Impact of Parental Impulsivity on Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder: Do Mothers' Attitudes Predict Symptom Severity in Children?

ABSTRACT

Attention deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder that occurs early in school-aged children, and it is highly comorbid with oppositional defiant disorder (ODD). Parents of children with ADHD frequently show mental problems related to impulsivity. The aim of this study was to examine the relationship between impulsivity of the mothers and the symptom patterns and severity of children. A total of 85 children between the ages of 6 and 12 and their mothers participated. Conners' Parent and Teacher Scales, Structured Clinical Interview for DSM-IV Personality Disorders, and ıowa gambling task were applied. We found a positive correlation between the impulsivity of the mothers and the total symptom severity of ADHD and ODD in children. During the treatment process of ADHD, the evaluation of impulsivity in mothers of children with ODD comorbidity and treatment of impulsivity in the mother would be beneficial. In future studies, examining the effects after treatment of impulsivity may contribute to the literature.

Using real patients in e-learning: case-based online training in child and adolescent psychiatry

Objectives: In undergraduate medical education and in the subject of child and adolescent psychiatry, examining young patients face-to-face is a key element of teaching. With the abrupt shutdown of face-to-face teaching caused by the SARS-CoV-2 pandemic, a case-based online training program integrating audio and video of real patients was developed. Methods: The blended learning platform CaseTrain guides medical students in their final year through real child-psychiatric patient cases, such as anorexia, autism, or attention deficit disorder, through presentation of video and audio of real patients and parents. The teaching format complements lectures on child psychiatric topics, comprising asynchronous elements (self-study using the digital material) as well as synchronous elements (web-conferences with a specialist). Learning objectives for students were set to develop knowledge of the spectra of psychiatric disorders that affect children and to recognize approaches how to assess and manage common psychiatric problems of childhood and adolescence. Results: The feedback from medical students through oral and written evaluation was positive. They appreciated getting to know 'real-world patients' in times of such a pandemic, to learn explorative techniques from role models, and to be in close contact with the supervising specialist. In consequence of critical feedback on the length of some video sequences, these training units will undergo revision. Conclusions: Case-based online training may continue to be a useful option in a post-pandemic future as integral part of medical education, complementing face-to-face lectures and training in (child) psychiatry.

Network Analysis of ADHD and ODD Symptoms: Novel Insights or Redundant Findings with the Latent Variable Model?

A latent variable model (LVM) and network analysis (NA) were applied to mother and father ratings of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) symptoms to determine if NA offers unique insights relative to the LVM. ADHD-inattention (IN), ADHD-hyperactivity/impulsivity (HI), and ODD symptoms along with academic competence behaviors (reading, arithmetic, and writing skills) were rated by mothers and fathers of Brazilian (n = 894), Thai (n = 2075), and United States (n = 817) children (M_age = 9.04, SD = 2.12, 49.5% females). LVM indicated that (1) the ADHD-IN, ADHD-HI, and ODD three-factor model yielded a close global-fit with no localized ill-fit; (2) nearly all loadings were substantial; (3) like-symptom loadings, like-symptom thresholds, and like-factor means showed invariance across mothers and fathers; (4) the three factors showed convergent and discriminant validity across mothers and fathers; and (5) only the ADHD-IN showed a unique negative relationship with academic competence. NA indicated that (1) a walktrap community analysis resulted in ADHD-IN, ADHD-HI, and ODD symptom communities; (2) the three symptom communities were consistent across mothers and fathers; (3) only three ADHD-IN symptoms showed unique relationships with the three academic competence items. NA has proven useful for numerous mental disorders. In the current study, NA results were mostly congruent with the LVM model, with a few notable exceptions. The results are discussed in the context of model assumptions and application considerations in the context of ADHD/ODD symptoms relative to other symptom dimensions.

Cognitive and Emotional Profiles of CU Traits and Disruptive Behavior in Adolescence: a Prospective Study

In this study we followed 82-90 adolescents, 50% boys, from 15 to 16 years, investigating CU traits and disruptive behaviors as predictors of cognitive skills and arousal to emotional pictures. At age 15, CU traits were rated by adolescents and disruptive (aggregated ADHD-ODD-delinquent) behaviors were rated by parents and adolescents. At age 16, executive function, reaction time variability (RTV), IQ and arousal to negative pictures were assessed. The results showed that, with control for disruptive behaviors, CU traits predicted lower RTV, higher IQ and lower arousal to negative pictures. With control for CU traits, disruptive behaviors predicted lower spatial working memory, lower interference control and higher RTV. Our findings are of theoretical and clinical relevance as they point to highly diverging cognitive and emotional profiles of CU traits and disruptive behaviors.

Application of the Bifactor S - 1 Model to Multisource Ratings of ADHD/ODD Symptoms: an Appropriate Bifactor Model for Symptom Ratings

The symmetrical bifactor model is often applied to attention-deficit/hyperactivity disorder (ADHD)-hyperactive/impulsive (HI), ADHD-inattentive (IN), and oppositional defiant disorder (ODD) symptoms, but this model frequently yields anomalous or inadmissible results. An alternative model, the bifactor S - 1 model, is more appropriate for examining the hierarchical structure of ADHD/ODD symptoms. Both models were applied to ADHD-HI, ADHD-IN, and ODD symptom ratings by mothers, fathers, and teachers for 2142 Spanish children (49.49% girls; ages 8-13 years). The symmetrical bifactor model yielded the typical anomalous loadings, with a weakly defined ADHD-HI specific factor and difficult to interpret associations of general and specific factors with correlates. In contrast, the bifactor S - 1 model with ADHD-HI symptoms as general reference factor produced clearly interpretable results. For mothers and fathers, slightly more than 50% of true score variance in ADHD-IN and ODD symptoms represented specific residual variance not shared with the general ADHD-HI reference factor. For teachers, approximately 69% and 39% of true score variance in ADHD-IN and ODD symptoms, respectively, represented specific residual variance not shared with the general ADHD-HI reference factor. The general ADHD-HI reference factor and specific ADHD-IN and ODD residual factors showed convergent and discriminant validity across sources, along with unique associations with peer rejection, social impairment, and academic impairment factors. The bifactor S - 1 model also yielded results consistent with predictions from trait-impulsivity theory of ADHD/ODD development. Researchers should use the bifactor S - 1 model rather than the symmetrical bifactor model if hypotheses involve the latent hierarchical structure of ADHD/ODD symptoms.

