Psychological heterogeneity in AD/HD--a dual pathway model of behaviour and cognition

Executive functions and adaptive functioning in young adult attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is associated with impairments in occupational, social, and educational functioning in adults. This study examined relations of adaptive impairment to ADHD symptom domains (inattentive-disorganized and hyperactive-impulsive) and to deficits in executive functioning (EF) in 195 well-characterized adults (105 ADHD, 90 non-ADHD, between ages 18 and 37). Participants completed a battery of EF measures as well as assessments of adaptive functioning. Confirmatory factor analyses were used to validate latent factors for adaptive functioning and EF. In a measurement model, weaker EF was associated with poorer adaptive functioning (r = -.30). When multi-informant composite variables for current inattentive-disorganized and hyperactive-impulsive ADHD symptoms were included in the structural model, EF no longer predicted adaptive functioning. While both symptom composites were similarly related to EF (inattentive-disorganized r = .36; hyperactive-impulsive r = .29), inattentive-disorganized symptoms accounted for more variance in adaptive functioning (67.2% vs. 3.6%). Furthermore, for retrospectively reported childhood symptoms of ADHD, only the inattentive-disorganized symptom domain was related to EF or adaptive impairment. These results suggest that, in adults with ADHD, inattentive-disorganized symptoms may be the primary contributor to key aspects of poorer adaptive function and may be the behavioral path through which EF deficits lead to adaptive impairment.

Ventral striatal hyporesponsiveness during reward anticipation in attention-deficit/hyperactivity disorder

BACKGROUND

Although abnormalities in reward processing have been proposed to underlie attention-deficit/hyperactivity disorder (ADHD), this link has not been tested explicitly with neural probes.

METHODS

This hypothesis was tested by using fMRI to compare neural activity within the striatum in individuals with ADHD and healthy controls during a reward-anticipation task that has been shown previously to produce reliable increases in ventral striatum activity in healthy adults and healthy adolescents. Eleven adolescents with ADHD (5 off medication and 6 medication-naïve) and 11 healthy controls (ages 12-17 y) were included. Groups were matched for age, gender, and intelligence quotient.

RESULTS

We found reduced ventral striatal activation in adolescents with ADHD during reward anticipation, relative to healthy controls. Moreover, ventral striatal activation was negatively correlated with parent-rated hyperactive/impulsive symptoms across the entire sample.

CONCLUSIONS

These findings provide neural evidence that symptoms of ADHD, and impulsivity or hyperactivity in particular, may involve diminished reward anticipation, in addition to commonly observed executive dysfunction.

Neuropsychological functioning of girls with attention-deficit/hyperactivity disorder followed prospectively into adolescence: evidence for continuing deficits?

The current study prospectively followed girls with attention-deficit/hyperactivity disorder (ADHD), along with a matched comparison sample, 5 years after childhood neuropsychological assessments. Follow-up neuropsychological measures emphasized attentional skills, executive functions, and language abilities. Paralleling childhood findings, the childhood-diagnosed ADHD group displayed moderate to large deficits in executive/attentional performance as well as in rapid naming relative to the comparison group at follow up (M-sub(age) 14.2 years). ADHD-inattentive versus ADHD-combined contrasts were nonsignificant and of negligible effect size, even when a refined, sluggish cognitive tempo subgroup of the inattentive type was examined. Although ADHD versus comparison group differences largely withstood statistical control of baseline demographics and comorbidities, control of childhood IQ reduced executive function differences to nonsignificance. Yet when the subset of girls meeting diagnostic criteria for ADHD in adolescence was compared with the remainder of the participants, neuropsychological deficits emerged even with full statistical control. Overall, childhood ADHD in girls portends neuropsychological and executive deficits that persist for at least 5 years.

Attention deficit/hyperactivity disorder (ADHD) symptoms and digit ratios in a college sample

Diagnosticians recognize three subtypes of attention deficit/hyperactivity disorder (ADHD) if there are developmentally inappropriate levels (six or more symptoms) of Hyperactive-Impulsive behavior, or Inattentive behavior, or both (Combined), respectively. ADHD may partly reflect androgen dysfunction, and an arguable proxy for prenatal androgen exposure is the 2D:4D finger ratio set at least as early as week 9 in the fetus; this is lower in men than in women. We examined the relationship between digit ratios and ADHD symptoms representing the three phenotypes: ADHD/Combined as measured by "summarized" (Rasched) scales, i.e., 1) the short version of the Wender Utah Rating Scale (WURS) and a total symptom list derived from the DSM IV, and the subdivided DSM IV into 2) ADHD/Inattentive and 3) ADHD/Hyperactive-Impulsive inventories, in a sample of European-descent college students (135 female, 52 male) not selected for ADHD. All digit ratios were calculated excluding the thumb. There were significant sex differences for the 2D:4D digit ratios of both hands (RH and LH), and between the RH 3D:4D and between the LH 2D:3D ratio. In females, the more masculine the LH 2D:4D ratio, the more the ADHD/Combined symptoms (both WURS and DSM) and the more the ADHD/Inattentive symptoms and ADHD/Hyperactive-Impulsive symptoms. More masculine ratios also correlated between the total WURS and RH 2D:3D, RH 2D:4D, and LH 2D:3D; and between the inattentive DSM symptoms and LH 2D:5D, and between the ADHD/Hyperactive and Impulsive symptoms and RH 3D:4D.

Brain dopamine transporter levels in treatment and drug naïve adults with ADHD

Attention deficit hyperactivity disorder (ADHD) is the most frequent psychiatric disorder in children, yet data are sparse on its pathophysiology. Particularly relevant are the dopamine transporters since these are the main targets of stimulant medications used for ADHD treatment. Though some imaging studies have shown increases in dopamine transporters in ADHD others have not and their role in the neurobiology of ADHD remains unclear. Here we investigate dopamine transporters in ADHD subjects with control of potentially confounding factors (previous medication and/or drug histories, comorbidity) and their association with clinical symptoms. Positron emission tomography and [11C]cocaine were used to measure dopamine transporters in 20 never medicated adults with ADHD and 25 controls. Dopamine transporters were lower in left caudate (13%, p < 0.05) and in left nucleus accumbens (p < 0.005) in ADHD subjects than in controls. In putamen dopamine transporters did not differ between groups but were associated with scores of inattention (Conners Adult Attention Rating Scale) both in ADHD subjects (p < 0.005) and in controls (p < 0.005). Thus, for a given transporter level the scores for inattention were on average five times greater in ADHD subjects than in controls. These results do not corroborate increases in dopamine transporters in ADHD subjects and show that in some they are reduced. It also provides evidence that dopamine transporter levels modulate attention but suggest that additional pathology (e.g., prefrontal or cingulostriatal pathways, noradrenergic neurotransmission) is necessary to account for the large differences in inattention observed between controls and ADHD subjects.

