Adult psychiatric disorders in parents of hyperactive children

A Systematic Review and Meta-analysis of Parental Depression, Antidepressant Usage, Antisocial Personality Disorder, and Stress and Anxiety as Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD) in Children

Poor parental mental health and stress have been associated with children's mental disorders, including attention-deficit/hyperactivity disorder (ADHD), through social, genetic, and neurobiological pathways. To determine the strength of the associations between parental mental health and child ADHD, we conducted a set of meta-analyses to examine the association of parent mental health indicators (e.g., parental depression, antidepressant usage, antisocial personality disorder, and stress and anxiety) with subsequent ADHD outcomes in children. Eligible ADHD outcomes included diagnosis or symptoms. Fifty-eight articles published from 1980 to 2019 were included. We calculated pooled effect sizes, accounting for each study's conditional variance, separately for test statistics based on ADHD as a dichotomous (e.g., diagnosis or clinical cutoffs) or continuous measurement (e.g., symptoms of ADHD subtypes of inattentiveness and hyperactivity/impulsivity). Parental stress and parental depression were significantly associated with increased risk for ADHD overall and both symptoms and diagnosis. Specifically, maternal stress and anxiety, maternal prenatal stress, maternal depression, maternal post-partum depression, and paternal depression were positively associated with ADHD. In addition, parental depression was associated with symptoms of ADHD inattentive and hyperactive/impulsive subtypes. Parental antisocial personality disorder was also positively associated with ADHD overall and specifically ADHD diagnosis. Prenatal antidepressant usage was associated with ADHD when measured dichotomously only. These findings raise the possibility that prevention strategies promoting parental mental health and addressing parental stress could have the potential for positive long-term impacts on child health, well-being, and behavioral outcomes.

Understudied and underrecognised

That Zwi & York (2004) have opened the discussion on adult attention-deficit hyperactivity disorder (ADHD) is to be applauded. Their main conclusion is that the diagnostic validity of adult ADHD remains uncertain and that further study is needed. This is based on a review of the ADHD concept in childhood and the longitudinal studies that have followed children with ADHD into adulthood.

Personality profile of parents of children with attention deficit hyperactivity disorder

Objectives. The present study was carried out aiming to identify the personality profile of parents of children with Attention Deficit Hyperactivity Disorder (ADHD). Methods. This study is of a descriptive, analytic, cross-sectional type in which parents of 6–12-year-old children with ADHD who were referred to the Bozorgmehr Psychiatric Clinic, affiliated with Tabriz University of Medical Sciences, were enrolled. ADHD was diagnosed according to the criteria of DSM-IV-TR and a quasi-structured diagnostic interview (K-SADS-PL). The personality profile of the parents was assessed with the Millon Clinical Multiaxial Inventory-III (MCMI-III). Results. According to the findings of this study, the most common personality problems based on the assessment scales in the MCMI-III belonged to the clinical patterns of depressive personality in 43 persons (25.3%), histrionic personality in 34 persons (20%), and compulsive personality in 29 persons (17.1%). According to discriminant analysis, four scales of somatoform, sadistic, dependence, and though disorder were direct and antisocial scale was reverse significant predictors of membership in the women group. Conclusion. According to the findings of this pilot study, personality disorders are prevalent in parents of ADHD children and mothers suffer from personality disorders more than fathers.

Osmotic release oral system-methylphenidate improves neural activity during low reward processing in children and adolescents with attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is neurobehavioral disorder characterized by inattention, hyperactivity/impulsivity and impaired reward system function, such as delay aversion and low reward sensitivity. The pharmacological treatment for ADHD includes methylphenidate (MPH), or osmotic release oral system-MPH (OROS-MPH), which increases extrasynaptic dopamine and noradrenaline levels by blocking their reuptake. Although previous functional magnetic resonance imaging (fMRI) studies revealed that acute treatment with MPH alters activation of the nucleus accumbens during delay aversion in children and adolescents with ADHD, the effects a relatively long period of OROS-MPH treatment on delay aversion as well as reward sensitivity remain unclear. Thus, we evaluated brain activation with fMRI during a reward sensitivity paradigm that consists of high monetary reward and low monetary reward conditions before and after a 3-month treatment with OROS-MPH in 17 children and adolescents with ADHD (mean age, 13.3 ± 2.2) and 17 age- and sex-matched healthy controls (mean age, 13.0 ± 1.9). We found that before treatment there was decreased activation of the nucleus accumbens and thalamus in patients with ADHD during only the low monetary reward condition, which was improved to same level as those of the healthy controls after the treatment. The observed change in brain activity was associated with improved ADHD symptom scores, which were derived from Japanese versions of the ADHD rating scale-IV. These results suggest that treatment with OROS-MPH for a relatively long period is effective in controlling reward sensitivity in children and adolescents with ADHD.

