ATTENTION 2.0 PROFESSIONAL EDITION,
Latest Published Studies on ADHD
Associations between problems with
crying, sleeping and/or feeding in infancy and long-term behavioural
outcomes in childhood: a meta-analysis.
Hemmi, Mirja Helen; Wolke,
Dieter; Schneider, Silvia.
Archives of Disease in Childhood, April 20, 2011, Online
BACKGROUND: Excessive crying, sleeping or feeding
problems are found in approximately 20% of infants and may predict
behavioural problems in childhood.
METHODS: A quantitative meta-analysis of 22
longitudinal studies from 1987 to 2006 that statistically tested the
association between infant regulatory problems and childhood
internalising, externalising and attention-deficit/hyperactivity
disorder (ADHD) problems was carried out; 1935 children with regulatory
problems were tested. Cohen's d was used to express the association
between regulatory problems and behavioural problems. Heterogeneity of
the effect sizes was assessed using the I² statistic and
meta-analysis of variance and meta-regressions were conducted to assess
the influence of moderators. Rosenthal's classic fail-safe N and
correlation of sample sizes to effect sizes were used to assess
RESULTS: The weighted mean effect size for the main
regulatory problems--behavioural problems association was 0.41 (95% CI
0.28 to 0.54), indicating that children with previous regulatory
problems have more behavioural problems than controls. Externalising and
ADHD problems were the strongest outcome of any regulatory problem,
indicated by the highest fail-safe N and lowest correlation of sample
size to effect size. Meta-analyses of variance revealed no significant
moderating influences of regulatory problem comorbidity (I² = 44.0,
p>0.05), type (I² =41.8, p>0.05) or duration (I² =44.0,
p>0.05). However, cumulative problems and clinical referral increased
the risk of behavioural problems.
CONCLUSIONS: The meta-analyses suggest that children
with previous regulatory problems have more behavioural problems than
controls, particularly in multi-problem families. Further studies are
required to assess the behavioural outcomes of previously sleep, feeding
or multiply disturbed children.
Preterm Birth and
Attention-Deficit/Hyperactivity Disorder in Schoolchildren
Lindström, Karolina; Lindblad, Frank; Hjern, Anders.
Pediatrics, April 18, 2011, Online Early.
OBJECTIVE: Previous studies have demonstrated an
increased risk for attention-deficit/hyperactivity disorder (ADHD) in
follow-up studies of preterm survivors from NICUs. In this study we
analyzed the effect of moderate as well as extreme preterm birth on the
risk for ADHD in school age, taking into account genetic, perinatal, and
METHODS: Register study in a Swedish national cohort of
1,180 616 children born between 1987 and 2000, followed up for ADHD
medication in 2006 at the age of 6 to 19 years. Logistic regression was
used to test hypotheses. A within-mother-between-pregnancy design was
used to estimate the importance of genetic confounding in a
subpopulation of offspring (N = 34,334) of mothers who had given birth
to preterm (34 weeks) as well as term infants.
RESULTS: There was a stepwise increase in odds ratios
for ADHD medication with increasing degree of immaturity at birth; from
2.1 (1.4-2.7) for 23 to 28 weeks' gestation, to 1.6 (1.4-1.7) for 29 to
32 weeks', 1.4 (1.2-1.7) for 33 to 34 weeks', 1.3 (1.1-1.4) for 35 to 36
weeks', and 1.1 (1.1-1.2) for 37 to 38 weeks' gestation compared with
infants born at 39 to 41 weeks' gestation in the fully adjusted model.
The odds ratios for the within-mother-between-pregnancy analysis were
very similar. Low maternal education increased the effect of moderate,
but not extreme, preterm birth on the risk for ADHD.
CONCLUSIONS: Preterm and early term birth increases the
risk of ADHD by degree of immaturity. This main effect is not explained
by genetic, perinatal, or socioeconomic confounding, but socioeconomic
context modifies the risk of ADHD in moderately preterm births.