Parent-of-origin effects in attention-deficit hyperactivity disorder

The goal of the present study was to investigate parent-of-origin effects in attention-deficit hyperactivity disorder (ADHD). Parent-of-origin effects in ADHD may be due to differences in the relative quantity of risk factors transmitted by each parent. Alternatively, parent-of-origin effects may be produced by qualitative differences in the risks transmitted, such as those carried on the sex chromosomes or regulated by genomic imprinting. 60 children with maternal-only history of ADHD and 131 children with paternal-only history of ADHD were compared on three domains for which prior evidence suggested parent-of-origin effects may exist: core symptoms, disruptive behaviours and depression. Dependent variables were derived from previously validated, age-appropriate and standardized parent and teacher interviews and questionnaires. Depression levels were rated using the Child Depression Inventory. Consistent with previous research and the predictions derived from threshold models of ADHD etiology, the maternal history group received higher ratings of behavioural disorder (ADHD, conduct disorder and oppositional symptoms) than the paternal history group. Parent-of-origin effects were also observed for depression, with the paternal history group rating themselves as significantly more depressed than children in the maternal history group, particularly girls. Heightened paternal transmission relative to maternal is suggestive of genomic imprinting, and the interaction with proband sex indicates the involvement of the sex chromosomes or sex-specific physiological or hormonal factors. Interpretations of these data in terms of environmental and genetic factors, including epigenetic and sex-linked hypotheses, are explored.

Co-ocorrência entre transtorno de déficit de atenção/hiperatividade e uso de substâncias psicoativas

Existe forte associação entre o transtorno de déficit de atenção/hiperatividade (TDAH) e o transtorno por uso de substâncias psicoativas (TUSP) em estudos clínicos e comunitários. Estimam-se que aproximadamente 30% dos sujeitos com TUSP apresentem comorbidade com o TDAH, taxa significativamente maior do que a vista na população geral. Vários estudos vêm analisando o possível efeito do TDAH no risco de desenvolvimento de TUSP. O presente artigo revisa a literatura disponível às seguintes questões: a) natureza da associação entre o TDAH e o TUSP; b) efeitos do TDAH no TUSP; c) tratamento do TDAH na concomitância do diagnóstico de TUSP. Por fim, é oferecida uma integração das diferentes informações, sob um enfoque predominantemente clínico.

Evidence-based guidelines for management of attention-deficit/hyperactivity disorder in adolescents in transition to adult services and in adults: recommendations from the British Association for Psychopharmacology

Attention-deficit/hyperactivity disorder (ADHD) is an established diagnosis in children, associated with a large body of evidence on the benefits of treatment. Adolescents with ADHD are now leaving children's services often with no readily identifiable adult service to support them, which presents problems as local pharmacy regulations often preclude the prescription of stimulant drugs by general practitioners (GPs). In addition, adults with ADHD symptoms are now starting to present to primary care and psychiatry services requesting assessment and treatment. For these reasons, the British Association for Psychopharmacology (BAP) thought it timely to hold a consensus conference to review the body of evidence on childhood ADHD and the growing literature on ADHD in older age groups. Much of this initial guidance on managing ADHD in adolescents in transition and in adults is based on expert opinion derived from childhood evidence. We hope that, by the time these guidelines are updated, much evidence will be available to address the many directions for future research that are detailed here.

ADHD and delay aversion: the influence of non-temporal stimulation on choice for delayed rewards

BACKGROUND

Delay aversion, the motivation to escape or avoid delay, results in preference for small immediate over large delayed rewards. Delay aversion has been proposed as one distinctive psychological process that may underlie the behavioural symptoms and cognitive deficits of attention deficit/hyperactivity disorder (ADHD). Furthermore, the delay aversion hypothesis predicts that ADHD children's preference for immediate small over large delayed rewards will be reduced when stimulation, which makes time appear to pass more quickly, is added to the delay interval. The current paper tests these predictions.

METHODS

A group of children with a diagnosis of ADHD (with or without oppositional defiant disorder (ODD)), a group with a diagnosis of high-functioning autism (HFA), and a normal control group were compared on an experimental paradigm giving repeated choices between small immediate and large delayed rewards (Maudsley Index of Delay Aversion-MIDA) under two conditions (stimulation and no stimulation).

RESULTS

As predicted, ADHD children displayed a stronger preference than the HFA and control children for the small immediate rewards under the no-stimulation condition. The ADHD children preferences were normalised under the stimulation condition with no differences between the groups. This pattern of results was the same whether the ADHD children had comorbid ODD or not.

DISCUSSION

The findings from the MIDA are consistent with the delay aversion hypothesis of ADHD in showing that preference for small immediate rewards over large delayed rewards is a specific feature of ADHD and that this preference can be reduced by the addition of stimulation. Further research is required to better understand the emotional and motivational mechanisms underpinning delay aversion.

State regulation in adult ADHD: an event-related potential study

The state regulation hypothesis postulates that poor task performance of children with ADHD is related to poor energetical state control. The current study aimed to investigate whether such a deficit persists in adult ADHD. Event-related potentials (ERPs) were recorded during administration of a Go/No-Go task that incorporated the stressor presentation rate of stimuli. It was found that males with ADHD responded slower than control males in the slow condition, which was accompanied by smaller parietal P3s, suggesting less effort allocation. No group differences were found with respect to the response inhibition measures (errors of commission and the N2 effect). In conclusion, problems in state regulation seem to persist in male adults with ADHD.

Subtypes of attention-deficit/hyperactivity disorder (ADHD): distinct or related disorders across measurement levels?