•

Attention deficit/hyperactivity disorder (ADHD) has low reward sensitivity.

•

Activity in thalamus and nucleus accumbens was decreased in low monetary reward.

•

Osmotic release oral system-methylphenidate (OROS-MPH) is a medication for ADHD.

•

Brain activity and ADHD symptoms were improved by 3-month treatment with OROS-MPH.

•

OROS-MPH treatment for long periods may change brain activity of pediatric ADHD.

Randomized clinical study of a histamine H3 receptor antagonist for the treatment of adults with attention-deficit hyperactivity disorder

BACKGROUND

Psychostimulants, including methylphenidate and amphetamine preparations, are commonly prescribed for the treatment of attention-deficit hyperactivity disorder (ADHD) in children and adults. Histamine H3 receptors reside on non-histamine neurons and regulate other neurotransmitters (e.g. acetylcholine, noradrenaline [norepinephrine]) suggesting that H3 antagonists have the potential to improve attention and impulsivity. Research indicates that H3 receptor antagonists due to their novel mechanism of action may have a unique treatment effect offering an important alternative for the treatment of ADHD. Bavisant (JNJ-31001074) is a highly selective, orally active antagonist of the human H3 receptor with a novel mechanism of action, involving wakefulness and cognition, with potential as a treatment for ADHD.

OBJECTIVE

The objective of this study was to evaluate the efficacy, safety and tolerability of three dosages of bavisant compared with placebo in adults with ADHD.

STUDY DESIGN

This randomized, double-blind, placebo- and active-controlled, parallel-group, multicentre study evaluated three dosages of bavisant (1 mg/day, 3 mg/day or 10 mg/day) and two active controls in adults with ADHD. The study consisted of a screening phase of up to 14 days, a 42-day double-blind treatment phase and a 7-day post-treatment follow-up phase. Efficacy and safety assessments were performed.

SETTING

The study was conducted at 37 study centres in the US from April 2009 through January 2010.

PARTICIPANTS

Men and women aged 18-55 years with an established diagnosis of ADHD as confirmed by clinician and self-report diagnostic measures were enrolled.

INTERVENTION

Participants were randomly assigned equally to one of six treatment groups: placebo, bavisant 1 mg/day, 3 mg/day or 10 mg/day, atomoxetine hydrochloride 80 mg/day or osmotic-release oral system (OROS) methylphenidate hydrochloride 54 mg/day.

MAIN OUTCOME MEASURE

The primary efficacy endpoint was the change in the Attention Deficit Hyperactivity Disorder Rating Scale, Version IV (ADHD-RS-IV) total score from baseline (day 1) to the end of the treatment phase (day 42), and included all randomized participants who received one or more doses of study drug and had baseline and one or more post-baseline assessments (intent-to-treat [ITT] population). Safety assessments included treatment-emergent adverse events (TEAEs), laboratory tests and ECG readings.

RESULTS

430 participants were randomized, 424 received one or more doses of study medication and 335 (78%) of those randomized completed the study. Study participants had a mean age of 33.9 years and were predominantly White men. Mean treatment duration ranged from 31.4 to 38.8 days across groups. Mean change from baseline in the total ADHD-RS-IV score at day 42 (primary efficacy endpoint) was -8.8 in the placebo group versus -9.3, -11.2 and -12.2 in the bavisant 1 mg/day, 3 mg/day and 10 mg/day groups, respectively; the change in the 10 mg/day group was not statistically superior to placebo (p=0.161), and hence statistical comparisons of the 1 mg/day and 3 mg/day groups with placebo based on a step-down closed testing procedure were not performed. Mean change from baseline in the total ADHD-RS-IV score at day 42 was superior to placebo in the atomoxetine (-15.3) and OROS methylphenidate (-15.7) groups (p<0.005). Secondary efficacy assessments demonstrated a similar pattern with a non-significant trend towards improvement in the bavisant groups. The two lower dosages showed a good tolerability profile, but the higher dosage of bavisant was less well tolerated, as evidenced by the incidence of total TEAEs (61.8%, 82.4%, 89.0%), and discontinuations due to TEAEs (4.4%, 7.4%, 19.2%) in the bavisant 1 mg/day, 3 mg/day and 10 mg/day groups, respectively, compared with 58.9% and 2.7%, respectively on placebo. In the atomoxetine and OROS methylphenidate groups, the incidence of total TEAEs was 83.8% and 82.4% and discontinuations due to TEAEs was 10.8% and 8.8%, respectively.

CONCLUSION

Bavisant, a highly selective, wakefulness-promoting H3 antagonist, did not display significant clinical effectiveness in the treatment of adults with ADHD.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00880217.