Predictors of Parent-Reported
Attention-Deficit/Hyperactivity Disorder in Children Aged 6-7 years: A
National Longitudinal Study
Sciberras, Emma; Ukoumunne, Obioha C.; Efron, Daryl.
Journal of Abnormal Child Psychology, April 12, 2011, Online Early.
This study examined the prenatal, postnatal and
demographic predictors of parent-reported
attention-deficit/hyperactivity disorder (ADHD) in an Australian
population-based sample. Participants were families participating in the
Longitudinal Study of Australian Children. There were approximately even
numbers of males (51%) and females (49%) in the sample. Predictors of
parent-reported ADHD status at Wave 2 (children aged 6-7 years) which
were measured at Wave 1 (children aged 4-5 years) included cigarette
smoking and alcohol use during pregnancy (prenatal factors); maternal
postnatal depression, intensive care at birth, birth weight, and
gestation (postnatal factors); and child gender, primary caregiver
education, income, family composition, and maternal age at childbirth
(socio-demographic factors). We found that male gender, cigarette
smoking during pregnancy, and maternal postnatal depression were the
only significant predictors (at the 5% level) of ADHD in the adjusted
analysis (N=3,474). Our results are consistent with previous findings
that male gender and cigarette smoking during pregnancy are risk factors
for ADHD. In addition, we found that postnatal depression was predictive
of parent-reported ADHD.
The impact of study design and diagnostic
approach in a large multi-centre ADHD study: Part 2: Dimensional
measures of psychopathology and intelligence
Muller, Ueli C.; Asherson, Philip; Banaschewski, Tobias; Buitelaar, Jan
K.; et al.
BMC Psychiatry, April 7, 2011, v11 n1:55
BACKGROUND: The International Multi-centre ADHD Genetics
(IMAGE) project with 11 participating centres from 7 European countries
and Israel has collected a large behavioural and genetic database for
present and future research. Behavioural data were collected from 1068
probands with ADHD and 1446 unselected siblings. The aim was to describe
and analyse questionnaire data and IQ measures from all probands and
siblings. In particular, to investigate the influence of age, gender,
family status (proband vs. sibling), informant, and centres on sample
homogeneity in psychopathological measures.
METHODS: Conners' Questionnaires, Strengths and
Difficulties Questionnaires, and Wechsler Intelligence Scores were used
to describe the phenotype of the sample. Data were analysed by use of
robust statistical multi-way procedures.
RESULTS: Besides main effects of age, gender,
informant, and centre, there were considerable interaction effects on
questionnaire data. The larger differences between probands and siblings
at home than at school may reflect contrast effects in the parents.
Furthermore, there were marked gender by status effects on the ADHD
symptom ratings with girls scoring one standard deviation higher than
boys in the proband sample but lower than boys in the siblings sample.
The multi-centre design is another important source of heterogeneity,
particularly in the interaction with the family status. To a large
extent the centres differed from each other with regard to differences
between proband and sibling scores.
CONCLUSIONS: When ADHD probands are diagnosed by use of
fixed symptom counts, the severity of the disorder in the proband sample
may markedly differ between boys and girls and across age, particularly
in samples with a large age range. A multi-centre design carries the
risk of considerable phenotypic differences between centres and,
consequently, of 4 additional heterogeneity of the sample even if
standardized diagnostic procedures are used. These possible sources of
variance should be counteracted in genetic analyses either by using age
and gender adjusted diagnostic procedures and regional normative data or
by adjusting for design artefacts by use of covariate statistics, by
eliminating outliers, or by other methods suitable for reducing
Relation Between Outcomes on a Continuous
Performance Test and ADHD Symptoms Over Time
Vaughn, Aaron J.; Epstein, Jeffery N.; Rausch, Joseph; Altaye, Mekibib;
Journal of Abnormal Child Psychology, April 8, 2011, Online
This study examined the relationship between the
developmental trajectories of neuropsychological functioning and ADHD
symptomatology in a longitudinal sample of children ages 9 to 14.
Participants and measures were derived from the Multimodal Treatment
Study for ADHD including 534 MTA participants and 254 normal controls.