The aim of this literature review is to assess the current state of knowledge regarding differences and similarities between the inattentive (IA) and combined (C) subtypes of Attention-Deficit/Hyperactivity Disorder (ADHD) in order to detail challenges concerning further conceptualization, diagnostics, and treatment. The literature on ADHD-IA and ADHD-C was reviewed and contrasted across genetic, neuroanatomical, neurophysiological/ neurochemical, neuro(psycho)logical, and clinical psychiatric measurement levels. It was found that the more fundamental the measurement level, the less unambiguous evidence is found for subtype differences. Only on the clinical psychiatric diagnostic level, do more or less clear-cut differences in cognitive, social, academic, and behavioural functioning emerge. In conclusion, fundamental research that compares ADHD-IA and ADHD-C is relatively rare. At this point, only irrefutable phenomenological evidence of subtype differences seems to be available, even in attention problems which are presumed to be identical. The question as to whether both subtypes should be considered as two independent disorders was not adequately resolved.

The Wuerzburg Research Initiative on Adult Attention-Deficit/Hyperactivity Disorder (WURIN-AADHD): multi-layered evaluation of long-term course

Although the neurobiological basis of the clinical entity of attention-deficit/hyperactivity disorder (ADHD) is evident, data from studies on pathomechanism-phenotype correlations are inconsistent. There are several obvious limitations of the DSM-IV diagnostic criteria to describe an adequate phenotype of adult ADHD. A dimensional model of neurobiologically based endophenotypes is therefore more likely to be compatible with the genetic model of quantitative trait loci. The primary goal of the Wuerzburg Research Initiative on Adult Attention-Deficit/Hyperactivity Disorder (WURIN-AADHD) is to test the validity of two endophenotypes, deficit in response inhibition and impairment of working memory, using various psychometric and neurobiological strategies of investigation in adult patients with ADHD. An additional objective is the investigation of the long-term course of adult ADHD. The conclusive description of valid endophenotypes of ADHD is an ongoing process that may result in a comprehensive neurobiological model for ADHD or its symptom dimensions integrating genetic, neural, cognitive, and behavioral mechanisms. This model will eventually facilitate description of complete causal connections occurring across the lifespan from early development to adulthood and is also likely to accelerate development of more specific and efficient therapeutic strategies in adult ADHD.

The adult psychiatrist's dilemma: psychostimulant use in attention deficit/hyperactivity disorder

Children who have taken psychostimulants long term for attention deficit/hyperactivity disorder (ADHD) are now presenting at adult psychiatry clinics at an age at which bipolar disorder and schizophrenia may first appear and at which pregnancy is a possibility. Doctors who may have little experience in the management of ADHD or use of psychostimulants are faced with decisions on whether to continue or withdraw medication. A literature search conducted to clarify these issues revealed that, although psychostimulants are generally efficacious in ADHD, the risks of withdrawal reactions and of possible long-term effects such as drug addiction, psychosis and depression, or effects in pregnancy, have not been adequately investigated. In particular, there is little information on the effects of withdrawal and no firm guidelines on methods of psychostimulant discontinuation. There is a need for further research to clarify the pharmacological issues involved in the drug treatment of ADHD and for overlapping arrangements between child and adult psychiatry clinics in the management of ADHD.

Neural systems implicated in delayed and probabilistic reinforcement

This review considers the theoretical problems facing agents that must learn and choose on the basis of reward or reinforcement that is uncertain or delayed, in implicit or procedural (stimulus-response) representational systems and in explicit or declarative (action-outcome-value) representational systems. Individual differences in sensitivity to delays and uncertainty may contribute to impulsivity and risk taking. Learning and choice with delayed and uncertain reinforcement are related but in some cases dissociable processes. The contributions to delay and uncertainty discounting of neuromodulators including serotonin, dopamine, and noradrenaline, and of specific neural structures including the nucleus accumbens core, nucleus accumbens shell, orbitofrontal cortex, basolateral amygdala, anterior cingulate cortex, medial prefrontal (prelimbic/infralimbic) cortex, insula, subthalamic nucleus, and hippocampus are examined.

Revisiting the role of the prefrontal cortex in the pathophysiology of attention-deficit/hyperactivity disorder

Most neural models for the pathophysiology of attention-deficit/hyperactivity disorder (ADHD) have centered on the prefrontal cortex and its interconnections with the striatum and other subcortical structures. However, research only partially supports these models, and they do not correspond with the development of the prefrontal cortex and its interrelated neurocircuitry. The neural and functional development of the prefrontal cortex more closely parallels recovery from ADHD as indicated by the developmental remission of symptomatology. The authors hypothesize that ADHD is due to noncortical dysfunction that manifests early in ontogeny, remains static throughout the lifetime, and is not associated with the remission of symptomatology. Data supporting this neurodevelopmental model of prefrontal cortex function in ADHD are reviewed. Research and treatment implications are discussed.

Associations among overeating, overweight, and attention deficit/hyperactivity disorder: a structural equation modelling approach

BACKGROUND

Some recent studies have reported strong links between obesity and ADHD in adults; however, to date, little work has focussed on possible behavioural mechanisms that could account for this association.

METHOD

This study used structural equation modelling (SEM) in a sample of healthy adult women to test the predictions that ADHD symptoms predict aspects of overeating, including binge eating and emotionally-induced eating, which in turn are positively correlated with Body Mass Index.

RESULTS

The SEM produced a non-significant chi-square and both the measurement model and the structural model fit the data very well.

CONCLUSIONS

Plausible mechanisms are discussed to help explain how the symptomatology of ADHD could foster different forms of overeating.

Behavioral models of impulsivity in relation to ADHD: translation between clinical and preclinical studies

Impulsivity, broadly defined as action without foresight, is a component of numerous psychiatric illnesses including attention deficit/hyperactivity disorder (ADHD), mania and substance abuse. In order to investigate the mechanisms underpinning impulsive behavior, the nature of impulsivity itself needs to be defined in operational terms that can be used as the basis for empirical investigation. Due to the range of behaviors that the term impulsivity describes, it has been suggested that impulsivity is not a unitary construct, but encompasses a variety of related phenomena that may differ in their biological basis. Through fractionating impulsivity into these component parts, it has proved possible to devise different behavioral paradigms to measure various aspects of impulsivity in both humans and laboratory animals. This review describes and evaluates some of the current behavioral models of impulsivity developed for use with rodents based on human neuropsychological tests, focusing on the five-choice serial reaction time task, the stop-signal reaction time task and delay-discounting paradigms. Furthermore, the contributions made by preclinical studies using such methodology to improve our understanding of the neural and neurochemical basis of impulsivity and ADHD are discussed, with particular reference to the involvement of both the serotonergic and dopaminergic systems, and frontostriatal circuitry.

