**Difficulties in Recognizing ADHD in an Urban Population and Treatment Satisfaction with a Short and a Long Acting Stimulant**

Antigone Papavasiliou, Irene Nikaina, Anna Spyridonidou and Eleanna Nianiou

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53791

#### **1. Introduction**

Attention deficit hyperactivity disorder (ADHD) is an established neuropsychiatric disorder in children and adolescents with paediatric or mental health services available across most of Europe. In spite of major improvements in the availability of services for the diagnosis of ADHD and several therapeutic options, including medications, psychosocial and psychoeducational therapies, families of children with ADHD experience considerable emotional and social burden [1-2]. The presence and severity of the child's ADHD is a significant predictor of heightened parental stress and the diagnosis of ADHD can result in impairments in the Quality of Life in patients and their families [3-4]. Yet, there is a rather limited number of studies exploring parental perceptions of the diagnosis and overall treatment of this disorder.

An American study determined that primary care physicians generally adhere to practices specified in the AAP guidelines [1] for the diagnosis and treatment of pediatric ADHD; some variations existed and improvements were possible. Poor access to mental health services, limited insurance coverage, and other potential system barriers to the delivery of ADHD care were noted [5]. An Australian study explored perceptions relating to the diagnosis, treatment and overall management of the disorder [6] in the families of 278 children with ADHD identified in a community sample of 11 184 children aged 10-12 years; only 66% of parents recalled the use of questionnaires or rating scales, drugs were tried in 82% and 66% of the children were still on them, behavioral intervention in 42% and alternative treatments, mostly elimination diet and/or fatty acid supplementation, were used in 71%. Overall, 55% of parents were satisfied or very satisfied with their child's care. The conclusion of this study was that adherence to recommended diagnostic guidelines was inadequate, behavioral intervention

© 2013 Papavasiliou et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

was underutilized and non-conventional therapies were widely used and considered helpful in one-third of the children who used them. A study conducted on 20 low socioeconomic status mothers with children 5-11 years of age with ADHD taking stimulants, aimed to examine the effect of a 5-week educational intervention on ADHD [7]. Parental satisfaction and parental sense of competency improved in mothers who participated in the educational intervention.

psychologist and special educator. Relevant patient characteristics such as demographic characteristics (age, sex), ADHD type, previous treatments, concomitant disorders, along with

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**Study group 1.** Thirty three families with children who fulfilled DSM-IV criteria for ADHD, 5-16 years old, who consecutively visited our outpatient department for the first time received an open ended questionnaire, consisting of 6 main questions and 12 sub-questions that investi‐ gated family impressions and experience in dealing with this disorder. More specifically, we asked about a. reasons for seeking help, b. source of referral (self-referred, schools, special edu‐ cators, physicians, psychologists), c. obstacles they confronted in reaching diagnosis and treat‐ ment (difficulty in reaching specialized care, difficulty in dealing with education problems). A DSM-IV derived inattention/hyperactivity scale was used in order for parents to rate their chil‐ dren for 18 DSM-IV category A symptoms, on a 4-point scale [20]. This form was used in the fol‐ low up visits of our patients in order to document response to treatment. Therapeutic options were then offered including the use of short acting MPH, with a dosage schedule that called for 5 mg qam or bid at the onset and dosage titration to less than 2.0 mg/kg/day or 60 mg per day [21]. Patients were also offered a psychotherapeutic program focusing in social capabilities practice. Their parents were involved in counseling sessions and were encouraged to participate in sup‐ port and advice groups, aiming at strengthening the net of care around the patients. Other treat‐ ment options were speech therapy, occupational therapy and special education as needed per individual child. The therapy that was actually used as well as the efficacy of the medication was subsequently explored by a different physician 6 months after the initial visit. The safety of

**Study group 2.** Eighty four patients ≤ 18 years old, who were also followed as outpatients in the Pediatric Neurology Department, were included in the current study group. Inclusion criteria were a. ADHD diagnosis and b. the decision to begin treatment with long acting MPH. Doses were calculated according to body weight with the final dose less than 2.0 mg/kg/day or 72 mg/day [21]. All patients had been also offered psychosocial and psychoeducational intervention programs and their parents were involved in counseling sessions as well as support and advice groups. Previous treatment with short acting MPH was not an exclusion

Six months after treatment initiation, a telephone interview was scheduled by a physician other than the one who prescribed the treatment, in order to determine their satisfaction level from the newly introduced treatment. A four level Likert scale was used for this purpose (0= no satisfaction at all, 1=modest satisfaction, 2=moderate satisfaction, 4=great satisfaction) and free comments on their impressions were encouraged and recorded. The safety of the treatment

Continuous variables were tested for normalcy with the Kolmogorov - Smirnov test. Normal variables were then presented as mean values (± standard deviation). Categorical variables

information on the prescribed treatment were recorded.

the prescribed medication was also explored at that time.

were expressed either as percentages or as absolute numbers.

criterion in this study.

was also explored.

**3. Statistical analysis**

Psychosocial and psycho-educational interventions as well as pharmacological treatments are effective in reducing ADHD symptom frequency and severity [1]. Stimulant medications are recommended as a first-line modality for treating ADHD [8]. They proved effective in improving both ADHD core symptoms (inattention, hyperactivity and impulsivity) and the behavioral problems that frequently accompany the disorder (such as aggressive behavior, depressive mood, anxiety, tics, impaired social functioning and academic productivity) [9]. Remission of ADHD symptoms via medication provides the best possible chance for educa‐ tional and social re-integration and improved functioning through the utilization of nonpharmacological interventions [10]. Methylphenidate (MPH), a stimulant, is available in immediate and extended release forms. Because the half-life of MPH in immediate-release formulations is short, twice or better thrice daily administration is needed in order to maintain the desirable therapeutic effect. This obviously creates many practical difficulties during school days; it affects the patient's emotions (embarrassment in taking medication at school), it interferes with medical privacy preservation, and contributes to poor compliance with the therapeutic regimen [10-11]. Once-daily MPH in extended release form is significantly more effective than short acting MPH based on multiple outcome measures including remission rate [10,12], with better compliance being a primary factor [13-16].

Satisfaction with medication or any therapeutic intervention is an important factor in the evaluation of overall treatment outcome in ADHD or any other disorder; it is predictive of better adherence and compliance to treatment, and prevents premature treatment termination [17]. It depends primarily on the effectiveness of the drug but it is also influenced by parental and patient expectations, demographic characteristics, social acceptability of the treatment, the relationship between patient/parents and physician as well as the physician's knowledge, competence and ability to communicate with patients and their families [18]. Cultural factors are also very important in the acceptability of the treatment [19]. Furthermore, use of stimulant medication combined with frequent reviews (at least 6 monthly) was more likely to be associated with overall management satisfaction [6].

The goals of this paper were a. to explore family experiences in seeking diagnosis and treatment of ADHD in an urban community and b. to investigate acceptance and compliance of stimulant medication and specifically the two preparations of MPΗ available in our country, one in immediate and one in extended-release form (Ritalin and Concerta).

#### **2. Patients and methods**

Two independent samples of children fulfilling DSM-IV criteria for ADHD and their families were recruited to test the study goals. Diagnosis was based on the clinical presentation of the child and on specific standardized diagnostic tools and was established by a specialized group of physicians (pediatrician, pediatric neurologist, pediatric psychiatrist), school and clinic psychologist and special educator. Relevant patient characteristics such as demographic characteristics (age, sex), ADHD type, previous treatments, concomitant disorders, along with information on the prescribed treatment were recorded.

**Study group 1.** Thirty three families with children who fulfilled DSM-IV criteria for ADHD, 5-16 years old, who consecutively visited our outpatient department for the first time received an open ended questionnaire, consisting of 6 main questions and 12 sub-questions that investi‐ gated family impressions and experience in dealing with this disorder. More specifically, we asked about a. reasons for seeking help, b. source of referral (self-referred, schools, special edu‐ cators, physicians, psychologists), c. obstacles they confronted in reaching diagnosis and treat‐ ment (difficulty in reaching specialized care, difficulty in dealing with education problems). A DSM-IV derived inattention/hyperactivity scale was used in order for parents to rate their chil‐ dren for 18 DSM-IV category A symptoms, on a 4-point scale [20]. This form was used in the fol‐ low up visits of our patients in order to document response to treatment. Therapeutic options were then offered including the use of short acting MPH, with a dosage schedule that called for 5 mg qam or bid at the onset and dosage titration to less than 2.0 mg/kg/day or 60 mg per day [21]. Patients were also offered a psychotherapeutic program focusing in social capabilities practice. Their parents were involved in counseling sessions and were encouraged to participate in sup‐ port and advice groups, aiming at strengthening the net of care around the patients. Other treat‐ ment options were speech therapy, occupational therapy and special education as needed per individual child. The therapy that was actually used as well as the efficacy of the medication was subsequently explored by a different physician 6 months after the initial visit. The safety of the prescribed medication was also explored at that time.

**Study group 2.** Eighty four patients ≤ 18 years old, who were also followed as outpatients in the Pediatric Neurology Department, were included in the current study group. Inclusion criteria were a. ADHD diagnosis and b. the decision to begin treatment with long acting MPH. Doses were calculated according to body weight with the final dose less than 2.0 mg/kg/day or 72 mg/day [21]. All patients had been also offered psychosocial and psychoeducational intervention programs and their parents were involved in counseling sessions as well as support and advice groups. Previous treatment with short acting MPH was not an exclusion criterion in this study.

Six months after treatment initiation, a telephone interview was scheduled by a physician other than the one who prescribed the treatment, in order to determine their satisfaction level from the newly introduced treatment. A four level Likert scale was used for this purpose (0= no satisfaction at all, 1=modest satisfaction, 2=moderate satisfaction, 4=great satisfaction) and free comments on their impressions were encouraged and recorded. The safety of the treatment was also explored.

#### **3. Statistical analysis**

was underutilized and non-conventional therapies were widely used and considered helpful in one-third of the children who used them. A study conducted on 20 low socioeconomic status mothers with children 5-11 years of age with ADHD taking stimulants, aimed to examine the effect of a 5-week educational intervention on ADHD [7]. Parental satisfaction and parental sense of competency improved in mothers who participated in the educational intervention. Psychosocial and psycho-educational interventions as well as pharmacological treatments are effective in reducing ADHD symptom frequency and severity [1]. Stimulant medications are recommended as a first-line modality for treating ADHD [8]. They proved effective in improving both ADHD core symptoms (inattention, hyperactivity and impulsivity) and the behavioral problems that frequently accompany the disorder (such as aggressive behavior, depressive mood, anxiety, tics, impaired social functioning and academic productivity) [9]. Remission of ADHD symptoms via medication provides the best possible chance for educa‐ tional and social re-integration and improved functioning through the utilization of nonpharmacological interventions [10]. Methylphenidate (MPH), a stimulant, is available in immediate and extended release forms. Because the half-life of MPH in immediate-release formulations is short, twice or better thrice daily administration is needed in order to maintain the desirable therapeutic effect. This obviously creates many practical difficulties during school days; it affects the patient's emotions (embarrassment in taking medication at school), it interferes with medical privacy preservation, and contributes to poor compliance with the therapeutic regimen [10-11]. Once-daily MPH in extended release form is significantly more effective than short acting MPH based on multiple outcome measures including remission rate

Satisfaction with medication or any therapeutic intervention is an important factor in the evaluation of overall treatment outcome in ADHD or any other disorder; it is predictive of better adherence and compliance to treatment, and prevents premature treatment termination [17]. It depends primarily on the effectiveness of the drug but it is also influenced by parental and patient expectations, demographic characteristics, social acceptability of the treatment, the relationship between patient/parents and physician as well as the physician's knowledge, competence and ability to communicate with patients and their families [18]. Cultural factors are also very important in the acceptability of the treatment [19]. Furthermore, use of stimulant medication combined with frequent reviews (at least 6 monthly) was more likely to be

The goals of this paper were a. to explore family experiences in seeking diagnosis and treatment of ADHD in an urban community and b. to investigate acceptance and compliance of stimulant medication and specifically the two preparations of MPΗ available in our country, one in

Two independent samples of children fulfilling DSM-IV criteria for ADHD and their families were recruited to test the study goals. Diagnosis was based on the clinical presentation of the child and on specific standardized diagnostic tools and was established by a specialized group of physicians (pediatrician, pediatric neurologist, pediatric psychiatrist), school and clinic

[10,12], with better compliance being a primary factor [13-16].

52 Attention Deficit Hyperactivity Disorder in Children and Adolescents

associated with overall management satisfaction [6].

**2. Patients and methods**

immediate and one in extended-release form (Ritalin and Concerta).

Continuous variables were tested for normalcy with the Kolmogorov - Smirnov test. Normal variables were then presented as mean values (± standard deviation). Categorical variables were expressed either as percentages or as absolute numbers.

**Study group 1.** Descriptive statistics based on the parents' answers are reported.

**Study group 2.** In order to determine the prognostic factors which could affect the satisfaction level from the treatment with long standing methylphenidate a logarithmic regression model was applied with the variable coding the level of satisfaction, used as dependent variable modified to include only two categories (median to great satisfaction versus no to mild satisfaction). As independent variables in the model we used variables coding patients' characteristics (age, sex, ADHD type) and features of the treatment under study (previous treatment with short acting MPH and the response rate to this previous therapy), that may affect the level of satisfaction or that may be important confounding factors. Continuous variables that were introduced in the model were previously centered.

**Study group 2.** Eighty four children, 66 boys and 18 girls, with a mean age of 13 years (± 3 years) were offered treatment with long standing methylphenidate (Table 1). Thirteen of them stopped prematurely or never started treatment and as consequence they were excluded from the statistics. In the subsequent analysis, 71 children who received treatment were finally included (55 males / 16 girls). According to their initial symptoms patients were categorized into three ADHD types: inattentive type 33,4% (ν=23), hyperkinetic/impulsive type 64,8% (ν=46) and mixed type 2,8% (ν=2). The age at diagnosis was 8 years and 4 months (SD = ± 3 years 3 months). Mean age at treatment onset was 10 years 8 months (± 3 years). Fifty of our patients (70.42%) had been previously treated with short acting MP. However, data about response to that treatment were available for 47 patients; with 34 out of them having responded

**Study group1 Study group 2**

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55

13/5/15 23/46/2

**Age** 10 years 3 months ± 2 years 10 months 10 years 8 months ± 3 years

**Male/female** 20/13 55/16

At the time of treatment initiation with the long acting MPH (Concerta), most of our patients (ν=47) were given an initial dose of 18 mg, that was subsequently titled to higher doses. A higher initial dose (36 mg) was given to 33 patients (46.48%) who had high body weight.

Concerning parent satisfaction level, the majority of them (80.28%) reported moderate to full satisfaction, 36.6% moderate satisfaction and 43.7% full satisfaction. The most frequent effect was observed in the attention domain (improvement in 97.18% of the children), followed by the effect in hyperkinetic behaviour (improvement in 63.38% of the children). Impulsivity was not controlled in the majority of the patients (improvement in 19.72% of them). Almost half of the patients reported improvement in two of the ADHD domains (n=34, 47,89%), 12 patients (19,9%) improved in all three domains and only one reported no improvement in any of the domains of the disorder. Thirty eight of the patients previously treated with short acting MPH (80.85%) reported moderate to full satisfaction with the long acting formulation. Only one of the parents who were not satisfied with short acting MPH (n=13) continued to be dissatisfied with the long acting one. Eight patients with good response (2-3) to the short acting MPH,

The logistic regression analysis applied in order to reveal prognostic factors affecting parental satisfaction level showed that only age at treatment initiation with long acting MP was an independent prognostic factor (OR=1.38, 95%CI=1.04 –1.83, p=0.025). Treatment initiation at an older age resulted in higher probability (by 38%) of moderate to full parental satisfaction

**Previous treatment (yes/no)** 0/33 50/21

**Table 1.** Demographic and clinical characteristics of the two study groups

however, were not satisfied with the long-acting MPH.

Lowering this initial dose became necessary in only one patient.

well to that treatment (27 had a good response and 7 a very good response).

**ADHD type (inattention / hyperactive/ combined)**

#### **4. Results**

Table 1 displays a summary of the characteristics of the two study groups.

**Study group 1.** The parents of 33 children (20 boys and 13 girls), 6-16 years old (10 years 3 months ± 2 years 10 months) reported the following: a. The reasons reported for seeking help were: 48.5 % increasing difficulties at home and poor school performance, 21.2 % school recommendation, 18.2 % other developmental problem (such as speech delay) and 12.1% parents' concern about child's behavior. b. Only 3% of our patients were referred by their peadiatrician, while 36.3% were self-referred, 27.3% were referred by a state mental health clinic, 21.2% by a psychologist/speech-therapist or occupational therapist, and 12.2% by a school teacher. c. Over half of the 33 families included in this study group had difficulties in reaching specialized help; more specifically, 33.3% encountered ignorance about ADHDappropriate medical services, 27.3% reported no difficulty, 21.2% encountered lack of appro‐ priate medical services, 12.1%, large waiting lists in hospitals and mental health services and 6.1%, other problems. Almost 50% of them reported ignorance and unwillingness on the part of school teachers to provide help with their children: 45.5 % of the school teachers were ignorant and not helpful, 30.5 % were ignorant but helpful and supportive to the child in the classroom and only 24 % were informed and helpful.

As for their impressions about the disorder, parents' considerations about the cause of ADHD were as follows: 30.3% reported ignorance, 24.3% believed that there was inheritance, 21.2% attributed it to a complication in pregnancy-delivery, 15.2%, to problems in school / family environment, 6%, to some psychological problem and 3%, to a complication due to a disease. Treatment with short acting MPH (Ritalin) was proposed to 91% and 79% of this patient population received Ritalin; of them 95% described benefit in attention and behavior (73% reported major improvement in the ADHD core symptoms, 23% reported little but important improvement). Continuation of treatment was accepted by 63%. Reasons for not accepting continuation of methylphenidate were fear of addiction and unspecified side effects. The medicine was well tolerated by the majority of them with only one having to interrupt the treatment because of gastrointestinal symptoms (vomiting). Other side effects (reported by 38% of the parents) were decreased appetite, sleepiness, tics, nervousness and headache.

**Study group 2.** Eighty four children, 66 boys and 18 girls, with a mean age of 13 years (± 3 years) were offered treatment with long standing methylphenidate (Table 1). Thirteen of them stopped prematurely or never started treatment and as consequence they were excluded from the statistics. In the subsequent analysis, 71 children who received treatment were finally included (55 males / 16 girls). According to their initial symptoms patients were categorized into three ADHD types: inattentive type 33,4% (ν=23), hyperkinetic/impulsive type 64,8% (ν=46) and mixed type 2,8% (ν=2). The age at diagnosis was 8 years and 4 months (SD = ± 3 years 3 months). Mean age at treatment onset was 10 years 8 months (± 3 years). Fifty of our patients (70.42%) had been previously treated with short acting MP. However, data about response to that treatment were available for 47 patients; with 34 out of them having responded well to that treatment (27 had a good response and 7 a very good response).


**Table 1.** Demographic and clinical characteristics of the two study groups

**Study group 1.** Descriptive statistics based on the parents' answers are reported.

54 Attention Deficit Hyperactivity Disorder in Children and Adolescents

variables that were introduced in the model were previously centered.

Table 1 displays a summary of the characteristics of the two study groups.

classroom and only 24 % were informed and helpful.

**4. Results**

**Study group 2.** In order to determine the prognostic factors which could affect the satisfaction level from the treatment with long standing methylphenidate a logarithmic regression model was applied with the variable coding the level of satisfaction, used as dependent variable modified to include only two categories (median to great satisfaction versus no to mild satisfaction). As independent variables in the model we used variables coding patients' characteristics (age, sex, ADHD type) and features of the treatment under study (previous treatment with short acting MPH and the response rate to this previous therapy), that may affect the level of satisfaction or that may be important confounding factors. Continuous

**Study group 1.** The parents of 33 children (20 boys and 13 girls), 6-16 years old (10 years 3 months ± 2 years 10 months) reported the following: a. The reasons reported for seeking help were: 48.5 % increasing difficulties at home and poor school performance, 21.2 % school recommendation, 18.2 % other developmental problem (such as speech delay) and 12.1% parents' concern about child's behavior. b. Only 3% of our patients were referred by their peadiatrician, while 36.3% were self-referred, 27.3% were referred by a state mental health clinic, 21.2% by a psychologist/speech-therapist or occupational therapist, and 12.2% by a school teacher. c. Over half of the 33 families included in this study group had difficulties in reaching specialized help; more specifically, 33.3% encountered ignorance about ADHDappropriate medical services, 27.3% reported no difficulty, 21.2% encountered lack of appro‐ priate medical services, 12.1%, large waiting lists in hospitals and mental health services and 6.1%, other problems. Almost 50% of them reported ignorance and unwillingness on the part of school teachers to provide help with their children: 45.5 % of the school teachers were ignorant and not helpful, 30.5 % were ignorant but helpful and supportive to the child in the

As for their impressions about the disorder, parents' considerations about the cause of ADHD were as follows: 30.3% reported ignorance, 24.3% believed that there was inheritance, 21.2% attributed it to a complication in pregnancy-delivery, 15.2%, to problems in school / family environment, 6%, to some psychological problem and 3%, to a complication due to a disease. Treatment with short acting MPH (Ritalin) was proposed to 91% and 79% of this patient population received Ritalin; of them 95% described benefit in attention and behavior (73% reported major improvement in the ADHD core symptoms, 23% reported little but important improvement). Continuation of treatment was accepted by 63%. Reasons for not accepting continuation of methylphenidate were fear of addiction and unspecified side effects. The medicine was well tolerated by the majority of them with only one having to interrupt the treatment because of gastrointestinal symptoms (vomiting). Other side effects (reported by 38% of the parents) were decreased appetite, sleepiness, tics, nervousness and headache.

At the time of treatment initiation with the long acting MPH (Concerta), most of our patients (ν=47) were given an initial dose of 18 mg, that was subsequently titled to higher doses. A higher initial dose (36 mg) was given to 33 patients (46.48%) who had high body weight. Lowering this initial dose became necessary in only one patient.

Concerning parent satisfaction level, the majority of them (80.28%) reported moderate to full satisfaction, 36.6% moderate satisfaction and 43.7% full satisfaction. The most frequent effect was observed in the attention domain (improvement in 97.18% of the children), followed by the effect in hyperkinetic behaviour (improvement in 63.38% of the children). Impulsivity was not controlled in the majority of the patients (improvement in 19.72% of them). Almost half of the patients reported improvement in two of the ADHD domains (n=34, 47,89%), 12 patients (19,9%) improved in all three domains and only one reported no improvement in any of the domains of the disorder. Thirty eight of the patients previously treated with short acting MPH (80.85%) reported moderate to full satisfaction with the long acting formulation. Only one of the parents who were not satisfied with short acting MPH (n=13) continued to be dissatisfied with the long acting one. Eight patients with good response (2-3) to the short acting MPH, however, were not satisfied with the long-acting MPH.

The logistic regression analysis applied in order to reveal prognostic factors affecting parental satisfaction level showed that only age at treatment initiation with long acting MP was an independent prognostic factor (OR=1.38, 95%CI=1.04 –1.83, p=0.025). Treatment initiation at an older age resulted in higher probability (by 38%) of moderate to full parental satisfaction from the treatment, with the type of ADHD, sex and the previous treatment with short acting MP treated as confounding factors (p=0,423 p=0,963 and p=0.299, respectively). Similar results were also reported when the analysis was restricted to the subset of patients who were previously treated with the short acting regimen. In this analysis we also examined the response rate to the previous medication as an important prognostic factor. Age at treatment with long acting MPH onset was again the only significant determinant of parental satisfaction (OR= 1.49, 95%CI= 1.05-2.11 p=0.026). ADHD type, sex and response to Ritalin (moderate to full response vs no response to modest response) were not significant covariates (p=0.929, 0.543 and p=0.320, respectively).

of problems and their perception of hyperactivity as a symptom of a disorder, rather than a childhood feature, were reported as to the most significant factors influencing contact with

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Recognition of the disorder by primary care physicians, though, was related to both child and parent factors (especially the first). Non-recognition of ADHD in the primary care setting was the main barrier to further accessing specialist services [39]; when the parent was unaware or reticent about the possibility of requesting a referral, then the diagnosis could be missed. Therefore, parental request for referral and thus parental recognition of hyperactive behaviour as problematic plays a crucial role in accessing primary care as well as specialist services [39]. Race has been one of the factors contributing to barriers in diagnosis; Caucasian children had twice the odds of being brought to attention than other racial groups, with boys having a 5 fold increased possibility of being evaluated [32]. Ethnic minorities had a lower rate of diagnosis and treatment for the disorder. Those racial/ethnic disparities in service use are the result of a combination of access barriers and individual, cultural, and societal factors [40]. After the diagnosis of ADHD was established, Hispanic families used the fewest services, single-mother families used the most of them and families with boys with ADHD used more services as compared to families with girls with ADHD [38]. Surprisingly, economic status of the family was not a stable prognostic factor of accessibility and usage of specialized services. In the study of Kendall et al income was not a significant factor in any services used or services requested, whereas in the study of Bussing et al poverty status was associated with lower

Another striking finding of this study was that only 3% of patients were referred to specialized care by a pediatrician; this points to the need for better education of paediatricians on ADHD and dissemination of existing knowledge and guidelines on diagnosis and treatment. Accord‐ ing to clinicians' perceptions about ADHD, the diagnostic process is considered complicated, time-consuming and experience requiring, while published guidelines were viewed as vague [42]. Referral rate by school teachers was also quite low (approximately 12%); we believe that lack of appropriate education of the teachers on ADHD seems to be the most important factor. In a survey aiming at exploring perceptions of ADHD with a focus on gender differences, many teachers reported that they have received little or no education in ADHD as part of their curriculum (with only 10% of schools providing significant training for teachers on ADHD), while few reported having received significant training [43]. Moreover, half of the interviewed teachers revealed that even when they suspected that a child suffered of ADHD, they hesitated to inform his/hers parent or guardian. The years of experience with hyperactive children, the number of hyperactive pupils in their classrooms, and the level of perceived self-efficacy of the teachers seems to have a positive correlation with their knowledge about ADHD, which is focusing more on symptoms and diagnosis [44]. Lack of educational support and teachers' understanding of ADHD were also identified as problems, in the study of Concannon and

Concerning perceptions about the etiology of ADHD, one third of the parents we contacted had complete ignorance about causes of ADHD, almost 20% believed that environmental and psychological factors had a causal relationship and the remainder attributed the disorder to a

treatment rates and with the most pervasive barriers [31, 41].

medical services [32, 39].

Tang [6].

#### **5. Discussion**

Families of children with ADHD frequently experience considerable emotional and financial stressors [21-23]. These harmful effects of ADHD on patients and families affirm the need for effective treatment and make it a public health concern [24]. Children with ADHD require more than 1.5 times more primary care visits, 9 times more outpatient mental health visits, and 3 times more prescriptions per year, compared to children without ADHD [25]. It was estimated that the total annual health care costs for children with ADHD is more than twice that of children without the disorder, and these costs become significantly larger when a child with ADHD is diagnosed with a comorbid condition [25-27]. It is also noted that the direct cost of treatment for this disorder has increased considerably during the last years. The increase in expenditure for the treatment of ADHD may be due to increasing demand for diagnostic and therapeutic services and improved availability of such services. [28-30].

The first important finding of this study was that only one fourth of the families studied (Study group 1) reported an easy accessibility to appropriate services for the diagnosis and therapy of ADHD in their children. Several barriers to the diagnosis of the disorder have been previ‐ ously reported. It is interesting to note that, although parents usually realize that something is wrong with their child, especially if symptoms are severe, they are not always seeking medical advice. In 2003, Bussing et al demonstrated that whereas 88% of high risk for ADHD elementary school students were recognized as having a problem, only 39% had been evalu‐ ated [31]. Few years later, in 2006, Sayal et al, in another study exploring barriers to the identification of ADHD, found that the main barrier to care for ADHD is the limited presen‐ tation of these problems to primary care [32]. Although most of the parents contacted (80%) recognized that their child had a problem, only few had consulted primary care physicians or had sought help from specialist health services while some had been in contact with profes‐ sionals in educational services. On the other hand, Leslie and coworkers suggested the existence of a pattern of delayed diagnosis, mostly associated with failure to recognize ADHD by parents/ caregivers [33]. This pattern was more common among youths with complicated clinical and/or environmental factors or primarily symptoms of inattention. Delayed diagnosis was reported especially in girls with ADHD, due to the predominance of symptoms of inattention rather than hyperactivity/impulsivity as compared to boys [34-35] and due to the lower frequency of conduct disorder, aggression, or delinquency [35-38]. Parental recognition of problems and their perception of hyperactivity as a symptom of a disorder, rather than a childhood feature, were reported as to the most significant factors influencing contact with medical services [32, 39].

from the treatment, with the type of ADHD, sex and the previous treatment with short acting MP treated as confounding factors (p=0,423 p=0,963 and p=0.299, respectively). Similar results were also reported when the analysis was restricted to the subset of patients who were previously treated with the short acting regimen. In this analysis we also examined the response rate to the previous medication as an important prognostic factor. Age at treatment with long acting MPH onset was again the only significant determinant of parental satisfaction (OR= 1.49, 95%CI= 1.05-2.11 p=0.026). ADHD type, sex and response to Ritalin (moderate to full response vs no response to modest response) were not significant covariates (p=0.929, 0.543

Families of children with ADHD frequently experience considerable emotional and financial stressors [21-23]. These harmful effects of ADHD on patients and families affirm the need for effective treatment and make it a public health concern [24]. Children with ADHD require more than 1.5 times more primary care visits, 9 times more outpatient mental health visits, and 3 times more prescriptions per year, compared to children without ADHD [25]. It was estimated that the total annual health care costs for children with ADHD is more than twice that of children without the disorder, and these costs become significantly larger when a child with ADHD is diagnosed with a comorbid condition [25-27]. It is also noted that the direct cost of treatment for this disorder has increased considerably during the last years. The increase in expenditure for the treatment of ADHD may be due to increasing demand for diagnostic and

The first important finding of this study was that only one fourth of the families studied (Study group 1) reported an easy accessibility to appropriate services for the diagnosis and therapy of ADHD in their children. Several barriers to the diagnosis of the disorder have been previ‐ ously reported. It is interesting to note that, although parents usually realize that something is wrong with their child, especially if symptoms are severe, they are not always seeking medical advice. In 2003, Bussing et al demonstrated that whereas 88% of high risk for ADHD elementary school students were recognized as having a problem, only 39% had been evalu‐ ated [31]. Few years later, in 2006, Sayal et al, in another study exploring barriers to the identification of ADHD, found that the main barrier to care for ADHD is the limited presen‐ tation of these problems to primary care [32]. Although most of the parents contacted (80%) recognized that their child had a problem, only few had consulted primary care physicians or had sought help from specialist health services while some had been in contact with profes‐ sionals in educational services. On the other hand, Leslie and coworkers suggested the existence of a pattern of delayed diagnosis, mostly associated with failure to recognize ADHD by parents/ caregivers [33]. This pattern was more common among youths with complicated clinical and/or environmental factors or primarily symptoms of inattention. Delayed diagnosis was reported especially in girls with ADHD, due to the predominance of symptoms of inattention rather than hyperactivity/impulsivity as compared to boys [34-35] and due to the lower frequency of conduct disorder, aggression, or delinquency [35-38]. Parental recognition

therapeutic services and improved availability of such services. [28-30].

and p=0.320, respectively).

56 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**5. Discussion**

Recognition of the disorder by primary care physicians, though, was related to both child and parent factors (especially the first). Non-recognition of ADHD in the primary care setting was the main barrier to further accessing specialist services [39]; when the parent was unaware or reticent about the possibility of requesting a referral, then the diagnosis could be missed. Therefore, parental request for referral and thus parental recognition of hyperactive behaviour as problematic plays a crucial role in accessing primary care as well as specialist services [39]. Race has been one of the factors contributing to barriers in diagnosis; Caucasian children had twice the odds of being brought to attention than other racial groups, with boys having a 5 fold increased possibility of being evaluated [32]. Ethnic minorities had a lower rate of diagnosis and treatment for the disorder. Those racial/ethnic disparities in service use are the result of a combination of access barriers and individual, cultural, and societal factors [40]. After the diagnosis of ADHD was established, Hispanic families used the fewest services, single-mother families used the most of them and families with boys with ADHD used more services as compared to families with girls with ADHD [38]. Surprisingly, economic status of the family was not a stable prognostic factor of accessibility and usage of specialized services. In the study of Kendall et al income was not a significant factor in any services used or services requested, whereas in the study of Bussing et al poverty status was associated with lower treatment rates and with the most pervasive barriers [31, 41].

Another striking finding of this study was that only 3% of patients were referred to specialized care by a pediatrician; this points to the need for better education of paediatricians on ADHD and dissemination of existing knowledge and guidelines on diagnosis and treatment. Accord‐ ing to clinicians' perceptions about ADHD, the diagnostic process is considered complicated, time-consuming and experience requiring, while published guidelines were viewed as vague [42]. Referral rate by school teachers was also quite low (approximately 12%); we believe that lack of appropriate education of the teachers on ADHD seems to be the most important factor. In a survey aiming at exploring perceptions of ADHD with a focus on gender differences, many teachers reported that they have received little or no education in ADHD as part of their curriculum (with only 10% of schools providing significant training for teachers on ADHD), while few reported having received significant training [43]. Moreover, half of the interviewed teachers revealed that even when they suspected that a child suffered of ADHD, they hesitated to inform his/hers parent or guardian. The years of experience with hyperactive children, the number of hyperactive pupils in their classrooms, and the level of perceived self-efficacy of the teachers seems to have a positive correlation with their knowledge about ADHD, which is focusing more on symptoms and diagnosis [44]. Lack of educational support and teachers' understanding of ADHD were also identified as problems, in the study of Concannon and Tang [6].

Concerning perceptions about the etiology of ADHD, one third of the parents we contacted had complete ignorance about causes of ADHD, almost 20% believed that environmental and psychological factors had a causal relationship and the remainder attributed the disorder to a medical condition/disease or to inheritance. Perceptions about ADHD causes have evolved during the recent years in different communities. Almost two decades before, the disorder was attributed to poor diet, antisocial conduct, lack of discipline, emotional problems at school and in interpersonal relations [45]. Yet, even today an impressing reluctance to accept the biomed‐ ical explanation of ADHD exists, especially in developing countries. Psychological problems, socio-environmental factors, learning and memory difficulties, inappropriate parenting and disciplinary practices [46-49] continue to be seen as possible causes. Guilt and self-blame, accusations towards the spouse and concerns about the volitional or non-volitional nature of the problem, still, prevail in parents' beliefs. In a study conducted in Greece, parents were more likely to report intentionality in boys with ADHD than in girls whereas biological dysfunction was considered as a more likely etiology in girls than in boys [50].

reasons for hesitating to start medication were concerns about side effects, worries about the stigma associated with ADHD or its treatment and concerns about medication (the belief that the medication would lead to drug addiction in adulthood) [43, 46]. Factors associated with earlier initiation of MPH treatment were older age, sex (with parents of girls being more willing to start medication), lower socioeconomic status, diagnosis of the disorder while school was in session, diagnosis from a physician specializing in pediatrics or psychiatry, and diagnosis in a district hospital/clinic [43, 52]. Patients more severely ill and/or having co-morbidities had also a greater possibility of receiving treatment [61] In a study aiming to evaluate predictors of long-term adherence to treatment with methylphenidate the authors reported that the presence of associated disorders, younger age, female gender, and single-parent families were predictors for continuing medication for 36 months (study duration) [62]. On the contrary, older age, medication concerns, the absence of associated disorders and serious side effects appeared to increase the risk of discontinuation of the treatment or loss to follow up [52, 62, 63, 65]. Generally, ADHD medication adherence and persistence seems to be suboptimal, with patients using non-stimulant medication being more compliant compared to stimulant users. Since ADHD can be effectively treated with medications, health professionals should be proactive in identifying patients with poor adherence and intervene to address barriers to medication adherence and persistence [66]. In this study, the reasons for treatment discontin‐

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Side effects reported in this study included mostly gastrointestinal and central nervous system symptoms. This finding is in accordance with a recent review in which, decrease in appetite, gastrointestinal pain, and headache were considered as the most frequently reported adverse reactions, with very few of them being rated as serious. However, since a large number of children drop out of studies due to serious side effects, it is believed that their actual number is probably higher. These side effects are reported in clinical studies of short duration, whereas long term safety is still a matter of research [69, 71]. Concerns about possible harm, especially, from the newly developed ADHD drugs have arisen, focusing on both minor adverse effects and extremely serious issues such as sudden cardiac death and suicidality [72]. Another important finding in this study was that a great percentage of the ADHD parents expressed at least moderate satisfaction from the long acting MPH. This is not surprising since previous studies had advocated overall medication satisfaction, as expressed by patients, parents/ caregivers and/or physicians. Generally, satisfaction with stimulant medication as the sole therapy has been shown to be relatively high and 63–87% of patients, parents and teachers made positive assessments [11, 64, 69 -70]. In most of these studies, the researchers explored satisfaction rates for long acting MPH as compared to short acting MPH. In a study presented at the 2004 Annual Meeting of the Canadian Academy of Child and Adolescent Psychiatry, on the pharmacological evolutions concerning ADHD, Swanson and Hechtman reported significantly higher remission rates and significantly higher Clinical Global Impression and parent satisfaction scores with long acting MPH as compared to short acting MPH (results from an 8-week open-label trial) [71]. Similar results were presented in 2006, in another 8 week, multicentre, randomized, open-label study in which 147 ADHD patients (6-12 years old) received either once-daily long acting MPH or usual care with the short acting regimen. The first drug proved to be superior to the latter in terms of remission rate, severity of ADHD and

uation were side effects and fears of addiction to treatment.

In this study, we explored attitudes towards ADHD treatment among the families that participated. In the first part of this study, 79% of the parents accepted MPH treatment following medical advice but only 63% finally continued the therapy. The respective percent‐ age of the second study group for treatment initiation/6-month continuation was 84.5%, which is considerably increased compared to the first one; this difference could be attributed to the evolution of time, (study 1 preceded chronologically study 2). Yet, both rates are quite high. Hoare et al, reported that 88.1% of their sample wanted their child to continue treatment more than 21 days (the initial trial period) and 63 % completed the 1-year trial (extension phase) [51]. In contrast, Chen et al reported that approximately 30% of young people received MPH treatment within one year after diagnosis, and virtually none remained in treatment beyond 12 months [52]. Sample study composition may be responsible for the discrepancy among our results and those of Hoare et al in one hand and the results of Chen et al in the other hand. In the study of Chen et al, only newly diagnosed, and thus treatment naive, children were enrolled, whereas in our study more than half of the participants had previously used the short acting MPH regimen and in the study of Hoare and coworkers, all participants had changed from the short to the long acting MPH medication. It is reported that, despite high response rates to the pharmacotherapy (approximately 70% or more when patients were strictly complying with the treatment) [53-55], parents and teachers consider non-pharmacological therapies or the combination of pharmacological and non-pharmacological therapies to be more acceptable [54, 56-59]. Leslie et al suggested three types of parental reactions to medica‐ tion proposal: a pattern of preference towards non medication treatment as their initial choice; a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and a rapid engagement in medication use pattern, characterized by directed movement to and maintenance of medication use [33].

Treatment decisions in ADHD are usually the result of a shared process between families, children, and the clinician [42]. Parents and clinicians conceptualize ADHD differently and they should negotiate a shared understanding of ADHD. Parents' terms reflected ADHD's effects on the child and family, while clinicians often mentioned school. Treatment discussions should be tailored to encompass families' varied emotional and educational needs [60]. Recognition of a medical etiology for the disorder was the most influential factor reported in willingness to accept drugs and/or combination treatment [58-59]. On the other hand, the main reasons for hesitating to start medication were concerns about side effects, worries about the stigma associated with ADHD or its treatment and concerns about medication (the belief that the medication would lead to drug addiction in adulthood) [43, 46]. Factors associated with earlier initiation of MPH treatment were older age, sex (with parents of girls being more willing to start medication), lower socioeconomic status, diagnosis of the disorder while school was in session, diagnosis from a physician specializing in pediatrics or psychiatry, and diagnosis in a district hospital/clinic [43, 52]. Patients more severely ill and/or having co-morbidities had also a greater possibility of receiving treatment [61] In a study aiming to evaluate predictors of long-term adherence to treatment with methylphenidate the authors reported that the presence of associated disorders, younger age, female gender, and single-parent families were predictors for continuing medication for 36 months (study duration) [62]. On the contrary, older age, medication concerns, the absence of associated disorders and serious side effects appeared to increase the risk of discontinuation of the treatment or loss to follow up [52, 62, 63, 65]. Generally, ADHD medication adherence and persistence seems to be suboptimal, with patients using non-stimulant medication being more compliant compared to stimulant users. Since ADHD can be effectively treated with medications, health professionals should be proactive in identifying patients with poor adherence and intervene to address barriers to medication adherence and persistence [66]. In this study, the reasons for treatment discontin‐ uation were side effects and fears of addiction to treatment.

medical condition/disease or to inheritance. Perceptions about ADHD causes have evolved during the recent years in different communities. Almost two decades before, the disorder was attributed to poor diet, antisocial conduct, lack of discipline, emotional problems at school and in interpersonal relations [45]. Yet, even today an impressing reluctance to accept the biomed‐ ical explanation of ADHD exists, especially in developing countries. Psychological problems, socio-environmental factors, learning and memory difficulties, inappropriate parenting and disciplinary practices [46-49] continue to be seen as possible causes. Guilt and self-blame, accusations towards the spouse and concerns about the volitional or non-volitional nature of the problem, still, prevail in parents' beliefs. In a study conducted in Greece, parents were more likely to report intentionality in boys with ADHD than in girls whereas biological dysfunction

In this study, we explored attitudes towards ADHD treatment among the families that participated. In the first part of this study, 79% of the parents accepted MPH treatment following medical advice but only 63% finally continued the therapy. The respective percent‐ age of the second study group for treatment initiation/6-month continuation was 84.5%, which is considerably increased compared to the first one; this difference could be attributed to the evolution of time, (study 1 preceded chronologically study 2). Yet, both rates are quite high. Hoare et al, reported that 88.1% of their sample wanted their child to continue treatment more than 21 days (the initial trial period) and 63 % completed the 1-year trial (extension phase) [51]. In contrast, Chen et al reported that approximately 30% of young people received MPH treatment within one year after diagnosis, and virtually none remained in treatment beyond 12 months [52]. Sample study composition may be responsible for the discrepancy among our results and those of Hoare et al in one hand and the results of Chen et al in the other hand. In the study of Chen et al, only newly diagnosed, and thus treatment naive, children were enrolled, whereas in our study more than half of the participants had previously used the short acting MPH regimen and in the study of Hoare and coworkers, all participants had changed from the short to the long acting MPH medication. It is reported that, despite high response rates to the pharmacotherapy (approximately 70% or more when patients were strictly complying with the treatment) [53-55], parents and teachers consider non-pharmacological therapies or the combination of pharmacological and non-pharmacological therapies to be more acceptable [54, 56-59]. Leslie et al suggested three types of parental reactions to medica‐ tion proposal: a pattern of preference towards non medication treatment as their initial choice; a reluctant receipt of an ADHD diagnosis and/or treatment pattern, mainly seen among the low-income, Spanish-speaking families; and a rapid engagement in medication use pattern,

characterized by directed movement to and maintenance of medication use [33].

Treatment decisions in ADHD are usually the result of a shared process between families, children, and the clinician [42]. Parents and clinicians conceptualize ADHD differently and they should negotiate a shared understanding of ADHD. Parents' terms reflected ADHD's effects on the child and family, while clinicians often mentioned school. Treatment discussions should be tailored to encompass families' varied emotional and educational needs [60]. Recognition of a medical etiology for the disorder was the most influential factor reported in willingness to accept drugs and/or combination treatment [58-59]. On the other hand, the main

was considered as a more likely etiology in girls than in boys [50].

58 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Side effects reported in this study included mostly gastrointestinal and central nervous system symptoms. This finding is in accordance with a recent review in which, decrease in appetite, gastrointestinal pain, and headache were considered as the most frequently reported adverse reactions, with very few of them being rated as serious. However, since a large number of children drop out of studies due to serious side effects, it is believed that their actual number is probably higher. These side effects are reported in clinical studies of short duration, whereas long term safety is still a matter of research [69, 71]. Concerns about possible harm, especially, from the newly developed ADHD drugs have arisen, focusing on both minor adverse effects and extremely serious issues such as sudden cardiac death and suicidality [72]. Another important finding in this study was that a great percentage of the ADHD parents expressed at least moderate satisfaction from the long acting MPH. This is not surprising since previous studies had advocated overall medication satisfaction, as expressed by patients, parents/ caregivers and/or physicians. Generally, satisfaction with stimulant medication as the sole therapy has been shown to be relatively high and 63–87% of patients, parents and teachers made positive assessments [11, 64, 69 -70]. In most of these studies, the researchers explored satisfaction rates for long acting MPH as compared to short acting MPH. In a study presented at the 2004 Annual Meeting of the Canadian Academy of Child and Adolescent Psychiatry, on the pharmacological evolutions concerning ADHD, Swanson and Hechtman reported significantly higher remission rates and significantly higher Clinical Global Impression and parent satisfaction scores with long acting MPH as compared to short acting MPH (results from an 8-week open-label trial) [71]. Similar results were presented in 2006, in another 8 week, multicentre, randomized, open-label study in which 147 ADHD patients (6-12 years old) received either once-daily long acting MPH or usual care with the short acting regimen. The first drug proved to be superior to the latter in terms of remission rate, severity of ADHD and ODD symptoms, Clinical Global Impression-Improvement, Parent Satisfaction with treatment (50% of parents were 'completely satisfied' with long acting MPH given once daily, compared with 21% with the short acting MPH given two or three times daily) and other secondary outcome scores [10]. In 2005, Hoare at al, also, reported that in the case of children previously treated with the short acting regimen and then switched to the long lasting one (n=105), the parent/caregiver global assessment of satisfaction ranged from 49 to 69% after an initial 21 day trial, and 49 to 71% of investigators rated the treatment as adequate [51]. Finally, in a double-blind comparison of a long-acting MPH formulation (osmotic release oral system [OROS] MPH [Concerta, Janssen-Cilag Ltd]) given once-daily versus three-times-daily MPH-IR, 47% of parents preferred the long-acting formulation, 31% the IR formulation, and 15% their previous MPH treatment [72].

satisfaction rates if their children showed a greater reduction in ADHD symptoms and greater improvements in all QoL domains [18]. They argued that symptom severity and/or functional impairment at the end of the study, as well as QoL, were the most significant predictors for parent and patient satisfaction. They also showed that satisfaction with medication slightly but significantly increased during the treatment and as time passed (from visit 1 to visit 3).

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Limitation 1: One major limitation of this study was that parents' satisfaction was assessed by asking parents how satisfied they were, using a Likert scale. At the time of study conduction, there were no standardized and validated rating scales for satisfaction in Greek, not to mention that the whole concept of using such scales was new. The method we used is clearly not consistent or uniform and prevents the conduction of immediately comparable studies [19]. In the literature on ADHD, measures of satisfaction with medication such as the medication satisfaction questionnaire (MSS) [76] or the parent consumer satisfaction questionnaire (PCSQ) [77] exist and these were not used by us. In a recent study, another measure, the satisfaction with medication scale (SAMS) has been validated [18]. This new rating scale was designed to assess the satisfaction with ADHD medication of parents and children on a per item basis. It would be very informative if a new study using these measures is conducted in our setting. Limitation 2: Satisfaction level in our study was reported only for parents/caregivers. Pa‐ tient satisfaction with medication though may be an important factor in the evaluation of overall treatment outcome [64]. In order for treatments to be considered effective, they have to be viewed favorably by patients who also have to be willing to use them [19]. Al‐ though parental satisfaction is usually in accordance with the child's feeling on treatment effect, this is not always the case. In a double-blind crossover study child and parent per‐ ceptions of treatment with stimulant medication in a sample of 102 children with ADHD was attempted; disagreement between child and parental perceptions of treatment re‐ sponse existed in >25%. This involved mostly parental viewing of the child's response fa‐ vorably, while the child's rating was unfavorable; side-effects were the main determinant of children's perceptions of adverse outcome. Thus, parental report alone is not infallible in providing reliable information regarding effects as experienced by the child [58]. In an‐ other study consisting of 79 child-parent peers, few differences between parents and chil‐ dren for positive effects existed, although parents reported higher levels of negative effects. This result suggested that parents' considerations clearly have an influence on the way children perceive medication [69]. In the study of Gortz-Dorten et al, patients report‐ ed slightly but significantly higher satisfaction than parents. Overall satisfaction with the medication was high for 79.0% of patients and 66.1% of children also reported high satis‐ faction with how the medication helped them feel good. In conclusion, it is important to assess parental and child perspectives separately, with comparable questions, as their per‐

The results of our study need to be viewed in light of several limitations.

ceptions of medication are correlated, but only to a moderate degree [18].

Limitation 3: This was an observational study; assuch, selection of participants was based on loose criteria and treatment conditions are less controlled and standardized. This study design could be considered an advantage, from a different point of view, as it reflects routine care conditions in a pragmatic setting. This could be especially true for studies evaluating satisfac‐

In this study, the vast majority (~81%) of the patients' subgroup previously treated with the short-acting regimen were at least moderately satisfied. From those parents who reported a good response with the short acting MPH, 26/34 were satisfied with the long acting one and only 8/34 were not. From those exhibiting an inadequate response with the short acting MPH, 12/13 subsequently report moderate to full satisfaction. This is consistent with previous results, according to which, switching from one MPH preparation to another appears to be a valid clinical approach that may contribute to treatment success. Four factors were postulated to be responsible of the observed improvement in various treatment outcomes: first, the increase (and thus optimization) of MPH dose; second, the shorter intervals between visits directly after switching, leading to more intense education and guidance of those involved; third, a positive expectation of improvement by all participants; and fourth, a possible increase in adherence in the long-term [18, 73-74]. On the other hand, dissatisfaction rate does not necessarily reflect low efficiency. In the study of Gortz-Dorten et al, approximately 30% of parents were dissat‐ isfied with the medication, while efficacy was highly rated, making treatment individualiza‐ tion a very important aspect of the pharmacological treatment [18].

In our study, most parents reported satisfaction with the MPH effect especially for inattention symptoms, followed by the satisfaction rate on the hyperkinetic behavior. This high satisfac‐ tion rate on the grounds of improvement in attention had also been reported in a recent study, in the school setting and in academic situations [18]. The overall parental satisfaction with the medication exceeded the percentage of 70% (63-75.6%). The parents were also very satisfied with the effects of the drug in the children's social interactions with other children and within the family. Finally, almost 56% of parents also reported high satisfaction with how the medication helped their child feel good. These results are supported by other studies, per‐ formed in the UK and in Sweden [70, 75].

Finally, according to our results, age at treatment initiation was a significant determinant of level of parent satisfaction. We were not able though to relate parent satisfaction with type of ADHD, sex of the patient or the previous experience with short acting MPH. In 2005, Hoare et al, exploring the efficacy of long acting MPH in the long term (12 months) reported that efficacy and satisfaction were more common in patients of older age (10-16 years), those on a higher dose (36 mg or 54 mg) and those with the predominantly inattentive ADHD subtype [51], results only partly in aggreement with ours. In another study, parents expressed higher satisfaction rates if their children showed a greater reduction in ADHD symptoms and greater improvements in all QoL domains [18]. They argued that symptom severity and/or functional impairment at the end of the study, as well as QoL, were the most significant predictors for parent and patient satisfaction. They also showed that satisfaction with medication slightly but significantly increased during the treatment and as time passed (from visit 1 to visit 3).

The results of our study need to be viewed in light of several limitations.

ODD symptoms, Clinical Global Impression-Improvement, Parent Satisfaction with treatment (50% of parents were 'completely satisfied' with long acting MPH given once daily, compared with 21% with the short acting MPH given two or three times daily) and other secondary outcome scores [10]. In 2005, Hoare at al, also, reported that in the case of children previously treated with the short acting regimen and then switched to the long lasting one (n=105), the parent/caregiver global assessment of satisfaction ranged from 49 to 69% after an initial 21 day trial, and 49 to 71% of investigators rated the treatment as adequate [51]. Finally, in a double-blind comparison of a long-acting MPH formulation (osmotic release oral system [OROS] MPH [Concerta, Janssen-Cilag Ltd]) given once-daily versus three-times-daily MPH-IR, 47% of parents preferred the long-acting formulation, 31% the IR formulation, and 15%

In this study, the vast majority (~81%) of the patients' subgroup previously treated with the short-acting regimen were at least moderately satisfied. From those parents who reported a good response with the short acting MPH, 26/34 were satisfied with the long acting one and only 8/34 were not. From those exhibiting an inadequate response with the short acting MPH, 12/13 subsequently report moderate to full satisfaction. This is consistent with previous results, according to which, switching from one MPH preparation to another appears to be a valid clinical approach that may contribute to treatment success. Four factors were postulated to be responsible of the observed improvement in various treatment outcomes: first, the increase (and thus optimization) of MPH dose; second, the shorter intervals between visits directly after switching, leading to more intense education and guidance of those involved; third, a positive expectation of improvement by all participants; and fourth, a possible increase in adherence in the long-term [18, 73-74]. On the other hand, dissatisfaction rate does not necessarily reflect low efficiency. In the study of Gortz-Dorten et al, approximately 30% of parents were dissat‐ isfied with the medication, while efficacy was highly rated, making treatment individualiza‐

In our study, most parents reported satisfaction with the MPH effect especially for inattention symptoms, followed by the satisfaction rate on the hyperkinetic behavior. This high satisfac‐ tion rate on the grounds of improvement in attention had also been reported in a recent study, in the school setting and in academic situations [18]. The overall parental satisfaction with the medication exceeded the percentage of 70% (63-75.6%). The parents were also very satisfied with the effects of the drug in the children's social interactions with other children and within the family. Finally, almost 56% of parents also reported high satisfaction with how the medication helped their child feel good. These results are supported by other studies, per‐

Finally, according to our results, age at treatment initiation was a significant determinant of level of parent satisfaction. We were not able though to relate parent satisfaction with type of ADHD, sex of the patient or the previous experience with short acting MPH. In 2005, Hoare et al, exploring the efficacy of long acting MPH in the long term (12 months) reported that efficacy and satisfaction were more common in patients of older age (10-16 years), those on a higher dose (36 mg or 54 mg) and those with the predominantly inattentive ADHD subtype [51], results only partly in aggreement with ours. In another study, parents expressed higher

tion a very important aspect of the pharmacological treatment [18].

their previous MPH treatment [72].

60 Attention Deficit Hyperactivity Disorder in Children and Adolescents

formed in the UK and in Sweden [70, 75].

Limitation 1: One major limitation of this study was that parents' satisfaction was assessed by asking parents how satisfied they were, using a Likert scale. At the time of study conduction, there were no standardized and validated rating scales for satisfaction in Greek, not to mention that the whole concept of using such scales was new. The method we used is clearly not consistent or uniform and prevents the conduction of immediately comparable studies [19]. In the literature on ADHD, measures of satisfaction with medication such as the medication satisfaction questionnaire (MSS) [76] or the parent consumer satisfaction questionnaire (PCSQ) [77] exist and these were not used by us. In a recent study, another measure, the satisfaction with medication scale (SAMS) has been validated [18]. This new rating scale was designed to assess the satisfaction with ADHD medication of parents and children on a per item basis. It would be very informative if a new study using these measures is conducted in our setting.

Limitation 2: Satisfaction level in our study was reported only for parents/caregivers. Pa‐ tient satisfaction with medication though may be an important factor in the evaluation of overall treatment outcome [64]. In order for treatments to be considered effective, they have to be viewed favorably by patients who also have to be willing to use them [19]. Al‐ though parental satisfaction is usually in accordance with the child's feeling on treatment effect, this is not always the case. In a double-blind crossover study child and parent per‐ ceptions of treatment with stimulant medication in a sample of 102 children with ADHD was attempted; disagreement between child and parental perceptions of treatment re‐ sponse existed in >25%. This involved mostly parental viewing of the child's response fa‐ vorably, while the child's rating was unfavorable; side-effects were the main determinant of children's perceptions of adverse outcome. Thus, parental report alone is not infallible in providing reliable information regarding effects as experienced by the child [58]. In an‐ other study consisting of 79 child-parent peers, few differences between parents and chil‐ dren for positive effects existed, although parents reported higher levels of negative effects. This result suggested that parents' considerations clearly have an influence on the way children perceive medication [69]. In the study of Gortz-Dorten et al, patients report‐ ed slightly but significantly higher satisfaction than parents. Overall satisfaction with the medication was high for 79.0% of patients and 66.1% of children also reported high satis‐ faction with how the medication helped them feel good. In conclusion, it is important to assess parental and child perspectives separately, with comparable questions, as their per‐ ceptions of medication are correlated, but only to a moderate degree [18].

Limitation 3: This was an observational study; assuch, selection of participants was based on loose criteria and treatment conditions are less controlled and standardized. This study design could be considered an advantage, from a different point of view, as it reflects routine care conditions in a pragmatic setting. This could be especially true for studies evaluating satisfac‐ tion with medication, in which ratings from clinical trials are less informative as they are influenced by the fact that the sample is likely to be biased, given that those who agree to participate in the studies tend to do so because they are not satisfied with their previous medication [18-19].

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[11] DosReis S, Zito JM, Safer DJ, Soeken KL, Mitchell JW Jr, Ellwood LC. Parental per‐ ceptions and satisfaction with stimulant medications for attention deficit/hyperactivi‐

[12] Chou WJ, Chen SJ, Chen YS, Liang HY, Lin CC, Tang CS, et al. Remission in Children and Adolescents Diagnosed with Attention-Deficit/Hyperactivity Disorder via an Ef‐ fective and Tolerable Titration Scheme for Osmotic Release Oral System Methylphe‐

[13] Dopfner M, Gerber WD, Banaschewski T, Breuer D, Freisleder FJ, Gerber-von MG, et al. Comparative efficacy of once-a-day extended-release methylphenidate, twotimes-daily immediate-release methylphenidate, and placebo in a laboratory school

parental perspective. J Paediatr Child health 2005;41(12):625-30.

Am Acad Child Adolesc Psychiatry 2002;41(Suppl2):26S-49S.

ty disorder. J Dev Behav Pediatr 2003; 24(3):155-162.

nidate. J Child Adolesc Phychiatr 2012; 22 (3); 215-25

setting. Eur Child Adolesc Psychiatry 2004; 13(Suppl 1):93–101

from a European survey. Child Adolesc Psychiatry Ment Health 2008; 2(1):31

Psychol 1992;20(5):503-20.

2004; 114 (5):e541–e547

(9481)237–248

Pharmacol 2006; 13 (1):e50–e62

Limitation 4: Both of our samples are comprised of parents who have already contacted specialized help. They have accepted the diagnosis and they decided to be involved in a therapeutic procedure, with some of them not treatment naive; parents who have not yet sought health care for their child may have different impressions and experiences. This may be considered as an important bias affecting perceptions, acceptance of the medication used and satisfaction with it.

#### **6. Conclusion**

Despite medical advances, barriers for families with children with ADHD in accessing medical services still exist. In this study, parents' perceptions, teachers' low educational status for the disorder and low recognition rate from the pediatricians were important factors of low accessibility of the medical services for diagnosis and treatment of the disorder. Most of the families having a diagnosis of ADHD and a prescription of a stimulant medication, followed medical advices. Stimulants, both short and long acting, were beneficial in improving ADHD symptoms. Parents were satisfied with the use of long acting stimulants, with older age of their child with ADHD being the only significant prognostic factor of their satisfaction level.

#### **Author details**

Antigone Papavasiliou1 , Irene Nikaina1 , Anna Spyridonidou2 and Eleanna Nianiou3

1 Neurology Department, Pendeli Childrens' Hospital, Athens, Greece

2 Child and Adolescent Psychiatry Department, Sismanogleio General Athens Hospital, Athens, Greece

3 Department of Neurology, Iaso General Hospital, Athens, Cyprus

#### **References**

[1] American Academy of Pediatrics: Clinical practice guideline: diagnosis and evalua‐ tion of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000, 105(5): 1158-1170.

[2] Coghill D, Soutullo C, d'Aubuisson C, Preuss U, Lindback T, Silverberg M, et al. Im‐ pact of attention-deficit/hyperactivity disorder on the patient and family: results from a European survey. Child Adolesc Psychiatry Ment Health 2008; 2(1):31

tion with medication, in which ratings from clinical trials are less informative as they are influenced by the fact that the sample is likely to be biased, given that those who agree to participate in the studies tend to do so because they are not satisfied with their previous

Limitation 4: Both of our samples are comprised of parents who have already contacted specialized help. They have accepted the diagnosis and they decided to be involved in a therapeutic procedure, with some of them not treatment naive; parents who have not yet sought health care for their child may have different impressions and experiences. This may be considered as an important bias affecting perceptions, acceptance of the medication used

Despite medical advances, barriers for families with children with ADHD in accessing medical services still exist. In this study, parents' perceptions, teachers' low educational status for the disorder and low recognition rate from the pediatricians were important factors of low accessibility of the medical services for diagnosis and treatment of the disorder. Most of the families having a diagnosis of ADHD and a prescription of a stimulant medication, followed medical advices. Stimulants, both short and long acting, were beneficial in improving ADHD symptoms. Parents were satisfied with the use of long acting stimulants, with older age of their child with ADHD being the only significant prognostic factor of their satisfaction level.

