinal studies that prospectively followed children with and without ADHD into adolescence or adulthood. Children with ADHD were significantly more likely to have ever used nicotine and other substances, but not alcohol. Children with ADHD were also more likely to develop disorders of abuse/dependence for nicotine, alcohol, marijuana, cocaine, and other substances (i.e., unspecified). Sex, age, race, publication year, sample source, and version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) used to diagnose ADHD did not significantly moderate the associations with substance outcomes that yielded heterogeneous effect sizes. These findings suggest that children with ADHD are significantly more likely to develop substance use disorders than children without ADHD and that this increased risk is robust to demographic and methodological differences that varied across the studies. Finally, few studies addressed ADHD and comorbid disruptive behavior disorders (DBD), thus preventing a formal meta-analytic review. However, we qualitatively summarize the results of these studies and conclude that comorbid DBD complicates inferences about the specificity of ADHD effects on substance use outcomes.

The delinquency outcomes of boys with ADHD with and without comorbidity

This study examined the association between childhood ADHD and juvenile delinquency by examining data from the Pittsburgh ADHD Longitudinal Study (PALS), a follow-up study of individuals diagnosed with ADHD in childhood (ages 5-12) and recontacted in adolescence and young adulthood for yearly follow-up (age at first follow-up interview M = 17.26, SD = 3.17). Participants were 288 males with childhood ADHD and 209 demographically similar males without ADHD who were recruited into the follow-up study. Delinquency information gathered yearly during the second through eighth follow-up provided a comprehensive history of juvenile delinquency for all participants. Four childhood diagnostic groups [ADHD-only (N = 47), ADHD + ODD (N = 135), ADHD + CD (N = 106), and comparison (N = 209)] were used to examine group differences on delinquency outcomes. Analyses were conducted across three dimensions of delinquency (i.e., severity, age of initiation, and variety). Individuals with childhood ADHD + CD displayed significantly worse delinquency outcomes than the other three groups, across almost all indices of offending. When compared to comparison participants, boys with ADHD-only and ADHD + ODD in childhood displayed earlier ages of delinquency initiation, a greater variety of offending, and higher prevalence of severe delinquency. These findings suggest that although childhood ADHD + CD creates the greatest risk for delinquency, boys with ADHD-only and ADHD + ODD also appear at a higher risk for later offending. The patterns of offending that emerged from the PALS are discussed in the context of the relationship between ADHD, comorbidity, and delinquency.

The characteristics of AD/HD symptoms, self-esteem, and aggression among serious juvenile offenders in Japan

Eighty-three inmates of a correctional facility, who committed serious offences, participated in this study. They were all male and aged 14-17 years, with a mean age of 15.5 (SD=1.21) years. Eighty-six age- and sex-matched controls were enrolled. Some psychological questionnaires such as on self-esteem and aggression were conducted in both groups. The aims of the present study were as follows: first, to clarify the characteristics of the subjects, such as IQ, psychological traits, and AD/HD symptoms; second, to examine how the subjects' self-esteem and aggression changed and/or improved on admission and at the time of parole (during the correctional educational period). For the results of paired t-tests, the self-esteem of subjects changed little. Therefore, our findings suggest that the improvement of antisocial behavior and transition of self-esteem are not directly linked with each other. Most inmates of the correctional facility showed a borderline IQ, markedly low self-esteem, unstable aggression, and serious AD/HD symptoms. In addition, the low self-esteem of subjects was not consistently elevated during the correctional education period. Moreover, their aggression was strongly correlated with AD/HD symptoms, both on admission and at the time of parole.