The effects of continuous and partial reward on the vigilance task performance of adults with attentional deficits: a pilot investigation

The effects of reward schedule (100% and 30%) and extinction on attention (reaction time to auditory stimuli) and frustration levels (pressure exerted on a response key) of 15 adults with attentional disorders and 21 normal adults were examined using a continuous performance task. We predicted, that adults with attentional deficits would (a) perform similar to comparisons when rewarded on a continuous schedule, (b) exhibit higher levels of frustration when that continuous schedule was moved to an extinction schedule, and (c) experience more frustration than comparisons when rewarded on a partial schedule. Overall, adults with attentional deficits were slower to respond and their responses were more variable than typical comparisons across trials, similar to what is observed for children. Continuous reward resulted in poorer performance earlier in the reward phase and continued throughout an extinction phase. The frustration levels of adults with attentional deficits did not differ from comparisons across schedule conditions. Results are discussed in terms of the role of arousal in mediating responding to various schedules of reward.

An integrative theory of attention-deficit/ hyperactivity disorder based on the cognitive and affective neurosciences

Attention-deficit/hyperactivity disorder (ADHD) is a behavioral syndrome that arises in early childhood, often co-occurs with conduct disorder and leads, developmentally, to antisocial behavior and substance abuse. Models from cognitive and affective neuroscience have been invoked in an effort to understand the development of ADHD, leading to a broad array of interrelated theories and hypothesized mechanisms. In this paper, we highlight core mechanisms that may cut across several theories and constructs, and thus provide some leverage for further study and conceptualization from a neuroscience perspective. We emphasize the joint operations of frontostriatal and frontocerebellar neural loops in detecting and predicting what and when important events in the environment will occur and their interaction with frontoamygdala loops in assigning emotional significance to these events. We note that weaknesses in the development of these basic operations could lead to decrement in the development of cognitive and affective control and other mental operations mediated by prefrontal cortex during development. In turn, such decrement could lead to many of the phenotypic cognitive and neuropsychological features seen in children with ADHD.

Diazepam impairs behavioral inhibition but not delay discounting or risk taking in healthy adults

There are reports that diazepam can increase, decrease, or have no effect on measures of impulsive behavior, which may be related, in part, to differences among the tasks used to measure impulsivity. This study examined the effects of a relatively high dose of diazepam (20 mg) on 5 measures of impulsive behavior in healthy adult men and women. Volunteers (N = 18) participated in a 2-session double-blind randomized design in which they received 20 mg diazepam or placebo. One hour after ingesting the capsule, participants completed mood questionnaires and several impulsivity tasks to measure subtypes of impulsive behavior, including behavioral inhibition, delay and probability discounting, and risk taking. Diazepam impaired behavioral inhibition but had no effect on measures of discounting or risk taking. These results are discussed in the context of other recent findings suggesting that different behavioral indices of impulsivity are dissociable and governed by separate underlying mechanisms.

Decision making in children with ADHD only, ADHD-anxious/depressed, and control children using a child version of the Iowa Gambling Task

OBJECTIVE

The goal of this study is to investigate decision making in children with ADHD using a child version of the Iowa Gambling Task (IGT). The effect of internalizing symptoms is also of interest.

METHOD

Twenty-one children with ADHD (high anxiety/depression and no anxiety/depression) are compared to an age- and sex-matched control group on the gambling task. Children in the ADHD-alone group demonstrate impaired performance on the IGT. In contrast, children in the control group and the ADHD-anxiety/depression group learn to choose more from the advantageous decks over time.

RESULTS

These findings of impaired decision making in children with ADHD parallel findings of real-life decision-making problems in this population.

CONCLUSION

Furthermore, the findings suggest that having a high number of internalizing symptoms leads to better performance for children with ADHD on this variant of the IGT.

Trastorno por déficit de atención con hiperactividad y alteraciones del sueño

The attention deficit hyperactivity disorder (ADHD) is an heterogeneous, complex and common childhood disorder that causes significant impairment of child's functioning. This paper reviews the epidemiology, etiology, diagnosis, comorbidity, course and treatment of ADHD. Special attention is paid to sleep problems both because these 2 conditions frequently co-exist and because there is substantial evidence that ADHD psychopathology and sleep-wake regulation share common neurobiologic mechanisms. Moreover, there could be an overlap between symptoms of ADHD and certain sleep problems such as obstructive sleep apnea syndrome, restless leg syndrome and periodic limb movements of sleep. Children undergoing evaluation for ADHD should be systematically assessed for sleep disturbances because treatment of sleep disorders is often associated with improved symptomatology and decreased need for stimulants.

The effect of reinforcement variables on inhibition in children with ADHD

Behavioral inhibition, often cited as a central deficit in children with ADHD, has been shown to change in response to reinforcement. In this preliminary investigation, children with ADHD (n= 20) and matched controls (ages 7 to 12) completed a new version of the stop signal paradigm, the Fire Fighter Game, a measure of inhibition of a prepotent motor response, under three conditions: (1) no reinforcement; (2) immediate reinforcement; and (3) delayed reinforcement. In all conditions, the stop signal reaction time (SSRT) of children with ADHD was consistently longer than controls. Both groups improved significantly with reinforcement, and there was no strong evidence that immediate reinforcement was more effective than delayed reinforcement. However, it appeared that the reason for the changes in SSRT in response to reinforcement differed between the groups. Children in the control group responded faster on go trials, whereas children with ADHD improved their ability to inhibit responding with shorter stop delays. The relevance of these findings is discussed in terms of current theories of ADHD.

