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Attention-deficit/hyperactivity disorder (ADHD) is a phenotypically heterogeneous and highly heritable syndrome. which commonly co-occurs with other psychiatry disorders. To assess the role of genetic influences in ADHD, we used latent class analysis (LCA) to identify subtypes of ADHD taking into account its comorbidity with separation anxiety, oppositional defiant disorder (ODD), and three major depression symptoms. A structured interview was used to collect diagnostic data from a population sample of 2,904 adolescent female twins and their parents. LCA was applied to ADHD. separation anxiety. ODD symptom profiles obtained from the twins' parents, and major depression symptom profiles obtained from the twins' self-report. Odds ratios were used to test for familiality of class membership by examining the effect of zygosity on twin concordance within and between latent classes. Structural equation modeling was used to compute heritabilities for latent class membership. LCA revealed three ADHD categories of clinical interest: an inattentive subtype without comorbidity, a second inattentive subtype with increased number of ODD symptoms. and a combined inattentive/hyperactive-impulsive type with elevated levels of ODD, separation anxiety, and depressive symptoms. LCA also distinguished an ODD class and a separation anxiety class, each without increased levels of other comorbid symptoms; a second ODD class co-occurring with increased separation anxiety and depression symptoms; and a pure depression class. Odds ratios for MZ contrasted with DZ twin concordance for individual latent class membership ranged from 2.5 to 19.4. Overall, 66% of MZ pairs, but only 36% of DZ pairs, were assigned to the same latent class, consistent with a genetic hypothesis for latent class membership. Individual class membership was shown to have high heritability ranging from .34-.85. The pattern of latent classes suggested that in the general female adolescent population, there are three highly heritable ADHD subtypes, two of which are comorbid with other disorders. These classes were consistent with a genetic hypothesis for ADHD, with each class potentially reflecting a unique genetic subtype.
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PMID:Latent class analysis of ADHD and comorbid symptoms in a population sample of adolescent female twins. 1169 88

Clinic-referred teens (ages 12-19) with ADHD and ODD (N = 101) were compared to community control (CC) teens, equated for age and sex, (N = 39) on a variety of psychological tasks assessing executive functioning (EF), temporal reward discounting, and time estimation and reproduction. A factor analysis reduced the EF measures to three dimensions, representing CPF Inattention, Working Memory, and CPT Inhibition. Results indicated that the ADHD group had significantly more CPT Inattention than the CC group. No differences were found for Working Memory or CPT Inhibition. The ADHD group displayed significantly greater temporal discounting of delayed hypothetical monetary rewards relative to immediate ones and manifested more impaired time reproduction, but not time estimation, than did the CC group. Main effects for level of IQ were found only on the Working Memory factor and largely did not interact with the group factor otherwise. The group differences in CPT Inattention, temporal discounting, and time reproduction were not a function of level of comorbid oppositional defiant disorder, delinquency, or anxiety-depression. Results are reasonably consistent with past research on EF and sense of time in children with ADHD and extend these findings to the adolescent age group. Problems with working memory and CPT inhibition found in prior studies of children with ADHD, however, were not evident here, perhaps owing to age-related improvements or insufficient task difficulty.
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PMID:Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). 1176 Dec 87