Does controlling for comorbidity matter? DSM-oriented scales and violent offending in Chicago youth

Mental health problems have long been linked to antisocial behaviors. Despite an impressive body of literature demonstrating this relationship and claims that comorbidity matters, few studies examine comorbidity using multiple distinct mental health indicators, with most studies instead adopting single or composite mental health measures. This study tested separate and comorbid effects of five DSM-oriented mental health issues on self-reported violence using a community-based sample of Chicago youths from the Project on Human Development in Chicago Neighborhoods. Moreover, it utilized both primary caregiver and youth self-reports of psychopathology across four developmental stages of childhood and adolescence. When examined separately, the results indicated affective/depressive, anxiety, attention deficit hyperactivity, and oppositional defiant/antisocial personality problems independently predicted violence. When considering comorbidity, however, only oppositional defiant and antisocial personality problems significantly predicted violence at any stage, regardless of informant type. Implications for future studies and policy are discussed.

Beyond categorical diagnostics in psychiatry: Scientific and medicolegal implications

Conforming to a medical disease model rooted in phenomenology and natural science, psychiatry classifies mental disorders according to signs and symptoms considered to be stable and homogeneous across individuals. Scientific studies addressing the validity of this classification are scarce. Following a seminal paper by Robins and Guze in 1970, validity of categories has been sought in specific criteria referring to symptoms and prognosis, aggregation in families, and "markers", preferentially laboratory tests. There is, however, a growing misfit between the model and empirical findings from studies putting it to the test. Diagnostic categories have not been shown to represent natural groups delineated from the normal variation or from each other. Aetiological factors (genetic and/or environmental), laboratory aberrations, and treatment effects do not respect categorical boundaries. A more adequate description of mental problems may be achieved by: 1) a clear definition of the epistemological frame in which psychiatry operates, 2) a basic rating of the severity of intra- and interpersonal dysfunctions, and 3) empirical comparisons to complementary rather than exclusive dimensions of inter-individual differences in context-specific mental functions, treatment effects, and laboratory findings. Such a pluralistic understanding of mental health problems would fit empirical models in the neurosciences and postmodern notions of subjectivity alike. It would also clarify the assessment of dysfunction and background factors in relation to the requisites for penal law exemptions or insurance policies and make them empirically testable rather than dependent on expert opinion on issues such as whether a specific dysfunction is "psychiatric", "medical", or ascribable to "personality".

The relationship between self-esteem and AD/HD characteristics in the serious juvenile delinquents in Japan

The purpose of this study was to clarify the following 2 points: (1) whether self-esteem changes after correctional education, and (2) whether attention deficit/hyperactivity characteristics affect self-esteem. The subjects were 118 juveniles (all males) admitted to "A" juvenile correctional facility. Our findings indicated that during the correctional education period, changes in self-esteem were limited. The AD/HD-YSR attention deficit score was negatively correlated with the self-esteem score on admission but was not associated with the self-esteem score at the time of parole. Next, the subjects were classified according to the self-esteem score. Consequently, the attention deficit score was significantly associated with self-esteem in all groups. Our results were suggested that total AD/HD-YSR score in the high self-esteem group was lower than that in the other groups. Our cross-sectional surveys have shown an association between the AD/HD-YSR score and self-esteem, suggesting the influences of developmental problems on self-esteem. Research implications were discussed.

Continuity of aggressive antisocial behavior from childhood to adulthood: The question of phenotype definition

Aiming to clarify the adult phenotype of antisocial personality disorder (ASPD), the empirical literature on its childhood background among the disruptive behaviour disorders, such as attention deficit/hyperactivity disorder (AD/HD), oppositional defiant disorder (ODD), conduct disorder (CD), or hyperkinetic conduct disorder (HKCD), was reviewed according to the Robins and Guze criteria for nosological validity. At least half of hyperactive children develop ODD and about a third CD (i.e. AD/HD+CD or HKCD) before puberty. About half of children with this combined problem constellation develop antisocial personality disorder (ASPD) in adulthood. Family and adoption/twin studies indicate that AD/HD and CD share a high heritability and that, in addition, there may be specific environmental effects for criminal behaviours. "Zones of rarity" delineating the disorders from each other, or from the normal variation, have not been identified. Neurophysiology, brain imaging, neurochemistry, neurocognition, or molecular genetics have not provided "external validity" for any of the diagnostic categories used today. Deficient mental functions, such as inattention, poor executive functions, poor verbal learning, and impaired social interaction (empathy), seem to form unspecific susceptibility factors. As none of today's proposed syndromes (e.g. AD/HD or psychopathy) seems to describe a natural category, a dimensional behavioural phenotype reflecting aggressive antisocial behaviours assessed by numbers of behaviours, the severity of their consequences and how early is their age at onset, which will be closely related to childhood hyperactivity, would bring conceptual clarity, and may form the basis for further probing into mental, cognitive, biological and treatment-related co-varying features.