Advances in understanding and treating ADHD

Attention deficit hyperactivity disorder (ADHD) is a neurocognitive behavioral developmental disorder most commonly seen in childhood and adolescence, which often extends to the adult years. Relative to a decade ago, there has been extensive research into understanding the factors underlying ADHD, leading to far more treatment options available for both adolescents and adults with this disorder. Novel stimulant formulations have made it possible to tailor treatment to the duration of efficacy required by patients, and to help mitigate the potential for abuse, misuse and diversion. Several new non-stimulant options have also emerged in the past few years. Among these, cognitive behavioral interventions have proven popular in the treatment of adult ADHD, especially within the adult population who cannot or will not use medications, along with the many medication-treated patients who continue to show residual disability.

Neurobiological and psychophysiological correlates of emotional dysregulation in ADHD patients

Emotional dysregulation in ADHD patients has become an important issue in recent years. Dysfunctions especially in brain regions related to emotional processing as well as psychophysiological reactions have been reported. This review includes functional MRI, event-related potentials as well as emotion-modulated startle studies in ADHD patients. It reflects a selective review of the authors with no claim of completeness. Changes in the processing of positive stimuli, with reduced brain activity in the amygdala, in the ventral striatum and reduced EEG potentials were found. The relevance of the observed dysregulation in emotional processing and psychophysiological reactions with regard to theoretical constructs of ADHD-specific emotional dysregulation versus comorbidity will be discussed.

Attention deficit hyperactivity disorder in men and women newly committed to prison: clinical characteristics, psychiatric comorbidity, and quality of life

Attention deficit hyperactivity disorder (ADHD) is associated with comorbid psychiatric diagnoses and antisocial behaviors that contribute to criminality, yet studies of ADHD in offenders are few. The authors evaluate a random sample of 319 offenders using a version of the Mini International Neuropsychiatric Interview and Medical Outcome Survey Health Survey. ADHD was present in 68 subjects (21.3%). Offenders with ADHD were more likely to report problems with emotional and social functioning and to have higher suicide risk scores (p < .001). They also had higher rates of mood, anxiety, psychotic, and somatoform disorders. Antisocial and borderline personality disorders were also more common among offenders with ADHD. The authors conclude that ADHD is common in offenders and is associated with comorbid disorders, worse quality of life, and higher risk for suicidal behaviors. Its presence should alert prison staff that the offender is likely to require more intensive mental health services.

Variability of response time as a predictor of methylphenidate treatment response in korean children with attention deficit hyperactivity disorder

PURPOSE

Methylphenidate (MPH) is an effective medication for the treatment of attention deficit hyperactivity disorder (ADHD). However, about 30% of patients do not respond to or are unable to tolerate MPH. Based on previous findings, we hypothesized that great variability in response time (RT) among Korean children with ADHD on a computerized continuous performance attention test would be related to poor MPH treatment response.

MATERIALS AND METHODS

Children (ages 6-18 years) with ADHD were recruited for a prospective 12-week, open-labeled, multicenter study to examine optimal dosage of OROS methylphenidate. Of the 144 subjects selected, 28 dropped out due to adverse events, medication noncompliance, or follow-up loss, and an additional 26 subjects with comorbid disorders were excluded from statistical analyses. We defined 'responders' as subjects who received a score of less than 18 on the attention deficit hyperactivity disorder rating scale (ARS; Korean version, K-ARS) and a score of 1 or 2 on the Clinical Global Impression-Improvement scale (CGI-I). RT variability was assessed with the ADHD diagnostic system (ADS).

RESULTS

Fifty-nine (67%) subjects responded to MPH treatment. The non-responders showed greater RT variability at baseline (Mann Whitney U = 577.0, p < 0.01). Baseline RT variability was a significant predictor of MPH response (Nagelkerke R(2) = 0.136, p < 0.01). It predicted 94.9% of responder, 17.2% of non-responder and 69.3% of overall group.

CONCLUSION

High RT variability may predict poor response to MPH treatment in children with ADHD.

Diagnosing and treating attention-deficit/hyperactivity disorder in adults

Adult attention deficit/hyperactivity disorder (ADHD) is a valid and impairing psychiatric disorder. In this article, we review the diagnosis of ADHD in adults, focusing on symptom presentation differences between pediatric and adult ADHD as well as the importance of assessing functional impairments. Differentiating ADHD from other clinical disorders is often the most difficult part of making an ADHD diagnosis in adults. Psychiatric comorbidities are also described and discussed as potential impact factors upon not only diagnosing ADHD but also treatment of adult ADHD. Especially in those adults with psychiatric comorbidities, treatments need to be multimodal and include both pharmacotherapy and psychosocial interventions.