, Anna Spyridonidou2

2 Child and Adolescent Psychiatry Department, Sismanogleio General Athens Hospital,

[1] American Academy of Pediatrics: Clinical practice guideline: diagnosis and evalua‐ tion of the child with attention-deficit/hyperactivity disorder. Pediatrics 2000, 105(5):

and Eleanna Nianiou3

medication [18-19].

62 Attention Deficit Hyperactivity Disorder in Children and Adolescents

and satisfaction with it.

**6. Conclusion**

**Author details**

Athens, Greece

**References**

1158-1170.

Antigone Papavasiliou1

, Irene Nikaina1

1 Neurology Department, Pendeli Childrens' Hospital, Athens, Greece

3 Department of Neurology, Iaso General Hospital, Athens, Cyprus


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**Chapter 4**

**Is ADHD a Stress-Related Disorder?**

Additional information is available at the end of the chapter

ADHD is the most common neurobehavioral disorder of childhood [1]. It is also one of the most extensively studied childhood disorders. In spite of the thousands of research articles written about ADHD, a cause has not been clearly identified. Theories include genetic abnormalities, structural differences in the brain, food additives, and more. Although these factors may be physiological correlates to the symptoms of ADHD, none has been

Factors that have been identified to increase the risk of ADHD include premature birth, low birth weight, poor maternal health, poverty, and maternal cigarette use. While at first glance it may be difficult to find a unifying relationship among these risk factors, at a closer look all of these situations place significant physiological, and potentially psychological, stress on the

This chapter will consider the effects of stress on the brain, the relationship between stress and ADHD, and the use of the Transcendental Meditation (TM) technique to reduce stress and reduce the symptoms of ADHD. It will also explore the potential of the technique as a means

ADHD is a developmental disorder causing impaired executive function, or higher order functioning of the brain. Therefore, it is important to consider how the brain develops.

and reproduction in any medium, provided the original work is properly cited.

© 2013 Grosswald; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

**Why Meditation Can Help**

Sarina J. Grosswald

**1. Introduction**

established as a cause.

developing fetus and growing child.

**2. The developing brain**

of lowering the risk, and possibly even preventing ADHD.

http://dx.doi.org/10.5772/55127

**Chapter 4**

### **Is ADHD a Stress-Related Disorder? Why Meditation Can Help**

Sarina J. Grosswald

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55127

#### **1. Introduction**

ADHD is the most common neurobehavioral disorder of childhood [1]. It is also one of the most extensively studied childhood disorders. In spite of the thousands of research articles written about ADHD, a cause has not been clearly identified. Theories include genetic abnormalities, structural differences in the brain, food additives, and more. Although these factors may be physiological correlates to the symptoms of ADHD, none has been established as a cause.

Factors that have been identified to increase the risk of ADHD include premature birth, low birth weight, poor maternal health, poverty, and maternal cigarette use. While at first glance it may be difficult to find a unifying relationship among these risk factors, at a closer look all of these situations place significant physiological, and potentially psychological, stress on the developing fetus and growing child.

This chapter will consider the effects of stress on the brain, the relationship between stress and ADHD, and the use of the Transcendental Meditation (TM) technique to reduce stress and reduce the symptoms of ADHD. It will also explore the potential of the technique as a means of lowering the risk, and possibly even preventing ADHD.

### **2. The developing brain**

ADHD is a developmental disorder causing impaired executive function, or higher order functioning of the brain. Therefore, it is important to consider how the brain develops.

© 2013 Grosswald; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

At birth, a baby has almost all the neurons, or brain cells, that individual will ever have. However, there are few strong connections. It is somewhat like a pile of electrical wires with a plug and a light bulb somewhere in the pile , but few of the wires are actually connected in order to send a functioning signal from the wall socket to the light bulb. During the first two years of life there is an explosion of brain connections, sometimes referred to as "neural exuberance." This is a critical period in brain development as the child learns from experience and the environment. By age three, the brain has formed about 1,000 trillion connections twice as many as what is found in adulthood. A baby's brain is very dense, and will stay that way throughout the first decade of life.

during the middle school years that these actions are often interpreted as signs of a deeper

Is ADHD a Stress-Related Disorder? Why Meditation Can Help

http://dx.doi.org/10.5772/55127

73

Developmental psychologists often say the "first years last forever," because this is a time of rapid development of the brain. It is a time when neurons are connecting in patterns and pathways based on the experiences to which the infant is exposed. These early experiences

Researchers have long known the importance of contact, touch and cuddling of a newborn for the child to have healthy emotional development. The "prime time" for "emotional intelli‐ gence" to develop is from birth to age 18 months. This provides the foundation for other aspects of emotional development as the child grows. The amygdala, which regulates emotion, is shaped early by experience, and forms the brain's emotional wiring. Early nurturing is

Traumatic events early in life, such as abuse, neglect, severe deprivation, or exposure to violence, negatively impact psychosocial development. Children who are exposed to violence and abuse at an early age tend to have both mental and physical health prob‐ lems in childhood, with lasting effects in adulthood and throughout life. As they grow up, these children are more prone to aggression, conduct disorder, delinquency, antisocial behavior, anxiety, depression, and suicide [2], [3]. They are vulnerable to developing more slowly in their social and behavioral skills than their peers, or to actually getting "stuck" developmentally, perpetually acting younger than their age, consequently increasing the

problem, and parents or teachers raise concern about ADHD.

**Figure 1.** Density of Neuronal Connections at Different Times During Brain Development

important to learning empathy, happiness, hopefulness and resilience.

**3. Factors that negatively affect the brain**

determine the strength and function of the brain's wiring.

risk of being diagnosed with ADHD (Table 1).

Around age 7 the brain begins actively pruning unused or little used connections. Repeat‐ ed experiences create strong connections, while processes that are used only once or twice, or are inhibited during this critical period, are pruned. The connections that remain are stronger and faster.

Though the brain reaches 90-95 percent of its adult size by age six, it continues to develop in waves, with different parts of the brain developing at different times. The brain grows and specializes, expanding from governing only the simple functions like appetite, sleep, and motor activities, to developing more complex functions such as emotions, and finally, reason‐ ing and critical thinking – the "executive functions." Executive function is controlled by the cortex, particularly the frontal cortex, and is the last area of the brain to develop.

Roughly between the ages of 10 and 13, the frontal cortex experiences another growth spurt (Figure 1). This growth is followed by another period of pruning, particularly in the prefrontal cortex, beginning about age 12 and continuing into the early 20s. Consequently the part of the brain responsible for higher executive functions such as planning, work‐ ing memory, organization, reasoning, judgment, and impulse control is undergoing major change during adolescence.

An important development during this period is the process called mylenation, development of a fatty layer around the brain cell fibers which takes place during the brain's growth spurts. Mylenation increases the speed of information processing. Since the cortex is the last part of the brain to mature, mylenation that connects the prefrontal cortex to the parts of the brain responsible for lower order functioning such as sensory functions, movement, and emotion does not begin to strengthen until the preteen and teen years. It is during this time that preadolescents and adolescents begin exerting independence, thinking for themselves, making their own decisions, and trying out independent reasoning.

As mentioned, this is also the time when the second period of pruning is taking place, particularly in the frontal area of the brain. Executive function is improving as the prefrontal cortex communicates more fully and effectively with other parts of the brain, including those areas that are particularly associated with planning and problem-solving, emotion, and impulses. As these connections strengthen over time, the teen may show mature, clear, lucid thinking. But as a consequence of pruning, the teen may forget these lucid thoughts the next day, and act in a more childish or impulsive way. Consequently, it is not surprising that it is during the middle school years that these actions are often interpreted as signs of a deeper problem, and parents or teachers raise concern about ADHD.

**Figure 1.** Density of Neuronal Connections at Different Times During Brain Development

#### **3. Factors that negatively affect the brain**

At birth, a baby has almost all the neurons, or brain cells, that individual will ever have. However, there are few strong connections. It is somewhat like a pile of electrical wires with a plug and a light bulb somewhere in the pile , but few of the wires are actually connected in order to send a functioning signal from the wall socket to the light bulb. During the first two years of life there is an explosion of brain connections, sometimes referred to as "neural exuberance." This is a critical period in brain development as the child learns from experience and the environment. By age three, the brain has formed about 1,000 trillion connections twice as many as what is found in adulthood. A baby's brain is very dense, and will stay that

Around age 7 the brain begins actively pruning unused or little used connections. Repeat‐ ed experiences create strong connections, while processes that are used only once or twice, or are inhibited during this critical period, are pruned. The connections that remain are

Though the brain reaches 90-95 percent of its adult size by age six, it continues to develop in waves, with different parts of the brain developing at different times. The brain grows and specializes, expanding from governing only the simple functions like appetite, sleep, and motor activities, to developing more complex functions such as emotions, and finally, reason‐ ing and critical thinking – the "executive functions." Executive function is controlled by the

Roughly between the ages of 10 and 13, the frontal cortex experiences another growth spurt (Figure 1). This growth is followed by another period of pruning, particularly in the prefrontal cortex, beginning about age 12 and continuing into the early 20s. Consequently the part of the brain responsible for higher executive functions such as planning, work‐ ing memory, organization, reasoning, judgment, and impulse control is undergoing major

An important development during this period is the process called mylenation, development of a fatty layer around the brain cell fibers which takes place during the brain's growth spurts. Mylenation increases the speed of information processing. Since the cortex is the last part of the brain to mature, mylenation that connects the prefrontal cortex to the parts of the brain responsible for lower order functioning such as sensory functions, movement, and emotion does not begin to strengthen until the preteen and teen years. It is during this time that preadolescents and adolescents begin exerting independence, thinking for themselves, making

As mentioned, this is also the time when the second period of pruning is taking place, particularly in the frontal area of the brain. Executive function is improving as the prefrontal cortex communicates more fully and effectively with other parts of the brain, including those areas that are particularly associated with planning and problem-solving, emotion, and impulses. As these connections strengthen over time, the teen may show mature, clear, lucid thinking. But as a consequence of pruning, the teen may forget these lucid thoughts the next day, and act in a more childish or impulsive way. Consequently, it is not surprising that it is

cortex, particularly the frontal cortex, and is the last area of the brain to develop.

their own decisions, and trying out independent reasoning.

way throughout the first decade of life.

72 Attention Deficit Hyperactivity Disorder in Children and Adolescents

stronger and faster.

change during adolescence.

Developmental psychologists often say the "first years last forever," because this is a time of rapid development of the brain. It is a time when neurons are connecting in patterns and pathways based on the experiences to which the infant is exposed. These early experiences determine the strength and function of the brain's wiring.

Researchers have long known the importance of contact, touch and cuddling of a newborn for the child to have healthy emotional development. The "prime time" for "emotional intelli‐ gence" to develop is from birth to age 18 months. This provides the foundation for other aspects of emotional development as the child grows. The amygdala, which regulates emotion, is shaped early by experience, and forms the brain's emotional wiring. Early nurturing is important to learning empathy, happiness, hopefulness and resilience.

Traumatic events early in life, such as abuse, neglect, severe deprivation, or exposure to violence, negatively impact psychosocial development. Children who are exposed to violence and abuse at an early age tend to have both mental and physical health prob‐ lems in childhood, with lasting effects in adulthood and throughout life. As they grow up, these children are more prone to aggression, conduct disorder, delinquency, antisocial behavior, anxiety, depression, and suicide [2], [3]. They are vulnerable to developing more slowly in their social and behavioral skills than their peers, or to actually getting "stuck" developmentally, perpetually acting younger than their age, consequently increasing the risk of being diagnosed with ADHD (Table 1).

Because early childhood is such a sensitive time in development, adverse influences during this time significantly increases the risk of ADHD (Table 1). For example, children whose parents divorce are almost twice as likely to be on ADHD medication after the split [2], [4]. Living with a single parent can increase the chances of a child being on ADHD medication by more than 50 percent. If a child is from a family on welfare, the likelihood of the child being on ADHD medication increases by a staggering 135 percent.

It is not only influences in the first few years that can permanently influence the growth and development of a child, but also influences during prenatal development. Studies show that when a mother drinks alcohol or takes drugs, especially early in pregnancy, it can alter the baby's brain development, reducing the number of neurons created, and affecting the way the neurotransmitters function.

Alcohol is a leading cause of the destruction of myelination in the brain. As a result of maternal alcohol abuse, the child comes into the world with neurobiological problems that include difficulties with attention, memory, problem solving, and abstract thinking – problems that will later become symptoms of ADHD.

redirected to the muscles. The response is intended to help the person react quickly and

Premature birth 70% increased risk Low birth weight (3-5 lbs) 90% increased risk Low birth weight (5-6 lbs) 50% increased risk

Living with single parent 50% increased risk

Maternal smoking 2.5 times more likely to be on ADHD

Poverty 135% increased risk

2.5 times higher risk

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medication

In a normal stress response, the autonomic nervous system, the HPA axis, and the cardiovas‐ cular, metabolic, and immune systems protect the body by responding to internal and external

However, chronic acute stress impairs the body's ability to return to alostasis, or baseline, leading to an out of balance biochemistry, with elevated cortisol and suppressed serotonin. Excessive levels of cortisol in the brain impair the function of the hippocampus, leading to neuronal atrophy and destruction of neurons, decreased short term and contextual memory,

Prolonged stress hinders the body's ability to tell the hypothalamus to stop calling for more stress hormones. As a result, stress hormones flood the bloodstream, causing additional damage to the hippocampus, and additional stress. The price can be allostatic load, which is the wear and tear that results from chronic overactivity or underactivity of allostatic

The increase in cortisol inhibits utilization of blood sugar by the hippocampus, the brain's primary memory center. Reduced glucose produces an energy shortage, and the brain has no way to imprint memories. This results in the immediate short-term memory problems that are associated with stress. Further, cortisol overproduction interferes with the brain's neurotrans‐ mitters, making it hard to retrieve stored memories. Too much cortisol disrupts normal brain

An increase in cortisol leads to a decrease in serotonin. Serotonin is a critical stress hormone, influencing body temperature, blood pressure, pain, digestion, sleep, and circadian rhythms. Deficiency in serotonin leads to behavioral concerns such as increases in irritability, aggression,

Chronic stress damages or kills neuronal connections. As much as 34% reduction in cells in the prefrontal cortex have been reported [11]. Significantly, chronic stress results in lower levels

cell metabolism, eventually producing free radicals, which kill brain cells.

effectively to a high-pressure situation (i.e., fight or flee).

Mother's depression in child's first 5 years

and poor regulation of the endocrine response to stress.

impulsivity, suicide, and alcohol and drug abuse.

stress, then return to a balanced state.

**Table 1.** Factors that Increase the Risk of ADHD

systems [9], [10].

Other aspects of the mother's health similarly influence the health of the child, and the likelihood of ADHD. Children born to mothers who have physical or mental health problems during pregnancy, including depression, anxiety, and musculoskeletal symp‐ toms are more likely to later have ADHD [5] [6]. Similarly, if the mother experiences these problems within two years after the baby is born, the child has a higher risk of ADHD [7]. If a mother suffers from depression in the first 5 years of the child's life, the child is 2.5 times more likely to have ADHD.

Stress at birth is another factor raising the risk of ADHD. Danish researchers found that babies born prematurely have up to 70% greater risk of ADHD. Similarly, babies born of low birth weight have 50-90% greater risk of ADHD, depending on the weight at birth [8]. Babies born prematurely who are exposed to prenatal smoking can have smaller frontal and cerebellar areas of the brain, which are responsible for executive function and motor coordination, respectively. Children of mothers who smoke more than a pack of cigarettes a day are two and a half times more likely to later be taking medication for ADHD.

#### **4. Effects of stress on the brain**

Chronic physical or psychological stress can change the brain. The body's natural response to stress is to activate the sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis, leading to an increase in levels of catecholamines, corticotropin, and cortisol, creating the fight-or-flight response. Adrenaline and then cortisol are secreted by the adrenal glands, revving up the body, then sustaining energy flow to different systems. The lungs pump faster, and the heart begins to race. Blood pressure rises, stimulating muscles and sharpening the mind to a singular focus of attention. The release of endorphins numbs the body. Appetite, libido, and the immune system shut down. Energy normally directed to these functions is


**Table 1.** Factors that Increase the Risk of ADHD

Because early childhood is such a sensitive time in development, adverse influences during this time significantly increases the risk of ADHD (Table 1). For example, children whose parents divorce are almost twice as likely to be on ADHD medication after the split [2], [4]. Living with a single parent can increase the chances of a child being on ADHD medication by more than 50 percent. If a child is from a family on welfare, the likelihood of the child being

It is not only influences in the first few years that can permanently influence the growth and development of a child, but also influences during prenatal development. Studies show that when a mother drinks alcohol or takes drugs, especially early in pregnancy, it can alter the baby's brain development, reducing the number of neurons created, and affecting the way the

Alcohol is a leading cause of the destruction of myelination in the brain. As a result of maternal alcohol abuse, the child comes into the world with neurobiological problems that include difficulties with attention, memory, problem solving, and abstract thinking – problems that

Other aspects of the mother's health similarly influence the health of the child, and the likelihood of ADHD. Children born to mothers who have physical or mental health problems during pregnancy, including depression, anxiety, and musculoskeletal symp‐ toms are more likely to later have ADHD [5] [6]. Similarly, if the mother experiences these problems within two years after the baby is born, the child has a higher risk of ADHD [7]. If a mother suffers from depression in the first 5 years of the child's life, the child is 2.5

Stress at birth is another factor raising the risk of ADHD. Danish researchers found that babies born prematurely have up to 70% greater risk of ADHD. Similarly, babies born of low birth weight have 50-90% greater risk of ADHD, depending on the weight at birth [8]. Babies born prematurely who are exposed to prenatal smoking can have smaller frontal and cerebellar areas of the brain, which are responsible for executive function and motor coordination, respectively. Children of mothers who smoke more than a pack of cigarettes a day are two and

Chronic physical or psychological stress can change the brain. The body's natural response to stress is to activate the sympathetic nervous system and hypothalamic-pituitary-adrenal (HPA) axis, leading to an increase in levels of catecholamines, corticotropin, and cortisol, creating the fight-or-flight response. Adrenaline and then cortisol are secreted by the adrenal glands, revving up the body, then sustaining energy flow to different systems. The lungs pump faster, and the heart begins to race. Blood pressure rises, stimulating muscles and sharpening the mind to a singular focus of attention. The release of endorphins numbs the body. Appetite, libido, and the immune system shut down. Energy normally directed to these functions is

on ADHD medication increases by a staggering 135 percent.

74 Attention Deficit Hyperactivity Disorder in Children and Adolescents

a half times more likely to later be taking medication for ADHD.

neurotransmitters function.

will later become symptoms of ADHD.

times more likely to have ADHD.

**4. Effects of stress on the brain**

redirected to the muscles. The response is intended to help the person react quickly and effectively to a high-pressure situation (i.e., fight or flee).

In a normal stress response, the autonomic nervous system, the HPA axis, and the cardiovas‐ cular, metabolic, and immune systems protect the body by responding to internal and external stress, then return to a balanced state.

However, chronic acute stress impairs the body's ability to return to alostasis, or baseline, leading to an out of balance biochemistry, with elevated cortisol and suppressed serotonin. Excessive levels of cortisol in the brain impair the function of the hippocampus, leading to neuronal atrophy and destruction of neurons, decreased short term and contextual memory, and poor regulation of the endocrine response to stress.

Prolonged stress hinders the body's ability to tell the hypothalamus to stop calling for more stress hormones. As a result, stress hormones flood the bloodstream, causing additional damage to the hippocampus, and additional stress. The price can be allostatic load, which is the wear and tear that results from chronic overactivity or underactivity of allostatic systems [9], [10].

The increase in cortisol inhibits utilization of blood sugar by the hippocampus, the brain's primary memory center. Reduced glucose produces an energy shortage, and the brain has no way to imprint memories. This results in the immediate short-term memory problems that are associated with stress. Further, cortisol overproduction interferes with the brain's neurotrans‐ mitters, making it hard to retrieve stored memories. Too much cortisol disrupts normal brain cell metabolism, eventually producing free radicals, which kill brain cells.

An increase in cortisol leads to a decrease in serotonin. Serotonin is a critical stress hormone, influencing body temperature, blood pressure, pain, digestion, sleep, and circadian rhythms. Deficiency in serotonin leads to behavioral concerns such as increases in irritability, aggression, impulsivity, suicide, and alcohol and drug abuse.

Chronic stress damages or kills neuronal connections. As much as 34% reduction in cells in the prefrontal cortex have been reported [11]. Significantly, chronic stress results in lower levels of expression of genes required for the function and structure of brain synapses [12]. Re‐ searchers found that a single transcription factor called GATA1, present with chronic stress, represses the expression of several genes that are necessary to form synaptic connections between brain cells in the prefrontal cortex (Figure 2).

can be said that the differences are simply the difference in the way the symptom might be

**Symptoms of Stress Symptoms of ADHD** Inability to concentrate Difficulty sustaining attention

Difficulty organizing Difficulty organizing Memory problems Forgetfulness

Recent research sheds further light on the relationship between stress and ADHD. Vance, et al., demonstrated dysfunction of the right prefrontal regions of the brain in ADHD children [16]. This region is responsible for developing coping strategies, influencing the ability to handle stress. Early experiences of stress are believed to affect the level of responsiveness of

Young children exposed to chronic stress, can become overly accustomed to dealing with fear states, becoming conditioned to having or tolerating higher levels of adrenaline. Chronic acute stress damages the body's ability to return to non-stress levels, leading to chronically elevated levels of cortisol, a biochemical marker of stress. In children with ADHD high cortisol levels

Dysregulation of the central noradrenergic pathways in the brain is believed to underlie the pathophysiology of ADHD [18]. The noradrenergic system is associated with the modulation of attention, alertness, vigilance and executive function. Specifically, dopamine is associated with behavior and impulsive control, while norepinephrine is associated with focus, planning, and concept thinking including sequence and time. Disruption of the noradrenergic function seen in the presence of the "fight-or-flight" response involves the same neurochemistry associated in ADHD. In fact, the majority of ADHD medication involves increasing the

Given the role stress seems to play in the symptoms of ADHD, it is logical to explore stress reduction techniques, such as meditation, as a means of minimizing the effects of stress and

impair executive function, self-regulation, and letter knowledge [17].

presence of dopamine, norepinephrine, and serotonin.

**6. The transcendental meditation technique**

reducing the related symptoms associated with ADHD.

Poor judgment Speaks without thinking Short temper Impulsivity

Not listening when spoken to

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77

expressed in an adult compared to a child.

**Table 2.** Symptoms of stress closely match symptoms of ADHD

the HPA axis and autonomic nervous system.

**Figure 2.** Tissue sample on the left from the prefrontal cortex of a Control subject. Tissue on the right, from a subject with depressive disorder shows dramatic reduction in prefrontal cortical synapses. (Figure courtesy of Kang, et al.)

#### **5. Relationship between stress and ADHD**

Disruptions of the neuronal connections in the prefrontal cortex caused by stress, interferes with executive function and behavior regulation [9]. Stress-impaired executive function is associated with impaired working memory, impaired impulse control, and lack of mental flexibility and coping strategies. Stress also dramatically compromises selective attention and the ability to sustain attention [10].

ADHD is associated with impaired executive function, specifically brain circuitry governing behavior [13], [14], [15]. Dysfunction of these circuits leads to impulsivity and lack of normal social inhibition, as well as impaired working memory, inability to focus attention, and impaired temporal organization.

In light of these similarities, the connection between stress and the symptoms of ADHD begins to emerge. Stress negatively affects brain function, resulting in the same symptoms associated with ADHD. Table 2 compares symptoms of stress identified by the US Centers for Disease Control and Prevention, and diagnostic factors for ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-lV). The symptoms are nearly parallel. In fact it can be said that the differences are simply the difference in the way the symptom might be expressed in an adult compared to a child.


**Table 2.** Symptoms of stress closely match symptoms of ADHD

of expression of genes required for the function and structure of brain synapses [12]. Re‐ searchers found that a single transcription factor called GATA1, present with chronic stress, represses the expression of several genes that are necessary to form synaptic connections

**Figure 2.** Tissue sample on the left from the prefrontal cortex of a Control subject. Tissue on the right, from a subject with depressive disorder shows dramatic reduction in prefrontal cortical synapses. (Figure courtesy of Kang, et al.)

Disruptions of the neuronal connections in the prefrontal cortex caused by stress, interferes with executive function and behavior regulation [9]. Stress-impaired executive function is associated with impaired working memory, impaired impulse control, and lack of mental flexibility and coping strategies. Stress also dramatically compromises selective attention and

ADHD is associated with impaired executive function, specifically brain circuitry governing behavior [13], [14], [15]. Dysfunction of these circuits leads to impulsivity and lack of normal social inhibition, as well as impaired working memory, inability to focus attention, and

In light of these similarities, the connection between stress and the symptoms of ADHD begins to emerge. Stress negatively affects brain function, resulting in the same symptoms associated with ADHD. Table 2 compares symptoms of stress identified by the US Centers for Disease Control and Prevention, and diagnostic factors for ADHD as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-lV). The symptoms are nearly parallel. In fact it

between brain cells in the prefrontal cortex (Figure 2).

76 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**5. Relationship between stress and ADHD**

the ability to sustain attention [10].

impaired temporal organization.

Recent research sheds further light on the relationship between stress and ADHD. Vance, et al., demonstrated dysfunction of the right prefrontal regions of the brain in ADHD children [16]. This region is responsible for developing coping strategies, influencing the ability to handle stress. Early experiences of stress are believed to affect the level of responsiveness of the HPA axis and autonomic nervous system.

Young children exposed to chronic stress, can become overly accustomed to dealing with fear states, becoming conditioned to having or tolerating higher levels of adrenaline. Chronic acute stress damages the body's ability to return to non-stress levels, leading to chronically elevated levels of cortisol, a biochemical marker of stress. In children with ADHD high cortisol levels impair executive function, self-regulation, and letter knowledge [17].

Dysregulation of the central noradrenergic pathways in the brain is believed to underlie the pathophysiology of ADHD [18]. The noradrenergic system is associated with the modulation of attention, alertness, vigilance and executive function. Specifically, dopamine is associated with behavior and impulsive control, while norepinephrine is associated with focus, planning, and concept thinking including sequence and time. Disruption of the noradrenergic function seen in the presence of the "fight-or-flight" response involves the same neurochemistry associated in ADHD. In fact, the majority of ADHD medication involves increasing the presence of dopamine, norepinephrine, and serotonin.

#### **6. The transcendental meditation technique**

Given the role stress seems to play in the symptoms of ADHD, it is logical to explore stress reduction techniques, such as meditation, as a means of minimizing the effects of stress and reducing the related symptoms associated with ADHD.

There are many systems of meditation. Techniques differ widely from one another in their procedures, content, beliefs, and goals. Each technique uses a different process and thus has different effects [19], [20].

During the course of instruction, the student learns how to let the mind move from active focused levels of thinking to silent, expanded levels of wakefulness at the source of thought,

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**Figure 3.** During the Transcendental Meditation technique the mind moves from the active, directed thinking level to the more subtle levels of thinking, to eventually go beyond the boundaries of thought to experience 'pure' conscious‐

Regular practice of the technique creates a state referred to as "restful alertness." The term reflects a combination of markedly decreased metabolism, heart rate, respiration rate, and blood flow to the limbs, similar to deep rest or sleep; while at the same time mental alertness is maintained, as demonstrated by EEG [25], [26], [27]. The TM technique produces a signifi‐ cantly greater degree of deep rest than sitting with eyes closed, measured by reduced respi‐ ration , reduced skin conductance (increased skin resistance), reduced plasma lactate [25], more rapid recovery from stressful stimulus, and leads to a reversal of symptomatology

Meta-analyses indicate that the Transcendental Meditation technique is two to four times more effective in reducing stress and anxiety than other meditation or relaxation techniques [19]. A 2012 meta-analysis found Transcendental Meditation to be the most effective technique across a broad spectrum of psychological and cognitive variables including negative emotions, neuroticism, perception, trait anxiety, behavior, and memory and learning [29] (Figure 4).

Measurements of brain function show increases in brain coherence both during the practice of the Transcendental Meditation technique, and afterwards in activity [21], [30], [31]. The primary areas of the brain that are activated are the frontal and prefrontal executive areas responsible for attention, executive function, emotional stability, and anxiety (Figure 5) [32], [31], [33], [34]. Study of college students demonstrated increased frontal coherence and reduced stress reactivity in the group practicing the Transcendental Meditation technique

without concentration or effort [24] (Figure 3).

associated with severe and chronic stress [28].

ness.

With advances in neuroscience, the study of meditation has become more specific and more evidence based. Most recently, using EEG signatures and the corresponding cognitive processes, meditation practices have been classified into three types: focused attention, open monitoring, and automatic self-transcending [21].

Techniques of focused attention are concentration techniques, and are associated with voluntary sustained control of attention on the object of meditation, such as an event, image, or sound. The brain activity during concentration meditations is characterized by EEG in the beta-2 (20-30 Hz) and gamma (30-50 Hz) frequency bands. Open monitoring or mindfulness-based techniques, involve dispassionate non-evaluative monitoring of ongo‐ ing experience. These techniques are characterized by frontal theta (5-8 Hz) EEG, and perhaps occipital gamma (30-50 Hz) EEG. Automatic self-transcending meditation is defined as effortless transcending of the meditation process itself [22], [21]. EEG activity of an automatic self-transcending technique is associated with alpha-1 (7-9 Hz), characteris‐ tic of reduced mental activity and relaxation.

The Transcendental Meditation technique falls into the category of automatic self-transcend‐ ing. Concentration and open monitoring meditations both require some mental effort (i.e., holding attention on its object or maintaining attention on an ongoing experience, respective‐ ly). The Transcendental Meditation technique automatically leads to the experience of "consciousness itself," awareness without any objects of awareness, a low-stress state called transcendental or pure consciousness [23].

Practice of the technique is not based on concentrative effort, contemplation, prayer, or deliberate attempts to make the awareness more mindful or alert. Rather, the technique allows the conscious awareness, or active thinking, to spontaneously "transcend" to deeper, quieter levels of the thinking process, eventually experiencing the most settled state of awareness, where the mind is fully awake within itself, without experiencing objects of perception.

The Transcendental Meditation technique is a mental technique practiced for 10-20 minutes twice each day, sitting in a chair with eyes closed. It is easy to learn and to practice. Because it does not require concentration or controlling the mind, it is particularly well suited for children or adults with ADHD.

The technique is taught by certified Transcendental Meditation teachers in a 7-Step course. The 7-Step course of instruction involves two informational lectures (Steps 1 and 2), a brief interview with the TM instructor (Step 3), individual personal instruction (Step 4), which is followed by three days of verification of practice and additional information (Steps 5-7). The interview is about 10 minutes, while the remaining steps are approximately 1-1.5 hr each day. Each step can be conducted in a group except Steps 3 and 4, which are conducted individually, one-on-one. Periodic meetings with the student assure correct practice and reinforce regularity of the practice.

During the course of instruction, the student learns how to let the mind move from active focused levels of thinking to silent, expanded levels of wakefulness at the source of thought, without concentration or effort [24] (Figure 3).

There are many systems of meditation. Techniques differ widely from one another in their procedures, content, beliefs, and goals. Each technique uses a different process and thus has

With advances in neuroscience, the study of meditation has become more specific and more evidence based. Most recently, using EEG signatures and the corresponding cognitive processes, meditation practices have been classified into three types: focused attention, open

Techniques of focused attention are concentration techniques, and are associated with voluntary sustained control of attention on the object of meditation, such as an event, image, or sound. The brain activity during concentration meditations is characterized by EEG in the beta-2 (20-30 Hz) and gamma (30-50 Hz) frequency bands. Open monitoring or mindfulness-based techniques, involve dispassionate non-evaluative monitoring of ongo‐ ing experience. These techniques are characterized by frontal theta (5-8 Hz) EEG, and perhaps occipital gamma (30-50 Hz) EEG. Automatic self-transcending meditation is defined as effortless transcending of the meditation process itself [22], [21]. EEG activity of an automatic self-transcending technique is associated with alpha-1 (7-9 Hz), characteris‐

The Transcendental Meditation technique falls into the category of automatic self-transcend‐ ing. Concentration and open monitoring meditations both require some mental effort (i.e., holding attention on its object or maintaining attention on an ongoing experience, respective‐ ly). The Transcendental Meditation technique automatically leads to the experience of "consciousness itself," awareness without any objects of awareness, a low-stress state called

Practice of the technique is not based on concentrative effort, contemplation, prayer, or deliberate attempts to make the awareness more mindful or alert. Rather, the technique allows the conscious awareness, or active thinking, to spontaneously "transcend" to deeper, quieter levels of the thinking process, eventually experiencing the most settled state of awareness, where the mind is fully awake within itself, without experiencing objects of perception.

The Transcendental Meditation technique is a mental technique practiced for 10-20 minutes twice each day, sitting in a chair with eyes closed. It is easy to learn and to practice. Because it does not require concentration or controlling the mind, it is particularly well suited for children

The technique is taught by certified Transcendental Meditation teachers in a 7-Step course. The 7-Step course of instruction involves two informational lectures (Steps 1 and 2), a brief interview with the TM instructor (Step 3), individual personal instruction (Step 4), which is followed by three days of verification of practice and additional information (Steps 5-7). The interview is about 10 minutes, while the remaining steps are approximately 1-1.5 hr each day. Each step can be conducted in a group except Steps 3 and 4, which are conducted individually, one-on-one. Periodic meetings with the student assure correct practice and reinforce regularity

different effects [19], [20].

monitoring, and automatic self-transcending [21].

78 Attention Deficit Hyperactivity Disorder in Children and Adolescents

tic of reduced mental activity and relaxation.

transcendental or pure consciousness [23].

or adults with ADHD.

of the practice.

**Figure 3.** During the Transcendental Meditation technique the mind moves from the active, directed thinking level to the more subtle levels of thinking, to eventually go beyond the boundaries of thought to experience 'pure' conscious‐ ness.

Regular practice of the technique creates a state referred to as "restful alertness." The term reflects a combination of markedly decreased metabolism, heart rate, respiration rate, and blood flow to the limbs, similar to deep rest or sleep; while at the same time mental alertness is maintained, as demonstrated by EEG [25], [26], [27]. The TM technique produces a signifi‐ cantly greater degree of deep rest than sitting with eyes closed, measured by reduced respi‐ ration , reduced skin conductance (increased skin resistance), reduced plasma lactate [25], more rapid recovery from stressful stimulus, and leads to a reversal of symptomatology associated with severe and chronic stress [28].

Meta-analyses indicate that the Transcendental Meditation technique is two to four times more effective in reducing stress and anxiety than other meditation or relaxation techniques [19]. A 2012 meta-analysis found Transcendental Meditation to be the most effective technique across a broad spectrum of psychological and cognitive variables including negative emotions, neuroticism, perception, trait anxiety, behavior, and memory and learning [29] (Figure 4).

Measurements of brain function show increases in brain coherence both during the practice of the Transcendental Meditation technique, and afterwards in activity [21], [30], [31]. The primary areas of the brain that are activated are the frontal and prefrontal executive areas responsible for attention, executive function, emotional stability, and anxiety (Figure 5) [32], [31], [33], [34]. Study of college students demonstrated increased frontal coherence and reduced stress reactivity in the group practicing the Transcendental Meditation technique

The effects of the Transcendental Meditation technique extend to the noradrenergic networks [26], [37], [38], resulting in a decrease in the stress hormone cortisol, both during meditation and continuing outside meditation, during activity. Practice of the technique increases serotonin availability, improving mood and reducing the activation of the brain centers for

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The use of the TM technique for stress reduction in adolescents has resulted in improvement in school behavior, decreases in absenteeism and rule infractions, and reduction in suspensions due to behavior-related problems [39]. Students practicing the TM technique show higher performance on scales of self-actualization [40], increased emotional regulation, and improved

The Transcendental Meditation technique creates a neurobiological response opposite to that induced by stress. It enlivens the executive areas of the brain, and is associated with improved

Studies of the TM technique with students with ADHD demonstrate that the benefits of the technique also extend to this population. A 3-month pilot study was conducted with children ages 11 to 14 with the diagnosis of ADHD, and in some cases comorbidities, including general anxiety disorder, dysthymia, obsessive compulsive disorder, pervasive developmental disorder, sleep disorders, and tics [42]. These children also had language-based learning disabilities. The study measured effects of the Transcendental Meditation technique on stress, anxiety, and ADHD symptoms; and measured changes in executive function. Measures of stress and ADHD symptoms included the Achenbach Child Behavior Checklist (CBCL) completed by parents and teachers, the companion inventory the Achenbach Youth Self-Report (YSR), and the Revised Children's Manifest Anxiety Scale (RCMAS). Measures of executive function included the Behavior Rating Inventory of Executive Function (BRIEF), the Cognitive Assessment System (CAS) Expressive Attention, Delis-Kaplan Executive Function

After three months, there were highly statistically significant reductions in anxiety and

Statistically significant improvements in executive function as measured by the BRIEF showed improved Behavioral Regulation (includes ability to Inhibit, Shift for one task to another, and Emotional Control). Similar improvements were seen in the Metacognition Index (includes

A second study, a randomized control trial of a similar population as the previous study, explored improvements in brain coherence and brain development [43]. The purpose was to provide insight into the underlying mechanisms of observed changes. The study measured

anxiousness, depression symptoms, attention problems, and total problems (Table 3).

ability to Initiate, Working Memory, Planning, Organize Material, and Monitoring).

well-being [41] as well as improved academic performance.

System (D-KEFS) Verbal Fluency test, and Connor's CPT II.

EEG coherence, theta/beta ratio, and executive function.

psychosocial behavior in normal populations.

**7. The Transcendental Meditation technique and ADHD**

fear, anxiety, and anger.

**Figure 4.** Meta-analysis of 163 studies of various meditation techniques, comparing the effects on psychological varia‐ bles [29].

compared to controls [35], [36]. Further, students in the TM group showed that TM may lead to a foundational or 'ground' state of cerebral functioning and more focused cognitive processes [36].

**Figure 5.** fMRI showing increased activation in the frontal areas of the brain during the practice of the Transcendental Meditation technique (Courtesy of M. Ludwig)

The effects of the Transcendental Meditation technique extend to the noradrenergic networks [26], [37], [38], resulting in a decrease in the stress hormone cortisol, both during meditation and continuing outside meditation, during activity. Practice of the technique increases serotonin availability, improving mood and reducing the activation of the brain centers for fear, anxiety, and anger.

The use of the TM technique for stress reduction in adolescents has resulted in improvement in school behavior, decreases in absenteeism and rule infractions, and reduction in suspensions due to behavior-related problems [39]. Students practicing the TM technique show higher performance on scales of self-actualization [40], increased emotional regulation, and improved well-being [41] as well as improved academic performance.

#### **7. The Transcendental Meditation technique and ADHD**

compared to controls [35], [36]. Further, students in the TM group showed that TM may lead to a foundational or 'ground' state of cerebral functioning and more focused cognitive

**Figure 4.** Meta-analysis of 163 studies of various meditation techniques, comparing the effects on psychological varia‐

**Figure 5.** fMRI showing increased activation in the frontal areas of the brain during the practice of the Transcendental

processes [36].

80 Attention Deficit Hyperactivity Disorder in Children and Adolescents

bles [29].

Meditation technique (Courtesy of M. Ludwig)

The Transcendental Meditation technique creates a neurobiological response opposite to that induced by stress. It enlivens the executive areas of the brain, and is associated with improved psychosocial behavior in normal populations.

Studies of the TM technique with students with ADHD demonstrate that the benefits of the technique also extend to this population. A 3-month pilot study was conducted with children ages 11 to 14 with the diagnosis of ADHD, and in some cases comorbidities, including general anxiety disorder, dysthymia, obsessive compulsive disorder, pervasive developmental disorder, sleep disorders, and tics [42]. These children also had language-based learning disabilities. The study measured effects of the Transcendental Meditation technique on stress, anxiety, and ADHD symptoms; and measured changes in executive function. Measures of stress and ADHD symptoms included the Achenbach Child Behavior Checklist (CBCL) completed by parents and teachers, the companion inventory the Achenbach Youth Self-Report (YSR), and the Revised Children's Manifest Anxiety Scale (RCMAS). Measures of executive function included the Behavior Rating Inventory of Executive Function (BRIEF), the Cognitive Assessment System (CAS) Expressive Attention, Delis-Kaplan Executive Function System (D-KEFS) Verbal Fluency test, and Connor's CPT II.

After three months, there were highly statistically significant reductions in anxiety and anxiousness, depression symptoms, attention problems, and total problems (Table 3).

Statistically significant improvements in executive function as measured by the BRIEF showed improved Behavioral Regulation (includes ability to Inhibit, Shift for one task to another, and Emotional Control). Similar improvements were seen in the Metacognition Index (includes ability to Initiate, Working Memory, Planning, Organize Material, and Monitoring).

A second study, a randomized control trial of a similar population as the previous study, explored improvements in brain coherence and brain development [43]. The purpose was to provide insight into the underlying mechanisms of observed changes. The study measured EEG coherence, theta/beta ratio, and executive function.


coherence in theta (5.0-7.5 Hz), alpha (8.0-12 Hz), beta1 (13-20 Hz), and gamma bands

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Results (Figure 6) indicated few sensors with higher coherence in the delayed-start group at the 3-month posttest compared to their pretest values. In contrast, in the TM group there were many frontal and parietal areas at 3-month posttest compared to pretest values. At 6-month posttest, the delayed start group (who learned TM at 3 months) also showed many frontal and

**Figure 6.** Coherence maps of at baseline, 3-months, and 6-months among children with ADHD. Top row is coherence during the 3-month posttest minus baseline coherence for the delayed-start subjects. Middle row is coherence during the 3-month posttest minus baseline coherence for the TM subjects. Bottom row is coherence during the 6-month

At the 3-month posttest, theta/beta ratios increased in the delayed-start group, which is opposite to the desired effect, while the TM subjects moved closer to normal values. At the 6 month posttest, after both groups were practicing the TM technique, theta/beta ratios de‐

posttest minus 3-month posttest for the delayed-start subjects, who had been meditating over this time.

parietal areas with higher coherence compared to the 3-month posttest values.

(20.5-50 Hz).

**Table 3.** Results of Achenbach Child Behavior Checklist and Youth Self Report after three months practice of the Transcendental Meditation technique among children with ADHD.

EEG of ADHD populations show decreased activation in parietal areas of the brain that weave sensory input into concrete perception [44], higher density and amplitude of theta activity [45], [46], and lower density and amplitude of alpha and beta activity [47]. Theta is thought to block out irrelevant stimuli during memory processing. In ADHD subjects, greater theta activity may block out relevant as well as irrelevant information. Theta/beta ratios are highly correlated with severity of ADHD symptoms.

Another brain marker of ADHD is EEG coherence, a measure that reflects the number and strength of connections between different brain areas. In children diagnosed with ADHD, coherence in all frequencies is lower [48]. Alpha coherence is thought to play an important role in attention.

In the TM study, EEG of ADHD students was taken during a computer-administered paired choice reaction-time task to calculate theta/beta ratios and patterns of EEG coherence. The study also applied employed several of the same measures of executive function used in the previous study. At pretest, all students showed theta/beta ratios well above the normal range (normal average=3). Subjects were randomly assigned to the TM group and delayed-start group. The delayed-start group served as controls for the first three months, then also learned the TM technique.

Coherence maps ere calculated at pretest, 3 months, and 6 months. At 3 months, from pretest to posttests compared the TM group to the control group. At six months, changes in coherence for the control group (delayed start, who had been meditating for 3 months) were calculated from 3-month to 6-month posttests. The resulting maps showed present coherence in theta (5.0-7.5 Hz), alpha (8.0-12 Hz), beta1 (13-20 Hz), and gamma bands (20.5-50 Hz).

Results (Figure 6) indicated few sensors with higher coherence in the delayed-start group at the 3-month posttest compared to their pretest values. In contrast, in the TM group there were many frontal and parietal areas at 3-month posttest compared to pretest values. At 6-month posttest, the delayed start group (who learned TM at 3 months) also showed many frontal and parietal areas with higher coherence compared to the 3-month posttest values.

EEG of ADHD populations show decreased activation in parietal areas of the brain that weave sensory input into concrete perception [44], higher density and amplitude of theta activity [45], [46], and lower density and amplitude of alpha and beta activity [47]. Theta is thought to block out irrelevant stimuli during memory processing. In ADHD subjects, greater theta activity may block out relevant as well as irrelevant information. Theta/beta ratios are highly correlated

**Table 3.** Results of Achenbach Child Behavior Checklist and Youth Self Report after three months practice of the

**Student Teacher Pretest Post Test Pretest Post Tes**t

Symptom Mean SD Mean SD ES Mean SD Mean SD ES

Affective Problems 5.8 3.4 4.1\* 2.5 .5 5.0 3.7 3.6 3.6 .4 Anxiety Problems 3.2 2.0 1.6\*\* 1.9 .8 3.7 3.5 2.1 2.4 .5

ADHD Problems 5.4 2.9 4.3 2.7 .4 12.4 5.7 11.7 5.7 .3 Total Problems 52.5 25.6 40\* 27.4 .5 63.1 24.8 56\* 31.2 .3

5.7 3.6 2.7\* 3.7 .8 10.2 6.4 5.6\* 3.6 .7

4.8 2.7 3.9\*\* 3.0 .3 4.3 3.8 3.6 4.0 .2

7.0 4.0 5.2\* 3.5 .5 23.6 10.5 22 11.0 .2

Another brain marker of ADHD is EEG coherence, a measure that reflects the number and strength of connections between different brain areas. In children diagnosed with ADHD, coherence in all frequencies is lower [48]. Alpha coherence is thought to play an important role

In the TM study, EEG of ADHD students was taken during a computer-administered paired choice reaction-time task to calculate theta/beta ratios and patterns of EEG coherence. The study also applied employed several of the same measures of executive function used in the previous study. At pretest, all students showed theta/beta ratios well above the normal range (normal average=3). Subjects were randomly assigned to the TM group and delayed-start group. The delayed-start group served as controls for the first three months, then also learned

Coherence maps ere calculated at pretest, 3 months, and 6 months. At 3 months, from pretest to posttests compared the TM group to the control group. At six months, changes in coherence for the control group (delayed start, who had been meditating for 3 months) were calculated from 3-month to 6-month posttests. The resulting maps showed present

with severity of ADHD symptoms.

Transcendental Meditation technique among children with ADHD.

82 Attention Deficit Hyperactivity Disorder in Children and Adolescents

in attention.

Anxious/ Depressed

Withdrawn/ Depressed

> Attention Problems

\* p ≤.05. \*\*p<.005 ES=Effect Size

the TM technique.

**Figure 6.** Coherence maps of at baseline, 3-months, and 6-months among children with ADHD. Top row is coherence during the 3-month posttest minus baseline coherence for the delayed-start subjects. Middle row is coherence during the 3-month posttest minus baseline coherence for the TM subjects. Bottom row is coherence during the 6-month posttest minus 3-month posttest for the delayed-start subjects, who had been meditating over this time.

At the 3-month posttest, theta/beta ratios increased in the delayed-start group, which is opposite to the desired effect, while the TM subjects moved closer to normal values. At the 6 month posttest, after both groups were practicing the TM technique, theta/beta ratios de‐ creased in both groups. For the delayed start group, theta/beta ratios also significantly decreased from the 3-month to 6-month posttest after three months practice of the TM technique (Figure 7).

Recognition of the role stress plays in ADHD offers an opportunity to intervene to alter the course of the disorder. Some risk factors such as maternal smoking can addressed through education and public health efforts, a child's risk of developing ADHD. Other causes of stress, however, may be more difficult to avoid or eliminate (e.g., premature birth, poverty). But many of the stress factors that raise the risk of ADHD are known (Table 1), therefore, interventions that immediately address reducing the effects of the stressors, have the potential of reducing the damaging effects on the brain, and possibly avoid development of the symptoms of ADHD. When a child, or even an adult, begins to show signs of difficulty with attention and focus, disorganization, behavior issues, and difficulty controlling anger or impulses, a thorough approach to diagnosis should include assessment of potential causative factors. In as many as 75- 85% of cases, ADHD is complicated by the presence of other emotional or behavioral disorders [49]. Treating the underlying disorder can result in reduction of ADHD symptoms. If the symptoms arise as a child enters school, an evaluation of learning can be useful. Approximately 20-30% of children with ADHD also have a learning disability [50]. When a child starts to show difficulty academically, he or she tends to lose interest in learning, can become easily distracted, or may engage in disruptive behaviour. This can lead to a diagnosis of ADHD since these are also clinical symptoms of the disorder. However, they may actually be caused by a learning problem, whether it is a learning disorder or simply the consequence of getting behind or confused in an academic subject and unable to catch up. An educational

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If symptoms arise when a child changes schools or environments, this can be an underlying cause of stress, and consequently the appearance of ADHD related problems. Traumatic events such as conflict at home, or lose or separation from parents or close caregivers can result in

Children who are exposed to geopolitical violence or natural disasters often display symptoms interpreted as ADHD, when they may actually be stress responses to the trauma or the chronic stress of living in fear. Each year in the US, more than five million chil‐ dren are exposed to some form of extreme traumatic stressor. These traumatic events include natural disasters such as tornados, floods, hurricanes; motor vehicle accidents; life threatening illness and associated painful experiences such as cancer or burns; or witness‐ ing violence in the home or community. Over 30 percent of these traumatized children develop a clinical syndrome with emotional, behavioral, cognitive, social and physical symptoms significant enough to be diagnosed with post traumatic disorder (PTSD). Some of the symptoms of PTSD are very similar to those of ADHD. Without an exploration of

the underlying causes of ADHD symptoms, other problems may go undiagnosed.

Regardless of the underlying cause of the stress, the Transcendental Meditation technique can provide an intervention that can reduce the effects of stress and related symptoms, including

For children as young as four or five years old, the Transcendental Meditation technique has been shown to effectively reduce stress and increase cognitive development. It can balance neurochemistry, reversing the cycle of high cortisol leading to low serotonin; thus improving

assessment can help distinguish the underlying problem.

symptoms that might be diagnosed as ADHD.

ADHD symptoms.

**Figure 7.** Theta/beta ratios compare results at pretest, 3-month and 6-month posttests. Transcendental Meditation group showed reductions at 3-months compared to delayed start controls. TM group showed continued improve‐ ments at six months. Delayed start showed significant improvements from 3-months to 6-months, after meditating for 3 months.

#### **8. Prevention**

An initial literature search of research on preventing ADHD turns up no significant contribu‐ tion to the subject of effecting the underlying causes. In fact, it seems to be an area that is not actively being addressed. Most research on prevention is focused on preventing of other social problems that arise among children with ADHD, such as smoking or criminal behavior.

Without an understanding of the disorder's etiology, prevention cannot be addressed. The etiology currently gaining most attention is genetic causes. However, genetic alterations associated with ADHD may be a correlate rather than a cause. As discussed earlier, chronic stress can result in changing gene expression, resulting in structural impairment of the prefrontal cortex.

Considering the factors discussed in this chapter, a unifying underlying cause emerges. Chronic stress, whether physical or emotional, can result in structural impairment to brain, and give rise to the symptoms identified as ADHD.

Recognition of the role stress plays in ADHD offers an opportunity to intervene to alter the course of the disorder. Some risk factors such as maternal smoking can addressed through education and public health efforts, a child's risk of developing ADHD. Other causes of stress, however, may be more difficult to avoid or eliminate (e.g., premature birth, poverty). But many of the stress factors that raise the risk of ADHD are known (Table 1), therefore, interventions that immediately address reducing the effects of the stressors, have the potential of reducing the damaging effects on the brain, and possibly avoid development of the symptoms of ADHD.

creased in both groups. For the delayed start group, theta/beta ratios also significantly decreased from the 3-month to 6-month posttest after three months practice of the TM

**Figure 7.** Theta/beta ratios compare results at pretest, 3-month and 6-month posttests. Transcendental Meditation group showed reductions at 3-months compared to delayed start controls. TM group showed continued improve‐ ments at six months. Delayed start showed significant improvements from 3-months to 6-months, after meditating for

An initial literature search of research on preventing ADHD turns up no significant contribu‐ tion to the subject of effecting the underlying causes. In fact, it seems to be an area that is not actively being addressed. Most research on prevention is focused on preventing of other social problems that arise among children with ADHD, such as smoking or criminal behavior.

Without an understanding of the disorder's etiology, prevention cannot be addressed. The etiology currently gaining most attention is genetic causes. However, genetic alterations associated with ADHD may be a correlate rather than a cause. As discussed earlier, chronic stress can result in changing gene expression, resulting in structural impairment of the

Considering the factors discussed in this chapter, a unifying underlying cause emerges. Chronic stress, whether physical or emotional, can result in structural impairment to brain,

technique (Figure 7).

84 Attention Deficit Hyperactivity Disorder in Children and Adolescents

3 months.

**8. Prevention**

prefrontal cortex.

and give rise to the symptoms identified as ADHD.

When a child, or even an adult, begins to show signs of difficulty with attention and focus, disorganization, behavior issues, and difficulty controlling anger or impulses, a thorough approach to diagnosis should include assessment of potential causative factors. In as many as 75- 85% of cases, ADHD is complicated by the presence of other emotional or behavioral disorders [49]. Treating the underlying disorder can result in reduction of ADHD symptoms.

If the symptoms arise as a child enters school, an evaluation of learning can be useful. Approximately 20-30% of children with ADHD also have a learning disability [50]. When a child starts to show difficulty academically, he or she tends to lose interest in learning, can become easily distracted, or may engage in disruptive behaviour. This can lead to a diagnosis of ADHD since these are also clinical symptoms of the disorder. However, they may actually be caused by a learning problem, whether it is a learning disorder or simply the consequence of getting behind or confused in an academic subject and unable to catch up. An educational assessment can help distinguish the underlying problem.

If symptoms arise when a child changes schools or environments, this can be an underlying cause of stress, and consequently the appearance of ADHD related problems. Traumatic events such as conflict at home, or lose or separation from parents or close caregivers can result in ADHD symptoms.

Children who are exposed to geopolitical violence or natural disasters often display symptoms interpreted as ADHD, when they may actually be stress responses to the trauma or the chronic stress of living in fear. Each year in the US, more than five million chil‐ dren are exposed to some form of extreme traumatic stressor. These traumatic events include natural disasters such as tornados, floods, hurricanes; motor vehicle accidents; life threatening illness and associated painful experiences such as cancer or burns; or witness‐ ing violence in the home or community. Over 30 percent of these traumatized children develop a clinical syndrome with emotional, behavioral, cognitive, social and physical symptoms significant enough to be diagnosed with post traumatic disorder (PTSD). Some of the symptoms of PTSD are very similar to those of ADHD. Without an exploration of the underlying causes of ADHD symptoms, other problems may go undiagnosed.

Regardless of the underlying cause of the stress, the Transcendental Meditation technique can provide an intervention that can reduce the effects of stress and related symptoms, including symptoms that might be diagnosed as ADHD.

For children as young as four or five years old, the Transcendental Meditation technique has been shown to effectively reduce stress and increase cognitive development. It can balance neurochemistry, reversing the cycle of high cortisol leading to low serotonin; thus improving mood and impulse control. (Note: for children below the age of 10 years old, the technique is slightly different, done with the eyes open, while engaged in non-focused activity.) The technique also leads to balancing dopamine and norepinephrine, the same neurotransmitters that are the target of common ADHD drugs.

individual situations may not have caused emotional stress for Jessie, combined over an extended period of time, likely caused a significant physiological response to chronic stress. Consequently, the effect of the early adversity, several of which are known to increase the risk of ADHD, may explain Jessie's symptoms and lack of self-control, which were diagnosed as

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87

Jessie's parents did not want to put him on medication, so they sought another approach. At age seven, Jessie and his whole family – parents and 5-year-old brother – learned the Tran‐ scendental Meditation technique. The boys learned the young child's technique called the

Jessie found it effective in calming himself down. It also resulted in immediate improvements in school. The next week after learning TM, he completed his weekly math test for the first time all year. He was able to maintain his attention, focus, and easily get through the task. When he turned 10 years old, Jessie learned the sitting, eyes closed technique. He does well in school, is better able to control his emotions, and gets along well with his younger brother.

Jessie eventually added a low dose of ADHD medication to augment the benefits of the meditation. He is a happy, well-adjusted child who does well in school. However, given the extreme behaviors he displayed at a younger age, his life could have quickly taken a different course. One could foresee significant behavior problems, the potential for strong life-long medication, poor success in school, and a more troubled life for him and his family. Though it is impossible to predict what would have happened over time, the value of early intervention with an effective technique for reducing stress, balancing the neurochemistry, and improving

A child or adult affected by trauma or severe stress looses the ability to return to a balanced state, consequently creating a cycle of chronic stress. Chronic stress alters the biochemistry and neuronal development particularly in the prefrontal cortex. The result is impaired executive function, creating lack of control of attention, focus, memory, organization, and impulses,

Early recognition of factors that cause severe or traumatic stress, and early intervention can help mitigate the effects. The Transcendental Meditation technique has been shown to be effective in reducing temporal and chronic stress, reducing ADHD symptoms, and improving executive function. The technique is easy to learn and easy to practice, is appropriate for people of all ages - children as young as four or five years old to adults of any age. In the presence of ADHD risk factors, the Transcendental Meditation technique offers potential for preventing

full manifestation of symptoms, and provides a field for study of ADHD prevention.

ADHD.

Word of Wisdom.

**10. Conclusion**

executive function can be appreciated.

displaying as symptoms of ADHD.

For children younger than four years old, who may be too young to learn the TM technique, the Maharishi Ayurveda Mother and Baby Program provides dietary and behavioral guide‐ lines that include foods cooked according to specific principles, and Ayurvedic massage that reduces stress and improves the baby's sleep and digestion [51]. When this approach is incorporated for the mother and the baby, along with the mother's practice of the Transcen‐ dental Meditation technique, it improves the mother's mental and physical health, and leads to a better start for the baby.

#### **9. Case study**

The following case study will illustrate how the concepts presented in this chapter can affect an individual child. At the first introduction to Jessie (not his real name), he was 7 years old and had just been diagnosed with ADHD. His mother explained, "He can't control his emotions - happy or sad emotions. He can be extreme in either direction." She described that sometimes he would be in such a rage, that he would hide under his bed or go out to his father's car to try to calm himself. "I'm afraid one day he'll be standing over me with a knife. I don't know what to do," she said. He was also having difficulty with attention and behaviour at school.

Jessie seemed like a very sweet, though rambunctious, boy. He did not seem to display any malice or meanness, but if he got frustrated or over-excited, he could not control his emotions. He was from a warm and loving family with both parents and a younger brother. They had a warm, healthy home life, and there did not seem to be cause for the level of stress that might lead to the behavior Jessie would sometimes exhibit.

Discussion with Jessie's mother, however, shed light on the situation. She had two miscarriages before Jessie was born. As a result she was very anxious during her pregnancy with Jessie. After he was born, she had another miscarriage, which led to depression and medication for her depression. When she became pregnant again, she had complications requiring bedrest for the last trimester, making it difficult to give full attention to Jessie.

During the time 2-year old Jessie's mother was in the hospital giving birth to his brother, Jessie stayed with his grandmother. While there, he got sick, requiring hospitalization, where he was temporarily put on oxygen. One can imagine how scary this would be for a young child, and though his father was with him, his mother was not.

Jessie's situation was not serious, and he was not hospitalized long. However the newborn had complications, which was finally diagnosed a year later as a digestive disease. This resulted in much attention and worry around the newborn, which to young Jessie may have seemed like a form of abandonment, creating greater stress for him. While any of these individual situations may not have caused emotional stress for Jessie, combined over an extended period of time, likely caused a significant physiological response to chronic stress. Consequently, the effect of the early adversity, several of which are known to increase the risk of ADHD, may explain Jessie's symptoms and lack of self-control, which were diagnosed as ADHD.

Jessie's parents did not want to put him on medication, so they sought another approach. At age seven, Jessie and his whole family – parents and 5-year-old brother – learned the Tran‐ scendental Meditation technique. The boys learned the young child's technique called the Word of Wisdom.

Jessie found it effective in calming himself down. It also resulted in immediate improvements in school. The next week after learning TM, he completed his weekly math test for the first time all year. He was able to maintain his attention, focus, and easily get through the task. When he turned 10 years old, Jessie learned the sitting, eyes closed technique. He does well in school, is better able to control his emotions, and gets along well with his younger brother.

Jessie eventually added a low dose of ADHD medication to augment the benefits of the meditation. He is a happy, well-adjusted child who does well in school. However, given the extreme behaviors he displayed at a younger age, his life could have quickly taken a different course. One could foresee significant behavior problems, the potential for strong life-long medication, poor success in school, and a more troubled life for him and his family. Though it is impossible to predict what would have happened over time, the value of early intervention with an effective technique for reducing stress, balancing the neurochemistry, and improving executive function can be appreciated.