Course of disinhibited social engagement behavior in clinically referred home-reared preschool children

BACKGROUND

Evidence supporting clinical relevance and persistence of disinhibited social engagement behavior (DSEB) pertains mostly to children reared in institutions and foster care. This study examined the course of DSEB in clinically referred home-reared children from early into middle childhood, and associations with neglect/emotional maltreatment, effortful control, Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Autism Spectrum Disorder.

METHODS

Disinhibited social engagement behavior was examined in 124 children (82% boys, M = 4.06 years, SD = 0.89), referred for treatment of emotional and behavioral problems, by use of the Disturbances of Attachment Interview (DAI) with biological parents. Neglect and emotional maltreatment were assessed from case records and effortful control by use of the Child Behavior Questionnaire. At follow-up, on average 4 years later, DSEB was examined by use of DAI as well as two observational ratings: the Stranger at the Door procedure (SatD) and a structured home observation of stranger approach. Psychiatric disorders were assessed by means of the Kiddie-Schedule for Affective Disorders and Schizophrenia.

RESULTS

Persistence of parent-reported DSEB was found in 57% (n = 27) of the children with DSEB at baseline (n = 47). Parent-reported DSEB at follow-up was significantly related to DSEB observed in the SatD (rpb  = .31, p = .001) and to observed stranger approach (rs  = .41, p < .001), but only stranger approach was associated with baseline DSEB. The course of DSEB was not related to neglect/emotional maltreatment, nor to the level of effortful control. There was no association between DSEB and Autism Spectrum Disorder, but course of DSEB was associated with Attention Deficit/Hyperactivity Disorder/Oppositional Defiant Disorder at follow-up (χ2  = 13.08, p = .004).

CONCLUSIONS

Although explanations for the onset and course of DSEB in home-reared children remain elusive, findings suggest that DSEB is part of a complex of clinically significant problem behaviors in referred home-reared preschool children.

Neurodevelopmental correlates of behavioural and emotional problems in a neuropaediatric sample

Most research does not address the overlap between neurodevelopmental disorders when investigating concomitant mental health problems. The purpose of the present study was to examine the association of intellectual disability (ID), autism spectrum disorder (ASD), and attention-deficit/hyperactivity disorder (ADHD) with the presence of behavioural and emotional problems after controlling for other well-known correlates and risk factors. The sample included 4- to 18-year-old children who attended neuropaediatric clinics (N = 331). After controlling for adversity, age, gender, other developmental/neurological disorders, parental emotional problems, and parenting strategies, the presence of ADHD but not ASD or ID was uniquely associated with behaviour problems. Neither ADHD nor ASD nor ID was significantly associated with emotional problems after controlling for other risk factors. However, ADHD, ASD and behavioural/emotional disorders but not ID were significantly associated with functional impairment in everyday activities after controlling for other risk factors. Because children with neurodevelopmental disorders have complex needs, a holistic approach to diagnosis and interventions is highly warranted, including the assessment and treatment of behavioural and emotional disorders.

Specificity of Reward Sensitivity and Parasympathetic-Based Regulation among Children with Attention-Deficit/Hyperactivity and Disruptive Behavior Disorders

Attention-deficit/hyperactivity disorder (ADHD) is associated with disruptionsin reward sensitivity and regulatory processes. However, it is unclear whether thesedisruptions are better explained by comorbid disruptive behavior disorder (DBD)symptomology. This study sought to examine this question using multiple levels ofanalysis (i.e., behavior, autonomic reactivity). One hundred seventeen children (aged 6 to 12 years; 72.6% male; 69 with ADHD) completed theBalloon-Analogue Risk Task (BART) to assess external reward sensitivity behaviorally.Sympathetic-based internal reward sensitivity and parasympathetic-based regulationwere indexed via cardiac pre-ejection period (PEP) and respiratory sinus arrhythmia(RSA), respectively. Children with ADHD exhibited reduced internal reward sensitivity (i.e.,lengthened PEP; F(1,112)=4.01, p=0.047) compared to healthy controls and werecharacterized by greater parasympathetic-based dysregulation (i.e., reduced RSAaugmentation F(1,112)=10.12, p=0.002). However, follow-up analyses indicated theADHD effect was better accounted for by comorbid DBD diagnoses; that is, childrenwith ADHD and comorbid ODD were characterized by reduced internal rewardsensitivity (i.e., lengthened PEP; t=2.47, p=0.046) and by parasympathetic-baseddysregulation (i.e., reduced RSA augmentation; t=3.51, p=0.002) in response to rewardwhen compared to typically developing youth. Furthermore, children with ADHD and comorbid CD exhibited greater behaviorally-based external reward sensitivity (i.e.,more total pops; F(3,110)= 5.96, p=0.001) compared to children with ADHD only (t=3.87, p=0.001) and children with ADHD and ODD (t=3.56, p=0.003). Results suggest that disruptions in sensitivity to reward may be betteraccounted for, in part, by comorbid DBD.Key Words: attention-deficit/hyperactivity disorder, autonomic nervous system,disruptive behavior disorders, reward sensitivityPowered.

Therapeutic body wraps (TBW) for treatment of severe injurious behaviour in children with autism spectrum disorder (ASD): A 3-month randomized controlled feasibility study

Introduction

The use of therapeutic body wraps (TBW) has been reported in small series or case reports, but has become controversial.

Objectives

This is a feasibility, multicentre, randomized, controlled, open-label trial with blinded outcome assessment (PROBE design).

Setting

Children with autism and severe-injurious behaviours (SIB) were enrolled from 13 specialized clinics.

Interventions

Dry-sheet TBW (DRY group) vs. wet-sheet TBW (WET group).

Primary outcome measures

3-month change in the Aberrant Behaviour Checklist irritability score (ABC-irritability) within per-protocol (PP) sample.

Results

From January 2008 to January 2015, we recruited 48 children (age range: 5.9 to 9.9 years, 78.1% male). Seven patients (4 in the DRY group, 3 in the WET group) were dropped from the study early and were excluded from PP analysis. At endpoint, ABC-irritability significantly improved in both groups (means (standard deviation) = -11.15 (8.05) in the DRY group and -10.57 (9.29) in the WET group), as did the other ABC scores and the Children Autism Rating scale score. However, there was no significant difference between groups. All but 5 patients were rated as much or very much improved. A repeated-measures analysis confirmed the significant improvement in ABC-irritability scores according to time (p < .0001), with no significant difference between the two groups (group effect: p = .55; interaction time x group: p = .27). Pooling both groups together, the mean 3-month change from baseline in ABC-irritability score was -10.90 (effect size = 1.59, p < .0001).