Despite improvement over time, MTA participants continued to receive
higher ratings of ADHD symptomatology and exhibit greater difficulties
across the majority of neuropsychological outcomes. No relations were
found between improvements in neuropsychological functioning and ADHD
symptomatology over time. Findings provide support for the persistence
of neuropsychological functioning and ADHD symptomatology. Findings did
not support the hypothesized relation between improvements in
frontally-mediated neuropsychological functioning and ADHD
symptomatology possibly due to the brief 1-year lag and limited
assessment battery. Findings are discussed in relation to
neuropsychological development including recommendations for future
Medication Costs to Private Insurers of
Diversion of Medications for Attention-Deficit Hyperactivity
Aldridge, Arnie P.; Kroutil, Larry A.; Cowell, Alexander J.; Reeves,
Daniel B.; Van Brunt, David L.
PharmacoEconomics, April 7, 2011, Online
BACKGROUND: The diversion of prescription stimulants
for misuse, particularly those used in the treatment of
attention-deficit hyperactivity disorder (ADHD), is potentially a
significant problem for public health and for healthcare funding and
delivery. Most prior research on the diversion of prescription
stimulants for misuse, particularly those used in the treatment of ADHD,
has focused on the 'end users' of diverted medications rather than the
suppliers. Furthermore, little is known about the direct costs of
diversion for third-party insurance payers in the US. OBJECTIVES: The
objectives of this study were to estimate the prevalence in the US of
people whose private insurance paid costs for ADHD prescriptions that
they gave or sold to another person (diversion), and to estimate
medication costs of diversion to private insurers.
METHODS: Estimates are from a cross-sectional survey of
respondents from two Internet survey panels targeting individuals aged
18-49 years in the civilian, noninstitutionalized US population,
principally for those who filled prescriptions for ADHD medications in
the past 30 days that were covered by private health insurance. Analysis
weights were post-stratified to control totals from the Current
Population Survey and National Health Interview Survey. Weighted
prevalence rates and standard errors for diversion are reported, as are
the costs of diverted pills using drug prices reported in the 2008
Thomson Reuters RED BOOK?. Sensitivity analyses were conducted that
varied the cost assumptions for medications.
RESULTS: Among individuals aged 18-49 years whose
private insurance paid some costs for ADHD medications in the past 30
days, 16.6% diverted medications from these prescriptions. Men aged
18-49 years for whom private insurance paid some costs of ADHD drugs in
the past 30 days were more than twice as likely as their female
counterparts to divert medications from these prescriptions (22.5% vs
9.1%; p?=?0.03). After a pro-rated co-payment share was subtracted,the
estimated value of diverted medications in a 30-day period was $US8.0
million. Lower- and upper-bound estimates were $US 6.9 million to $US17
million, for a range of $US83 million to $US204 million annually.
Overall, diversion accounted for about 3.6% of the total costs that
private insurers paid for ADHD medications (range: 3.5-4.5%). The
percentages varied by medication category, although relative differences
were sensitive to inclusion of a pro-rated co-payment. A higher
percentage of the costs of extended-release (XR) medications was lost to
diversion compared with that for immediate-release (IR) medications.
CONCLUSIONS: Costs of ADHD medications paid for by
private insurers that were lost to diversion were small relative to the
total estimated medication costs and relative to total estimated
healthcare costs for treating ADHD. Nevertheless, there may be
significant cost savings for insurers if diversion can be reduced,
particularly for XR medications. These findings represent a first step
to informing policies to reduce diversion both in the interest of public
health and for direct and indirect cost savings to insurers.
Psychomotor Functioning and Alertness with
Guanfacine Extended Release in Subjects with
Kollins, Scott H.; López, Frank A.; Vince, Bradley D.; Turnbow,
John M.; et al.
Journal of Child and Adolescent Psychopharmacology, April 2011,
v21 n2, pp. 111-120.
OBJECTIVES: To determine whether treatment with
guanfacine extended release (GXR) in subjects with
attention-deficit/hyperactivity disorder (ADHD) disrupted psychomotor
functioning and alertness, or impacted daytime sleepiness.