#### **10. Conclusion**

mood and impulse control. (Note: for children below the age of 10 years old, the technique is slightly different, done with the eyes open, while engaged in non-focused activity.) The technique also leads to balancing dopamine and norepinephrine, the same neurotransmitters

For children younger than four years old, who may be too young to learn the TM technique, the Maharishi Ayurveda Mother and Baby Program provides dietary and behavioral guide‐ lines that include foods cooked according to specific principles, and Ayurvedic massage that reduces stress and improves the baby's sleep and digestion [51]. When this approach is incorporated for the mother and the baby, along with the mother's practice of the Transcen‐ dental Meditation technique, it improves the mother's mental and physical health, and leads

The following case study will illustrate how the concepts presented in this chapter can affect an individual child. At the first introduction to Jessie (not his real name), he was 7 years old and had just been diagnosed with ADHD. His mother explained, "He can't control his emotions - happy or sad emotions. He can be extreme in either direction." She described that sometimes he would be in such a rage, that he would hide under his bed or go out to his father's car to try to calm himself. "I'm afraid one day he'll be standing over me with a knife. I don't know what to do," she said. He was also having difficulty with attention and behaviour at

Jessie seemed like a very sweet, though rambunctious, boy. He did not seem to display any malice or meanness, but if he got frustrated or over-excited, he could not control his emotions. He was from a warm and loving family with both parents and a younger brother. They had a warm, healthy home life, and there did not seem to be cause for the level of stress that might

Discussion with Jessie's mother, however, shed light on the situation. She had two miscarriages before Jessie was born. As a result she was very anxious during her pregnancy with Jessie. After he was born, she had another miscarriage, which led to depression and medication for her depression. When she became pregnant again, she had complications requiring bedrest

During the time 2-year old Jessie's mother was in the hospital giving birth to his brother, Jessie stayed with his grandmother. While there, he got sick, requiring hospitalization, where he was temporarily put on oxygen. One can imagine how scary this would be for a young child, and

Jessie's situation was not serious, and he was not hospitalized long. However the newborn had complications, which was finally diagnosed a year later as a digestive disease. This resulted in much attention and worry around the newborn, which to young Jessie may have seemed like a form of abandonment, creating greater stress for him. While any of these

that are the target of common ADHD drugs.

86 Attention Deficit Hyperactivity Disorder in Children and Adolescents

lead to the behavior Jessie would sometimes exhibit.

though his father was with him, his mother was not.

for the last trimester, making it difficult to give full attention to Jessie.

to a better start for the baby.

**9. Case study**

school.

A child or adult affected by trauma or severe stress looses the ability to return to a balanced state, consequently creating a cycle of chronic stress. Chronic stress alters the biochemistry and neuronal development particularly in the prefrontal cortex. The result is impaired executive function, creating lack of control of attention, focus, memory, organization, and impulses, displaying as symptoms of ADHD.

Early recognition of factors that cause severe or traumatic stress, and early intervention can help mitigate the effects. The Transcendental Meditation technique has been shown to be effective in reducing temporal and chronic stress, reducing ADHD symptoms, and improving executive function. The technique is easy to learn and easy to practice, is appropriate for people of all ages - children as young as four or five years old to adults of any age. In the presence of ADHD risk factors, the Transcendental Meditation technique offers potential for preventing full manifestation of symptoms, and provides a field for study of ADHD prevention.

#### **Author details**

Sarina J. Grosswald

Address all correspondence to: Sarina@grosswald.com

SJ Grosswald & Associates, USA

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Sarina J. Grosswald

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[50] Wender PH. ADHD: attention-deficit hyperactivity disorder in children and adults. New York: Oxford University Press; 2000.

**Section 2**

**Role of Endocrine Hormones**

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92 Attention Deficit Hyperactivity Disorder in Children and Adolescents

2002;Spring(61):23–4, 63.

**Chapter 5**

**The Potential Role of Neuroendocrine in**

Liang-Jen Wang and Chih-Ken Chen

pathogenesis of ADHD (Martel et al., 2009).

http://dx.doi.org/10.5772/53609

**1. Introduction**

Additional information is available at the end of the chapter

**Patients with Attention-Deficit/Hyperactivity Disorder**

**Attention**-**Deficit**/**HyperactivityDisorder** (**ADHD**) is one of the most prevalent neurodeve‐ lopmental **disorders** among children. It affects 3-10% of school-age children (Polanczyk et al., 2007), and a prevalence rate of 7.5% was reported in a local Taiwan study (Gau et al., 2005). The core symptoms of ADHD are inattention, hyperactivity, and impulsivity, and ADHD patients are commonly comorbid with other neuropsychiatric disorders, such as Op‐ positional Defiant Disorder (ODD), Conduct Disorder (CD), and tic disorders (American Psychiatric Association, 2000; Spencer et al., 2007). The most well-known neurobiological hypotheses to account for the complexity in etiology of ADHD are the dysregulation of cate‐ cholaminergic neurotransmission (Biederman & Faraone, 2002). In recent years, many re‐ searchers have raised concerns with regards to the potential roles of the neuroendocrine system in the pathogenesis of ADHD (Dubrovsky, 2005; Golubchik et al., 2007; Goodyer et al., 2001; Martel et al., 2009; Strous et al., 2006), based on observations of the epidemiological data of ADHD. ADHD is more prevalent in boys than in girls, with the ratio ranging from 4 to 1 to as much as 9 to 1, and boys generally exhibit more impaired cognitive control than girls (American Psychiatric Association, 2000). In addition, longitudinal studies have shown that there is a clear decline of symptoms with age, and a possible remission occurs after the age of 12 (Polanczyk & Rohde, 2007). The neuroendocrine system, the activation of which is closely associated with age and gender, may influence developing neural circuitry and be‐ havioral systems; thus it has reasonably been speculated that this system plays a role in the

Methylphenidate (MPH), classified as a psychostimulant, is the most widely used drug for the pharmacological management of children with ADHD (Swanson et al., 2002). The effects of MPH on attention result from a combination of noradrenergic and dopaminergic mecha‐

and reproduction in any medium, provided the original work is properly cited.

© 2013 Wang and Chen; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

### **The Potential Role of Neuroendocrine in Patients with Attention-Deficit/Hyperactivity Disorder**

Liang-Jen Wang and Chih-Ken Chen

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53609

#### **1. Introduction**

**Attention**-**Deficit**/**HyperactivityDisorder** (**ADHD**) is one of the most prevalent neurodeve‐ lopmental **disorders** among children. It affects 3-10% of school-age children (Polanczyk et al., 2007), and a prevalence rate of 7.5% was reported in a local Taiwan study (Gau et al., 2005). The core symptoms of ADHD are inattention, hyperactivity, and impulsivity, and ADHD patients are commonly comorbid with other neuropsychiatric disorders, such as Op‐ positional Defiant Disorder (ODD), Conduct Disorder (CD), and tic disorders (American Psychiatric Association, 2000; Spencer et al., 2007). The most well-known neurobiological hypotheses to account for the complexity in etiology of ADHD are the dysregulation of cate‐ cholaminergic neurotransmission (Biederman & Faraone, 2002). In recent years, many re‐ searchers have raised concerns with regards to the potential roles of the neuroendocrine system in the pathogenesis of ADHD (Dubrovsky, 2005; Golubchik et al., 2007; Goodyer et al., 2001; Martel et al., 2009; Strous et al., 2006), based on observations of the epidemiological data of ADHD. ADHD is more prevalent in boys than in girls, with the ratio ranging from 4 to 1 to as much as 9 to 1, and boys generally exhibit more impaired cognitive control than girls (American Psychiatric Association, 2000). In addition, longitudinal studies have shown that there is a clear decline of symptoms with age, and a possible remission occurs after the age of 12 (Polanczyk & Rohde, 2007). The neuroendocrine system, the activation of which is closely associated with age and gender, may influence developing neural circuitry and be‐ havioral systems; thus it has reasonably been speculated that this system plays a role in the pathogenesis of ADHD (Martel et al., 2009).

Methylphenidate (MPH), classified as a psychostimulant, is the most widely used drug for the pharmacological management of children with ADHD (Swanson et al., 2002). The effects of MPH on attention result from a combination of noradrenergic and dopaminergic mecha‐

© 2013 Wang and Chen; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

nisms (Overtoom et al., 2003; Wilens, 2008). MPH exerts treatment effects by reducing im‐ pulsivity and disruptive behavior (Huang & Tsai, 2011), and it improves plenty of dimensions of neurocognitive function in ADHD patients (Huang et al., 2007; Pollak et al., 2010). Furthermore, some evidence has been revealed that MPH treatment possibly influen‐ ces the neuroendocrine system (Hibel et al., 2007; Lurie & O'Quinn, 1991), and these influen‐ ces possibly play a role as a mediator of the therapeutic effects for ADHD patients. Therefore, we herein review the related literature which investigates the relationship be‐ tween ADHD, neuroendocrine, and MPH administration.

cantly during a 12-week MPH treatment and under a 12-week bupropion treatment as well. These studies revealed a substantial increase in DHEA levels among pre-pubertal ADHD patients; however, there was no data with regards to age- and gender-matched healthy con‐ trols for comparison. Finally, our research team demonstrated that salivary DHEA levels were significantly lower in ADHD patients than those in healthy controls (Wang et al., 2011b). Salivary DHEA levels were not significantly correlated with ADHD clinical symp‐ tom severity, but positively correlated with performance in a neuropsychological test (Con‐ ner's Continuous Performance Test, CPT). Thus the authors suggested that lower morning DHEA levels might be a biological laboratory marker for ADHD, particularly for perform‐ ance during CPT. In the longitudinal analyses, we found that morning salivary DHEA levels significantly increased under the 6-month MPH treatment course for ADHD patients. How‐ ever, the salivary DHEA levels in healthy age- and gender- matched controls remain un‐ changed during the 6-month natural observation. Similar with the findings in the crosssectional survey, DHEA levels exhibited a significant and independent association with overall CPT performance during the course of MPH treatment (Wang et al., 2011a). We could thus determine that the elevation of DHEA levels among ADHD patients is not de‐

The Potential Role of Neuroendocrine in Patients with Attention-Deficit/Hyperactivity Disorder

http://dx.doi.org/10.5772/53609

97

There is interesting coincidence in the similarity of the natural course of ADHD, brain devel‐ opment and age-related change in DHEA/DHEA-S levels. ADHD symptoms generally de‐ cline in severity between puberty and the early twenties (Biederman et al., 2000). Some brain imaging studies have found there to be a dysfunction of the cerebellar-striatal-prefrontal cir‐ cuitry in ADHD (Gogtay et al., 2002), and that this may be the result of delayed maturation of the cerebral cortex, especially the prefrontal region (Shaw et al., 2007; McAlonan et al., 2009). Plasma DHEA/DHEA-S levels change with age, being low in the first years of life, then rapidly increasing from about eight years of age through puberty to reach their highest levels during early adulthood (de Peretti & Forest, 1978). DHEA-S has antiamnestic effects, and also anxiolytic and anti-aggressive properties (Wolf & Kirschbaum, 1999). Both DHEA and DHEA-S have been shown to regulate the motility and growth of neocortical neurons in the rodent brain (Compagnone & Mellon, 1998). This implies that DHEA/DHEA-S exert bio‐ logical actions that may play crucial roles in guiding cortical projections to appropriate tar‐ gets, and thus may be important for the regulation of neurodevelopment (Golubchik et al., 2007). It has been proposed that DHEA/DHEA-S exerts its positive effects in ADHD patients through stimulatory or antagonist effects at the gammaaminobutyric acid A (GABAA) recep‐ tor and facilitation of the N-methyl-*D*-aspartate (NMDA) activity (Davies et al., 2009; Strous et al., 2001; Tang et al., 1999). DHEA protects hippocampal neuronal activity from glutamate toxicity. DHEA-S also protects hippocampal neuronal cells from excitatory amino acid in‐ duced neurotoxicity. Taken together, DHEA and DHEA-S may provide an important antiox‐ idant function and may thus play a role in neurodevelopment and have neuroprotective

Some molecular genetic studies demonstrated candidate genes contributing to ADHD. The steroid sulfatase (STS) gene, which escapes X inactivation in humans, desulfates several sul‐ fatedsteroids, including DHEA-S to DHEA. In an animal study, it has been noticed that the

rived from natural physiological change, but from MPH administration.

effects (Strous et al., 2006).

#### **2. ADHD and neurosteroids**

The term "neurosteroid" was first introduced by Baulieu (1981), which indicated steroid hormones synthesized in brain cells from cholesterol, independent of peripheral endocrine sources, acted at the central nervous system. Initially, neurosteroid referred to dehydroe‐ piandrosterone sulfate (DHEA-S) (Baulieu & Robel, 1996). DHEA-S concentration in the brain was found to remain stable following adrenalectomy and gonadectomy. This implied that DHEA-S levels in the central neural system appeared to be independent of peripheral formation in the adrenals or gonads (Strous et al., 2006). Subsequently, progesterone, allo‐ pregnanolone, pregnenolone, dehydroepiandrosterone (DHEA) and their corresponding sulfate esters were identified as neurosteroids (Baulieu & Robel, 1998). Neurosteroids are important substrates that have been demonstrated to affect mood expression, energy level, aggression, and general activity (Wolkowitz et al., 1999).

#### **2.1. DHEA and DHEA-S**

DHEA is one of the major circulating neurosteroids in human, and it is also an ACTH-regu‐ lated steroid and a substrate for the synthesis of androstenedione and testosterone (Gurnell & Chatterjee, 2001). DHEA has been demonstrated to play several vital neurophysiological roles and to be affected by various physiological processes, including those associated with neurotrophic and neuronal excitability effects, circadian rhythms, sexual responses, immu‐ nological and stress reactions, memory, and sleep (Baulieu & Robel, 1996; Herbert, 1998). DHEA-S is a sulfated form of DHEA that is believed to be the most abundant steroid in the body (Wolf et al., 1997). DHEA-S is measured more frequently than DHEA because circulat‐ ing levels of DHEA-S are approximately 500 times higher due to its lower metabolic clear‐ ance rate and minimal diurnal variation (Longcope, 1996).

Strous et al. (2001) demonstrated that DHEA and DHEA-S levels in blood are inversely re‐ lated to the severity of hyperactivity/impulsivity symptoms in children with ADHD aged between 7 and 12 years. Another study found that ADHD patients treated with methylphe‐ nidate for 3 months exhibited pre- to post-treatment increases in plasma levels of DHEA and DHEA-S for 23% and 53.6%, respectively (Maayan et al., 2003). Subsequently, Lee et al. (2008) were the first research group investigating the role of neurosteroids in Asian ADHD population. They suggested that plasma DHEA-S levels in ADHD patients increased signifi‐ cantly during a 12-week MPH treatment and under a 12-week bupropion treatment as well. These studies revealed a substantial increase in DHEA levels among pre-pubertal ADHD patients; however, there was no data with regards to age- and gender-matched healthy con‐ trols for comparison. Finally, our research team demonstrated that salivary DHEA levels were significantly lower in ADHD patients than those in healthy controls (Wang et al., 2011b). Salivary DHEA levels were not significantly correlated with ADHD clinical symp‐ tom severity, but positively correlated with performance in a neuropsychological test (Con‐ ner's Continuous Performance Test, CPT). Thus the authors suggested that lower morning DHEA levels might be a biological laboratory marker for ADHD, particularly for perform‐ ance during CPT. In the longitudinal analyses, we found that morning salivary DHEA levels significantly increased under the 6-month MPH treatment course for ADHD patients. How‐ ever, the salivary DHEA levels in healthy age- and gender- matched controls remain un‐ changed during the 6-month natural observation. Similar with the findings in the crosssectional survey, DHEA levels exhibited a significant and independent association with overall CPT performance during the course of MPH treatment (Wang et al., 2011a). We could thus determine that the elevation of DHEA levels among ADHD patients is not de‐ rived from natural physiological change, but from MPH administration.

nisms (Overtoom et al., 2003; Wilens, 2008). MPH exerts treatment effects by reducing im‐ pulsivity and disruptive behavior (Huang & Tsai, 2011), and it improves plenty of dimensions of neurocognitive function in ADHD patients (Huang et al., 2007; Pollak et al., 2010). Furthermore, some evidence has been revealed that MPH treatment possibly influen‐ ces the neuroendocrine system (Hibel et al., 2007; Lurie & O'Quinn, 1991), and these influen‐ ces possibly play a role as a mediator of the therapeutic effects for ADHD patients. Therefore, we herein review the related literature which investigates the relationship be‐

The term "neurosteroid" was first introduced by Baulieu (1981), which indicated steroid hormones synthesized in brain cells from cholesterol, independent of peripheral endocrine sources, acted at the central nervous system. Initially, neurosteroid referred to dehydroe‐ piandrosterone sulfate (DHEA-S) (Baulieu & Robel, 1996). DHEA-S concentration in the brain was found to remain stable following adrenalectomy and gonadectomy. This implied that DHEA-S levels in the central neural system appeared to be independent of peripheral formation in the adrenals or gonads (Strous et al., 2006). Subsequently, progesterone, allo‐ pregnanolone, pregnenolone, dehydroepiandrosterone (DHEA) and their corresponding sulfate esters were identified as neurosteroids (Baulieu & Robel, 1998). Neurosteroids are important substrates that have been demonstrated to affect mood expression, energy level,

DHEA is one of the major circulating neurosteroids in human, and it is also an ACTH-regu‐ lated steroid and a substrate for the synthesis of androstenedione and testosterone (Gurnell & Chatterjee, 2001). DHEA has been demonstrated to play several vital neurophysiological roles and to be affected by various physiological processes, including those associated with neurotrophic and neuronal excitability effects, circadian rhythms, sexual responses, immu‐ nological and stress reactions, memory, and sleep (Baulieu & Robel, 1996; Herbert, 1998). DHEA-S is a sulfated form of DHEA that is believed to be the most abundant steroid in the body (Wolf et al., 1997). DHEA-S is measured more frequently than DHEA because circulat‐ ing levels of DHEA-S are approximately 500 times higher due to its lower metabolic clear‐

Strous et al. (2001) demonstrated that DHEA and DHEA-S levels in blood are inversely re‐ lated to the severity of hyperactivity/impulsivity symptoms in children with ADHD aged between 7 and 12 years. Another study found that ADHD patients treated with methylphe‐ nidate for 3 months exhibited pre- to post-treatment increases in plasma levels of DHEA and DHEA-S for 23% and 53.6%, respectively (Maayan et al., 2003). Subsequently, Lee et al. (2008) were the first research group investigating the role of neurosteroids in Asian ADHD population. They suggested that plasma DHEA-S levels in ADHD patients increased signifi‐

tween ADHD, neuroendocrine, and MPH administration.

96 Attention Deficit Hyperactivity Disorder in Children and Adolescents

aggression, and general activity (Wolkowitz et al., 1999).

ance rate and minimal diurnal variation (Longcope, 1996).

**2. ADHD and neurosteroids**

**2.1. DHEA and DHEA-S**

There is interesting coincidence in the similarity of the natural course of ADHD, brain devel‐ opment and age-related change in DHEA/DHEA-S levels. ADHD symptoms generally de‐ cline in severity between puberty and the early twenties (Biederman et al., 2000). Some brain imaging studies have found there to be a dysfunction of the cerebellar-striatal-prefrontal cir‐ cuitry in ADHD (Gogtay et al., 2002), and that this may be the result of delayed maturation of the cerebral cortex, especially the prefrontal region (Shaw et al., 2007; McAlonan et al., 2009). Plasma DHEA/DHEA-S levels change with age, being low in the first years of life, then rapidly increasing from about eight years of age through puberty to reach their highest levels during early adulthood (de Peretti & Forest, 1978). DHEA-S has antiamnestic effects, and also anxiolytic and anti-aggressive properties (Wolf & Kirschbaum, 1999). Both DHEA and DHEA-S have been shown to regulate the motility and growth of neocortical neurons in the rodent brain (Compagnone & Mellon, 1998). This implies that DHEA/DHEA-S exert bio‐ logical actions that may play crucial roles in guiding cortical projections to appropriate tar‐ gets, and thus may be important for the regulation of neurodevelopment (Golubchik et al., 2007). It has been proposed that DHEA/DHEA-S exerts its positive effects in ADHD patients through stimulatory or antagonist effects at the gammaaminobutyric acid A (GABAA) recep‐ tor and facilitation of the N-methyl-*D*-aspartate (NMDA) activity (Davies et al., 2009; Strous et al., 2001; Tang et al., 1999). DHEA protects hippocampal neuronal activity from glutamate toxicity. DHEA-S also protects hippocampal neuronal cells from excitatory amino acid in‐ duced neurotoxicity. Taken together, DHEA and DHEA-S may provide an important antiox‐ idant function and may thus play a role in neurodevelopment and have neuroprotective effects (Strous et al., 2006).

Some molecular genetic studies demonstrated candidate genes contributing to ADHD. The steroid sulfatase (STS) gene, which escapes X inactivation in humans, desulfates several sul‐ fatedsteroids, including DHEA-S to DHEA. In an animal study, it has been noticed that the STS may modify the attentional function and motor impulsivity through administration of the substrate DHEA and DHEA-S (Davies et al., 2009). The same research team showed that the 39,X(Y\*)O mice (which lack the STS gene but no other known genes as a consequence of end-to-end fusion of the X and Y chromosomes) exhibited significantly lower DHEA serum levels than 40,XY mice. They concluded that STS-deficient mice exhibit endophenotypes rel‐ evant to ADHD (Trent et al., 2012). In human studies, Kent et al. (2008) have demonstrated that boys with X-linked ichthyosis who have a deletion or point mutation of STS are at an increased risk of ADHD. In addition, Brookes et al. (2008) indicated that common variants within the STS gene may increase susceptibility to ADHD. The over transmitted risk allele of rs12861247 was also associated with reduced STS mRNA expression, and hence deficit in STS protein production is at a significantly increased risk of developing ADHD (Brookes et al., 2010). However, ethnic differences in epidemiology and genetic polymorphism of ADHD patients have been demonstrated in some studies (Nikolaidis & Gray, 2009; Pastor & Reuben, 2005). It remains unclear whether the relationships between the STS gene, ADHD and neurosteroids also exist among non-Caucasian populations.

2001). PREG is the principal precursor of DHEA. The sulfated form of **pregnenolone** (PREG-S) exerts its neurochemical action as a negative modulator of the GABAA and also as a posi‐ tive modulator of the NMDA subtype of glutamate receptor (Mayo et al., 2001). PREG-S is also capable of modulating acetylcholine neurotransmission associated with paradoxical sleep modifications (Mayo et al., 2003). **In animal studies,** PREG-S in the hippocampus re‐ gion plays a physiological role in preserving and enhancing cognitive abilities, possibly via an interaction with central cholinergic systems (Vallee et al., 1997; Vallee et al., 2001). Among humans, PREG appears to improve clinical symptoms in patients with mood disor‐ ders (Osuji et al., 2010), and in patients with schizophrenia as well (Marx et al., 2011). To date, there has been only one study investigating the relationship of PREG and ADHD (Strous et al., 2001), and this study revealed that PREG levels in the blood are inversely relat‐

The Potential Role of Neuroendocrine in Patients with Attention-Deficit/Hyperactivity Disorder

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99

ed to the severity of hyperactivity/impulsivity symptoms in children with ADHD.

not yet been well-established in clinical studies.

Gonadal hormones may act on the prenatal development of dopaminergic neural circuitry and dopamine function in the nucleus accumbens, striatum, and prefrontal cortex via its masculinizing effects (Martel et al., 2009). Therefore, gonadal hormones may modulate cor‐ responding deficits in cognitive control and reward processes in ADHD. In animal studies, estradiol and progesterone both appear capable of inducing increases in dendritic spine density during development. Estradiol and progesterone have been also proposed to play a role in ADHD, because they are synthesized *de novo* in the cerebellum during critical devel‐ opmental periods (Dean & McCarthy, 2008). In addition, estrogen has been identified to have neuroprotective effects through protection against oxidative stress, and neurotrophic cross-talk through the signal cascade shared with neurotrophic factors (Sawada & Shimoha‐ ma, 2000). However, the relationship of estradiol, progesterone and ADHD in humans has

Prenatal **testosterone** exposure has been implied in the etiology of **ADHD**. High levels of prenatal testosterone may moderate the relationship between prenatal risk factors, and fur‐ ther affect dopaminergic neural circuitry by slowing down neural development globally (Morris et al., 2004). Several studies have examined the association between the presence of **ADHD phenotype** and the ratio of the length of the second and fourth digits (2D:4D ratio), which is a marker of fetal **testosterone** exposure (de Bruin et al., 2006; Lemiere et al., 2010; Stevenson et al., 2007). However, the findings are inconsistent between these studies. Fur‐ thermore, Yu & Shi (2009) found that salivary testosterone levels are higher in children with aggressive tendencies than those without aggressive tendencies. Whereas Dorn et al., (2009) suggested that no significant difference in salivary testosterone levels between children with and without disruptive behavior disorders. Regarding the effects of MPH on testosterone, Avital et al., (2011) indicated that long-term exposure to MPH led to elevated **testosterone** levels in rodents. However, Mattison et al., (2011) reported that MPH administration in rhe‐ sus macaques, beginning before puberty, led to delay in pubertal testicular development un‐ til 5 years of age. Among humans, Hibel et al. (2007) investigated the relationship of salivary biomarker levels, diurnal variation and the effects of medications among maltreated or lowincome disadvantaged children. They found that testosterone in non-medicated children de‐ creased along with time in a day, but those in children taking psychostimulants remained

Neurochemical findings showing MPH exerts its effects on catecholamines in areas such as the prefrontal cortex, nucleus accumbens, and striatum are consistent with the neurobiologi‐ cal and clinical effects of MPH on memory, attention, and movement (Wilens, 2008). The neuroendocrine effects of MPH administration might be related to its dopaminergic and adrenergic agonistic activity (Hibel et al., 2007; Lurie & O'Quinn, 1991; Weizman et al., 1987). Hibel et al. (2007) demonstrated that children taking concerta (methylphenidate ex‐ tended-release tablets) had higher average levels of DHEA than those who were non-medi‐ cated. Several studies suggested that MPH increased DHEA or DHEA-S levels of ADHD patients during a 3-month treatment (Lee et al., 2008; Maayan et al., 2003; Wang et al., 2011a). One possible neurochemical explanation for this phenomenon is that MPH-induced increases in DHEA or DHEA-S may act either by decreasing levels of the GABAA antago‐ nist-like pregnenolone sulfate, or by increasing levels of the GABAA agonist-like progester‐ one metabolites (Robel & Baulieu, 1995). In addition, the direct influence of medications on salivary hormones may act on the secretion and feedback control of the HPA and hypothala‐ mic-pituitary-gonadal (HPG) axes. MPH may also indirectly influence DHEA or DHEA-S by attenuating or potentiating the impact of environmental events and subjective experience on HPA axis and HPG activity (Hibel et al., 2007). However, it is not clear whether DHEA or DHEA-S exerts effects in conjunction with or independently of MPH on neurocognitive function in ADHD. It remains to be clarified whether DHEA or DHEA-S plays a role as a mediator of the therapeutic effects of MPH, or if these associations are epiphenomena of the benefits of MPH treatment. Moreover, it would also be interesting to investigate whether DHEA or DHEA-S could directly benefit the treatment of ADHD patients.

#### **2.2. Other neurosteroids and gonadal hormones**

Neurosteroids, other than DHEA and DHEA-S, mainly contain pregnenolone (PREG) and progesterone, which is metabolized to 5a-dihydroprogesterone (5α-DH PROG) and 3α,5αtetrahydroprogesterone (3α,5α-TH PROG), also named allopregnanolone (Vallee et al., 2001). PREG is the principal precursor of DHEA. The sulfated form of **pregnenolone** (PREG-S) exerts its neurochemical action as a negative modulator of the GABAA and also as a posi‐ tive modulator of the NMDA subtype of glutamate receptor (Mayo et al., 2001). PREG-S is also capable of modulating acetylcholine neurotransmission associated with paradoxical sleep modifications (Mayo et al., 2003). **In animal studies,** PREG-S in the hippocampus re‐ gion plays a physiological role in preserving and enhancing cognitive abilities, possibly via an interaction with central cholinergic systems (Vallee et al., 1997; Vallee et al., 2001). Among humans, PREG appears to improve clinical symptoms in patients with mood disor‐ ders (Osuji et al., 2010), and in patients with schizophrenia as well (Marx et al., 2011). To date, there has been only one study investigating the relationship of PREG and ADHD (Strous et al., 2001), and this study revealed that PREG levels in the blood are inversely relat‐ ed to the severity of hyperactivity/impulsivity symptoms in children with ADHD.

STS may modify the attentional function and motor impulsivity through administration of the substrate DHEA and DHEA-S (Davies et al., 2009). The same research team showed that the 39,X(Y\*)O mice (which lack the STS gene but no other known genes as a consequence of end-to-end fusion of the X and Y chromosomes) exhibited significantly lower DHEA serum levels than 40,XY mice. They concluded that STS-deficient mice exhibit endophenotypes rel‐ evant to ADHD (Trent et al., 2012). In human studies, Kent et al. (2008) have demonstrated that boys with X-linked ichthyosis who have a deletion or point mutation of STS are at an increased risk of ADHD. In addition, Brookes et al. (2008) indicated that common variants within the STS gene may increase susceptibility to ADHD. The over transmitted risk allele of rs12861247 was also associated with reduced STS mRNA expression, and hence deficit in STS protein production is at a significantly increased risk of developing ADHD (Brookes et al., 2010). However, ethnic differences in epidemiology and genetic polymorphism of ADHD patients have been demonstrated in some studies (Nikolaidis & Gray, 2009; Pastor & Reuben, 2005). It remains unclear whether the relationships between the STS gene, ADHD

Neurochemical findings showing MPH exerts its effects on catecholamines in areas such as the prefrontal cortex, nucleus accumbens, and striatum are consistent with the neurobiologi‐ cal and clinical effects of MPH on memory, attention, and movement (Wilens, 2008). The neuroendocrine effects of MPH administration might be related to its dopaminergic and adrenergic agonistic activity (Hibel et al., 2007; Lurie & O'Quinn, 1991; Weizman et al., 1987). Hibel et al. (2007) demonstrated that children taking concerta (methylphenidate ex‐ tended-release tablets) had higher average levels of DHEA than those who were non-medi‐ cated. Several studies suggested that MPH increased DHEA or DHEA-S levels of ADHD patients during a 3-month treatment (Lee et al., 2008; Maayan et al., 2003; Wang et al., 2011a). One possible neurochemical explanation for this phenomenon is that MPH-induced increases in DHEA or DHEA-S may act either by decreasing levels of the GABAA antago‐ nist-like pregnenolone sulfate, or by increasing levels of the GABAA agonist-like progester‐ one metabolites (Robel & Baulieu, 1995). In addition, the direct influence of medications on salivary hormones may act on the secretion and feedback control of the HPA and hypothala‐ mic-pituitary-gonadal (HPG) axes. MPH may also indirectly influence DHEA or DHEA-S by attenuating or potentiating the impact of environmental events and subjective experience on HPA axis and HPG activity (Hibel et al., 2007). However, it is not clear whether DHEA or DHEA-S exerts effects in conjunction with or independently of MPH on neurocognitive function in ADHD. It remains to be clarified whether DHEA or DHEA-S plays a role as a mediator of the therapeutic effects of MPH, or if these associations are epiphenomena of the benefits of MPH treatment. Moreover, it would also be interesting to investigate whether

and neurosteroids also exist among non-Caucasian populations.

98 Attention Deficit Hyperactivity Disorder in Children and Adolescents

DHEA or DHEA-S could directly benefit the treatment of ADHD patients.

Neurosteroids, other than DHEA and DHEA-S, mainly contain pregnenolone (PREG) and progesterone, which is metabolized to 5a-dihydroprogesterone (5α-DH PROG) and 3α,5αtetrahydroprogesterone (3α,5α-TH PROG), also named allopregnanolone (Vallee et al.,

**2.2. Other neurosteroids and gonadal hormones**

Gonadal hormones may act on the prenatal development of dopaminergic neural circuitry and dopamine function in the nucleus accumbens, striatum, and prefrontal cortex via its masculinizing effects (Martel et al., 2009). Therefore, gonadal hormones may modulate cor‐ responding deficits in cognitive control and reward processes in ADHD. In animal studies, estradiol and progesterone both appear capable of inducing increases in dendritic spine density during development. Estradiol and progesterone have been also proposed to play a role in ADHD, because they are synthesized *de novo* in the cerebellum during critical devel‐ opmental periods (Dean & McCarthy, 2008). In addition, estrogen has been identified to have neuroprotective effects through protection against oxidative stress, and neurotrophic cross-talk through the signal cascade shared with neurotrophic factors (Sawada & Shimoha‐ ma, 2000). However, the relationship of estradiol, progesterone and ADHD in humans has not yet been well-established in clinical studies.

Prenatal **testosterone** exposure has been implied in the etiology of **ADHD**. High levels of prenatal testosterone may moderate the relationship between prenatal risk factors, and fur‐ ther affect dopaminergic neural circuitry by slowing down neural development globally (Morris et al., 2004). Several studies have examined the association between the presence of **ADHD phenotype** and the ratio of the length of the second and fourth digits (2D:4D ratio), which is a marker of fetal **testosterone** exposure (de Bruin et al., 2006; Lemiere et al., 2010; Stevenson et al., 2007). However, the findings are inconsistent between these studies. Fur‐ thermore, Yu & Shi (2009) found that salivary testosterone levels are higher in children with aggressive tendencies than those without aggressive tendencies. Whereas Dorn et al., (2009) suggested that no significant difference in salivary testosterone levels between children with and without disruptive behavior disorders. Regarding the effects of MPH on testosterone, Avital et al., (2011) indicated that long-term exposure to MPH led to elevated **testosterone** levels in rodents. However, Mattison et al., (2011) reported that MPH administration in rhe‐ sus macaques, beginning before puberty, led to delay in pubertal testicular development un‐ til 5 years of age. Among humans, Hibel et al. (2007) investigated the relationship of salivary biomarker levels, diurnal variation and the effects of medications among maltreated or lowincome disadvantaged children. They found that testosterone in non-medicated children de‐ creased along with time in a day, but those in children taking psychostimulants remained unchanged. In summary, evidence about the role of gonadal hormones in the aetiology of **ADHD in humans is remains scarce, thus future clinical studies are warranted to eluci‐ date this issue.**

thermore, a recent meta-analysis revealed that the age of the children significantly moder‐ ated the relation between basal cortisol and externalizing behavior. Externalizing behavior was associated with higher basal cortisol in preschoolers, and with lower basal cortisol in

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101

Regarding with the effects of MPH on cortisol, Weizman et al. (1987) reported that plasma cortisol levels of ADHD patients increased under acute challenge of MPH; nevertheless, the effects disappeared when subjects were re-challenged after 4 weeks. Similar effect of acute challenge MPH for increasing cortisol levels was also observed among normal adults (Joyce et al., 1986). However, Lee et al. (2008) showed that during a 12-week period, there was no significant change in cortisol levels in ADHD patients under MPH treatment. In contrast, Chen et al. (2012) reported that basal plasma cortisol levels were significant increased after treatment either with MPH or with atomoxetine. Furthermore, our research team showed that the morning levels of salivary cortisol in the patients with ADHD were significantly in‐ creased from baseline at 1 month after the MPH treatment was started (Wang et al., 2012). Subsequently, the cortisol levels dropped to an intermediary level that differed from the baseline and 1-month values. The effects of MPH on the neuroendocrine system were pro‐ posed to result from a combination of noradrenergic and dopaminergic mechanisms (Lurie & O'Quinn, 1991). The higher concentrations of dopamine and norepinephrine could pro‐ mote the release of corticotropin releasing hormone (CRH) and the adrenocorticotropic hor‐ mone (ACTH) (Biondi & Picardi, 1999). It might be a possible explanation of MPH-induced cortisol elevation; however, the effect of MPH on cortisol secretion seems to be temporary. Acute tolerance to MPH has long been reported in the treatment of ADHD in children (Swanson et al., 1999). It warrants further investigation to clarify whether the transient effect on cortisol increment shares similar neurobiological mechanisms with the tolerance of MPH.

Awareness of the prominent position that the neuroendocrine system has to play in patho‐ physiology of ADHD is increasing. DHEA and DHEA-S are important neurosteroids sub‐ strates which demonstrate a potential correlation to symptoms severity and neurocognitive

**ADHD**, exerts its pharmacological effects via increasing the level of the dopamine and nore‐ pinephrine. Extant studies almost identically indicate that MPH administration would lead to increases in the levels of DHEA or DHEA-S. With regards to other neurosteroids or gona‐ dal hormones, their influence on developing neural circuitry and behavioral systems has al‐ ready been established in animal models. However, many findings noted in animal studies have yet to be replicated in humans, in particular patients with ADHD. The HPA-axis dys‐ function, which was measured by cortisol levels, has also been indicated to address the com‐ plexity in the pathogenesis of ADHD. Current studies revealed that ADHD patients, especially for those with higher aggression tendencies or comorbidities, might have lower levels of cortisol than healthy controls. MPH administration is able to elevate cortisol levels,

function in ADHD patients. MPH, the most therapeutically efficient drugs in

elementary school-aged children (Alink et al., 2008).

**4. Conclusion**

#### **3. Cortisol**

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis in ADHD children was pro‐ posed to address the complexity in the pathophysiology of ADHD (Kaneko et al., 1993; Ma et al., 2011). The HPA axis plays an important role in regulating central nervous system neu‐ rotransmitters and behavior, such as attention, emotion, memory, and learning (Talge et al., 2007). The function of the HPA axis has typically been assessed by cortisol levels, which can be measured from a number of sources (saliva, urine, and blood plasma) (Hellhammer et al., 2009). Low cortisol levels generally reflect under arousal or an elevated threshold for the de‐ tection of stressors (Freitag et al., 2009; Kaneko et al., 1993). Many clinical studies investigat‐ ed cortisol levels in either a stress response or an awakening response (Freitag et al., 2009; Popma et al., 2006; Stadler et al., 2011; Yang et al., 2007). For example, Popma et al. (2006) reported that patients with disruptive behavior disorders showed a significantly decreased cortisol response after a standard public speaking task as compared with the normal con‐ trols. Yang et al. (2007) demonstrated that the magnitude of the increase in cortisol reactivity to stress was inversely correlated with aggression tendency in patients with ADHD. Freitag et al. (2009) indicated that ADHD children comorbid with ODD showed a weaker cortisol awakening response compared to ADHD children without comorbidity and control chil‐ dren. Stadler et al. (2011) reported that ADHD patients scoring high on callous unemotional traits showed a blunted HPA axis reactivity to the experimentally induced stress. Moreover, it has also been suggested that the cortisol reactivity to stress at baseline in ADHD patients could predict treatment effects (van de Wiel et al., 2004), and was associated with the oneyear outcome (King et al., 1998).

On the other hand, some studies aimed to determine the basal level of morning cortisol in ADHD patients, and to determine the relationship between cortisol levels and ADHD re‐ lated social/behavioral symptoms or cognition deficit. Among these, Schulz et al., (1997) showed that there was no significant difference in basal cortisol levels between aggressive and nonaggressive boys with ADHD. In addition, the basal level of morning cortisol was not significantly correlated with the severity of ADHD hyperactivity/impulsivity symp‐ toms (Strous et al., 2001) and the performance in neuropsychological test (Wang et al., 2011b). However, there is one study which demonstrated gender differences in the corti‐ sol levels among a community sample of adolescents, which showed that females carry a positive and males a negative association between cortisol and conduct symptoms (Young et al., 2012). For ADHD subtypes, Ma et al. (2011) reported that the level of cortisol in the ADHD group was significantly lower than that of the control group. There was a signifi‐ cant difference in cortisol levels between ADHD subtypes: The level of cortisol of the ADHD-predominantly hyperactive impulsive type was significantly lower than that of ADHD-predominantly inattention type and ADHD-combined type (Ma et al., 2011). Fur‐ thermore, a recent meta-analysis revealed that the age of the children significantly moder‐ ated the relation between basal cortisol and externalizing behavior. Externalizing behavior was associated with higher basal cortisol in preschoolers, and with lower basal cortisol in elementary school-aged children (Alink et al., 2008).

Regarding with the effects of MPH on cortisol, Weizman et al. (1987) reported that plasma cortisol levels of ADHD patients increased under acute challenge of MPH; nevertheless, the effects disappeared when subjects were re-challenged after 4 weeks. Similar effect of acute challenge MPH for increasing cortisol levels was also observed among normal adults (Joyce et al., 1986). However, Lee et al. (2008) showed that during a 12-week period, there was no significant change in cortisol levels in ADHD patients under MPH treatment. In contrast, Chen et al. (2012) reported that basal plasma cortisol levels were significant increased after treatment either with MPH or with atomoxetine. Furthermore, our research team showed that the morning levels of salivary cortisol in the patients with ADHD were significantly in‐ creased from baseline at 1 month after the MPH treatment was started (Wang et al., 2012). Subsequently, the cortisol levels dropped to an intermediary level that differed from the baseline and 1-month values. The effects of MPH on the neuroendocrine system were pro‐ posed to result from a combination of noradrenergic and dopaminergic mechanisms (Lurie & O'Quinn, 1991). The higher concentrations of dopamine and norepinephrine could pro‐ mote the release of corticotropin releasing hormone (CRH) and the adrenocorticotropic hor‐ mone (ACTH) (Biondi & Picardi, 1999). It might be a possible explanation of MPH-induced cortisol elevation; however, the effect of MPH on cortisol secretion seems to be temporary. Acute tolerance to MPH has long been reported in the treatment of ADHD in children (Swanson et al., 1999). It warrants further investigation to clarify whether the transient effect on cortisol increment shares similar neurobiological mechanisms with the tolerance of MPH.

#### **4. Conclusion**

unchanged. In summary, evidence about the role of gonadal hormones in the aetiology of **ADHD in humans is remains scarce, thus future clinical studies are warranted to eluci‐**

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis in ADHD children was pro‐ posed to address the complexity in the pathophysiology of ADHD (Kaneko et al., 1993; Ma et al., 2011). The HPA axis plays an important role in regulating central nervous system neu‐ rotransmitters and behavior, such as attention, emotion, memory, and learning (Talge et al., 2007). The function of the HPA axis has typically been assessed by cortisol levels, which can be measured from a number of sources (saliva, urine, and blood plasma) (Hellhammer et al., 2009). Low cortisol levels generally reflect under arousal or an elevated threshold for the de‐ tection of stressors (Freitag et al., 2009; Kaneko et al., 1993). Many clinical studies investigat‐ ed cortisol levels in either a stress response or an awakening response (Freitag et al., 2009; Popma et al., 2006; Stadler et al., 2011; Yang et al., 2007). For example, Popma et al. (2006) reported that patients with disruptive behavior disorders showed a significantly decreased cortisol response after a standard public speaking task as compared with the normal con‐ trols. Yang et al. (2007) demonstrated that the magnitude of the increase in cortisol reactivity to stress was inversely correlated with aggression tendency in patients with ADHD. Freitag et al. (2009) indicated that ADHD children comorbid with ODD showed a weaker cortisol awakening response compared to ADHD children without comorbidity and control chil‐ dren. Stadler et al. (2011) reported that ADHD patients scoring high on callous unemotional traits showed a blunted HPA axis reactivity to the experimentally induced stress. Moreover, it has also been suggested that the cortisol reactivity to stress at baseline in ADHD patients could predict treatment effects (van de Wiel et al., 2004), and was associated with the one-

On the other hand, some studies aimed to determine the basal level of morning cortisol in ADHD patients, and to determine the relationship between cortisol levels and ADHD re‐ lated social/behavioral symptoms or cognition deficit. Among these, Schulz et al., (1997) showed that there was no significant difference in basal cortisol levels between aggressive and nonaggressive boys with ADHD. In addition, the basal level of morning cortisol was not significantly correlated with the severity of ADHD hyperactivity/impulsivity symp‐ toms (Strous et al., 2001) and the performance in neuropsychological test (Wang et al., 2011b). However, there is one study which demonstrated gender differences in the corti‐ sol levels among a community sample of adolescents, which showed that females carry a positive and males a negative association between cortisol and conduct symptoms (Young et al., 2012). For ADHD subtypes, Ma et al. (2011) reported that the level of cortisol in the ADHD group was significantly lower than that of the control group. There was a signifi‐ cant difference in cortisol levels between ADHD subtypes: The level of cortisol of the ADHD-predominantly hyperactive impulsive type was significantly lower than that of ADHD-predominantly inattention type and ADHD-combined type (Ma et al., 2011). Fur‐

**date this issue.**

100 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**3. Cortisol**

year outcome (King et al., 1998).

Awareness of the prominent position that the neuroendocrine system has to play in patho‐ physiology of ADHD is increasing. DHEA and DHEA-S are important neurosteroids sub‐ strates which demonstrate a potential correlation to symptoms severity and neurocognitive function in ADHD patients. MPH, the most therapeutically efficient drugs in

**ADHD**, exerts its pharmacological effects via increasing the level of the dopamine and nore‐ pinephrine. Extant studies almost identically indicate that MPH administration would lead to increases in the levels of DHEA or DHEA-S. With regards to other neurosteroids or gona‐ dal hormones, their influence on developing neural circuitry and behavioral systems has al‐ ready been established in animal models. However, many findings noted in animal studies have yet to be replicated in humans, in particular patients with ADHD. The HPA-axis dys‐ function, which was measured by cortisol levels, has also been indicated to address the com‐ plexity in the pathogenesis of ADHD. Current studies revealed that ADHD patients, especially for those with higher aggression tendencies or comorbidities, might have lower levels of cortisol than healthy controls. MPH administration is able to elevate cortisol levels, but the effects seem to be temporary. To date, much remains unclear about the complex in‐ teraction between neuroendocrine system, pathophysiology of ADHD and effects of MPH. Further research at the basic scientific level as well as in the context of double-blinded place‐ bo controlled investigation is mandated to better elucidate the role of neuroendocrine in the understanding and management of ADHD patients.

[8] Biondi, M. & Picardi, A. (1999). Psychological stress and neuroendocrine function in humans: the last two decades of research. *Psychother Psychosom*, 68, 114-150.

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[11] Chen, Y.H., Lin, X.X., Chen, H., Liu, Y.Y., Lin, G.X., Wei, L.X., et al. (2012). The change of the cortisol levels in children with ADHD treated by methylphenidate or

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#### **Author details**

Liang-Jen Wang1,2 and Chih-Ken Chen2,3

1 Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital - Kaoh‐ siung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan

2 Chang Gung University School of Medicine, Taoyuan, Taiwan

3 Department of Psychiatry, Chang Gung Memorial Hospital, Keelung, Taiwan

#### **References**


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1 Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital - Kaoh‐ siung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan

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2 Chang Gung University School of Medicine, Taoyuan, Taiwan

3 Department of Psychiatry, Chang Gung Memorial Hospital, Keelung, Taiwan

Liang-Jen Wang1,2 and Chih-Ken Chen2,3

**Author details**

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**Chapter 6**

**Dopamine and Glutamate Interactions in ADHD:**

**ADHD**

Erin M. Miller, Theresa C. Thomas,

http://dx.doi.org/10.5772/54207

**1. Introduction**

hyperactive subtypes.

Greg A. Gerhardt and Paul E. A. Glaser

Additional information is available at the end of the chapter

may aid in furthering the future pharmacotherapy of ADHD.

**2. ADHD and the link to neurochemistry**

**Implications for the Future Neuropharmacology of**

In this chapter, we will discuss the interactions between a neurotransmitter that has been heavily implicated in ADHD, dopamine, and a neurotransmitter just beginning to be inves‐ tigated, glutamate. We will examine the literature to reveal how current treatments for ADHD affect these neurotransmitter levels in specific areas of the brain that are thought to be dysfunctional in ADHD. Additionally, we will detail new data on dopamine and gluta‐ mate dysfunction utilizing approaches that are capable of accurately measuring levels of these neurotransmitters in two separate rodent models of ADHD. Finally, we will speculate on the role that the dopamine-glutamate interaction will play in the future neuropharmacol‐ ogy of ADHD and how measuring these neurotransmitter levels in rodent models of ADHD

Throughout the text, we will use ADHD (Attention-Deficit/Hyperactivity Disorder) without reference to the DSM-IV type, unless a specific reference pertains to combined, inattentive or

When the Diagnostic and Statistical Manual of Mental Disorders (DSM-1) was first publish‐ ed in 1952, childhood psychiatric disorders were thought to be caused by environment and referred to as 'reactions' [1]. It wasn't until the DSM-2 was published in 1968 that ADHD

and reproduction in any medium, provided the original work is properly cited.

© 2013 Miller et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.


## **Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD**

Erin M. Miller, Theresa C. Thomas, Greg A. Gerhardt and Paul E. A. Glaser

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54207

#### **1. Introduction**

with attention deficit hyperactivity disorder during six months of treatment with

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Treatment. J Attention Disorders, (In press)

108 Attention Deficit Hyperactivity Disorder in Children and Adolescents

humans. *Brain Res Brain Res Rev*, 30, 264-288.

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cents. *Soc Psychiatry Psychiatr Epidemiol*, 47, 723-733.

tivity. *Life Sci*, 40, 2247-2252.

*Am J Psychiatry*, 156, 646-649.

In this chapter, we will discuss the interactions between a neurotransmitter that has been heavily implicated in ADHD, dopamine, and a neurotransmitter just beginning to be inves‐ tigated, glutamate. We will examine the literature to reveal how current treatments for ADHD affect these neurotransmitter levels in specific areas of the brain that are thought to be dysfunctional in ADHD. Additionally, we will detail new data on dopamine and gluta‐ mate dysfunction utilizing approaches that are capable of accurately measuring levels of these neurotransmitters in two separate rodent models of ADHD. Finally, we will speculate on the role that the dopamine-glutamate interaction will play in the future neuropharmacol‐ ogy of ADHD and how measuring these neurotransmitter levels in rodent models of ADHD may aid in furthering the future pharmacotherapy of ADHD.

Throughout the text, we will use ADHD (Attention-Deficit/Hyperactivity Disorder) without reference to the DSM-IV type, unless a specific reference pertains to combined, inattentive or hyperactive subtypes.

#### **2. ADHD and the link to neurochemistry**

When the Diagnostic and Statistical Manual of Mental Disorders (DSM-1) was first publish‐ ed in 1952, childhood psychiatric disorders were thought to be caused by environment and referred to as 'reactions' [1]. It wasn't until the DSM-2 was published in 1968 that ADHD

began to be separated from general reactions and become its own diagnosis, referred to as the 'hyperkinetic reaction of childhood.' This reaction was characterized by a short attention span, hyperactivity, and restlessness [2], and in 1980, with the publication of the DSM-3, the ADHD diagnosis became more specific and was described as ADD (attention-deficit disor‐ der) [3]; however, by this time, this disorder was already being treated with stimulant medi‐ cations, a treatment still used to this day.

lating dopamine neurotransmission, especially in the PFC [11]. The final and most impor‐ tant method in which dopamine is cleared from the synapse is via the dopamine transporter (DAT). The DAT primarily exists on the presynaptic neuron and can transport dopamine ei‐ ther into or out of the neuron, dependent upon the concentration gradient. It has been dis‐ covered that the removal of dopamine from the synapse is predominantly performed by the

Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD

http://dx.doi.org/10.5772/54207

111

**Figure 1.** Modulatory dopaminergic neurons (blue) project to the dorsal striatum via the substantia nigra (SN, A9) and the ventral striatum and prefrontal cortex (PFC) via the ventral tegmental area (VTA, A10) in the rodent brain. From the striatum, inhibitory GABA neurons (green) extend to multiple regions including the thalamus, which has reciprocal excitatory glutamate connections (red) to the striatum, as well as connections to the PFC. Prefrontal cortical efferent

Intracellularly, dopamine is packaged into vesicles via the vesicular monoamine transporter (VMAT-2). The release of dopamine from the vesicle is Ca2+ and Na+ dependent and occurs when an action potential raises the Ca2+ levels in the presynaptic neuron, causing vesicles stored with dopamine to bind to the cellular membrane and release their contents. The re‐ sulting synaptic dopamine is then able to bind to dopamine receptors on both the pre- and postsynaptic neurons. These receptors are classified into two major categories: 1) D1-type re‐ ceptors, consisting of D1 and D5 and expressed postsynaptically, and 2) D2-type receptors ex‐ pressed both pre- and postsynaptically, consisting of D2 (short), D2 (long), D3 and D4. Stimulation of D1-type receptors causes increased cAMP production (activating), whereas stimulation of D2-type receptors causes inhibition of cAMP production (inhibiting). The ef‐ fects of these receptors give dopamine the classification of a modulatory neurotransmitter.

excitatory glutamate neurons extend to the striatum, nucleus accumbens (NA), SN, as well as the VTA.

For a simplified PFC dopamine synapse diagram, see Figure 2.

DAT and not metabolism or diffusion [12].

Stimulant medications were initially discovered to treat hyperactivity in the early 1900s when the psychiatrist Charles Bradley used amphetamines to treat children with headaches caused by pneumoencephalography and found it improved their school performance, social interactions and emotional responses. However, amphetamine as a treatment for ADHD was ignored until years later due to a variety of reasons [4]. In the 1950s, researchers were beginning to look for the underlying mechanisms causing behavioral problems and it was at this time that Bradley's discovery of amphetamine as a treatment for hyperactivity was un‐ covered and investigations into the mechanism of action of amphetamine began. The am‐ phetamine formulation Bradley used in his patients was called Benzedrine, a racemic mixture of 50/50 d- and l-amphetamine, produced by the company Smith, Kline and French [4]. Treatment with this medication in a variety of experimental paradigms reduced hyper‐ activity [5]; however, of particular note is a study published in 1976 showing decreased hy‐ peractivity when treated with amphetamine in rodents with dopamine depletion [6]. This was the first time that hyperactivity was linked to dopamine, but far from the last.

#### **2.1. Dopamine**

Dopamine, classified as a catecholamine neurotransmitter, is produced in the cells of the substantia nigra (SN, A9) and ventral tegmental area (VTA, A10) of the midbrain and project to numerous brain regions, including the prefrontal cortex (PFC), striatum and nucleus ac‐ cumbens (NA, see Figure 1). Projections from the VTA to the NA are identified as the meso‐ limbic pathway, or the "reward pathway," because these dopamine projections are involved in rewarding behaviors, [7] firing when a reward is greater than expected or when a reward is anticipated [8-10]. Projections from the SN to the striatum are referred to as the nigrostria‐ tal pathway and play a role in many aspects of motor control [11]. The mesocortical system consists of dopaminergic projections from the VTA to the PFC, and it is implicated in many cognitive functions including, but most certainly not limited to, attention and memory [11]. The mesocortical system will be the main focus in this chapter.

Dopamine is produced from tyrosine into 3,4-dihydroxyphenylalanine (DOPA) by the en‐ zyme tyrosine hydroxylase. DOPA is then made into dopamine via DOPA-decarboxylase. Conversely, dopamine is broken down or converted by a number of mechanisms: 1) dopa‐ mine-β-hydroxylase converts dopamine into norepinephrine, 2) monoamine oxidase (MAO) converts dopamine into 3,4-dihydroxyphenylacetic acid (DOPAC), and 3) catechol-*o*-methyl‐ transferase (COMT) catalyzes the formation of homovanillic acid (HVA). Dopamine-β -hy‐ droxylase only exists in norepinephrine neurons and thus will not be a focus here; however, MAO exists on the outer mitochondrial membrane and is also thought to be in abundance extracellularly, and COMT is mostly present extracellularly and plays a major role in regu‐ lating dopamine neurotransmission, especially in the PFC [11]. The final and most impor‐ tant method in which dopamine is cleared from the synapse is via the dopamine transporter (DAT). The DAT primarily exists on the presynaptic neuron and can transport dopamine ei‐ ther into or out of the neuron, dependent upon the concentration gradient. It has been dis‐ covered that the removal of dopamine from the synapse is predominantly performed by the DAT and not metabolism or diffusion [12].

began to be separated from general reactions and become its own diagnosis, referred to as the 'hyperkinetic reaction of childhood.' This reaction was characterized by a short attention span, hyperactivity, and restlessness [2], and in 1980, with the publication of the DSM-3, the ADHD diagnosis became more specific and was described as ADD (attention-deficit disor‐ der) [3]; however, by this time, this disorder was already being treated with stimulant medi‐

Stimulant medications were initially discovered to treat hyperactivity in the early 1900s when the psychiatrist Charles Bradley used amphetamines to treat children with headaches caused by pneumoencephalography and found it improved their school performance, social interactions and emotional responses. However, amphetamine as a treatment for ADHD was ignored until years later due to a variety of reasons [4]. In the 1950s, researchers were beginning to look for the underlying mechanisms causing behavioral problems and it was at this time that Bradley's discovery of amphetamine as a treatment for hyperactivity was un‐ covered and investigations into the mechanism of action of amphetamine began. The am‐ phetamine formulation Bradley used in his patients was called Benzedrine, a racemic mixture of 50/50 d- and l-amphetamine, produced by the company Smith, Kline and French [4]. Treatment with this medication in a variety of experimental paradigms reduced hyper‐ activity [5]; however, of particular note is a study published in 1976 showing decreased hy‐ peractivity when treated with amphetamine in rodents with dopamine depletion [6]. This

was the first time that hyperactivity was linked to dopamine, but far from the last.

The mesocortical system will be the main focus in this chapter.

Dopamine, classified as a catecholamine neurotransmitter, is produced in the cells of the substantia nigra (SN, A9) and ventral tegmental area (VTA, A10) of the midbrain and project to numerous brain regions, including the prefrontal cortex (PFC), striatum and nucleus ac‐ cumbens (NA, see Figure 1). Projections from the VTA to the NA are identified as the meso‐ limbic pathway, or the "reward pathway," because these dopamine projections are involved in rewarding behaviors, [7] firing when a reward is greater than expected or when a reward is anticipated [8-10]. Projections from the SN to the striatum are referred to as the nigrostria‐ tal pathway and play a role in many aspects of motor control [11]. The mesocortical system consists of dopaminergic projections from the VTA to the PFC, and it is implicated in many cognitive functions including, but most certainly not limited to, attention and memory [11].

Dopamine is produced from tyrosine into 3,4-dihydroxyphenylalanine (DOPA) by the en‐ zyme tyrosine hydroxylase. DOPA is then made into dopamine via DOPA-decarboxylase. Conversely, dopamine is broken down or converted by a number of mechanisms: 1) dopa‐ mine-β-hydroxylase converts dopamine into norepinephrine, 2) monoamine oxidase (MAO) converts dopamine into 3,4-dihydroxyphenylacetic acid (DOPAC), and 3) catechol-*o*-methyl‐ transferase (COMT) catalyzes the formation of homovanillic acid (HVA). Dopamine-β -hy‐ droxylase only exists in norepinephrine neurons and thus will not be a focus here; however, MAO exists on the outer mitochondrial membrane and is also thought to be in abundance extracellularly, and COMT is mostly present extracellularly and plays a major role in regu‐

cations, a treatment still used to this day.

110 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**2.1. Dopamine**

**Figure 1.** Modulatory dopaminergic neurons (blue) project to the dorsal striatum via the substantia nigra (SN, A9) and the ventral striatum and prefrontal cortex (PFC) via the ventral tegmental area (VTA, A10) in the rodent brain. From the striatum, inhibitory GABA neurons (green) extend to multiple regions including the thalamus, which has reciprocal excitatory glutamate connections (red) to the striatum, as well as connections to the PFC. Prefrontal cortical efferent excitatory glutamate neurons extend to the striatum, nucleus accumbens (NA), SN, as well as the VTA.

Intracellularly, dopamine is packaged into vesicles via the vesicular monoamine transporter (VMAT-2). The release of dopamine from the vesicle is Ca2+ and Na+ dependent and occurs when an action potential raises the Ca2+ levels in the presynaptic neuron, causing vesicles stored with dopamine to bind to the cellular membrane and release their contents. The re‐ sulting synaptic dopamine is then able to bind to dopamine receptors on both the pre- and postsynaptic neurons. These receptors are classified into two major categories: 1) D1-type re‐ ceptors, consisting of D1 and D5 and expressed postsynaptically, and 2) D2-type receptors ex‐ pressed both pre- and postsynaptically, consisting of D2 (short), D2 (long), D3 and D4. Stimulation of D1-type receptors causes increased cAMP production (activating), whereas stimulation of D2-type receptors causes inhibition of cAMP production (inhibiting). The ef‐ fects of these receptors give dopamine the classification of a modulatory neurotransmitter. For a simplified PFC dopamine synapse diagram, see Figure 2.

and is converted by glutamine synthetase into glutamine and transported out of the glial cell by system N transporter. The glutamine is then taken up by the system A transport‐ er on the presynaptic neuron to help replenish glutamate levels through the mitochondri‐ al bound glutaminase [11]. Glutamate acts on synaptic glutamate receptors in the target brain region, which are classified into two major types: 1) ionotropic, which include the NMDA, AMPA and kainate receptors and 2) metabotropic, including the excitatory mGluRs 1 and 5 (postsynaptic) and the inhibitory mGluRs 2, 3, 4, 6, 7, and 8 (presynap‐

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A dysfunctional interaction between the dopamine and glutamate systems has been impli‐ cated in numerous neuropsychiatric disorders such as drug addiction, Alzheimer's disease, schizophrenia, and ADHD. The brain regions most often linked to these disorders and the dopamine-glutamate dysfunction are the PFC and striatum, as these regions both receive heavy innervation from the dopaminergic SN/VTA and glutamate innervation from thala‐

Studies of signaling interactions between the dopaminergic and glutamatergic systems dem‐ onstrate that the NMDA receptor is crucial in activating dopamine neurons in the VTA/SN [17, 18]. Also, it has been found that stimulation of the D2-class dopamine receptor is in‐ volved in the downstream inhibition of the NMDA receptor, weakening the excitatory re‐ sponse to those neurons [19]. Likewise, it was found that activation of D4 receptors depressed AMPA receptor-mediated excitatory synaptic transmission in PFC pyramidal neurons, which was accompanied by a D4-induced decrease of AMPA receptors at the syn‐ apse [20]. These results provide substantial evidence that the dopamine and glutamate neu‐ ronal systems work in tandem to create a balance of neurotransmission in these regions.