The relationship between attention deficit hyperactivity disorder, conduct disorder, and psychopathy in adolescent male and female detainees

Although ADHD and CD are apparent risk factors for adult psychopathy, there are three distinct perspectives regarding their relationships to psychopathy: (1) ADHD may contribute uniquely to the development of psychopathy or (2) its contribution may reflect its high comorbidity with CD. Alternatively, (3) the comorbid presence of ADHD and CD may confer unique risk for the development of psychopathy. Although prior adult studies have yielded conflicting findings, no prior studies of adolescents address this issue. We examined these three hypotheses and the possibility of sex differences using cross-sectional analyses in 90 male and 123 female incarcerated adolescents. Among males the influence of ADHD was largely attributable to the overlap between ADHD and CD, whereas among females ADHD contributed independently to psychopathy scores and to scores on several dimensions of psychopathy. In addition, among females, the ADHD x CD interaction was significant for the total score and the antisocial component of psychopathy and in a direction opposite to that predicted by the comorbid subtype hypothesis. These findings indicate that there may be sex-specific pathways to elevations in psychopathic traits and suggest that the comorbid subtype hypothesis is probably not correct for either boys or girls.

Few girls with childhood attention-deficit/hyperactivity disorder show positive adjustment during adolescence

Employing data from 140 prospectively followed girls with attention-deficit/hyperactivity disorder (ADHD) and 88 age- and ethnicity-matched comparison girls, we adopted a person-centered analytic approach to assess rates of adolescent positive adjustment (PA) across six domains: ADHD symptoms, externalizing symptoms, internalizing symptoms, social skills, peer acceptance, and school achievement. During adolescence, between 19.8% and 61.1% of the girls with childhood ADHD met criteria for PA when the six domains were considered independently. A total of 16.4% of the ADHD sample showed PA in at least five of six domains, versus 86.4% of the comparison girls. Results were similar when PA was examined excluding the ADHD symptom domain. Most girls did not "grow out of" the symptoms and impairments related to their ADHD.

Verhaltenstherapie und Jugendhilfe

Fragestellung: Im Setting einer Jugendhilfe-Einrichtung wurde das Training mit aggressiven Kindern (TAK; Petermann & Petermann, 2008 ) in das Betreuungskonzept (KJH) integriert. Ziel dieser Studie war es, Effekte der Kombination beider Interventionen (KJH + TAK) nach sechs Monaten mit denjenigen des TAK alleine zu vergleichen, um zu klären, wie die Versorgung aggressiver Kinder in der Jugendhilfe optimiert werden kann. Methodik: Es nahmen 25 verhaltensauffällige Kinder (24 Jungen, ein Mädchen) im Alter von 7;6 bis 13;0 Jahren an der Studie teil. Ergebnisse: Auf den Skalen der Child Behavior Checklist (CBCL) gaben Eltern für die kombinierte Maßnahme eine starke Abnahme des aggressiv-delinquenten Verhaltens und der sozialen Probleme an; im Strengths and Difficulties Questionnaire (SDQ-E) verringerten sich Verhaltensprobleme und Schwierigkeiten mit anderen Kindern deutlich. In der KJH + TAK-Maßnahme zeigten sich gegenüber der TAK-Gruppe stärkere Effekte in den Bereichen Verhaltensauffälligkeiten, Aufmerksamkeitsprobleme, soziale Probleme und delinquentes Verhalten. Schlussfolgerungen: Die Kombination von Jugendhilfe und Aggressionstraining scheint ein breiteres Spektrum an Auffälligkeiten effektiver zu reduzieren als das TAK alleine, so dass durch eine Verknüpfung die Versorgung aggressiver Kinder beachtlich verbessert werden kann.