METHOD: This was a randomized, double-blind,
placebo-controlled, multicenter, phase 2, dose-optimization,
noninferiority, laboratory classroom study of GXR (1, 2, and 3mg/day) in
182 subjects aged 6 to 17 years with ADHD. Psychomotor functioning and
alertness were assessed through several measures, including the Choice
Reaction Time (CRT) test from the Cambridge Neuropsychological Test
Automated Battery. Sedative effects were examined via spontaneously
reported adverse events of sedation, somnolence, and hypersomnia as well
as fatigue and lethargy, and with two validated subject- and
observer-rated sleepiness scales. Standard efficacy measures for ADHD
also were included. Cardiovascular and laboratory parameters were
RESULTS: There were no significant differences between
the GXR and placebo groups on measures of psychomotor functioning or
alertness from the CRT at endpoint (least-square mean difference: 2.5
[95% confidence interval (CI): -22.9, 28.0], p=0.8 for CRT; 2.5 [95% CI:
-21.5, 26.4], p=0.84 for correct responses; 15.5 [95% CI: -45.1, 14.1],
p=0.30 for movement time; and -8.2 [95% CI: -54.1, 37.6] p=0.72 for
total time). Most sedative adverse events were mild to moderate,
occurred during dose titration, decreased with dose maintenance, and
resolved during the study period. One subject in the GXR group
discontinued due to fatigue and somnolence. GXR was not associated with
increased daytime sleepiness. GXR treatment was associated with
significant improvement in ADHD symptoms (6.3 [95% CI: 2.7, 9.8],
p=0.001 for ADHD Rating Scale IV total scores at endpoint).
CONCLUSIONS: At doses that resulted in significant
improvement in ADHD symptoms, impairment on cognitive tasks was not
observed. Daytime sleepiness did not differ with GXR compared with
placebo. Results suggest that the beneficial effects of GXR on
ADHD symptoms are independent of sedation.
Scales for the identification of adults
with attention deficit hyperactivity disorder (ADHD): A systematic
Taylor, Abigail; Deb, Shoumitro; Unwin, Gemma.
Research Developmental Disabilities, May-June 2011, v32 n3, pp.
Attention deficit hyperactivity disorder (ADHD) is
prevalent in the adult population. The associated co-morbidities and
impairments can be relieved with treatment. Therefore, several rating
scales have been developed to identify adults with ADHD who may benefit
from treatment. No systematic review has yet sought to evaluate these
scales in more detail. The present systematic review was undertaken to
describe the properties, including psychometric statistics, of the
currently available adult ADHD rating scales and their scoring methods,
along with the procedure for development. Descriptive synthesis of the
data is presented and study quality has been assessed by an objective
quality assessment tool. The properties of each scale are discussed to
make judgements about their validity and usefulness. The literature
search retrieved 35 validation studies of adult ADHD rating scales and
14 separate scales were identified. The majority of studies were of poor
quality and reported insufficient detail. Of the 14 scales, the Conners'
Adult ADHD Rating scale and the Wender Utah Rating Scale (short version)
had more robust psychometric statistics and content validity. More
research into these scales, with good quality studies, is needed to
confirm the findings of this review. Future studies of ADHD rating
scales should be reported in more detail so that further reviews have
more support for their findings.;
Research highlights; ► A variety of scales are available for
identifying ADHD in adults. ► Psychometric properties vary across
studies and across scales. ► The CAARS and WURS currently have the
most evidence to support their use. ► Further research is needed
that assesses measurement properties of such scales.
Parental and Professional Beliefs on the
Treatment and Management of ADHD
Dryer, Rachel; Kiernan, Michael J.; Tyson, Graham A.
Journal of Attention Disorders, April 13, 2011, Online
OBJECTIVE: This study examined parental and professional
beliefs about the efficacy of various treatment strategies for ADHD.