The hypodopaminergic theory of ADHD asserts that the hyperactive and inattentive behav‐ iors are caused by low levels of either tonic or phasic dopamine. If true, decreased dopamine released in the striatum and PFC would then be expected to lead to more active NMDA and AMPA receptors based on the studies mentioned above resulting in increased glutamatergic output to the striatum and SN/VTA, as well as an increased glutamate signal to the PFC. Glutamate coming into the SN/VTA would normally go on to release more dopamine [17];

Investigations into the effects of stimulant action on the dopaminergic system have revealed that these medications increase extracellular dopamine levels via numerous mechanisms. First, amphetamine has been found to increase dopamine through calcium-independent mechanisms such as increased release of dopamine and blocking the reuptake of dopamine through the DAT [21, 22]. Methylphenidate (MPH), another stimulant medication common‐ ly used to treat ADHD, increases dopamine levels by inhibiting dopamine reuptake via the

however, in the ADHD brain, this feedback does not seem to occur.

**2.4. Translational neuropharmacology of ADHD treatments**

DAT [23-29].

mic relays and other glutamate rich regions, as described in the previous section.

tic). For a simplified PFC glutamate synapse diagram, see Figure 2.

**2.3. Dopamine and glutamate interactions**

**Figure 2.** Dopaminergic and glutamatergic synapses in the PFC, simplified. Left: pre-synaptically, dopamine is trans‐ ported into vesicles, which release their contents upon increase of the Ca2+ concentration. Synaptic dopamine is then able to stimulate dopamine receptors on both the pre- and postsynaptic neurons before it is cleared by the DAT or metabolism. Right: presynaptically, glutamate is stored in vesicles and then released into the extracellular space. Syn‐ aptic glutamate is then able to stimulate glutamate receptors (here represented as the NMDA and mGluR) on both the pre- and postsynaptic neurons before it is cleared by the EAAT located on nearby glial cells.

#### **2.2. Glutamate**

Recent clinical evidence has implicated glutamate in ADHD. Much of the initial evidence stems from proton magnetic resonance spectroscopy studies of children and adults with ADHD. These studies have shown increased levels of a marker for glutamate in the striatum and anterior cingulate cortex of the PFC [13-15]. Based on this evidence, new in‐ vestigations into glutamatergic function in ADHD are ongoing. Glutamate is the major excitatory neurotransmitter in the central nervous system and must be tightly regulated for proper neuronal signaling to occur [16]. Unlike dopamine, glutamate is in abundance in most areas of the brain. Glutamate projections originating in the PFC extend to the striatum, NA, VTA and SN of the midbrain (see Figure 1). Glutamate is produced in the nerve terminals of these projections from two sources: 1) the Krebs cycle and 2) gluta‐ mine produced and excreted into the extracellular space via glial cells. Once produced, glutamate is transported into vesicles via the vesicular glutamate transporter (VGLUT) and when Ca2+ levels increase to cause an action potential, vesicles stored with glutamate bind to the cellular membrane and release their contents. Clearance of glutamate after this calcium-dependent release into the extracellular space is primarily performed by the membrane-bound glutamate transporter, called the excitatory amino acid transporter (EAAT), located on the presynaptic neuron and to the greatest extent by surrounding glial cells. The glutamate is primarily taken up by the EAATs located on the glial cells and is converted by glutamine synthetase into glutamine and transported out of the glial cell by system N transporter. The glutamine is then taken up by the system A transport‐ er on the presynaptic neuron to help replenish glutamate levels through the mitochondri‐ al bound glutaminase [11]. Glutamate acts on synaptic glutamate receptors in the target brain region, which are classified into two major types: 1) ionotropic, which include the NMDA, AMPA and kainate receptors and 2) metabotropic, including the excitatory mGluRs 1 and 5 (postsynaptic) and the inhibitory mGluRs 2, 3, 4, 6, 7, and 8 (presynap‐ tic). For a simplified PFC glutamate synapse diagram, see Figure 2.

#### **2.3. Dopamine and glutamate interactions**

**Figure 2.** Dopaminergic and glutamatergic synapses in the PFC, simplified. Left: pre-synaptically, dopamine is trans‐ ported into vesicles, which release their contents upon increase of the Ca2+ concentration. Synaptic dopamine is then able to stimulate dopamine receptors on both the pre- and postsynaptic neurons before it is cleared by the DAT or metabolism. Right: presynaptically, glutamate is stored in vesicles and then released into the extracellular space. Syn‐ aptic glutamate is then able to stimulate glutamate receptors (here represented as the NMDA and mGluR) on both

Recent clinical evidence has implicated glutamate in ADHD. Much of the initial evidence stems from proton magnetic resonance spectroscopy studies of children and adults with ADHD. These studies have shown increased levels of a marker for glutamate in the striatum and anterior cingulate cortex of the PFC [13-15]. Based on this evidence, new in‐ vestigations into glutamatergic function in ADHD are ongoing. Glutamate is the major excitatory neurotransmitter in the central nervous system and must be tightly regulated for proper neuronal signaling to occur [16]. Unlike dopamine, glutamate is in abundance in most areas of the brain. Glutamate projections originating in the PFC extend to the striatum, NA, VTA and SN of the midbrain (see Figure 1). Glutamate is produced in the nerve terminals of these projections from two sources: 1) the Krebs cycle and 2) gluta‐ mine produced and excreted into the extracellular space via glial cells. Once produced, glutamate is transported into vesicles via the vesicular glutamate transporter (VGLUT) and when Ca2+ levels increase to cause an action potential, vesicles stored with glutamate bind to the cellular membrane and release their contents. Clearance of glutamate after this calcium-dependent release into the extracellular space is primarily performed by the membrane-bound glutamate transporter, called the excitatory amino acid transporter (EAAT), located on the presynaptic neuron and to the greatest extent by surrounding glial cells. The glutamate is primarily taken up by the EAATs located on the glial cells

the pre- and postsynaptic neurons before it is cleared by the EAAT located on nearby glial cells.

112 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**2.2. Glutamate**

A dysfunctional interaction between the dopamine and glutamate systems has been impli‐ cated in numerous neuropsychiatric disorders such as drug addiction, Alzheimer's disease, schizophrenia, and ADHD. The brain regions most often linked to these disorders and the dopamine-glutamate dysfunction are the PFC and striatum, as these regions both receive heavy innervation from the dopaminergic SN/VTA and glutamate innervation from thala‐ mic relays and other glutamate rich regions, as described in the previous section.

Studies of signaling interactions between the dopaminergic and glutamatergic systems dem‐ onstrate that the NMDA receptor is crucial in activating dopamine neurons in the VTA/SN [17, 18]. Also, it has been found that stimulation of the D2-class dopamine receptor is in‐ volved in the downstream inhibition of the NMDA receptor, weakening the excitatory re‐ sponse to those neurons [19]. Likewise, it was found that activation of D4 receptors depressed AMPA receptor-mediated excitatory synaptic transmission in PFC pyramidal neurons, which was accompanied by a D4-induced decrease of AMPA receptors at the syn‐ apse [20]. These results provide substantial evidence that the dopamine and glutamate neu‐ ronal systems work in tandem to create a balance of neurotransmission in these regions.

The hypodopaminergic theory of ADHD asserts that the hyperactive and inattentive behav‐ iors are caused by low levels of either tonic or phasic dopamine. If true, decreased dopamine released in the striatum and PFC would then be expected to lead to more active NMDA and AMPA receptors based on the studies mentioned above resulting in increased glutamatergic output to the striatum and SN/VTA, as well as an increased glutamate signal to the PFC. Glutamate coming into the SN/VTA would normally go on to release more dopamine [17]; however, in the ADHD brain, this feedback does not seem to occur.

#### **2.4. Translational neuropharmacology of ADHD treatments**

Investigations into the effects of stimulant action on the dopaminergic system have revealed that these medications increase extracellular dopamine levels via numerous mechanisms. First, amphetamine has been found to increase dopamine through calcium-independent mechanisms such as increased release of dopamine and blocking the reuptake of dopamine through the DAT [21, 22]. Methylphenidate (MPH), another stimulant medication common‐ ly used to treat ADHD, increases dopamine levels by inhibiting dopamine reuptake via the DAT [23-29].

The non-stimulant medication atomoxetine (ATX) is becoming increasingly popular as a treatment for ADHD compared to the stimulant medications because it has lower abuse lia‐ bility. ATX has been found to increase levels of the catecholamines by selectively blocking the norepinephrine transporter (NET), which is also able to clear dopamine [30-32] and, like stimulants, is effective at lessoning the intensity of ADHD symptoms [33-36]. *In vitro* work has shown that ATX acts as an NMDA receptor antagonist [37], providing preliminary evi‐ dence that current treatments for ADHD may have a direct effect on the glutamatergic sys‐ tem.

**2.5. Animal models of ADHD: Hypotheses**

**The dopamine receptor D4 knockout mouse**

amine and glutamate interactions in the PFC.

The spontaneously hypertensive rat (SHR) has been used as an animal model for ADHD combined type since the 1970's because of its sustained attention deficits [46], motor im‐ pulsiveness [47-49], and hyperactivity [46] with the hyperactivity absent in novel situa‐ tions [50]. Currently, there exists conflicting data on dopamine release and uptake levels in the brain areas thought to be involved in the pathophysiology of ADHD, including the PFC [51]. Our lab has previously reported enhanced dopamine uptake in the ventral striatum and nucleus accumbens core of the SHR [52]; however, investigations into PFC dopamine regulation are still not clear. The PFC of the SHR has been reported to have decreased dopamine uptake [53], yet a study found no differences in the levels of DAT, tyrosine hydroxylase, D1, D2, D3, D5 receptors, and dopamine-β-hydroxylase between the SHR and its progenitor strain, the Wistar Kyoto (WKY), in the PFC. Regional differences in the D4 receptors in the PFC were found, providing evidence that the SHR's D4 levels are lower than those of the WKY [54]. Further, it was found that PFC AMPA receptor activity was increased in the SHR [55] and inhibitory dopaminergic activity was found to be decreased while noradrenergic activity increased in the SHR [56]. These findings all convey a message that dopamine regulation is dysfunctional in the PFC of the SHR mod‐ el of ADHD; however, direct observation of in vivo dopamine dynamics in the separate PFC sub-regions (cingulate, prelimbic, and infralimbic) of the SHR have not yet been ac‐

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The correlation between ADHD and the 7-repeat polymorphism in the dopamine D4 recep‐ tor (DRD4.7) is supported by neuroanatomical, neurochemical, molecular genetics and phar‐ macological studies [57-60]. Recently, the DRD4.7 was identified as having the most significant genetic relationship to ADHD in pooled family and case-controlled studies [61]. Clinical studies in adolescents report that ADHD patients with the DRD4.7 have thinner frontal cortical structures in comparison to age matched controls [62]. The highest concen‐ tration of DRD4s is in the frontal cortex, an area implicated in the pathophysiology of ADHD using neuroimaging and neuropsychological evaluation of ADHD patients [63-66]. There is evidence that changes in DRD4 expression can affect glutamate levels in the stria‐ tum of DRD4-/- mice [67]. Previous studies show that DRD4-/- mice are supersensitive to etha‐ nol, cocaine and methamphetamine [68]; have enhanced reactivity to unconditioned fear [69]; reduced exploration of novel stimuli [70]; and hypersensitivity to amphetamine [71]. In the cortex, hyperexcitability has been demonstrated in DRD4-/- mice using immunohisto‐ chemical, electrophysiological, pharmacological and ultrastructural methods, indicating that DRD4 activation has an inhibitory influence on glutamate neurons in the frontal cortex [72]. At this time, no direct studies of in vivo glutamate have been investigated in the intact PFC of the DRD4-/- mouse. Therefore, *in vivo* measures of glutamatergic modulation in the PFC may correlate changes in glutamate neurotransmission to the expression levels of the DRD4 and understanding the physiological role of the DRD4 may elucidate the importance of dop‐

**The spontaneously hypertensive rat**

curately defined.

Using magnetic resonance spectroscopy, it was found that children treated with ATX, but not MPH, had decreased levels of a marker for glutamate/glutamine in the PFC, though MPH was able to decrease glutamate in the anterior cingulate cortex [38]. In the striatum, both ATX and MPH decreased the glutamate/glutamine marker levels compared to controls [13]. These results suggest that ATX may be regulating and activating prefrontal cortex neu‐ rons. However, another clinical study using a similar technique found that chronic long-act‐ ing MPH decreased glutamate levels in the PFC of children with ADHD [39]. Wiguna et al. (2012) also discovered that MPH treatment resulted in an increase in the amount of and functional state of the neurons in the PFC, supporting that the current ADHD stimulant treatment MPH can activate PFC neurons as well. Further evidence of PFC activation comes from a study of brain-derived neurotropic factor (BDNF), a marker for neuronal plasticity. ATX was found to increase BDNF expression in the PFC; however, MPH had the opposite effect and reduced BDNF expression in the PFC [40], though it must be noted that this study was completed in naïve rodents and may explain why these results do not match those seen in ADHD patients.

Many second-line and experimental treatments for ADHD are now targeting both the dopamine and glutamate systems. Memantine is an uncompetitive NMDA receptor an‐ tagonist [41] and has also been found to act as a D2 receptor agonist [42]. It has been ap‐ proved and used as a treatment for Alzheimer's disease; however, in an 8 week openlabel pilot study in children with ADHD, memantine was found to improve ADHD symptoms (Findling et al, 2007). Surman et al. (2011) extended these findings to adults with ADHD in a separate open-label study lasting 12 weeks and found similar results, with memantine improving ADHD symptoms and neuropsychological performance [43]. The MAO-B inhibitor (deprenyl), which stops the degradation of dopamine and is used as a treatment in Parkinson's disease, was found to alleviate ADHD symptoms [44, 45]. These clinical data using glutamate and dopamine altering drugs provide strong links for dysfunctional dopamine-glutamate interactions in ADHD, though the importance of this dysfunction is still unknown. Based on these data, we believe it's important to not over‐ look the possible role of dysfunctional dopamine-glutamate interactions, but to instead focus on this relationship. Animal models of ADHD provide a unique opportunity to in‐ vestigate neurotransmitter system dysfunction as well as to develop novel ways to treat ADHD targeting these systems. We will next highlight two separate models of ADHD and how they are implicating both dopamine and glutamate dysfunction in ADHD.

#### **2.5. Animal models of ADHD: Hypotheses**

#### **The spontaneously hypertensive rat**

The non-stimulant medication atomoxetine (ATX) is becoming increasingly popular as a treatment for ADHD compared to the stimulant medications because it has lower abuse lia‐ bility. ATX has been found to increase levels of the catecholamines by selectively blocking the norepinephrine transporter (NET), which is also able to clear dopamine [30-32] and, like stimulants, is effective at lessoning the intensity of ADHD symptoms [33-36]. *In vitro* work has shown that ATX acts as an NMDA receptor antagonist [37], providing preliminary evi‐ dence that current treatments for ADHD may have a direct effect on the glutamatergic sys‐

114 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Using magnetic resonance spectroscopy, it was found that children treated with ATX, but not MPH, had decreased levels of a marker for glutamate/glutamine in the PFC, though MPH was able to decrease glutamate in the anterior cingulate cortex [38]. In the striatum, both ATX and MPH decreased the glutamate/glutamine marker levels compared to controls [13]. These results suggest that ATX may be regulating and activating prefrontal cortex neu‐ rons. However, another clinical study using a similar technique found that chronic long-act‐ ing MPH decreased glutamate levels in the PFC of children with ADHD [39]. Wiguna et al. (2012) also discovered that MPH treatment resulted in an increase in the amount of and functional state of the neurons in the PFC, supporting that the current ADHD stimulant treatment MPH can activate PFC neurons as well. Further evidence of PFC activation comes from a study of brain-derived neurotropic factor (BDNF), a marker for neuronal plasticity. ATX was found to increase BDNF expression in the PFC; however, MPH had the opposite effect and reduced BDNF expression in the PFC [40], though it must be noted that this study was completed in naïve rodents and may explain why these results do not match those seen

Many second-line and experimental treatments for ADHD are now targeting both the dopamine and glutamate systems. Memantine is an uncompetitive NMDA receptor an‐ tagonist [41] and has also been found to act as a D2 receptor agonist [42]. It has been ap‐ proved and used as a treatment for Alzheimer's disease; however, in an 8 week openlabel pilot study in children with ADHD, memantine was found to improve ADHD symptoms (Findling et al, 2007). Surman et al. (2011) extended these findings to adults with ADHD in a separate open-label study lasting 12 weeks and found similar results, with memantine improving ADHD symptoms and neuropsychological performance [43]. The MAO-B inhibitor (deprenyl), which stops the degradation of dopamine and is used as a treatment in Parkinson's disease, was found to alleviate ADHD symptoms [44, 45]. These clinical data using glutamate and dopamine altering drugs provide strong links for dysfunctional dopamine-glutamate interactions in ADHD, though the importance of this dysfunction is still unknown. Based on these data, we believe it's important to not over‐ look the possible role of dysfunctional dopamine-glutamate interactions, but to instead focus on this relationship. Animal models of ADHD provide a unique opportunity to in‐ vestigate neurotransmitter system dysfunction as well as to develop novel ways to treat ADHD targeting these systems. We will next highlight two separate models of ADHD and how they are implicating both dopamine and glutamate dysfunction in ADHD.

tem.

in ADHD patients.

The spontaneously hypertensive rat (SHR) has been used as an animal model for ADHD combined type since the 1970's because of its sustained attention deficits [46], motor im‐ pulsiveness [47-49], and hyperactivity [46] with the hyperactivity absent in novel situa‐ tions [50]. Currently, there exists conflicting data on dopamine release and uptake levels in the brain areas thought to be involved in the pathophysiology of ADHD, including the PFC [51]. Our lab has previously reported enhanced dopamine uptake in the ventral striatum and nucleus accumbens core of the SHR [52]; however, investigations into PFC dopamine regulation are still not clear. The PFC of the SHR has been reported to have decreased dopamine uptake [53], yet a study found no differences in the levels of DAT, tyrosine hydroxylase, D1, D2, D3, D5 receptors, and dopamine-β-hydroxylase between the SHR and its progenitor strain, the Wistar Kyoto (WKY), in the PFC. Regional differences in the D4 receptors in the PFC were found, providing evidence that the SHR's D4 levels are lower than those of the WKY [54]. Further, it was found that PFC AMPA receptor activity was increased in the SHR [55] and inhibitory dopaminergic activity was found to be decreased while noradrenergic activity increased in the SHR [56]. These findings all convey a message that dopamine regulation is dysfunctional in the PFC of the SHR mod‐ el of ADHD; however, direct observation of in vivo dopamine dynamics in the separate PFC sub-regions (cingulate, prelimbic, and infralimbic) of the SHR have not yet been ac‐ curately defined.

#### **The dopamine receptor D4 knockout mouse**

The correlation between ADHD and the 7-repeat polymorphism in the dopamine D4 recep‐ tor (DRD4.7) is supported by neuroanatomical, neurochemical, molecular genetics and phar‐ macological studies [57-60]. Recently, the DRD4.7 was identified as having the most significant genetic relationship to ADHD in pooled family and case-controlled studies [61]. Clinical studies in adolescents report that ADHD patients with the DRD4.7 have thinner frontal cortical structures in comparison to age matched controls [62]. The highest concen‐ tration of DRD4s is in the frontal cortex, an area implicated in the pathophysiology of ADHD using neuroimaging and neuropsychological evaluation of ADHD patients [63-66]. There is evidence that changes in DRD4 expression can affect glutamate levels in the stria‐ tum of DRD4-/- mice [67]. Previous studies show that DRD4-/- mice are supersensitive to etha‐ nol, cocaine and methamphetamine [68]; have enhanced reactivity to unconditioned fear [69]; reduced exploration of novel stimuli [70]; and hypersensitivity to amphetamine [71]. In the cortex, hyperexcitability has been demonstrated in DRD4-/- mice using immunohisto‐ chemical, electrophysiological, pharmacological and ultrastructural methods, indicating that DRD4 activation has an inhibitory influence on glutamate neurons in the frontal cortex [72]. At this time, no direct studies of in vivo glutamate have been investigated in the intact PFC of the DRD4-/- mouse. Therefore, *in vivo* measures of glutamatergic modulation in the PFC may correlate changes in glutamate neurotransmission to the expression levels of the DRD4 and understanding the physiological role of the DRD4 may elucidate the importance of dop‐ amine and glutamate interactions in the PFC.

#### **Measuring neurotransmitters in these rodent models of ADHD**

Recent studies point to the importance of a dysfunctional relationship between dopaminer‐ gic and glutamatergic neurotransmission in ADHD, therefore new investigations into this relationship are necessary to improve our understanding and may lead to improved thera‐ peutics for ADHD. Based on our development of novel and revolutionary methods of meas‐ uring dopamine and glutamate in vivo, we realize we are in a unique position to test our hypotheses that dopamine and glutamate regulation play a major role in the pathophysiolo‐ gy of ADHD. The development of carbon fiber microelectrodes and glutamate oxidase-coat‐ ed microelectrode arrays (MEAs) provide improved spatial resolution, sub-second temporal resolution, and low limits of detection (<10 nM for dopamine [52], <0.2 µM for glutamate [73]) over conventional techniques used in the past, such as microdialysis. The smaller size of these probes and decreased damage to tissue compared to microdialysis probes allows for the *in vivo* characterization of dopamine and glutamate signaling closer to the synapse. Us‐ ing these technologies, we were able to explore if dysfunction in dopamine and glutamate neurotransmission occur in the PFC of the SHR and DRD4 models of ADHD. The studies described here could potentially lead to the development of novel therapies for ADHD, which will be discussed in detail later.

trode was affixed to a micropipette (10 µm inner diameter) which was positioned approxi‐ mately 200 µm from the carbon fiber electrode tip using sticky wax (Kerr USA, Romulus,

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Rats were anesthetized intraperitonealy (i.p.) using a 25% urethane solution (1.25 g/kg) and placed in a stereotaxic frame (David Kopf Instruments, Tujunga, California). A circulating heating pad (Gaymar Industries, Inc., Orchard Park, New York) was used to maintain body temperature. The skull was removed bilaterally for recordings in the PFC (AP +3.2, ML ±1.0, DV -2 to -6 in 0.5 mm increments) [75]. A small hole remote from the site of surgery was drilled for placement of the miniature Ag/AgCl reference electrode. Prior to experimenta‐ tion, the micropipette was filled with filtered isotonic KCl (120 mM KCl, 29 mM NaCl, 2.5 mM CaCl2•2H2O) solution (pH 7.2-7.4) using a 4 inch filling needle (Cadence Inc., Staunton, Virginia) and a 5 ml syringe. Experiments were then initiated with the insertion of the mi‐ cropipette/microelectrode assembly into a stereotactically selected region of the left or right hemisphere's PFC. After a 30-45 minute baseline, the effect of a single local application of KCl on dopamine release was determined [52]. The KCl solution was locally applied by pressure ejection (5–25 psi for 0.5 seconds) and the single application of a set volume of KCl (75–125 nl) was delivered to each sub-region, measured by determining the amount of fluid ejected from the micropipette using a dissection microscope fitted with an eyepiece reticule that was calibrated so that 1 mm of movement was equivalent to 25 nl of fluid ejected [76, 77]. If the volume was determined to be greater or less than 75-100 nl, then that data point was excluded. After the KCl studies, the micropipette/microelectrode assembly was filled with filtered isotonic 200 µM dopamine solution containing 100 µM ascorbic acid (an antioxidant) in 0.9% saline (pH 7.2-7.4). The micropipette/microelectrode assembly was inserted stereotactically into the animal's contralateral PFC. Again, a stable baseline was achieved be‐ fore the dopamine solution was locally applied by pressure ejection (10-30 psi for 0.5-10 s) to achieve a maximum amplitude between the range of 0.5 to 1 µM dopamine. The maximum concentration of the dopamine in the extracellular space was measured by subtracting the apex of the recorded peak from the baseline recorded prior to the ejection. If the peak ampli‐ tude was greater or less than 0.5 to 1 µM dopamine, then that data point was excluded. Brains were removed and processed (frozen) for histological evaluation of microelectrode recording tracks. Only data from histologically confirmed placements of microelectrodes in‐ to the PFC were used for final data analysis. Based on histological analyses, no animals were

Collected data were processed using a custom Matlab®-based analysis package. For KClevoked DA release, maximum amplitude of the evoked dopamine peak was used. The vol‐ ume of KCl applied was kept constant across depths and strains (75–125 nl). For dopamine uptake the time to 80% decay of the dopamine signal (T80) was examined. dopamine signals were amplitude matched (ranging from 0.5 to 1 µM dopamine) to ensure accurate measure‐ ment of dopamine uptake kinetics [52, 74]. Outliers were excluded via the Grubb's test be‐ fore averaging if the conditions for homogeneity of variance were met. To compare dopamine dynamics in the separate PFC subregions, one-way ANOVAs followed by Bonfer‐ roni post-hoc comparisons were used. Significance was set at p<0.05 (GraphPad Prism 5.0).

Michigan).

excluded due to microelectrode placement errors.

#### **2.6. Neurotransmitter recording techniques: Methods**

#### **High-speed chronoamperometric recordings of dopamine release and uptake in the PFC of the SHR**

Male, 8-10 weeks old, inbred spontaneously hypertensive rats (SHR, average 225 g, average PND 60), inbred Wistar Kyoto rats (WKY, average 210 g, average PND 61), and outbred Sprague Dawley rats (SD, average 289 g, average PND 69) were obtained from Charles River Laboratories (NCrl), Wilmington, Massachusetts. Animals were given access to food and water ad libitum and housed in a 12 hour light/dark cycle. Protocols for animal use were approved by the Institutional Animal Care and Use Committee, which is Association for As‐ sessment and Accreditation of Laboratory Animal Care International approved. All proce‐ dures were carried out in accordance with the National Institutes of Health Guide for Care and Use of Laboratory Animals and all efforts were made to minimize animal suffering and to reduce the number of animals used.

High-speed chronoamperometric measurements (1 Hz sampling rate, 200 ms total) were performed using the FAST16mkII recording system (Fast Analytical Sensing Technology, Quanteon, LLC, Nicholasville, Kentucky) as previously described [52, 74]. Single carbon fi‐ ber electrodes (SF1A; 30 µm outer diameter × 150 µm length; Quanteon, LLC, Nicholasville, Kentucky) were coated with Nafion® (5% solution, 1–3 coats at 180o C, Aldrich Chemical Co., Milwaukee, Wisconsin) prior to an in vitro calibration used to determine selectivity, limit of detection, and sensitivity before use in vivo: average selectivity for all microelectrodes used in these experiments was 1877 ± 664 µM for dopamine vs. ascorbic acid; average limit of de‐ tection for the measurement of dopamine was 0.028 ± 0.008 µM (S/N of 3); average slope for the electrodes was -0.492 ± 0.111 nA/µM dopamine. After calibration, miniature Ag/AgCl reference electrodes were prepared as previously described [74]. The carbon fiber microelec‐ trode was affixed to a micropipette (10 µm inner diameter) which was positioned approxi‐ mately 200 µm from the carbon fiber electrode tip using sticky wax (Kerr USA, Romulus, Michigan).

**Measuring neurotransmitters in these rodent models of ADHD**

116 Attention Deficit Hyperactivity Disorder in Children and Adolescents

which will be discussed in detail later.

to reduce the number of animals used.

**of the SHR**

**2.6. Neurotransmitter recording techniques: Methods**

Recent studies point to the importance of a dysfunctional relationship between dopaminer‐ gic and glutamatergic neurotransmission in ADHD, therefore new investigations into this relationship are necessary to improve our understanding and may lead to improved thera‐ peutics for ADHD. Based on our development of novel and revolutionary methods of meas‐ uring dopamine and glutamate in vivo, we realize we are in a unique position to test our hypotheses that dopamine and glutamate regulation play a major role in the pathophysiolo‐ gy of ADHD. The development of carbon fiber microelectrodes and glutamate oxidase-coat‐ ed microelectrode arrays (MEAs) provide improved spatial resolution, sub-second temporal resolution, and low limits of detection (<10 nM for dopamine [52], <0.2 µM for glutamate [73]) over conventional techniques used in the past, such as microdialysis. The smaller size of these probes and decreased damage to tissue compared to microdialysis probes allows for the *in vivo* characterization of dopamine and glutamate signaling closer to the synapse. Us‐ ing these technologies, we were able to explore if dysfunction in dopamine and glutamate neurotransmission occur in the PFC of the SHR and DRD4 models of ADHD. The studies described here could potentially lead to the development of novel therapies for ADHD,

**High-speed chronoamperometric recordings of dopamine release and uptake in the PFC**

Male, 8-10 weeks old, inbred spontaneously hypertensive rats (SHR, average 225 g, average PND 60), inbred Wistar Kyoto rats (WKY, average 210 g, average PND 61), and outbred Sprague Dawley rats (SD, average 289 g, average PND 69) were obtained from Charles River Laboratories (NCrl), Wilmington, Massachusetts. Animals were given access to food and water ad libitum and housed in a 12 hour light/dark cycle. Protocols for animal use were approved by the Institutional Animal Care and Use Committee, which is Association for As‐ sessment and Accreditation of Laboratory Animal Care International approved. All proce‐ dures were carried out in accordance with the National Institutes of Health Guide for Care and Use of Laboratory Animals and all efforts were made to minimize animal suffering and

High-speed chronoamperometric measurements (1 Hz sampling rate, 200 ms total) were performed using the FAST16mkII recording system (Fast Analytical Sensing Technology, Quanteon, LLC, Nicholasville, Kentucky) as previously described [52, 74]. Single carbon fi‐ ber electrodes (SF1A; 30 µm outer diameter × 150 µm length; Quanteon, LLC, Nicholasville,

Milwaukee, Wisconsin) prior to an in vitro calibration used to determine selectivity, limit of detection, and sensitivity before use in vivo: average selectivity for all microelectrodes used in these experiments was 1877 ± 664 µM for dopamine vs. ascorbic acid; average limit of de‐ tection for the measurement of dopamine was 0.028 ± 0.008 µM (S/N of 3); average slope for the electrodes was -0.492 ± 0.111 nA/µM dopamine. After calibration, miniature Ag/AgCl reference electrodes were prepared as previously described [74]. The carbon fiber microelec‐

C, Aldrich Chemical Co.,

Kentucky) were coated with Nafion® (5% solution, 1–3 coats at 180o

Rats were anesthetized intraperitonealy (i.p.) using a 25% urethane solution (1.25 g/kg) and placed in a stereotaxic frame (David Kopf Instruments, Tujunga, California). A circulating heating pad (Gaymar Industries, Inc., Orchard Park, New York) was used to maintain body temperature. The skull was removed bilaterally for recordings in the PFC (AP +3.2, ML ±1.0, DV -2 to -6 in 0.5 mm increments) [75]. A small hole remote from the site of surgery was drilled for placement of the miniature Ag/AgCl reference electrode. Prior to experimenta‐ tion, the micropipette was filled with filtered isotonic KCl (120 mM KCl, 29 mM NaCl, 2.5 mM CaCl2•2H2O) solution (pH 7.2-7.4) using a 4 inch filling needle (Cadence Inc., Staunton, Virginia) and a 5 ml syringe. Experiments were then initiated with the insertion of the mi‐ cropipette/microelectrode assembly into a stereotactically selected region of the left or right hemisphere's PFC. After a 30-45 minute baseline, the effect of a single local application of KCl on dopamine release was determined [52]. The KCl solution was locally applied by pressure ejection (5–25 psi for 0.5 seconds) and the single application of a set volume of KCl (75–125 nl) was delivered to each sub-region, measured by determining the amount of fluid ejected from the micropipette using a dissection microscope fitted with an eyepiece reticule that was calibrated so that 1 mm of movement was equivalent to 25 nl of fluid ejected [76, 77]. If the volume was determined to be greater or less than 75-100 nl, then that data point was excluded. After the KCl studies, the micropipette/microelectrode assembly was filled with filtered isotonic 200 µM dopamine solution containing 100 µM ascorbic acid (an antioxidant) in 0.9% saline (pH 7.2-7.4). The micropipette/microelectrode assembly was inserted stereotactically into the animal's contralateral PFC. Again, a stable baseline was achieved be‐ fore the dopamine solution was locally applied by pressure ejection (10-30 psi for 0.5-10 s) to achieve a maximum amplitude between the range of 0.5 to 1 µM dopamine. The maximum concentration of the dopamine in the extracellular space was measured by subtracting the apex of the recorded peak from the baseline recorded prior to the ejection. If the peak ampli‐ tude was greater or less than 0.5 to 1 µM dopamine, then that data point was excluded. Brains were removed and processed (frozen) for histological evaluation of microelectrode recording tracks. Only data from histologically confirmed placements of microelectrodes in‐ to the PFC were used for final data analysis. Based on histological analyses, no animals were excluded due to microelectrode placement errors.

Collected data were processed using a custom Matlab®-based analysis package. For KClevoked DA release, maximum amplitude of the evoked dopamine peak was used. The vol‐ ume of KCl applied was kept constant across depths and strains (75–125 nl). For dopamine uptake the time to 80% decay of the dopamine signal (T80) was examined. dopamine signals were amplitude matched (ranging from 0.5 to 1 µM dopamine) to ensure accurate measure‐ ment of dopamine uptake kinetics [52, 74]. Outliers were excluded via the Grubb's test be‐ fore averaging if the conditions for homogeneity of variance were met. To compare dopamine dynamics in the separate PFC subregions, one-way ANOVAs followed by Bonfer‐ roni post-hoc comparisons were used. Significance was set at p<0.05 (GraphPad Prism 5.0). Urethane, dopamine, ascorbic acid, sodium chloride, potassium chloride, calcium chloride and Nafion® were obtained from Sigma (St. Louis, MO). Carbon fiber microelectrodes (SF1A's) were fabricated by the Center for Microelectrode Technology.

skull overlying the PFC was removed bilaterally. The MEA–micropipette assembly was positioned in the brain according to the following stereotaxic coordinates where all anteriorposterior (AP) measures were from bregma, medial-lateral (ML) measures were from mid‐ line and dorsal-ventral (DV) measures were from dura: AP: +2 mm, ML: ±1 mm, DV: -1.8 to 2.6 mm at an angle of 8 degrees according to the atlas of The Mouse Brain in Stereotaxic Co‐ ordinates [82]. An additional hole, remote from the surgery site, was opened for a Ag/AgCl reference electrode. Prior to placement of the MEA-pipette assembly, the micropipette was filled with isotonic 125 µM glutamate (125 µM L-glutamate in 0.9% physiological saline; pH= 7.2-7.4) using a combination of a 1 ml syringe filled with glutamate solution, a 0.22 µm sterile syringe filter (Costar Corporation), and a 4" stainless steel pulled needle (30 gauge, beveled tip; Popper and Son, Inc., NY). A potential of +0.7 V was applied versus a miniature Ag/AgCl reference electrode and the data were displayed at a frequency of 2 Hz. Upon ster‐ eotaxic placement of the MEA-micropipette assembly, 10-20 minutes of baseline data were acquired. Extracellular levels of glutamate were measured by averaging 30 seconds of base‐ line recordings prior to application of glutamate or KCl. Then, a 125 µM glutamate solution was locally applied via pressure ejection using a Picospritzer II connected to the open end of the micropipette by plastic tubing (Parker Hannifin Corp., General Valve Corporation). Pressure was applied at 5-25 psi for 1 second in all of the experiments. Glutamate was ap‐ plied every 30-60 seconds for a total of 10 recordings. The MEA was then lowered in 350 µm increments. Baseline recordings were acquired for 5-10 minutes and the recordings were re‐ peated. Parameters from three of the ten signals ranging from 10-30 µM in amplitude were averaged for each Pt electrode site at each depth. Signals were analyzed for time required to rise to maximum amplitude (rise time), time for 80% of the signal to decay from maximum amplitude (T80), and the rate of uptake. The uptake rate was calculated by multiplying the first order rate constant (k-1, seconds-1) by the maximum amplitude (uptake rate = µM/s) [81]. All data from local applications of glutamate from a given site were pooled into a single point. Amplitude-matched signals were compared to assess genotypic differences in the rates of clearance of exogenous glutamate [83]. Brains were removed and processed for his‐ tological evaluation of microelectrode recording tracts. Only data from histologically con‐ firmed placements of microelectrodes within the PFC were used for final data analysis.

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Data from the side-by-side recordings were averaged and used as a single data point. If only one microelectrode site provided usable data, then the recordings were reported as from that site. Very few data points were omitted in this study due to outlier status, with excep‐ tion for constraints on amplitude-matching. To determine statistical significance (p<0.05), processed data were analyzed using a one-way ANOVA with Tukey's post-hoc compari‐ sons across all genotypes (Graphpad Prism 4.0). Urethane, L-glutamate, dopamine, ascorbic acid, and 1,3-phenylenediamine dihydrochloride were obtained from Sigma-Alderich, St. Louis MO). Microelectrode arrays were provided by Quanteon L.L.C. (Nicholasville, KY).

High-speed chronoamperometry coupled with carbon fiber microelectrodes was used to evaluate KCl-evoked dopamine release because of its capability to record dopamine release

**2.7. Dopamine dysfunction in the PFC of the SHR model of ADHD: Results**

#### **High-speed amperometric recordings of glutamate levels in the PFC of the DRD4 knock‐ out mouse**

Male mice (5-7 months; ~32 g) descended from the original F2 hybrid of mice with a truncat‐ ed and non-expressing DRD4 gene (DRD4-/-; 129/SvEv × C57BL/6J) were derived by back‐ crossing the DRD4+/- mouse line for 20 generations [68]. In all experiments, the DRD4-/- mice (n=5-8) and DRD4+/- (n=5-9) were compared to litter-matched DRD4+/+ (n=5-8) animals. Mice were group-housed (2-4 per cage) with unlimited access to food and water. Mice were main‐ tained on a twelve hour light/dark cycle. Protocols for animal use were approved by the In‐ stitutional Animal Care and Use Committee (IACUC), which is Association for Assessment and Accreditation of Laboratory Animal Care International approved, and all procedures were carried out in accordance with the National Institutes of Health Guide for Care and Use of Laboratory Animals.

Ceramic-based microelectrode arrays (MEA) that contained 4 platinum (Pt) recording surfa‐ ces (sites 1-4) in an S2 configuration (two sets of side-by-side recording sites) were prepared to selectively measure glutamate. The electrodes were fabricated for in vivo recordings us‐ ing published methods [73, 78, 79]. All 4 sites were electroplated with meta-phenylene dia‐ mine (mPD) by applying a potential of +0.5 V to the Pt sites vs. a silver/silver chloride (Ag/ AgCl) reference electrode (Bioanalytical Systems, RE-5) in a deoxygenated 0.05 M phosphate buffered saline (PBS; pH 7.1-7.4) with 5 mM mPD. The mPD forms a size-exclusion layer over the sites, blocking dopamine, ascorbic acid (AA), DOPAC, and other electroactive com‐ pounds. Pt sites 1 and 2 were coated with glutamate oxidase (Glu-Ox) within an inert pro‐ tein matrix of bovine serum albumin (BSA) and gluteraldehyde, enabling these sites to detect glutamate levels on a sub-second timescale with low levels of detection (0.2 µM). Sites 3 and 4 were coated with only BSA and gluteraldehyde [80, 81]. In the presence of Glu-Ox, glutamate is broken down into α-ketoglutarate and peroxide (H2O2). The H2O2 is small enough to traverse the mPD layer and is readily oxidized and recorded as current using the FAST-16 equipment (Fast Analytical Sensor Technology (FAST); Quanteon L.L.C., Nicholas‐ ville, KY). For calibration details, see [73, 78]. From the calibration, average values for slope were -7.7 ± 4.8 pA/µM, selectivity 214 ± 64 to 1 and LOD 0.59 ± 0.06 µM (n=26 electrodes; 51 glutamate recording sites). After the MEA was calibrated; a single barrel glass capillary with filament (1.0 x 0.58 mm2 , 6", A-M Systems, Inc., Everett, WA) was pulled using a Kopf Pip‐ ette Puller (David Kopf Instruments, Tujunga, CA) and bumped against a glass rod so that the inner diameter of the micropipette was 10-12 µm. The tip of the micropipette was placed between the 4 Pt recording sites, approximately 50-80 µm away from the electrode surface and secured using Sticky Wax (Kerr Manufacturing Co, Detroit, Michigan).

Mice were anesthetized using i.p. injections of 10% urethane solution (1.25 g/kg) and placed in a stereotaxic frame (David Kopf Instruments, Tujunga, CA) fitted with a Cunningham™ Mouse and Neonatal Rat Adaptor (Stoelting Co., Wood Dale, IL). A circulating heating pad (Gaymar Industries, Inc., Orchard Park, NY) was used to maintain body temperature. The Urethane, dopamine, ascorbic acid, sodium chloride, potassium chloride, calcium chloride and Nafion® were obtained from Sigma (St. Louis, MO). Carbon fiber microelectrodes

**High-speed amperometric recordings of glutamate levels in the PFC of the DRD4 knock‐**

Male mice (5-7 months; ~32 g) descended from the original F2 hybrid of mice with a truncat‐ ed and non-expressing DRD4 gene (DRD4-/-; 129/SvEv × C57BL/6J) were derived by back‐ crossing the DRD4+/- mouse line for 20 generations [68]. In all experiments, the DRD4-/- mice (n=5-8) and DRD4+/- (n=5-9) were compared to litter-matched DRD4+/+ (n=5-8) animals. Mice were group-housed (2-4 per cage) with unlimited access to food and water. Mice were main‐ tained on a twelve hour light/dark cycle. Protocols for animal use were approved by the In‐ stitutional Animal Care and Use Committee (IACUC), which is Association for Assessment and Accreditation of Laboratory Animal Care International approved, and all procedures were carried out in accordance with the National Institutes of Health Guide for Care and

Ceramic-based microelectrode arrays (MEA) that contained 4 platinum (Pt) recording surfa‐ ces (sites 1-4) in an S2 configuration (two sets of side-by-side recording sites) were prepared to selectively measure glutamate. The electrodes were fabricated for in vivo recordings us‐ ing published methods [73, 78, 79]. All 4 sites were electroplated with meta-phenylene dia‐ mine (mPD) by applying a potential of +0.5 V to the Pt sites vs. a silver/silver chloride (Ag/ AgCl) reference electrode (Bioanalytical Systems, RE-5) in a deoxygenated 0.05 M phosphate buffered saline (PBS; pH 7.1-7.4) with 5 mM mPD. The mPD forms a size-exclusion layer over the sites, blocking dopamine, ascorbic acid (AA), DOPAC, and other electroactive com‐ pounds. Pt sites 1 and 2 were coated with glutamate oxidase (Glu-Ox) within an inert pro‐ tein matrix of bovine serum albumin (BSA) and gluteraldehyde, enabling these sites to detect glutamate levels on a sub-second timescale with low levels of detection (0.2 µM). Sites 3 and 4 were coated with only BSA and gluteraldehyde [80, 81]. In the presence of Glu-Ox, glutamate is broken down into α-ketoglutarate and peroxide (H2O2). The H2O2 is small enough to traverse the mPD layer and is readily oxidized and recorded as current using the FAST-16 equipment (Fast Analytical Sensor Technology (FAST); Quanteon L.L.C., Nicholas‐ ville, KY). For calibration details, see [73, 78]. From the calibration, average values for slope were -7.7 ± 4.8 pA/µM, selectivity 214 ± 64 to 1 and LOD 0.59 ± 0.06 µM (n=26 electrodes; 51 glutamate recording sites). After the MEA was calibrated; a single barrel glass capillary with

ette Puller (David Kopf Instruments, Tujunga, CA) and bumped against a glass rod so that the inner diameter of the micropipette was 10-12 µm. The tip of the micropipette was placed between the 4 Pt recording sites, approximately 50-80 µm away from the electrode surface

Mice were anesthetized using i.p. injections of 10% urethane solution (1.25 g/kg) and placed in a stereotaxic frame (David Kopf Instruments, Tujunga, CA) fitted with a Cunningham™ Mouse and Neonatal Rat Adaptor (Stoelting Co., Wood Dale, IL). A circulating heating pad (Gaymar Industries, Inc., Orchard Park, NY) was used to maintain body temperature. The

and secured using Sticky Wax (Kerr Manufacturing Co, Detroit, Michigan).

, 6", A-M Systems, Inc., Everett, WA) was pulled using a Kopf Pip‐

(SF1A's) were fabricated by the Center for Microelectrode Technology.

118 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**out mouse**

Use of Laboratory Animals.

filament (1.0 x 0.58 mm2

skull overlying the PFC was removed bilaterally. The MEA–micropipette assembly was positioned in the brain according to the following stereotaxic coordinates where all anteriorposterior (AP) measures were from bregma, medial-lateral (ML) measures were from mid‐ line and dorsal-ventral (DV) measures were from dura: AP: +2 mm, ML: ±1 mm, DV: -1.8 to 2.6 mm at an angle of 8 degrees according to the atlas of The Mouse Brain in Stereotaxic Co‐ ordinates [82]. An additional hole, remote from the surgery site, was opened for a Ag/AgCl reference electrode. Prior to placement of the MEA-pipette assembly, the micropipette was filled with isotonic 125 µM glutamate (125 µM L-glutamate in 0.9% physiological saline; pH= 7.2-7.4) using a combination of a 1 ml syringe filled with glutamate solution, a 0.22 µm sterile syringe filter (Costar Corporation), and a 4" stainless steel pulled needle (30 gauge, beveled tip; Popper and Son, Inc., NY). A potential of +0.7 V was applied versus a miniature Ag/AgCl reference electrode and the data were displayed at a frequency of 2 Hz. Upon ster‐ eotaxic placement of the MEA-micropipette assembly, 10-20 minutes of baseline data were acquired. Extracellular levels of glutamate were measured by averaging 30 seconds of base‐ line recordings prior to application of glutamate or KCl. Then, a 125 µM glutamate solution was locally applied via pressure ejection using a Picospritzer II connected to the open end of the micropipette by plastic tubing (Parker Hannifin Corp., General Valve Corporation). Pressure was applied at 5-25 psi for 1 second in all of the experiments. Glutamate was ap‐ plied every 30-60 seconds for a total of 10 recordings. The MEA was then lowered in 350 µm increments. Baseline recordings were acquired for 5-10 minutes and the recordings were re‐ peated. Parameters from three of the ten signals ranging from 10-30 µM in amplitude were averaged for each Pt electrode site at each depth. Signals were analyzed for time required to rise to maximum amplitude (rise time), time for 80% of the signal to decay from maximum amplitude (T80), and the rate of uptake. The uptake rate was calculated by multiplying the first order rate constant (k-1, seconds-1) by the maximum amplitude (uptake rate = µM/s) [81]. All data from local applications of glutamate from a given site were pooled into a single point. Amplitude-matched signals were compared to assess genotypic differences in the rates of clearance of exogenous glutamate [83]. Brains were removed and processed for his‐ tological evaluation of microelectrode recording tracts. Only data from histologically con‐ firmed placements of microelectrodes within the PFC were used for final data analysis.

Data from the side-by-side recordings were averaged and used as a single data point. If only one microelectrode site provided usable data, then the recordings were reported as from that site. Very few data points were omitted in this study due to outlier status, with excep‐ tion for constraints on amplitude-matching. To determine statistical significance (p<0.05), processed data were analyzed using a one-way ANOVA with Tukey's post-hoc compari‐ sons across all genotypes (Graphpad Prism 4.0). Urethane, L-glutamate, dopamine, ascorbic acid, and 1,3-phenylenediamine dihydrochloride were obtained from Sigma-Alderich, St. Louis MO). Microelectrode arrays were provided by Quanteon L.L.C. (Nicholasville, KY).

#### **2.7. Dopamine dysfunction in the PFC of the SHR model of ADHD: Results**

High-speed chronoamperometry coupled with carbon fiber microelectrodes was used to evaluate KCl-evoked dopamine release because of its capability to record dopamine release within sub-regions of the striatum and the NA [52, 74] using a local application of 75-125 nl KCl in 500 µm increments. To examine potential differences in evoked dopamine release in the separate sub-regions of the PFC between the outbred SD, the WKY progenitor, and the SHR model of ADHD, one-way ANOVAs were used. No significant differences were found between strains (cingulate cortex, p=0.1295; prelimbic cortex, p=0.1998; infralimbic cortex, p=0.1050). These data suggests that the cingulate, prelimbic and infralimbic regions in all three strains have a similar capacity to release dopamine during an action potential event. It's important to note that in both the SD and SHR strains, dopamine peak amplitudes in‐ creased as the microelectrode was moved ventrally; however, the WKY strain displayed the opposite effect. See Figure 3. Note that all dopamine signals were indicative of the detection of dopamine and/or norepinephrine based on the reduction/oxidation rations of the signals that averaged ~0.8-1.0 for all recordings.

**Cingulate Cortex**

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\*\*\* \*

**SD WKY SHR**

**Prelimbic Cortex**

**SD WKY SHR**

**Infralimbic Cortex**

\*\*

\*

**SD WKY SHR**

**Figure 4.** The SHR model of ADHD and the outbred SD control strain exhibited significantly faster dopamine uptake than the WKY strain in the cingulate cortex (\**p*<0.05, \*\*\**p*<0.001). No dopamine uptake differences were observed in the prelimbic cortex; however, the SHR exhibited significantly faster dopamine uptake in the infralimbic cortex com‐

To examine differences in dopamine uptake in the separate prefrontal cortical sub-regions, we used local applications of dopamine to directly observe the functional properties of the dopamine and norepinephrine transporters. One-way ANOVAs followed by Bonferroni post-hoc comparisons were used in each sub-region. It was discovered that the SHR model of ADHD (*p*<0.05) and the outbred SD control strain (*p*<0.001) displayed significantly faster dopamine uptake compared to the WKY strain in the cingulate cortex (F(2,23)=11.11). The average dopamine uptake times in the cingulate cortex were: SD, 30.8 ± 2 seconds; WKY, 79.1 ± 10 seconds; and SHR, 44.8 ± 3 seconds. No dopamine uptake differences were ob‐ served in the prelimbic cortex (p=0.9605); however, the SHR exhibited significantly faster

pared to both the SD control and WKY strain (\**p*<0.05, \*\**p*<0.01). Values represent the mean ± SEM.

**0**

**0**

**0**

**30**

**T 80 (Seconds)**

**60**

**90**

**120**

**30**

**T 80**

 **(Seconds)**

**60**

**90**

**120**

**30**

**T 80**

 **(Seconds)**

**60**

**90**

**120**

**Figure 3.** No differences were observed between the outbred SD control strain, the WKY progenitor strain, and the SHR model of ADHD in the KCl-evoked dopamine peak amplitudes following a local application of KCl in any of the prefrontal cortical sub-regions. Values represent the mean ± SEM.

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within sub-regions of the striatum and the NA [52, 74] using a local application of 75-125 nl KCl in 500 µm increments. To examine potential differences in evoked dopamine release in the separate sub-regions of the PFC between the outbred SD, the WKY progenitor, and the SHR model of ADHD, one-way ANOVAs were used. No significant differences were found between strains (cingulate cortex, p=0.1295; prelimbic cortex, p=0.1998; infralimbic cortex, p=0.1050). These data suggests that the cingulate, prelimbic and infralimbic regions in all three strains have a similar capacity to release dopamine during an action potential event. It's important to note that in both the SD and SHR strains, dopamine peak amplitudes in‐ creased as the microelectrode was moved ventrally; however, the WKY strain displayed the opposite effect. See Figure 3. Note that all dopamine signals were indicative of the detection of dopamine and/or norepinephrine based on the reduction/oxidation rations of the signals

**Cingulate Cortex**

**SD WKY SHR**

**Prelimbic Cortex**

**SD WKY SHR**

**Infralimbic Cortex**

**SD WKY SHR 0.0**

**Figure 3.** No differences were observed between the outbred SD control strain, the WKY progenitor strain, and the SHR model of ADHD in the KCl-evoked dopamine peak amplitudes following a local application of KCl in any of the

that averaged ~0.8-1.0 for all recordings.

120 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**0.0 0.2 0.4 0.6 0.8 1.0**

**0.0 0.2 0.4 0.6 0.8 1.0**

**0.2 0.4 0.6 0.8 1.0**

prefrontal cortical sub-regions. Values represent the mean ± SEM.

**Peak Amplitude (**m**M)**

**Peak Amplitude (**m**M)**

**Peak Amplitude (**m**M)**

**Figure 4.** The SHR model of ADHD and the outbred SD control strain exhibited significantly faster dopamine uptake than the WKY strain in the cingulate cortex (\**p*<0.05, \*\*\**p*<0.001). No dopamine uptake differences were observed in the prelimbic cortex; however, the SHR exhibited significantly faster dopamine uptake in the infralimbic cortex com‐ pared to both the SD control and WKY strain (\**p*<0.05, \*\**p*<0.01). Values represent the mean ± SEM.

To examine differences in dopamine uptake in the separate prefrontal cortical sub-regions, we used local applications of dopamine to directly observe the functional properties of the dopamine and norepinephrine transporters. One-way ANOVAs followed by Bonferroni post-hoc comparisons were used in each sub-region. It was discovered that the SHR model of ADHD (*p*<0.05) and the outbred SD control strain (*p*<0.001) displayed significantly faster dopamine uptake compared to the WKY strain in the cingulate cortex (F(2,23)=11.11). The average dopamine uptake times in the cingulate cortex were: SD, 30.8 ± 2 seconds; WKY, 79.1 ± 10 seconds; and SHR, 44.8 ± 3 seconds. No dopamine uptake differences were ob‐ served in the prelimbic cortex (p=0.9605); however, the SHR exhibited significantly faster dopamine uptake compared to both the SD control (*p*<0.01) and the WKY strain (*p*<0.05) in the infralimbic cortex (F(2,28)=6.53). The average dopamine uptake times in the infralimbic cortex were: SD, 61.6 ± 8 seconds; WKY, 49.8 ± 11 seconds; and SHR, 18 ± 4 seconds. These data reveal that the dopamine and norepinephrine transporters clear dopamine faster in the SHR in the cingulate and infralimbic cortices compared to control, but not the prelimbic cor‐ tex. It's important to note that as the microelectrode was moved ventrally in the control SD strain, the dopamine uptake became slower; however, in the WKY and SHR strains, dopa‐ mine uptake became faster as the electrode moved ventrally.

#### **2.8. Glutamate dysfunction in the PFC of the DRD4-/ mouse model of ADHD: Results**

In order to evaluate the effect of DRD4s on extracellular levels of glutamate, we com‐ pared extracellular glutamate levels across genotypes in the PFC. Extracellular resting levels of glutamate were higher by approximately 73% in the PFC of DRD4-/- mice in comparison to their DRD4+/+ littermates (DRD4+/+: 1.4 ± 0.2 µM, n=8, signals=22; DRD4+/-: 1.9 ± 0.3 µM, n=8, signals=23; DRD4-/-: 2.5 ± 0.3 µM, n=8, signals=24; *p*<0.05, see Figure 5). A depth analysis showed that DRD4+/+ mice maintained similar extracellular resting glu‐ tamate levels across depths (1.4 ± 0.3 µM), while DRD4-/- mice tended to have higher lev‐ els throughout all areas. The most profound difference was the stepwise increase in extracellular glutamate levels in the cingulate cortex with a significant difference ob‐ served between the DRD4+/+ and DRD4-/- mice (DRD4+/+: 1.4 ± 0.3 µM, n=8; DRD4+/-: 2.0 ± 0.6 µM, n=7 ; DRD4-/-: 3.0 ± 0.7 µM, n=8; Student's t-test: *p*<0.05; see Figure 5) These data indicate that the loss of DRD4s results in increased extracellular resting glutamate levels in the PFC, most dramatically in the cingulate cortex.

**Figure 5.** Extracellular resting levels of glutamate in the PFC. The top bar graph shows increased extracellular levels of glutamate in the PFC of DRD4-/- in comparison to DRD4+/+ mice (\**p*<0.05). The bottom graph depicts extracellular rest‐ ing glutamate levels broken down by depth in the PFC. The numbers on the x-axis represent the depth of the micro‐ electrode (1.8, 2.15 and 2.5 mm) and indicate the cingulate cortex, the prelimbic area and the infralimbic area;

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Based on current stimulant treatments for ADHD that target the dopaminergic system, such as MPH, the hypofunctional catecholamine theory has evolved and states that behaviors seen with ADHD are caused by decreased levels of catecholamines in the brain regions asso‐ ciated with attention and reward processing [84] including the striatum and PFC. In the spontaneously hypertensive rat (SHR) model of ADHD, there have been conflicting reports of dopamine levels in the striatum and PFC; however, the techniques used varied with each study. Some studies revealed a hypodopaminergic tone [85, 86], while others found no dif‐ ference in dopamine levels [87, 88]. Microdialysis measures of dopamine levels in the SHR are at most unreliable and poorly reflect concentrations of dopamine near the synapse due to the limited spatial resolution (>1 mm), slow sampling rates (1-20 min), and significant damage to the surrounding tissue [89-91]. Based on this premise, it is necessary that a tech‐

respectively. Values represent the mean ± SEM.

**The SHR and dopaminergic PFC dysfunction**

**2.9. Implications of dysfunctional neurotransmitter systems**

The *in vivo* activity of glutamate uptake was examined with a high degree of temporal and spatial resolution by locally applying exogenous glutamate to the extracellular space of the brain and measuring the presence and successive clearance kinetics. Resulting data provid‐ ed kinetic measures that allowed us to evaluate the efficiency of exogenous glutamate re‐ moval from the extracellular space within the 3 different brain areas of the medial PFC. Statistical comparisons were made on amplitude-matched data in order to make sure that variations in maximum amplitude would not contribute to changes in rise time, uptake rate and T80. Average maximum amplitudes were 15.39 ± 1.30 µM (n=8; signals= 21), 13.62 ± 0.78 µM (n=9; signals =25) and 13.93 ± 0.91 µM (n=8; signals = 21) in the DRD4+/+, DRD4+/- and DRD4-/-, respectively. Uptake rates within the PFC were similar across genotypes (DRD4+/+: 4.85 ± 0.69 µM, n=8; DRD4+/-: 4.82 ± 0.46 µM, n=9; DRD4-/-: 5.28 ± 0.74 µM, n=8; see Figure 6). The time it took for 80% of the signal to decay (T80) was significantly longer in DRD4-/- mice than wildtype (DRD4+/+: 2.50 ± 0.16 µM, n=8; DRD4+/-: 2.84 ± 0.12 µM, n=9; DRD4-/-: 3.00 ± 0.14 µM, n=8; *p*<0.05) with the most profound changes occurring in the prelimbic area (*p*<0.05). These kinetic measures of glutamate clearance in the PFC indicate that the DRD4 may play an important role in glutamate clearance.

**Figure 5.** Extracellular resting levels of glutamate in the PFC. The top bar graph shows increased extracellular levels of glutamate in the PFC of DRD4-/- in comparison to DRD4+/+ mice (\**p*<0.05). The bottom graph depicts extracellular rest‐ ing glutamate levels broken down by depth in the PFC. The numbers on the x-axis represent the depth of the micro‐ electrode (1.8, 2.15 and 2.5 mm) and indicate the cingulate cortex, the prelimbic area and the infralimbic area; respectively. Values represent the mean ± SEM.

#### **2.9. Implications of dysfunctional neurotransmitter systems**

#### **The SHR and dopaminergic PFC dysfunction**

dopamine uptake compared to both the SD control (*p*<0.01) and the WKY strain (*p*<0.05) in the infralimbic cortex (F(2,28)=6.53). The average dopamine uptake times in the infralimbic cortex were: SD, 61.6 ± 8 seconds; WKY, 49.8 ± 11 seconds; and SHR, 18 ± 4 seconds. These data reveal that the dopamine and norepinephrine transporters clear dopamine faster in the SHR in the cingulate and infralimbic cortices compared to control, but not the prelimbic cor‐ tex. It's important to note that as the microelectrode was moved ventrally in the control SD strain, the dopamine uptake became slower; however, in the WKY and SHR strains, dopa‐

In order to evaluate the effect of DRD4s on extracellular levels of glutamate, we com‐ pared extracellular glutamate levels across genotypes in the PFC. Extracellular resting levels of glutamate were higher by approximately 73% in the PFC of DRD4-/- mice in comparison to their DRD4+/+ littermates (DRD4+/+: 1.4 ± 0.2 µM, n=8, signals=22; DRD4+/-: 1.9 ± 0.3 µM, n=8, signals=23; DRD4-/-: 2.5 ± 0.3 µM, n=8, signals=24; *p*<0.05, see Figure 5). A depth analysis showed that DRD4+/+ mice maintained similar extracellular resting glu‐ tamate levels across depths (1.4 ± 0.3 µM), while DRD4-/- mice tended to have higher lev‐ els throughout all areas. The most profound difference was the stepwise increase in extracellular glutamate levels in the cingulate cortex with a significant difference ob‐ served between the DRD4+/+ and DRD4-/- mice (DRD4+/+: 1.4 ± 0.3 µM, n=8; DRD4+/-: 2.0 ± 0.6 µM, n=7 ; DRD4-/-: 3.0 ± 0.7 µM, n=8; Student's t-test: *p*<0.05; see Figure 5) These data indicate that the loss of DRD4s results in increased extracellular resting glutamate levels

The *in vivo* activity of glutamate uptake was examined with a high degree of temporal and spatial resolution by locally applying exogenous glutamate to the extracellular space of the brain and measuring the presence and successive clearance kinetics. Resulting data provid‐ ed kinetic measures that allowed us to evaluate the efficiency of exogenous glutamate re‐ moval from the extracellular space within the 3 different brain areas of the medial PFC. Statistical comparisons were made on amplitude-matched data in order to make sure that variations in maximum amplitude would not contribute to changes in rise time, uptake rate and T80. Average maximum amplitudes were 15.39 ± 1.30 µM (n=8; signals= 21), 13.62 ± 0.78 µM (n=9; signals =25) and 13.93 ± 0.91 µM (n=8; signals = 21) in the DRD4+/+, DRD4+/- and DRD4-/-, respectively. Uptake rates within the PFC were similar across genotypes (DRD4+/+: 4.85 ± 0.69 µM, n=8; DRD4+/-: 4.82 ± 0.46 µM, n=9; DRD4-/-: 5.28 ± 0.74 µM, n=8; see Figure 6). The time it took for 80% of the signal to decay (T80) was significantly longer in DRD4-/- mice than wildtype (DRD4+/+: 2.50 ± 0.16 µM, n=8; DRD4+/-: 2.84 ± 0.12 µM, n=9; DRD4-/-: 3.00 ± 0.14 µM, n=8; *p*<0.05) with the most profound changes occurring in the prelimbic area (*p*<0.05). These kinetic measures of glutamate clearance in the PFC indicate that the DRD4 may play

mine uptake became faster as the electrode moved ventrally.

