Hyperactivity: prevalence and relationship with conduct disorder

The North American Perspective On Attention Deficit Hyperactivity Disorder

The purpose of the present paper is to (1) provide an overview of the nature of attention-deficit hyperactivity disorder (ADHD) as it seems to be viewed by North American clinicians and clinical scientists; (2) describe its diagnostic criteria as they are applied in that region; (3) discuss the prevalence of ADHD in the region; and (4) briefly present a new theoretical model of the authors emerging from that North American perspective. Some of the critical issues related to these matters will be raised along the way. Given the thousands of scientific papers on this topic, however, an overview of these various topics is all that space here can afford. Readers wishing a more thorough treatment of these topics as well as those pertaining to history, developmental courses, associated risks, assessment, and treatments for ADHD are directed to other writings by the author (Barkley, 1990).

Secular trends in the mental health of primary school children

Over the recent past, reports have argued that there has been a decline in the mental health of children and young people in Western societies. This is said to have occurred gradually over the second half of the last century and possibly longer. This view is based on evidence of a progressively declining peak age for adult type depressive disorders, and an apparent increase in adolescent disturbance such as substance abuse, attempted and completed suicide, perhaps eating disorders, and behaviour disorders. These phenomena have been attributed to the major changes in social values and behaviour, with their impact on child rearing and family life that gathered pace over the course of the last century.

Hyperactivity and conduct disorder: exploring origins

Objectives: This paper explores the relationship of hyperactivity (HA), conduct disorder (CD) and combined hyperactivity and conduct disorder (HACD) with certain environmental and biological stresses and vulnerabilities.

Method: It is based upon a large epidemiological database from the North of England.

Results: The findings suggest that CD is uncommon and strongly related to environmental stresses. This is true to a lesser extent of HACD. While both CD and HACD were related to family adversity and adverse styles of parental discipline, subtly different patterns of associations are also evident. In particular, CD is linked with poverty, parental violence and contact with child care social agencies. These findings are consistent with the hypothesis that HA contributes to a pattern of confrontation and punishment associated, in some cases, with the emergence of a more complex combination disturbance. However, CD occurs against a background of family conflict and poor child-care.

Conclusions: Most apparent cases of conduct disorder are in fact hybrid conditions including symptoms of HA and CD. True CD should be diagnosed not only by positive symptomatology but also by the absence of hyperactivity symptoms.

It is time for a more integrated bio-psycho-social approach to ADHD

The role of psychosocial factors in perpetuating and predisposing towards the development of attention deficit hyperactivity disorder (ADHD) symptoms has been neglected within the field of child mental health. Clinicians, when told that a child had a diagnosis of ADHD, have been found to underestimate the presence of psychosocial factors, and are less likely to ask about the possibility of neglect or abuse. This article details the considerable research showing links between ADHD symptoms and parental mental illness, child maltreatment, post-traumatic stress disorder (PTSD), attachment disorders and other environmental factors. Recent neuro-biological findings showing the impact on brain development of early abuse and attachment concerns are cited. The implications of these findings both for clinicians, and at policy level, are discussed, and the reasons underlying the need for a more integrated Bio-Psycho-Social approach to ADHD are outlined.

Prevalence of parent-rated attention deficit hyperactivity disorder and associated parent-related factors in primary school children of Navi Mumbai--a school based study

OBJECTIVES

To study the prevalence of parent-rated attention deficit hyperactivity disorder and associated parent-related factors in primary school children of Navi Mumbai.

METHODS

One hundred twenty two children including both boys and girls aged between 6 y and 11 y were selected from a school at Navi Mumbai and their parents were given the National Innovative for Children's Healthcare Quality (NICHQ) Vanderbilt Assessment Scale to be filled and returned, which was subsequently analyzed using SPSS (version 16).

RESULTS

The prevalence of attention deficit hyperactivity disorder was 12.3 % with boy to girl ratio of 3:2. It was more prevalent in nuclear type of family and in families where a single parent was working especially where the father was the sole breadwinner and doing semi-skilled or unskilled type of work. No significant relation was found between the numbers of work-related hours when parents were away from children and attention deficit hyperactivity disorder.