Attention-deficit/hyperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology

In this report, we provide an evidence-based overview of attention-deficit/hyperactivity disorder (ADHD), including diagnosis, prevalence, developmental expression of symptoms, persistence, the heterogeneity of functional outcome, impairment in afflicted adults, psychiatric comorbidity, pathophysiology, genetics, psychosocial and biologic risk factors, and neurobiology. Attention-deficit/hyperactivity disorder is an early-onset, highly prevalent neurobehavioral disorder, with genetic, environmental, and biologic etiologies, that persists into adolescence and adulthood in a sizable majority of afflicted children of both sexes. It is characterized by behavioral symptoms of inattention, hyperactivity, and impulsivity across the life cycle and is associated with considerable morbidity and disability. Comorbidity is a distinct clinical feature of both childhood and adult ADHD. Although its etiology remains unclear, emerging evidence documents its strong neurobiologic and genetic underpinnings. Despite the high diagnostic reliability and the robust evidence of the validity of ADHD, there are many underlying issues that remain to be resolved. These include establishing developmentally appropriate diagnostic criteria at older ages, further elaborating the impact of gender on symptom expression, and examining risk and protective factors in relationship to prevention or amelioration of ADHD as well as related functional impairments.

Co-morbidity of adult attention-deficit/hyperactivity disorder with focus on personality traits and related disorders in a tertiary referral center

OBJECTIVE

The prevalence and consequences of co-morbid axis-I and axis-II disorders as well as personality traits were examined in a large cohort of adult attention-deficit/hyperactivity disorder (AADHD) at a tertiary referral center.

METHODS

In- and outpatients referred for diagnostic assessment of AADHD were screened. 372 affected probands were examined by means of the Structured Clinical Interview of DSM-IV axis-I/II disorders, the Revised NEO Personality Inventory (NEO-PI-R), and the Tridimensional Personality Questionnaire (TPQ).

RESULTS

Lifetime co-morbidity with mood disorders was 57.3%, with anxiety disorders 27.2%, and with substance use disorders 45.0%. The histrionic personality disorder (35.2%) was the most frequent personality disorder. AADHD patients exhibited significantly altered scores on most of the NEO-PI-R and TPQ personality dimensions. The extent of substance abuse and dependence, as well as the presence of antisocial personality disorder alone or the cumulative number of other specific personality disorders was associated with lower psychosocial status (p<.0001).

DISCUSSION

In a cohort of patients with AADHD referred to a single tertiary center co-morbidity with axis-I/II disorders was remarkably prevalent. In AADHD co-morbid mood, anxiety, and personality disorders as well as substance abuse/dependence is likely to be predictive of poor outcome.

Family based association analysis of statistically derived quantitative traits for drug use in ADHD and the dopamine transporter gene

OBJECTIVE

To determine whether SNPs within the dopamine transporter gene (DAT) are associated with quantitative phenotypes generated from drug frequency variables in an ADHD sample.

METHOD

35 SNPs were genotyped in and around DAT. We developed a quantitative phenotype at each SNP by weighting the drug frequency variables. The weights were selected to maximize the heritability at each SNP. Once a quantitative phenotype was generated at each SNP, a screening procedure was used to select and test the SNPs with the greatest power to detect an association in DAT.

RESULTS

No SNPs in DAT were associated with the quantitative phenotypes generated from the drug frequency variables after the multiple comparisons adjustment; however, some SNPs achieved nominal significance. A sliding window of analysis of 3 SNPs also resulted in only nominal associations.

CONCLUSIONS

SNPs in DAT do not appear to be associated with the phenotypes generated from drug frequency variables among individuals with ADHD.

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.

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.

Does parental ADHD bias maternal reports of ADHD symptoms in children?

Within families, co-occurring attention-deficit/hyperactivity disorder (ADHD) in parents and children may be common. The authors evaluated the hypothesis that parental ADHD may lead to a reporting bias of ADHD symptoms in offspring. They combined 2 family case-controlled studies of ADHD using structured interviews. They compared rates of maternal reported ADHD symptoms among 3 groups of ADHD children: no parental ADHD (n = 231), mother with ADHD (n = 63), and father with ADHD (n = 57). With the exception of 1 symptom, the rates of reporting between groups did not differ. There was no evidence that the discrepancy between maternal reports and self-reports of symptoms differed by parental ADHD. Results were similar across child gender or referral status. These results do not support the notion that parental ADHD affects maternal reports of offspring ADHD.