Conclusions

We found that feasibility was overall satisfactory with a slow recruitment rate and a rather good attrition rate. TBW was a safe complementary therapy in this population. There was no difference between wet and dry TBW at 3 months, and ABC-irritability significantly decreased with both wet and dry sheet TBW. To assess whether TBW may constitute an alternative to medication or behavioural intervention for treating SIB in ASD patients, a larger randomized comparative trial (e.g. TBW vs. antipsychotics) is warranted.

Trial registration

ClinicalTrials.gov NCT03164746.

Problem behaviour and psychosocial functioning in young children with Williams syndrome: parent and teacher perspectives

BACKGROUND

There is sparse literature about problem behaviour in young children with Williams syndrome (WS) and little consideration of the perspectives of multiple respondents.

METHODS

Problem behaviour of 35 children with WS ages 2 to 6 was examined based on both parent and teacher report using the Achenbach preschool forms.

RESULTS

The most prominent areas of difficulty based on both parent and teacher report were attention problems, pervasive developmental problems and emotion reactivity difficulties. Some rater differences were observed; most notably, teachers reported more externalising behaviour problems including more aggressive behaviour, Attention Deficit/Hyperactivity problems and Oppositional Defiant problems than did parents. Few relations to intellectual functioning, age or gender were observed.

DISCUSSION

Some aspects of problem behaviour evident in older children (e.g. attention problems, social problems) are also apparent for young children with WS, while other areas are less prominent (e.g. anxiety). The implications of the findings for understanding the behavioural phenotype associated with WS are discussed.

Disruptive Behavior Disorders in Children 0 to 6 Years Old

Disruptive behavior disorders (DBDs), specifically oppositional defiant disorder and conduct disorder, are common, serious, and treatable conditions among preschoolers. DBDs are marked by frequent aggression, deceitfulness, and defiance, and often persist through the lifespan. Exposure to harsh or inconsistent parenting, as frequently seen with parental depression and stress, increases DBD risk. Candidate genes that may increase DBD risk in the presence of childhood adversity have also been identified, but more research is needed. Neurophysiologic and structural correlates with DBD also exist. Parent management training programs, focusing on increasing parenting competence and confidence, are the gold standard treatment of preschool DBDs.

Trait Impulsivity and the Externalizing Spectrum

This article reviews evidence that trait impulsivity-expressed early in life as the hyperactive-impulsive and combined presentations of attention-deficit/hyperactivity disorder (ADHD)-is a bottom-up, subcortically mediated vulnerability to all externalizing disorders. This vulnerability arises from deficient mesolimbic dopamine responding, which imbues psychological states (irritability, discontentment) that motivate excessive approach behavior (hyperactivity, impulsivity). Through complex interactions with (a) aversive motivational states that arise from largely independent subcortical systems, (b) emotion regulatory mechanisms that arise from top-down, cortical modulation of subcortical neural function, and (c) environmental risk factors that shape and maintain emotion dysregulation, trait impulsivity confers vulnerability to increasingly severe externalizing behaviors across development. This perspective highlights the importance of identifying transdiagnostic neural vulnerabilities to psychopathology; dovetails with the hierarchical, latent structure of psychopathology; and suggests that progression along the externalizing spectrum is an ontogenic process whereby a common, multifactorially inherited trait interacts with endogenous and exogenous influences to yield increasingly intractable externalizing behaviors across development.

Latent class profiles of depressive symptoms from early to middle childhood: predictors, outcomes, and gender effects

BACKGROUND

There has been little available data to inform the predictors and outcomes of latent class trajectories of depressive symptoms beginning during preschool and continuing throughout school age. Further, the extant literature in this domain has been limited by the use of parent report checklists of nonspecific 'internalizing' psychopathology rather than diagnostic interviews for depression.

METHODS

To address these gaps in the literature, this study applied growth mixture modeling to depressive symptom severity endorsed by children and/or their caregivers (N = 348) during a structured clinical interview in a 10-year longitudinal dataset spanning from preschool into late school age.

RESULTS

Three distinct trajectories of depressive symptom severity were found in boys and girls. For boys, but not girls, the high depression severity latent class increased in depressive symptoms from preschool through school age, followed by a decline in depressive symptom severity during later school age. For girls, the high depression severity latent class remained stable across time. Early childhood social adversity, familial history of affective disorder, preschool-onset ODD/CD, and school age functional impairment differentiated high-risk trajectory classes among both boys and girls.

CONCLUSIONS

Extending the literature on trajectories of depressive symptoms to the preschool period, these findings incorporate structured clinical interviews of depressive symptom severity and indicate gender differences as well as psychosocial predictors and functional outcomes among children in high severity latent classes. The findings from this study suggest that increased attention to screening for depressive symptoms in early childhood is of significant public health importance.

Beyond Symptom Counts for Diagnosing Oppositional Defiant Disorder and Conduct Disorder?

Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD) are among the most commonly diagnosed childhood behavioral health disorders. Although there is substantial evidence of heterogeneity of symptom presentations, DSM diagnoses of CD and ODD are formally diagnosed on the basis of symptom counts without regard to individual symptom patterns. We used unidimensional item response theory (IRT) two-parameter logistic (2PL) models to examine item parameters for the individual symptoms of CD and ODD using data on 6,491 adolescents (ages 13-17) from the National Comorbidity Study: Adolescent Supplement (NCS-A). For each disorder, the symptoms differed in terms of severity and discrimination parameters. As a result, some adolescents who were above DSM diagnostic thresholds for disruptive behavior disorders exhibited lower levels of the underlying construct than others below the thresholds, based on their unique symptom profile. In terms of incremental benefit, our results suggested an advantage of latent trait scores for CD but not ODD.

Dual neurocircuitry dysfunctions in disruptive behavior disorders: emotional responding and response inhibition

BACKGROUND

To determine the functional integrity of the neural systems involved in emotional responding/regulation and response control/inhibition in youth (age 10-18 years) with disruptive behavioral disorders (DBDs: conduct disorder and/or oppositional defiant disorder) as a function of callous-unemotional (CU) traits.

METHOD

Twenty-eight healthy youths and 35 youths with DBD [high CU (HCU), n = 18; low CU (LCU), n = 17] performed the fMRI Affective Stroop task. Participants viewed positive, neutral, and negative images under varying levels of cognitive load. A 3-way ANOVA (group×emotion by task) was conducted on the BOLD response data.

RESULTS

Youth with DBD-HCU showed significantly less activation of ventromedial prefrontal cortex (vmPFC) and amygdala in response to negative stimuli, compared to healthy youth and youth with DBD-LCU. vmPFC responsiveness was inversely related to CU symptoms in DBD. Youth with DBD-LCU showed decreased functional connectivity between amygdala and regions including inferior frontal gyrus in response to emotional stimuli. Youth with DBD (LCU and HCU) additionally showed decreased insula responsiveness to high load (incongruent trials) compared to healthy youth. Insula responsiveness was inversely related to ADHD symptoms in DBD.