It is imperative to know what risk factors are more likely to appear during specific developmental stages so that identification and interventions can be used to decrease the risk for future SUD. Continued surveying of risk factors that can occur at any stage in childhood are important to ensure that other risk factors are anticipated and intervened upon as well. Multiple risk factors increase the magnitude of the risk for SUD, and therefore all risk factors should be detected to convert these to protective factors. Screening instruments that can assess risk factors found to increase the risk for substance abuse can be found in examples, such as the Drug Usage Screening Instrument [81] and the Problem-Oriented Screening Instrument for Teenagers. The detection of risk factors by primary care providers is becoming increasingly important. However, other professionals are beginning to recognize that early recognition and treatment can enable a youth to go on to a productive life in other arenas as well. Drug courts and diversion programs are beginning to treat first-time offenders and their families rather than taking the punitive approach. These have proven to be very successful. Primary care physicians also should become familiar with motivational enhancement therapy when confronting a youth with a suspected substance abuse problem [57]. This method has proven to be more effective in getting youth into treatment than the direct, confrontational style, which often puts the youth in a defensive mode. Motivational enhancement therapy includes interventions that are delivered in a neutral and empathetic way. The six components of motivational enhancement therapy (also called FRAMES) include: Feedback on personal impairment Emphasis on personal responsibility Clear advice to change Menu of alternative options Empathy as a counseling style Self-efficacy In this way, a clinician can elicit pros and cons, give advice, provide choices, practice empathy, clarify goals, and remove barriers. This technique allows youth to be less defensive and more proactive. Monti et al. [59] have demonstrated that this technique has been useful in getting youth into treatment. Primary care physicians can use instruments that will assess the possibility of both externalizing (e.g., ADHD) and internalizing (e.g., depression and anxiety) disorders. Examples of this type of instrument are the Auchenbach child behavior checklist, teacher report form, and youth self-report form, which survey symptoms for these disorders [1]. Social anxiety disorder can be detected by asking whether the prelatency child went into new situations willingly and tended to hang back or whether the child had difficulty separating from his or her parents. Other questions to ask are whether the child tended to isolate or was fearful of speaking in front of the class. Of course, any bruising or behavior that suggests exposure to adult-related sexual acts may cause concern for physical or sexual abuse and possible PTSD. However, interest in sex earlier than expected for the age of the child may also indicate the possibility of bipolar disorder. These children have many symptoms of ADHD with a high degree of irritability and may seem boastful or grandiose. They may be "daredevils" with no fear of dangerous consequences. Referral to a specialist is necessary to evaluate these children further. Because substance use at age 14 or 15 years can be predicted by academic and social behavior at ages 7 to 9 years, early detection of poor social skills and learning difficulties is essential [43]. Learning disorders can be uncovered by asking the school to do an evaluation. However, schools having economic problems may not be able to accommodate all requests. A parent may have to pay a private provider to complete this workup because insurance companies seldom pay for educational testing. Learning disorders may go undetected because many school systems opt to use a higher deviation from the full-scale IQ to detect learning problems. For instance, if a student has an IQ of 115, the standard nationally recommended deviation from this IQ to detect a learning disorder is 15. Therefore, any child who scores 100 or less on an achievement test should be considered to have a learning disorder. Some schools prefer to use a deviation of up to 23 so that learning disorders are not detected. Few schools screen for processing problems, including auditory and visual motor processing problems, processing speed, comprehension, and short-term and long-term memory problems. This is extremely important because ADHD can be confused with an auditory processing problem. Stimulants may help this condition, but accommodations must be made to ensure continued success. Early-intervention programs, such as Drug Abuse Resistance Education (DARE), proved to be ineffective because the programs did not target components that have been shown to predict future drug use [54]. One program that has targeted these components, normative beliefs, lifestyle-behavior incongruence, and commitment is the All Stars program [39,40]. A strong initial dosage with booster interventions for at least 2 years is also important [10]. Before a child is diagnosed with oppositional defiant disorder or conduct disorder, every effort should be made to detect any underlying psychiatric disorder that has not been treated and therefore may look like a conduct disorder (e.g., bipolar disorder). Proper psychopharmacologic interventions should be made for psychiatric disorders. If one drug has been ineffective, another untreated psychiatric disorder may be present, and it is always important to tease out what remaining symptoms are present after a therapeutic trial has been tried. It is important to form a team approach so that all risk factors can be approached. Members of the team often include a primary care physician, a child psychologist, the parents, the patient, a teacher, a school counselor, a child psychiatrist, and sometimes a pediatric neurologist. No one member of the treatment team can provide all of the necessary services to prevent the future risk for substance abuse.
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PMID:Adolescent substance use disorders and comorbidity. 1199 93