Attention-deficit/hyperactivity disorder in adults: an overview

To assess the validity of adult attention-deficit/hyperactivity disorder (ADHD), we reviewed clinical, family, psychopharmacologic, neurobiological, and outcome studies. We found multiple reports describing adults with clinical features highly reminiscent of the childhood ADHD. These adults, who are impulsive, inattentive, and restless, have the clinical "look and feel" of ADHD children. As with their childhood counterparts, many adults with ADHD suffer from antisocial, depressive, and anxiety disorders. They also show clinically significant impairments--histories of school failure, occupational problems, and traffic accidents. Studies of biological features show correspondences between child and adult cases of ADHD. Both show familial aggregation and a characteristic profile of neuropsychologic deficits; an emerging neuroimaging literature suggests that abnormalities in the same brain regions underlie both the child and adult forms of the disorder. Although these converging lines of evidence support the validity of ADHD in adults, follow-up studies of ADHD children have yielded ambiguous results. This ambiguity is in part due to differences in how researchers define the persistence of ADHD, a problem that suggests future research focus on how best to diagnose ADHD in adulthood.

Pregnancy, delivery and infancy complications and attention deficit hyperactivity disorder: issues of gene-environment interaction

We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit hyperactivity disorder (ADHD) and addressed issues of comorbidity and familiarity by testing multiple hypotheses. Subjects were 6-17-year-old boys with DSM-III-R ADHD (n = 140) and normal controls (n = 120) and their first-degree biologic relatives. Information on PDICs was obtained from mothers in a standardized manner blind to the proband's clinical status. Using linear and logistic regression models, a positive association was found between ADHD and PDICs in the probands. Additionally, PDICs were associated with the correlates of ADHD (i.e., impaired cognitive functioning and poor school performance). Moreover, it was those specific complications that reflect chronic exposure, such as maternal bleeding, smoking, family problems, and illicit drug use during pregnancy that accounted for these findings. No interaction between genetic factors and PDICs were found. Our findings add to the literature supporting an association between ADHD and PDICs. Our results may help clinicians focus on particular complications rather than the wide range of possible perinatal complications.

Families of children with attention deficit hyperactivity disorder: a review

OBJECTIVES

1) To review the evidence of attention deficit hyperactivity disorder (ADHD) and other conditions in family members (siblings and parents) of children with ADHD and determine the importance of genetic and environmental factors in this condition. 2) To describe the prospective 10-year follow-up of 65 families with ADHD children and 43 families of matched normal controls. 3) To review various studies that have looked at parent-child interactions with ADHD children on and off stimulant medication, and such interactions over time. The paper thus provides an overview of family pathology and functioning of families of ADHD children over time.

METHOD

The paper outlines twin, sibling, family and adoption studies with regard to possible genetic and environmental factors in ADHD. It also presents data of a prospective 10-year follow-up of 65 families with ADHD children and 43 families of normal controls. This family study evaluated sociocultural factors, child rearing practices, health of family members and relationships, as well as the parental view of the child's functioning over time.

RESULTS

A review of the literature suggests that ADHD has a strong genetic component, but that environmental factors also play an important role. Families of children with ADHD have more problems than families of normal controls, but these problems improve as the child with ADHD grows up and leaves home. Families of ADHD subjects can appreciate positive as well as negative changes in their children over time. Generally, family interactions with children with ADHD are problematic but improve when the child is on medication and when the child becomes an adult.

CONCLUSIONS

This condition has strong genetic underpinnings; therefore, diagnosing and treating family members (parents and siblings) as well as the child with ADHD is important in improving parent-child interactions and better long-term outcome for the child and his or her family.

New phenotype definition of attention deficit hyperactivity disorder in relatives for genetic analyses

The goal of the present investigation was to create a phenotype definition in relatives of probands that reflects a more genetic form of attention deficit hyperactivity disorder (ADHD). Logistic regression was applied to the first-degree relatives of ADHD and normal control probands to create a quantitative phenotype that combined information across psychiatric, cognitive, and demographic domains. Models were run separately in mothers, fathers, sisters, and brothers. Although there was some overlap between the variables retained in each model, no two models had exactly the same variables. Our results suggest that the use of fitted logits may be valuable as a potential index of caseness. Since different characteristics were included in different groups of relatives, our results suggest that gender and generation may moderate the expression of ADHD.

Parent characteristics and parent-child interactions in families of nonproblem children and ADHD children with higher and lower levels of oppositional-defiant behavior

This study examined parent-child interactions and parent characteristics in families of nonproblem children and attention deficit hyperactivity disorder (ADHD) children with lower (ADHD-LOD) and higher (ADHD-HOD) levels of oppositional-defiant behavior. Families of ADHD children were recruited from a parent training program. Observed and parent-reported child behavior problems were highest in the ADHD-HOD group. Observed parent behavior revealed few differences, but daily reports indicated that parents in both ADHD groups used more negative-reactive and fewer positive parenting strategies than control parents. Maternal psychological functioning differed between the ADHD and nonproblem groups, but not between the two ADHD groups. Fathers of ADHD-HOD children reported more psychological disturbance than controls. Parenting self-esteem was lowest in the ADHD-HOD group and highest in the nonproblem group. The results support the LOD and HOD distinction, but also suggest that, although certain difficulties are more common in the families of ADHD-HOD children, families of ADHD-LOD children also differ from controls on a number of dimensions.