CONCLUSIONS

These data reveal two forms of pathophysiology in DBD. One associated with reduced amygdala and vmPFC responses to negative stimuli and related to increased CU traits. Another associated with reduced insula responses during high load task trials and related to ADHD symptoms. Appropriate treatment will need to be individualized according to the patient's specific pathophysiology.

The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School

OBJECTIVE

This study examines the effectiveness and tolerability of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD).

METHODS

To be eligible, participants had to meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV) criteria for the combined subtype of ADHD and National Institute of Mental Health (NIMH) severe mood dysregulation criteria. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) DMDD criteria were retrospectively assessed after the study was completed. An open-label medication trial lasting up to 6 weeks was completed to optimize the central nervous system (CNS) stimulant dose. Measures of affective symptoms, ADHD symptoms and other disruptive behaviors, impairment, and structured side effect ratings were collected before and after the medication trial.

RESULTS

Optimization of stimulant medication was associated with a significant decline in depressive symptoms on the Childhood Depression Rating Score-Revised Scale (p<0.05, Cohen's d=0.61) and Mood Severity Index score (p<0.05, Cohen's d=0.55), but not in manic-like symptoms on the Young Mania Rating Scale. There was a significant reduction in ADHD (p<0.05, Cohen's d=0.95), oppositional defiant disorder (ODD) (p<0.05, Cohen's d=0.5), and conduct disorder (CD) symptoms (p<0.05, Cohen's d=0.65) as rated by parents. There was also a significant reduction in teacher-rated ADHD (p<0.05, Cohen's d=0.33) but not in ODD symptoms. Medications were well tolerated and there was no increase in side effect ratings seen with dose optimization. Significant improvement in functioning was reported by clinicians and parents (all p's<0.05), but youth still manifested appreciable impairment at end-point.

CONCLUSIONS

CNS simulants were well tolerated by children with ADHD comorbid with a diagnosis of DMDD. CNS stimulants were associated with clinically significant reductions in externalizing symptoms, along with smaller improvements in mood. However, most participants still exhibited significant impairment, suggesting that additional treatments may be needed to optimize functioning.

A Systematic Review and Meta-analysis of Neuroimaging in Oppositional Defiant Disorder (ODD) and Conduct Disorder (CD) Taking Attention-Deficit Hyperactivity Disorder (ADHD) Into Account

Oppositional defiant disorder (ODD) and conduct disorder (CD) are common behavioural disorders in childhood and adolescence and are associated with brain abnormalities. This systematic review and meta-analysis investigates structural (sMRI) and functional MRI (fMRI) findings in individuals with ODD/CD with and without attention-deficit hyperactivity disorder (ADHD). Online databases were searched for controlled studies, resulting in 12 sMRI and 17 fMRI studies. In line with current models on ODD/CD, studies were classified in hot and cool executive functioning (EF). Both the meta-analytic and narrative reviews showed evidence of smaller brain structures and lower brain activity in individuals with ODD/CD in mainly hot EF-related areas: bilateral amygdala, bilateral insula, right striatum, left medial/superior frontal gyrus, and left precuneus. Evidence was present in both structural and functional studies, and irrespective of the presence of ADHD comorbidity. There is strong evidence that abnormalities in the amygdala are specific for ODD/CD as compared to ADHD, and correlational studies further support the association between abnormalities in the amygdala and ODD/CD symptoms. Besides the left precuneus, there was no evidence for abnormalities in typical cool EF related structures, such as the cerebellum and dorsolateral prefrontal cortex. Resulting areas are associated with emotion-processing, error-monitoring, problem-solving and self-control; areas associated with neurocognitive and behavioural deficits implicated in ODD/CD. Our findings confirm the involvement of hot, and to a smaller extent cool, EF associated brain areas in ODD/CD, and support an integrated model for ODD/CD (e.g. Blair, Development and Psychopathology, 17(3), 865-891, 2005).

UNEQUAL BRAINS: DISABILITY DISCRIMINATION LAWS AND CHILDREN WITH CHALLENGING BEHAVIOUR

At a time when brain-based explanations of behaviour are proliferating, how will law respond to the badly behaved child? In Australia, children and youth with challenging behaviours such as aggression, swearing, or impulsivity are increasingly understood as having a behavioural disability and so may be afforded the protections of discrimination law. A brain-based approach to challenging behaviour also offers a seemingly neutral framework that de-stigmatises a child's 'bad' behaviour, making it a biological or medical issue rather than a failure of discipline or temperament. Yet this 'brain-based' framework is not as neutral as it appears. How law regulates the brain-based subject in the form of the badly behaved child depends on how law conceptualises the brain. This article examines two competing approaches to the brain in law: a structural, deterministic model and a 'plastic', flexible model. Each of these impacts differently on disabled and abled identity and consequently on discrimination law and equality rights. Using examples from Australian discrimination law, this article argues that as new brain-based models of identity develop, existing inequalities based on race, gender, and disability are imported, and new forms of stigma emerge. In the neurological age, not all brains are created equal.

Behavioral and electrophysiological indicators of auditory distractibility in children with ADHD and comorbid ODD

Involuntary switching of attention to distracting sounds was studied by measuring effects of these events on auditory discrimination performance and event-related brain potentials (ERPs) in 6-11-year-old boys with Attention Deficit-Hyperactivity Disorder (ADHD) and comorbid Oppositional Defiant Disorder (ODD) and in age-matched controls. The children were instructed to differentiate between two animal calls by pressing one response button, for example, to a dog bark and another button to a cat mew. These task-relevant sounds were presented from one of two loudspeakers in front of the child, and there were occasional task-irrelevant changes in the sound location, that is, the loudspeaker. In addition, novel sounds (e.g., a sound of hammer, rain, or car horn) unrelated to the task were presented from a loudspeaker behind the child. The percentage of correct responses was lower for target sounds preceded by a novel sound than for targets not preceded by such sound in the ADHD group, but not in the control group. In both groups, a biphasic positive P3a response was observed in ERPs to the novel sounds. The later part of the P3a appeared to continue longer over the frontal scalp areas in the ADHD group than in the controls presumably because a reorienting negativity (RON) ERP response following the P3a was smaller in the ADHD group than in the control group. This suggests that the children with ADHD had problems in reorienting their attention to the current task after a distracting novel sound leading to deterioration of performance in this task. The present study also indicates that children with ADHD and comorbid ODD show same kind of distractibility as found in previous studies for children with ADHD without systematic comorbid ODD.