Executive functions and ADHD in adults: evidence for selective effects on ADHD symptom domains

Dual-process models of attention-deficit/hyperactivity disorder (ADHD) suggest that both executive functioning and regulatory functions (e.g., processing speed) are involved and that executive function weaknesses may be associated specifically with symptoms of inattention-disorganization but not hyperactivity-impulsivity. Adults aged 18-37 (105 with ADHD, 90 controls) completed a neuropsychological battery. The ADHD group had weaker performance than did the control group (p<.01) on both executive and speed measures. Symptoms of inattention-disorganization were uniquely related to executive functioning with hyperactivity-impulsivity controlled. Inattention was associated with slower response speed, and hyperactivity-impulsivity with faster output speed. Results were not accounted for by IQ, age, gender, education level, or comorbid disorders. Findings are discussed in terms of developmental and dual-process models of ADHD leading into adulthood.

Attention deficit disorders: are we barking up the wrong tree?

Attention deficit disorder (AAD) and attention deficit/hyperactivity disorder (ADHD) are very frequent and protean developmental disorders without a definite biologic marker. This review proposes a framework to understand the enlarged spectrum of its manifestations based on current knowledge of the mechanisms underlying arousal and attention variations during sleep/wake cycle. The neuro-modulation's pivotal role in this process as well as in the fine tuning of synaptic architecture during development must be taken into account when trying to understand the marked fuzziness of the symptoms and the very high prevalence of reported co-morbidities. The series of related interactions includes a cyclic deactivation of the dorso-lateral portion of the prefrontal cortex (DLPFC) during sleep, suspending executive functions, co-occurring with rhythmic periods of decreased noradrenergic tonus. A protracted unbalance in modulation, with catecholaminergic relative deficiency, could explain less-than-optimum waking DLPFC activation and the most important manifestations of ADD. Beside the well documented dopaminergic effects of stimulant medication used in ADD and ADHD, a more important role must be assigned to noradrenaline (NA). At this light hyperactivity and impulsivity are less important dimensions. Rather, an attention deficit spectrum disorder should probably be regarded as a complication of a core defect in prefrontal cortex dependent inhibitory control, underlying inattention.

Continuities and discontinuities in psychopathology between childhood and adult life

The possible mechanisms involved in continuities and discontinuities in psychopathology between childhood and adult life are considered in relation to the findings from systematic, prospective, long-term longitudinal studies. Findings on schizophrenia, neurodevelopmental disorders, emotional disturbances, antisocial behaviour and substance abuse are used as conditions illustrating the key issues. The overarching themes are then discussed in relation to heterotypic continuity and psychopathologic progression, early age at onset and a range of possible mediating mechanisms - including genetic mediation, 'kindling' effects, environmental influences, coping mechanisms and cognitive processing of experiences. Some of the key research challenges that remain concern the testing of competing hypotheses on mediating processes, the changes involved in adolescence, the transition from prodromal phase to overt schizophrenia and the emergence of adolescent-limited antisocial behaviour. Greater use needs to be made of genetic research strategies and of the testing of possible cognitive processing mediation effects.

Attention deficit hyperactivity disorder: a review of the essential facts

Abstract Attention deficit hyperactivity disorder (ADHD) is a complex disorder, where both genetic and environmental influences make a substantial contribution to the risk for the disorder. One of the challenges facing clinicians is to simplify for parents the multifaceted reasons why their child may have developed ADHD, explain the associated symptoms, and encourage parents to participate in intervention. Increasing parents understanding about ADHD should make them better informed about the disorder, more likely to consent to intervention, and increase adherence to both psychosocial and pharmacological treatment. The aim of this review is to provide clinicians with a brief synopsis of our current understanding about the aetiology of ADHD, co-morbidity and associated problems, developmental course and intervention options.

ADHD and schizophrenia phenomenology: visual scanpaths to emotional faces as a potential psychophysiological marker?

Commonalities in the clinical phenomenology and psychopharmacology of ADHD and schizophrenia are reviewed. The potential of psychostimulants to produce psychotic symptoms emphasizes the need for objective psychophysiological distinctions between these disorders. Impaired emotion perception in both disorders is discussed. It is proposed that visual scanpaths to facial expressions of emotion might prove a potentially useful psychophysiological distinction between ADHD and schizophrenia. There is consistent evidence that both facial affect recognition and scanpaths to facial expressions are impaired in schizophrenia, with emerging empirical evidence showing that facial affect recognition is impaired in ADHD also. Brain imaging studies show reduced activity in the medial prefrontal and limbic (amygdala) brain regions required to process emotional faces in schizophrenia, but suggest more localized loss of activity in these regions in ADHD. As amygdala activity in particular has been linked to effective visual scanning of face stimuli, it is postulated that condition-specific breakdowns in these brain regions that subserve emotional behavior might manifest as distinct scanpath aberrations to facial expressions of emotion in schizophrenia and ADHD.

Temporal information processing in ADHD: Findings to date and new methods

The ability to perceive and represent time is a fundamental but complex cognitive skill that allows us to perceive and organize sequences of events and actions, and to anticipate or predict when future events will occur. It is a multidimensional construct, and a variety of methods have been used to understand timing performance in ADHD samples, which makes it difficult to integrate findings across studies. While further replication is needed, growing evidence links ADHD to problems in several aspects of temporal information processing, including duration discrimination, duration reproduction, and finger tapping. Neuroimaging studies of ADHD have also implicated cerebellar, basal ganglia, and prefrontal regions of the brain, which are believed to subserve temporal information processing. This line of research implicates more basic cognitive mechanisms than previously linked with ADHD and challenges researchers to develop and utilize innovative, multidisciplinary, scientific methods to dissect the various components of temporal information processing. Recent advances in neuroimaging, such as magnetoencephalography in collaboration with structural magnetic resonance imaging, can discriminate temporal processing at the level of a millisecond. This approach can lay the groundwork to provide a more precise understanding of neural network activity during different aspects and stages of temporal information processing in ADHD.

ADHD and the dopamine transporter: are there reasons to pay attention?