Morphometric brain abnormalities in boys with conduct disorder

OBJECTIVE

Children with the early-onset type of conduct disorder (CD) are at high risk for developing an antisocial personality disorder. Although there have been several neuroimaging studies on morphometric differences in adults with antisocial personality disorder, little is known about structural brain aberrations in boys with CD.

METHOD

Magnetic resonance imaging and voxel-based morphometry were used to assess abnormalities in gray matter volumes in 23 boys ages 12 to 17 years with CD (17 comorbid for attention-deficit/hyperactivity disorder) in comparison with age- and IQ-matched controls.

RESULTS

Compared with healthy controls, mean gray matter volume was 6% smaller in the clinical group. Compared with controls, reduced gray matter volumes were found in the left orbitofrontal region and bilaterally in the temporal lobes, including the amygdala and hippocampus on the left side in the CD group. Regression analyses in the clinical group indicated an inverse association of hyperactive/impulsive symptoms and widespread gray matter abnormalities in the frontoparietal and temporal cortices. By contrast, CD symptoms correlated primarily with gray matter reductions in limbic brain structures.

CONCLUSIONS

The data suggest that boys with CD and comorbid attention-deficit/hyperactivity disorder show brain abnormalities in frontolimbic areas that resemble structural brain deficits, which are typically observed in adults with antisocial behavior.

Clinical precursors of adolescent conduct disorder in children with attention-deficit/hyperactivity disorder

OBJECTIVE

To examine precursors of adolescent conduct disorder (CD) in children with attention-deficit/hyperactivity disorder (ADHD), investigating the significance of childhood oppositional defiant disorder (ODD) and ADHD.

METHOD

A total of 151 children with ADHD recruited from child psychiatric and pediatric clinics were assessed through standardized diagnostic interviews at ages 6 to 13 years and in adolescence 5 years later. Using multiple regression analysis, we assessed baseline ODD diagnosis and ODD, CD, and ADHD symptom scores as clinical predictors of adolescent CD diagnosis and symptom scores.

RESULTS

Childhood ODD (diagnosis and severity) was significantly associated with adolescent CD (diagnosis and severity), independent of childhood ADHD severity and childhood CD. Children with a diagnosis of ODD were almost three times more likely to develop CD in adolescence (odds ratio = 2.79, 95% CI 1.16-6.70, p = .02). Childhood ADHD severity predicted adolescent CD scores but not diagnosis of CD (although there was a trend toward association). The presence of at least one CD symptom in childhood predicted adolescent CD severity.

CONCLUSIONS

ODD is a significant precursor of adolescent CD in children with ADHD independent of ADHD severity. Considering the negative prognosis of ADHD with comorbid CD, it is imperative that clinicians pay specific attention to the presence of childhood ODD behaviors.

Transtorno de oposição e desafio e transtorno de conduta: os desfechos no TDAH em adultos

Os autores examinam a influência dos transtornos de oposição e desafio (TOD), de conduta (TC) e de personalidade anti-social (TPAS) ao longo da vida do indivíduo com TDAH. Os principais achados mostram que o TDAH é modulado por essas comorbidades e que seu prognóstico é modificado dependendo da presença ou não desses transtornos. O transtorno de oposição e desafio intensificaria as características de impulsividade e isolacionismo do TDAH, porém não acarretaria em um aumento na incidência de TPAS na vida adulta. Já o TC associado ao TDAH implica um aumento significativo na impulsividade e agressividade, estando associado significativamente a TPAS e um pior prognóstico. A diferenciação entre os diferentes transtornos e seu correto diagnóstico é essencial para o tratamento adequado do TDAH. Futuros estudos precisam determinar se o tratamento do TDAH produziria uma mudança significativa no prognóstico desse grupo de pacientes.