The serotonin transporter in psychiatric disorders: insights from PET imaging

Over the past 20 years, psychotropics affecting the serotonergic system have been used extensively in the treatment of psychiatric disorders. Molecular imaging, in particular PET, has allowed for elucidation of the essential contribution of the serotonin transporter to the pathophysiology of various psychiatric disorders and their treatment. We review studies that use PET to measure cerebral serotonin transporter activity in psychiatric disorders, focusing on major depressive disorder and antidepressant treatment. We also discuss opportunities and limitations in the application of this neuroimaging method in clinical practice. Although results from individual studies diverge, meta-analysis indicates a trend towards reduced serotonin transporter availability in patients with major depressive disorder. Inconsistencies in results might suggest symptom heterogeneity in major depressive disorder and might therefore be relevant for stratification of patients into clinical subsets. PET has enabled the elucidation of mechanisms of response to selective serotonin reuptake inhibitors (SSRIs) and hence provides a basis for rational pharmacological treatment of major depressive disorder. Such imaging studies have also suggested that the pattern of serotonin transporter binding before treatment might predict response to antidepressant treatment, which could potentially be clinically useful in the future. Additionally, this Review discusses PET studies investigating the serotonin transporter in anxiety, obsessive-compulsive disorder, and eating disorders. Few studies have shown changes in serotonin transporter activity in schizophrenia and attention deficit hyperactivity disorder. By showing the scarcity of data in these psychiatric disorders, we highlight the potential for further investigation in this field.

Prevalence and predictors of affective lability after paediatric traumatic brain injury

OBJECTIVE

Paediatric severe traumatic brain injury (TBI) is associated with significant post-injury affective and behavioural problems. Few studies have examined the prevalence and characteristics of affective lability after paediatric TBI.

METHODS

Ninety-seven children with severe TBI were evaluated 1 year post-injury for the presence of affective lability using the Children's Affective Lability Scale (CALS). Demographic, clinical and brain lesion characteristics were also assessed.

RESULTS

Affective lability significantly increased after injury. Eighty-six children had a pre-injury CALS score of 1 SD or less from the group pre-injury mean (M = 8.11, SD = 9.31), of which 35 and 15 children had a 1 SD and 2 SD increase in their CALS score from pre- to post-injury, respectively. A variety of affective shifts manifested post-injury including anxiety, silliness, dysphoria and irritability. The most severe symptoms were irritability and unpredictable temper outbursts. Risk factors for affective lability included elevated pre-injury affective lability and psychosocial adversity as well as greater damage to the orbitofrontal cortex. Post-injury affective lability was most frequently associated with a post-injury diagnosis of attention-deficit hyperactivity disorder.

CONCLUSIONS

Affective lability is common after paediatric TBI and frequently manifests as irritability and unpredictable outbursts. Early intervention is needed to improve psychiatric outcomes.

State-related electroencephalographic deviances in attention deficit hyperactivity disorder

This study investigated the stability and state-related characteristics of electroencephalographic (EEG) deviances in attention-deficit/hyperactivity disorder (ADHD). Three minutes resting EEG with eyes closed and eyes open were compared between 21 children with ADHD and 29 typically developing children. Across resting conditions, children with ADHD exhibited divergent topographic distribution for theta, alpha and beta power compared to typically developing children. In addition, less alpha and theta suppression to eye opening was found in children with ADHD, but only in those without comorbid ODD/CD. Findings of the present study refer to a consistent divergence in topographic distribution in ADHD across resting state conditions, yet demonstrate that state-related factors and comorbidity may also contribute to resting EEG deviances in ADHD. The state-related findings are in accord with several theoretical accounts emphasizing the role of contextual and state factors defining deficits in ADHD.

Poor comprehenders in the classroom: teacher ratings of behavior in children with poor reading comprehension and its relationship with individual differences in working memory

Differing etiological explanations have been proposed to account for poor comprehenders' difficulties with reading comprehension, with some researchers emphasizing working memory deficits and others arguing for oral language weaknesses playing a key causal role. The authors contrasted these two theoretical accounts using data obtained from direct measures of working memory and from teacher ratings of poor comprehenders' behavior in the classroom. At the group level, poor comprehenders showed weaknesses on verbal but not nonverbal working memory tasks, in keeping with the "language account." However, they also showed evidence of elevated levels of problem behaviors specifically associated with working memory deficits. Further analysis revealed that these group differences in working-memory-related problem behaviors were carried by a small subgroup of poor comprehenders who also displayed domain-general (verbal and nonverbal) working memory problems, argued to be reflective of "genuine" underlying working memory deficits.

Empathic responsiveness in amygdala and anterior cingulate cortex in youths with psychopathic traits

BACKGROUND

Psychopathic traits are associated with increases in antisocial behaviors such as aggression and are characterized by reduced empathy for others' distress. This suggests that psychopathic traits may also impair empathic pain sensitivity. However, whether psychopathic traits affect responses to the pain of others versus the self has not been previously assessed.

METHOD

We used whole-brain functional magnetic resonance imaging to measure neural activation in 14 adolescents with oppositional defiant disorder or conduct disorder and psychopathic traits, as well as 21 healthy controls matched on age, gender, and intelligence. Activation in structures associated with empathic pain perception was assessed as adolescents viewed photographs of pain-inducing injuries. Adolescents imagined either that the body in each photograph was their own or that it belonged to another person. Behavioral and neuroimaging data were analyzed using random-effects analysis of variance.

RESULTS

Youths with psychopathic traits showed reduced activity within regions associated with empathic pain as the depicted pain increased. These regions included rostral anterior cingulate cortex, ventral striatum (putamen), and amygdala. Reductions in amygdala activity particularly occurred when the injury was perceived as occurring to another. Empathic pain responses within both amygdala and rostral anterior cingulate cortex were negatively correlated with the severity of psychopathic traits as indexed by PCL:YV scores.

CONCLUSIONS

Youths with psychopathic traits show less responsiveness in regions implicated in the affective response to another's pain as the perceived intensity of this pain increases. Moreover, this reduced responsiveness appears to predict symptom severity.

The relationship between large cavum septum pellucidum and antisocial behavior, callous-unemotional traits and psychopathy in adolescents

BACKGROUND

The presence of a large cavum septum pellucidum (CSP) has been previously associated with antisocial behavior/psychopathic traits in an adult community sample.

AIMS

The current study investigated the relationship between a large CSP and symptom severity in disruptive behavior disorders (DBD; conduct disorder and oppositional defiant disorder).