The catecholamine dopamine (DA) plays an important role as a neurotransmitter in the brain in circuits linked to motor function, reward, and cognition. The presynaptic DA transporter (DAT) inactivates DA following release and provides a route for non-exocytotic DA release (efflux) triggered by amphetamines. The synaptic role of DATs first established through antagonist studies and more recently validated through mouse gene-knockout experiments, raises questions as to whether altered DAT structure or regulation support clinical disorders linked to compromised DA signaling, including drug abuse, schizophrenia, and attention deficit hyperactivity disorder (ADHD). As ADHD appears to have highly heritable components and the most commonly prescribed therapeutics for ADHD target DAT, studies ranging from brain imaging to genomic and genetic analyses have begun to probe the DAT gene and its protein for possible contributions to the disorder and/or its treatment. In this review, after a brief overview of ADHD prevalence and diagnostic criteria, we examine the rationale and experimental findings surrounding a role for human DAT in ADHD. Based on the available evidence from our lab and labs of workers in the field, we suggest that although a common variant within the human DAT (hDAT) gene (SLC6A3) is unlikely to play a major role in the ADHD, contributions of hDAT to risk maybe most evident in phenotypic subgroups. The in vitro and in vivo validation of functional variants, pursued for contributions to endophenotypes in a within family approach, may help elucidate DAT and DA contributions to ADHD and its treatment.

Online measurement of motivational processes: introducing the Continuous Delay Aversion Test (ConDAT)

The Continuous Delay Aversion Test (ConDAT), a new computer task for online monitoring and continuously measuring delay aversion (DA), is introduced. DA is a motivational style related to a shortened delay gradient which is proposed as a major endophenotype of attention deficit hyperactivity disorder (ADHD). It is characterised by avoiding or escaping from delay-rich situations despite the prospects of a reward. In each ConDAT trial the rapidly diminishing reward/delay ratio, which tends asymptotically towards zero, is visually presented on the computer screen. The test subject is permanently confronted with the question whether to quit or to continue the trial in the face of the deteriorating reward/time ratio. An elaborated control of stimuli and responses, including the sending of trigger codes to external recording devices, makes the task useful for neurophysiological or brain imaging experiments. Compared to existing tasks, the ConDAT is more flexible and sensitive due to its asymptotic open-ended trials and the interval-scaled output measure. Pilot data give evidence for satisfactory reliability and external validity of the task.

Probing the limits of delay intolerance: preliminary young adult data from the Delay Frustration Task (DeFT)

Delay intolerance/aversion is one amongst a number of candidate neuropsychological endophenotypes for ADHD. Pilot data suggest that, because of potential ceiling effects, simple choice measures of delay tolerance used for children are probably not appropriate for adolescents and adults. The Delay Frustration Task (DeFT) is a new measure of delay intolerance, designed to be used in a similar form with adolescents and adults as well as children. In it delay frustration is indexed as the number and duration of responses made on a response key during a series of unpredictable and unsignalled delay periods, which interrupt the completion of a simple computer-based tests. The aim of this study was to provide preliminary data on the applicability of the task in a sample of young adults. The DeFT was administered to 49 male and female undergraduate students selected from a normal population-base. Their mean age was 23.14 (S.D.=1.54). Three measures of delay frustration were recorded across time intervals during the response window; the number of responses, their duration and their combined product (total time button was pressed) was calculated for each second interval bin during the post-response delay period. The AARS and HADS were used as screening questionnaires for ADHD and anxiety behaviour, respectively. The results indicated that young adults with high-ADHD symptoms scores pressed the button more than those with low ADHD scores during the post-response delay condition. While both groups increased responding across time within intervals this was significantly more marked in the high-ADHD symptom group. These effects became more pronounced when anxiety was controlled. Young adults with high-ADHD symptoms appear to be more sensitive to the imposition of unscheduled and unsignalled delay during a simple maths test. DeFT may provide a useful index of delay tolerance in young adults with ADHD. Future research needs to examine DeFT performance in different age groups and in clinical and non-clinical populations.

Temporal and probabilistic discounting of rewards in children and adolescents: effects of age and ADHD symptoms

This study investigated whether age and ADHD symptoms affected choice preferences in children and adolescents when they chose between (1) small immediate rewards and larger delayed rewards and (2) small certain rewards and larger probabilistic uncertain rewards. A temporal discounting (TD) task and a probabilistic discounting (PD) task were used to measure the degree to which the subjective value of a large reward decreased as one had to wait longer for it (TD), and as the probability of obtaining it decreased (PD). Rewards used were small amounts of money. In the TD task, the large reward (10 cents) was delayed by between 0 and 30s, and the immediate reward varied in magnitude (0-10 cents). In the PD task, receipt of the large reward (10 cents) varied in likelihood, with probabilities of 0, 0.25, 0.5, 0.75, and 1.0 used, and the certain reward varied in magnitude (0-10 cents). Age and diagnostic group did not affect the degree of PD of rewards: All participants made choices so that total gains were maximized. As predicted, young children, aged 6-11 years (n = 25) demonstrated steeper TD of rewards than adolescents, aged 12-17 years (n = 21). This effect remained significant even when choosing the immediate reward did not shorten overall task duration. This, together with the lack of interaction between TD task version and age, suggests that steeper discounting in young children is driven by reward immediacy and not by delay aversion. Contrary to our predictions, participants with ADHD (n = 22) did not demonstrate steeper TD of rewards than controls (n = 24). These results raise the possibility that strong preferences for small immediate rewards in ADHD, as found in previous research, depend on factors such as total maximum gain and the use of fixed versus varied delay durations. The decrease in TD as observed in adolescents compared to children may be related to developmental changes in the (dorsolateral) prefrontal cortex. Future research needs to investigate these possibilities.

Time Perception: Modality and Duration Effects in Attention-Deficit/Hyperactivity Disorder (ADHD)

Time perception performance was systematically investigated in adolescents with and without attention-deficit/hyperactivity disorder (ADHD). Specifically, the effects of manipulating modality (auditory and visual) and length of duration (200 and 1000 ms) were examined. Forty-six adolescents with ADHD and 44 controls were administered four duration discrimination tasks and two control tasks, and a set of standardized measures. Participants with ADHD had higher thresholds than controls on all of the duration discrimination tasks, with the largest effect size obtained on the visual 1000 ms duration discrimination task. No group differences were observed on the control tasks. Visual-spatial memory was found to be a significant predictor of visual and auditory duration discrimination at longer intervals (1000 ms) in the ADHD sample, whereas auditory verbal working memory predicted auditory discrimination at longer intervals (1000 ms) in the control sample. These group differences suggest impairments in basic timing mechanisms in ADHD.