METHOD: Parents of children with and without ADHD and
seven medical and nonmedical professional groups(N = 673) completed a
questionnaire examining their beliefs about the efficacy of various
RESULTS: Principle component analysis identified four
factors--school-based interventions, medical and allied health
interventions, parent interventions, and nontraditional interventions.
Although there were some group differences in the level of endorsement
for these factors, there was a high degree of concordance between the
groups. The school-based interventions factor was the most highly
endorsed, whereas the nontraditional interventions factor was the least
endorsed by the sample as a whole.
CONCLUSION: The results suggest that the low level of
interdisciplinary interaction that has been reported in the literature
is not due to differences in beliefs about the efficacy of various
treatment strategies for ADHD.
PAH/Aromatic DNA Adducts in Cord Blood and
Behavior Scores in New York City Children
Perera, Frederica P.; Wang, Shuang; Vishnevetsky, Julia; Zhang,
Bingzhi; et al.
Environmental Health Perspectives, April 12, 2011, Online
BACKGROUND: Airborne polycyclic aromatic hydrocarbons
(PAH) are widespread urban pollutants that can bind to DNA to form
PAH-DNA adducts. Prenatal PAH exposure measured by personal monitoring
has been linked to cognitive deficits in childhood in a prospective
study conducted by the Columbia Center for Children’s
Environmental Health (CCCEH). OBJECTIVES: We measured PAH-DNA and other
bulky aromatic adducts in umbilical cord white blood cells using the
32P-postlabeling assay to determine the association between this
molecular dosimeter and behavioral/attention problems in childhood.
METHODS: Children born to nonsmoking African-American
and Dominican women residing in New York City (NYC) were followed from
in utero to 7-8 years of age. At two time points prior to age 8 (mean
ages 4.8 years and 7 years), child behavior was assessed using the Child
Behavior Checklist (CBCL). To estimate and test the association between
adducts and behavioral outcomes, both CBCL continuous raw scores and
dichotomized T-scores were analyzed.
RESULTS: Higher cord adducts were associated with
higher symptom scores of Anxious/Depressed at 4.8 years and Attention
Problems at 4.8 and 7 years, and with Diagnostic and Statistical Manual
of Mental Disorders (DSM) oriented Anxiety Problems at the 4.8
CONCLUSIONS: These results suggest that PAH exposure,
measured by DNA adducts, may adversely affect child behavior,
potentially affecting school performance.
A Double-Blind, Placebo-Controlled Study
of Atomoxetine in Young Children With ADHD
Kratochvil, Christopher J.; Vaughan, Brigette S.; Stoner, Julie A.;
Daughton, Joan M.; et al.
Pediatrics, April 2011, v127 n4, pp. e862-e868 [March 21, 2011,
OBJECTIVE: To evaluate the efficacy and tolerability of
atomoxetine for the treatment of attention-deficit/hyperactivity
disorder (ADHD) in 5- and 6-year-old children.
METHODS: This was an 8-week, double-blind,
placebo-controlled randomized clinical trial of atomoxetine in 101
children with ADHD. Atomoxetine or placebo was flexibly titrated to a
maximum dose of 1.8 mg/kg per day. The pharmacotherapist reviewed
psychoeducational material on ADHD and behavioral-management strategies
with parents during each study visit.
RESULTS: Significant mean decreases in parent (P =
.009) and teacher (P = .02) ADHD-IV Rating Scale scores were
demonstrated with atomoxetine compared with placebo. A total of 40% of
children treated with atomoxetine met response criteria (Clinical Global
Impression-Improvement Scale indicating much or very much improved)
compared with 22% of children on placebo, which was not significant (P =
.1). Decreased appetite, gastrointestinal upset, and sedation were
significantly more common with atomoxetine than placebo. Although some
children demonstrated a robust response to atomoxetine, for others the
response was more attenuated. Sixty-two percent of subjects who received
atomoxetine were moderately, markedly, or severely ill according to the
Clinical Global Impression-Severity Scale at study completion.
CONCLUSIONS: To our knowledge, this is the first
randomized controlled trial of atomoxetine in children as young as 5
years. Atomoxetine generally was well tolerated and reduced core ADHD
symptoms in the children on the basis of parent and teacher reports.