CONCLUSIONS

Attention deficit hyperactivity disorder is prevalent in the primary school-going population of Navi Mumbai, especially in boys. The increased prevalence in nuclear families and families with single working parent should further be explored. Further studies with larger sample size and longer period of follow up may be recommended. The study also recommends screening of school children for symptoms of attention deficit hyperactivity disorder (ADHD) for early diagnosis and treatment.

Occupational issues of adults with ADHD

BACKGROUND

ADHD is a common neurodevelopmental disorder that persists into adulthood. Its symptoms cause impairments in a number of social domains, one of which is employment. We wish to produce a consensus statement on how ADHD affects employment.

METHODS

This consensus development conference statement was developed as a result of a joint international meeting held in July 2010. The consensus committee was international in scope (United Kingdom, mainland Europe, United Arab Emirates) and consisted of individuals from a broad range of backgrounds (Psychiatry, Occupational Medicine, Health Economists, Disability Advisors). The objectives of the conference were to discuss some of the occupational impairments adults with ADHD may face and how to address these problems from an inclusive perspective. Furthermore the conference looked at influencing policy and decision making at a political level to address impaired occupational functioning in adults with ADHD and fears around employing people with disabilities in general.

RESULTS

The consensus was that there were clear weaknesses in the current arrangements in the UK and internationally to address occupational difficulties. More so, Occupational Health was not wholly integrated and used as a means of making positive changes to the workplace, but rather as a superfluous last resort that employers tried to avoid. Furthermore the lack of cross professional collaboration on occupational functioning in adults with ADHD was a significant problem.

CONCLUSIONS

Future research needs to concentrate on further investigating occupational functioning in adults with ADHD and pilot exploratory initiatives and tools, leading to a better and more informed understanding of possible barriers to employment and potential schemes to put in place to address these problems.

ADHD and delinquency--a developmental perspective

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood and adolescence. Until now, it has been unclear whether ADHD by itself constitutes a risk factor for later delinquency or does so only in combination with other disruptive symptoms. This article seeks to give a comprehensive account of the literature to shed light on the developmental pathway from childhood ADHD to adult criminality. Comorbid ADHD and conduct disorder (CD) are significantly related to a range of biological and environmental risk factors such as neurocognitive impairment, high parental psychopathology, poor social functioning, and other comorbid mental disorders, particularly substance abuse, that are described in this review. In addition, the results of treatment studies are presented, with a special focus on the results of the Multimodal Treatment Study of Children with ADHD (MTA). Although treatment programs, including medication and psychosocial treatment, can be very effective in improving the functioning of children with ADHD in the social and academic domains in the short term, there is no conclusive evidence that such treatments lower the risk for developing delinquency in adulthood.

Changes in Hyperactivity and Temperament in Behaviourally Disturbed Preschoolers after Parent–Child Interaction Therapy (PCIT)

Changes in hyperactivity and temperament in preschool-aged children who underwent a behavioural management program with their mothers were examined. Families of 34 behaviourally disturbed preschool-aged children (aged 3–5) were randomly allocated to either parent–child interaction therapy (PCIT; Eyberg, 1988) or a waiting-list control group (WL). A group of 21 nondisturbed preschoolers was recruited as a social validation comparison condition (SV). Diagnostic status was assessed using a structured clinical interview forDSM-IVdisruptive behaviour disorders, with measures of behaviour and temperament obtained via parent report. At posttreatment, PCIT preschoolers were reported by their mothers to have reduced hyperactivity and more flexible temperament, and were less likely to meet criteria for ADHD than the WL group. By 6-month follow-up, children who had received PCIT were comparable to the SV group on ratings of oppositional behaviour and hyperactivity. The finding that a behavioural intervention may influence stable child characteristics is discussed.