This study examined response to methylphenidate in children with attention-deficit/hyperactivity disorder (ADHD) and chronic multiple tic disorder. The primary goal was to determine if children with anxiety or depression symptoms showed a less favorable response to treatment. Subjects were 38 prepubertal children who participated in an 8-week, double-blind, placebo-controlled, methylphenidate crossover evaluation. Treatment effects were assessed with direct observations of child behavior in public school and clinic settings; rating scales completed by parents, teachers, and clinicians; and laboratory analogue tasks. There was little evidence (group data) that children with anxiety or depression symptoms responded in a clinically different manner to methylphenidate than youngsters who did not exhibit these symptoms, particularly in school observations of the core features of ADHD. Seeming differences between children with and without comorbid anxiety or depression symptoms and drug response are likely explained by differences in pretreatment levels of negativistic behaviors (i.e., symptoms of oppositional defiant disorder or conduct disorder). Methylphenidate appears to be effective for the management of ADHD behaviors in children with mild to moderate anxiety or depression symptoms; nevertheless, much research remains to be performed in this area.
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PMID:Anxiety and depression symptoms and response to methylphenidate in children with attention-deficit hyperactivity disorder and tic disorder. 1200 97

The purpose of this study is to clarify psychosocial characteristics of the comorbidity of attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) in comparison with ADHD or ODD alone. Thirty-one patients with ADHD comorbid with ODD were compared with 23 ADHD alone and 10 with ODD alone, in terms of various examination items including objective assessment scales. The comorbid group demonstrated higher Children Depression Inventory score and State-Trait Anxiety Inventory for Children (state-anxiety) score than the ADHD or the ODD group, possessing more problems in the relationship with teachers than the ADHD group, with friends more than the ADHD or the ODD group, and with their mothers more than the ADHD group and less than the ODD group. School refusal occurred more frequently in the comorbid group than the ADHD group and less than the ODD group. The comorbid group had more psychosocial problems than the ADHD group and the ODD group. These problems could be classified into three types: (i) those derived from ODD, problems in the relationship with teachers; (ii) those derived from ODD but reduced by the coexistence of ADHD, problems in the relationship with their mothers; and (iii) those resulting from the comorbidity of ADHD and ODD, problems in the relationship with friends and anxious and depressive tendency. The difficulties in the relationship with teachers and friends observed in the comorbid group may lead to school refusal.
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PMID:Psychosocial problems in attention-deficit hyperactivity disorder with oppositional defiant disorder. 1210 53

Past studies find that attention deficit hyperactivity disorder (ADHD) creates a higher risk for adverse driving outcomes. This study comprehensively evaluated driving in adults with ADHD by comparing 105 young adults with the disorder (age 17-28) to 64 community control (CC) adults on five domains of driving ability and a battery of executive function tasks. The ADHD group self-reported significantly more traffic citations, particularly for speeding, vehicular crashes, and license suspensions than the CC group, with most of these differences corroborated in the official DMV records. Cognitively, the ADHD group was less attentive and made more errors during a visual reaction task under rule-reversed conditions than the CC group. The ADHD group also obtained lower sceres on a test of driving rules and decision-making but not on a simple driving simulator. Both self- and other-ratings showed the CC group employed safer routine driving habits than the ADHD group. Relationships between the cognitive and driving measures and the adverse outcomes were limited or absent, calling into question their use in screening ADHD adults for driving risks. Several executive functions also were significantly yet modestly related to accident frequency and total traffic violations after controlling for severity of ADHD. These results are consistent with earlier studies showing significant driving problems are associated with ADHD. This study found that these driving difficulties were not a function of comorbid oppositional defiant disorder, depression, anxiety, or frequency of alcohol or illegal drug use. Findings to date argue for the development of interventions to reduce driving risks among adults with ADHD.
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PMID:Driving in young adults with attention deficit hyperactivity disorder: knowledge, performance, adverse outcomes, and the role of executive functioning. 1216 75