Gender differences in a sample of adults with attention deficit hyperactivity disorder

Although originally conceptualized as a childhood disorder, attention deficit hyperactivity disorder (ADHD) may also be an adult disorder. However, despite increasing media attention to adult ADHD, its validity has only recently been studied in a systematic fashion. The overrepresentation of females in adult samples in comparison to pediatric samples of ADHD raises additional questions about the validity of this disorder in adults. The goal of this article is to explore whether ADHD is a valid clinical entity in female subjects and whether it is expressed differently in male and female adults. To this end, we examined the clinical, cognitive, and functional characteristics of 128 referred adult ADHD cases of both sexes. Each subject had a clinical diagnosis of childhood-onset ADHD confirmed by structured interview. The male and female ADHD adults were similar to one another but more disturbed and impaired than non-ADHD adult control subjects. Compared with normal control females, ADHD women had higher rates of major depression, anxiety disorders, and conduct disorder; and more evidence of school failure and cognitive impairment. The consistency of these findings in both genders further supports the validity of the diagnosis of ADHD in adults. Our results stress the viability and importance of identification of female subjects with ADHD. The underidentification and undertreatment of females with ADHD may have substantial mental health and educational implications, suggesting that research is needed to develop a better understanding of clinical indicators of ADHD in females.

An exploratory study of ADHD among second-degree relatives of ADHD children

Family-genetic studies consistently show that attention deficit hyperactivity disorder (ADHD) aggregates in nuclear families. Little is known about the aggregation of ADHD in second-degree relatives. We examined the prevalence of ADHD in second-degree relatives of 140 ADHD probands and 120 normal controls. Information pertinent to the diagnosis of ADHD in second-degree relatives was collected from the probands' parents. The second-degree relatives of ADHD probands were at increased risk for ADHD compared with the second-degree relatives of normal control probands. These risks were greatest when the second-degree relative was biologically related to an ADHD parent of an ADHD proband. Consistent with the greater prevalence of ADHD among boys compared with girls, grandfathers were at greater risk than grandmothers and uncles were at greater risk than aunts. Our results support the usefulness of ascertaining information from second-degree relatives in studies evaluating the genetic epidemiology of ADHD. If confirmed, such studies may help clarify the mechanism of familial transmission of ADHD.

Genetic factors in substance abuse based on studies of Tourette syndrome and ADHD probands and relatives. II. Alcohol abuse

Prior studies have suggested childhood attention deficit hyperactivity disorder (ADHD) as a risk factor for alcohol abuse in adults. Gilles de la Tourette Syndrome, a hereditary tic and impulse disorder, is clinically and genetically similar to ADHD. To examine the hypothesis that individuals carrying the Gts gene are at increased risk to develop alcohol use problems, the same TS (Tourette Syndrome) and ADHD probands, relatives and controls used in the prior study of drug abuse were also studied using a structured questionnaire based on the Diagnostic Interview Schedule and the MAST test. The frequency of a positive response to any of 16 different questions concerning alcohol abuse showed a highly significant increase with increased genetic loading for Gts and ADHD genes. The percentage of more than one positive response in TS probands was markedly influenced by the presence of comorbid ADHD, discipline, obsessive-compulsive or drug abuse problems. Comorbid drug abuse problems were the best predictor of alcohol abuse problems. These results suggest that the genes responsible for TS and ADHD play an important role in alcohol abuse/dependence as well as drug abuse/dependence. One of the elements common to all of these disorders may be mutant genes affecting serotonin metabolism.

Are perinatal complications relevant to the manifestation of ADD? Issues of comorbidity and familiality

OBJECTIVE

We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit disorder (ADD) addressing issues of comorbidity and familiarity by formulating and testing multiple hypotheses.

METHOD

Subjects were six to 17-year-old boys with DSM-III attention deficit disorder (ADD, N = 73), psychiatric (N = 26), and normal (N = 26) controls and their relatives. Information on PDICs was obtained from the mothers in a standardized manner blind to the proband's clinical status.

RESULTS

Using odds ratio analyses, an association was found between ADD and PDICs that was strongest for the comorbid and nonfamilial subtypes. In contrast, noncomorbid and familial ADD subgroups differed less from normal controls in the risk for PDICs.

CONCLUSIONS

The increased risk for PDICs in nonfamilial ADD children and the lack of evidence for increased risk among familial ADD patients suggests that PDICs may be part of nongenetic etiologic mechanisms in this disorder, especially for children who have comorbid disorders.