**2.8. Glutamate dysfunction in the PFC of the DRD4-/-**

122 Attention Deficit Hyperactivity Disorder in Children and Adolescents

in the PFC, most dramatically in the cingulate cortex.

an important role in glutamate clearance.

**mouse model of ADHD: Results**

Based on current stimulant treatments for ADHD that target the dopaminergic system, such as MPH, the hypofunctional catecholamine theory has evolved and states that behaviors seen with ADHD are caused by decreased levels of catecholamines in the brain regions asso‐ ciated with attention and reward processing [84] including the striatum and PFC. In the spontaneously hypertensive rat (SHR) model of ADHD, there have been conflicting reports of dopamine levels in the striatum and PFC; however, the techniques used varied with each study. Some studies revealed a hypodopaminergic tone [85, 86], while others found no dif‐ ference in dopamine levels [87, 88]. Microdialysis measures of dopamine levels in the SHR are at most unreliable and poorly reflect concentrations of dopamine near the synapse due to the limited spatial resolution (>1 mm), slow sampling rates (1-20 min), and significant damage to the surrounding tissue [89-91]. Based on this premise, it is necessary that a tech‐ nique with increased spatial and temporal resolution over microdialysis, such as carbon fi‐ ber microelectrodes coupled to high-speed chronoamperometric recordings, be used to measure dopamine dynamics in this popular animal model [92].

ty, it's likely that similar dopamine dysfunction exists in the PFC of the SHR. It's important to clarify that the norepinephrine transporter (NET) is present in certain regions of the PFC in much greater concentrations than the DAT and dopamine uptake in the PFC is thought to be preferentially due to the NET instead of the DAT [99], so investigations into the mecha‐

Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD

http://dx.doi.org/10.5772/54207

125

Using similar volumes of a potassium solution, evoked overflow of catecholamine nerve ter‐ minals surrounding the tip of the carbon fiber microeletrode was used to attempt to locate differences in vesicular dopamine storage in the different PFC sub-regions. Upon stimula‐ tion, no differences were observed between the inbred SHR model of ADHD, the inbred progenitor WKY and the outbred SD control strains. The lack of differences signifies to us that the separate PFC sub-regions all have the same capacity to store and release dopamine and/or norepinephrine in these strains. MAO and VMAT, both implicated in ADHD, can then be considered to be functional in the PFC of the SHR model of ADHD and drugs tar‐

Though no differences were observed in the KCl-evoked dopamine signals, there were sig‐ nificant differences in the length of time required to clear exogenous dopamine applications between the SHR and control strains. Similar maximum dopamine amplitudes were ach‐ ieved by applying various volumes of an exogenous dopamine solution in order to evaluate the uptake kinetics of the signals. The DAT is electrogenic and depolarization causes the DAT to change from the basal state [100-104] and in order to test the full uptake capabilities of the transporters, including both the DAT and NET, it was necessary to study the trans‐ porters in their more natural state using local applications of dopamine. Utilizing this ap‐ proach, it was discovered that the SHR displayed faster uptake in the cingulate and infralimbic cortices compared to the WKY strain, but not the prelimbic cortex. The SHR model of ADHD was also discovered to have faster dopamine uptake compared to the SD strain in the infralimbic cortex. These results are significant because the cingulate cortex is involved with learning and memory, playing a vital role in the Papez circuit and the cortical control of emotions in humans [105]. These data further demonstrate that there exists a neu‐ rochemical dysfunction in a region important for linking behavioral outcomes to motivation [106, 107] in the SHR. Also, the infralimbic cortex in rodents is known to be involved with attention to stimulus features, task contingencies, and attentional set-shifting [108] – all be‐

The SHR has previously been found to have dysfunctional dopamine dynamics in the stria‐ tum and NA core [52], but here we also show evidence for faster dopamine uptake in the cingulate and infralimbic cortices of the medial PFC. These regions are heavily implicated in ADHD [66, 112, 113] and these data give further evidence for use of the SHR as a model of ADHD. Therapeutics targeting this dysfunction may prove to be useful in the SHR. Howev‐ er, MPH, a DAT blocker, has been investigated and found to not be useful in this model be‐ cause instead of calming these animals as it does in humans, it increased locomotion in clinically relevant doses [46, 47, 114]. This signifies to us that targeting the NET instead of the DAT, such as with the use of ATX, may provide a more useful option of targeting PFC

nism of dopamine clearance in the PFC of the SHR should be examined in the future.

geting these proteins, such as deprenyl, may not be useful in this model.

haviors known to be affected in individuals with ADHD [109-111].

dopamine dysfunction in the SHR model of ADHD.

**Figure 6.** Glutamate clearance in the PFC. The top bar graphs represent changes in glutamate clearance in the PFC as a function of DRD4 expression for amplitude-matched signals. The T80 is significantly longer in DRD4-/- mice in com‐ parison to DRD4+/+ (\**p*<0.05). A depth profile of the T80 values (bottom) indicate that the most significant difference was in the prelimbic area of the PFC (2.15 mm) in the DRD4-/-. Values represent the mean ± SEM.

Recent data from our lab using carbon fiber microelectrodes with high-speed chronoamper‐ ometry have shown decreased potassium-evoked dopamine signals in the dorsal striatum of the SHR model of ADHD compared to the WKY, as well as faster dopamine uptake in the ventral striatum and NA core in the SHR compared to both the SD and WKY controls [52]. Previous investigations have implicated the dopamine transporter (DAT) in the dopamine dysfunction of the SHR model of ADHD [93-98] and our data revealing differences in dopa‐ mine regulation in the striatum can be attributed to increased activity of the DAT in the striatum of the SHR. It is reasonable to assume that if the striatum has increased DAT activi‐ ty, it's likely that similar dopamine dysfunction exists in the PFC of the SHR. It's important to clarify that the norepinephrine transporter (NET) is present in certain regions of the PFC in much greater concentrations than the DAT and dopamine uptake in the PFC is thought to be preferentially due to the NET instead of the DAT [99], so investigations into the mecha‐ nism of dopamine clearance in the PFC of the SHR should be examined in the future.

nique with increased spatial and temporal resolution over microdialysis, such as carbon fi‐ ber microelectrodes coupled to high-speed chronoamperometric recordings, be used to

**Figure 6.** Glutamate clearance in the PFC. The top bar graphs represent changes in glutamate clearance in the PFC as a function of DRD4 expression for amplitude-matched signals. The T80 is significantly longer in DRD4-/- mice in com‐ parison to DRD4+/+ (\**p*<0.05). A depth profile of the T80 values (bottom) indicate that the most significant difference

Recent data from our lab using carbon fiber microelectrodes with high-speed chronoamper‐ ometry have shown decreased potassium-evoked dopamine signals in the dorsal striatum of the SHR model of ADHD compared to the WKY, as well as faster dopamine uptake in the ventral striatum and NA core in the SHR compared to both the SD and WKY controls [52]. Previous investigations have implicated the dopamine transporter (DAT) in the dopamine dysfunction of the SHR model of ADHD [93-98] and our data revealing differences in dopa‐ mine regulation in the striatum can be attributed to increased activity of the DAT in the striatum of the SHR. It is reasonable to assume that if the striatum has increased DAT activi‐

was in the prelimbic area of the PFC (2.15 mm) in the DRD4-/-. Values represent the mean ± SEM.

measure dopamine dynamics in this popular animal model [92].

124 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Using similar volumes of a potassium solution, evoked overflow of catecholamine nerve ter‐ minals surrounding the tip of the carbon fiber microeletrode was used to attempt to locate differences in vesicular dopamine storage in the different PFC sub-regions. Upon stimula‐ tion, no differences were observed between the inbred SHR model of ADHD, the inbred progenitor WKY and the outbred SD control strains. The lack of differences signifies to us that the separate PFC sub-regions all have the same capacity to store and release dopamine and/or norepinephrine in these strains. MAO and VMAT, both implicated in ADHD, can then be considered to be functional in the PFC of the SHR model of ADHD and drugs tar‐ geting these proteins, such as deprenyl, may not be useful in this model.

Though no differences were observed in the KCl-evoked dopamine signals, there were sig‐ nificant differences in the length of time required to clear exogenous dopamine applications between the SHR and control strains. Similar maximum dopamine amplitudes were ach‐ ieved by applying various volumes of an exogenous dopamine solution in order to evaluate the uptake kinetics of the signals. The DAT is electrogenic and depolarization causes the DAT to change from the basal state [100-104] and in order to test the full uptake capabilities of the transporters, including both the DAT and NET, it was necessary to study the trans‐ porters in their more natural state using local applications of dopamine. Utilizing this ap‐ proach, it was discovered that the SHR displayed faster uptake in the cingulate and infralimbic cortices compared to the WKY strain, but not the prelimbic cortex. The SHR model of ADHD was also discovered to have faster dopamine uptake compared to the SD strain in the infralimbic cortex. These results are significant because the cingulate cortex is involved with learning and memory, playing a vital role in the Papez circuit and the cortical control of emotions in humans [105]. These data further demonstrate that there exists a neu‐ rochemical dysfunction in a region important for linking behavioral outcomes to motivation [106, 107] in the SHR. Also, the infralimbic cortex in rodents is known to be involved with attention to stimulus features, task contingencies, and attentional set-shifting [108] – all be‐ haviors known to be affected in individuals with ADHD [109-111].

The SHR has previously been found to have dysfunctional dopamine dynamics in the stria‐ tum and NA core [52], but here we also show evidence for faster dopamine uptake in the cingulate and infralimbic cortices of the medial PFC. These regions are heavily implicated in ADHD [66, 112, 113] and these data give further evidence for use of the SHR as a model of ADHD. Therapeutics targeting this dysfunction may prove to be useful in the SHR. Howev‐ er, MPH, a DAT blocker, has been investigated and found to not be useful in this model be‐ cause instead of calming these animals as it does in humans, it increased locomotion in clinically relevant doses [46, 47, 114]. This signifies to us that targeting the NET instead of the DAT, such as with the use of ATX, may provide a more useful option of targeting PFC dopamine dysfunction in the SHR model of ADHD.

#### **The DRD4 and glutamatergic PFC dysfunction**

The 7-repeat polymorphism of the DRD4 has been implicated in ADHD. Little is known about the neurochemical effects of the DRD4 and thus the DRD4.7. While the DRD4-/- mouse is not an exact model for ADHD, it does provide insight to the neurochemistry of DRD4 sig‐ naling. In these studies we used *in vivo* amperometry coupled to a glutamate-selective MEA to measure extracellular levels of glutamate and glutamate clearance in the PFC of DRD4+/+, DRD4+/- and DRD4-/- mice. We measured a significant increase in extracellular resting levels of glutamate, most prevalent in the cingulate cortex of the medial PFC. We also discovered increased glutamate uptake times that were seen primarily in the prelimbic area. These data support the hypothesis that DRD4 signaling is actively involved in regulating glutamate neurotransmission in the PFC.

mine and glutamate interactions in DRD4-/- mice in PFC neurotransmission. Dopamine neu‐ rotransmission studies have not been done in these mice, but changes in whole tissue levels

Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD

http://dx.doi.org/10.5772/54207

127

In multiple publications, the DRD4 has been indicated as having an important role in the cortico-striatal-thalamic loop. Previously, we measured increased extracellular glutamate and slower clearance of glutamate in the striatum, indicating DRD4 regulation in the corti‐ costriatal projections [67]. In these experiments, we measured increased extracellular gluta‐ mate levels and slower glutamate clearance in the PFC, representing alterations in glutamatergic projections that primarily originate in the thalamus. Mrzljak et al. (1996) al‐ luded that the DRD4s role in pallido-thalamic pathways may be as a regulator of GABA re‐ lease [117]. By blocking these receptors, GABA release would be weakened and result in enhanced excitatory pathways beginning in the thalamus. This presents a feed forward sit‐ uation in which lack of inhibitory modulation of the excitatory pathways of the cortico-stria‐ tal-thalamic loop results in increased levels of glutamate in the PFC and the striatum. Although measures of GABA in the pallido-thalamic and striatopallidal projections are nec‐ essary, our data continues to support the importance of the DRD4 in the cortico-striatal-tha‐

Region specific changes may be due to the concentration of DRD4s and cell types to which they are localized. In a study where bacterial artificial chromosomes expressed enhanced green florescent protein under the transcriptional control of the DRD4, DRD4 localization was found to be high in the orbital, prelimbic, cingulate and rostral agranular potions of the prefrontal cortex [116]. Our study found changes in the cingulate and prelimbic areas, but not the infralimbic area. Localization of DRD4s to interneurons vs. pyramidal neurons may be helpful in elucidating a relationship between altered extracellular glutamate levels in the cingulate cortex in comparison to altered clearance times in the prelimbic area. One caveat of transgenic mice is that compensatory effects may be contributing to the neurochemical ef‐ fects that we measured. While compensatory effects in the PFC have not been evaluated, al‐ terations in dopamine D1 receptor and NMDA receptor expression were reported in the striatum, nucleus accumbens and hippocampus [67, 120, 121]. Assessment of dopamine, glu‐ tamate, and GABA related receptors in the PFC would provide important information nec‐ essary for proper evaluation of receptors that could be contributing to the findings reported in this paper and need to be further investigated. Compensatory mechanisms can be indica‐ tive of developmental functions that are influenced by the absence of the DRD4 and are im‐ portant to consider when evaluating glutamate function in the PFC of these knockouts.

The data presented above in the SHR and DRD4-/- rodent models of ADHD provide evi‐ dence for dopaminergic and glutamatergic system dysfunction in the PFC. Likewise, it has previously been demonstrated that in the striatum of both models, similar neurotransmitter system dysfunction exists [52, 67]. The DRD4 knockout mouse has also been found to exhibit decreased dopamine levels in the striatum [120]. These data in the DRD4-/- reveal that the D4 receptor is vital in the regulation of dopamine-glutamate interactions in the striatum and

of dopamine and dopamine metabolites do not indicate any changes [72].

lamic loop, specifically in the regulation of tonic glutamate.

**2.10. Future directions in the neuropharmacology of ADHD**

We found that lack of DRD4 expression resulted in increased extracellular resting levels of glutamate in the PFC. We are unaware of any extracellular glutamate levels reported from the PFC of anesthetized C57BL\6 mice. Using similar technology, Hascup et al. (2007) found extracellular levels of glutamate in the PFC of awake, freely-moving C57Bl \6 mice to be 3.3 ± 0.1 µM [81]. In this study, we reported approximately 60% of the ex‐ tracellular levels recorded from these prior studies in awake animals (1.42 ± 0.19 µM). Urethane anesthesia has been documented to reduce extracellular glutamate levels by 58-80% in rats and may be contributing to the lower levels of glutamate measured here [81, 115]. The relative contributions of metabolic and neuronal pools of glutamate to ex‐ tracellular levels of glutamate and the role of D4 receptors in astrocytic regulation of glu‐ tamate still requires investigation. Consequences of increased extracellular levels of glutamate in the PFC would cause alterations in signaling due to increased stimulation of glutamate receptors on astrocytes and presynaptic and postsynaptic neurons. Further studies are required to test these potential changes. There is also indication that the DRD4 is localized to GABA containing interneurons in the PFC [116, 117]. Lack of inhibi‐ tion resulting from loss of expression of the DRD4 could result in decreased release of GABA. This loss of inhibition could also contribute to increased tonic levels of glutamate in the PFC.

Loss of DRD4 resulted in approximately a 20% increase in clearance times in DRD4-/- mice. The mechanism of the increased clearance time is unknown, but the capacity of this tissue to clear similar amounts of exogenous glutamate was not significantly altered in the DRD4-/ mice, suggesting that transporter expression was unchanged. It is not known whether the measured effects on uptake rate were a direct or indirect effect of DRD4 signaling loss. In all areas of the brain, 80-90% of glutamate transporters are located on astrocytes [16]. Increased activation of metabotropic glutamate receptors (mGluRs) on astrocytes could potentially af‐ fect glutamate clearance in this case, depending on the affinity for glutamate by the mGluRs on astrocytes [118]. Interestingly, there have been reports of the presence of dopamine D2 receptors on the astrocytes in the PFC [119]. Prior microdialysis data suggests that extracel‐ lular dopamine content and KCl-evoked release of dopamine are lower in the striatum and NAc of DRD4-/- mice [120]. Alterations in dopamine neurotransmission in the PFC of these mice may elucidate a special role for the D2 receptor on astrocytes in regulation of dopa‐ mine and glutamate interactions in DRD4-/- mice in PFC neurotransmission. Dopamine neu‐ rotransmission studies have not been done in these mice, but changes in whole tissue levels of dopamine and dopamine metabolites do not indicate any changes [72].

**The DRD4 and glutamatergic PFC dysfunction**

126 Attention Deficit Hyperactivity Disorder in Children and Adolescents

neurotransmission in the PFC.

in the PFC.

The 7-repeat polymorphism of the DRD4 has been implicated in ADHD. Little is known about the neurochemical effects of the DRD4 and thus the DRD4.7. While the DRD4-/- mouse is not an exact model for ADHD, it does provide insight to the neurochemistry of DRD4 sig‐ naling. In these studies we used *in vivo* amperometry coupled to a glutamate-selective MEA to measure extracellular levels of glutamate and glutamate clearance in the PFC of DRD4+/+, DRD4+/- and DRD4-/- mice. We measured a significant increase in extracellular resting levels of glutamate, most prevalent in the cingulate cortex of the medial PFC. We also discovered increased glutamate uptake times that were seen primarily in the prelimbic area. These data support the hypothesis that DRD4 signaling is actively involved in regulating glutamate

We found that lack of DRD4 expression resulted in increased extracellular resting levels of glutamate in the PFC. We are unaware of any extracellular glutamate levels reported from the PFC of anesthetized C57BL\6 mice. Using similar technology, Hascup et al. (2007) found extracellular levels of glutamate in the PFC of awake, freely-moving C57Bl \6 mice to be 3.3 ± 0.1 µM [81]. In this study, we reported approximately 60% of the ex‐ tracellular levels recorded from these prior studies in awake animals (1.42 ± 0.19 µM). Urethane anesthesia has been documented to reduce extracellular glutamate levels by 58-80% in rats and may be contributing to the lower levels of glutamate measured here [81, 115]. The relative contributions of metabolic and neuronal pools of glutamate to ex‐ tracellular levels of glutamate and the role of D4 receptors in astrocytic regulation of glu‐ tamate still requires investigation. Consequences of increased extracellular levels of glutamate in the PFC would cause alterations in signaling due to increased stimulation of glutamate receptors on astrocytes and presynaptic and postsynaptic neurons. Further studies are required to test these potential changes. There is also indication that the DRD4 is localized to GABA containing interneurons in the PFC [116, 117]. Lack of inhibi‐ tion resulting from loss of expression of the DRD4 could result in decreased release of GABA. This loss of inhibition could also contribute to increased tonic levels of glutamate

Loss of DRD4 resulted in approximately a 20% increase in clearance times in DRD4-/- mice. The mechanism of the increased clearance time is unknown, but the capacity of this tissue to clear similar amounts of exogenous glutamate was not significantly altered in the DRD4-/ mice, suggesting that transporter expression was unchanged. It is not known whether the measured effects on uptake rate were a direct or indirect effect of DRD4 signaling loss. In all areas of the brain, 80-90% of glutamate transporters are located on astrocytes [16]. Increased activation of metabotropic glutamate receptors (mGluRs) on astrocytes could potentially af‐ fect glutamate clearance in this case, depending on the affinity for glutamate by the mGluRs on astrocytes [118]. Interestingly, there have been reports of the presence of dopamine D2 receptors on the astrocytes in the PFC [119]. Prior microdialysis data suggests that extracel‐ lular dopamine content and KCl-evoked release of dopamine are lower in the striatum and NAc of DRD4-/- mice [120]. Alterations in dopamine neurotransmission in the PFC of these mice may elucidate a special role for the D2 receptor on astrocytes in regulation of dopa‐

In multiple publications, the DRD4 has been indicated as having an important role in the cortico-striatal-thalamic loop. Previously, we measured increased extracellular glutamate and slower clearance of glutamate in the striatum, indicating DRD4 regulation in the corti‐ costriatal projections [67]. In these experiments, we measured increased extracellular gluta‐ mate levels and slower glutamate clearance in the PFC, representing alterations in glutamatergic projections that primarily originate in the thalamus. Mrzljak et al. (1996) al‐ luded that the DRD4s role in pallido-thalamic pathways may be as a regulator of GABA re‐ lease [117]. By blocking these receptors, GABA release would be weakened and result in enhanced excitatory pathways beginning in the thalamus. This presents a feed forward sit‐ uation in which lack of inhibitory modulation of the excitatory pathways of the cortico-stria‐ tal-thalamic loop results in increased levels of glutamate in the PFC and the striatum. Although measures of GABA in the pallido-thalamic and striatopallidal projections are nec‐ essary, our data continues to support the importance of the DRD4 in the cortico-striatal-tha‐ lamic loop, specifically in the regulation of tonic glutamate.

Region specific changes may be due to the concentration of DRD4s and cell types to which they are localized. In a study where bacterial artificial chromosomes expressed enhanced green florescent protein under the transcriptional control of the DRD4, DRD4 localization was found to be high in the orbital, prelimbic, cingulate and rostral agranular potions of the prefrontal cortex [116]. Our study found changes in the cingulate and prelimbic areas, but not the infralimbic area. Localization of DRD4s to interneurons vs. pyramidal neurons may be helpful in elucidating a relationship between altered extracellular glutamate levels in the cingulate cortex in comparison to altered clearance times in the prelimbic area. One caveat of transgenic mice is that compensatory effects may be contributing to the neurochemical ef‐ fects that we measured. While compensatory effects in the PFC have not been evaluated, al‐ terations in dopamine D1 receptor and NMDA receptor expression were reported in the striatum, nucleus accumbens and hippocampus [67, 120, 121]. Assessment of dopamine, glu‐ tamate, and GABA related receptors in the PFC would provide important information nec‐ essary for proper evaluation of receptors that could be contributing to the findings reported in this paper and need to be further investigated. Compensatory mechanisms can be indica‐ tive of developmental functions that are influenced by the absence of the DRD4 and are im‐ portant to consider when evaluating glutamate function in the PFC of these knockouts.

#### **2.10. Future directions in the neuropharmacology of ADHD**

The data presented above in the SHR and DRD4-/- rodent models of ADHD provide evi‐ dence for dopaminergic and glutamatergic system dysfunction in the PFC. Likewise, it has previously been demonstrated that in the striatum of both models, similar neurotransmitter system dysfunction exists [52, 67]. The DRD4 knockout mouse has also been found to exhibit decreased dopamine levels in the striatum [120]. These data in the DRD4-/- reveal that the D4 receptor is vital in the regulation of dopamine-glutamate interactions in the striatum and PFC. Recent pilot data from our lab (unpublished) reveal that in the SHR model of ADHD, there exists increased resting glutamate levels in the striatum and PFC; however, further ex‐ perimentation is necessary to verify these results. Glutamate dysfunction in the SHR would then create the possibility that targeting the dopamine-glutamate interaction in this model of ADHD may prove useful as well.

**Author details**

, Theresa C. Thomas2

\*Address all correspondence to: pglas0@uky.edu

Mental Hospital Service. xii, 130 p.

Psychiatric Assn. 494 p.

Med, 2011. 84(1): p. 27-33.

gy, 1979. 18(12): p. 931-50.

*6-hydroxydopamine.* Nature, 1976. 261(5556): p. 153-5.

Medical Center, Lexington, KY, USA

sity of Kentucky Chandler Medical Center, Lexington, KY, USA

, Greg A. Gerhardt1,3,5 and Paul E. A. Glaser1,3,4

http://dx.doi.org/10.5772/54207

129

1 Department of Anatomy & Neurobiology, Center for Microelectrode Technology, Univer‐

Dopamine and Glutamate Interactions in ADHD: Implications for the Future Neuropharmacology of ADHD

2 Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix,

3 Department of Neurology, Department of Psychiatry, University of Kentucky Chandler

4 Department of Pediatrics, University of Kentucky Chandler Medical Center, Lexington,

[1] American Psychiatric Association. Committee on Nomenclature and Statistics. and American Psychiatric Association. Committee on Statistics., *Diagnostic and statistical manual: mental disorders*. [1st ed. 1952, Washington,: American Psychiatric Assn.,

[2] American Psychiatric Association. Committee on Nomenclature and Statistics., *Diag‐ nostic and statistical manual of mental disorders*. 2d ed. 1968, Washington,. xv, 119 p.

[3] American Psychiatric Association. Task Force on Nomenclature and Statistics. and American Psychiatric Association. Committee on Nomenclature and Statistics., *Diag‐ nostic and statistical manual of mental disorders*. 3d ed. 1980, Washington: American

[4] Strohl, M.P., *Bradley's Benzedrine studies on children with behavioral disorders.* Yale J Biol

[5] Robbins, T.W. and B.J. Sahakian, *"Paradoxical" effects of psychomotor stimulant drugs in hyperactive children from the standpoint of behavioural pharmacology.* Neuropharmacolo‐

[6] Shaywitz, B.A., et al., *Paradoxical response to amphetamine in developing rats treated with*

5 Department of Electrical Engineering, University of Kentucky, Lexington, KY, USA

Erin M. Miller1

AZ, USA

KY, USA

**References**

These animal models grant us the ability to investigate neurotransmitter system regulation *in vivo*, creating a more accurate depiction of the dysfunction in multiple subregions within the PFC. Using these animals, we plan to use common ADHD treatments, such as MPH and ATX, as well as unconventional treatments, such as memantine and deprenyl, to examine the effects of these drugs on the dopamine and glutamate neuronal systems. Our ultimate goal is to discover novel ways to treat ADHD with minimal side-effects and clear long-term safety and efficacy. Avoiding the confounding side effect of abuse potential will be especial‐ ly advantageous given the difficulties this presents to prescribing stimulants. We believe that targeting the interaction between the dopamine and glutamate systems will provide a new avenue to achieve our goal.

As more and more research is beginning to implicate a dysfunctional glutamate system in ADHD, it's hard to ignore that glutamate may be playing some role in the pathophysiology of ADHD. Although it is too early to know if pharmaceuticals that modulate glutamate will be able to benefit ADHD without their own set of side-effects, it is still our hope that through modification of these interactions, we will be able to better treat individuals with ADHD and greatly improve their quality of life.

#### **3. Conclusion**

In this chapter, we have reviewed dopamine and glutamate neurotransmission, as well as dopamine-glutamate interactions, specifically relating to ADHD. We have reviewed current literature and have shown the effects of ADHD treatments on these neurotransmitters. We have discussed and detailed two rodent models of ADHD as well as the techniques used to highlight novel data revealing dopamine and glutamate dysfunction in these models of ADHD. Finally, we've examined ways these data will enable the future neuropharmacology of ADHD to move forward. Ultimately, our goal is to find novel therapies targeting dopa‐ mine-glutamate interactions to better treat ADHD in individuals of all ages.

#### **Acknowledgements**

This study was supported by USPHS grants MH070840, AG13494, and 5T32AG000242-13, NSF EEC-0310723, and DARPA N66001-09-C- 2080. In addition, the projects described were supported by the National Center for Research Resources, UL1RR033173, and the National Center for Advancing Translational Sciences, UL1TR000117. The content is solely the re‐ sponsibility of the authors and does not necessarily represent the official views of the NIH.

#### **Author details**

PFC. Recent pilot data from our lab (unpublished) reveal that in the SHR model of ADHD, there exists increased resting glutamate levels in the striatum and PFC; however, further ex‐ perimentation is necessary to verify these results. Glutamate dysfunction in the SHR would then create the possibility that targeting the dopamine-glutamate interaction in this model of

These animal models grant us the ability to investigate neurotransmitter system regulation *in vivo*, creating a more accurate depiction of the dysfunction in multiple subregions within the PFC. Using these animals, we plan to use common ADHD treatments, such as MPH and ATX, as well as unconventional treatments, such as memantine and deprenyl, to examine the effects of these drugs on the dopamine and glutamate neuronal systems. Our ultimate goal is to discover novel ways to treat ADHD with minimal side-effects and clear long-term safety and efficacy. Avoiding the confounding side effect of abuse potential will be especial‐ ly advantageous given the difficulties this presents to prescribing stimulants. We believe that targeting the interaction between the dopamine and glutamate systems will provide a

As more and more research is beginning to implicate a dysfunctional glutamate system in ADHD, it's hard to ignore that glutamate may be playing some role in the pathophysiology of ADHD. Although it is too early to know if pharmaceuticals that modulate glutamate will be able to benefit ADHD without their own set of side-effects, it is still our hope that through modification of these interactions, we will be able to better treat individuals with

In this chapter, we have reviewed dopamine and glutamate neurotransmission, as well as dopamine-glutamate interactions, specifically relating to ADHD. We have reviewed current literature and have shown the effects of ADHD treatments on these neurotransmitters. We have discussed and detailed two rodent models of ADHD as well as the techniques used to highlight novel data revealing dopamine and glutamate dysfunction in these models of ADHD. Finally, we've examined ways these data will enable the future neuropharmacology of ADHD to move forward. Ultimately, our goal is to find novel therapies targeting dopa‐

This study was supported by USPHS grants MH070840, AG13494, and 5T32AG000242-13, NSF EEC-0310723, and DARPA N66001-09-C- 2080. In addition, the projects described were supported by the National Center for Research Resources, UL1RR033173, and the National Center for Advancing Translational Sciences, UL1TR000117. The content is solely the re‐ sponsibility of the authors and does not necessarily represent the official views of the NIH.

mine-glutamate interactions to better treat ADHD in individuals of all ages.

ADHD may prove useful as well.

128 Attention Deficit Hyperactivity Disorder in Children and Adolescents

new avenue to achieve our goal.

**3. Conclusion**

**Acknowledgements**

ADHD and greatly improve their quality of life.

Erin M. Miller1 , Theresa C. Thomas2 , Greg A. Gerhardt1,3,5 and Paul E. A. Glaser1,3,4

\*Address all correspondence to: pglas0@uky.edu

1 Department of Anatomy & Neurobiology, Center for Microelectrode Technology, Univer‐ sity of Kentucky Chandler Medical Center, Lexington, KY, USA

2 Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA

3 Department of Neurology, Department of Psychiatry, University of Kentucky Chandler Medical Center, Lexington, KY, USA

4 Department of Pediatrics, University of Kentucky Chandler Medical Center, Lexington, KY, USA

5 Department of Electrical Engineering, University of Kentucky, Lexington, KY, USA

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[94] Roessner, V., et al., *Methylphenidate normalizes elevated dopamine transporter densities in an animal model of the attention-deficit/hyperactivity disorder combined type, but not to the same extent in one of the attention-deficit/hyperactivity disorder inattentive type.* Neuro‐

[95] Simchon, Y., A. Weizman, and M. Rehavi, *The effect of chronic methylphenidate adminis‐ tration on presynaptic dopaminergic parameters in a rat model for ADHD.* Eur Neuropsy‐

[96] Viggiano, D., D. Vallone, and A. Sadile, *Dysfunctions in dopamine systems and ADHD:*

[97] Watanabe, Y., et al., *Brain dopamine transporter in spontaneously hypertensive rats.* J Nucl

[98] Womersley, J.S., et al., *Maternal separation affects dopamine transporter function in the Spontaneously Hypertensive Rat: An in vivo electrochemical study.* Behav Brain Funct,

[99] Moron, J.A., et al., *Dopamine uptake through the norepinephrine transporter in brain re‐ gions with low levels of the dopamine transporter: evidence from knock-out mouse lines.* J

[100] El Ayadi, A., I. Afailal, and M. Errami, *Effects of voltage-sensitive calcium channel block‐ ers on extracellular dopamine levels in rat striatum.* Metab Brain Dis, 2001. 16(3-4): p.

[101] Hoffman, A.F., et al., *Voltage-dependency of the dopamine transporter in the rat substantia*

[102] Kandasamy, S.B., *Possible involvement of L-type voltage-gated calcium channels in release of dopamine in the striatum of irradiated rats.* Radiat Res, 2000. 154(1): p. 39-43.

[103] Reith, M.E., et al., *Effect of metaphit on dopaminergic neurotransmission in rat striatal sli‐ ces: involvement of the dopamine transporter and voltage-dependent sodium channel.* J Phar‐

[104] Zahniser, N.R., et al., *Voltage-dependency of the dopamine transporter in rat brain.* Adv

*evidence from animals and modeling.* Neural Plast, 2004. 11(1-2): p. 97-114.

*terminals in rat striatum.* J Neurosci Methods, 2012. 208(1): p. 34-9.

*animal model of ADHD.* Neurosci Biobehav Rev, 2003. 27(7): p. 661-9.

*cal technique.* J Neurochem, 1986. 46(3): p. 842-50.

science, 2010. 167(4): p. 1183-91.

136 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Med, 1997. 38(3): p. 470-4.

Neurosci, 2002. 22(2): p. 389-95.

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[120] Thomas, T.C., et al., *Dopamine D4 receptor knockout mice exhibit neurochemical changes consistent with decreased dopamine release.* J Neurosci Methods, 2007. 166(2): p. 306-14.

**Section 3**

**Assessment and Diagnosis**

[121] Gan, L., et al., *Enhanced expression of dopamine D(1) and glutamate NMDA receptors in dopamine D(4) receptor knockout mice.* J Mol Neurosci, 2004. 22(3): p. 167-78.

### **Assessment and Diagnosis**

[120] Thomas, T.C., et al., *Dopamine D4 receptor knockout mice exhibit neurochemical changes consistent with decreased dopamine release.* J Neurosci Methods, 2007. 166(2): p. 306-14.

138 Attention Deficit Hyperactivity Disorder in Children and Adolescents

[121] Gan, L., et al., *Enhanced expression of dopamine D(1) and glutamate NMDA receptors in dopamine D(4) receptor knockout mice.* J Mol Neurosci, 2004. 22(3): p. 167-78.

**Chapter 7**

**Clinical Phenomena of ADHD**

Additional information is available at the end of the chapter

Three types of ADHD have been identified:

The diagnosis of ADD/ADHD is a clinical diagnosis.

pulsive symptoms.

ual of Mental Disorders (DSM).

ADHD is the most common behavior diagnosis given in a approximately 5.4 million chil‐ dren between 4 and 17 years of age [1]. ADHD can profoundly affect the academic achieve‐ ment, well being and social interactions of children. Clinically, ADHD may be confused with other medical conditions, including seizures and anxiety but not limited to behavior or paying attention only. If a child is not hyperactive, it may take a long time before it is brought to the attention of others for treatment. The American Academy of Pediatrics (AAP) recently issued new guidelines for the diagnosis and treatment of ADHD, expanding recom‐

mendations for age ranges including both early pre-school children and adolescence.

**1.** ADHD combined type; the individual displays both inattentive and hyperactive/ im‐

**2.** ADHD, predominately inattentive type; the individual has symptoms primarily related to inattention. Individuals do not display significant hyperactivity/impulsive behaviors.

**3.** ADHD, predominately hyperactivity/impulsive type; symptoms are primarily related to hyperactivity and impulsivity. The individual does not display significant attention problems [2]. Symptoms are typically seen early in the child's life, often when he or she enters the school setting. In order to meet the criteria for ADD/ADHD symptoms must be more excessive than would be appropriate for individual's age and developmental level. Problematic behaviors may continue through adolescence and into adulthood.

The individual must meet criteria requirements listed in the Diagnostic and Statistical Man‐

and reproduction in any medium, provided the original work is properly cited.

© 2013 Patel; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

Nitin Patel

**1. Introduction**

http://dx.doi.org/10.5772/53789

**Chapter 7**

### **Clinical Phenomena of ADHD**

Nitin Patel

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53789

#### **1. Introduction**

ADHD is the most common behavior diagnosis given in a approximately 5.4 million chil‐ dren between 4 and 17 years of age [1]. ADHD can profoundly affect the academic achieve‐ ment, well being and social interactions of children. Clinically, ADHD may be confused with other medical conditions, including seizures and anxiety but not limited to behavior or paying attention only. If a child is not hyperactive, it may take a long time before it is brought to the attention of others for treatment. The American Academy of Pediatrics (AAP) recently issued new guidelines for the diagnosis and treatment of ADHD, expanding recom‐ mendations for age ranges including both early pre-school children and adolescence.

Three types of ADHD have been identified:


The individual must meet criteria requirements listed in the Diagnostic and Statistical Man‐ ual of Mental Disorders (DSM).

© 2013 Patel; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Six or more of the following symptoms of inattention have been present for at least 6 months to the point that it is disruptive and inappropriate for the developmental level.

schizophrenia or other psychotic disorder; and the symptoms are not better accounted for by other mental disorder, sensory disorder (hearing or visual impairment) and those who

Clinical Phenomena of ADHD http://dx.doi.org/10.5772/53789 143

The American Academy of Pediatrics (AAP) recently stated, "a primary care provider should initiate an evaluation for ADHD for any child, 4-18 years of age who presents with academic or behavior problems and symptoms of inattention, hyperactivity or impulsivity. The AAP went further in stating that the clinician should determine that the diagnostic crite‐ ria of DSM-IV have been met including documentation from parents, teachers or others

There are many different rating scales available to be completed by parent, other care givers

The Vanderbilt ADHD diagnostic rating scale includes DSM-IV based skills with teacher and parent report forms. It screens for co-morbid conditions. It is normed for age and sex. The Vanderbilt separates inattention and hyperactivity/impulsive behaviors. It can be used

The Connors rating scale has been the most utilized method of trying to diagnose ADHD and other problem childhood behavior. It follows the DSM-IV guidelines. There are forms for teachers and parents to fill that are gender specific. There is a form for the child to fill out

Child attention profile. This is based on inattention and over reactive items from the Achen‐ bach Child Behavior Checklist. It is normed by sex. It separates inattention and over reactive

The Weschsler Individual Achievement Test, 2nd edition, this provides standardized nor‐ mative value academic achievement scores across a variety of subjects for individuals be‐ tween the ages of 4 and 85. The reading, numerical, and spelling subtest provide brief

Changes in the definition of the diagnosis of ADHD are being considered with the next edition of the DSM that is expected to be published in May 2013. One problem with using the current DSM-IV subtypes is they are often unstable and changing over time. For exam‐ ple, a child may meet the criteria for one subtype at the initial evaluation and meet the criteria for another at the follow up appointment. In order for more accuracy, one pro‐ posed revision is to specify diagnosis based on current presentation of symptoms: com‐ bined presentation predominately inattentive presentation or predominately hyperactive/ impulsive presentation. In addition a fourth presentation: inattentive presentation (restric‐ tive) may be added to be more precise in identifying individuals who display impairment

Symptoms of impulsivity are also under represented in the current DSM-IV criteria. Possible

updates to the DSM-V include adding additional criteria to impulsivity.

school personnel and mental health clinician involved in the child's care.

have experienced child abuse and sexual abuse [4].

and school personnel.

free of charge [6].

called "a self report" [7].

factors. This can be used free of charge [8].

estimates of academic achievements [9].

only in attention not hyperactivity.

Examples are:

Often does not give close attention to details or makes careless mistakes in school work, work or other activities.

Often has trouble keeping attention on task or play activities.

Often does not seem to listen when spoken to directly.

Often does not follow instructions and fails to finish school work, chores or duties in the workplace. Often has trouble organizing activities.

Often avoids dislikes or doesn't want to do things that take a lot of mental effort for a long period of time.

Often loses things needed for tasks and activities.

Is often easily distracted.

Is often forgetful in daily activities.

Six or more of following symptoms of hyperactivity/ impulsivity have been present for at least 6 months to an extent that it is disruptive and inappropriate for the developmental level.

#### **2. Hyperactivity**

Often fidgets with hands or feet or squirms in seat.

Often gets up from seat when remaining is seat is expected.

Often runs about or climbs where it is not appropriate.

Adolescence and adults may feel very restless.

Often has trouble playing or enjoying leisure activities quietly.

Is often "On the go" or acts as if "Driven by a motor".

Often talks excessively.

#### **3. Impulsivity**

Often blurts out answers before questions have been finished.

Often has trouble waiting when it's his turn.

Often interrupts or intrudes on others [3].

There must be clear evidence of clear impairment in social, school or work function; these symptoms do not occur only during the course of a pervasive developmental disorder, schizophrenia or other psychotic disorder; and the symptoms are not better accounted for by other mental disorder, sensory disorder (hearing or visual impairment) and those who have experienced child abuse and sexual abuse [4].

The American Academy of Pediatrics (AAP) recently stated, "a primary care provider should initiate an evaluation for ADHD for any child, 4-18 years of age who presents with academic or behavior problems and symptoms of inattention, hyperactivity or impulsivity. The AAP went further in stating that the clinician should determine that the diagnostic crite‐ ria of DSM-IV have been met including documentation from parents, teachers or others school personnel and mental health clinician involved in the child's care.

There are many different rating scales available to be completed by parent, other care givers and school personnel.

The Vanderbilt ADHD diagnostic rating scale includes DSM-IV based skills with teacher and parent report forms. It screens for co-morbid conditions. It is normed for age and sex. The Vanderbilt separates inattention and hyperactivity/impulsive behaviors. It can be used free of charge [6].

The Connors rating scale has been the most utilized method of trying to diagnose ADHD and other problem childhood behavior. It follows the DSM-IV guidelines. There are forms for teachers and parents to fill that are gender specific. There is a form for the child to fill out called "a self report" [7].

Child attention profile. This is based on inattention and over reactive items from the Achen‐ bach Child Behavior Checklist. It is normed by sex. It separates inattention and over reactive factors. This can be used free of charge [8].

The Weschsler Individual Achievement Test, 2nd edition, this provides standardized nor‐ mative value academic achievement scores across a variety of subjects for individuals be‐ tween the ages of 4 and 85. The reading, numerical, and spelling subtest provide brief estimates of academic achievements [9].

Changes in the definition of the diagnosis of ADHD are being considered with the next edition of the DSM that is expected to be published in May 2013. One problem with using the current DSM-IV subtypes is they are often unstable and changing over time. For exam‐ ple, a child may meet the criteria for one subtype at the initial evaluation and meet the criteria for another at the follow up appointment. In order for more accuracy, one pro‐ posed revision is to specify diagnosis based on current presentation of symptoms: com‐ bined presentation predominately inattentive presentation or predominately hyperactive/ impulsive presentation. In addition a fourth presentation: inattentive presentation (restric‐ tive) may be added to be more precise in identifying individuals who display impairment only in attention not hyperactivity.

Symptoms of impulsivity are also under represented in the current DSM-IV criteria. Possible updates to the DSM-V include adding additional criteria to impulsivity.

Examples are:

Six or more of the following symptoms of inattention have been present for at least 6 months

Often does not give close attention to details or makes careless mistakes in school work,

Often does not follow instructions and fails to finish school work, chores or duties in the

Often avoids dislikes or doesn't want to do things that take a lot of mental effort for a long

Six or more of following symptoms of hyperactivity/ impulsivity have been present for at least 6 months to an extent that it is disruptive and inappropriate for the developmental level.

There must be clear evidence of clear impairment in social, school or work function; these symptoms do not occur only during the course of a pervasive developmental disorder,

to the point that it is disruptive and inappropriate for the developmental level.

Often has trouble keeping attention on task or play activities.

Often does not seem to listen when spoken to directly.

workplace. Often has trouble organizing activities.

142 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Often loses things needed for tasks and activities.

Often fidgets with hands or feet or squirms in seat.

Adolescence and adults may feel very restless.

Often has trouble waiting when it's his turn. Often interrupts or intrudes on others [3].

Often gets up from seat when remaining is seat is expected.

Often has trouble playing or enjoying leisure activities quietly.

Often blurts out answers before questions have been finished.

Often runs about or climbs where it is not appropriate.

Is often "On the go" or acts as if "Driven by a motor".

work or other activities.

period of time.

Is often easily distracted.

**2. Hyperactivity**

Often talks excessively.

**3. Impulsivity**

Is often forgetful in daily activities.

tends to act without thinking, starts a task without adequate preparation or avoids listening or reading instructions.

and defiant behaviors that include losing their temper, arguing with adults, refusing to com‐ ply with the rules of society, deliberately annoying people, consistent anger/resentment to‐ wards others. There is a history of physical aggression towards people or animals [16]. These children make no effort to hide their aggressive behaviors. They may have a hard time making friends. Children with conduct disorder require treatment for their ADHD as well as for their conduct disorder. The child's family needs to be closely involved. Parents can learn techniques to help manage their child's problem behavior. Many "behavior modi‐ fication" school, "wilderness programs" or "boot camps" are sold to parents as solutions for conduct disorder. These programs use a form of "confrontation" which can actually be

Clinical Phenomena of ADHD http://dx.doi.org/10.5772/53789 145

Anxiety. *Does the person appear to be nervous and anxious? Are there times when the person ap‐ pears panicked, stricken, or frozen by anxiety? Does the person appear very shy compared to others*

The most common anxiety disorder with ADHD is social phobia. This condition is present in nearly 1/3 of patients with ADHD. Social phobia describes a chronic and persistent fear of being scrutinized in social situations. Many people with ADHD experience repetitive nega‐ tive social encounters related to inattention which results in their misreading social cues. Disorganization causes them to be chronically tardy for social events. Impulsivity explains why they blurt out unedited and embarrassing comments. This causes them to be over whelmed and uncomfortable in social situations [12]. The treatment for this is to stabilize the

Depression. *Does the person appear sad, blue or down and how can you tell? Is the person irritable, cranky, and moody? Has the person been doing the activity once enjoyed? Does the person talk about*

Depression frequently occurs independently of ADHD. If depression is not identified and treated concurrently with the ADHD it can become treatment resistant depression. (12) De‐ pression is the most common co-morbid condition in adolescents with ADHD [4]. Prelimi‐ nary studies suggest that depression co-exists with the predominately inattentive and combined sub-types of ADHD [14, 15]. In many cases, ADHD related problems at school and with family and friends trigger depression by undermining a child's self esteem. This is called "secondary" depression, because it arises as the aftermath of another problem, includ‐ ing ADHD, it is important to taylor the treatment for the depression to the cause. If it is

Bipolar disorders: *are there times where the person thinks he or she is able to do anything he or she wants? Does the person appear unusually energetic at times or almost high without drugs? Does the person miss a lot of sleep at night but still acts energetic the next day? Does the person appear to have*

Bipolar disorder may occur with ADHD or may mimic its symptoms. Half of the boys and one-fourth of the girls with bipolar disorder also meet the criteria for ADHD. Children and adolescents with bipolar disorder often show strong emotional feelings, hyperactive behav‐ ior, overbearing manner, and difficulty waking up in the morning. Children and adolescents

harmful. Treating the child at home with their family is more effective [18].

*his same age? Does the person repeat certain actions over and over like a ritual?*

ADHD [11]. Some children with anxiety did require the addition of an SSRI.

*suicide or about uselessness of life, has the person attempted suicide?*

*thought that appear so fast that it is impossible to keep up with them?*

ADHD, treat the ADHD [19].

Is often impatient, restless when waiting for others, wanting others to get to the point, speeding when driving.

Is uncomfortable doing things slowly and systematically.

Often rushes through activities or tasks.

Finds it difficult to resist temptations or opportunities, even if it means taking risks. Exam‐ ple: a child may play with dangerous objects; or adults may commit to a relationship after a brief acquaintance [10].

There is mounting evidence that many conditions exist with ADHD and modify the overall clinical presentation and treatment response. Co-morbid conditions should be considered si‐ multaneously and in order to better understand and maximize therapy. These conditions may be emotional, behavioral, developmental or physical conditions. Co-morbid conditions include Oppositional Defiance Disorder (ODD), substance abuse, conduct disorder, anxiety, depression, tic disorder, Tourette's syndrome, and learning disability. Co-morbidities have their own symptoms, which may or may not overlap the symptoms of ADHD.

Oppositional Defiance Disorder (ODD). *Does the person defy you or the teacher by simply saying no or ignoring you? Does the person appear to be annoyed easily and bothered by trivial things? Does the person appear to annoy other people on purpose? Does the person appear angry, hot tempered, resentful or full of spite?*

Oppositional defiant disorder is a pattern of disobedient, hostile and defiant behavior to‐ ward authority figures. This disorder is more common in boys than girls. Children with ODD are overly stubborn, rebellious, often argue with adults and refuse to obey rules [11]. These children often blame others for their mistakes. Are in constant trouble in school. Are touchy or easily annoyed. Are spiteful and seek revenge. To fit this diagnosis, the pattern must last for at least 6 months and must be more than normal childhood misbehaviors. ODD is a less severe condition than Conduct Disorder. Frequently those who have persis‐ tent ODD later develop symptoms that qualify for diagnosis of conduct disorder [13]. Chil‐ dren with a diagnosis of ODD often require treatment for the ADHD as well as individual and possibly family therapy. The parents should learn how to manage the child's behavior.

#### Conduct Disorder. *Does the person lie a lot? Does the person get into physical fights? Does the per‐ son try of hurt people? Has the person ever stolen or damaged people's property?*

Conduct disorder is a disorder of childhood and adolescence that involves long-term (chronic) behavior problems. Conduct disorder has been associated with child abuse, drug addiction or alcoholism in the parents, genetic defects and poverty. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes or play with fire. They may carry or use weapons. These chil‐ dren are at greater risk of using illegal substances. Children with conduct disorder are at risk of getting in trouble at school or with police [11]. The presence of negativistic, hostile and defiant behaviors that include losing their temper, arguing with adults, refusing to com‐ ply with the rules of society, deliberately annoying people, consistent anger/resentment to‐ wards others. There is a history of physical aggression towards people or animals [16]. These children make no effort to hide their aggressive behaviors. They may have a hard time making friends. Children with conduct disorder require treatment for their ADHD as well as for their conduct disorder. The child's family needs to be closely involved. Parents can learn techniques to help manage their child's problem behavior. Many "behavior modi‐ fication" school, "wilderness programs" or "boot camps" are sold to parents as solutions for conduct disorder. These programs use a form of "confrontation" which can actually be harmful. Treating the child at home with their family is more effective [18].

tends to act without thinking, starts a task without adequate preparation or avoids listening

Is often impatient, restless when waiting for others, wanting others to get to the point,

Finds it difficult to resist temptations or opportunities, even if it means taking risks. Exam‐ ple: a child may play with dangerous objects; or adults may commit to a relationship after a

There is mounting evidence that many conditions exist with ADHD and modify the overall clinical presentation and treatment response. Co-morbid conditions should be considered si‐ multaneously and in order to better understand and maximize therapy. These conditions may be emotional, behavioral, developmental or physical conditions. Co-morbid conditions include Oppositional Defiance Disorder (ODD), substance abuse, conduct disorder, anxiety, depression, tic disorder, Tourette's syndrome, and learning disability. Co-morbidities have

Oppositional Defiance Disorder (ODD). *Does the person defy you or the teacher by simply saying no or ignoring you? Does the person appear to be annoyed easily and bothered by trivial things? Does the person appear to annoy other people on purpose? Does the person appear angry, hot tempered,*

Oppositional defiant disorder is a pattern of disobedient, hostile and defiant behavior to‐ ward authority figures. This disorder is more common in boys than girls. Children with ODD are overly stubborn, rebellious, often argue with adults and refuse to obey rules [11]. These children often blame others for their mistakes. Are in constant trouble in school. Are touchy or easily annoyed. Are spiteful and seek revenge. To fit this diagnosis, the pattern must last for at least 6 months and must be more than normal childhood misbehaviors. ODD is a less severe condition than Conduct Disorder. Frequently those who have persis‐ tent ODD later develop symptoms that qualify for diagnosis of conduct disorder [13]. Chil‐ dren with a diagnosis of ODD often require treatment for the ADHD as well as individual and possibly family therapy. The parents should learn how to manage the child's behavior.

Conduct Disorder. *Does the person lie a lot? Does the person get into physical fights? Does the per‐*

Conduct disorder is a disorder of childhood and adolescence that involves long-term (chronic) behavior problems. Conduct disorder has been associated with child abuse, drug addiction or alcoholism in the parents, genetic defects and poverty. This condition includes behaviors in which the child may lie, steal, fight, or bully others. He or she may destroy property, break into homes or play with fire. They may carry or use weapons. These chil‐ dren are at greater risk of using illegal substances. Children with conduct disorder are at risk of getting in trouble at school or with police [11]. The presence of negativistic, hostile

*son try of hurt people? Has the person ever stolen or damaged people's property?*

their own symptoms, which may or may not overlap the symptoms of ADHD.

or reading instructions.

speeding when driving.

brief acquaintance [10].

*resentful or full of spite?*

Is uncomfortable doing things slowly and systematically.

144 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Often rushes through activities or tasks.

Anxiety. *Does the person appear to be nervous and anxious? Are there times when the person ap‐ pears panicked, stricken, or frozen by anxiety? Does the person appear very shy compared to others his same age? Does the person repeat certain actions over and over like a ritual?*

The most common anxiety disorder with ADHD is social phobia. This condition is present in nearly 1/3 of patients with ADHD. Social phobia describes a chronic and persistent fear of being scrutinized in social situations. Many people with ADHD experience repetitive nega‐ tive social encounters related to inattention which results in their misreading social cues. Disorganization causes them to be chronically tardy for social events. Impulsivity explains why they blurt out unedited and embarrassing comments. This causes them to be over whelmed and uncomfortable in social situations [12]. The treatment for this is to stabilize the ADHD [11]. Some children with anxiety did require the addition of an SSRI.

Depression. *Does the person appear sad, blue or down and how can you tell? Is the person irritable, cranky, and moody? Has the person been doing the activity once enjoyed? Does the person talk about suicide or about uselessness of life, has the person attempted suicide?*

Depression frequently occurs independently of ADHD. If depression is not identified and treated concurrently with the ADHD it can become treatment resistant depression. (12) De‐ pression is the most common co-morbid condition in adolescents with ADHD [4]. Prelimi‐ nary studies suggest that depression co-exists with the predominately inattentive and combined sub-types of ADHD [14, 15]. In many cases, ADHD related problems at school and with family and friends trigger depression by undermining a child's self esteem. This is called "secondary" depression, because it arises as the aftermath of another problem, includ‐ ing ADHD, it is important to taylor the treatment for the depression to the cause. If it is ADHD, treat the ADHD [19].

Bipolar disorders: *are there times where the person thinks he or she is able to do anything he or she wants? Does the person appear unusually energetic at times or almost high without drugs? Does the person miss a lot of sleep at night but still acts energetic the next day? Does the person appear to have thought that appear so fast that it is impossible to keep up with them?*

Bipolar disorder may occur with ADHD or may mimic its symptoms. Half of the boys and one-fourth of the girls with bipolar disorder also meet the criteria for ADHD. Children and adolescents with bipolar disorder often show strong emotional feelings, hyperactive behav‐ ior, overbearing manner, and difficulty waking up in the morning. Children and adolescents with sever bipolar symptoms may have excessive and lengthy temper tantrums that are de‐ structive and often based on gross distortion of objective events. For example, when a friend wants to play a different game, bipolar children may think the friend is trying to purposeful‐ ly be mean. The child gets angry at such mistreatment. This may result in a temper tantrum. Other symptoms include excessive talking, increased activity, inappropriate actions and ver‐ bal responses in social situations, lack of inhibition, chronic irritability and distractibility. The prevalence is up to 20% [21, 22]. According to an Italian study, 24% of 7-18 year old clin‐ ic attendees with bipolar disease had existing ADHD [23].

Tourette syndrome is any combination of verbal and motor tics. There is a strong genetic ba‐ sis for Tourette syndrome and environmental factors play a role. Stimulants provoke tics in

Clinical Phenomena of ADHD http://dx.doi.org/10.5772/53789 147

Onset is anytime from 2 to 15 years of age. The period of greatest severity is between 8 and 12 years of age and half of the children are tic free by 18 years of age. Common tics include eye blinking, grimacing, lip smacking, and shoulder shrugging. The initial verbal tics are usually throat clearing, shorting or sniffing. Symptoms wax and wane in response to stress and excitement. The decision to prescribe medication depends on whether the tics bother the child. Drug therapy is not required if the tics bother the parents but do not disturb the

Obsessive compulsive disorders: Obsessive –compulsive disorders are characterized by re‐ current intrusive thoughts and images and repetitive behaviors that aim to reduce anxiety. Up to 30% [27] of children and adolescents with obsessive-compulsive disorders are present with ADHD symptoms. The rate of OCD among children with ADHD is 8-11% [28], but that rate is higher among children with Tourrette's disorder. Patient with comorbid ADHD and OCD were characterized by early onset of OCD symptoms. Patients with cormorbid OCD and ADHD symptoms seem to require special care and treatment because the longer those symptoms persist, the more they increase in severity. OCH can be treated with and SSRI,

Learning disability. *Even when the person is paying attention, is learning difficult? Are there cer‐ tain subjects that the person has extreme difficulty with? How does this person do in reading, writ‐*

Preschool children with a learning disability may have difficulty understanding certain sounds or words, or have problems expressing himself or herself in words. School age child may struggle with reading, spelling, writing, or math [11]. Poor school performance may in‐ dicate a disability in learning. Testing may be required to determine whether a discrepancy exists between the child's learning potential (intelligence quotient) and his actual academic progress (achievement test scores), indicating the presence of a learning disability [13]. If a child with ADHD also has a learning disability, neuropsychological testing can be done to help determine the best ways to help the child learn. The school can provide an Individual‐

Substance abuse. *Do you suspect this person smokes, uses drugs and drinks alcohol? Why do you*

Substance abuse disorder is common in adult ADHD patients [12]. It can be seen in adoles‐ cent patients as well. These patients will demonstrate behaviors of increasing isolation from family and friends. May see the presence of drug paraphernalia. They may use alcohol or drugs to alter their mood state or to escape. There are consequences at school, in the home or authorities related to their use of alcohol or drugs [16]. Drugs may provide temporary re‐ lief from the distress caused by the anxiety, social dysfunction, stress and conflict that can result from ADHD. Parents should stay aware in child's social relationships, unexpected

*ing, and mathematic? Hs the person ever been tested for a learning disability?*

ized education program to assist the child in learning.

changes in mood, and notable declines in academic performances.

pre disposed children.

child's life [20].

*suspect this?*

like Prozac, and behavior modification.

The child behavior check list score better discriminates between children with ADHD, comania in context to pediatric bipolar disorders and control subjects.

The pharmacological treatment, mood stabilizers are the first line treatment for periodic bi‐ polar disorders. However, when ADHD symptoms are present, subjects may benefit from short-term co-concomitant treatment with a stimulant or a co-medication of a non-stimulant.

The etiology of comorbid pediatric bipolar and ADHD have distinct characteristics. Neuro imaging studies suggest general changes in prefrontal areas in both disorders. However, there are a few primary differences between the two patient groups in the areas in indiffer‐ ence control, working memory, planning cognitive flexibility and fluency. Several authors reported that ADHD with comorbid pediatric bipolar disorder is its own distinct form of ADHD [24]

Fifty percent of the prepubescent depressed children in one sample manifest bipolar disor‐ der within ten year of the onset of depression [25]. Another study found 20%of depressed adolescents in another sample had revealed a bipolar disorder within 1-4 years [26]. When comparing to the children with ADHD without mania, the manic children have significantly higher rates of major depression, psychosis, multiple anxiety, conduct disorder, or opposition‐ al defiant disorder, as well as significantly greater impairment of psychosocial functioning.

As with depression, bipolar must be treated effectively with symptoms of ADHD to resolve comorbidity affecting the individual. An atypical anti-psychotic agent appears to be effec‐ tive in the elimination of juvenile mania. In an open study, Risperdal was found to be effec‐ tive anti-manic but did not help ADHD symptoms, among bipolar adults comorbid for ADHD, Bupropion is effective for ADHD and depression but may lower the threshold for inducing mania.

Tic disorder and Tourette's syndrome. *Does the person have movement such as eye blinking, mak‐ ing an odd face, shrugging or moving an arm a lot that is not intentional? Does the person make noise without meaning to such as grunting, sniffing, or saying certain words? Do these symptoms get worse when the person is under stress or anxiety and/or are these symptoms present while the person sleeping?*

Tics are complex, stereotyped movements (motor tics) or utterances (verbal tics) that are sudden, brief and purposeless. Tics are suppressible for short periods of time, with some discomfort and never incorporated into a voluntary movement. Stress exacerbates tics and they disappear during sleep.