METHOD

Structural MRI scans of youth with DBDs (N = 32) and healthy comparison youth (N = 27) were examined for the presence of a large CSP and if this was related to symptom severity.

RESULTS

Replicating previous results, a large CSP was associated with DBD diagnosis, proactive aggression, and level of psychopathic traits in youth. However, the presence of a large CSP was unrelated to aggression or psychopathic traits within the DBD sample.

CONCLUSIONS

Early brain mal-development may increase the risk of a DBD diagnosis, but does not mark a particularly severe form of DBD within patients receiving these diagnoses.

A new look at borderline personality disorder and related disorders: hyper-reactivity in the limbic system and lower centers

Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.

An affective dimension within oppositional defiant disorder symptoms among boys: personality and psychopathology outcomes into early adulthood

BACKGROUND

A dimension of negatively oriented affect within oppositional defiant disorder (ODD) symptoms, which has been described as irritability, has been shown to predict depression and anxiety. Related constructs have been linked to temperament and personality constructs. However, only a few studies have examined the prediction from irritability within ODD to psychopathology or personality outcomes. Further, no studies have investigated whether irritability distinguishes among classes of youth.

METHODS

Data from a clinic-referred sample of 7-12-year-old boys followed up to age 18 were used. Measures included structured clinical interviews with parents through adolescence, and youth self-report of depression and personality domains at age 18.

RESULTS

Variable-oriented analyses found predictive links between irritability and outcomes of depression, anxiety, and Neuroticism. Latent classes of youth were distinguished by the presence or absence of irritability symptoms. Youth classified by irritability symptoms at baseline were significantly more likely to show anxiety and depression through adolescence and depression and Neuroticism at 18. No relationship was observed for the other of the Big Five personality factors.

CONCLUSION

Irritability symptoms within ODD distinguish youth at risk for persisting problems with internalizing disorders and Neuroticism into adulthood. The findings are suggestive of a model in which the early emergence of irritability marks life-course risks for specific types of psychopathology and personality problems.

Defining the developmental parameters of temper loss in early childhood: implications for developmental psychopathology

BACKGROUND

Temper modulation problems are both a hallmark of early childhood and a common mental health concern. Thus, characterizing specific behavioral manifestations of temper loss along a dimension from normative misbehaviors to clinically significant problems is an important step toward identifying clinical thresholds.

METHODS

Parent-reported patterns of temper loss were delineated in a diverse community sample of preschoolers (n = 1,490). A developmentally sensitive questionnaire, the Multidimensional Assessment of Preschool Disruptive Behavior (MAP-DB), was used to assess temper loss in terms of tantrum features and anger regulation. Specific aims were: (a) document the normative distribution of temper loss in preschoolers from normative misbehaviors to clinically concerning temper loss behaviors, and test for sociodemographic differences; (b) use Item Response Theory (IRT) to model a Temper Loss dimension; and (c) examine associations of temper loss and concurrent emotional and behavioral problems.

RESULTS

Across sociodemographic subgroups, a unidimensional Temper Loss model fit the data well. Nearly all (83.7%) preschoolers had tantrums sometimes but only 8.6% had daily tantrums. Normative misbehaviors occurred more frequently than clinically concerning temper loss behaviors. Milder behaviors tended to reflect frustration in expectable contexts, whereas clinically concerning problem indicators were unpredictable, prolonged, and/or destructive. In multivariate models, Temper Loss was associated with emotional and behavioral problems.

CONCLUSIONS

Parent reports on a developmentally informed questionnaire, administered to a large and diverse sample, distinguished normative and problematic manifestations of preschool temper loss. A developmental, dimensional approach shows promise for elucidating the boundaries between normative early childhood temper loss and emergent psychopathology.

Contributions of hot and cool self-regulation to preschool disruptive behavior and academic achievement

The construct of self-regulation can be meaningfully distinguished into hot and cool components. The current study investigated self-regulation in a sample of 926 children aged 3-5 years old. Children's performance on self-regulatory tasks was best described by two latent factors representing hot and cool regulation. When considered alone, hot and cool regulation were both significantly correlated with disruptive behavior and academic achievement. When considered together, cool regulation was uniquely associated with academic achievement, while hot regulation was uniquely associated with inattentive-overactive behaviors. Results are discussed with respect to treatment studies that directly target improvement in children's self-regulation.

Dimensions of oppositional defiant disorder as predictors of depression and conduct disorder in preadolescent girls

OBJECTIVE

To examine whether oppositional defiant disorder (ODD) rather than conduct disorder (CD) may explain the comorbidity between behavioral disorders and depression; to test whether distinct affective and behavioral dimensions can be discerned within the symptoms of ODD; and to determine whether an affective dimension of ODD symptoms is specifically predictive of later depression.

METHOD

The dimensions of ODD and their prediction to later CD and depression were examined in a community sample of 2,451 girls between the ages of 5 and 8 years, followed up annually over a 5-year period, using parent, child, and teacher questionnaire ratings of the severity of symptoms of psychopathology.

RESULTS

Dimensions of negative affect, oppositional behavior, and antagonistic behavior were found within ODD symptoms. Negative affect predicted later depression. Oppositional and antagonistic behavior predicted CD overall, and for Caucasian girls, negative affect also predicted later CD. CD was not predictive of later depression, controlling for comorbid conditions.

CONCLUSIONS

ODD plays a key role in the early development of psychopathology. It is central in the comorbidity between internalizing and externalizing psychopathology, which may be caused by a dimension of negative affective symptoms within ODD. How this dimension relates to later CD appears to vary by race.

[Study based on ICA of "dorsal attention network" in patients with temporal lobe epilepsy]

Many functional magnetic resonance imaging (fMRI) studies have revealed the deactivation phenomenon of default mode network in the patients with epilepsy; however, nearly not any of the reports has focused on the dorsal attention network of epilepsy. In this paper, independent component analysis (ICA) was used to isolate the dorsal attention network of 16 patients with temporal lobe epilepsy (TLE) and of 20 healthy normals; and a goodness-of-fit analysis was applied at the individual subject level to choose the interesting component. Intra-group analysis and inter-group analysis were performed. The results indicated that the dorsal attention network included bilateral intraparietal sulcus, middle frontal gyrus, human frontal eye field, posterior lobe of right cerebellum, etc. The TLE group showed decreased functional connectivity in most of the dorsal attention regions with the predominance in the bilateral intraparietal sulcus, middle frontal gyrus, and posterior lobe of right cerebellum. These data suggested that the intrinsic organization of the brain function might be disrupted in TLE. In addition, the decrease of goodness-of-fit scores suggests that activity in the dorsal attention network may ultimately prove a sensitive biomarker for TLE.