Reductions in the ADHD-IV Rating Scale scores, however, did not
necessarily translate to overall clinical and functional improvement, as
demonstrated on the Clinical Global Impression-Severity Scale and the
Clinical Global Impression-Improvement Scale. Despite benefits, the
children in the atomoxetine group remained, on average, significantly
impaired at the end of the study.
Detection of Response Bias and Noncredible
Performance in Adult Attention-Deficit/Hyperactivity Disorder
Young, J. Christopher; Gross, Alan M.
Archives of Clinical Neuropsychology, March 25, 2011, Online
Adults with attention-deficit/hyperactivity disorder
(ADHD) are frequently prescribed stimulant medication and eligible for
accommodations at work or school that serve as potent incentives to
feign ADHD symptoms. The current investigation examined the predictive
validity of Minnesota Multiphasic Personality Inventory-2 (MMPI-2)
validity scales in detecting and accurately classifying individuals
attempting to feign ADHD. An archival ADHD clinical group (n = 34),
normal control group (n = 37), and group instructed to feign ADHD
symptoms (n = 32) completed the MMPI-2 and ADHD Current and Childhood
Symptoms Scales. Behavior rating scales were unable to differentiate the
clinical group from the simulated malingering group. Logistic
regressions revealed that Infrequency-Psychopathology scale best
detected response bias, followed by Infrequency scale, Back-Infrequency
scale, Response Bias Scale (RBS), Henry-Heilbronner Index scale (HHI),
and Fake Bad Scale (FBS). Results also indicate that recommended cutoffs
for HHI, RBS, and FBS display inadequate sensitivity and specificity.
Nevertheless, the MMPI-2 offers a number of validity indices that may
assist in detecting individuals attempting to feign ADHD.
Developmental trajectories of DSM-IV
symptoms of attention-deficit/hyperactivity disorder: genetic effects,
family risk and associated psychopathology
Larsson, Henrik; Dilshad, Rezin; Lichtenstein, Paul; Barker, Edward
Journal of Child Psychology and Psychiatry, March 16, 2011,
BACKGROUND: DSM-IV specifies three ADHD subtypes; the
combined, the hyperactive-impulsive and the inattentive. Little is known
about the developmental relationships underlying these subtypes. The
objective of this study was to describe the development of
parent-reported hyperactivity-impulsivity and inattention symptoms from
childhood to adolescence and to study their associations with genetic
factors, family risk, and later adjustment problems in early
METHOD: Data in this study comes from 1,450 twin pairs
participating in a population-based, longitudinal twin study.
Developmental trajectories were defined using parent-ratings of
hyperactivity-impulsivity and inattention symptoms at age 8-9, 13-14,
and 16-17. Twin methods were used to explore genetic influences on
trajectories. Family risk measures included low socioeconomic status,
large family size and divorce. Self-ratings of externalizing and
internalizing problems in early adulthood were used to examine
adjustment problems related to the different trajectory
RESULTS: We found two hyperactivity-impulsivity
trajectories (low, high/decreasing) and two inattention trajectories
(low, high/increasing). Twin modeling revealed a substantial genetic
component underlying both the hyperactivity-impulsivity and the
inattention trajectory. Joint trajectory analyses identified four groups
of adolescents with distinct developmental patterns of
hyperactivity-impulsivity and inattention: a low/low group, a primarily
hyperactive, a primarily inattentive and a combined (high/high)
trajectory type. These trajectory combinations showed discriminant
relations to adjustment problems in early adulthood. The hyperactive,
inattentive and combined trajectory subtypes were associated with higher
rates of family risk environments compared to the low/low group.
CONCLUSION: Study results showed that for those on a
high trajectory, hyperactivity decreased whereas inattention increased.
The combinations of these trajectories lend developmental insight into
how children shift from (i) a combined to inattentive subtype, and (ii)
a hyperactive-impulsive to a combined subtype. This study suggests that
ADHD subtypes cannot be viewed as discrete and stable categories.