Attention deficit hyperactivity disorder with reading disabilities: preliminary genetic findings on the involvement of the ADRA2A gene

BACKGROUND

Attention deficit/hyperactivity disorder (ADHD) and reading disability (RD) tend to co-occur and quantitative genetic studies have shown this to arise primarily through shared genetic influences. However, molecular genetic studies have shown different genes to be associated with each of these conditions. Neurobiological studies have implicated noradrenergic function in the aetiology of ADHD that is comorbid with RD. This paper examines the neurobiological evidence and presents preliminary testing of the hypothesis that the ADRA2A receptor gene is contributing to ADHD and comorbid RD.

METHODS

One hundred and fifty-two children (140 boys, 12 girls) of British Caucasian origin, aged between 6 and 13 years and with a diagnosis of ADHD, were recruited. The children's reading ability was tested. Children were identified as having ADHD or ADHD plus RD (n=82). DNA was available for 110 parent child trios and 42 parent child duos. Genotyping was undertaken for an ADRA2A polymorphism.

RESULTS

For those with ADHD plus RD there was evidence of association with the alpha 2A adrenergic receptor (ADRA2A) polymorphism with the G allele being preferentially transmitted.

CONCLUSIONS

The preliminary evidence together with other neurobiological research findings suggests that the ADRA2A gene may contribute to comorbid ADHD and RD and needs to be properly examined.

Supportive neurodevelopmental evidence for ADHD as a developmental disorder

A baby is dependent on its primary caregiver (hereafter referred to as 'mother') for its emotional regulation. The development of emotional self-regulation is dependent on the growth and myelinisation of connections between cortical (control) and limbic (emotion) structures in the infant brain. The subcortical sympathetic limbic system is dominant from birth, and it is only at 14-18 months of age that the parasympathetic cortical inhibitory part develops. The maturation of specifically the right orbitofrontal cortex, which dominates both the sympathetic and parasympathetic limbic systems, is essential for the regulation of emotion for the rest of an individual's life. Behavioral hyperactivity, impulsivity and inattention are considered normal for children in the early practising phase (10-14 months). This stage is characterised by sympathetic dominance stimulated by the ventral tegmental limbic circuit. We hypothesise that children with Attention Deficit Hyperactivity Disorder remain stuck in this phase, and accordingly do not enter the next stage of emotional development, i.e., the late practising period, in which the lateral tegmental limbic circuit, which stimulates the parasympathetic system develops. Parental reactions, which may contribute to this block in emotional development, include: largely ignoring their child, until the child does something the parent disapproves of, then scolding the child, without consoling the child again afterwards. This leads susceptible children to develop defensive hyperactivity and inattention in order to avoid a shame state they are unable to cope with. Implications for therapy are that caregivers should be taught firstly to give lots of positive attention to their child, and if necessary to scold, to console the child immediately afterwards. If this can be achieved consistently, the child will have the chance to develop their parasympathetic lateral limbic circuit, and eventually right orbitofrontal dominance over both limbic circuits, which translates into the ability to self-regulate their emotional states.

Motor flexibility problems as a marker for genetic susceptibility to attention-deficit/hyperactivity disorder

BACKGROUND

Since many children with attention-deficit/hyperactivity disorder (ADHD) have fine visuomotor problems that are already evident at a young age, motor dysfunctioning is investigated in family-genetic perspective. We hypothesized that if fine motor problems may be a marker for genetic susceptibility to ADHD, nonaffected siblings of ADHD probands would experience motor problems similar to those of their ADHD siblings.

METHODS

Twenty-five carefully phenotyped ADHD probands with a family history of ADHD, their nonaffected siblings (n = 25), and 48 normal control subjects (aged 6 to 17) completed a motor fluency task and a motor flexibility task. The motor fluency task involved completion of a familiar, automatized trajectory, whereas the motor flexibility task required continuous adjustment of movement to complete an unpredictable random trajectory.

RESULTS

On the motor fluency task, the performance of the nonaffected children was significantly better than that of the ADHD probands; strikingly, on the motor flexibility task, they performed as well as their ADHD siblings.

CONCLUSIONS

Nonaffected siblings experience complex motor problems similar to their ADHD siblings but only in nonautomatized movements that require controlled processing. The results suggest that higher-order controlled motor deficits in ADHD may be associated with genetic susceptibility for ADHD.

More to ADHD than meets the eye: observable abnormalities in search behaviour do not account for performance deficits on a discrimination task

Children with Attention Deficit/Hyperactivity Disorder (ADHD) often perform poorly on tasks requiring sustained and systematic attention to stimuli for extended periods of time. The current paper tested the hypothesis that such deficits are the result of observable abnormalities in search behaviour (e.g., attention-onset, -duration and -sequencing), and therefore can be explained without reference to deficits in non-observable (i.e., cognitive) processes. Forty boys (20 ADHD and 20 controls) performed a computer-based complex discrimination task adapted from the Matching Familiar Figures Task with four different fixed search interval lengths (5-, 10-, 15- and 20-s). Children with ADHD identified fewer targets than controls (p < 0.001), initiated searches later, spent less time attending to stimuli, and searched in a less intensive and less systematic way (p's < 0.05). There were significant univariate associations between ADHD, task performance and search behaviour. However, there was no support for the hypothesis that abnormalities in search carried the effect of ADHD on performance. The pattern of results in fact suggested that abnormal attending during testing is a statistical marker, rather than a mediator, of ADHD performance deficits. The results confirm the importance of examining covert processes, as well as behavioural abnormalities when trying to understand the psychopathophyiology of ADHD.