Children of people with somatization disorder

OBJECTIVE

The author investigated psychopathology, suicidal behavior, child abuse, somatization, and health care utilization in 34 children with a parent who has somatization disorder (SD-P) and two comparison groups: 41 children with a somatizing parent (SOM) (fewer symptoms than required for diagnosis of SD-P), and 30 pediatrically ill controls (CON).

METHOD

Child and parent versions of the Diagnostic Interview for Children and Adolescents were scored for diagnosis and symptom counts in specified categories. Medical records were obtained and abstracted.

RESULTS

Children of SD-P had significantly more psychiatric disorders and suicide attempts than did children of SOM or the CON. SD-P and CON had significantly more unexplained physical symptoms than SOM. SD-P showed a trend toward more hospitalizations and experienced significantly more maltreatment.

CONCLUSIONS

Children of SD-P are at significant risk in several respects. Clinical implications of these findings include a need for awareness and cooperation among general psychiatrists, primary care physicians, and child and adolescent psychiatrists to facilitate detection and treatment of these children's problems.

The impact of young children with externalizing behaviors on their families

Compared the impact on families of young children with externalizing behaviors (e.g., hyperactive, aggressive; n = 22), autism (n = 20), or no significant problem behaviors (n = 22) on several measures of family functioning. Previous studies have found heightened stress and parental maladjustment in families with externalizing children. The present study expanded upon that literature by (1) including a clinical control group to determine the specific impact of externalizing problems, (2) focusing on preschool aged children, and (3) using a new measure to directly ascertain parents' perception of impact. Compared to parents with normally developing children, parents with externalizing children reported more negative impact on social life, more negative and less positive feelings about parenting, and higher child-related stress. Moreover, parents of externalizing children reported levels of impact and stress as high as those reported by parents of children with autism. On broader measures of parental and marital well-being, however, the three groups of families of preschoolers did not differ. The implications of these findings for intervention are discussed.

A double-blind placebo controlled study of desipramine in the treatment of ADD: III. Lack of impact of comorbidity and family history factors on clinical response

A 6-week randomized, double-blind, placebo controlled trial of desipramine (DMI) in daily doses averaging 4 to 5 mg/kg for the treatment of children and adolescents with attention deficit disorder with hyperactivity (ADDH) was further analyzed. Investigators examined whether comorbidity of ADDH with conduct disorder, major depression, an anxiety disorder, or a family history of ADDH predicted response to DMI treatment. There was a highly significant effect of treatment with DMI in outcome assessments, but responses to DMI were indistinguishable in ADDH patients with and without a comorbid disorder or familial ADDH. Cases of "pure" ADDH (lacking comorbidity with depression, anxiety, or conduct disorder and having a positive family history of ADDH) showed a trend toward lesser placebo responses and a corresponding greater DMI-placebo difference. These findings suggest that (1) DMI is effective in simple, noncomorbid cases, (2) DMI is not selective for comorbid cases, but (3) a response to DMI can be obtained even in complex cases of ADDH with associated comorbidity.

Attention deficit disorder: association with familial-genetic factors

The etiology of attention deficit disorder and hyperactivity (ADDH) is controversial because both biologic and social factors have been postulated. To study such factors, we undertook a referral study based on an entire cohort (N = 6,950) of children born in Jerusalem in 1976. Of 479 children referred for learning disabilities, hyperactivity, and behavioral problems, 381 were available for study. Information regarding obstetric, developmental, and family histories was obtained by a detailed, structured interview. A DSM-III-based questionnaire for ADDH was completed by parents and teachers. Each child underwent neurologic examination and 133 had IQ testing. Of these children, 145 fulfilled the criteria for ADDH. Our results revealed a number of significant familial-genetic factors: boys outnumbered girls by 3:1, 30% of ADDH children had siblings with learning disabilities (P less than .001); and ADDH children clustered within families of North African descent (P less than .001). The only significant developmental factor was delayed language development. Of numerous pre- and peri-natal factors investigated, only intrauterine growth retardation was significantly associated with ADDH. No correlation was found between ADDH and IQ, parental age, years of education, profession, and language spoken at home. Our study supports the hypothesis that familial-genetic factors are contributory to ADDH.

Separation of DSM-III attention deficit disorder and conduct disorder: evidence from a family-genetic study of American child psychiatric patients