"Cool" inferior frontostriatal dysfunction in attention-deficit/hyperactivity disorder versus "hot" ventromedial orbitofrontal-limbic dysfunction in conduct disorder: a review

Attention-deficit/hyperactivity disorder (ADHD) and conduct disorder overlap behaviorally, clinically, and cognitively. An important question of potential future clinical relevance is whether these two overlapping disorders are mediated by similar or distinct underlying brain substrates. This article reviews the modern neuroimaging literature on brain structure, function, and connectivity in both disorders, shaping out commonalities and differences. Findings show that ADHD is characterized predominantly by abnormalities in inferior frontal, striatal, parietotemporal, and cerebellar regions and networks that mediate "cool"-cognitive, i.e., inhibitory, attention and timing functions associated with the disorder. Conduct disorder, by contrast, has consistently been associated with abnormalities of the "hot" paralimbic system that regulates motivation and affect, comprising lateral orbital and ventromedial prefrontal cortices, superior temporal lobes, and underlying limbic structures, most prominently the amygdala. Direct comparisons in functional imaging show that these associations of cool inferior fronto-striato-cerebellar dysfunction in ADHD and of hot orbitofrontal-paralimbic dysfunction in conduct disorder are disorder-specific. There is, hence, evidence for dissociated underlying pathophysiologies for these two disorders that may have implications for future anatomy-based differential diagnosis and prevention and intervention.

The prevalence of ADHD-like symptoms in a community sample

OBJECTIVE

The aim of the present study was to explore the prevalence of ADHD symptoms in a community sample of children in the United Kingdom.

METHOD

There were 964 ten year olds (55% boys; M = 10.4 years; SD = 0.6) from mainstream schools in the United Kingdom in this study. The ADHD Rating Scale-IV, which provides ratings on the frequency of ADHD symptoms drawn from DSM-IV criteria, was administered to class teachers.

RESULTS

The findings indicated an overall 8% prevalence rate, with the majority of children identified as the Hyperactive/Impulsive subtype (5%). Almost half of these children were receiving additional support in the classroom as a result of learning difficulties.

CONCLUSION

It is therefore of value for educators to be able to conduct early screening to support these children before problems worsen.

The diagnostic utility of behavioral checklists in identifying children with ADHD and children with working memory deficits

The present study investigated whether children with ADHD and those with working memory impairments have a common behavioral profile in the classroom. Three teacher checklists were used: the Conners' teacher rating scale (CTRS), the behavior rating inventory of executive function (BRIEF), and the working memory rating scale. The Conners' continuous performance test (CPT) was also included to determine whether there is a correspondence between performance on this widely used cognitive measure of attention deficits and teacher ratings of classroom behavior. All three behavior scales, but not the CPT, were able to successfully discriminate children with ADHD and those with working memory deficits from typically-developing children. Both the CTRS and the BRIEF discriminated a significant proportion of the children with ADHD from those with working memory deficits, indicating that while both groups exhibit behavioral problems in the classroom, they are characterized by differential attention profiles. The children with ADHD were identified on the basis of oppositional and hyperactive behavior, while those with working memory deficits were more inattentive.

Hyperactive-impulsive symptom scores and oppositional behaviours reflect alternate manifestations of a single liability

Attention deficit hyperactivity disorder and oppositional behaviours frequently co-occur, We aimed to study the etiology of this overlap in a general population-based twin sample, assessing the symptom domains of hyperactivity-impulsivity and inattentiveness separately for their overlap with oppositionality. We further aimed to investigate whether rater bias may contribute to the overlap in previous data which used one rater only. Using parent and teacher ratings on hyperactivity-impulsivity, inattentiveness and oppositionality, and actigraph measurements of activity level, for 668 7-9-year-old twin pairs, oppositionality showed a higher overlap with hyperactivity-impulsivity (r = 0.95) than with inattentiveness (r = 0.52) and all etiological influences on hyperactivity-impulsivity were shared with those on oppositionality, indicated by a genetic correlation of 0.95 and a child-specific environmental correlation of 0.94. Actigraph data did not show an overlap with ratings of oppositionality. In middle childhood, symptoms of hyperactivity-impulsivity and oppositional behaviour may represent the same underlying liability, whereas the inattentive domain is more distinct.