A prospective high-risk study of the association among maternal negativity, apparent frontal lobe dysfunction, and the development of bipolar disorder

In a previous paper, the authors found that impairment on the Wisconsin Card Sorting Test (WCST) in adolescence was predictive of bipolar disorder in young adulthood among offspring of mothers with bipolar illness. In the present study, the authors explore the contribution of maternal characteristics, beyond maternal mood disorder, to the prediction of offspring dysfunction on the WCST. Results showed that maternal bipolar disorder and maternal negativity were both predictive of impaired performance on the WCST during adolescence. The contribution of maternal negativity to offspring WCST impairment was not better explained by maternal personality disorder, mother's functional impairment, family loading for bipolar disorder, or offspring disruptive behavioral disturbance. Findings did not support a moderator model. However, support was found for a mediation model in which maternal negativity contributed to risk for offspring bipolar disorder through its negative association with apparent frontal lobe functioning, as measured by the WCST. Findings are discussed from the perspective of a vulnerability-stress model. In addition, the authors consider the possibility that maternal negativity and offspring impairment on the WCST may be reflective of a common heritable trait.

Relationship of family environment and parental psychiatric diagnosis to impairment in ADHD

OBJECTIVE

Family environmental factors as well as parental attention-deficit/hyperactivity disorder (ADHD) status have shown associations with variability in ADHD. The purpose of the present study was to examine the links among family environment, parental psychiatric diagnosis, and child impairment within a sample of ADHD-affected sibling pairs (ASPs) ages 5 to 18 years.

METHOD

Parents in 220 ASP families completed a measure of family functioning, the Family Environment Scale. Children's impairment was measured by clinical ratings of global functioning and by maternal ratings of behavior.

RESULTS

Parents of children with ADHD rate their families as higher in conflict and lower in achievement and organization than normative samples. High family conflict is significantly associated with impairment in ADHD ASPs accounting for approximately 40% of the sibling similarity in impairment. Parental psychiatric diagnosis revealed no significant direct link to sibling impairment, but rather a significant indirect link to impairment mediated by family conflict. Direct associations with parental diagnosis depend on birth order of the ASP members despite the comparable mean impairment scores for older and younger ADHD siblings.

CONCLUSIONS

There are strong links between impairment in children with ADHD and family environment. Different processes and mechanisms may contribute to impairment in different children in the same family.

Predictors of antisocial behaviour in children with attention deficit hyperactivity disorder

INTRODUCTION

Antisocial behaviour is an important adverse outcome of ADHD. The aim of this review is to examine what is known about the clinical, genetic and environmental factors that contribute to the link between ADHD and antisocial behaviour.

METHODS

Electronic literature searches for the years 1980-2004 and examination of key reference books were undertaken.

RESULTS

ADHD symptom severity and pervasiveness predict the development of antisocial behaviour. Genetic factors contribute substantially to the risk of developing both problems, although specific genes that influence the development of antisocial behaviour in ADHD have yet to be identified. Some of these genetic effects may be indirectly mediated through environmental risk (gene-environment correlation) or by increasing individual susceptibility to specific environmental adversity (gene-environment interaction). Antisocial behaviour in children with ADHD is also linked with family adversity as well as peer rejection, although some of this adversity may arise as a result of the child's symptoms.

CONCLUSION

Despite the increased risk of antisocial outcomes in those with ADHD, relatively little is known about what risk factors and mechanisms contribute to the link between both these problems. Given the need for appropriate intervention and prevention strategies and targeting resources, more research is needed in this area.

Personality differences in children and adolescents with attention-deficit/hyperactivity disorder, conduct disorder, and controls

BACKGROUND

Differences in personality profiles were examined between children who differed in their co-morbidity of externalizing disorders: attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD).