Using family study methodology and assessments by blind raters, this study tested hypotheses about patterns of familial association between DSM-III attention deficit disorder (ADD) and antisocial disorders (childhood conduct (CD) and oppositional disorder (OPD) and adult antisocial personality disorder) among 457 first-degree relatives of clinically referred children and adolescents with ADD (73 probands, 264 relatives), psychiatric (26 probands, 101 relatives) and normal controls (26 probands, 92 relatives). Among the 73 ADD probands, 33 (45%) met criteria for OPD, 24 (33%) met criteria for CD, and 16 (22%) had no antisocial diagnosis. After stratifying the ADD sample into those with CD (ADD + CD), those with OPD (ADD + OPD) and those with neither (ADD) familial risk analysis revealed the following: (1) relatives of each ADD proband subgroup were at significantly greater risk for ADD than relatives of both psychiatric and normal controls: (2) the morbidity risk for ADD was highest among relatives of ADD + CD probands (38%), moderate among relatives of ADD + OPD (17%) and ADD probands (24%) and lowest among relatives of psychiatric and normal controls (5% for both); (3) the risk for any antisocial disorder was highest among relatives of ADD + CD (34%) and ADD + OPD (24%) which were significantly greater than the risk to relatives of ADD probands (11%), psychiatric (7%) and normal controls (4%); and (4) both ADD and antisocial disorders occurred in the same relatives more often than expected by chance alone. Although these findings suggest that ADD with and without antisocial disorders may be aetiologically distinct disorders, they are also consistent with a multifactorial hypothesis in which ADD, ADD + OPD and ADD + CD fall along a continuum of increasing levels of familial aetiological factors and, correspondingly, severity of illness.

Attention deficit disorder with hyperactivity among paediatric outpatients

Out of 1,000 children (aged 3-12 years) screened in a paediatric outpatient department over a 3 1/2-year period, 112 were found to have attention deficit disorder with hyperactivity (ADDH). The prevalence of ADDH increased with age, from 5.2% in those aged 3-4 years, up to 29.2% in those aged 11-12 years. There were four times as many boys as girls with ADDH. ADDH was most common in first born children and those from a lower social class. Children with ADDH had a higher rate of complications during pregnancy and delivery relative to a comparison group. Delayed development, temper-tantrums, enuresis, tics, broken homes, persistent parental discord and psychiatric illness in parents were all more common in children with ADDH than in the comparison group.

Family history of alcoholism in males: absence of distinguishing features for treatment matching

One variable for subtyping the alcoholic population that could influence treatment-matching efforts is family history of alcoholism. This study compared two groups of male patients undergoing rehabilitation for alcohol dependence (39 family history positive [FHP] versus 36 family history negative [FHN]) on a number of salient dimensions for which specific targeted intervention components might be implemented. The FHP were similar to FHN subjects on all variables except that FHP had significantly fewer years of education than did FHN. Several possible explanations to account for these findings are discussed.

Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder

Using family study methodology and assessments made by blind raters, this study evaluated family-genetic and psychosocial risk factors for DSM-III attention deficit disorder (ADD) among the 457 first-degree relatives of clinically referred children and adolescents with ADD (N = 73), compared with psychiatric (N = 26) and normal controls (N = 26). Relatives of ADD probands had a higher morbidity risk for ADD (25.1% versus 5.3% versus 4.6%, ps less than 0.00001), antisocial disorders (25.3% versus 6.9% versus 4.2%, ps less than 0.00001), and mood disorders (27.1% versus 13.9%, p = 0.038 and 27.1% versus 3.6%, p = 0.00001) than did relatives of psychiatric and normal controls. The increased risk for ADD could not be accounted for by gender or generation of relative, the age of proband, social class, or the intactness of the family. These results confirm and extend previous findings indicating important family-genetic risk factors in ADD.

Attention and impulsivity characteristics of the biological and adoptive parents of hyperactive and normal control children

On tests comparing 176 biological and adoptive parents of hyperactive and normal control children, biological parents of hyperactives evidenced more attentional difficulties, slower mean reaction times, and fewer correct recognitions than did the other parents. They showed no significant differences in impulsivity. A familial association between childhood hyperactivity and attentional deficits in the biological parents was suggested, as was the persistence of attentional difficulties as compared to impulse control problems.

A family study of patients with attention deficit disorder and normal controls

In a family study of Attention Deficit Disorder (ADD), we collected data on first-degree relatives of 22 children with ADD and 20 normal children. The morbidity risk for ADD was 31.5% in the first group. This was significantly higher than the rate of 5.7% in the control group. Relatives of ADD probands were also shown to be at higher risk for Oppositional Disorders and Major Depressive Disorder (MDD). The findings indicate that ADD is a familial disorder associated with increased familial risk of other psychiatric disorders.

Hyperactive and normal girls and boys: mother-child interaction, parent psychiatric status and child psychopathology

This study compared hyperactive and normal girls and boys on their mother-child interactions, family psychiatric status and ratings on the Personality Inventory for Children (PIC). Hyperactive children were less compliant and more negative, and their mothers responded more negatively to their compliance than mothers of normal children. Mothers of hyperactive children reported more depression, marital discord and psychiatric problems in their relatives, and rated their children more deviant on 15 of 16 PIC scales than normal children. Hyperactive boys received more direction and praise, and had greater maternal concern about their adjustment than hyperactive girls or normal children.