Attention-deficit/hyperactivity disorder and social dysfunctioning

Attention-deficit/hyperactivity disorder (ADHD) is associated with functional impairments in different areas of daily life. One such area is social functioning. The purpose of this paper is to critically review research on social dysfunctioning in children with ADHD. Children with ADHD often have conflicts with adults and peers, and suffer from unpopularity, rejection by peers, and a lack of friendships, in part as a consequence of their ADHD symptoms. Comorbid oppositional defiant or conduct disorder aggravates these impairments. In some cases the inadequate social behavior of children with ADHD may be phenomenologically and etiologically related to pervasive developmental disorders (PDD). However, the causes and consequences of PDD symptoms in ADHD are understudied. Also, the relative contributions of ADHD, on the one hand, and comorbid disorders, on the other, to the course of social impairments are unknown. Social dysfunctioning in children with ADHD appears to increase their risk of later psychopathology other than ADHD. Thus far effective treatment for social dysfunctioning is lacking. Future research should address the exact nature and long-term consequences of social dysfunctioning in children with ADHD, and focus on development of effective treatment strategies.

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.

Event-related potentials in adolescents with combined ADHD and CD disorder: a single stimulus paradigm

Some studies of the event-related potentials demonstrated a reduction of the voluntary component P3 (P300 or P3b) in youngsters with the attention deficit/hyperactivity disorder (ADHD) or in conduct disorders (CD), and a reduction of the automatic processing component, mismatch negativity, in patients with both ADHD and CD (ADHD+CD). Recently, a passive auditory P3 potential has been elicited by a single stimulus. We therefore tried this potential study in 20 healthy subjects and 20 teenagers with ADHD+CD to search for further evidence of the altered automatic cerebral processing in the latter. Subjects also answered a self-report Dimensional Assessment of Personality Pathology (DAPP). The patient group scored significantly higher on most DAPP traits that reflect problems of emotion control, showed significantly prolonged P2, N2, and P3, and reduced P3. In all subjects Stimulus Seeking was positively correlated with P3 latencies at Fz, Cz, and Pz, and with P3 amplitude at Cz. This study suggests that youngsters with ADHD+CD had pronounced emotion dysregulation, and prominent deficit in passive attention, as reflected by the automatic processing of auditory stimuli.

Variation in children's cognitive and behavioural adjustment between different types of place in the British National Child Development Study

Several recent studies suggest that there is a link between children's development and the types of neighbourhood in which they live. This paper examines the relationship of a classification of different types of neighbourhood to children's cognitive and behavioural outcomes using British data on children who have a parent who is a member of the 1958 Birth Cohort Study. Substantial variations in children's outcomes were observed between the neighbourhood types. Part of the variation between neighbourhood types was accounted for by various family risk factors but children living in neighbourhoods classified as Deprived City Areas continued to have higher levels of behaviour problems and lower cognitive test scores than average after adjustment for these factors. Significant adjusted associations were also found between living in neighbourhoods described as Middling Britain and lower cognitive test scores and neighbourhoods described as Prosperous Areas and better cognitive test scores. For children's cognitive outcomes, both the size and statistical significance of coefficients on the neighbourhood categories were smaller than those of family-level measures. In contrast, residence in a Deprived City Area was as significant as the family factors in predicting higher levels of behaviour problems. The association between behaviour problems and family risk factors was mediated by the home environment and cohort member parent's psychological health. Mediated effects were stronger for the family risk factors behavioural problems association than for the neighbourhood classification.

Prevalence of psychiatric disorder: with and without psychosocial impairment

OBJECTIVE

To identify rates of psychiatric disorder in a representative sample of primary school children in a North of England city.

METHOD

The study obtained multi-criterion screen data on a representative one-in-three sample of 7- and 8-year-old children in Newcastle upon Tyne. It also obtained psychiatric interview data for screen-positive and a proportion of screen negative children. In addition the clinically trained interviewers rated psychiatric impairment.