METHODS

11- and 17-year-old male and female twins from a community sample were categorized as ADHD only, CD only, co-morbid CD-ADHD, and controls (no ADHD or CD) based on threshold and subthreshold CD and ADHD diagnoses assessed with structured interviews. Multivariate analyses were used to identify patterns of personality that differentiate these four diagnostic groups. It was hypothesized that significant differences would be found in the pattern of personality variables between participants in the co-morbid group, compared to the other three groups, and that these differences would hold across developmental periods.

RESULTS

As expected, the co-morbid group had a pattern of personality marked by higher Negative Emotionality and lower Constraint than the other diagnostic groups. This pattern was evidenced across gender and age cohort.

CONCLUSIONS

An extreme personality profile may represent a liability toward the occurrence of ADHD and CD with more extreme profiles contributing to the occurrence of both disorders among boys and girls. Implications for treatment planning and theoretical development are discussed.

Attention-deficit/hyperactivity disorder: an overview of the etiology and a review of the literature relating to the correlates and lifecourse outcomes for men and women

This paper provides a summary of the current conceptualization of what AD/HD is, and its etiology, and then reviews some of the recent literature on the correlates and lifecourse outcomes for individuals diagnosed with Attention-Deficit/Hyperactivity Disorder (AD/HD). The intention is to synthesize that which is known, and to identify important gaps in the literature and knowledge base, which secondary analysis of prospective large-scale longitudinal cohorts, tracking individuals from birth to adulthood, could help to fill. This review highlights the fact that such datasets are rare and that their analysis offers important opportunities for advancing knowledge, particularly of the adult outcomes of childhood AD/HD.

Personality disorder traits during adolescence and relationships with family members during the transition to adulthood

Data from the Children in the Community Transitions Study, a prospective longitudinal investigation, were used to examine the association between adolescent personality disorder (PD) traits and conflict with family members during the transition to adulthood. PD traits at mean age 16 years were associated with elevated contact and conflict with family members between ages 17 and 27 years after Axis I disorders were controlled. There was a significant association between frequent contact and elevated conflict with family members. Both declined gradually during the transition to adulthood. Reduced family contact was associated with reduced family conflict, particularly among individuals who had numerous PD traits during adolescence. Among individuals who had a high level of family conflict during adolescence, reduced family contact between ages 17 and 22 years was associated with a subsequent reduction in conflict with family members between ages 22 and 27 years.

The scientific foundation for understanding attention-deficit/hyperactivity disorder as a valid psychiatric disorder

Continued questioning of the validity of a diagnosis of attention-deficit/hyperactivity disorder (ADHD) has created uncertainties about its management in the minds of many clinicians and the public. Inaccurate beliefs about the validity of ADHD hinder the clinical care of many ADHD patients and lead to confusion about the need to seek out or accept treatment. Critics describe ADHD as a diagnosis used to label difficult children who are not ill but whose behavior is at the extreme end of normal. They further contend that, far from having a biological basis, ADHD results from poor parenting and ineffective teaching practices. Such attitudes do much to further stigmatize patients and their families and increase the burden of this debilitating condition. This review attempts to address these challenges by presenting evidence to show that ADHD meets the criteria for a valid psychiatric diagnosis. Not only does it cause specific disabling symptoms that frequently persist into adulthood, but many studies show it has a biological basis and a characteristic response to treatment. Such data support the idea that ADHD is a valid diagnostic category.

Co-existing disorders in ADHD -- implications for diagnosis and intervention

BACKGROUND

It is only recently that "comorbidity" in ADHD has come to the forefront as one of the most important aspects of the disorder. It is agreed that, often, these problems are at least as important as ADHD in contributing to the longer term outcome in the individual child.

OBJECTIVE

To provide the reader with basic information about clinics and treatment of "comorbidity" in ADHD.

METHOD

Review of the empirically based literature.

RESULTS

ADHD exists in a surprisingly high frequency together with a broad range of child neuropsychiatric disorders. This is accompanied with many still unresolved treatment problems.