Scatter plot analysis of excessive daytime sleepiness and severe disruptive behavior in adults with Prader-Willi syndrome: a pilot study

Individuals with Prader-Willi syndrome (PWS) are at risk for excessive daytime sleepiness (EDS) and disruptive behavior. This pilot study explores temporal characteristics of EDS and severe disruptive behavior across time of day and day of week in seven individuals with PWS (aged between 33 and 49 years) of whom five were matched to controls. Direct care staff and/or parents used a scatter plot (i.e., 2-h partial interval recording) to collect data during 28 successive days. Overall frequency of EDS and severe disruptive behavior was low in both groups. Individuals with PWS generally showed more EDS when there were no scheduled activities compared to when activities were scheduled, specifically in the afternoon and in the evening and during the weekend. Scatter plot methodology may be useful in identifying situations that evoke excessive sleepiness and severe disruptive behaviors in people with PWS.

[Oppositional defiant disorder: aspects related to sex differences and informant]

INTRODUCTION

Oppositional defiant disorder (ODD) is one of the most common externalizing disorders in childhood. ODD prevalence global rates vary from 2% to 16%. Along with conduct disorder and attention deficit disorder, ODD is one of the leading reasons for referral to neuropediatric and psychiatric services. Even though ODD has recognized clinical importance, key aspects of its conceptualization and prevalence in childhood and adolescence remain uncertain.

DEVELOPMENT

We examine previous research findings of ODD prevalence and analyze sex differences and differences according to informants.

CONCLUSIONS

ODD prevalence rates present high variability. A number of studies suggest that ODD is more common in boys than in girls. Nevertheless, some authors point that this sex differences may be due to methodological bias. We recommend the validation of an ODD scale that has into consideration the following aspects: level of the subject's development (age), gender and environment.

[The Cys allele of the DRD2 (Ser311Cys polymorphism) is associated with schizophrenia and worse sustained attention in patients]

The DRD2 Ser311Cys polymorphism was studied in a sample which included 366 patients with schizophrenia and 387 healthy controls. The frequency of the Cys allele was significantly higher (p<0,009) in the group of patients compared to the controls (8,5% and 3,9%, respectively). Sustained attention assessed by P300 parameters was studied in 66 patients with the SerSer and SerCys genotypes (the CysCys genotype was not observed in the sample studied). A significant effect (p=0,01) of the SerCys genotype on P300 latency in frontal, central and temporal regions was found. Patients with the at-risk allele presented delayed latencies that reflected the lower speed of mental processes related to activation of attention resources. In conclusion, our data support the evidence of association between the Cys allele and schizophrenia obtained earlier for other populations and revealed that carriers of the genotype containing the at-risk allele had delayed P300 latencies.

Puppets, robots, critics, and actors within a taxonomy of attention for developmental disorders

This review proposes a new taxonomy of automatic and controlled attention. The taxonomy distinguishes among the role of the attendee (puppet and robot, critic and actor), the attention process (stimulus orienting vs. response control), and the attention operation (activation vs. inhibition vs. adjustment), and identifies cognitive phenotypes by which attention is overtly expressed. We apply the taxonomy to four childhood attention disorders: attention deficit hyperactivity disorder, spina bifida meningomyelocele, traumatic brain injury, and acute lymphoblastic leukemia. Variations in attention are related to specific brain regions that support normal attention processes when intact, and produce disordered attention when impaired. The taxonomy explains group differences in behavioral inattention, hyperactivity, and impulsiveness, as well as medication response. We also discuss issues relevant to theories of the cognitive and neural architecture of attention: functional dissociations within and between automatic and controlled attention; the relative importance of type of brain damage and developmental timing to attention profile; cognitive-energetic models of attention and white matter damage; temporal processing deficits, attention deficits and cerebellar damage; and the issue of cognitive phenotypes as candidate endophenotypes.

Disruptive behaviors and HPA-axis activity in young adolescent boys and girls from the general population

It is important to investigate associations between biological factors and disruptive behaviors in children and adolescents. Antisocial, aggressive, and criminal behaviors in adults often begin early in life. Disruptive behaviors are often thought to be associated with low activity of the hypothalamic-pituitary-adrenal (HPA) axis. Cortisol, the end-product of this axis, can be measured to investigate HPA-axis activity. Previous studies on this topic concerned clinical or high risk samples. The aim of the present study was to investigate to which extent HPA-axis functioning plays a role in disruptive behaviors in pre-adolescents from the general population. One thousand seven hundred and sixty eight 10- to 12-year-olds from the Dutch general population were investigated. Disruptive behaviors were assessed with the Child Behavior Checklist, the Youth Self-Report, and the Antisocial Behavior Questionnaire. Baseline morning and evening salivary cortisol levels were assessed. Unexpectedly, small associations were found between disruptive behaviors, including attention problems, and higher cortisol levels. However, all effect sizes of significant effects were very small. Our study indicated that HPA-axis functioning may be more relevant in clinical or high risk samples than at the general population level. The association between HPA-axis functioning and attention problems, that has gotten less attention than that with aggressive or delinquent behaviors, requires further research. Furthermore, because effect sizes were relatively small, it can be concluded that, in pre-adolescence, the measures of baseline HPA-axis functioning that were used for the present study can not be used as biological markers for disruptive behaviors.

Dissociation of sad facial expressions and autonomic nervous system responding in boys with disruptive behavior disorders

Although deficiencies in emotional responding have been linked to externalizing behaviors in children, little is known about how discrete response systems (e.g., expressive, physiological) are coordinated during emotional challenge among these youth. We examined time-linked correspondence of sad facial expressions and autonomic reactivity during an empathy-eliciting task among boys with disruptive behavior disorders (n=31) and controls (n=23). For controls, sad facial expressions were associated with reduced sympathetic (lower skin conductance level, lengthened cardiac preejection period [PEP]) and increased parasympathetic (higher respiratory sinus arrhythmia [RSA]) activity. In contrast, no correspondence between facial expressions and autonomic reactivity was observed among boys with conduct problems. Furthermore, low correspondence between facial expressions and PEP predicted externalizing symptom severity, whereas low correspondence between facial expressions and RSA predicted internalizing symptom severity.

