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

[Situating atention deficit and hyperactivity in Portugal: social, historical, and ethical dimensions of an emerging global health issue]

Attention deficit and hyperactivity disorder (ADHD) is considered one of the most frequent behavioral and neurodevelopmental problems in school-age children and adolescents, both in Portugal and worldwide. The diagnostic categorization of ADHD and the prescription of psychostimulants as its first-line treatment have been the object not only of scientific research and clinical validation, but also of controversy and social critique, especially in light of the concept of medicalization. Despite its high profile and salience in such diverse fields as education, pharmaceuticals, mental health, and public policy, a significant gap remains in the characterization of social-historical, ethical, and institutional dimensions of ADHD outside English-speaking countries. Combining historical and ethnographic research with document and media analysis, the article addresses that challenge by tracing the social trajectory of ADHD in Portugal, from the emergence of "hyperactivity" in the 1970s and 1980s to the current public and political debates on psychostimulant treatments and prescribing trends. From this interdisciplinary perspective and based on the Portuguese case study, the aim of this article is to contextualize the definition, validation, and expansion of ADHD as part of a dynamic and socially situated process in which global diagnostic and pharmaceutical systems intersect with institutional and socioeconomic contingencies, as well as local specificities and needs. More broadly, the article discusses how the case study of ADHD contributes to the development of interdisciplinary research that helps rethinking the social scope of mental health across local and global health contexts.

Entropy-Based Quantitative Electroencephalogram Analysis for Diagnosing Attention-Deficit Hyperactivity Disorder in Girls

Diagnosis of attention-deficit hyperactivity disorder (ADHD) is currently based on core symptoms or checklists; however, the inevitability of practitioner subjectivity leads to over- and underdiagnosis. Although the Federal Drug Administration has approved an elevated theta/beta ratio (TBR) of the electroencephalogram (EEG) band as a tool for assisting ADHD diagnosis, several studies have reported no significant differences of the TBR between ADHD and control subjects. This study detailed the development of a method based on approximate entropy (ApEn) analysis of EEG to compare ADHD and control groups. Differences between ADHD presentation in boys and girls indicate the necessity of separate investigations. This study enrolled 30 girls with ADHD and 30 age-matched controls. The results revealed significantly higher ApEn values in most brain areas in the control group than in the ADHD group. Compared with TBR-related feature descriptors, ApEn-related feature descriptors can produce the higher average true positive rate (0.846), average true negative rate (0.814), average accuracy (0.817), and average area under the receiver operating characteristic curve value (0.862). Therefore, compared with TBR, ApEn possessed the better potential for differentiating between girls with ADHD and controls.

Novel method using Hjorth mobility analysis for diagnosing attention-deficit hyperactivity disorder in girls

BACKGROUND

Attention-deficit hyperactivity disorder (ADHD) is a common childhood neuropsychiatric disorder. Diagnosis of ADHD is based on core symptoms or checklists; however, practitioner subjectivity inevitably results in instances of over- or under-diagnosis. Although an elevated theta/beta ratio (TBR) of the electroencephalography (EEG) band has been approved by the Food and Drug Administration as a factor that may be used in diagnosis of ADHD, several studies have reported no significant differences between the TBR of patients with ADHD and controls.

PURPOSE

In this study, a method was developed based on Hjorth Mobility (M) analysis of EEG to compare patients with ADHD and controls.

METHODS

Differences in the presentations of ADHD between boys and girls are well established; therefore, separate investigations are required. The present study enrolled 30 girls with ADHD and 30 age-matched controls.

RESULTS

The results revealed that the control group had significantly higher Hjorth M values in most brain areas in EEG readings compared with the values for the ADHD group. Compared with TBR, our method revealed a greater number of more significant differences between the girls in the ADHD group and the controls. Moreover, our method can produce the higher average sensitivity (0.796), average specificity (0.796), average accuracy (0.792), and average area under the curve of receiver operating characteristic curve (AUC) value (0.885). Therefore, compared with TBR, Hjorth M possessed the better potential for differentiating between girls with ADHD and controls.

CONCLUSION

The proposed method was more accurate than the TBR in diagnosing ADHD. Therefore, Hjorth M may be a promising tool for differentiating between children with ADHD and controls.

Treatment outcomes after methylphenidate in adults with attention-deficit/hyperactivity disorder treated with lisdexamfetamine dimesylate or atomoxetine

PURPOSE

To compare treatment adherence, discontinuation, add-on, and daily average consumption (DACON) among adults with attention-deficit/hyperactivity disorder receiving second-line lisdexamfetamine dimesylate (LDX) or atomoxetine (ATX), following methylphenidate.

PATIENTS AND METHODS

A retrospective cohort study using US commercial claims databases (Q2/2009-Q3/2013).

RESULTS

At month 12, the LDX cohort (N=2,718) had a higher adherence level (proportion of days covered: 0.48 versus 0.30, P<0.001) and was less likely to discontinue (Kaplan-Meier estimate: 63% versus 85%, P<0.001) than the ATX cohort (N=674). There were no statistical differences in treatment add-on rates between cohorts (Kaplan-Meier estimate: 26% versus 25%, P=0.297). The LDX cohort had a lower DACON (1.10 versus 1.31, P<0.001) and was less likely to have a DACON >1 (adjusted odds ratio: 0.20, 95% confidence interval: 0.15-0.25, P<0.001) than the ATX cohort.

CONCLUSION

Adults with attention-deficit/hyperactivity disorder treated with LDX following methylphenidate had a higher treatment adherence and lower discontinuation and DACON relative to those treated with ATX following methylphenidate.