RESULTS

Estimated rates of disorder with impairment, calibrated to be equivalent to that of children attending local child psychiatric clinics, were 1.2% for emotional disorder, 5.6% for disruptive behaviour disorder and 6.7% for any disorder.

CONCLUSION

These findings are consistent with other contemporary studies using similar impairment criteria.

School-based indicated prevention: a randomised trial of group therapy

BACKGROUND

One hundred and twenty-two children identified by teachers as at risk for behavioural or emotional problems were randomly allocated to drama-group therapy or to a curriculum-studies control, based in school.

METHODS

One hundred and seventeen completed the intervention phase of the trial, which comprised 12 hour-long sessions. Post-intervention self-reports showed significant effects associated with both interventions.

RESULTS

However, there was a clear advantage of group therapy over both a waiting list control and curriculum studies, according to teacher reports. This was true also of categorical analyses focusing on those with the most severe symptoms.

CONCLUSIONS

These analyses confirmed sustained teacher-reported improvement over a year-long follow-up period.

Dual diagnosis in offenders with intellectual disability: setting research priorities: a review of research findings concerning psychiatric disorder (excluding personality disorder) among offenders with intellectual disability

Studies of so-called 'dual diagnosis', i.e. intellectual disability (ID) with an additional psychiatric disorder, are reviewed with particular reference to offending behaviour. Because of the paucity of studies of psychopathology in offenders with ID, the present paper opens with studies of broader issues of psychopathology among people with ID, notably those with depression, schizophrenia, mild depressive disorder, other major psychotic disorders, anxiety/neurotic disorder, autistic spectrum disorders and attention deficit hyperactivity disorder. There follows a review of the most established and commonly used measurement scales for dual diagnosis in ID. The review then focuses directly on those studies which have looked at the issues of dual diagnosis among offenders with ID. In keeping with other reviews in this series, the latter studies are classified according to the same criteria. Based on this review, it is apparent that there are high-priority research questions which concern the extent and nature of psychopathology among offenders with ID, most notably those with autistic spectrum disorders.

Pharmacokinetic and pharmacodynamic drug interactions in the treatment of attention-deficit hyperactivity disorder

The psychostimulants methylphenidate, amphetamine and pemoline are among the most common medications used today in child and adolescent psychiatry for the treatment of patients with attention-deficit hyperactivity disorder. Frequently, these medications are used in combination with other medications on a short or long term basis. The present review examines psychostimulant pharmacology, summarises reported drug-drug interactions and explores underlying pharmacokinetic and pharmacodynamic considerations for interactions. A computerised search was undertaken using Medline (1966 to 2000) and Current Contents to provide the literature base for reports of drug-drug interactions involving psychostimulants. These leads were further cross-referenced for completeness of the survey. Methylphenidate appears to be more often implicated in pharmacokinetic interactions suggestive of possible metabolic inhibition, although the mechanisms still remain unclear. Amphetamine was more often involved in apparent pharmacodynamic interactions and could potentially be influenced by medications affecting cytochrome P450 (CYP) 2D6. No published reports of drug interactions involving pemoline were found. The alpha2-adrenergic agonists clonidine and guanfacine have been implicated in several interactions. Perhaps best documented is their antagonism by tricyclic antidepressants and phenothiazines. In additional, concurrent beta-blocker use, or abrupt discontinuation, can lead to hypertensive response. Although there are few published well-controlled interaction studies with psychostimulants and alpha2-adrenergic agonists, it appears that these agents may be safely coadministered. The interactions of monoamine oxidase inhibitors with psychostimulants represent one of the few strict contraindications.