Tourette syndrome is any combination of verbal and motor tics. There is a strong genetic ba‐ sis for Tourette syndrome and environmental factors play a role. Stimulants provoke tics in pre disposed children.

with sever bipolar symptoms may have excessive and lengthy temper tantrums that are de‐ structive and often based on gross distortion of objective events. For example, when a friend wants to play a different game, bipolar children may think the friend is trying to purposeful‐ ly be mean. The child gets angry at such mistreatment. This may result in a temper tantrum. Other symptoms include excessive talking, increased activity, inappropriate actions and ver‐ bal responses in social situations, lack of inhibition, chronic irritability and distractibility. The prevalence is up to 20% [21, 22]. According to an Italian study, 24% of 7-18 year old clin‐

The child behavior check list score better discriminates between children with ADHD, co-

The pharmacological treatment, mood stabilizers are the first line treatment for periodic bi‐ polar disorders. However, when ADHD symptoms are present, subjects may benefit from short-term co-concomitant treatment with a stimulant or a co-medication of a non-stimulant.

The etiology of comorbid pediatric bipolar and ADHD have distinct characteristics. Neuro imaging studies suggest general changes in prefrontal areas in both disorders. However, there are a few primary differences between the two patient groups in the areas in indiffer‐ ence control, working memory, planning cognitive flexibility and fluency. Several authors reported that ADHD with comorbid pediatric bipolar disorder is its own distinct form of

Fifty percent of the prepubescent depressed children in one sample manifest bipolar disor‐ der within ten year of the onset of depression [25]. Another study found 20%of depressed adolescents in another sample had revealed a bipolar disorder within 1-4 years [26]. When comparing to the children with ADHD without mania, the manic children have significantly higher rates of major depression, psychosis, multiple anxiety, conduct disorder, or opposition‐ al defiant disorder, as well as significantly greater impairment of psychosocial functioning.

As with depression, bipolar must be treated effectively with symptoms of ADHD to resolve comorbidity affecting the individual. An atypical anti-psychotic agent appears to be effec‐ tive in the elimination of juvenile mania. In an open study, Risperdal was found to be effec‐ tive anti-manic but did not help ADHD symptoms, among bipolar adults comorbid for ADHD, Bupropion is effective for ADHD and depression but may lower the threshold for

Tic disorder and Tourette's syndrome. *Does the person have movement such as eye blinking, mak‐ ing an odd face, shrugging or moving an arm a lot that is not intentional? Does the person make noise without meaning to such as grunting, sniffing, or saying certain words? Do these symptoms get worse when the person is under stress or anxiety and/or are these symptoms present while the*

Tics are complex, stereotyped movements (motor tics) or utterances (verbal tics) that are sudden, brief and purposeless. Tics are suppressible for short periods of time, with some discomfort and never incorporated into a voluntary movement. Stress exacerbates tics and

ic attendees with bipolar disease had existing ADHD [23].

146 Attention Deficit Hyperactivity Disorder in Children and Adolescents

ADHD [24]

inducing mania.

*person sleeping?*

they disappear during sleep.

mania in context to pediatric bipolar disorders and control subjects.

Onset is anytime from 2 to 15 years of age. The period of greatest severity is between 8 and 12 years of age and half of the children are tic free by 18 years of age. Common tics include eye blinking, grimacing, lip smacking, and shoulder shrugging. The initial verbal tics are usually throat clearing, shorting or sniffing. Symptoms wax and wane in response to stress and excitement. The decision to prescribe medication depends on whether the tics bother the child. Drug therapy is not required if the tics bother the parents but do not disturb the child's life [20].

Obsessive compulsive disorders: Obsessive –compulsive disorders are characterized by re‐ current intrusive thoughts and images and repetitive behaviors that aim to reduce anxiety. Up to 30% [27] of children and adolescents with obsessive-compulsive disorders are present with ADHD symptoms. The rate of OCD among children with ADHD is 8-11% [28], but that rate is higher among children with Tourrette's disorder. Patient with comorbid ADHD and OCD were characterized by early onset of OCD symptoms. Patients with cormorbid OCD and ADHD symptoms seem to require special care and treatment because the longer those symptoms persist, the more they increase in severity. OCH can be treated with and SSRI, like Prozac, and behavior modification.

Learning disability. *Even when the person is paying attention, is learning difficult? Are there cer‐ tain subjects that the person has extreme difficulty with? How does this person do in reading, writ‐ ing, and mathematic? Hs the person ever been tested for a learning disability?*

Preschool children with a learning disability may have difficulty understanding certain sounds or words, or have problems expressing himself or herself in words. School age child may struggle with reading, spelling, writing, or math [11]. Poor school performance may in‐ dicate a disability in learning. Testing may be required to determine whether a discrepancy exists between the child's learning potential (intelligence quotient) and his actual academic progress (achievement test scores), indicating the presence of a learning disability [13]. If a child with ADHD also has a learning disability, neuropsychological testing can be done to help determine the best ways to help the child learn. The school can provide an Individual‐ ized education program to assist the child in learning.

Substance abuse. *Do you suspect this person smokes, uses drugs and drinks alcohol? Why do you suspect this?*

Substance abuse disorder is common in adult ADHD patients [12]. It can be seen in adoles‐ cent patients as well. These patients will demonstrate behaviors of increasing isolation from family and friends. May see the presence of drug paraphernalia. They may use alcohol or drugs to alter their mood state or to escape. There are consequences at school, in the home or authorities related to their use of alcohol or drugs [16]. Drugs may provide temporary re‐ lief from the distress caused by the anxiety, social dysfunction, stress and conflict that can result from ADHD. Parents should stay aware in child's social relationships, unexpected changes in mood, and notable declines in academic performances.

It is important to have an accurate diagnosis which involves a combination of physical ex‐ amination to rule out organic causes (ear infections, elevated lead levels, seizure), behavioral observation and standard tests. Public interest in ADHD has increased along with medical debate in diagnosis and treatment. Some concerns have been emphasized over diagnosis. There is a wide variation of diagnostic criteria and treatment seen among primary care doc‐ tors. Primary care physicians should recognize ADHD as a chronic condition, therefore con‐ sider children, adolescence, and children with special health care needs. No instrument can replace clinical judgment regarding initial diagnosis and follow up of treatment assessment in children with ADHD. For treatment purposes this varies by age. The specific behavior modification in psychological counseling must be considered in addition to pharmacological treatment titrated to achieve maximum benefit with minimum side effects.

Scale in a Referred Population. *J Pediatr, Psychol.*, 28(8), 559-568, doi/10.1093/Jpepsy/

Clinical Phenomena of ADHD http://dx.doi.org/10.5772/53789 149

[7] Connors, C. K. (1969). A teacher rating scale for use in drug studies with children.

[8] Barkley Clinical Interview by Barkley RA. (1991). Attention Deficit Hyperactivity

[9] Langberg, J. M, Vaughn, A. J, Brinkman, W. B, Froehlich, T, & Epstein, J. N. (2010). Clinical Utility of the Vanderbilt ADHD Rating Scale for Ruling Out Comorbid

[10] Low, K. (2011). ADHD Diagnosis-Changes Being Considered. http:// add.about.com/od/evaluationand/a/adhd-diagnosis-changes-being-considered., Ac‐

[11] Attention Deficit Hyperactivity Disorder. (2008). National Institute of Mental Health, US Department of Health and Human Services., http://www.nimh.nih.gov/health/

[12] Young, J. L. (2010). ADHD and Psychiatric comorbities: Treatment Approaches to Improve Outcomes. Http://.medscape.org/viewarticle/704639., Accessed 6-13-12. [13] Clinical Practice Guideline: Diagnosis and Evaluation of the child with Attention Deficit/Hyperactivity Disorder Committee on Quality Improvement, Subcommittee

on Attention Deficit/Hyperactivity Disorder. Pediatrics. , 105(5), 1158-1170.

country-wide sample. *J Am Acad Chid Adoles Psychiatry*, 35, 319-324.

ant disorder. *J Am Acad Child Adolesc Psychiatry.*, 46, 126-141.

[14] Wolraich, M. L, Hannah, J. N, Pinnock, T. Y, Baumgaertel, A, & Brown, J. (1996). Comparison of diagnostic criteria for attention deficit/hyperactivity disorder in a

[15] Wolraich, M, Hannah, J. N, Baumgaerter, A, Pinnock, T. Y, & Feurer, I. (1998). Exami‐ nation of DSM-IV criteria for attention deficit/hyperactivity in a country-wide sam‐

[16] Dobie, C, Donald, W. B, Hanson, M, Hein, C, Huxsahl, J, Karasov, R, Kippes, C, Neu‐ mann, A, Spinner, P, Staples, T, & Steiner, L. (2013). Institute for Clinical Systems Im‐ provement. Diagnosis and Management of Attention Deficit Hyperactivity Disorder in Primary Care for School-Age Children and Adolescents. http://bit.ly/ADHD0312.,

[17] Steiner, H, & Remsing, L. (2007). Work Group on Quality Issues. Practice parameters for the assessment and treatment of children and adolescents with oppositional defi‐

[18] Whittinger, N. S. (2007). Clinical precursors of adolescent conduct disorder in chil‐ dren with attention-deficit/hyperactivity disorder. *J Am Acad Child Adolesc Psychia‐*

[19] Silver, L. (2006). How to treat Depression in Children with ADHD. *Attitude.*

Learning Disorders. *Pediatrics*, 1033-1038, doi: peds.2012-1267.

*American Journal of Psychiatry,*, 126, 884-888.

Disorder: a clinical workbook.

jsg046.

cessed 7-2-12.

topics/index.sht.ml.

ple. *J Dev Behav Pediatr*, 19, 162-168.

Updated March, Accessed 9-13-12.

*try.*, 46, 179-187.

#### **Author details**

#### Nitin Patel\*

Address all correspondence to: pateln@health.missouri.edu

University of Missouri-Columbia, Missouri, USA

#### **References**


Scale in a Referred Population. *J Pediatr, Psychol.*, 28(8), 559-568, doi/10.1093/Jpepsy/ jsg046.

[7] Connors, C. K. (1969). A teacher rating scale for use in drug studies with children. *American Journal of Psychiatry,*, 126, 884-888.

It is important to have an accurate diagnosis which involves a combination of physical ex‐ amination to rule out organic causes (ear infections, elevated lead levels, seizure), behavioral observation and standard tests. Public interest in ADHD has increased along with medical debate in diagnosis and treatment. Some concerns have been emphasized over diagnosis. There is a wide variation of diagnostic criteria and treatment seen among primary care doc‐ tors. Primary care physicians should recognize ADHD as a chronic condition, therefore con‐ sider children, adolescence, and children with special health care needs. No instrument can replace clinical judgment regarding initial diagnosis and follow up of treatment assessment in children with ADHD. For treatment purposes this varies by age. The specific behavior modification in psychological counseling must be considered in addition to pharmacological

[1] Moore, G. (2012). New guidelines for ADHD. *Chain Drug Review.*, www.findarti‐

[2] Low, K. (2012). AHDH Symptoms. Signs, and Symptoms of ADHD. http:// add.about.com/od/signs and symptoms/a/sypmtoms.htm, Accessed 7/2/12.

[3] Low, K. (2009). What are the Symptoms of ADD/ADHD/ Diagnostic criteria and symptoms of ADD/ADHD. http://add.about.com/od/evaluationanddiagnosis/a/

[4] Jensen, P. S. (2009). Clinical Considerations for the Diagnosis and Treatment of ADHD in the Managed Care Setting. *The AM J of Managed Care.*, 15, 5129-5140.

[5] AHDH: Clinical Practice Guideline for the Diagnosis. (2011). Evaluation and Treat‐ ment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Sub‐ committee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. *Pediatrics*, originally published online Octo‐

[6] Wolraich, M. L, Lambert, W, Doffing, M, Bickman, L, Simmons, T, & Worley, K. (2003). Pshcyometric properties of the Vanderbilt ADHD Diagnostic Parent Rating

ber 16,, DOI: 10.1542/peds 2011-2654., Accessed 9-13-12.

treatment titrated to achieve maximum benefit with minimum side effects.

Address all correspondence to: pateln@health.missouri.edu

University of Missouri-Columbia, Missouri, USA

148 Attention Deficit Hyperactivity Disorder in Children and Adolescents

cles.com/p/articles.141., Accessed 7/2/12.

**Author details**

Nitin Patel\*

**References**

dsmcriteria.htm.


[20] Fenichel, G. (2009). Clinical Pediatric Neurology A Signs and Symptoms Approach. 6th Ed.

**Chapter 8**

**Review of Tools Used for Assessing Teachers' Level of**

ADHD is currently one of most widely studied neuro-developmental disorders in chil‐ dren and adolescents. It is a severe disorder that can cause grave problems for sufferers and those around them. The interest in the study of ADHD in the scientific community is undeniable, as proved by the multitude of articles and books on the subject published annually. As indicated by Lavigne and Romero [1], interest in this condition is such that it has breached the boundaries of academic research and study and has become a social phenomenon in itself, to such an extent that any child who shows a certain degree of activity, who does not remain seated and quiet for hours and does not instantly obey each and every instruction he or she receives is immediately suspected of having ADHD. The readiness with which children are labeled as having ADHD is surely due, in part, to the lack of information about the various factors apart from ADHD, that

Neither are teachers free from the tendency to attribute ADHD to too many children in spite of having greater possibilities of obtaining more reliable information about ADHD either through professional articles and books, training courses or other professionals at their schools that work with pupils with ADHD, etc. Despite this greater ease of access to infor‐ mation, various studies have shown that teachers' knowledge of ADHD could be improved [2-7]. Furthermore the knowledge teachers have about ADHD is also the source of ever greater interest among scientists as they are actors with a key role in the development of the condition. The training of educators in this area is of direct benefit to students with ADHD

> © 2013 Soroa et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**Knowledge with Regards Attention Deficit**

**Hyperactivity Disorder (ADHD)**

Marian Soroa, Arantxa Gorostiaga and

Additional information is available at the end of the chapter

cause lack of attention, hyperactivity and/or impulsiveness.

Nekane Balluerka

**1. Introduction**

http://dx.doi.org/10.5772/54277


## **Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity Disorder (ADHD)**

Marian Soroa, Arantxa Gorostiaga and Nekane Balluerka

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54277

#### **1. Introduction**

[20] Fenichel, G. (2009). Clinical Pediatric Neurology A Signs and Symptoms Approach.

[21] Singh, M. K, DelGEllo, MP, Kowatch, RA, & Strakowski, JM. Co-occurrence of bipo‐ lar and attention-deficit hyperactivity disorder in children:. *Bipolar Disorder*, 8,

[22] Strober, M, & Carson, G. (1982). Bipolar illness in adolescents with major depression: clinical, genetic, and psycholpharmacologic predictors in three- to four year prospec‐

[23] Masi, G, Toni, C, Pergni, G, Travierson, M. C, Millipiedi, S, Mucci, M, & Akiskal, H. S. (2003). Externalizing disorders in consecutively referred children and adolescents

[24] Biederman, J, Faron, S. V, Mick, E, et al. (1999). Clinical correlates at ADHD in fe‐ male: finding from large group of girls ascertained from pediatric and psychiatric re‐

[25] Geller, B, Zimmerman, B, Williams, M, et al. (2002a). DSM-IV mania symptoms in a prepubertal and early onset bipolar disorder phenotype compared to attention-defi‐ cit hyperactivity and normal controls. *J Child Adolesc Psychopharmacol*, 12, 11-25.

[26] Kowatch, R. A, Fristad, M, Birmaher, B, Wagner, K. D, Findling, R. L, & Hellander, M. (2005). Child Psychiatric work group on Bipolar disorder. Treatment Guidelines for Children With Bipolar Disorder. *J. Am Acad Child Adolsc Psychiatry*, abstract.

[27] Geller, D. A, Biederman, J, Griffin, S, Jones, J, & Lefkowitz, T. R. (1996). Comorbidity of juvenile obsessive-compulsive disorder with disruptive behavior disorders. *J Am*

[28] Arnold, P. D, Ickowicz, A, Chen, S, & Schachar, R. (2005). Attention-deficit hyperac‐ tivity disorder with and without obsessive-compulsive behaviours: clinical character‐

[29] Patel, N, Patel, M, & Patel, H. (2012). ADHD and Comorbid Conditions. *Attention Deficit Hyperactivity Disorder/ Book 1,*, 978-9-53307-756-7, March, 2012,, 25-46.

istics, cognitive assessment, and risk factors. *Can J Psychiatry*, 50, 59-66.

tive follow-up investigation. *Arch Gen Psychiatry.*, 39(5), 549-55.

with bipolar disorder. *Comprehensive Psychiatry*, 44, 184-189.

ferral sources. *J.AM Acad Adols C Psychiatry*, 966-75.

*Acad Child Adolesc Psychiatry*, 35, 1637-1646.

6th Ed.

150 Attention Deficit Hyperactivity Disorder in Children and Adolescents

710-720.

ADHD is currently one of most widely studied neuro-developmental disorders in chil‐ dren and adolescents. It is a severe disorder that can cause grave problems for sufferers and those around them. The interest in the study of ADHD in the scientific community is undeniable, as proved by the multitude of articles and books on the subject published annually. As indicated by Lavigne and Romero [1], interest in this condition is such that it has breached the boundaries of academic research and study and has become a social phenomenon in itself, to such an extent that any child who shows a certain degree of activity, who does not remain seated and quiet for hours and does not instantly obey each and every instruction he or she receives is immediately suspected of having ADHD. The readiness with which children are labeled as having ADHD is surely due, in part, to the lack of information about the various factors apart from ADHD, that cause lack of attention, hyperactivity and/or impulsiveness.

Neither are teachers free from the tendency to attribute ADHD to too many children in spite of having greater possibilities of obtaining more reliable information about ADHD either through professional articles and books, training courses or other professionals at their schools that work with pupils with ADHD, etc. Despite this greater ease of access to infor‐ mation, various studies have shown that teachers' knowledge of ADHD could be improved [2-7]. Furthermore the knowledge teachers have about ADHD is also the source of ever greater interest among scientists as they are actors with a key role in the development of the condition. The training of educators in this area is of direct benefit to students with ADHD

and their families. For this reason, in order to find out exactly what level of knowledge teachers have about this problem it is crucial to have assessment tools with appropriate psy‐ chometric properties, that are reliable and valid and that provide accurate data about teach‐ ers' knowledge of ADHD.

A fifth reason for teachers to be trained about ADHD lies in direct contact they have with the parents of the children. Several authors have argued that teachers make recommenda‐ tions, appropriate or inappropriate, about ADHD to the parents, who tend to follow such

Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity

Disorder (ADHD)

153

http://dx.doi.org/10.5772/54277

The sixth and final reason is that the knowledge that teachers have about ADHD affects their behavior and attitudes towards children with this condition [17]. Teachers with more knowledge about ADHD have a more favorable conduct and attitudes towards students

In spite of the existence of many reasons why teachers should have knowledge on ADHD, various studies have shown that, in general, teachers show only moderate knowledge of ADHD and that it is necessary to improve this level of knowledge [3-6, 19, 20]. Also it must be noted that many teachers present a general lack of knowledge and/or false ideas on the nature, course, consequences, causes and treatment of ADHD [21]. In some research programmes the average percentage of correct answers by teach‐ ers to questionnaires prepared in order to measure their knowledge on ADHD was around 80% [14, 18, 22-24], while in other studies the average percentage of correct an‐ swers did not exceed 53% [4-6, 20, 25]. At world level there is much research in prog‐ ress on the knowledge that teachers have on ADHD; however, there is a scarcity of

It has been found that teachers who consider that their level of knowledge about ADHD is optimum do not seek additional information; in contrast, those who consider that they do not understand many aspects referring to this topic, do look for it. For this reason, it is im‐ portant that the teachers should be aware of their actual knowledge about ADHD and the possible repercussions of a lack of knowledge or erroneous knowledge. For this purpose, it is essential to use evaluation instruments which have appropriate psychometric properties

**3. Instruments for assessing the level of knowledge of teachers regarding**

Over recent decades, many instruments have been developed in order to assess the level of knowledge of teachers regarding ADHD. Given that the school setting is probably the place where children and young people spend most of the day, it is important to have a range of instruments to measure teacher knowledge about ADHD throughout the different stages of child development. These instruments, in addition to identifying gaps that teachers may have in their knowledge of the disorder, can be useful to educate the teachers about the

In this section a review is carried out of each of the main instruments developed for the eval‐ uation of teachers' knowledge about ADHD. In the course of the description of each instru‐ ment their general characteristics are set out (the construct evaluated, items, response

recommendations [14, 16].

with this disorder [3, 16, 18].

for measuring such knowledge.

need for more training in this area.

**ADHD**

instruments to measure this knowledge precisely [9].

In this chapter, the fundamental reasons for which teachers have to have a basic level of knowledge of ADHD are examined, an exhaustive analysis is carried out of the main instru‐ ments which have been developed to assess teachers' knowledge of ADHD, and the chapter ends with the main conclusions drawn from this study.

#### **2. ADHD and teachers**

ADHD is currently one of the disorders that has generated the largest number of research studies among the scientific community but despite this, in the words of Barkley [8], a lot remains unknown or misunderstood about it. Teachers, along with the family, are one of the most important agents of socialization during infancy, so they are one of the most suitable groups to receive information and training with regard to ADHD. A significant percentage of teachers have false ideas or gaps in their knowledge of ADHD, which causes them to be‐ have inappropriately in the classroom. In this regard, it has been observed that specific training of teachers in the field and positive attitudes on their part have positive consequen‐ ces for children with ADHD.

Soroa, Balluerka and Gorostiaga [9] hold that infant and primary school teachers should have general and specific knowledge about ADHD for six fundamental reasons. Firstly, be‐ cause ADHD is one of the most common psychological disorders among children. The American Psychiatric Association [10] indicates that between 3% and 5% of school children suffer from ADHD, that is to say that on average there is one pupil with ADHD in every classroom of 25 [11-13].

Secondly, teachers are in a uniquely advantageous position for detecting possible cases of ADHD. They can pretty accurately distinguish normal development from what is not. Therefore, increasing teachers' knowledge about ADHD can facilitate, among other factors, early detection of the disorder and the application of the appropriate treatment [4, 14].

Thirdly, it should be noted that the role of the teacher is also essential in establishing the diagnosis. The assessments made of the behavior of the students, along with those of the pa‐ rents and the results of other tests to which children are subjected, are part of the data that allow the diagnosis to be established [4-6].

Fourthly, it should be noted that teachers play a very important role in the implementation, evaluation and support of the treatment received by children with ADHD [14]. Their coop‐ eration is necessary for the results of the treatment received by the child to be successful, and their evaluation of and opinions about the treatment of ADHD have a profound effect on its efficacy [15].

A fifth reason for teachers to be trained about ADHD lies in direct contact they have with the parents of the children. Several authors have argued that teachers make recommenda‐ tions, appropriate or inappropriate, about ADHD to the parents, who tend to follow such recommendations [14, 16].

and their families. For this reason, in order to find out exactly what level of knowledge teachers have about this problem it is crucial to have assessment tools with appropriate psy‐ chometric properties, that are reliable and valid and that provide accurate data about teach‐

In this chapter, the fundamental reasons for which teachers have to have a basic level of knowledge of ADHD are examined, an exhaustive analysis is carried out of the main instru‐ ments which have been developed to assess teachers' knowledge of ADHD, and the chapter

ADHD is currently one of the disorders that has generated the largest number of research studies among the scientific community but despite this, in the words of Barkley [8], a lot remains unknown or misunderstood about it. Teachers, along with the family, are one of the most important agents of socialization during infancy, so they are one of the most suitable groups to receive information and training with regard to ADHD. A significant percentage of teachers have false ideas or gaps in their knowledge of ADHD, which causes them to be‐ have inappropriately in the classroom. In this regard, it has been observed that specific training of teachers in the field and positive attitudes on their part have positive consequen‐

Soroa, Balluerka and Gorostiaga [9] hold that infant and primary school teachers should have general and specific knowledge about ADHD for six fundamental reasons. Firstly, be‐ cause ADHD is one of the most common psychological disorders among children. The American Psychiatric Association [10] indicates that between 3% and 5% of school children suffer from ADHD, that is to say that on average there is one pupil with ADHD in every

Secondly, teachers are in a uniquely advantageous position for detecting possible cases of ADHD. They can pretty accurately distinguish normal development from what is not. Therefore, increasing teachers' knowledge about ADHD can facilitate, among other factors, early detection of the disorder and the application of the appropriate treatment [4, 14].

Thirdly, it should be noted that the role of the teacher is also essential in establishing the diagnosis. The assessments made of the behavior of the students, along with those of the pa‐ rents and the results of other tests to which children are subjected, are part of the data that

Fourthly, it should be noted that teachers play a very important role in the implementation, evaluation and support of the treatment received by children with ADHD [14]. Their coop‐ eration is necessary for the results of the treatment received by the child to be successful, and their evaluation of and opinions about the treatment of ADHD have a profound effect

ers' knowledge of ADHD.

**2. ADHD and teachers**

ces for children with ADHD.

classroom of 25 [11-13].

on its efficacy [15].

allow the diagnosis to be established [4-6].

ends with the main conclusions drawn from this study.

152 Attention Deficit Hyperactivity Disorder in Children and Adolescents

The sixth and final reason is that the knowledge that teachers have about ADHD affects their behavior and attitudes towards children with this condition [17]. Teachers with more knowledge about ADHD have a more favorable conduct and attitudes towards students with this disorder [3, 16, 18].

In spite of the existence of many reasons why teachers should have knowledge on ADHD, various studies have shown that, in general, teachers show only moderate knowledge of ADHD and that it is necessary to improve this level of knowledge [3-6, 19, 20]. Also it must be noted that many teachers present a general lack of knowledge and/or false ideas on the nature, course, consequences, causes and treatment of ADHD [21]. In some research programmes the average percentage of correct answers by teach‐ ers to questionnaires prepared in order to measure their knowledge on ADHD was around 80% [14, 18, 22-24], while in other studies the average percentage of correct an‐ swers did not exceed 53% [4-6, 20, 25]. At world level there is much research in prog‐ ress on the knowledge that teachers have on ADHD; however, there is a scarcity of instruments to measure this knowledge precisely [9].

It has been found that teachers who consider that their level of knowledge about ADHD is optimum do not seek additional information; in contrast, those who consider that they do not understand many aspects referring to this topic, do look for it. For this reason, it is im‐ portant that the teachers should be aware of their actual knowledge about ADHD and the possible repercussions of a lack of knowledge or erroneous knowledge. For this purpose, it is essential to use evaluation instruments which have appropriate psychometric properties for measuring such knowledge.

### **3. Instruments for assessing the level of knowledge of teachers regarding ADHD**

Over recent decades, many instruments have been developed in order to assess the level of knowledge of teachers regarding ADHD. Given that the school setting is probably the place where children and young people spend most of the day, it is important to have a range of instruments to measure teacher knowledge about ADHD throughout the different stages of child development. These instruments, in addition to identifying gaps that teachers may have in their knowledge of the disorder, can be useful to educate the teachers about the need for more training in this area.

In this section a review is carried out of each of the main instruments developed for the eval‐ uation of teachers' knowledge about ADHD. In the course of the description of each instru‐ ment their general characteristics are set out (the construct evaluated, items, response format, dimensionality, etc.), as well as their scoring rules and psychometric properties. Their strengths and weaknesses are also evaluated. The instruments are presented in chro‐ nological order.

**3.2. Knowledge of Attention Deficit Disorder Questionnaire (Riley, 1994) [26]**

with ADHD with an X marking the space before each statement.

any other information is given about the sample.

*3.2.2. Scoring standards*

*3.2.3. Psychometric properties*

*3.2.4. Strengths and weaknesses*

*3.3.1. Description and development*

the highest.

This is an instrument drawn up in the United States and in the English language to investi‐ gate teachers', counselors' and principals' knowledge of ADHD in school age children. The instrument has two sections. The first is made up of six items that gather information of a socio-demographic character (sex, training, education experience, etc.) and a second made up of 35 items which evaluates participants' knowledge of ADHD. The 35 items were taken from the DSM-III: 15 related to Attention Deficit Disorder (ADD), 11 related to diagnostic criteria for Conduct Disorder (CD) and 9 that deal with Oppositional Defiant Disorder (ODD). Participants are asked to identify the 15 statements that best characterize children

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The instrument was applied to a stratified sample of 303 participants in the Kansas School district: 160 teachers, 61 principals and 82 counselors. 91 were male and 212 female. Hardly

Correct answers to the items received 1 point, while the rest of the answers received 0 points. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 15, for

No publications have been found which provide validity evidences or reliability indices.

This is a simple and easy instrument to apply. The problem is that the response format is similar to the dichotomous one and respondents can try to guess the right answer. Further‐

This is an instrument developed in the United States and in the English language in order to examine the effectiveness of a training program on ADHD given to infant and primary school teachers. The questionnaire is based on the items produced by Jerome et al. [23] and consists of two sections: A first socio-demographic section and a second section consisting of 27 items that assess teachers' knowledge regarding ADHD. The response format of the in‐ strument is dichotomous (True, False), and includes positive and negative items (the au‐

more, the psychometric properties of the instrument are not known.

**3.3. ADHD Knowledge Questionnaire (Barbaresi & Olsen, 1998) [21]**

thors do not specify the number of positive and negative items).

*3.2.1. Description and development*

#### **3.1. ADHD Knowledge Scale (Jerome, Gordon & Hustler, 1994) [23]**

#### *3.1.1. Description and development*

This instrument was developed by American and Canadian researchers, in the English lan‐ guage, in order to assess the general knowledge of teachers regarding ADHD. It consists of two sections, the first includes 20 items that are socio-demographic in nature (age, sex, train‐ ing about ADHD, etc.) in a multiple choice format, and a second section with 20 items, 13 positive and 7 negative, with a dichotomous (True/False) response format.

In the preparation of the questionnaire, the authors contacted several teachers and directors of special education to review the instrument. The authors do not provide more information about the process.

The instrument was applied to a sample of 1289 elementary school teachers, 439 in the Unit‐ ed States and 850 in Canada. No information is given about the sampling procedure. 46% of the sample in the United States was made up of teachers from the state of New York school district, and 54% by teachers from Broward County in Florida. The majority were women (86%), aged between 31 and 50 (67%) and had been teachers for 9 or more years. 79% taught the general school population in ordinary classes while 21% were special education teachers. The Canadian sample consisted of teachers from a wide area of south west Ontario and no further information is given by the authors about it.

#### *3.1.2. Scoring rules*

Correct answers receive 1 point and incorrect ones 0 points. So the range of possible scores goes from 0, the lowest level of knowledge, to 20, for the highest.

#### *3.1.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.1.4. Strengths and weaknesses*

This is believed to be the first study designed to test the knowledge of elementary school teachers about ADHD. A great number of subsequent studies have used this questionnaire or been inspired by it due to its simplicity and that the fact that it was a pioneer in the field that concerns us here. Furthermore, the sample used is very broad and heterogeneous. How‐ ever, the response format is dichotomous, so does not provide detailed information about the real knowledge the teachers have about ADHD. Furthermore, the psychometric proper‐ ties of the questionnaire are not provided.

#### **3.2. Knowledge of Attention Deficit Disorder Questionnaire (Riley, 1994) [26]**

#### *3.2.1. Description and development*

format, dimensionality, etc.), as well as their scoring rules and psychometric properties. Their strengths and weaknesses are also evaluated. The instruments are presented in chro‐

This instrument was developed by American and Canadian researchers, in the English lan‐ guage, in order to assess the general knowledge of teachers regarding ADHD. It consists of two sections, the first includes 20 items that are socio-demographic in nature (age, sex, train‐ ing about ADHD, etc.) in a multiple choice format, and a second section with 20 items, 13

In the preparation of the questionnaire, the authors contacted several teachers and directors of special education to review the instrument. The authors do not provide more information

The instrument was applied to a sample of 1289 elementary school teachers, 439 in the Unit‐ ed States and 850 in Canada. No information is given about the sampling procedure. 46% of the sample in the United States was made up of teachers from the state of New York school district, and 54% by teachers from Broward County in Florida. The majority were women (86%), aged between 31 and 50 (67%) and had been teachers for 9 or more years. 79% taught the general school population in ordinary classes while 21% were special education teachers. The Canadian sample consisted of teachers from a wide area of south west Ontario and no

Correct answers receive 1 point and incorrect ones 0 points. So the range of possible scores

No publications have been found which provide validity evidences or reliability indices.

This is believed to be the first study designed to test the knowledge of elementary school teachers about ADHD. A great number of subsequent studies have used this questionnaire or been inspired by it due to its simplicity and that the fact that it was a pioneer in the field that concerns us here. Furthermore, the sample used is very broad and heterogeneous. How‐ ever, the response format is dichotomous, so does not provide detailed information about the real knowledge the teachers have about ADHD. Furthermore, the psychometric proper‐

**3.1. ADHD Knowledge Scale (Jerome, Gordon & Hustler, 1994) [23]**

positive and 7 negative, with a dichotomous (True/False) response format.

further information is given by the authors about it.

goes from 0, the lowest level of knowledge, to 20, for the highest.

nological order.

about the process.

*3.1.2. Scoring rules*

*3.1.3. Psychometric properties*

*3.1.4. Strengths and weaknesses*

ties of the questionnaire are not provided.

*3.1.1. Description and development*

154 Attention Deficit Hyperactivity Disorder in Children and Adolescents

This is an instrument drawn up in the United States and in the English language to investi‐ gate teachers', counselors' and principals' knowledge of ADHD in school age children. The instrument has two sections. The first is made up of six items that gather information of a socio-demographic character (sex, training, education experience, etc.) and a second made up of 35 items which evaluates participants' knowledge of ADHD. The 35 items were taken from the DSM-III: 15 related to Attention Deficit Disorder (ADD), 11 related to diagnostic criteria for Conduct Disorder (CD) and 9 that deal with Oppositional Defiant Disorder (ODD). Participants are asked to identify the 15 statements that best characterize children with ADHD with an X marking the space before each statement.

The instrument was applied to a stratified sample of 303 participants in the Kansas School district: 160 teachers, 61 principals and 82 counselors. 91 were male and 212 female. Hardly any other information is given about the sample.

#### *3.2.2. Scoring standards*

Correct answers to the items received 1 point, while the rest of the answers received 0 points. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 15, for the highest.

#### *3.2.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.2.4. Strengths and weaknesses*

This is a simple and easy instrument to apply. The problem is that the response format is similar to the dichotomous one and respondents can try to guess the right answer. Further‐ more, the psychometric properties of the instrument are not known.

#### **3.3. ADHD Knowledge Questionnaire (Barbaresi & Olsen, 1998) [21]**

#### *3.3.1. Description and development*

This is an instrument developed in the United States and in the English language in order to examine the effectiveness of a training program on ADHD given to infant and primary school teachers. The questionnaire is based on the items produced by Jerome et al. [23] and consists of two sections: A first socio-demographic section and a second section consisting of 27 items that assess teachers' knowledge regarding ADHD. The response format of the in‐ strument is dichotomous (True, False), and includes positive and negative items (the au‐ thors do not specify the number of positive and negative items).

The questionnaire was administered to 44 teachers, of whom 33 were women and 11 men. The mean age of participants was 42 years, and they had an average of 15 years of teaching experience. 66% were ordinary classroom teachers while the remaining 34% were specialists (art, music, physical education, etc.). They had an average of 24 students per teacher. 77% had not received any training on ADHD while being trained as teachers and 27% had re‐ ceived no training in the subject after completion of their studies.

strument. They also sought to include positive and negative aspects relating to ADHD, and

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Disorder (ADHD)

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Once they had drawn up the items the authors contacted a group of 40 students working for doctorates in clinical and child psychology. The participants, based on the three sub-scales provided by the authors, had to assign each item to one of the sub-scales provided. An item was considered as belonging to a particular sub-scale if at least 75% of the group was in

The authors then conducted a series of preliminary investigations to explore the reliabili‐ ty coefficients of the instrument. They administered an instrument of 27 items with a di‐ chotomous response format (True, False) to 73 teachers of kindergartens and elementary schools [27] and obtained a *Cronbach's alpha* of 0.38 for the total scale. In a subsequent study they modified the items that had an inadequate item-total correlation and incorpo‐ rated the three option (True, False, Don't Know) response format. The resulting scale was administered to 46 undergraduate and graduate education students and the overall *alpha* coefficient obtained for this version was 0.71 [27]. Several items were reformulated and 9 new items were included in the final version of the instrument which now had 36 items and which Bender [28] administered to 63 prospective elementary teachers, obtaining a

Finally, Sciutto et al. [5] administered the resulting 36 item scale along with a socio-demo‐ graphic questionnaire (age, sex, teaching experience, teaching speciality, etc.) and a scale of seven points dealing with respondents' self-perception of their effectiveness as teachers of children with ADHD to a broader sample. 149 primary school teachers from six public schools participated in the validation of the instrument. The sampling procedure is not ex‐ plained. There were 134 female and 9 male participants; the sex of six participants was not given. Their average age was 41 years (*SD*=11.43) and they had an average of 12.57 years of experience as teachers (*SD*=8.06). 19% of the sample were special needs teachers and 37% said they had done special needs teaching at some point. 79% of participants had a Master's degree, whereas the other 21% reported having a Bachelor's degree. With regard to ADHD, 52% of the teachers said that had taught at least one pupil who had been diagnosed with

It is worth pointing out that Sciutto and Terjesen [29] carried out an additional study on primary school teachers and university students in the state of Ohio to expand the relia‐ bility and the evidence of validity of KADDS. This study has not been published and no more data is available about the sample. However, the authors refer to this study along with the study Sciutto, Nolfi & Bluhm [30] carried out on primary school teachers with

1 point was given for correct answers and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 36, for the highest.

positive and negative statements in nature.

agreement with the decision.

coefficient *alpha* of 0.81.

this condition.

the KADDS manual.

*3.4.1.2. Scoring standards*

#### *3.3.2. Scoring standards*

Correct answers received a score of 1 and incorrect ones 0. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 27, for the highest.

#### *3.3.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.3.4. Strengths and weaknesses*

This is a simple and easy instrument to apply. However, the sample is very small and the dichotomous response format (True/False) places limits on the possibility of assessing the real level of knowledge of the teachers as the absence of a third (Don't Know) option invites respondents to guess the right answer. Furthermore, the psychometric properties of the in‐ strument are not known.

#### **3.4. The Knowledge of Attention Deficit Disorders Scale (KADDS)**

#### *3.4.1. Original version of The Knowledge of Attention Deficit Disorders Scale (KADDS) (Sciutto, Terjesen & Bender, 2000) [5]*

#### *3.4.1.1. Description and development*

It was developed in the United States and in the English language. This is one of the most widely used instruments to assess the level of knowledge of teachers regarding ADHD, and is the first instrument whose indices of reliability and validity were published in this field. It consists of 36 items, 18 positive and 18 negative, and measures three areas of knowledge re‐ lated to ADHD: 1) Symptoms/Diagnosis of ADHD (9 items), 2) General information on the nature, causes and impact of ADHD (15 items), and 3) Treatment of ADHD (12 items). It has a three option response format (True, False, Don't Know), which allows it to overcome the limits of previously used dichotomous formats (True, False) and collect more detailed infor‐ mation about the knowledge of teachers with respect to ADHD. The use of the three option response format allows the authors to discern those areas in which teachers have more knowledge, areas where they have the least knowledge and the areas in which they commit the greatest number of errors.

In the drawing up of the items the authors strove to include only those with the support of the scientific literature, citing references for each item in the manual accompanying the in‐ strument. They also sought to include positive and negative aspects relating to ADHD, and positive and negative statements in nature.

Once they had drawn up the items the authors contacted a group of 40 students working for doctorates in clinical and child psychology. The participants, based on the three sub-scales provided by the authors, had to assign each item to one of the sub-scales provided. An item was considered as belonging to a particular sub-scale if at least 75% of the group was in agreement with the decision.

The authors then conducted a series of preliminary investigations to explore the reliabili‐ ty coefficients of the instrument. They administered an instrument of 27 items with a di‐ chotomous response format (True, False) to 73 teachers of kindergartens and elementary schools [27] and obtained a *Cronbach's alpha* of 0.38 for the total scale. In a subsequent study they modified the items that had an inadequate item-total correlation and incorpo‐ rated the three option (True, False, Don't Know) response format. The resulting scale was administered to 46 undergraduate and graduate education students and the overall *alpha* coefficient obtained for this version was 0.71 [27]. Several items were reformulated and 9 new items were included in the final version of the instrument which now had 36 items and which Bender [28] administered to 63 prospective elementary teachers, obtaining a coefficient *alpha* of 0.81.

Finally, Sciutto et al. [5] administered the resulting 36 item scale along with a socio-demo‐ graphic questionnaire (age, sex, teaching experience, teaching speciality, etc.) and a scale of seven points dealing with respondents' self-perception of their effectiveness as teachers of children with ADHD to a broader sample. 149 primary school teachers from six public schools participated in the validation of the instrument. The sampling procedure is not ex‐ plained. There were 134 female and 9 male participants; the sex of six participants was not given. Their average age was 41 years (*SD*=11.43) and they had an average of 12.57 years of experience as teachers (*SD*=8.06). 19% of the sample were special needs teachers and 37% said they had done special needs teaching at some point. 79% of participants had a Master's degree, whereas the other 21% reported having a Bachelor's degree. With regard to ADHD, 52% of the teachers said that had taught at least one pupil who had been diagnosed with this condition.

It is worth pointing out that Sciutto and Terjesen [29] carried out an additional study on primary school teachers and university students in the state of Ohio to expand the relia‐ bility and the evidence of validity of KADDS. This study has not been published and no more data is available about the sample. However, the authors refer to this study along with the study Sciutto, Nolfi & Bluhm [30] carried out on primary school teachers with the KADDS manual.

#### *3.4.1.2. Scoring standards*

The questionnaire was administered to 44 teachers, of whom 33 were women and 11 men. The mean age of participants was 42 years, and they had an average of 15 years of teaching experience. 66% were ordinary classroom teachers while the remaining 34% were specialists (art, music, physical education, etc.). They had an average of 24 students per teacher. 77% had not received any training on ADHD while being trained as teachers and 27% had re‐

Correct answers received a score of 1 and incorrect ones 0. Thus, the possible scores ranged

No publications have been found which provide validity evidences or reliability indices.

This is a simple and easy instrument to apply. However, the sample is very small and the dichotomous response format (True/False) places limits on the possibility of assessing the real level of knowledge of the teachers as the absence of a third (Don't Know) option invites respondents to guess the right answer. Furthermore, the psychometric properties of the in‐

*3.4.1. Original version of The Knowledge of Attention Deficit Disorders Scale (KADDS) (Sciutto,*

It was developed in the United States and in the English language. This is one of the most widely used instruments to assess the level of knowledge of teachers regarding ADHD, and is the first instrument whose indices of reliability and validity were published in this field. It consists of 36 items, 18 positive and 18 negative, and measures three areas of knowledge re‐ lated to ADHD: 1) Symptoms/Diagnosis of ADHD (9 items), 2) General information on the nature, causes and impact of ADHD (15 items), and 3) Treatment of ADHD (12 items). It has a three option response format (True, False, Don't Know), which allows it to overcome the limits of previously used dichotomous formats (True, False) and collect more detailed infor‐ mation about the knowledge of teachers with respect to ADHD. The use of the three option response format allows the authors to discern those areas in which teachers have more knowledge, areas where they have the least knowledge and the areas in which they commit

In the drawing up of the items the authors strove to include only those with the support of the scientific literature, citing references for each item in the manual accompanying the in‐

ceived no training in the subject after completion of their studies.

156 Attention Deficit Hyperactivity Disorder in Children and Adolescents

from 0, for the lowest level of knowledge, to 27, for the highest.

**3.4. The Knowledge of Attention Deficit Disorders Scale (KADDS)**

*3.3.2. Scoring standards*

*3.3.3. Psychometric properties*

*3.3.4. Strengths and weaknesses*

strument are not known.

*Terjesen & Bender, 2000) [5]*

*3.4.1.1. Description and development*

the greatest number of errors.

1 point was given for correct answers and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 36, for the highest.

#### *3.4.1.3. Psychometric properties*

For reliability analysis, internal consistency was first calculated, producing a *Cronbach's al‐ pha* of 0.71 for each sub-scale and 0.86 for the scale as a whole. Furthermore, it was also seen that each KADDS sub-scale had a high correlation with the total KADDS score (range *r*=0.85 to *r*=0.91) and that there was a correlation between the three sub-scales (range *r*=0.63 to *r*=0.69). In order to analyze the stability of the scale, Sciutto and Terjesen [29] administered the KADDS in two occasions to a group of 185 university students (what they were students of is not stated) leaving an interval of two weeks between one application and the other. The test-retest correlations for the KADDS scores range between *r*=0.59 and *r*=0.70 for the three sub-scales and were *r*=0.76 for the scale as a whole.

more, there is no factorial analysis which would justify the sub-scales defended by the au‐

Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity

Disorder (ADHD)

159

http://dx.doi.org/10.5772/54277

In any case we regard the instrument developed by Sciutto et al. [5] to be a significant refer‐ ence point for any researcher trying to create one with a similar purpose because it was a pioneering effort in the field with good reliability and sufficient external validity. As well as that, it is an instrument that is easy to answer due to its brief and precise instructions, its small size and its three option response format. It is also worth mentioning that it has a sim‐ ple scoring system and thanks to the aforementioned response format, it provides informa‐ tion regarding the knowledge, false beliefs and areas of lack of knowledge of the teachers, information which the previous instruments, with their dichotomous response format, could

*3.4.2. The Spanish version of The Knowledge of Attention Deficit Disorders Scale (KADDS) (Jarque,*

This is the Spanish adaptation of the KADDS [5]. Like the original instrument it has 36 items, 18 positive and 18 negative, and it measures three areas of knowledge related to ADHD: 1) Symptoms/Diagnosis of ADHD (9 items), 2) General information on the nature, causes and impact of ADHD (15 items), and 3) Treatment of ADHD (12 items). The three option response format (True, False, Don't Know) is the same as that of the original instru‐ ment and it has a more extensive socio-demographic section than the original instrument

In the first phase of the adaptation process of the instrument, two doctoral students in devel‐ opmental and educational psychology translated KADDS into Spanish making the adjust‐ ments required for the new socio-cultural context. After that, native speakers of English translated the text back into English to test the validity of the original translation. In this sec‐ ond phase the authors found 18 words different from the original version and agreed on a final version of the translation of those words and drew up initial version of the instrument. The initial version was sent to 15 experts in ADHD (ADHD researchers and educational psychologists) who were asked to place each of the items on one of the three sub-scales that make up the instrument. The level of agreement on the assignment of items to the sub-scales was 94%. Finally, a pilot study was conducted on a sample of 35 primary school teachers who were asked to reply to the scale and indicate errata, difficulties to understand expres‐ sions or doubts that may have arisen during completion of the questionnaire. Corrections

For the analysis of reliability and validity of the final version of the instrument, the authors contacted various public and subsidized schools in the province of Valencia. The sampling was not random. The Spanish version of the KADDS was administered to 193 teachers, 68 from infant education and 125 from primary education, of whom 130 were women and 43 men (20 teachers did not specify their sex). They had a mean age of 42 years (*SD*=11.40), and an average of 17 years of teaching experience (*SD*=12.03). 13.8% were special education

(age, sex, years of experience as a teacher, teaching speciality, etc.).

were made and the final version was thus produced.

thors of the KADDS.

not provide.

*Tárraga & Miranda, 2007) [4]*

*3.4.2.1. Description and development*

No test was carried out on the factorial structure of the instrument. In order to find evidence of validity, the correlations between the scale scores and a series of variable related to the construct to be measured were examined. With regard to the previous exposure of teachers in their classrooms to pupils diagnosed with ADHD, statistically significant differences were found in the KADDS scores obtained (*p*<0.01), as well as in various sub-scales (*p*<0.01 for the General information and Symptoms/Diagnosis sub-scales). The same occurred with the uni‐ versity students who knew a person with ADHD. In the KADDS and the Treatment subscale they achieved significantly higher scores (*p*<0.01) than those that had no contact whatever with people with ADHD [29]. Furthermore the authors of the KADDS have point‐ ed out that the scores obtained by the teachers on the scale correlated in a statistically signif‐ icant and positive way with the number of ADHD students that had in their classes (*r*=0.23, *p*<0.01 for the New York sample and *r*=0.31, *p*<0.01 for the Ohio sample in the KADDS total) [5, 30]. In this case, the same phenomenon also occurred with the university students that had some kind of contact with people with ADHD (*r*=0.18, *p*<0.01 for the KADDS total) [29]. Finally, they found that people with more information about ADHD had higher KADDS scores, both in the case of teachers (*r*=0.40, *p*<0.001 for the KADDS total) [30] and in the case of university students (*r*=0.36, *p*<0.001 for the total KADDS score) [29].

#### *3.4.1.4. Strengths and weaknesses*

Considering that the validation of the KADDS was carried out mainly based on the study of Sciutto et al. [5], it should be emphasized that the sample used is fairly small in size and geo‐ graphically homogenous. Furthermore, the specific data from the Ohio sample are not known [29].

The reliability of the KADDS was analyzed satisfactorily. As to evidence of validity, we be‐ lieve that it could be improved but this is understandable considering it was the first instru‐ ment constructed to assess knowledge of teachers regarding ADHD whose psychometric properties have been published. The authors provide information on content validity, thanks to which it is known that they tried to be careful in their selection of test items but they do not provide detailed information about the construction of the instrument (number of items initially created, etc.), and the panel of experts consulted in the process for getting content validity was fairly homogeneous (students in the same doctoral program). Further‐ more, there is no factorial analysis which would justify the sub-scales defended by the au‐ thors of the KADDS.

In any case we regard the instrument developed by Sciutto et al. [5] to be a significant refer‐ ence point for any researcher trying to create one with a similar purpose because it was a pioneering effort in the field with good reliability and sufficient external validity. As well as that, it is an instrument that is easy to answer due to its brief and precise instructions, its small size and its three option response format. It is also worth mentioning that it has a sim‐ ple scoring system and thanks to the aforementioned response format, it provides informa‐ tion regarding the knowledge, false beliefs and areas of lack of knowledge of the teachers, information which the previous instruments, with their dichotomous response format, could not provide.

*3.4.2. The Spanish version of The Knowledge of Attention Deficit Disorders Scale (KADDS) (Jarque, Tárraga & Miranda, 2007) [4]*

#### *3.4.2.1. Description and development*

*3.4.1.3. Psychometric properties*

*3.4.1.4. Strengths and weaknesses*

known [29].

sub-scales and were *r*=0.76 for the scale as a whole.

158 Attention Deficit Hyperactivity Disorder in Children and Adolescents

of university students (*r*=0.36, *p*<0.001 for the total KADDS score) [29].

For reliability analysis, internal consistency was first calculated, producing a *Cronbach's al‐ pha* of 0.71 for each sub-scale and 0.86 for the scale as a whole. Furthermore, it was also seen that each KADDS sub-scale had a high correlation with the total KADDS score (range *r*=0.85 to *r*=0.91) and that there was a correlation between the three sub-scales (range *r*=0.63 to *r*=0.69). In order to analyze the stability of the scale, Sciutto and Terjesen [29] administered the KADDS in two occasions to a group of 185 university students (what they were students of is not stated) leaving an interval of two weeks between one application and the other. The test-retest correlations for the KADDS scores range between *r*=0.59 and *r*=0.70 for the three

No test was carried out on the factorial structure of the instrument. In order to find evidence of validity, the correlations between the scale scores and a series of variable related to the construct to be measured were examined. With regard to the previous exposure of teachers in their classrooms to pupils diagnosed with ADHD, statistically significant differences were found in the KADDS scores obtained (*p*<0.01), as well as in various sub-scales (*p*<0.01 for the General information and Symptoms/Diagnosis sub-scales). The same occurred with the uni‐ versity students who knew a person with ADHD. In the KADDS and the Treatment subscale they achieved significantly higher scores (*p*<0.01) than those that had no contact whatever with people with ADHD [29]. Furthermore the authors of the KADDS have point‐ ed out that the scores obtained by the teachers on the scale correlated in a statistically signif‐ icant and positive way with the number of ADHD students that had in their classes (*r*=0.23, *p*<0.01 for the New York sample and *r*=0.31, *p*<0.01 for the Ohio sample in the KADDS total) [5, 30]. In this case, the same phenomenon also occurred with the university students that had some kind of contact with people with ADHD (*r*=0.18, *p*<0.01 for the KADDS total) [29]. Finally, they found that people with more information about ADHD had higher KADDS scores, both in the case of teachers (*r*=0.40, *p*<0.001 for the KADDS total) [30] and in the case

Considering that the validation of the KADDS was carried out mainly based on the study of Sciutto et al. [5], it should be emphasized that the sample used is fairly small in size and geo‐ graphically homogenous. Furthermore, the specific data from the Ohio sample are not

The reliability of the KADDS was analyzed satisfactorily. As to evidence of validity, we be‐ lieve that it could be improved but this is understandable considering it was the first instru‐ ment constructed to assess knowledge of teachers regarding ADHD whose psychometric properties have been published. The authors provide information on content validity, thanks to which it is known that they tried to be careful in their selection of test items but they do not provide detailed information about the construction of the instrument (number of items initially created, etc.), and the panel of experts consulted in the process for getting content validity was fairly homogeneous (students in the same doctoral program). Further‐ This is the Spanish adaptation of the KADDS [5]. Like the original instrument it has 36 items, 18 positive and 18 negative, and it measures three areas of knowledge related to ADHD: 1) Symptoms/Diagnosis of ADHD (9 items), 2) General information on the nature, causes and impact of ADHD (15 items), and 3) Treatment of ADHD (12 items). The three option response format (True, False, Don't Know) is the same as that of the original instru‐ ment and it has a more extensive socio-demographic section than the original instrument (age, sex, years of experience as a teacher, teaching speciality, etc.).

In the first phase of the adaptation process of the instrument, two doctoral students in devel‐ opmental and educational psychology translated KADDS into Spanish making the adjust‐ ments required for the new socio-cultural context. After that, native speakers of English translated the text back into English to test the validity of the original translation. In this sec‐ ond phase the authors found 18 words different from the original version and agreed on a final version of the translation of those words and drew up initial version of the instrument. The initial version was sent to 15 experts in ADHD (ADHD researchers and educational psychologists) who were asked to place each of the items on one of the three sub-scales that make up the instrument. The level of agreement on the assignment of items to the sub-scales was 94%. Finally, a pilot study was conducted on a sample of 35 primary school teachers who were asked to reply to the scale and indicate errata, difficulties to understand expres‐ sions or doubts that may have arisen during completion of the questionnaire. Corrections were made and the final version was thus produced.

For the analysis of reliability and validity of the final version of the instrument, the authors contacted various public and subsidized schools in the province of Valencia. The sampling was not random. The Spanish version of the KADDS was administered to 193 teachers, 68 from infant education and 125 from primary education, of whom 130 were women and 43 men (20 teachers did not specify their sex). They had a mean age of 42 years (*SD*=11.40), and an average of 17 years of teaching experience (*SD*=12.03). 13.8% were special education teachers. 51.6% had received specific training on ADHD, with an average of 7.80 hours (*SD*=17) training. In addition, 59.1% of the teachers had had some experience teaching chil‐ dren with ADHD, and the average number of children with ADHD that they had in their classrooms during the previous two school years was 1.39 (*SD*=1.89).

secondary education have regarding ADHD [33], and the fourth and final version [31] has

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1 point was given for correct answers and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 21, for the highest.

No publications have been found which provide validity evidences or reliability indices.

On the positive side, it should be noted that the questionnaire is short and simple to com‐ plete, but it uses a response format with two options (True, False) which can lead to a bias in the collection of information as those subjects who did not know what to answer are re‐ quired to choose one of the two alternatives provided. In addition, there is a lack of publish‐ ed information relating to the development of the instrument and its psychometric

**3.6. Attention Deficit Hyperactivity Disorder and Stimulant Medication Survey (Snider,**

This is an instrument developed in the United States in the English language and it is aimed at primary school and special education teachers. Its aim is to test their knowledge of the nature of ADHD and its treatment through stimulant medication. The questionnaire is div‐ ided into six sections. The first consists of 8 socio-demographic items: The number of stu‐ dents the teacher has, the number of students diagnosed with ADHD, years of teaching experience, etc. The second section is made up of 47 Likert scale items with 5 options (1=Strongly Disagree, 2=Disagree; 3=Neutral/Don't know, 4=Agree, 5=Strongly Agree) divid‐ ed into three blocks: A first block of 13 items to assess factual knowledge about ADHD and the use of stimulant medication, a second block of 23 items that asked participants to indi‐ cate their views about the effects of stimulant medication on classroom behavior, and a third block of 11 items assessing teachers' experience and involvement with students who have ADHD. In the third section the subjects have to state which sources they regard as most reli‐ able for obtaining information about ADHD. In the fourth section they had to state which people usually recommend that children suspected of having ADHD be evaluated by. In the fifth section the teachers are asked about what teaching techniques they have most frequent‐ ly used for dealing with children with ADHD. In the sixth and final section, there is an open question which enquires about teachers' opinions regarding the use of stimulant medication

not been published, so its target population is unknown.

*3.5.2. Scoring standards*

*3.5.3. Psychometric properties*

*3.5.4. Strengths and weaknesses*

**Busch & Arrowood, 2003) [34].**

*3.6.1. Description and development*

for the treatment of students with ADHD.

properties.

#### *3.4.2.2. Scoring standards*

Identical to KADDS [5].

#### *3.4.2.3. Psychometric properties*

The reliability of the scale, measured by the *Cronbach's alpha* coefficient showed adequate in‐ ternal consistency. The *alpha* coefficient ranged between 0.74 and 0.77 for the three subscales and was 0.89 for the total scale. These rates were higher than those obtained by Sciutto et al. [5] in the original instrument. In addition, each of the sub-scales showed a high correlation with the total scale score (range *r*=0.85 to *r*=0.90), and there also was correlation between the three sub-scales (range *r*=0.62 to *r*=0.69). These data are also consistent with those provided by Sciutto et al. [5]. There was no test-retest reliability check conducted.

The validity of the scale was studied using a series of *Pearson correlations* between teacher knowledge of ADHD and various socio-demographic variables, specifically, teachers' knowledge of ADHD correlated in a statistically significant way with the number of hours of training they had received, *r*(152)=0.17, *p*=0.036; with the number of children with ADHD they had taught, *r*(180)=0.29, *p*=0.001; with the number of courses during which they had children with ADHD in their classes, *r*(172)=0.23, *p*=0.002; and their self-perceived level of effectiveness as teachers of children with ADHD, *r*(179)=0.50, *p*=0.001.

#### *3.4.2.4. Strengths and weaknesses*

The sample used for the KADDS adaptation was quite small and geographically homogene‐ ous. Also, test-retest reliability was not checked and the factorial structure of the scale was not analyzed. Apart from these weaknesses and those mentioned in the original version of KADDS, it should be noted that the instrument has adequate internal consistency and some evidence of external validity.

#### **3.5. Attention-Deficit Hyperactivity Disorder Knowledge and Opinion Survey (AKOS-IV) – Knowledge Scale (Power & Rostain, 2003) [31]**

#### *3.5.1. Description and development*

This instrument was developed in the United States in the English language and consists of 21 items, 8 positive and 13 negative with a dichotomous response format (True, False). The lead author of AKOS-IV participated in the development of different versions of the instru‐ ment. The first version was designed to analyze the level of knowledge among parents re‐ garding ADHD [see 32]. There is a lack of published information about the second version. The third version was used to assess the level of knowledge that teachers of primary and secondary education have regarding ADHD [33], and the fourth and final version [31] has not been published, so its target population is unknown.

#### *3.5.2. Scoring standards*

teachers. 51.6% had received specific training on ADHD, with an average of 7.80 hours (*SD*=17) training. In addition, 59.1% of the teachers had had some experience teaching chil‐ dren with ADHD, and the average number of children with ADHD that they had in their

The reliability of the scale, measured by the *Cronbach's alpha* coefficient showed adequate in‐ ternal consistency. The *alpha* coefficient ranged between 0.74 and 0.77 for the three subscales and was 0.89 for the total scale. These rates were higher than those obtained by Sciutto et al. [5] in the original instrument. In addition, each of the sub-scales showed a high correlation with the total scale score (range *r*=0.85 to *r*=0.90), and there also was correlation between the three sub-scales (range *r*=0.62 to *r*=0.69). These data are also consistent with those provided by Sciutto et al. [5]. There was no test-retest reliability check conducted.

The validity of the scale was studied using a series of *Pearson correlations* between teacher knowledge of ADHD and various socio-demographic variables, specifically, teachers' knowledge of ADHD correlated in a statistically significant way with the number of hours of training they had received, *r*(152)=0.17, *p*=0.036; with the number of children with ADHD they had taught, *r*(180)=0.29, *p*=0.001; with the number of courses during which they had children with ADHD in their classes, *r*(172)=0.23, *p*=0.002; and their self-perceived level of

The sample used for the KADDS adaptation was quite small and geographically homogene‐ ous. Also, test-retest reliability was not checked and the factorial structure of the scale was not analyzed. Apart from these weaknesses and those mentioned in the original version of KADDS, it should be noted that the instrument has adequate internal consistency and some

**3.5. Attention-Deficit Hyperactivity Disorder Knowledge and Opinion Survey (AKOS-**

This instrument was developed in the United States in the English language and consists of 21 items, 8 positive and 13 negative with a dichotomous response format (True, False). The lead author of AKOS-IV participated in the development of different versions of the instru‐ ment. The first version was designed to analyze the level of knowledge among parents re‐ garding ADHD [see 32]. There is a lack of published information about the second version. The third version was used to assess the level of knowledge that teachers of primary and

classrooms during the previous two school years was 1.39 (*SD*=1.89).