CONCLUSION

It would not be appropriate to develop ADHD-services where clinicians would only have expertise in ADHD as such. Anyone working with children, adolescents and adults with ADHD would need to have training in general neuropsychiatry. Further research in this field is urgently needed.

Reduced temporal lobe volume in early onset conduct disorder

Regional brain volumes derived from magnetic resonance imaging (MRI) scans from 10 youths with early onset conduct disorder and 10 healthy controls matched for age, sex and handedness were compared to determine whether prefrontal or temporal lobe brain volumes differed in the two groups. Right temporal lobe and right temporal gray matter volumes were significantly reduced in subjects with conduct disorder compared with controls. Prefrontal volumes in subjects with conduct disorder were 16% smaller than in controls, but the difference did not reach statistical significance. Early onset conduct disorder without substance abuse comorbidity was also significantly associated with smaller right temporal gray volumes. Further investigation of both the temporal and frontal localizations of the pathophysiology of early onset conduct disorder is warranted in larger samples.

Genetics of adult attention-deficit/hyperactivity disorder

Results of behavioral genetic investigations using family twin and adoption studies converge with those of molecular genetic studies in showing that genes influence susceptibility to'attention-deficit/hyperactivity disorder (ADHD). These finding suggest that genetic mechanisms that predispose individuals to ADHD are complex. It seems likely that the disorder is caused by the combined actions of several genes. It is equally clear that aberrant genes create a vulnerability to the disorder that is not expressed in all environments. The literature about the genetics of adult ADHD is relatively small, but it suggests not only that the persistent form of ADHD is familial, but that it is more familial than the nonpersistent form. More work from twin and molecular genetic studies is needed to determine if the increased familiality of persistent ADHD reflects the actions of genes or of familial environmental causes.

Gender effects on attention-deficit/hyperactivity disorder in adults, revisited

BACKGROUND

This study reexamined gender differences in a large sample of adults with attention-deficit/hyperactivity disorder (ADHD).

METHODS

We assessed the effects of ADHD, gender, and their interaction on rates of psychiatric comorbidity and cognitive functioning in 219 adults with ADHD who were referred to an outpatient psychiatric clinic over the last 7 years compared with 215 control subjects group-matched to control subjects on age and gender, and ascertained from ongoing family genetic case control adults with ADHD.

RESULTS

There was no evidence that gender moderated the association between ADHD and other psychiatric disorders. Attention-deficit/hyperactivity disorder was associated with cognitive deficits and higher rates of major depression, anxiety, substance use disorders, and antisocial personality disorder.

CONCLUSIONS

Attention-deficit/hyperactivity disorder in adults is associated with psychiatric and cognitive impairment in both genders. These results bear striking similarities to findings reported in pediatric samples, supporting the validity of ADHD and stressing the importance of identifying and treating the disorder in adulthood.

ADHD and conduct disorder: an MRI study in a community sample

MRI studies of children with Attention-Deficit Hyperactivity Disorder (ADHD) have consistently attributed core deficits of inattention and impulsivity to frontal-striatal-cerebellar abnormalities; however, no study has investigated the neuroanatomical characteristics of children with ADHD and Conduct Disorder (CD). This study examined a community sample of 12 children with combined subtype ADHD (aged 8-12, 7 with CD) and 19 healthy controls matched for age, gender, handedness and poverty. Volume measurements, including left/right asymmetries, were quantified from MRI of the total brain, caudate and cerebellar vermis. No significant differences in total brain volume, caudate volume, asymmetry of the hemispheres or asymmetry of the caudate were found between the groups. Measurements of the left and total posterior superior and inferior lobes of the vermis, however, indicated smaller volumes for both pure ADHD and co-morbid children compared to the controls. Analysis of variance demonstrated no significant volumetric differences between the pure ADHD and co-morbid types. Prolonged exposure to methylphenidate was associated with caudate volumes. These results suggest ADHD and ADHD co-morbid with CD have similar deviant cerebellar morphology and replicate previous studies with an epidemiologically derived sample.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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