Association of the dopamine transporter (DAT1) 10/10-repeat genotype with ADHD symptoms and response inhibition in a general population sample

Association between attention-deficit hyperactivity disorder (ADHD) and the 10-repeat allele of the dopamine transporter gene (DAT1) has been reported in independent clinical samples using a categorical clinical definition of ADHD. The present study adopts a quantitative trait loci (QTL) approach to examine the association between DAT1 and a continuous measure of ADHD behaviours in a general-population sample, as well as to explore whether there is an independent association between DAT1 and performance on neuropsychological tests of attention, response inhibition, and working memory. From an epidemiological sample of 872 boys aged 6-11 years, we recruited 58 boys scoring above the 90th percentile for teacher reported ADHD symptoms (SWAN ADHD scale) and 68 boys scoring below 10th percentile for genotyping and neuropsychological testing. A significant association was found between the DAT1 homozygous 10/10-repeat genotype and high-scoring boys (chi(2)square=4.6, P<0.03; odds ratio=2.4, 95% CI 1.1-5.0). Using hierarchical linear regression, a significant independent association was found between the DAT1 10/10-repeat genotype and measures of selective attention and response inhibition after adjusting for age, IQ, and ADHD symptoms. There was no association between DAT1 and any component of working memory. Furthermore, performance on tasks of selective attention although associated with DAT1 was not associated with SWAN ADHD high scores after controlling for age and IQ. In contrast, impairment on tasks that tapped sustained attention and the central executive component of working memory were found in high-scoring boys after adjusting for age and IQ. The results suggest that DAT1 is a QTL for continuously distributed ADHD behaviours in the general population and the cognitive endophenotype of response inhibition.

Are endophenotypes based on measures of executive functions useful for molecular genetic studies of ADHD?

BACKGROUND

Behavioral genetic studies provide strong evidence that attention-deficit/hyperactivity disorder (ADHD) has a substantial genetic component. Yet, due to the complexity of the ADHD phenotype, questions remain as to the specific genes that contribute to this condition as well as the pathways from genes to behavior. Endophenotypes, or phenotypes that are more closely linked to the neurobiological substrate of a disorder, offer the potential to address these two issues simultaneously (Freedman, Adler, & Leonard, 1999). Thus far, potential endophenotypes for ADHD have not been systematically studied.

METHOD

The current paper reviews evidence supporting the use of deficits on neurocognitive measures of executive functions for this purpose.

RESULTS

Such deficits are a correlate of ADHD and show preliminary evidence of heritability and association with relevant candidate genes. Nonetheless, studies that have assessed the familial and genetic overlap of neurocognitive impairments with ADHD have yielded inconsistent results.

CONCLUSIONS

In order for executive function deficits to be used as an endophenotype for ADHD, we recommend greater attention to the neurocognitive heterogeneity of this disorder and to the precision of measurement of the neuropsychological tests employed. We also discuss empirical strategies that may be necessary to allow such research to progress prior to full resolution of the pathophysiological basis of ADHD.

Behavioral effects of intra-cranial self-stimulation in an animal model of attention-deficit/hyperactivity disorder (ADHD)

Attention deficit/hyperactivity disorder (ADHD), characterized by inappropriate levels of activity, attention, and impulsivity, has been suggested to be caused by changes in reinforcement and extinction processes possibly linked to dysfunctioning dopamine systems. The present study investigated reinforcement processes in spontaneously hypertensive rats (SHR), an animal model of ADHD. Using intra-cranial self-stimulation (ICSS), behavioral effects of varying current intensity, reinforcer density, and reinforcer delay were tested. Current was varied in order to find the weakest current producing the maximal response rate (optimal current) in the SHR and the controls during high (120 reinforcers/min) and low reinforcer densities (1 reinforcer/min). The results showed that optimal current was significantly lower in the SHR than in the controls during high reinforcer density while maximal response rates were not significantly different. During low reinforcer density, optimal current was not significantly different in the two strains, but maximal response rate was significantly higher in the SHR than in the controls. The SHR produced more responses during the testing of reinforcer density, but changes in reinforcer density affected response rates similarly in the two strains. The decrease in response rate as a function of reinforcer delay was more pronounced in the SHR than in the controls. Overall, more responses with short inter-response times (IRT) were found in the SHR compared to the controls during intermittent reinforcement. The results are consistent with a steepened delay-of-reinforcement gradient in SHR.

Effects of delayed reinforcers on the behavior of an animal model of attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD), affecting 3-5% of grade-school children, is a behavioral disorder characterized by developmentally inappropriate levels of inattention, hyperactivity, and impulsivity. It has been suggested that the symptoms are caused by altered reinforcement and extinction processes, behaviorally described as an abnormally short and steep delay-of-reinforcement gradient in ADHD. The present study tested predictions from the suggested shortened and steepened delay gradient in ADHD in an animal model, the spontaneously hypertensive rats (SHRs). It was predicted that SHR responding during baseline would mainly consist of responses with short inter-response times, and that responding would be more rapidly reduced in the SHR than in the controls by the introduction of a time interval between the response and reinforcer delivery. Effects of a resetting delay of reinforcement procedure with water as the reinforcer were tested on two baseline reinforcement schedules: variable interval 30 s (VI 30 s) and conjoint variable interval 60 s differential reinforcement of high rate 1s (VI 60 s DRH 1 s). The results showed a higher rate of responses in the SHR than in the controls during baseline, mainly consisting of responses with short inter-response times. The statistical analyses showed that response rates decreased more rapidly as a function of reinforcer delay in the SHR than in the controls. The analyses of the estimates of the reinforcer decay parameter showed no strain differences during the VI 30 s schedule but showed a significant strain difference at the end, but not at the start, of the sessions during the VI 60 s DRH 1 s schedule. In general, the results support predictions from the suggested steepened delay gradient in SHR. However, the predictions were only partly confirmed by the analyses of the decay parameter.

Executive and motivational processes in adolescents with Attention-Deficit-Hyperactivity Disorder (ADHD)

BACKGROUND

The objective of the current study was to examine performance and correlates of performance on a decision-making card task involving risky choices (Iowa Gambling Task) in adolescents with ADHD and comparison controls. Forty-four participants with ADHD and 34 controls were administered measures of estimated intellectual ability, working memory, and the card task. Also, behavioural ratings were obtained from parents and teachers.

RESULTS

Adolescents with ADHD scored lower on the measures of intellectual ability, working memory, and made less advantageous selections on the card task compared to controls. Performance on measures of intellectual ability and working memory were unrelated to card task performance in both the ADHD and control samples. Parent ratings of hyperactivity/impulsivity were significantly associated with card task performance in the adolescents with ADHD, but not in controls.

CONCLUSION

These findings demonstrate impaired decision-making in adolescents with ADHD, and the separability of motivational and executive function processes, supporting current dual pathway models of ADHD.