This study describes the preliminary psychometric characteristics of a new parent-as-respondent assessment tool, the Coolidge Personality and Neuropsychological Inventory for Children (CPNI). The CPNI contains 200 items answered on a 4-point Likert-type scale. The CPNI has a three-fold purpose: (a) to assess the 12 personality disorders according to the criteria on Axis II and Appendix B of the Diagnostic and Statistical Manual of Mental Disorders; (b) to assess neuropsychological dysfunction, including Attention-Deficit/Hyperactivity Disorder, Mild Neurocognitive Disorder, executive function deficits, and other related symptoms; and (c) to measure some Axis I diagnoses including Separation Anxiety Disorder, Oppositional Defiant Disorder, depression, and general anxiety, as well as other clinical syndromes. The scale reliabilities and test-retest reliabilities were moderate to high, and construct validity was good, which supports further research with the inventory.
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PMID:The Coolidge Personality and Neuropsychological Inventory for Children (CPNI). Preliminary psychometric characteristics. 1220 27

Six waves of structured diagnostic assessments were conducted of 168 clinic-referred 7- to 12-year-olds, over 7 years. Wave-to-wave changes in the number of conduct disorder (CD) behaviors were paralleled by correlated changes in the numbers of symptoms of oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. In addition, CD in Wave 1 predicted levels of ODD, ADHD, depression, and anxiety in later waves when initial levels of those symptoms were controlled, but only ODD in Wave 1 predicted CD in later waves when initial CD levels were controlled. These findings indicate a striking degree of dynamic comorbidity between CD and other types of psychopathology and provide an initial empirical framework for needed developmental models of comorbidity.
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PMID:Waxing and waning in concert: dynamic comorbidity of conduct disorder with other disruptive and emotional problems over 7 years among clinic-referred boys. 1242 69

A literature review on community studies of adolescent substance use, abuse, or dependence (SU/AID) and psychiatric comorbidity yielded 22 articles from 15 studies with information on rates, specificity, timing, and differential patterns of comorbidity by gender, race/ethnicity, and other factors. Results revealed that 60% of youths with SU/A/D had a comorbid diagnosis, and conduct disorder (CD) and oppositional defiant disorder (not attention-deficit/hyperactivity disorder) were most commonly associated with SU/A/D, followed by depression. Child psychopathology (particularly CD) was associated with early onset of substance use and abuse in later adolescence. The authors suggest that available data relevant to SU/A/D and psychiatric comorbidity can be used to better address such questions.
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PMID:Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. 1247 99

This community study assigned 129 4-year-olds to groups at risk for attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), both ADHD and ODD, or no problems. Mothers of children at risk for ODD reported more family dysfunction, felt less competent as parents, suggested fewer solutions to child behavior problems, demonstrated a less assertive approach to child management, and reported more child internalizing problems than did mothers of children not elevated on ODD symptoms. Mothers of children at risk for ADHD reported higher personal depression scores than did those of the non-ADHD subgroup. Children at risk for ADHD evidenced the most difficulties in school where teachers reported more social behavior, classroom management, and internalizing problems relative to other children not at risk for ADHD. When solving child management problems, mothers of children in all groups suggested twice as many controlling/negative management strategies as positive/preventive strategies. In addition, faced with oppositional and conduct problems, mothers of children in all groups increased controlling/negative suggestions and decreased positive/preventive suggestions. Mothers of girls at risk for ADHD, ODD, and ADHD/ODD gave more rewards per positive behavior than did mothers of boys.
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PMID:Preschoolers at risk for attention-deficit hyperactivity disorder and oppositional defiant disorder: family, parenting, and behavioral correlates. 1248 71


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