A meta-analytic examination of comorbid hyperactive-impulsive-attention problems and conduct problems

The author quantitatively reviewed prevalence rates, defining features, associated features, developmental trajectory, and etiology to examine 3 taxonomic questions about comorbid hyperactive-impulsive-attention problems (HIA) and conduct problems (CP): Do HIA and CP co-occur randomly? Does comorbid HIA-CP differ from HIA-only and CP-only? Do HIA and CP combine synergistically? Results showed that HIA and CP co-occur at a greater than random rate, that comorbid HIA-CP differs from HIA-only and CP-only in multiple ways, and that there is little evidence that HIA and CP combine synergistically. However, sample type, grouping definition, age, gender, and subtype of disruptive behavior often moderated these findings. Overall, the review suggests that HIA-CP is best conceptualized as an additive combination of HIA and CP rather than as a distinct category.

A utilidade do wisc na detecção de problemas de atenção em escolares

Este trabalho é parte de um estudo maior destinado a comparar aspectos neurológicos e psicológicos de escolares e tem como objetivo verificar a viabilidade de utilização da Escala Wechsler de Inteligência para Crianças (WISC) para identificação de problemas de atenção em escolares e do Roteiro de Investigação da Atenção (RIA). Foram sujeitos 29 escolares de primeira série de uma escola pública. Os resultados obtidos com o RIA possibilitaram a definição de dois grupos de sujeitos, um com 10 sujeitos com indicativos de problemas de atenção e o outro com 19 sujeitos sem indicativos de problemas de atenção. Os resultados obtidos na análise estatística indicaram a existência de diferença significativa para duas dimensões de QI, o Verbal e Total, que se apresentam inferiores no grupo com indícios de problemas com a atenção. A média obtida entre os resultados dos três subtestes do WISC revelou diferença significativa para Aritmética e Dígitos, com médias inferiores para o grupo de sujeitos com indícios de problemas com a atenção, o mesmo não ocorrendo para o subteste Código.

Prospective, longitudinal study of tic, obsessive-compulsive, and attention-deficit/hyperactivity disorders in an epidemiological sample

OBJECTIVE

Understanding the interrelatedness of tics, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD) has been complicated by studying only cross-sectional samples of clinically referred subjects. The authors report the cross-sectional and longitudinal associations of these disorders in an epidemiological sample of children followed prospectively into early adulthood.

METHOD

Structured diagnostic interview information was acquired on 976 children, aged 1 to 10 years, who were randomly selected from families living in upstate New York in 1975. Reassessments were acquired in 776 of these subjects 8, 10, and 15 years later. Diagnostic prevalences were estimated at each time point. The associations among tics, OCD, and ADHD were assessed within and across time points, as were their associations with comorbid illnesses and demographic risk factors.

RESULTS

In temporal cross-section, tics and ADHD symptoms were associated with OCD symptoms in late adolescence and early adulthood after demographic features and comorbid psychiatric symptoms were controlled. In prospective analyses, tics in childhood and early adolescence predicted an increase in OCD symptoms in late adolescence and early adulthood. ADHD symptoms in adolescence predicted more OCD symptoms in early adulthood, and OCD in adolescence predicted more ADHD symptoms in adulthood. The associations of tics with ADHD were unimpressive in temporal cross-section and were not significant in prospective analyses. Tics, OCD, and ADHD shared numerous complex associations with demographic and psychopathological risk factors. ADHD was associated with lower IQ and lower social status, whereas OCD was associated with higher IQ.

CONCLUSIONS

Tics and OCD were significantly associated in this sample, as were OCD and ADHD. These findings are in general consistent with those from family studies, and they help to define the natural history, comorbid illnesses, and interrelatedness of these conditions.

Validity of structured clinical evaluations in adolescents with conduct and substance problems

OBJECTIVE

To determine discriminative and convergent validity for certain structured diagnostic assessments among adolescents with conduct and substance problems.

METHOD

Patients were 87 adolescents (both genders) in treatment for conduct and substance problems. Most controls (n = 85; both genders) came from patients' neighborhoods. Assessments included Diagnostic Interview Schedule for Children, Composite International Diagnostic Instrument-Substance Abuse Module, Child Behavior Checklist, and others. Patients' data guided clinical care.