160 Attention Deficit Hyperactivity Disorder in Children and Adolescents

effectiveness as teachers of children with ADHD, *r*(179)=0.50, *p*=0.001.

*3.4.2.2. Scoring standards* Identical to KADDS [5].

*3.4.2.3. Psychometric properties*

*3.4.2.4. Strengths and weaknesses*

evidence of external validity.

*3.5.1. Description and development*

**IV) – Knowledge Scale (Power & Rostain, 2003) [31]**

1 point was given for correct answers and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 21, for the highest.

#### *3.5.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.5.4. Strengths and weaknesses*

On the positive side, it should be noted that the questionnaire is short and simple to com‐ plete, but it uses a response format with two options (True, False) which can lead to a bias in the collection of information as those subjects who did not know what to answer are re‐ quired to choose one of the two alternatives provided. In addition, there is a lack of publish‐ ed information relating to the development of the instrument and its psychometric properties.

#### **3.6. Attention Deficit Hyperactivity Disorder and Stimulant Medication Survey (Snider, Busch & Arrowood, 2003) [34].**

#### *3.6.1. Description and development*

This is an instrument developed in the United States in the English language and it is aimed at primary school and special education teachers. Its aim is to test their knowledge of the nature of ADHD and its treatment through stimulant medication. The questionnaire is div‐ ided into six sections. The first consists of 8 socio-demographic items: The number of stu‐ dents the teacher has, the number of students diagnosed with ADHD, years of teaching experience, etc. The second section is made up of 47 Likert scale items with 5 options (1=Strongly Disagree, 2=Disagree; 3=Neutral/Don't know, 4=Agree, 5=Strongly Agree) divid‐ ed into three blocks: A first block of 13 items to assess factual knowledge about ADHD and the use of stimulant medication, a second block of 23 items that asked participants to indi‐ cate their views about the effects of stimulant medication on classroom behavior, and a third block of 11 items assessing teachers' experience and involvement with students who have ADHD. In the third section the subjects have to state which sources they regard as most reli‐ able for obtaining information about ADHD. In the fourth section they had to state which people usually recommend that children suspected of having ADHD be evaluated by. In the fifth section the teachers are asked about what teaching techniques they have most frequent‐ ly used for dealing with children with ADHD. In the sixth and final section, there is an open question which enquires about teachers' opinions regarding the use of stimulant medication for the treatment of students with ADHD.

The pilot version was administered to 15 teachers participating in a graduate clinical experi‐ ence at the University of Wisconsin. Small changes were made in the wording of the items and it was confirmed that the time required to respond to the questionnaire was about 10 to 15 minutes.

drawn up to assess respondents real knowledge of ADHD. Section c) has a focus on identi‐ fying the teaching strategies which subjects might use with pupils with ADHD. For this pur‐ pose they were given a brief description of a practical case and a series of multiple choice and open questions. Section d) collects information about participants' beliefs about ADHD and the possibility of having pupils with it in their classes. For this purpose it had 31 items which required a response on an analog scale of 10 cm the bottom of which indicated com‐ plete agreement with the statement (Strongly Agree) and the top of which indicated com‐ plete disagreement (Strongly Disagree). Section e) was designed to evaluate beliefs regarding the different strategies for action possible in classes with pupils with ADHD. It has 56 items divided into various sub-sections to which respondents had to respond on 10 cm analogical scales the bottom ends of which indicated complete agreement (Strongly Agree) and the upper ends of which indicated complete disagreement (Strongly Disagree). Finally, section f) includes two multiple choice items to which subjects have to respond re‐ garding whether or not they want more training on ADHD and to specify the way they be‐

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The questionnaire was revised by two educational and developmental psychologists not as‐ sociated with the study. It was later piloted on a sample of 9 primary school teachers from Victoria (Australia), arising from which no change was made. The questionnaire was finally administered to 120 primary school teachers in Victoria, 91 women and 29 men with an average age of 39.2 years (*SD*=10.2), and 45 students in the last year of their education de‐ gree, all women and with an average age of 23.6 years (*SD*=5.6). The sampling procedure

Section b) of the questionnaire had 27 items. Correct responses received a score of 1 and incor‐ rect ones, 0. Thus, the possible scores ranged from 0, for the minimum level of knowledge, to

27, for the maximum level. The scoring standards for the other sections were not given.

No publications have been found which provide validity evidences or reliability indices.

On the positive side, it should be noted that the authors have attempted to develop an in‐ strument that collects a variety of information relating to ADHD. However, the instrument has many weaknesses: The sample used is quite small and geographically homogeneous, the information given relating to the development of the instrument is scant, the presentation of the items and response formats vary from one section to another, and there are questions with 34 possible answers and analog scales of 10 cm which make it difficult to interpret the response provided by the subject. In short, it is a long and complex questionnaire for the

subject. Additionally, the psychometric properties are not known.

lieve most appropriate to find out more about ADHD.

was not explained.

*3.7.2. Scoring standards*

*3.7.3. Psychometric properties*

*3.7.4. Strengths and weaknesses*

The definitive version of the questionnaire was administered to 145 teachers in Wisconsin, 29 women and 116 men. The subjects were randomly chosen from the Department of Public Instruction. Among the participants 43% were special education teachers and 30% general education teachers. The teachers had an average of 16.5 years of teaching experience (*SD*=9.46).

#### *3.6.2. Scoring standards*

Not provided.

#### *3.6.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.6.4. Strengths and weaknesses*

On the positive side, it should be noted that this is a questionnaire with clear instructions and is easy to fill out. However, the response format used by the authors (Likert 5 options) may complicate the interpretation of the results, since it offers the option to partially agree or disagree with the questionnaire items. Moreover, the sample used for the application of the instrument was small and geographically homogeneous, and the psychometric proper‐ ties of the instrument are not known. Finally, it should be noted that one of the main objec‐ tives of the questionnaire was to analyze teachers' knowledge of stimulant medication, a very specific purpose and one distinct from the object of study of the other questionnaires that have been examined in this chapter.

#### **3.7. Attention Deficit Hyperactivity Disorder (ADHD) Questionnaire (Kos, Richdale & Jackson, 2004) [20]**

#### *3.7.1. Description and development*

This instrument was drawn up in Australia in the English language to test the perceived and real knowledge of primary teachers and trainee teachers of ADHD. Section b) of the ques‐ tionnaire was drawn up to examine this main point and contains some items from Jerome et al. [23], Sciutto et al. [5] and another series of items taken from the scientific literature relat‐ ed to ADHD. The instrument was made up of 131 items divided into six sections. Section a) collects information on socio-demographic aspects of the sample and included an analog scale of 10 cm on which respondents had to indicate what they thought they knew about ADHD. The bottom end of this scale indicates the minimum level of knowledge (Very Lit‐ tle), while the upper level indicates the maximum level (A Lot). Section b) includes 27 items, 11 positive and 16 negative, with a three option response format (True, False, Don't know) drawn up to assess respondents real knowledge of ADHD. Section c) has a focus on identi‐ fying the teaching strategies which subjects might use with pupils with ADHD. For this pur‐ pose they were given a brief description of a practical case and a series of multiple choice and open questions. Section d) collects information about participants' beliefs about ADHD and the possibility of having pupils with it in their classes. For this purpose it had 31 items which required a response on an analog scale of 10 cm the bottom of which indicated com‐ plete agreement with the statement (Strongly Agree) and the top of which indicated com‐ plete disagreement (Strongly Disagree). Section e) was designed to evaluate beliefs regarding the different strategies for action possible in classes with pupils with ADHD. It has 56 items divided into various sub-sections to which respondents had to respond on 10 cm analogical scales the bottom ends of which indicated complete agreement (Strongly Agree) and the upper ends of which indicated complete disagreement (Strongly Disagree). Finally, section f) includes two multiple choice items to which subjects have to respond re‐ garding whether or not they want more training on ADHD and to specify the way they be‐ lieve most appropriate to find out more about ADHD.

The questionnaire was revised by two educational and developmental psychologists not as‐ sociated with the study. It was later piloted on a sample of 9 primary school teachers from Victoria (Australia), arising from which no change was made. The questionnaire was finally administered to 120 primary school teachers in Victoria, 91 women and 29 men with an average age of 39.2 years (*SD*=10.2), and 45 students in the last year of their education de‐ gree, all women and with an average age of 23.6 years (*SD*=5.6). The sampling procedure was not explained.

#### *3.7.2. Scoring standards*

The pilot version was administered to 15 teachers participating in a graduate clinical experi‐ ence at the University of Wisconsin. Small changes were made in the wording of the items and it was confirmed that the time required to respond to the questionnaire was about 10 to

The definitive version of the questionnaire was administered to 145 teachers in Wisconsin, 29 women and 116 men. The subjects were randomly chosen from the Department of Public Instruction. Among the participants 43% were special education teachers and 30% general education teachers. The teachers had an average of 16.5 years of teaching experience

No publications have been found which provide validity evidences or reliability indices.

On the positive side, it should be noted that this is a questionnaire with clear instructions and is easy to fill out. However, the response format used by the authors (Likert 5 options) may complicate the interpretation of the results, since it offers the option to partially agree or disagree with the questionnaire items. Moreover, the sample used for the application of the instrument was small and geographically homogeneous, and the psychometric proper‐ ties of the instrument are not known. Finally, it should be noted that one of the main objec‐ tives of the questionnaire was to analyze teachers' knowledge of stimulant medication, a very specific purpose and one distinct from the object of study of the other questionnaires

**3.7. Attention Deficit Hyperactivity Disorder (ADHD) Questionnaire (Kos, Richdale &**

This instrument was drawn up in Australia in the English language to test the perceived and real knowledge of primary teachers and trainee teachers of ADHD. Section b) of the ques‐ tionnaire was drawn up to examine this main point and contains some items from Jerome et al. [23], Sciutto et al. [5] and another series of items taken from the scientific literature relat‐ ed to ADHD. The instrument was made up of 131 items divided into six sections. Section a) collects information on socio-demographic aspects of the sample and included an analog scale of 10 cm on which respondents had to indicate what they thought they knew about ADHD. The bottom end of this scale indicates the minimum level of knowledge (Very Lit‐ tle), while the upper level indicates the maximum level (A Lot). Section b) includes 27 items, 11 positive and 16 negative, with a three option response format (True, False, Don't know)

15 minutes.

(*SD*=9.46).

Not provided.

*3.6.2. Scoring standards*

*3.6.3. Psychometric properties*

162 Attention Deficit Hyperactivity Disorder in Children and Adolescents

*3.6.4. Strengths and weaknesses*

that have been examined in this chapter.

*3.7.1. Description and development*

**Jackson, 2004) [20]**

Section b) of the questionnaire had 27 items. Correct responses received a score of 1 and incor‐ rect ones, 0. Thus, the possible scores ranged from 0, for the minimum level of knowledge, to 27, for the maximum level. The scoring standards for the other sections were not given.

#### *3.7.3. Psychometric properties*

No publications have been found which provide validity evidences or reliability indices.

#### *3.7.4. Strengths and weaknesses*

On the positive side, it should be noted that the authors have attempted to develop an in‐ strument that collects a variety of information relating to ADHD. However, the instrument has many weaknesses: The sample used is quite small and geographically homogeneous, the information given relating to the development of the instrument is scant, the presentation of the items and response formats vary from one section to another, and there are questions with 34 possible answers and analog scales of 10 cm which make it difficult to interpret the response provided by the subject. In short, it is a long and complex questionnaire for the subject. Additionally, the psychometric properties are not known.

#### **3.8. Knowledge of ADHD Rating Evaluation (KARE) (Vereb & DiPerna, 2004) [35]**

In order to analyze the stability of the instrument, the authors administered the KARE a sec‐ ond time to a sample of 24 subjects (without further details being given of the sample) with a time interval of four weeks between the first and the second administration. The test-retest reliability ranged from 0.76 (Behavioral management acceptability sub-scale) to 0.80 (Medi‐

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On the positive side, it should be noted that this is a not too long instrument with response formats that are easy to fill out. It also has an acceptable internal consistency for three of the four subs-scales that compose it, and has good test-retest stability. However, the sample used for obtaining the reliability indices is small, and no published validity evidences of the

This instrument was drawn up in the United States in the English language. The main pur‐ pose of it is to assess the level of knowledge of elementary school teachers regarding ADHD before and after they received a specific training program on the subject. The instrument consists of 23 items and has a multiple choice format: Each item is followed by five possible

In the course of its development process, the instrument was administered to 10 doctors working as psychologists in the Cypress-Fairbanks school district (Texas) to receive their feedback. Adjustments have been made for a better understanding of the items and re‐ sponse options (the authors did not provide further details). The test authors also conducted a pilot study with 133 participants (no further description were given of the sample), as a

The resulting instrument was administered to 47 elementary school teachers in the Cypress-Fairbanks school district. 91.5% of the participants were female and 8.5% male. 55.3% of them were general teachers while 44.7% were special education teachers. The age of the teachers ranged from 18 upwards, and they had an average of 11 years teaching experience. 30% of the sample had never received training about ADHD, and 95.7% had a child in their

1 point was given for each correct answer so the possible scores ranged from 0, for the low‐

cation acceptability and Knowledge of treatment sub-scales).

**3.9. Educator ADHD knowledge (Niznik, 2004) [36]**

*3.8.4. Strengths and weaknesses*

instrument have been found.

*3.9.1. Description and development*

answers, one correct and four distractors.

result of which a number of items were removed.

classroom with the disorder diagnosed in recent years.

est level of knowledge, to 23, for the highest level.

*3.9.2. Scoring standards*

No publications have been found which provide validity evidences.

#### *3.8.1. Description and development*

This instrument was developed in the United States and in the English language. Its pur‐ pose is to analyze the knowledge that elementary school teachers have about ADHD and assess their level of acceptance with respect to the medication and behaviorist treatments that are used with children with ADHD. The instrument is divided into three sections. The first section collects socio-demographic data. The second section consists of 43 items, positive and negative in nature (the authors do not specify the number of each), and is divided into two sub-scales: A first sub-scale assesses knowledge of the etiology, symp‐ toms and prognosis of ADHD (31 items), and a second sub-scale assesses knowledge about treatments that are used most frequently in ADHD cases (12 items). The third and final section consists of 10 items divided into two sub-scales: The first sub-scale assesses the level of acceptance that subjects presented with respect to medication (5 items), and the second sub-scale assesses the level of acceptance of the behavioral intervention guide‐ lines used with children with ADHD (5 items). The second section of the instrument has a response format of three options (True, False, Don't Know) and the third section, being an opinion section, has a Likert-type response format of 4 options (1=Not at all Likely, 2=Somewhat Likely, 3=Moderately Likely, 4=Very Likely).

The preliminary version of the instrument was made up of 59 items. 20 experts, members of the International Society for Research in Child and Adolescent Psychopatology who had conducted research in the area of ADHD and/or treatment acceptability were called upon to revise it. The items that received a negative evaluation from these experts were modified or removed.

Finally, the study was carried out on 47 elementary school teachers in five different districts of Pennsylvania and New Jersey. The sampling procedure was not specified. 94% of the sample was female and had an average of 13 years of teaching experience (*SD*=8.76). 85% of the teachers were general teachers, while 4.35% worked in special education and 10.6% worked in both areas.

#### *3.8.2. Scoring standards*

In the second section of the instrument 1 point was given for correct answers and 0 for in‐ correct ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 43, for the highest. The scoring standards for the third section of the questionnaire are unknown.

#### *3.8.3. Psychometric properties*

For the reliability analysis, the internal consistency was first calculated, obtaining a *Cron‐ bach's alpha* coefficient that ranged from 0.58 (Knowledge of treatments sub-scale) to 0.81 (Behavioral management acceptability sub-scale) for the four sub-scales in the questionnaire. In order to analyze the stability of the instrument, the authors administered the KARE a sec‐ ond time to a sample of 24 subjects (without further details being given of the sample) with a time interval of four weeks between the first and the second administration. The test-retest reliability ranged from 0.76 (Behavioral management acceptability sub-scale) to 0.80 (Medi‐ cation acceptability and Knowledge of treatment sub-scales).

No publications have been found which provide validity evidences.

#### *3.8.4. Strengths and weaknesses*

**3.8. Knowledge of ADHD Rating Evaluation (KARE) (Vereb & DiPerna, 2004) [35]**

This instrument was developed in the United States and in the English language. Its pur‐ pose is to analyze the knowledge that elementary school teachers have about ADHD and assess their level of acceptance with respect to the medication and behaviorist treatments that are used with children with ADHD. The instrument is divided into three sections. The first section collects socio-demographic data. The second section consists of 43 items, positive and negative in nature (the authors do not specify the number of each), and is divided into two sub-scales: A first sub-scale assesses knowledge of the etiology, symp‐ toms and prognosis of ADHD (31 items), and a second sub-scale assesses knowledge about treatments that are used most frequently in ADHD cases (12 items). The third and final section consists of 10 items divided into two sub-scales: The first sub-scale assesses the level of acceptance that subjects presented with respect to medication (5 items), and the second sub-scale assesses the level of acceptance of the behavioral intervention guide‐ lines used with children with ADHD (5 items). The second section of the instrument has a response format of three options (True, False, Don't Know) and the third section, being an opinion section, has a Likert-type response format of 4 options (1=Not at all Likely,

The preliminary version of the instrument was made up of 59 items. 20 experts, members of the International Society for Research in Child and Adolescent Psychopatology who had conducted research in the area of ADHD and/or treatment acceptability were called upon to revise it. The items that received a negative evaluation from these experts were

Finally, the study was carried out on 47 elementary school teachers in five different districts of Pennsylvania and New Jersey. The sampling procedure was not specified. 94% of the sample was female and had an average of 13 years of teaching experience (*SD*=8.76). 85% of the teachers were general teachers, while 4.35% worked in special education and 10.6%

In the second section of the instrument 1 point was given for correct answers and 0 for in‐ correct ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the lowest level of knowledge, to 43, for the highest. The scoring standards for the third section of the

For the reliability analysis, the internal consistency was first calculated, obtaining a *Cron‐ bach's alpha* coefficient that ranged from 0.58 (Knowledge of treatments sub-scale) to 0.81 (Behavioral management acceptability sub-scale) for the four sub-scales in the questionnaire.

*3.8.1. Description and development*

164 Attention Deficit Hyperactivity Disorder in Children and Adolescents

modified or removed.

worked in both areas.

*3.8.2. Scoring standards*

questionnaire are unknown.

*3.8.3. Psychometric properties*

2=Somewhat Likely, 3=Moderately Likely, 4=Very Likely).

On the positive side, it should be noted that this is a not too long instrument with response formats that are easy to fill out. It also has an acceptable internal consistency for three of the four subs-scales that compose it, and has good test-retest stability. However, the sample used for obtaining the reliability indices is small, and no published validity evidences of the instrument have been found.

#### **3.9. Educator ADHD knowledge (Niznik, 2004) [36]**

#### *3.9.1. Description and development*

This instrument was drawn up in the United States in the English language. The main pur‐ pose of it is to assess the level of knowledge of elementary school teachers regarding ADHD before and after they received a specific training program on the subject. The instrument consists of 23 items and has a multiple choice format: Each item is followed by five possible answers, one correct and four distractors.

In the course of its development process, the instrument was administered to 10 doctors working as psychologists in the Cypress-Fairbanks school district (Texas) to receive their feedback. Adjustments have been made for a better understanding of the items and re‐ sponse options (the authors did not provide further details). The test authors also conducted a pilot study with 133 participants (no further description were given of the sample), as a result of which a number of items were removed.

The resulting instrument was administered to 47 elementary school teachers in the Cypress-Fairbanks school district. 91.5% of the participants were female and 8.5% male. 55.3% of them were general teachers while 44.7% were special education teachers. The age of the teachers ranged from 18 upwards, and they had an average of 11 years teaching experience. 30% of the sample had never received training about ADHD, and 95.7% had a child in their classroom with the disorder diagnosed in recent years.

#### *3.9.2. Scoring standards*

1 point was given for each correct answer so the possible scores ranged from 0, for the low‐ est level of knowledge, to 23, for the highest level.

#### *3.9.3. Psychometric properties*

The reliability of the instrument was calculated using the *Kuder-Richardson formula 20*, and a reliability of 0.65 was obtained. No publications have been found that provide validity evi‐ dences.

*3.10.2. Scoring standards*

*3.10.3. Psychometric properties*

*3.10.4. Strengths and weaknesses*

*3.11.1. Description and development*

knowledge, to 67, for the maximum level.

In the SPSS statistical package correct answers were coded with a 1, incorrect ones with a 0, and the gaps as a missing value. Possible answers ranged from 0, for the minimum level of

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The reliability of the KADD-Q and its sub-scales was estimated using *Cronbach's alpha* coeffi‐ cient. The results suggest that the internal consistency of the KADD-Q is high for the sample of teachers (*alpha*=0.91) and parents (*alpha*=0.93). For the sub-scales Causes, Characteristics and Treatment, *alphas* obtained were of 0.86, 0.80 and 0.79 for teachers and 0.85, 0.84 and 0.84 for the parents, respectively. In addition, each of the sub-scales of the KADD-Q had a high correlation with the total scale score (range *r*=0.73 to 0.92) in both the sample of teach‐ ers and parents. There were moderate correlations between the three sub-scales of teachers in the sample (range *r*=0.34 to 0.56), and somewhat ones higher in the sample of parents

Convergent validity was not evaluated, nor was any test of the factorial structure of the in‐ strument made. The scale authors present data on a series of relationships that exist between the scale scores and several variables related to the construct they purport to measure, which provide certain information concerning the external validity. The level of teachers' knowledge about ADHD was significantly higher depending on the stage of their profession they were at. Primary school teachers obtained higher scores than their secondary education colleagues (*p*=0.001). Teachers who had attended to professional development sessions about ADHD in the previous 12 months and those who had specific training in special edu‐

On the positive side, it is noteworthy that the authors of KADD-Q have tried to create a sin‐ gle instrument to assess the knowledge of teachers in primary and secondary education and the parents of children with ADHD. This instrument has an easily completed response for‐ mat and has good internal consistency. However, the teachers and parents samples used for the study were small and geographically homogeneous, the information relating to the de‐ velopment of the instrument is scant, the instrument lacks test-retest reliability indices, evi‐ dence of convergent validity is not provided, and nor is there any factorial analysis to confirm the presence of the three sub-scales of the instrument. To all this must be added the

This instrument was drawn up in the United States and in the English language for the pur‐ pose of assessing teachers' knowledge of ADHD after they have receiving training related to

(range *r*=0.56 to 0.77). There was no test test-retest reliability conducted.

cation had higher scores on the scale (*p*<0.001 and *p*=0.024, respectively).

fact that data concerning the external validity of the instrument are scarce.

**3.11. Teacher knowledge about ADHD (Jones & Chronis-Tuscano, 2008) [24]**

#### *3.9.4. Strengths and weaknesses*

On the positive side, it should be noted that this is a not too long instrument with a novel response format in the field that concerns us. However, the authors provide few details about the construction process of the test, the sample that has been used with the final in‐ strument is quite small and homogeneous, and has a low reliability index. Furthermore, the validity evidences of the instrument were not provided.

#### **3.10. The knowledge about Attention Deficit Disorder Questionnaire (KADD-Q) (West, Taylor, Houghton & Hudyma, 2005) [6]**

#### *3.10.1. Description and development*

This is an instrument that was drawn up in Australia in the English language in order to assess the knowledge about ADHD of primary and secondary teachers and parents of chil‐ dren with the same condition. It consists of a scale of 67 items, constructed on the basis of 20 items from the KADDS [5]. It has a three option response format (True, False, Don't Know) and measures three areas of knowledge connected to ADHD: 1) Causes of ADHD, 2) Char‐ acteristics of ADHD, and 3) Treatment of ADHD. Like the KADDS scale it has positive and negative items, and for the drawing up of which the authors made efforts to use only those items with support in the scientific literature.

The KADD-Q authors obtained the sample needed for the analysis of reliability and validity of the scale by making a random selection of schools in metropolitan Perth (Western Aus‐ tralia) and by way of the Centre for Attention and Related Disorders of The University of Western Australia. The sample consisted of 348 participants: 256 teachers (51% primary and 43% secondary) and 92 parents. Of the teachers involved in the sample, 22% were male and 78% female. 180 teachers were recruited in their workplaces and had an average of 20.2 years (*SD*=10.3) of teaching experience, the remaining 76 teachers were recruited through the Centre for Attention and Related Disorders, and had an average amount of teaching ex‐ perience of 15.8 years (*SD*=10). 96% of teachers said they had a student with ADHD in the classroom at some point and 20% were qualified in special education. As for the group of 92 parents participating in the study, it should be noted that 8% were male and 92% female. In addition, the average age at which their child had been diagnosed with ADHD was 10.3 years (*SD*=3.1). 23% of the parents were attending a support group for parents of children with ADHD and 31% had attended informational seminars about ADHD in the preceding 12 months.

#### *3.10.2. Scoring standards*

*3.9.3. Psychometric properties*

166 Attention Deficit Hyperactivity Disorder in Children and Adolescents

*3.9.4. Strengths and weaknesses*

validity evidences of the instrument were not provided.

**Taylor, Houghton & Hudyma, 2005) [6]**

items with support in the scientific literature.

*3.10.1. Description and development*

dences.

12 months.

The reliability of the instrument was calculated using the *Kuder-Richardson formula 20*, and a reliability of 0.65 was obtained. No publications have been found that provide validity evi‐

On the positive side, it should be noted that this is a not too long instrument with a novel response format in the field that concerns us. However, the authors provide few details about the construction process of the test, the sample that has been used with the final in‐ strument is quite small and homogeneous, and has a low reliability index. Furthermore, the

**3.10. The knowledge about Attention Deficit Disorder Questionnaire (KADD-Q) (West,**

This is an instrument that was drawn up in Australia in the English language in order to assess the knowledge about ADHD of primary and secondary teachers and parents of chil‐ dren with the same condition. It consists of a scale of 67 items, constructed on the basis of 20 items from the KADDS [5]. It has a three option response format (True, False, Don't Know) and measures three areas of knowledge connected to ADHD: 1) Causes of ADHD, 2) Char‐ acteristics of ADHD, and 3) Treatment of ADHD. Like the KADDS scale it has positive and negative items, and for the drawing up of which the authors made efforts to use only those

The KADD-Q authors obtained the sample needed for the analysis of reliability and validity of the scale by making a random selection of schools in metropolitan Perth (Western Aus‐ tralia) and by way of the Centre for Attention and Related Disorders of The University of Western Australia. The sample consisted of 348 participants: 256 teachers (51% primary and 43% secondary) and 92 parents. Of the teachers involved in the sample, 22% were male and 78% female. 180 teachers were recruited in their workplaces and had an average of 20.2 years (*SD*=10.3) of teaching experience, the remaining 76 teachers were recruited through the Centre for Attention and Related Disorders, and had an average amount of teaching ex‐ perience of 15.8 years (*SD*=10). 96% of teachers said they had a student with ADHD in the classroom at some point and 20% were qualified in special education. As for the group of 92 parents participating in the study, it should be noted that 8% were male and 92% female. In addition, the average age at which their child had been diagnosed with ADHD was 10.3 years (*SD*=3.1). 23% of the parents were attending a support group for parents of children with ADHD and 31% had attended informational seminars about ADHD in the preceding In the SPSS statistical package correct answers were coded with a 1, incorrect ones with a 0, and the gaps as a missing value. Possible answers ranged from 0, for the minimum level of knowledge, to 67, for the maximum level.

#### *3.10.3. Psychometric properties*

The reliability of the KADD-Q and its sub-scales was estimated using *Cronbach's alpha* coeffi‐ cient. The results suggest that the internal consistency of the KADD-Q is high for the sample of teachers (*alpha*=0.91) and parents (*alpha*=0.93). For the sub-scales Causes, Characteristics and Treatment, *alphas* obtained were of 0.86, 0.80 and 0.79 for teachers and 0.85, 0.84 and 0.84 for the parents, respectively. In addition, each of the sub-scales of the KADD-Q had a high correlation with the total scale score (range *r*=0.73 to 0.92) in both the sample of teach‐ ers and parents. There were moderate correlations between the three sub-scales of teachers in the sample (range *r*=0.34 to 0.56), and somewhat ones higher in the sample of parents (range *r*=0.56 to 0.77). There was no test test-retest reliability conducted.

Convergent validity was not evaluated, nor was any test of the factorial structure of the in‐ strument made. The scale authors present data on a series of relationships that exist between the scale scores and several variables related to the construct they purport to measure, which provide certain information concerning the external validity. The level of teachers' knowledge about ADHD was significantly higher depending on the stage of their profession they were at. Primary school teachers obtained higher scores than their secondary education colleagues (*p*=0.001). Teachers who had attended to professional development sessions about ADHD in the previous 12 months and those who had specific training in special edu‐ cation had higher scores on the scale (*p*<0.001 and *p*=0.024, respectively).

#### *3.10.4. Strengths and weaknesses*

On the positive side, it is noteworthy that the authors of KADD-Q have tried to create a sin‐ gle instrument to assess the knowledge of teachers in primary and secondary education and the parents of children with ADHD. This instrument has an easily completed response for‐ mat and has good internal consistency. However, the teachers and parents samples used for the study were small and geographically homogeneous, the information relating to the de‐ velopment of the instrument is scant, the instrument lacks test-retest reliability indices, evi‐ dence of convergent validity is not provided, and nor is there any factorial analysis to confirm the presence of the three sub-scales of the instrument. To all this must be added the fact that data concerning the external validity of the instrument are scarce.

#### **3.11. Teacher knowledge about ADHD (Jones & Chronis-Tuscano, 2008) [24]**

#### *3.11.1. Description and development*

This instrument was drawn up in the United States and in the English language for the pur‐ pose of assessing teachers' knowledge of ADHD after they have receiving training related to it. It consists of 25 items with a dichotomous response format (True, False). The items were designed to cover six areas of content: 1) Causes of ADHD, 2) Assessment of ADHD, 3) ADHD sub-types, 4) Associated problems of ADHD, 5) Treatment of ADHD, and 6) Specific school-based behavioral strategies for children with ADHD.

ADHD: 1) General information about ADHD (4 items), 2) Symptoms/Diagnosis of ADHD (11 items), 3) Etiology of ADHD (4 items), and 4) Treatment of ADHD (7 items). The ques‐

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169

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To obtain data on content validity, the authors of the instrument sought the cooperation of 8 experts in ADHD (university lecturers from different fields of knowledge and clinical or ed‐ ucational psychologists). Thanks to their participation the initial questionnaire of 105 items was reduced to 76 which were distributed into their corresponding sub-scales of the ques‐ tionnaire when there was an agreement level of 70% among the experts. Subsequently, a pi‐ lot study was conducted on 98 infant and primary school teachers in the Autonomous Community of the Basque Country and Navarre. 83 participants were women and 15 men, with a mean age of 40 years (*SD*=9.8). They had an average of 15 years (*SD*=10) in the teach‐ ing profession, 50.5% had never received training about ADHD, and 47% said they had ex‐ perience of having a child with ADHD in their classroom. 86% were infant education specialists or primary teachers and 8% were special education teachers. Thanks to the partic‐ ipation of these teachers, the authors of the questionnaire selected those items with high dis‐ crimination power and revised the wording of 6 statements, obtaining a preliminary

The draft instrument was finally applied to a sample of 752 infant and primary education teachers in 84 schools in the Autonomous Community of the Basque Country and Navarre. The schools were randomly selected. 86% of participants were female and 14% male, with a mean age of 42 years (*SD*=9.68). They had an average of 17 years (*SD*=10.55) experience as teachers, 80% were infant and primary teachers and 12% special education teachers. 59% said they never received training about ADHD, and 54% stated that they had had experi‐ ence of children with ADHD during their careers. The final instrument of 26 items as descri‐

1 point was given for each correct answer and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the minimum level of knowledge, to 26, for the

With the purpose of selecting the final items for the IRA-AGHN, a factor analysis with obli‐ que rotation was carried out. Items with a factor loading equal to or greater than .35, and which adequately reflected the underlying construct, were selected. Using the 26 selected items, the dimensionality of the instrument was examined by means of an exploratory factor analysis based on polychoric correlations. The Unweighted Least Squares (ULS) estimation method was used. Kaiser procedure was used to decide the number of factors, and the Di‐ rect Oblimin rotation method was selected in order to simplify the factor structure. The re‐ sulting structure confirmed the multi-dimensional character of the construct. Four factors were obtained which explained 53.2% of the variance: The first factor, Etiology of ADHD,

tionnaire items were developed from an extensive review of the literature on ADHD.

instrument of 51 items.

*3.12.1.2. Scoring standards*

*3.12.1.3. Psychometric properties*

highest level.

bed earlier in this section was thus obtained.

The questionnaire was administered to a non-random sample of 142 elementary school teachers in the Washington DC metropolitan area, of whom 74 belonged to the experimental group receiving training in ADHD and the remaining 68 to a control group that did not re‐ ceive such training. The average age of all participants in the sample was about 37 years (*SD*=12.45) and they had an average amount of teaching experience of 11.34 years (*SD*=10.40). 92% were women and only 17% were special education teachers. Approximately 34% of the sample had had experience of a child with ADHD in their classroom.

#### *3.11.2. Scoring standards*

1 point was given for correct answers and 0 for incorrect ones, so the range of possible scores went from 0, for the lowest possible level, to 25, for the highest possible level.

#### *3.11.3. Psychometric properties*

Internal consistency scores were 0.68 and 0.97 before and after training, respectively. No publications have been found which provide validity evidences of the instrument.

#### *3.11.4. Strengths and weaknesses*

On the positive side, it should be noted that the questionnaire is short and easy to fill out. However, it uses a dichotomous response format which prevents information being collect‐ ed about the areas where the teachers' lack of knowledge is concentrated. Furthermore, in‐ formation about the validity of the instrument is not available.

#### **3.12. Questionnaire to Assess Teachers' Knowledge about ADHD**

*3.12.1. Basque language version of the Questionnaire to Assess Teachers' Knowledge about ADHD (Irakasleek AGHNari buruz duten ezagutza ebaluatzeko galdera-sorta – IRA-AGHN) (Soroa, Balluerka & Gorostiaga, unpublished)*

#### *3.12.1.1. Description and development*

This is a newly developed questionnaire produced in Spain in the Basque language and which has yet to be published. Its purpose is to assess the knowledge of infant and primary school teachers about ADHD. It is divided into two sections. The first collects socio-demo‐ graphic data (age, sex, teaching speciality, teaching experience, etc.) as well as data on the perceived knowledge of teachers of ADHD and their perceived capacity to teach children suffering from this condition. The second section assesses their real knowledge of these mat‐ ters with 26 items that use a three option response format (True, False, Don't Know). The questionnaire items, 21 positive and 5 negative, assessed four areas of knowledge related to ADHD: 1) General information about ADHD (4 items), 2) Symptoms/Diagnosis of ADHD (11 items), 3) Etiology of ADHD (4 items), and 4) Treatment of ADHD (7 items). The ques‐ tionnaire items were developed from an extensive review of the literature on ADHD.

To obtain data on content validity, the authors of the instrument sought the cooperation of 8 experts in ADHD (university lecturers from different fields of knowledge and clinical or ed‐ ucational psychologists). Thanks to their participation the initial questionnaire of 105 items was reduced to 76 which were distributed into their corresponding sub-scales of the ques‐ tionnaire when there was an agreement level of 70% among the experts. Subsequently, a pi‐ lot study was conducted on 98 infant and primary school teachers in the Autonomous Community of the Basque Country and Navarre. 83 participants were women and 15 men, with a mean age of 40 years (*SD*=9.8). They had an average of 15 years (*SD*=10) in the teach‐ ing profession, 50.5% had never received training about ADHD, and 47% said they had ex‐ perience of having a child with ADHD in their classroom. 86% were infant education specialists or primary teachers and 8% were special education teachers. Thanks to the partic‐ ipation of these teachers, the authors of the questionnaire selected those items with high dis‐ crimination power and revised the wording of 6 statements, obtaining a preliminary instrument of 51 items.

The draft instrument was finally applied to a sample of 752 infant and primary education teachers in 84 schools in the Autonomous Community of the Basque Country and Navarre. The schools were randomly selected. 86% of participants were female and 14% male, with a mean age of 42 years (*SD*=9.68). They had an average of 17 years (*SD*=10.55) experience as teachers, 80% were infant and primary teachers and 12% special education teachers. 59% said they never received training about ADHD, and 54% stated that they had had experi‐ ence of children with ADHD during their careers. The final instrument of 26 items as descri‐ bed earlier in this section was thus obtained.

#### *3.12.1.2. Scoring standards*

it. It consists of 25 items with a dichotomous response format (True, False). The items were designed to cover six areas of content: 1) Causes of ADHD, 2) Assessment of ADHD, 3) ADHD sub-types, 4) Associated problems of ADHD, 5) Treatment of ADHD, and 6) Specific

The questionnaire was administered to a non-random sample of 142 elementary school teachers in the Washington DC metropolitan area, of whom 74 belonged to the experimental group receiving training in ADHD and the remaining 68 to a control group that did not re‐ ceive such training. The average age of all participants in the sample was about 37 years (*SD*=12.45) and they had an average amount of teaching experience of 11.34 years (*SD*=10.40). 92% were women and only 17% were special education teachers. Approximately

1 point was given for correct answers and 0 for incorrect ones, so the range of possible

Internal consistency scores were 0.68 and 0.97 before and after training, respectively. No

On the positive side, it should be noted that the questionnaire is short and easy to fill out. However, it uses a dichotomous response format which prevents information being collect‐ ed about the areas where the teachers' lack of knowledge is concentrated. Furthermore, in‐

*3.12.1. Basque language version of the Questionnaire to Assess Teachers' Knowledge about ADHD (Irakasleek AGHNari buruz duten ezagutza ebaluatzeko galdera-sorta – IRA-AGHN) (Soroa,*

This is a newly developed questionnaire produced in Spain in the Basque language and which has yet to be published. Its purpose is to assess the knowledge of infant and primary school teachers about ADHD. It is divided into two sections. The first collects socio-demo‐ graphic data (age, sex, teaching speciality, teaching experience, etc.) as well as data on the perceived knowledge of teachers of ADHD and their perceived capacity to teach children suffering from this condition. The second section assesses their real knowledge of these mat‐ ters with 26 items that use a three option response format (True, False, Don't Know). The questionnaire items, 21 positive and 5 negative, assessed four areas of knowledge related to

34% of the sample had had experience of a child with ADHD in their classroom.

scores went from 0, for the lowest possible level, to 25, for the highest possible level.

publications have been found which provide validity evidences of the instrument.

formation about the validity of the instrument is not available.

**3.12. Questionnaire to Assess Teachers' Knowledge about ADHD**

school-based behavioral strategies for children with ADHD.

168 Attention Deficit Hyperactivity Disorder in Children and Adolescents

*3.11.2. Scoring standards*

*3.11.3. Psychometric properties*

*3.11.4. Strengths and weaknesses*

*Balluerka & Gorostiaga, unpublished)*

*3.12.1.1. Description and development*

1 point was given for each correct answer and 0 for incorrect ones and gaps in knowledge. Thus, the possible scores ranged from 0, for the minimum level of knowledge, to 26, for the highest level.

#### *3.12.1.3. Psychometric properties*

With the purpose of selecting the final items for the IRA-AGHN, a factor analysis with obli‐ que rotation was carried out. Items with a factor loading equal to or greater than .35, and which adequately reflected the underlying construct, were selected. Using the 26 selected items, the dimensionality of the instrument was examined by means of an exploratory factor analysis based on polychoric correlations. The Unweighted Least Squares (ULS) estimation method was used. Kaiser procedure was used to decide the number of factors, and the Di‐ rect Oblimin rotation method was selected in order to simplify the factor structure. The re‐ sulting structure confirmed the multi-dimensional character of the construct. Four factors were obtained which explained 53.2% of the variance: The first factor, Etiology of ADHD, explained 29.15% of the variance; the second factor, Symptoms/Diagnosis of ADHD, ex‐ plained 9.8% of the variance; the third factor, General information about ADHD, explained 7.8% of the variance; and the fourth and final factor, Treatment of ADHD, explained 6.4% of the variance.

*3.12.2. Spanish version of the Questionnaire to Assess Teachers' Knowledge about ADHD*

*Balluerka & Gorostiaga, unpublished)*

*3.12.2.1. Description and development*

the instrument in the Basque language.

*(Cuestionario para evaluar el conocimiento de los maestros acerca del TDAH – MAE-TDAH) (Soroa,*

Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity

Disorder (ADHD)

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http://dx.doi.org/10.5772/54277

This is a questionnaire recently produced in Spain in the Spanish language and which has yet to be published. The description is the same as that for the above mentioned version of

To obtain evidence of content validity, the authors of the instrument sought the cooperation of 8 experts in ADHD (university lecturers from different fields of knowledge, child and youth psychiatrists, pediatricians, one educational psychologist and one education expert who are members of various associations of families of children with ADHD). Thanks to their participation, the initial questionnaire of 105 items was reduced to 76 items that were distributed in the corresponding sub-scales of the questionnaire with the agreement of at least 70% of the judges. Subsequently, a pilot study was conducted on 68 infant and primary school teachers in the Autonomous Community of the Basque Country and Navarre. 53 par‐ ticipants were women and 15 men, with a mean age of 43 years (*SD*=10.87). They had an average of 18 years (*SD*=11.67) in the teaching profession, 47% had never received training regarding ADHD, and 73% said they had a child diagnosed with ADHD in their classroom at some point in their career. 73% were infant or primary school teachers, and 15% were spe‐ cial education teachers. Thanks to the participation of these teachers, the authors of the questionnaire selected those items with high discrimination power and revised the wording

Finally, the draft instrument was applied to a sample of 526 infant and primary school teachers in 57 schools in the Autonomous Community of the Basque Country and Navarre. The schools were randomly selected. 85% of participants were female and 15% male, with a mean age of 43 years (*SD*=10.89). They had an average of 17 years (*SD*=11.31) experience as teachers, 77% were infant or primary teachers and 11% were special education teachers. 56% said they had never received training regarding ADHD, and 67% stated that they had a child diagnosed with ADHD in their classroom at some point in their career. From this

With the aim of selecting the final items for the MAE-TDAH, a factor analysis with oblique rotation was carried out. Items with a factor loading equal to or greater than .35, and which adequately reflected the underlying construct, were selected. Using the 26 selected items, the dimensionality of the instrument was examined by means of an exploratory factor analy‐ sis based on polychoric correlations. The Unweighted Least Squares (ULS) estimation meth‐

of two of the statements, obtaining a preliminary instrument of 51 items.

Identical to those in the Basque language version of the questionnaire.

study the final 26 items instrument was obtained.

*3.12.2.2. Scoring standards*

*3.12.2.3. Psychometric properties*

For the reliability analysis, the internal consistency was first calculated, with an *Omega* coef‐ ficient which ranged from 0.76 to 0.90 being obtained for the four sub-scales. For the pur‐ pose of analyzing the stability of the instrument the authors administered the IRA-AGHN a second time to a sample of 123 teachers with a period of four weeks between the first and second administration. The *Spearman's Rho* test-retest correlations for the IRA-AGHN scores ranged from *r*=0.49 to *r*=0.77 (*p<*0.01) for the four sub-scales.

Convergent validity was tested by comparing the results obtained by the subjects in the IRA-AGHN with the results obtained in the Spanish version of the KADDS [4]. The correla‐ tion between the scores obtained by the subjects in the dimensions shared by both question‐ naires was *r*=0.54 for the General information sub-scale, *r*=0.45 for the Symptoms/Diagnosis sub-scale and *r*=0.33 for the Treatment sub-scale (*p<0*.01 in all cases).

Finally, to obtain evidence of external validity, the relationships between the scores obtained by the participants in the IRA-AGHN sub-scales and a series of variables related to the con‐ struct that it was sought to measure were examined. The data showed that the scores ob‐ tained by the teachers in the Symptoms/Diagnosis sub-scale had a moderate correlation with variables such as the number of children diagnosed with ADHD the teachers had taught in the course of their careers (*r* = .29, *p* = .001), the teachers' perceived knowledge of ADHD (*r* = .37, *p* = .001), and the teachers' perceived capacity to teach effectively children with ADHD (*r* = 0.30, *p* = 0.001). Meanwhile, it was observed that the scores obtained by the teachers in the General information sub-scale showed a moderate correlation with the teachers' per‐ ceived knowledge of ADHD variable (*r* = .30, *p* = .001). In addition, using the Mann-Whitney U test a comparison was drawn between the average score ranges obtained by teachers who had taught children diagnosed with ADHD in the course of their careers and those who hadn't. Results showed that there were statistically significant differences between the groups' mean score ranges in the Symptoms/Diagnosis sub-scale (*Mann-Whitney U test* = 44503; *p* = .0001; *r* = .29).

#### *3.12.1.4. Strengths and weaknesses*

On the positive side, it should be noted that this is a short questionnaire and easy to com‐ plete with a three option response format (True, False, Don't Know), and that it success‐ fully evaluates teachers' knowledge, false beliefs and areas of lack of knowledge regarding ADHD. The sample used for the validation of the instrument is geographically diverse and extensive, being representative of the target population for the questionnaire. The instrument development process was thorough and rigorous, and has appropriate psychometric properties, although evidence of external validity is not supported by high levels of correlation.

*3.12.2. Spanish version of the Questionnaire to Assess Teachers' Knowledge about ADHD (Cuestionario para evaluar el conocimiento de los maestros acerca del TDAH – MAE-TDAH) (Soroa, Balluerka & Gorostiaga, unpublished)*

#### *3.12.2.1. Description and development*

explained 29.15% of the variance; the second factor, Symptoms/Diagnosis of ADHD, ex‐ plained 9.8% of the variance; the third factor, General information about ADHD, explained 7.8% of the variance; and the fourth and final factor, Treatment of ADHD, explained 6.4% of

For the reliability analysis, the internal consistency was first calculated, with an *Omega* coef‐ ficient which ranged from 0.76 to 0.90 being obtained for the four sub-scales. For the pur‐ pose of analyzing the stability of the instrument the authors administered the IRA-AGHN a second time to a sample of 123 teachers with a period of four weeks between the first and second administration. The *Spearman's Rho* test-retest correlations for the IRA-AGHN scores

Convergent validity was tested by comparing the results obtained by the subjects in the IRA-AGHN with the results obtained in the Spanish version of the KADDS [4]. The correla‐ tion between the scores obtained by the subjects in the dimensions shared by both question‐ naires was *r*=0.54 for the General information sub-scale, *r*=0.45 for the Symptoms/Diagnosis

Finally, to obtain evidence of external validity, the relationships between the scores obtained by the participants in the IRA-AGHN sub-scales and a series of variables related to the con‐ struct that it was sought to measure were examined. The data showed that the scores ob‐ tained by the teachers in the Symptoms/Diagnosis sub-scale had a moderate correlation with variables such as the number of children diagnosed with ADHD the teachers had taught in the course of their careers (*r* = .29, *p* = .001), the teachers' perceived knowledge of ADHD (*r* = .37, *p* = .001), and the teachers' perceived capacity to teach effectively children with ADHD (*r* = 0.30, *p* = 0.001). Meanwhile, it was observed that the scores obtained by the teachers in the General information sub-scale showed a moderate correlation with the teachers' per‐ ceived knowledge of ADHD variable (*r* = .30, *p* = .001). In addition, using the Mann-Whitney U test a comparison was drawn between the average score ranges obtained by teachers who had taught children diagnosed with ADHD in the course of their careers and those who hadn't. Results showed that there were statistically significant differences between the groups' mean score ranges in the Symptoms/Diagnosis sub-scale (*Mann-Whitney U test* =

On the positive side, it should be noted that this is a short questionnaire and easy to com‐ plete with a three option response format (True, False, Don't Know), and that it success‐ fully evaluates teachers' knowledge, false beliefs and areas of lack of knowledge regarding ADHD. The sample used for the validation of the instrument is geographically diverse and extensive, being representative of the target population for the questionnaire. The instrument development process was thorough and rigorous, and has appropriate psychometric properties, although evidence of external validity is not supported by high

ranged from *r*=0.49 to *r*=0.77 (*p<*0.01) for the four sub-scales.

170 Attention Deficit Hyperactivity Disorder in Children and Adolescents

sub-scale and *r*=0.33 for the Treatment sub-scale (*p<0*.01 in all cases).

the variance.

44503; *p* = .0001; *r* = .29).

levels of correlation.

*3.12.1.4. Strengths and weaknesses*

This is a questionnaire recently produced in Spain in the Spanish language and which has yet to be published. The description is the same as that for the above mentioned version of the instrument in the Basque language.

To obtain evidence of content validity, the authors of the instrument sought the cooperation of 8 experts in ADHD (university lecturers from different fields of knowledge, child and youth psychiatrists, pediatricians, one educational psychologist and one education expert who are members of various associations of families of children with ADHD). Thanks to their participation, the initial questionnaire of 105 items was reduced to 76 items that were distributed in the corresponding sub-scales of the questionnaire with the agreement of at least 70% of the judges. Subsequently, a pilot study was conducted on 68 infant and primary school teachers in the Autonomous Community of the Basque Country and Navarre. 53 par‐ ticipants were women and 15 men, with a mean age of 43 years (*SD*=10.87). They had an average of 18 years (*SD*=11.67) in the teaching profession, 47% had never received training regarding ADHD, and 73% said they had a child diagnosed with ADHD in their classroom at some point in their career. 73% were infant or primary school teachers, and 15% were spe‐ cial education teachers. Thanks to the participation of these teachers, the authors of the questionnaire selected those items with high discrimination power and revised the wording of two of the statements, obtaining a preliminary instrument of 51 items.

Finally, the draft instrument was applied to a sample of 526 infant and primary school teachers in 57 schools in the Autonomous Community of the Basque Country and Navarre. The schools were randomly selected. 85% of participants were female and 15% male, with a mean age of 43 years (*SD*=10.89). They had an average of 17 years (*SD*=11.31) experience as teachers, 77% were infant or primary teachers and 11% were special education teachers. 56% said they had never received training regarding ADHD, and 67% stated that they had a child diagnosed with ADHD in their classroom at some point in their career. From this study the final 26 items instrument was obtained.

#### *3.12.2.2. Scoring standards*

Identical to those in the Basque language version of the questionnaire.

#### *3.12.2.3. Psychometric properties*

With the aim of selecting the final items for the MAE-TDAH, a factor analysis with oblique rotation was carried out. Items with a factor loading equal to or greater than .35, and which adequately reflected the underlying construct, were selected. Using the 26 selected items, the dimensionality of the instrument was examined by means of an exploratory factor analy‐ sis based on polychoric correlations. The Unweighted Least Squares (ULS) estimation meth‐ od was used. Kaiser procedure was used to decide the number of factors, and the Direct Oblimin rotation method was selected in order to simplify the factor structure. The resulting structure confirmed the multi-dimensional character of the construct. Four factors were ob‐ tained which explained 60.73% of the variance: Etiology of ADHD explained 34.04% of the variance, General information about ADHD explained 12.14% of the variance, Treatment of ADHD explained 8.92% of the variance, and the fourth and final factor, Symptoms/Diagno‐ sis of ADHD, explained 5.6% of the variance.

metric properties to measure teachers' knowledge of ADHD with rigor. These instruments, in addition to identifying gaps in teachers' knowledge of the disorder, can be useful in rais‐ ing the awareness of teachers about the need for more training in this area, help in the de‐ sign of training tailored to the needs of teachers, and ultimately, promote the welfare of

Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity

Disorder (ADHD)

173

http://dx.doi.org/10.5772/54277

This lack of methodological rigor in these measurement instruments may cause the obtain‐ ing of erratic and false results. With regard to the measurement instruments used to assess teachers' knowledge of ADHD it can be seen that this knowledge varies among the studies examined here. This variability may, in part, be due to an increase in teachers' knowledge of ADHD over recent decades but it might also be due to methodological reasons such as the following: The number and content of the items in the various instruments varies; the re‐ sponse formats also differ and this affects the results; the size of the samples also varies con‐ siderably, in some cases being very big and in others quite small; different studies have collected different socio-demographic data from their sample, which affects the description made of it and the interpretations which might be made of the reasons for the knowledge teachers have about ADHD. All these aspects should be taken into account when it comes to interpreting, comparing and generalizing the results obtained from these instruments.

Regarding the dimensionality of the instruments analyzed here, it should be noted that five of the twelve (KADDS [4, 5], KARE [35], KADD-Q [6], Teacher Knowledge About ADHD [24], and IRA-AGHN/MAE-TDAH) used a number of dimensions ranging from 2 to 6 for the assessment of teachers knowledge of ADHD. It can be seen that Treatment is the only common to all the instruments. In general, the various dimensions proposed by the authors deal with the symptoms, sub-types, associated problems, evaluation, prognosis and etiology of ADHD. However, it should be noted that only one of the instruments reviewed, the IRA-AGHN/MAE-TDAH conducted a factor analysis to confirm the multidimensional nature of

Furthermore, the external validity of the instruments analyzed provides information about the variables that can influence the knowledge that teachers have regarding ADHD. Three of the twelve instruments reviewed (KADDS [4, 5], KADD-Q [6], and IRA-AGHN/MAE-TDAH) provide evidence of external validity. If we focus on those variables that have rela‐ tionships with knowledge about ADHD with effect size equal to or greater than 0.30 in any of the instruments, it can be concluded that the variables that correlated with teachers' knowledge about ADHD are: Prior exposure of teachers to children diagnosed with ADHD in the classroom, the number of children with ADHD teachers have had in their classrooms, having had specific training about ADHD, the degree of teachers' self-perceived efficacy in

Finally, it should be pointed out that we consider the present chapter to be of interest be‐ cause it provides an exhaustive review of the main instruments identified in the scientific literature to assess teachers' knowledge of ADHD. The identification of instruments with optimal psychometric properties is fundamental because it allows for the obtaining of valid and reliable data about the construct being studied. With regard to teachers' knowledge of ADHD it has been shown that there exist a significant percentage of teachers with gaps in

teaching children with ADHD and teachers' self-perceived knowledge of ADHD.

children and young people with ADHD.

the construct.

For reliability analysis, the internal consistency was first calculated and an *Omega* coefficient which ranged from 0.83 to 0.91 for four sub-scales was obtained. In order to analyze the sta‐ bility of the instrument, the authors administered the MAE-TDAH a second time to a group of 112 teachers four weeks after the first application. The *Spearman's Rho* test-retest correla‐ tions for the MAE-TDAH scores ranged from *r*=0.62 to *r*=0.79 (*p<*0.01) for the four sub-scales.

Convergent validity was tested by comparing the results obtained by the subjects in the MAE-TDAH with the results obtained in the Spanish version of KADDS [4]. The correla‐ tions observed between the scores obtained by the subjects in the dimensions shared by both questionnaires were *r*=0.58 for the General information sub-scale, *r*=0.43 for the Symptoms/ Diagnosis sub-scale, *r*=0.30 for the Etiology and *r*=0.39 for the Treatment sub-scale (*p<*0.01 in all cases).

In order to find evidence of external validity the authors of the MAE-TDAH examined the correlations between the questionnaire scores and a series of variables related to the con‐ struct it was sought to measure. Significant statistical differences were found between the teachers' perceived knowledge of ADHD and the scores they obtained for all the sub-scales of the questionnaire (*r*=0.38 for General information, *r*=0.37 for Symptoms/Diagnosis, *r*=0.30 for Etiology and *r*=0.31 for Treatment; *p*=0.001 for all cases), as well between the teachers perceived capacity to effectively teach children with ADHD and the scores obtained in the sub-scales General information and Symptoms/Diagnosis of ADHD (*r*=0.29, *p*=0.001 and *r*=0.30, *p*=0.001, respectively).

#### *3.12.2.4. Strengths and weaknesses*

These are similar to those set out regarding the Basque language version of the question‐ naire. The main difference is that in this case the sample used for the validation of the ques‐ tionnaire was quite homogenous as it was confined to two autonomous communities of the Spanish state.

#### **4. Conclusions**

In the review that has been carried out in this chapter, it has been observed that there exist a great number of tools that have been developed to assess the level of knowledge of teachers regarding ADHD. However, most of them do not have good psychometric properties. The authors of this chapter consider necessary to develop and validate instruments with psycho‐ metric properties to measure teachers' knowledge of ADHD with rigor. These instruments, in addition to identifying gaps in teachers' knowledge of the disorder, can be useful in rais‐ ing the awareness of teachers about the need for more training in this area, help in the de‐ sign of training tailored to the needs of teachers, and ultimately, promote the welfare of children and young people with ADHD.

od was used. Kaiser procedure was used to decide the number of factors, and the Direct Oblimin rotation method was selected in order to simplify the factor structure. The resulting structure confirmed the multi-dimensional character of the construct. Four factors were ob‐ tained which explained 60.73% of the variance: Etiology of ADHD explained 34.04% of the variance, General information about ADHD explained 12.14% of the variance, Treatment of ADHD explained 8.92% of the variance, and the fourth and final factor, Symptoms/Diagno‐

For reliability analysis, the internal consistency was first calculated and an *Omega* coefficient which ranged from 0.83 to 0.91 for four sub-scales was obtained. In order to analyze the sta‐ bility of the instrument, the authors administered the MAE-TDAH a second time to a group of 112 teachers four weeks after the first application. The *Spearman's Rho* test-retest correla‐ tions for the MAE-TDAH scores ranged from *r*=0.62 to *r*=0.79 (*p<*0.01) for the four sub-scales.

Convergent validity was tested by comparing the results obtained by the subjects in the MAE-TDAH with the results obtained in the Spanish version of KADDS [4]. The correla‐ tions observed between the scores obtained by the subjects in the dimensions shared by both questionnaires were *r*=0.58 for the General information sub-scale, *r*=0.43 for the Symptoms/ Diagnosis sub-scale, *r*=0.30 for the Etiology and *r*=0.39 for the Treatment sub-scale (*p<*0.01 in

In order to find evidence of external validity the authors of the MAE-TDAH examined the correlations between the questionnaire scores and a series of variables related to the con‐ struct it was sought to measure. Significant statistical differences were found between the teachers' perceived knowledge of ADHD and the scores they obtained for all the sub-scales of the questionnaire (*r*=0.38 for General information, *r*=0.37 for Symptoms/Diagnosis, *r*=0.30 for Etiology and *r*=0.31 for Treatment; *p*=0.001 for all cases), as well between the teachers perceived capacity to effectively teach children with ADHD and the scores obtained in the sub-scales General information and Symptoms/Diagnosis of ADHD (*r*=0.29, *p*=0.001 and

These are similar to those set out regarding the Basque language version of the question‐ naire. The main difference is that in this case the sample used for the validation of the ques‐ tionnaire was quite homogenous as it was confined to two autonomous communities of the

In the review that has been carried out in this chapter, it has been observed that there exist a great number of tools that have been developed to assess the level of knowledge of teachers regarding ADHD. However, most of them do not have good psychometric properties. The authors of this chapter consider necessary to develop and validate instruments with psycho‐

sis of ADHD, explained 5.6% of the variance.

172 Attention Deficit Hyperactivity Disorder in Children and Adolescents

all cases).

*r*=0.30, *p*=0.001, respectively).

Spanish state.

**4. Conclusions**

*3.12.2.4. Strengths and weaknesses*

This lack of methodological rigor in these measurement instruments may cause the obtain‐ ing of erratic and false results. With regard to the measurement instruments used to assess teachers' knowledge of ADHD it can be seen that this knowledge varies among the studies examined here. This variability may, in part, be due to an increase in teachers' knowledge of ADHD over recent decades but it might also be due to methodological reasons such as the following: The number and content of the items in the various instruments varies; the re‐ sponse formats also differ and this affects the results; the size of the samples also varies con‐ siderably, in some cases being very big and in others quite small; different studies have collected different socio-demographic data from their sample, which affects the description made of it and the interpretations which might be made of the reasons for the knowledge teachers have about ADHD. All these aspects should be taken into account when it comes to interpreting, comparing and generalizing the results obtained from these instruments.

Regarding the dimensionality of the instruments analyzed here, it should be noted that five of the twelve (KADDS [4, 5], KARE [35], KADD-Q [6], Teacher Knowledge About ADHD [24], and IRA-AGHN/MAE-TDAH) used a number of dimensions ranging from 2 to 6 for the assessment of teachers knowledge of ADHD. It can be seen that Treatment is the only common to all the instruments. In general, the various dimensions proposed by the authors deal with the symptoms, sub-types, associated problems, evaluation, prognosis and etiology of ADHD. However, it should be noted that only one of the instruments reviewed, the IRA-AGHN/MAE-TDAH conducted a factor analysis to confirm the multidimensional nature of the construct.

Furthermore, the external validity of the instruments analyzed provides information about the variables that can influence the knowledge that teachers have regarding ADHD. Three of the twelve instruments reviewed (KADDS [4, 5], KADD-Q [6], and IRA-AGHN/MAE-TDAH) provide evidence of external validity. If we focus on those variables that have rela‐ tionships with knowledge about ADHD with effect size equal to or greater than 0.30 in any of the instruments, it can be concluded that the variables that correlated with teachers' knowledge about ADHD are: Prior exposure of teachers to children diagnosed with ADHD in the classroom, the number of children with ADHD teachers have had in their classrooms, having had specific training about ADHD, the degree of teachers' self-perceived efficacy in teaching children with ADHD and teachers' self-perceived knowledge of ADHD.