The interaction of psychosocial adversity and biological risk in childhood aggression

Childhood aggression has both biological and environmental underpinnings. However, the manner in which these factors interact to influence various types of aggression remains an important area of study. The current study examined the degree to which biological risk and psychosocial adversity, both alone and in combination, are associated with childhood aggression. Linear regression procedures were used to assess the extent to which biological risk status (low vs. high serotonergic responsivity, as measured by prolactin response to fenfluramine), magnitude of psychosocial risk, and the interaction of these factors predicted parent and teacher ratings of aggression and delinquency. After accounting for the independent contribution of biological and psychosocial risk, the interaction of biological and psychosocial risk was significantly associated with parent-rated aggression and marginally related to parent-rated delinquency. In contrast, no such interaction was observed for teacher-rated aggression. Findings suggest that individuals at biological risk for aggression may be particularly vulnerable to the impact of psychosocial adversity.

[Alpha competitive structure in children with attention deficit hyperactivity disorder with/without oppositional defiant disorder]

OBJECTIVE

To explore the alpha competitive structure in children with attention deficit hyperactivity disorder (ADHD) with/without oppositional defiant disorder (ODD).

METHODS

According to DSM-IV diagnostic criteria, the study involved ADHD children with ODD, pure ADHD children and normal controls. Each group consisted of 46 subjects. All subjects were between the ages of 7 and 14 years, and the groups were matched by gender, age and ADHD subtypes. Electroencephalogram(EEG) data were recorded during an eye-closed resting period and then were analyzed with EEG-elecephaloflutuographic technology (EEG-ET) .

RESULTS

(1) The pure ADHD children showed significantly more 8 Hz activity(28.07%+/-15.57%) than that of the normal control group(18.72%+/-1.42%, P=0. 004). Compared with ADHD children with ODD, there were no significant differences in pure ADHD children and normal controls in terms of the dominant probability of 8 Hz(P> 0.05)h (2) The entropy value of the ADHD with ODD group was significantly higher than that of the normal controls in the right frontal region, right central region, and bilateral occipital region(P< 0.05).

CONCLUSION

The pure ADHD children show more maturational lag pattern in the central neurons system than that of children with ADHD and comorbidity ODD. However, children with ADHD and comorbidity ODD have poor brain self-organization ability in the right frontal lobe. The current results suggest that the pathogenic mechanisms may be different between ADHD comorbid with or without ODD.

[Contribution of disruptive behavior disorder to balance function of children with attention deficit hyperactivity disorder]

OBJECTIVE

To investigate whether the likelihood of balance impairment in children with attention deficit hyperactivity disorder (ADHD) increases with the presence of disruptive behavior disorder (DBD), and whether the likelihood of co-occurring diagnosis of DBD increases in ADHD children with severer balance deficit.

METHODS

Three groups of 20 children each, representing pure ADHD, ADHD+DBD, and typically developing control children, were included and group matched by age and gender. Balance functions were assessed with the Balance Master in different conditions. We compared the percentages of children in each group who swayed faster than 85% of the typical control children in all conditions.

RESULTS

In the conditions of firm surface with eyes open (FI/EO) and eyes closed (FI/EC), and foam surface with eyes open (FO/EO) and eyes closed (FO/EC), the sway velocities of ADHD only group (0.65+/-0.26 degrees /s, 0.65+/-0.30 degrees /s, 0.95+/-0.29 degrees /s, and 1.70+/-0.49 degrees /s, respectively) were significantly higher than those of the typical control group (0.47+/-0.18 degrees /s, 0.43+/-0.19 degrees /s, 0.76+/-0.21 degrees /s, and 1.27+/-0.38 degrees /s, respectively) (P<0.05). The sway velocities of ADHD+DBD group (1.00+/-0.33 degrees /s and 1.78+/-0.66 degrees /s)were significantly higher than those of the control group only in FO/EO and FO/EC conditions (P<0.05). There was no difference between the two case groups. The percentages of children who swayed faster than 85% of normal children in the ADHD only group (50%, 50%, and 50%, respectively) were significantly higher than those of typical control group (10%, 5%, and 10%, respectively) in the conditions of FI/EO, FI/EC, and FO/EC (P<0.01); There was no difference between ADHD+DBD group and control group; In FI/EC condition, the percentage of ADHD only group (50%) was significantly higher than that of ADHD+DBD group (P<0.01).

CONCLUSION

Balance impairment in ADHD did not increase as a function of co-occurring DBD, and was due to the ADHD itself rather than to the coexisting DBD; and the probability of co-occurring DBD did not increase in ADHD with severer balance deficit.

Differential stimulant response on attention in children with comorbid anxiety and oppositional defiant disorder

Attention-deficit hyperactivity disorder (ADHD) affects 3% to 7% of school-age children. Approximately 30% of the children with ADHD also have comorbid anxiety or oppositional defiant disorder. Methylphenidate is the drug of choice for the medical treatment of such cases. When compared with children with ADHD alone, children with comorbid anxiety or oppositional defiant disorder may show worsening of the global attention score in response to methylphenidate and not only a "reduced response," as reported in previous studies. This study included 1122 children diagnosed as ADHD, of which 174 were diagnosed with comorbid anxiety and 141 with comorbid oppositional defiant disorder. All patients performed the Test of Variables of Attention before and after methylphenidate administration. A normal distribution (Gaussian distribution) of reaction to methylphenidate, as measured by the global ADHD score in children diagnosed as pure ADHD, was found. These findings were in contrast to children with ADHD and comorbid anxiety or oppositional defiant disorder who showed a bimodal distribution and hence represent a distinct population. In both groups with comorbid disorders, there was a larger subgroup in which significant worsening of global ADHD score occurred after methylphenidate administration (P < .05). Children with ADHD and comorbid anxiety or oppositional defiant disorder might represent clinically distinct populations in which inattention is secondary to those disorders; therefore, methylphenidate may be an inappropriate treatment for such children.

Error-related event-related potentials in children with attention-deficit hyperactivity disorder, oppositional defiant disorder, reading disorder, and math disorder

We studied error-related negativity (ERN) and error positivity (Pe) during a discrimination task in 319 unmedicated children divided into subtypes of ADHD (Not-ADHD/inattentive/combined), learning disorder (Not-LD/reading/math/reading+math), and oppositional defiant disorder. Response-locked ERPs contained a frontocentral ERN and posterior Pe. Error-related negativity and positivity exhibited larger amplitude and later latency than corresponding waves for correct responses matched on reaction time. ADHD did not affect performance on the task. The ADHD/combined sample exceeded controls in ERN amplitude, perhaps reflecting patients' adaptive monitoring efforts. Compared with controls, subjects with reading disorder and reading+math disorder performed worse on the task and had marginally more negative correct-related negativities. In contrast, Pe/Pc was smaller in children with reading+math disorder than among subjects with reading disorder and Not-LD participants; this nonspecific finding is not attributable to error processing. The results reflect anomalies in error processing in these disorders but further research is needed to address inconsistencies in the literature.