RESULTS

Youths' self-reports significantly discriminated patients from controls in DSM-IVconduct and substance use disorders (CD, SUD) and in numerous associated measures. CD and SUD symptoms correlated strongly. However, some patients apparently minimized symptoms. Youths' self-reports did not discriminate patients from controls in attention-deficit/hyperactivity disorder (ADHD) or major depression (MDD). Parent information raised prevalence rates of ADHD and MDD, which then discriminated patients from controls. However, patients and parents usually disagreed on MDD and ADHD diagnoses.

CONCLUSIONS

Despite some dissimulation, patients' self-reports of CD and SUD correlated highly and had superb discriminative validity, making them useful for treatment and research. Self-reports of ADHD and MDD, apparently lacking discriminative validity, are less useful. Parent reports improve these discriminations but present additional problems.

Is there a comorbid relationship between hyperactivity and emotional psychopathology?

Some of the early literature implied that emotional disorders were almost incompatible with hyperactivity in childhood. The paper addresses this issue using a large epidemiological data base--of two cohorts of 7- & 8-year-old and 11- & 12-year-old children from the North of England. There are two themes, first, the paper reports on the prevalence of emotional symptoms and disorder among hyperactive children. Second, it explores co-occurrence of hyperactivity and emotional psychopathology according to whether the hyperactivity is situational or pervasive and according to the age of the child. Hyperactivity proved to have an association with emotional symptoms and disorder at both ages but the links with disorder were most prominent among the older children. Among our high risk or maladjusted samples the strongest links were with home-based situational hyperactivity. However, among the general population cohort, emotional disorder proved to be a function of pervasiveness of hyperactivity and older age.

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.

Separation and comorbidity of hyperactivity and conduct disturbance in Chinese schoolboys

In a two-stage community study of 3069 Chinese schoolboys in Hong Kong, those entering stage 2 were classified by scores on Rutter's teacher and parent questionnaires into: (1) a mixed hyperactive/conduct-disturbed (HA-CD) group; (2) a pure hyperactive (HA) group; (3) a pure conduct-disturbed (CD) group; and (4) a normal control group. The four groups of children were compared on a series of psychosocial, cognitive and neurodevelopmental measures. This was followed by a regression analysis to examine the specificity of the differential patterns of associations between HA and CD. There was a mix of negative and positive findings defying a simple, definitive conclusion. However, the positive findings that did emerge supported a growing body of recent literature which favoured a separation of HA from CD and their cross-cultural validity: the former was associated with neurodevelopmental impairments, the latter with family disharmony. The mixed condition, HA-CD, was a hybrid of its two constituent conditions, displaying the attributes of both.

The changing mental health of children and adolescents: evidence for a deterioration?

This paper reviews the evidence for changing patterns of mental health over time in childhood and youth in Western societies. The evidence suggests that the prevalence of major depression, substance abuse and offending behaviour, as well as the incidence of suicide, is increasing in adolescent populations, particularly among males. There are also indications that problem behaviours among younger children are becoming more common. There is no evidence of a deterioration in the adjustment of the pre-school population.

Hyperkinetic or attention deficit disorder

BACKGROUND

In the face of rapidly expanding empirical knowledge about this common childhood condition, there is a need for an up-to-date synthesis, especially for the use of practising clinicians.

METHOD

The main epidemiological, experimental and clinical studies over the past decade are selectively reviewed.

RESULTS

Hyperkinetic/attention deficit hyperactivity disorder is common, with young school-age males most frequently affected. The prevalence figures vary depending on the criteria used. Overlap with conduct disorder is high. The causes are likely to stem from a combination of biological, often genetically determined neurochemical disturbances, and environmental disadvantages, with the biological risk tending to be highest in severely hyperactive girls. Good clinical management combines pharmacological, psychological and educational approaches in a sustained manner. Even then, the outcome is often equivocal and the long-term psychosocial adaptation unpredictable.

CONCLUSIONS

Clinically significant hyperactivity is rooted in biological, often genetically transmitted vulnerabilities, upon which environmental disadvantages transect. It may be viewed as a disorder of self-regulation with its roots partly in strained early caregiver-child interactions and disrupted primary attachments.