General versus executive cognitive ability in pupils with ADHD and with milder attention problems

BACKGROUND

The aim of this study was to analyze two main types of cognitive domains in school children with different types and severities of attention-related problems. The cognitive domains examined were general cognitive ability and executive abilities.

METHODS

Three different clinical samples of pupils with school problems were analyzed to assess their cognitive Wechsler Intelligence Scale for Children profiles. In particular, the general cognitive ability index and the executive markers (ie, verbal memory index and processing speed index) were of interest. Of the total sample (n = 198), two main groups were contrasted; one met the full criteria for attention deficit hyperactivity disorder (ADHD)/subthreshold ADHD, and one was comprised of those with milder attention problems, insufficient to meet the criteria for ADHD/subthreshold ADHD.

RESULTS

It could be demonstrated that both groups had a significantly higher score on the general cognitive ability index than on measures of working memory and processing speed. This difference was more pronounced for boys.

CONCLUSION

These types of cognitive differences need to be considered in children with different kinds of learning, behavior, and attention problems; this is also true for children presenting with an average general intelligence quotient and with milder attention problems. Current educational expectations are demanding for children with mild difficulties, and such cognitive information will add to the understanding of the child's learning problems, hopefully leading to a better adapted education than that conventionally available.

Academic performance of adolescents with ADHD and other behavioural and learning problems -a population-based longitudinal study

AIM

To study academic performance (final grades at the age of 16 years) in individuals with i) attention-deficit/hyperactivity disorder (ADHD) and ii) other learning and/or behavioural problems.

METHODS

Of a total population of 591 children, originally assessed at the age of 10-11 years, it was possible to obtain final grades for 536 16-year-olds (in grade 9). Those fulfilling the criteria for ADHD/sub-threshold ADHD (n = 39) and those with 'Behaviour and Learning Problems' (BLP group), (n = 80) and a comparison group (n = 417) were contrasted.

RESULTS

The ADHD and BLP groups had a significantly lower total mean grade at the age of 16 years than the comparison group. In addition, the ADHD and BLP groups also qualified for further studies in the upper secondary school to a significantly lesser extent than the controls (72%, 68% and 92%, respectively). All IQ measures (at the age of 10-11 years) were positively correlated with the overall grade after grade 9, with especially strong correlations for verbal capacity.

CONCLUSION

ADHD and similar problems entail a risk of underachievement at school. The results indicate that pupils with ADHD underachieve in the school situation in relation to their optimal cognitive capacity. The contextual situation and the particular requirements should be considered in order for adequate educational measures to be undertaken.

Cognitive strengths and deficits in schoolchildren with ADHD

BACKGROUND

Few studies provide detailed analyses of the various aspects of the entire cognitive profile of children with ADHD.

MATERIAL AND METHODS

Cognitive test data were analysed for 10- to 11-year-old children with (1) ADHD, (2) subthreshold ADHD and (3) milder attention and/or learning problems, and compared with normative data.

RESULTS

Thirty-two had ADHD and 10 met the criteria for subthreshold ADHD, prevalence rates of 5.4% and 1.6%, respectively. On a group level, children with ADHD/subthreshold ADHD, and those with milder attention and/or learning problems had almost identical cognitive profiles for the 13 subtests comprising the WISC III, with particularly low results on the arithmetic, coding, information and digit span subtests (ACID profile). When analyzed individually, a complete or incomplete ACID profile (three of four subtests) was equally common in children with ADHD/subthreshold ADHD and in children with milder problems, found in about 1/5. The relative strengths of both groups were in areas demanding logical thinking, reasoning and common sense.

CONCLUSION

The specific ACID profile is as common in children with ADHD as in those with minor attention and/or learning problems. The cognitive weaknesses reflected in the ACID profile might play a role as an underlying factor in various developmental disorders.

Schlafverhalten bei Kindern mit Tic-Störungen - eine polysomnographische Studie

Zusammenfassung: Fragestellung: Charakterisierung des Schlafmusters einer größeren Gruppe Kinder mit Tic-Störung sowie Untersuchung ob und wie Veränderungen des Schlafs mit der Schwere der Tic-Störung assoziiert sind. Methodik: Das Schlafverhalten von 25, zum Untersuchungszeitpunkt unmedizierten Kinder mit chronischer Tic-Störung wurde polysomnographisch untersucht und mit den Befunden von 22 gesunden Kontrollen verglichen. Zwischen beiden Gruppen bestanden keine Unterschiede hinsichtlich Alter, Geschlechtsverhältnis und Intelligenz. Ergebnisse: Kinder mit einer Tic-Störung zeigten eine reduzierte Schlafqualität sowie vermehrtes, bewegungsbezogenes Arousal im Vergleich zu gesunden Kontrollen. Hinsichtlich des Schlafs ging bei Kindern mit Tic-Störung eine schwerere Ausprägung der Tics mit häufigeren bewegungsbezogenen Arousals einher. Die Anzahl der kurzen, mit motorischen Phänomenen assoziierten Arousals korrelierte mit geringerer Schlafeffizienz, verzögertem Schlafbeginn und verlängerter Tiefschlaflatenz. Des weiteren bestimmten geringere Schlafeffizienz und verlängerte Tiefschlaflatenz bei Kindern mit Tic-Störung die Schwere der Tics am Tag. Schlussfolgerungen: Bei Kindern mit Tic-Störung scheint ein Zusammenhang zwischen den bewegungsbezogenen Arousals im Schlaf und der Ausprägung der Tics am Tag zu bestehen. Beeinträchtigungen des Schlafs bei Tic-Störungen könnten die Tic-Symptomatik am Tag verschlechtern.