Finally, it should be pointed out that we consider the present chapter to be of interest be‐ cause it provides an exhaustive review of the main instruments identified in the scientific literature to assess teachers' knowledge of ADHD. The identification of instruments with optimal psychometric properties is fundamental because it allows for the obtaining of valid and reliable data about the construct being studied. With regard to teachers' knowledge of ADHD it has been shown that there exist a significant percentage of teachers with gaps in this area [3-7, 19, 20]. For this reason, we believe that the use of instruments which measure this knowledge with rigor could contribute to devising of training materials and courses ap‐ propriate for the needs of teachers. And this would, of course, result in benefits for the chil‐ dren who suffer from this condition.

[5] Sciutto, M. J., Terjesen, M. D., & Bender, A. S. (2000). Teachers' knowledge and mis‐ perceptions of Attention-Deficit/Hyperactivity Disorder. Psychology in the Schools,

Review of Tools Used for Assessing Teachers' Level of Knowledge with Regards Attention Deficit Hyperactivity

Disorder (ADHD)

175

http://dx.doi.org/10.5772/54277

[6] West, J., Taylor, M., Houghton, S., & Hudyma, S. (2005). A Comparison of Teachers' and Parents' Knowledge and Beliefs About Attention-Deficit/Hyperactivity Disorder

[7] White, S. W., Sukhodolsky, D. G., Rains, A. L., Foster, D., McGuire, J. F., & Scahill, L. (2011). Elementary School Teachers' Knowledge of Tourette Syndrome, Obsessive-Compulsive Disorder, & Attention-Deficit/Hyperactivity Disorder: Effects of Teacher

[8] Barkley, R. A. (2005). Prólogo. In I. Moreno, El niño hiperactivo (pp. 13). Madrid: Pi‐

[9] Soroa, M., Balluerka, N., & Gorostiaga, A. (2012). Evaluation of the level of knowl‐ edge of infant and primary school teachers with respect to the Attention Deficit Hy‐ peractivity Disorder (ADHD): Content validity of a newly created questionnaire. In J. M. Norvilitis (Ed.), Contemporary trends in ADHD research (pp. 127-152 ). Rijeka: InTech. (available from: http://www.intechopen.com/articles/show/title/evaluationof-the-level-of-knowledge-of-infant-and-primary-school-teachers-with-respect-to-

[10] American Psychiatric Association (APA, 2000). Diagnostic and statistical manual of

[11] Barkley, R. A. (1999). Niños hiperactivos: Cómo comprender y atender sus necesi‐

[12] Moreno, I. & Servera, M. (2002). Intervención en los trastornos del comportamiento infantil. In M. Servera (Coord.), Los trastornos por déficit de atención con hiperactivi‐

[14] Ohan, J. L., Cormier, N., Hepp, S. L., Visser, T. A. V., & Strain, M. C. (2008). Does Knowledge About Attention-Deficit/Hyperactivity Disorder Impact Teachers' Re‐

ported Behaviors and Perceptions?. School Psychology Quarterly, 23, 436-449.

[15] Sherman, J., Rasmussen, C., & Baydala, L. (2008). The impact of teacher factors on ar‐ chievement and behavioural outcomes of children with Attention Deficit/Hyperac‐ tivity Disorder (ADHD): A review of the literature. Educational Research, 50(4),

[16] Kos, J., Richdale, A. L., & Hay, D. A. (2006). Children with Attention deficit Hyperac‐ tivity Disorder and their Teachers: A review of the literature. International Journal of

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[13] Moreno, I. (2008). Hiperactividad infantil: Guía de actuación. Madrid: Pirámide.

mental disorders (4th. ed.). Washington: Author text revision.

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#### **Acknowledgements**

The authors appreciate the cooperation of all those authors who provided additional infor‐ mation about the assessment instruments examined in this chapter.

This work was partially funded by a grant from the Research Bureau of the University of the Basque Country UPV/EHU (General Funding for Research Groups, GIU11/29).

#### **Author details**

Marian Soroa1 , Arantxa Gorostiaga2 and Nekane Balluerka2

\*Address all correspondence to: marian.soroa@ehu.es

1 Developmental and Educational Psychology Department, University Teacher Training College of Donostia of the UPV/EHU, Donostia-San Sebastián, Spain

2 Social Psychology and Methodology of the Behavioral Sciences Department, Psychology Faculty of the UPV/EHU, Donostia-San Sebastián, Spain

#### **References**


[5] Sciutto, M. J., Terjesen, M. D., & Bender, A. S. (2000). Teachers' knowledge and mis‐ perceptions of Attention-Deficit/Hyperactivity Disorder. Psychology in the Schools, 37, 115-122.

this area [3-7, 19, 20]. For this reason, we believe that the use of instruments which measure this knowledge with rigor could contribute to devising of training materials and courses ap‐ propriate for the needs of teachers. And this would, of course, result in benefits for the chil‐

The authors appreciate the cooperation of all those authors who provided additional infor‐

This work was partially funded by a grant from the Research Bureau of the University of the

and Nekane Balluerka2

1 Developmental and Educational Psychology Department, University Teacher Training

2 Social Psychology and Methodology of the Behavioral Sciences Department, Psychology

[1] Lavigne, R. & Romero, J. F. (2010). El TDAH: ¿Qué es?, ¿qué lo causa?, ¿cómo eval‐

[2] Canu, W. H. & Mancil, E. B. (2012). An Examination of Teacher Trainees' Knowledge of Attention-Deficit/Hyperactivity Disorder. School Mental Health, 4, 105-114.

[3] Ghanizadeh, A., Bahredar, M. J., & Moeini, S. R. (2006). Knowledge and attitudes to‐ wards attention deficit hyperactivity disorder among elementary school teachers. Pa‐

[4] Jarque, S., Tárraga, R., & Miranda, A. (2007). Conocimientos, concepciones erróneas y lagunas de los maestros sobre el trastorno por déficit de atención con hiperactividad.

mation about the assessment instruments examined in this chapter.

College of Donostia of the UPV/EHU, Donostia-San Sebastián, Spain

, Arantxa Gorostiaga2

\*Address all correspondence to: marian.soroa@ehu.es

Faculty of the UPV/EHU, Donostia-San Sebastián, Spain

uarlo y tratarlo?. Madrid: Pirámide.

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Psicothema, 19(4), 585-590.

Basque Country UPV/EHU (General Funding for Research Groups, GIU11/29).

dren who suffer from this condition.

174 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**Acknowledgements**

**Author details**

Marian Soroa1

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**Section 4**

**Drugs in ADHD**

**Section 4**

### **Drugs in ADHD**

**Chapter 9**

**Effects of Methylphenidate in Children with Attention**

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common mental disorders in children and adolescents, with an estimated 3–5% of children diagnosed with this disorder [1,2]. ADHD is characterized by symptoms of inattention, impulsivity and hyperactivity. It has been suggested that a core deficiency in inhibitory control accounts for many deficits in executive function observed in ADHD that underlie most of the dysfunctional behaviors associated with this syndrome [3]. The apparent importance of executive dysfunction in children with ADHD has thus led to an increasing number of investigations in this area.

Executive control is engaged in situations requiring decision making, conflict resolution, error correction, and response inhibition. An important aspect of executive function is the inhibition of a prepared response, where inhibition refers to the ability to actively suppress, interrupt or delay an action [4]. Without inhibition, there is no capacity to avoid the execution of inappro‐ priate responses, or ensure attainment of appropriate responses, thereby preventing realiza‐

One commonly used paradigm in the investigation of executive function is the continu‐ ous performance test (CPT), which is a classical GO/NOGO paradigm. CPT was firstly used as a measure of sustained attention [5], and has since been widely applied in the investiga‐ tion of cognitive response control and response inhibition, in both clinical groups and

Event-related potentials (ERPs) are electroencephalogram (EEG) recorded changes that are time locked to sensory, motor, or cognitive events. Event-related potentials provide a safe, noninvasive approach to study of the psychophysiological correlates of mental processing.

and reproduction in any medium, provided the original work is properly cited.

© 2013 Yan-ling and Xuan; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Deficit Hyperactivity Disorder: A Comparison of**

**Behavioral Results and Event–Related Potentials**

Ren Yan-ling and Dong Xuan

http://dx.doi.org/10.5772/53782

**1. Introduction**

tion of an intended result.

healthy subjects [6].

Additional information is available at the end of the chapter

## **Effects of Methylphenidate in Children with Attention Deficit Hyperactivity Disorder: A Comparison of Behavioral Results and Event–Related Potentials**

Ren Yan-ling and Dong Xuan

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53782

#### **1. Introduction**

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common mental disorders in children and adolescents, with an estimated 3–5% of children diagnosed with this disorder [1,2]. ADHD is characterized by symptoms of inattention, impulsivity and hyperactivity. It has been suggested that a core deficiency in inhibitory control accounts for many deficits in executive function observed in ADHD that underlie most of the dysfunctional behaviors associated with this syndrome [3]. The apparent importance of executive dysfunction in children with ADHD has thus led to an increasing number of investigations in this area.

Executive control is engaged in situations requiring decision making, conflict resolution, error correction, and response inhibition. An important aspect of executive function is the inhibition of a prepared response, where inhibition refers to the ability to actively suppress, interrupt or delay an action [4]. Without inhibition, there is no capacity to avoid the execution of inappro‐ priate responses, or ensure attainment of appropriate responses, thereby preventing realiza‐ tion of an intended result.

One commonly used paradigm in the investigation of executive function is the continu‐ ous performance test (CPT), which is a classical GO/NOGO paradigm. CPT was firstly used as a measure of sustained attention [5], and has since been widely applied in the investiga‐ tion of cognitive response control and response inhibition, in both clinical groups and healthy subjects [6].

Event-related potentials (ERPs) are electroencephalogram (EEG) recorded changes that are time locked to sensory, motor, or cognitive events. Event-related potentials provide a safe, noninvasive approach to study of the psychophysiological correlates of mental processing.

GO/NOGO tasks are a particularly suitable paradigm for investigating response inhibition with ERPs. In this task, subjects are usually required to respond either overtly or covertly to a given target stimulus (a tone or a letter) (GO condition). In a second condition, however, subjects are required to withhold a response to a given stimulus (NOGO condition). The ERPs of CPT tasks are investigated by comparing ERP differences induced by the GO condition ("9" after "1") and NOGO condition (no "9" after "1"). The NOGO condition has a more significant N2 component between 200 and 300 ms over the frontocentral scalp than the Go condition, and the subsequent frontal-central region a larger P3 component; the GO stimulus has a larger P3 component in the parietal region. The NOGO-N2 and the NOGO-P3 components are related to response inhibition [7]. The GO-P3 component is related to the attention of the GO stimulus [8]. An increasing body of recent evidence suggests that the NOGO-N2 is related to conflict monitoring, while the NOGO-P3 is related to response inhibition [9, 10]. The source of response inhibition has been localized in the anterior cingulate cortex (ACC).

interview and parent rating scales. Excluded from the study were subjects with a conduct disorder, internalizing disorder (e.g. anxiety), low intelligence (IQ<85), and gross neurological and other organic disorders. All subjects had not taken any stimulant medication. ADHD children were given a low dose of 0.3mg/kg of methylphenidate (MPH). Verbal assent was

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183

The control group consisted of 28 age- and gender-matched healthy children, 6.8-13.2 years old (mean age = 9.15 ± 1.94 years), were right-handed, with Screened IQ ≥ 85, visual or corrected visual acuity greater than 1.0, without diseases of the nervous system, and no special learning difficulties or language barriers. They were tested only one time. Verbal assent was obtained from the children and their teachers, with written informed consent

Children with ADHD were tested twice. They were tested once following diagnosis (preadministration of M PH); and a second time two hours post-administration of MPH

The ADHD good performance group: after taking MPH, behavioral results were improved, with the number of omission errors and/or commission errors reduced by a factor of five in a total of 12 patients (1 female), mean age 9.17 ± 2.19 years old. Prior to administration of MPH, the number of omission errors and commission errors (respectively 8.37 ± 3.92, 7.78 ± 5.10) were significantly higher than the results obtained of 2 hours post-administration of MPH

The ADHD poor performance group: post-administration of MPH, behavioral results were not significantly improved, with behavioral changes not meeting behavioral improvement standards in a total of 16 patients (3 females), mean age 9.31 ± 1.66 years old. Prior to administration of MPH, the number of omission errors and commission errors (respective‐ ly 7.95 ± 4.61, 7.46 ± 5.81) were higher than the results obtained 2 hours post-administra‐ tion MPH (respectively 5.79 ± 2.71, 5.83 ± 2.91), but the differences were not statistically

The participants were investigated electrophysiologically in an electrically shielded, dimly lit room, sitting on a comfortable chair in front of a computer screen to perform the CPT tasks, with a viewing distance of 80 cm, horizontal visual angle of 0.7°, and a vertical visual angle of 1.4°. During the task, digits were presented in a random order, and subjects instructed to press a response button whenever the digit "9"appeared immediately after the digit"1". The whole stimulus set consisted of 400 digits, with 80 prime conditions (digit"1"), 40 GO ("9" after "1") and NOGO (no "9" after "1") conditions and 240 distracters (other digits, including the digit "9", without a preceding "1") (see fig.1). The digits were presented for 200 ms each, followed

provided by the subjects and written informed consent obtained from their parents.

*2.1.2. The control group*

obtained from their parents.

(0.3mg/kg body weight).

significant (P> 0.05).

**2.2. Electrophysiological paradigm**

*2.1.3. Behavioral results–basis for group division*

(respectively 2.92 ± 3.61, 3.91 ± 2.62) (P< 0.05).

Stimulant medication [11,21], particularly methylphenidate (MPH), is the most common treatment for children with ADHD, and has been shown to improve attention and behavior; low doses of MPH are highly effective and widely prescribed for the treatment of ADHD [12]. ERP analysis has been employed in efforts to gain knowledge about stimulant mechanisms and their relationship to appropriate effect, and studies have suggested that ERPs may predict the clinical response of children with ADHD to MPH [13]. Low dose MPH has been associated with reduced impulsivity (fewer false alarms) and decreased P3 latencies, whereas the higher doses have been associated with reduced impulsivity and less inattention (more hits), in addition to increased P2 and N2 latencies and decreased P3 latencies [14]. The Continuous Performance Test (CPT) is an appropriate instrument for assessment of the correlates between attention-related electrical activity levels in the brain and responses to stimulant medication [15].

This study investigates the effect of Methylphenidate on the relationship between the ERP waveform and behavioral results of children with ADHD. Therefore, based on their behavioral results pre- and post-administration of MPH, the ADHD children were divided into two groups: an ADHD good performance group and an ADHD poor performance group. We are interested in whether the changes in the ERP waveform correlate with the behavioral results, and the ERP waveform differences from the control group waveforms.

#### **2. Materials and methods**

#### **2.1. Subjects**

#### *2.1.1. ADHD group*

Twenty-eight children aged from 6 to 13 years (24 males and 4 females, mean age =9.25±1.86 years) with a primary diagnosis of ADHD participated. Children with ADHD were recruited from the ADHD clinic at the Third Affiliated Hospital of Soochow University. All of the children were identified as meeting DSM-IV criteria for ADHD based on a structured clinical interview and parent rating scales. Excluded from the study were subjects with a conduct disorder, internalizing disorder (e.g. anxiety), low intelligence (IQ<85), and gross neurological and other organic disorders. All subjects had not taken any stimulant medication. ADHD children were given a low dose of 0.3mg/kg of methylphenidate (MPH). Verbal assent was provided by the subjects and written informed consent obtained from their parents.

#### *2.1.2. The control group*

GO/NOGO tasks are a particularly suitable paradigm for investigating response inhibition with ERPs. In this task, subjects are usually required to respond either overtly or covertly to a given target stimulus (a tone or a letter) (GO condition). In a second condition, however, subjects are required to withhold a response to a given stimulus (NOGO condition). The ERPs of CPT tasks are investigated by comparing ERP differences induced by the GO condition ("9" after "1") and NOGO condition (no "9" after "1"). The NOGO condition has a more significant N2 component between 200 and 300 ms over the frontocentral scalp than the Go condition, and the subsequent frontal-central region a larger P3 component; the GO stimulus has a larger P3 component in the parietal region. The NOGO-N2 and the NOGO-P3 components are related to response inhibition [7]. The GO-P3 component is related to the attention of the GO stimulus [8]. An increasing body of recent evidence suggests that the NOGO-N2 is related to conflict monitoring, while the NOGO-P3 is related to response inhibition [9, 10]. The source of response

Stimulant medication [11,21], particularly methylphenidate (MPH), is the most common treatment for children with ADHD, and has been shown to improve attention and behavior; low doses of MPH are highly effective and widely prescribed for the treatment of ADHD [12]. ERP analysis has been employed in efforts to gain knowledge about stimulant mechanisms and their relationship to appropriate effect, and studies have suggested that ERPs may predict the clinical response of children with ADHD to MPH [13]. Low dose MPH has been associated with reduced impulsivity (fewer false alarms) and decreased P3 latencies, whereas the higher doses have been associated with reduced impulsivity and less inattention (more hits), in addition to increased P2 and N2 latencies and decreased P3 latencies [14]. The Continuous Performance Test (CPT) is an appropriate instrument for assessment of the correlates between attention-related electrical activity levels in the brain

This study investigates the effect of Methylphenidate on the relationship between the ERP waveform and behavioral results of children with ADHD. Therefore, based on their behavioral results pre- and post-administration of MPH, the ADHD children were divided into two groups: an ADHD good performance group and an ADHD poor performance group. We are interested in whether the changes in the ERP waveform correlate with the behavioral results,

Twenty-eight children aged from 6 to 13 years (24 males and 4 females, mean age =9.25±1.86 years) with a primary diagnosis of ADHD participated. Children with ADHD were recruited from the ADHD clinic at the Third Affiliated Hospital of Soochow University. All of the children were identified as meeting DSM-IV criteria for ADHD based on a structured clinical

inhibition has been localized in the anterior cingulate cortex (ACC).

and the ERP waveform differences from the control group waveforms.

and responses to stimulant medication [15].

182 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**2. Materials and methods**

**2.1. Subjects**

*2.1.1. ADHD group*

The control group consisted of 28 age- and gender-matched healthy children, 6.8-13.2 years old (mean age = 9.15 ± 1.94 years), were right-handed, with Screened IQ ≥ 85, visual or corrected visual acuity greater than 1.0, without diseases of the nervous system, and no special learning difficulties or language barriers. They were tested only one time. Verbal assent was obtained from the children and their teachers, with written informed consent obtained from their parents.

#### *2.1.3. Behavioral results–basis for group division*

Children with ADHD were tested twice. They were tested once following diagnosis (preadministration of M PH); and a second time two hours post-administration of MPH (0.3mg/kg body weight).

The ADHD good performance group: after taking MPH, behavioral results were improved, with the number of omission errors and/or commission errors reduced by a factor of five in a total of 12 patients (1 female), mean age 9.17 ± 2.19 years old. Prior to administration of MPH, the number of omission errors and commission errors (respectively 8.37 ± 3.92, 7.78 ± 5.10) were significantly higher than the results obtained of 2 hours post-administration of MPH (respectively 2.92 ± 3.61, 3.91 ± 2.62) (P< 0.05).

The ADHD poor performance group: post-administration of MPH, behavioral results were not significantly improved, with behavioral changes not meeting behavioral improvement standards in a total of 16 patients (3 females), mean age 9.31 ± 1.66 years old. Prior to administration of MPH, the number of omission errors and commission errors (respective‐ ly 7.95 ± 4.61, 7.46 ± 5.81) were higher than the results obtained 2 hours post-administra‐ tion MPH (respectively 5.79 ± 2.71, 5.83 ± 2.91), but the differences were not statistically significant (P> 0.05).

#### **2.2. Electrophysiological paradigm**

The participants were investigated electrophysiologically in an electrically shielded, dimly lit room, sitting on a comfortable chair in front of a computer screen to perform the CPT tasks, with a viewing distance of 80 cm, horizontal visual angle of 0.7°, and a vertical visual angle of 1.4°. During the task, digits were presented in a random order, and subjects instructed to press a response button whenever the digit "9"appeared immediately after the digit"1". The whole stimulus set consisted of 400 digits, with 80 prime conditions (digit"1"), 40 GO ("9" after "1") and NOGO (no "9" after "1") conditions and 240 distracters (other digits, including the digit "9", without a preceding "1") (see fig.1). The digits were presented for 200 ms each, followed by an inter-stimulus interval of 1400 ms, resulting in a total duration of approximately 11 minutes. After a short training session, subjects performed this version of the CPT while an ongoing EEG was recorded.

**3. Results**

significantly difference (P> 0.05).

(1) Comparing to pre- administration of MPH, P <0.05; (2) Comparing to pre- administration of MPH, P<0.01.

electrodes amplitudes of the NOGO-N2 and NOGO-P3 comparison (*x*¯± s) (μ v)

**3.2. ERP results of the ADHD poor performance group**

See Table 1 for details.

**electrode ERP**

See Table 2 for details.

**3.1. ERP results of the ADHD good performance group**

**pre- administration of MPH**

Comparing the results of this group, both pre- and post-administration of MPH, with the control group, the amplitude of the NOGO-N2 displayed no significant difference (P> 0.05). Pre-administration of MPH, the amplitude of the NOGO-P3 was significantly lower than the results obtained 2 hours post-administration of MPH and by the control group; at the Fz and Cz electrodes the differences were statistically significant (P <0.05). Comparied to the control group, the amplitude of the NOGO-P3 2 hours post-administration of MPH showed no

Effects of Methylphenidate in Children with Attention Deficit Hyperactivity Disorder…

**2 hours postadministration of MPH**

P3(400-500ms) 20.34±11.42 30.24±10.78(1) 33.26±9.83 (2) 6.49 0.003

P3(400-500ms) 16.28±6.36 22.20±5.07 (1) 23.67±8.14(1) 4.52 0.02

P3(420-520ms) 14.34±5.72 18.20±4.41 18.88±7.69 2.00 0.15

Fz N2(250-300ms) -7.17±5.81 -5.84±4.71 -7.67±4.32 0.62 0.54

Cz N2(250-300ms) -3.01±4.68 -2.08±3.37 -4.76±6.60 1.09 0.34

Pz N2(280-330ms) -1.73±3.63 -0.28±2.71 -1.25±3.94 0.51 0.60

**Table 1.** The ADHD good performance group pre- and post-administration of MPH and the control group at Fz, Cz, Pz

As with the ADHD good performance group, in comparing the results pre- and post-admin‐ istration of MPH with the control group, the amplitude of the NOGO-N2 also displayed no significant difference (P> 0.05). However, in this case both pre- and 2 hours post-administration of MPH, no statistically significant difference in the amplitude of the NOGP-P3 (P> 0.05) was found. Pre- and post-administration of MPH, the amplitude of the NOGO-P3 at the Fz electrode was significantly lower than that of control group (P <0.05). At the Cz electrode, the amplitude of the NOGO-P3 pre-administration of MPH was also significantly lower than that of the control group (P <0.05). However, compared to the control group, the amplitude of the

NOGO-P3 post-administration of MPH showed no significant difference (P> 0.05).

**the control group F value P value**

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**Figure 1.** The sequence of stimulus presentation

#### **2.3. EEG recording**

Scalp voltages were collected with a StellateTM System 32 channel Digital Video EEG (Stellate System Inc., CA) connected to a 32-Channel Digital Amplifier (LA MONT MEDICAL Inc., Montreal, CA). The EEG was recorded from 23 scalp electrodes which were placed according to the International 10-20 system at FP1, FP2, Fz, F3, F4, F7, F8, CZ, C3, C4, T3, T4, PZ, P3, P4, T5, T6, OZ, O1, O2, M1, M2 and a common reference. Vertical electro-oculogram (VEOG) electrodes, located at 2 cm above and below the left eye, were used to subtract the eye movement artifact. Impedances was <5 KΩ, bandpass filtered from 0.1 to 35 Hz and digitized at 500 Hz. A midline electrode was used as the common reference for recording.

Trials were discarded from analysis if they contained eye movements (vertical EOG channel differences greater than 100µV) or more than five bad channels.

#### **2.4. Data analysis**

Grand average ERP waveforms were used to determine the individual NOGO-N2 and NOGO-P3 time window. NOGO-N2 at Fz and Cz electrodes were maximal from 250-300 ms, 280-350 ms at Pz electrode; NOGO-P3 at Fz and Cz electrodes were maximal from 400-500 ms, 420-520 ms at Pz electrode. In each time window, the amplitudes of NOGO-N2 and NOGO-P3 at Fz, Cz, Pz electrodes were measured. Latency represented the time from the stimulus onset to the wave peak; amplitude represented the vertical distance from the baseline to the wave peak.

#### **2.5. Statistical analysis**

SPSS12.0 statistical software was used for data processing, using t-test for the difference between two groups and ANOV for the differences among multiple groups. All data were expressed as Mean ± SD (*x*¯± s), with the difference was considered significant if the P value was smaller than 0.05.

#### **3. Results**

by an inter-stimulus interval of 1400 ms, resulting in a total duration of approximately 11 minutes. After a short training session, subjects performed this version of the CPT while an

Scalp voltages were collected with a StellateTM System 32 channel Digital Video EEG (Stellate System Inc., CA) connected to a 32-Channel Digital Amplifier (LA MONT MEDICAL Inc., Montreal, CA). The EEG was recorded from 23 scalp electrodes which were placed according to the International 10-20 system at FP1, FP2, Fz, F3, F4, F7, F8, CZ, C3, C4, T3, T4, PZ, P3, P4, T5, T6, OZ, O1, O2, M1, M2 and a common reference. Vertical electro-oculogram (VEOG) electrodes, located at 2 cm above and below the left eye, were used to subtract the eye movement artifact. Impedances was <5 KΩ, bandpass filtered from 0.1 to 35 Hz and digitized at 500 Hz. A midline

Trials were discarded from analysis if they contained eye movements (vertical EOG channel

Grand average ERP waveforms were used to determine the individual NOGO-N2 and NOGO-P3 time window. NOGO-N2 at Fz and Cz electrodes were maximal from 250-300 ms, 280-350 ms at Pz electrode; NOGO-P3 at Fz and Cz electrodes were maximal from 400-500 ms, 420-520 ms at Pz electrode. In each time window, the amplitudes of NOGO-N2 and NOGO-P3 at Fz, Cz, Pz electrodes were measured. Latency represented the time from the stimulus onset to the wave peak; amplitude represented the vertical distance from the baseline to the wave peak.

SPSS12.0 statistical software was used for data processing, using t-test for the difference between two groups and ANOV for the differences among multiple groups. All data were expressed as Mean ± SD (*x*¯± s), with the difference was considered significant if the P value

ongoing EEG was recorded.

184 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**Figure 1.** The sequence of stimulus presentation

electrode was used as the common reference for recording.

differences greater than 100µV) or more than five bad channels.

**2.3. EEG recording**

**2.4. Data analysis**

**2.5. Statistical analysis**

was smaller than 0.05.

#### **3.1. ERP results of the ADHD good performance group**

Comparing the results of this group, both pre- and post-administration of MPH, with the control group, the amplitude of the NOGO-N2 displayed no significant difference (P> 0.05). Pre-administration of MPH, the amplitude of the NOGO-P3 was significantly lower than the results obtained 2 hours post-administration of MPH and by the control group; at the Fz and Cz electrodes the differences were statistically significant (P <0.05). Comparied to the control group, the amplitude of the NOGO-P3 2 hours post-administration of MPH showed no significantly difference (P> 0.05).

See Table 1 for details.


(1) Comparing to pre- administration of MPH, P <0.05;

(2) Comparing to pre- administration of MPH, P<0.01.

**Table 1.** The ADHD good performance group pre- and post-administration of MPH and the control group at Fz, Cz, Pz electrodes amplitudes of the NOGO-N2 and NOGO-P3 comparison (*x*¯± s) (μ v)

#### **3.2. ERP results of the ADHD poor performance group**

As with the ADHD good performance group, in comparing the results pre- and post-admin‐ istration of MPH with the control group, the amplitude of the NOGO-N2 also displayed no significant difference (P> 0.05). However, in this case both pre- and 2 hours post-administration of MPH, no statistically significant difference in the amplitude of the NOGP-P3 (P> 0.05) was found. Pre- and post-administration of MPH, the amplitude of the NOGO-P3 at the Fz electrode was significantly lower than that of control group (P <0.05). At the Cz electrode, the amplitude of the NOGO-P3 pre-administration of MPH was also significantly lower than that of the control group (P <0.05). However, compared to the control group, the amplitude of the NOGO-P3 post-administration of MPH showed no significant difference (P> 0.05).

See Table 2 for details.


(1) Comparing to pre- administration of MPH, P <0.05;

(2) Comparing to 2 hours post-administration of MPH, P<0.05.

**Table 2.** The ADHD poor performance group pre- and post-administration of MPH and the control group at Fz, Cz, Pz electrodes amplitudes of the NOGO-N2 and the NOGO-P3 comparison (*x*¯± s) (μ v)

between behavioral results and ERP changes pre- and post-administration of MPH in children

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This study found that in the ADHD group pre-administration of MPH the amplitude of the NOGO-P3 was significantly lower than that of the control group, while the amplitude of the NOGO-N2 showed no difference between the control group and the ADHD group preadministration of MPH. This suggests the existence of frontal inhibition functional deficiencies rather than the conflict monitoring deficiencies, consistent with Fallgatter's study [16],

In the ADHD good performance group, 2 hours post-administration of MPH, behavioral results were significantly improved; that is, omission errors and commission errors significantly reduced and the amplitude of the NOGO-P3 was significantly higher, although the amplitude of the NOGO-N2 showed no significant changes. Methylphenidate can improve attention deficit and the ability to inhibit impulsive reactions in children with ADHD. However, no significant changes in conflict monitoring ability were observed 2 hours post-administration of MPH. The amplitude of the NOGO-P3 was significantly increased, with no significant difference in comparison to the control group, suggesting MPH can normalize both the amplitude of the NOGO-P3 and the ability to inhibit

In the ADHD poor performance group, 2 hours post-administration of MPH, behavioral results showed no significant improvement; that is, omission errors and commission errors were reduced, but the difference did not reach statistical significance. The amplitudes of the NOGO-N2 and NOGO- P3 showed no significant changes either pre- or post-administration of MPH; changes in ERP and behavioral results were consistent. This suggested that MPH had no significant impact on behavioral performance and ERP results, that it does not improve attention deficit and the ability to inhibit response, and there is no effect on the conflict monitoring and response inhibition. 2 hours post-administration of MPH, the amplitude of the NOGO-P3 was still lower than that of the control group, in which the frontal electrode had

confirming the existence of cingulate cortex dysfunction in children with ADHD.

with ADHD, and compares these results to a control group.

**Figure 2.** The grand average EPR waveforms

impulsive reactions in children with ADHD.

#### **3.3. ERP results of the two ADHD group pre-administration of MPH**

The amplitudes of the NOGO-N2 and the NOGO-P3 showed no significant differences (P> 0.05).

#### **3.4. Grand average ERP waves**

As can be seen in Figure 2, the ERP components of the ADHD good performance group, the ADHD poor performance group and the control group were consistent; all showed N1, P2, N2 and P3 components. In the ADHD good performance group, the amplitudes of the NOGO-N2 pre- and post-administration of MPH showed no significant changes; At the Fz and Cz electrodes, the amplitude of the NOGO-P3 2 hours post-administration of MPH was signifi‐ cantly higher than pre-administration of MPH, while the amplitude of the NOGO-P3 at the Pz electrode showed no significant changes. In the ADHD poor performance group, the ampli‐ tudes of the NOGO-N2 and NOGO-P3 at the Fz, Cz, Pz electrodes showed no significant changes both pre- and post-administration of MPH; the amplitude of the NOGO-P3 was significantly lower than that of the control group.

#### **4. Discussion**

Central stimulants are the first choice for the treatment children with ADHD, and the most widely used is Methylphenidate. MPH can improve attention deficit and interpersonal relations, lower activity levels and impulsivity, and improve academic achievement, and have a positive effect on children with ADHD. While there is a previously reported efficiency of approximately 75% [11], our clinical work indicates an efficiency rate was below this number. This study uses the continuous performance test (CPT) to s investigate the relationship

**Figure 2.** The grand average EPR waveforms

**electrode ERP**

0.05).

**4. Discussion**

(1) Comparing to pre- administration of MPH, P <0.05;

**3.4. Grand average ERP waves**

(2) Comparing to 2 hours post-administration of MPH, P<0.05.

186 Attention Deficit Hyperactivity Disorder in Children and Adolescents

significantly lower than that of the control group.

electrodes amplitudes of the NOGO-N2 and the NOGO-P3 comparison (*x*¯± s) (μ v)

**3.3. ERP results of the two ADHD group pre-administration of MPH**

**preadministration of MPH**

**2 hours postadministration of MPH**

Fz N2(250-300ms) -6.88±6.59 -7.08±8.18 -7.67±4.32 0.10 0.91

Cz N2(250-300ms) -2.79±6.61 -2.22±6.33 -4.76±6.60 0.92 0.40

Pz N2(280-330ms) 0.48±6.33 -0.36±4.68 -1.25±3.94 0.66 0.52

**Table 2.** The ADHD poor performance group pre- and post-administration of MPH and the control group at Fz, Cz, Pz

The amplitudes of the NOGO-N2 and the NOGO-P3 showed no significant differences (P>

As can be seen in Figure 2, the ERP components of the ADHD good performance group, the ADHD poor performance group and the control group were consistent; all showed N1, P2, N2 and P3 components. In the ADHD good performance group, the amplitudes of the NOGO-N2 pre- and post-administration of MPH showed no significant changes; At the Fz and Cz electrodes, the amplitude of the NOGO-P3 2 hours post-administration of MPH was signifi‐ cantly higher than pre-administration of MPH, while the amplitude of the NOGO-P3 at the Pz electrode showed no significant changes. In the ADHD poor performance group, the ampli‐ tudes of the NOGO-N2 and NOGO-P3 at the Fz, Cz, Pz electrodes showed no significant changes both pre- and post-administration of MPH; the amplitude of the NOGO-P3 was

Central stimulants are the first choice for the treatment children with ADHD, and the most widely used is Methylphenidate. MPH can improve attention deficit and interpersonal relations, lower activity levels and impulsivity, and improve academic achievement, and have a positive effect on children with ADHD. While there is a previously reported efficiency of approximately 75% [11], our clinical work indicates an efficiency rate was below this number. This study uses the continuous performance test (CPT) to s investigate the relationship

P3(400-500ms) 23.51±11.97 25.88±13.96 33.26±9.83 (1) (2) 4.23 0.02

P3(400-500ms) 17.28±7.56 19.94±7.09 23.67±8.14 (1) 3.68 0.03

P3(420-520ms) 15.21±6.17 16.34±5.90 18.88±7.69 1.63 0.20

**the control group F value P value**

between behavioral results and ERP changes pre- and post-administration of MPH in children with ADHD, and compares these results to a control group.

This study found that in the ADHD group pre-administration of MPH the amplitude of the NOGO-P3 was significantly lower than that of the control group, while the amplitude of the NOGO-N2 showed no difference between the control group and the ADHD group preadministration of MPH. This suggests the existence of frontal inhibition functional deficiencies rather than the conflict monitoring deficiencies, consistent with Fallgatter's study [16], confirming the existence of cingulate cortex dysfunction in children with ADHD.

In the ADHD good performance group, 2 hours post-administration of MPH, behavioral results were significantly improved; that is, omission errors and commission errors significantly reduced and the amplitude of the NOGO-P3 was significantly higher, although the amplitude of the NOGO-N2 showed no significant changes. Methylphenidate can improve attention deficit and the ability to inhibit impulsive reactions in children with ADHD. However, no significant changes in conflict monitoring ability were observed 2 hours post-administration of MPH. The amplitude of the NOGO-P3 was significantly increased, with no significant difference in comparison to the control group, suggesting MPH can normalize both the amplitude of the NOGO-P3 and the ability to inhibit impulsive reactions in children with ADHD.

In the ADHD poor performance group, 2 hours post-administration of MPH, behavioral results showed no significant improvement; that is, omission errors and commission errors were reduced, but the difference did not reach statistical significance. The amplitudes of the NOGO-N2 and NOGO- P3 showed no significant changes either pre- or post-administration of MPH; changes in ERP and behavioral results were consistent. This suggested that MPH had no significant impact on behavioral performance and ERP results, that it does not improve attention deficit and the ability to inhibit response, and there is no effect on the conflict monitoring and response inhibition. 2 hours post-administration of MPH, the amplitude of the NOGO-P3 was still lower than that of the control group, in which the frontal electrode had statistically significance. The result suggests that MPH failed to improve the ability of response inhibition of children with ADHD to normal levels.

**Acknowledgements**

**Author details**

**References**

Ren Yan-ling and Dong Xuan\*

We wish to thank Michael Stewart for his helpful comments on this study.

\*Address all correspondence to: dx6868@hotmail.com; ren93961981@163.com

Hospital of Soochow University), Chang Zhou, China

ders (4th ed). Washington, 1994, DC:Author.

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This study was supported by the National Nature Science Foundation of China (NSFC Grant 30470566, 30870868), and the applied basic research Foundation of Changzhou (CJ20122016).

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Department of Neuroscience, The First People's Hospital of Chan Zhou (Third Affiliated

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[4] Clark JM. Contributions of inhibitory mechanisms to unified theory in neuroscience

[5] Rosvold HE, Mirsky AF, Sarason I, Bransome ED, Beck LH. A continuous perform‐

[6] Ehlis AC, Zielasek J, Herrmann M J, Ringel T, Jacob C, Wagener A, Fallgatter AJ. Evi‐ dence for unaltered brain electrical topography during prefrontal response control in cycloid psychoses. International Journal of Psychophysiology 2005; 55: 165– 178.

[7] Falkenstein M, Hoormann J, Hohnsbein J. ERP components in go/nogo tasks and

[8] Picton TW. The P300 wave of the human event-related potential. J. Clin. Neurophy‐

Methylphenidate can be effective in improving the symptoms of children with ADHD, primarily through the promotion of dopamine (DA) and norepinephrine (NE) release to reduce reuptake. The pre-frontal region is rich with DA and NE receptors, and it is assumed that MPH acts through these receptors. ADHD is associated with a irregularity in a variety of cognitive and behavioral processes [11]. Recent studies have found that low-dose MPH in the treatment of ADHD may activate the locus coeruleus - norepinephrine (LC -NE) system, by influencing the locus coeruleus neurons in different discharge modes (phase- and tension-type) to alter behavioral and cognitive processes [17]. Neuroimaging, neuropsychological and neurochem‐ ical studies have also implicated dysfunction of fronto-striatal structures [18]. An fMRI study found that fronto-striatal activation, significantly lower in an ADHD group compared to a control group, increased post-administration of MPH [19]. The frontal lobe plays an important role in attention, executive function, working memory, regulating activities and decisionmaking. Most of the studies of children with ADHD consider that the frontal lobe dysfunction causes attention deficit and presents obstacles to response regulation. MPH treatment may be either effective or ineffective in children with ADHD, dependent on their age and emotional state, with treatment least effective in older age groups [20]. While this present study did not find such factors, children are nevertheless primary candidates for MPH treatment, though it should be observed that individuals respond differently

Young ES, et al [13] used an auditory oddball P300 paradigm to compare the ERP changes preadministration and 2 hours post-administration of MPH. A prediction of the long-term benefit of medication was then made, based on the magnitude of the acute changes in P3b amplitude. The MPH challenge classification accurately predicted the outcome in 81% of cases. This present study used CPT tasks to test children with ADHD pre-administration and 2 hours post-administration of MPH. According to their behavioral results, the ADHD group was divided into an ADHD good performance group and an ADHD poor performance group. In the good performance group, the amplitude of the NOGO-P3 was significantly higher; the poor performance group, however, showed no obvious changes. The results suggested the amplitudes of the NOGO-P3 pre-administration and 2 hours post-administration of MPH were consistent with the behavioral results. Therefore, it can be posited that the amplitude of the NOGO-P3 can predict the long-term clinical efficacy of MPH treatment for ADHD. Where the amplitude of the NOGO-P3 is significantly increased post-administration of MPH, MPH may be an effective treatment; where the amplitude of the NOGO-P3 shows no significant increase post-administration of MPH, MPH is less likely to be an effective treatment. This can be primarily used to predict the efficacy of Methylphenidate for the treatment of ADHD, and assist in the selection of suitable treatment for children with ADHD. Further clinical tests will determine the accuracy of the prediction of Methylphenidate efficacy in children with ADHD. The present study can not avoid confounding medication effects with retest effects; this variable should be eliminated in future studies.

#### **Acknowledgements**

statistically significance. The result suggests that MPH failed to improve the ability of response

Methylphenidate can be effective in improving the symptoms of children with ADHD, primarily through the promotion of dopamine (DA) and norepinephrine (NE) release to reduce reuptake. The pre-frontal region is rich with DA and NE receptors, and it is assumed that MPH acts through these receptors. ADHD is associated with a irregularity in a variety of cognitive and behavioral processes [11]. Recent studies have found that low-dose MPH in the treatment of ADHD may activate the locus coeruleus - norepinephrine (LC -NE) system, by influencing the locus coeruleus neurons in different discharge modes (phase- and tension-type) to alter behavioral and cognitive processes [17]. Neuroimaging, neuropsychological and neurochem‐ ical studies have also implicated dysfunction of fronto-striatal structures [18]. An fMRI study found that fronto-striatal activation, significantly lower in an ADHD group compared to a control group, increased post-administration of MPH [19]. The frontal lobe plays an important role in attention, executive function, working memory, regulating activities and decisionmaking. Most of the studies of children with ADHD consider that the frontal lobe dysfunction causes attention deficit and presents obstacles to response regulation. MPH treatment may be either effective or ineffective in children with ADHD, dependent on their age and emotional state, with treatment least effective in older age groups [20]. While this present study did not find such factors, children are nevertheless primary candidates for MPH treatment, though it

Young ES, et al [13] used an auditory oddball P300 paradigm to compare the ERP changes preadministration and 2 hours post-administration of MPH. A prediction of the long-term benefit of medication was then made, based on the magnitude of the acute changes in P3b amplitude. The MPH challenge classification accurately predicted the outcome in 81% of cases. This present study used CPT tasks to test children with ADHD pre-administration and 2 hours post-administration of MPH. According to their behavioral results, the ADHD group was divided into an ADHD good performance group and an ADHD poor performance group. In the good performance group, the amplitude of the NOGO-P3 was significantly higher; the poor performance group, however, showed no obvious changes. The results suggested the amplitudes of the NOGO-P3 pre-administration and 2 hours post-administration of MPH were consistent with the behavioral results. Therefore, it can be posited that the amplitude of the NOGO-P3 can predict the long-term clinical efficacy of MPH treatment for ADHD. Where the amplitude of the NOGO-P3 is significantly increased post-administration of MPH, MPH may be an effective treatment; where the amplitude of the NOGO-P3 shows no significant increase post-administration of MPH, MPH is less likely to be an effective treatment. This can be primarily used to predict the efficacy of Methylphenidate for the treatment of ADHD, and assist in the selection of suitable treatment for children with ADHD. Further clinical tests will determine the accuracy of the prediction of Methylphenidate efficacy in children with ADHD. The present study can not avoid confounding medication effects with retest effects; this

inhibition of children with ADHD to normal levels.

188 Attention Deficit Hyperactivity Disorder in Children and Adolescents

should be observed that individuals respond differently

variable should be eliminated in future studies.

We wish to thank Michael Stewart for his helpful comments on this study.

This study was supported by the National Nature Science Foundation of China (NSFC Grant 30470566, 30870868), and the applied basic research Foundation of Changzhou (CJ20122016).

#### **Author details**

Ren Yan-ling and Dong Xuan\*

\*Address all correspondence to: dx6868@hotmail.com; ren93961981@163.com

Department of Neuroscience, The First People's Hospital of Chan Zhou (Third Affiliated Hospital of Soochow University), Chang Zhou, China

#### **References**


[9] Bekker EM, Kenemans JL, Verbaten MN. Electrophysiological correlates of attention, inhibition,sensitivity and bias in a continuous performance task. Clin.Neurophysiol 2004; 115: 2001–2013.

[21] Biederman J, Mick E , Fried R, et al. Are stimulants effective in the treatment of exec‐ utive function deficits? Results from a randomized double blind study of ROS-meth‐ ylphenidate in adults with ADHD. European Neuropsychopharmacology 2011 (21):

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[21] Biederman J, Mick E , Fried R, et al. Are stimulants effective in the treatment of exec‐ utive function deficits? Results from a randomized double blind study of ROS-meth‐ ylphenidate in adults with ADHD. European Neuropsychopharmacology 2011 (21): 508–515.

[9] Bekker EM, Kenemans JL, Verbaten MN. Electrophysiological correlates of attention, inhibition,sensitivity and bias in a continuous performance task. Clin.Neurophysiol

[10] Jonkman LM. The development of preparation, conflict monitoring and inhibition from early childhood to young adulthood: a Go/Nogo ERP study. Brain research

[11] Solanto MV. Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behav Brain Res

[12] Greenhill LL. Clinical effects of stimulant medication in ADHD, in Stimulant Drugs and ADHD: Basic and Clinical Neuroscience, Oxford University Press 2001, New

[13] Young ES, Perros P, Price GW, Sadler T. Acute challenge ERP as a Prognostic of Stimulant therapy outcome in attention-deficit/hyperactivity disorder. Biol Psychia‐

[14] Sunohara GA, Malone MA, Rovet J. Effect of Methylphenidate on Attention in Chil‐ dren with Attention Deficit Hyperactivity Disorder (ADHD): ERP Evidence. Neuro‐

[15] Seifert J,Scheuerpflug P,Zillessen KE,et al. Electrophysiological investigation of the effectiveness of methylphenidate in children with and without ADHD.J Neural

[16] Fallgatter AJ, Ehlis AC, Seifert J, Strik WK, Scheuerpflug P, Zillessen KE, et al. Al‐ tered response control and anterior cingulated function in attention-deficit/hyperac‐

[17] Devilbiss DM, Berridge CW. Low-Dose Methylphenidate Actions on Tonic and Pha‐ sic Locus Coeruleus Discharge. J Pharmacol Exp Ther 2006; 319: 1327-1335.

[18] Bush G, Valera EM, Seidman LJ. Functional Neuroimaging of Attention-Deficit/ Hyperactivity Disorder: A Review and Suggested Future Directions. BIOL PSY‐

[19] Vaidya CJ, Austin G, Kirkorian G, Ridlehuber HW, Desmond JE, Glover GH, Gabrie‐ li JD. Selective effects of methylphenidate in attention deficit hyperactivity disorder: A functional magnetic resonance study. Proc Natl Acad Sci 1998; 95(24): 14494 –

[20] Sunohara GA, Voros JG, Malone MA, Taylor MJ. Effects of methylphenidate in chil‐ dren with attention deficit hyperactivity disorder: a comparison of event-related po‐ tentials between medication responders and non-responders. International Journal of

tivity disorder boys. Clinical Neurophysiolgy 2004; 115: 973-981.

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York, 31-71.

**Chapter 10**

**The Impact of Attention Deficit/Hyperactivity Disorder**

ADHD constitutes a serious issue in the African-American community. The Center for Dis‐ ease Control and Prevention lists the African American males as leading other racial groups and gender in the diagnosis of learning and behavioral disorders, incarceration rates, new HIV infections, homicide and poverty. Although the reason for these observations are quite complex and multidimensional, some of the comorbidities found in untreated African Americans patients with ADHD include conduct disorder, oppositional defiant disorder, de‐ pression, anxiety disorders, learning disabilities, and alcohol or drug addiction. In addition, even though African American males living in poverty are most likely to be referred to men‐ tal health agencies for mental health services, they are the least likely to receive mental health services. In 2006, the number of children in the United States aged between 5 and 7 who were diagnosed with ADHD was 4.5 million. In the last decades the number of chil‐ dren diagnosed with ADHD who are on psychotropic medication continues to rise steadily. However, the impact of this steady rise has been skewed and not evenly distributed by eth‐ nicity, socioeconomic status and gender as minorities (African Americans and Hispanics) are most often diagnosed or misdiagnosed. The incidence of ADHD appears to be similar in African-Americans and White populations. ADHD is diagnosed in 4.1% of all children with the greatest prevalence among Caucasian children (5.1%). However, when the prevalence of ADHD among male children are considered by race, African American children and adoles‐ cents are disproportionately diagnosed with ADHD, with an estimated prevalence rate of 5.65%, 4.3% for Hispanics, 3% for Whites; and 1.77% for females of all races. The prevalence of ADHD in African-Americans is most likely similar to that in the general population (3-5%); nevertheless, minority children have lower likelihood of receiving a diagnosis of

> © 2013 Bailey and Ofoemezie; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

> © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

and reproduction in any medium, provided the original work is properly cited.

**in African-Americans; Current Challenges Associated**

**with Diagnosis and Treatment**

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54276

**1. Introduction**

Rahn Kennedy Bailey and Ejike Kingsley Ofoemezie

## **The Impact of Attention Deficit/Hyperactivity Disorder in African-Americans; Current Challenges Associated with Diagnosis and Treatment**

Rahn Kennedy Bailey and Ejike Kingsley Ofoemezie

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54276

#### **1. Introduction**

ADHD constitutes a serious issue in the African-American community. The Center for Dis‐ ease Control and Prevention lists the African American males as leading other racial groups and gender in the diagnosis of learning and behavioral disorders, incarceration rates, new HIV infections, homicide and poverty. Although the reason for these observations are quite complex and multidimensional, some of the comorbidities found in untreated African Americans patients with ADHD include conduct disorder, oppositional defiant disorder, de‐ pression, anxiety disorders, learning disabilities, and alcohol or drug addiction. In addition, even though African American males living in poverty are most likely to be referred to men‐ tal health agencies for mental health services, they are the least likely to receive mental health services. In 2006, the number of children in the United States aged between 5 and 7 who were diagnosed with ADHD was 4.5 million. In the last decades the number of chil‐ dren diagnosed with ADHD who are on psychotropic medication continues to rise steadily. However, the impact of this steady rise has been skewed and not evenly distributed by eth‐ nicity, socioeconomic status and gender as minorities (African Americans and Hispanics) are most often diagnosed or misdiagnosed. The incidence of ADHD appears to be similar in African-Americans and White populations. ADHD is diagnosed in 4.1% of all children with the greatest prevalence among Caucasian children (5.1%). However, when the prevalence of ADHD among male children are considered by race, African American children and adoles‐ cents are disproportionately diagnosed with ADHD, with an estimated prevalence rate of 5.65%, 4.3% for Hispanics, 3% for Whites; and 1.77% for females of all races. The prevalence of ADHD in African-Americans is most likely similar to that in the general population (3-5%); nevertheless, minority children have lower likelihood of receiving a diagnosis of

© 2013 Bailey and Ofoemezie; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ADHD and of receiving any treatment. Reasons for this disparity are multifaceted and di‐ verse and have not been fully elucidated. Among some of the identifiable barriers that at‐ tempt to explain these disparities are family-driven (parent, patient, and family) and Policydriven (healthcare system and physician bias) obstacles.

well-informed about the symptoms and treatment of ADHD. Indeed, studies suggest that African-American parents may be even more uninformed about ADHD, its causes, diagno‐ sis and treatment than are parents form other ethnic and racial backgrounds. Bussing and colleagues (1998) conducted a study that sought to identify the differences in ADHD knowl‐ edge between 224 African-American parents and 262 White parents. They reported that only 69% of African-American parents compared with 95% of White parents had ever heard about ADHD (p<0.01), and that 36% of African-Americans knew "a lot", "some" or "a little" about ADHD, compared with 70% of White parents (p<0.01). In addition, as reported by Af‐ rican-American parents, only 18% of them received information about ADHD from their physician, compared with 29% of White parents (p<0.01). Equally important, the study found the effects of ethnicity on ADHD familiarity were independent of other covariates, such as socioeconomic status. Furthermore, the lack of knowledge about ADHD among the African-American community has been described as a "vicious cycle" that may be caused when members of this community seek medical advice from other individuals within their

The Impact of Attention Deficit/Hyperactivity Disorder in African-Americans…

http://dx.doi.org/10.5772/54276

195

ADHD in African-American children is associated with comorbid disruptive behavior; mood and anxiety disorders. However, African-American families may not attribute the symptoms of ADHD to the disorder itself and are less aware than White families about the etiology of ADHD. For example, sugar intake has been reported as a common explanation for the symptoms of ADHD among members of the African-America community. ADHD symptoms in African-Americans are frequently missed or incorrectly diagnosed and comor‐ bid disorders go unattended. African-American parents feel more uneasy than White pa‐ rents about treating their children with pharmacologic interventions. Dos and other investigators evaluated parental perceptions of stimulant medication for the treatment of ADHD; they demonstrated that significant numbers of non-whites parents (63%) than white parents (29%) thought that counseling was the best choice of treatment, whereas 59% of white parents of white parents preferred medication over counseling compared with 36% of non-white parents. In addition, 16% of non-whites compared with 5% of white parents be‐ lieved that the use of stimulants would lead to drug abuse. School officials are more likely to assign African-American children to special education classes (which is the only educational resource employed to address many black children with ADHD), although many of the symptoms they display may be resolved with proper treatment that would allow them to remain in their regular classes. Between 1980 and 1990, black children were placed in special

African-American parents (57%) are more likely to believe that their children's race or eth‐ nicity and fears of being "labeled" remain one of the important factors preventing accept‐ ance of the diagnosis and treatment of children with ADHD. Many parents fear the perceived social stigma of ADHD diagnosis, and some fear overdiagnosis and misdiagnosis.

own ethnic background who are equally uninformed about ADHD.

*2.1.2. Fear of over-, under-, and misdiagnosis*

education at more than twice the rate of whites.

*2.1.3. Fear of social stigma*

The primary goals of treatment of ADHD are to decrease disruptive behaviors, enhance aca‐ demic performance, improve interpersonal relationships with peers, family and friends, im‐ prove self-esteem, and promote independence. There are difficulties inherent in the diagnosis of ADHD. These include absence of specific diagnostic tests, the lack of specificity of symptoms, inability to observe symptoms that may not be present in an office setting, low rate of concordance in symptom-reporting among various informants (i.e. parents, teachers and parents) and a lack of a standard evaluative process. Although medical professionals may use different diagnostic routes to diagnose ADHD, most agree that the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is the basis for an appropriate diagnostic process. Others have suggested the use of multiple methods of assessment which are cultur‐ ally-sensitive and, which involves several people with varying degrees of relationship to the child to be the most effective way to reduce the bias associated with diagnosis. Whaley & Geller observed that the use of informal interviews and methods of assessment seem to in‐ crease the bias towards more diagnosis of ADHD towards African Americans. In recent years, following extensive research in this subject by major medical organizations such as the American Academy of Pediatrics (AAP) and the American Academy of Child and Ado‐ lescent Psychiatry (AACAP), guidelines have been published to assist physicians in making the diagnosis of ADHD. Efforts must be made to identify these barriers of the diagnosis and treatment of ADHD, awareness among healthcare providers, and the African-American and other Minority communities. The objective of this chapter is to examine the disparities in the diagnosis and treatment of ADHD in the minority groups in America, especially the Afri‐ can-American community, the factors associated with disparities and the impacts of these disparities. The strategies and interventions to address the issue will also be outlined.

#### **2. Challenges in diagnosis and treatment of ADHD in African-Americans**

#### **2.1. Parent-driven barriers to care**

#### *2.1.1. Lack of knowledge/awareness about ADHD*

Perceptions of ADHD-related symptoms among parents of African American children ap‐ pear to differ in important ways from those of parents of White children. African American families from low to middle class incomes, compared with Whites, tend to view behavioral and emotional difficulties as problems of and for families, institutions and communities rather than as constituting individual psychopathology. It is not uncommon for African-American parents to perceive many of the symptoms and behaviors associated with ADHD to be variants of normal behavior and not in need of professional intervention. When com‐ pared with parents from other ethnic backgrounds, many African-American parents are not well-informed about the symptoms and treatment of ADHD. Indeed, studies suggest that African-American parents may be even more uninformed about ADHD, its causes, diagno‐ sis and treatment than are parents form other ethnic and racial backgrounds. Bussing and colleagues (1998) conducted a study that sought to identify the differences in ADHD knowl‐ edge between 224 African-American parents and 262 White parents. They reported that only 69% of African-American parents compared with 95% of White parents had ever heard about ADHD (p<0.01), and that 36% of African-Americans knew "a lot", "some" or "a little" about ADHD, compared with 70% of White parents (p<0.01). In addition, as reported by Af‐ rican-American parents, only 18% of them received information about ADHD from their physician, compared with 29% of White parents (p<0.01). Equally important, the study found the effects of ethnicity on ADHD familiarity were independent of other covariates, such as socioeconomic status. Furthermore, the lack of knowledge about ADHD among the African-American community has been described as a "vicious cycle" that may be caused when members of this community seek medical advice from other individuals within their own ethnic background who are equally uninformed about ADHD.

#### *2.1.2. Fear of over-, under-, and misdiagnosis*

ADHD and of receiving any treatment. Reasons for this disparity are multifaceted and di‐ verse and have not been fully elucidated. Among some of the identifiable barriers that at‐ tempt to explain these disparities are family-driven (parent, patient, and family) and Policy-

The primary goals of treatment of ADHD are to decrease disruptive behaviors, enhance aca‐ demic performance, improve interpersonal relationships with peers, family and friends, im‐ prove self-esteem, and promote independence. There are difficulties inherent in the diagnosis of ADHD. These include absence of specific diagnostic tests, the lack of specificity of symptoms, inability to observe symptoms that may not be present in an office setting, low rate of concordance in symptom-reporting among various informants (i.e. parents, teachers and parents) and a lack of a standard evaluative process. Although medical professionals may use different diagnostic routes to diagnose ADHD, most agree that the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is the basis for an appropriate diagnostic process. Others have suggested the use of multiple methods of assessment which are cultur‐ ally-sensitive and, which involves several people with varying degrees of relationship to the child to be the most effective way to reduce the bias associated with diagnosis. Whaley & Geller observed that the use of informal interviews and methods of assessment seem to in‐ crease the bias towards more diagnosis of ADHD towards African Americans. In recent years, following extensive research in this subject by major medical organizations such as the American Academy of Pediatrics (AAP) and the American Academy of Child and Ado‐ lescent Psychiatry (AACAP), guidelines have been published to assist physicians in making the diagnosis of ADHD. Efforts must be made to identify these barriers of the diagnosis and treatment of ADHD, awareness among healthcare providers, and the African-American and other Minority communities. The objective of this chapter is to examine the disparities in the diagnosis and treatment of ADHD in the minority groups in America, especially the Afri‐ can-American community, the factors associated with disparities and the impacts of these

disparities. The strategies and interventions to address the issue will also be outlined.

**2. Challenges in diagnosis and treatment of ADHD in African-Americans**

Perceptions of ADHD-related symptoms among parents of African American children ap‐ pear to differ in important ways from those of parents of White children. African American families from low to middle class incomes, compared with Whites, tend to view behavioral and emotional difficulties as problems of and for families, institutions and communities rather than as constituting individual psychopathology. It is not uncommon for African-American parents to perceive many of the symptoms and behaviors associated with ADHD to be variants of normal behavior and not in need of professional intervention. When com‐ pared with parents from other ethnic backgrounds, many African-American parents are not

driven (healthcare system and physician bias) obstacles.

194 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**2.1. Parent-driven barriers to care**

*2.1.1. Lack of knowledge/awareness about ADHD*

ADHD in African-American children is associated with comorbid disruptive behavior; mood and anxiety disorders. However, African-American families may not attribute the symptoms of ADHD to the disorder itself and are less aware than White families about the etiology of ADHD. For example, sugar intake has been reported as a common explanation for the symptoms of ADHD among members of the African-America community. ADHD symptoms in African-Americans are frequently missed or incorrectly diagnosed and comor‐ bid disorders go unattended. African-American parents feel more uneasy than White pa‐ rents about treating their children with pharmacologic interventions. Dos and other investigators evaluated parental perceptions of stimulant medication for the treatment of ADHD; they demonstrated that significant numbers of non-whites parents (63%) than white parents (29%) thought that counseling was the best choice of treatment, whereas 59% of white parents of white parents preferred medication over counseling compared with 36% of non-white parents. In addition, 16% of non-whites compared with 5% of white parents be‐ lieved that the use of stimulants would lead to drug abuse. School officials are more likely to assign African-American children to special education classes (which is the only educational resource employed to address many black children with ADHD), although many of the symptoms they display may be resolved with proper treatment that would allow them to remain in their regular classes. Between 1980 and 1990, black children were placed in special education at more than twice the rate of whites.

#### *2.1.3. Fear of social stigma*

African-American parents (57%) are more likely to believe that their children's race or eth‐ nicity and fears of being "labeled" remain one of the important factors preventing accept‐ ance of the diagnosis and treatment of children with ADHD. Many parents fear the perceived social stigma of ADHD diagnosis, and some fear overdiagnosis and misdiagnosis. The stigma of ADHD and lack of information about ADHD were found to be significant bar‐ riers to treatment of ADHD among African Americans [Table 1]. In their survey study, Omolara and colleagues (2007) found evidence of racial concerns about the stigma of ADHD diagnosis among African American participants. While some believe that a diagnosis of ADHD "gives children a label for the rest of their lives', others viewed that medicalization as a form of social control with historical roots.

**2.2. Health system/clinician-driven barriers**

*2.2.1. Lack of culturally competent healthcare providers*

*2.2.2. Healthcare provider/teacher bias or prejudice*

A substantial number of obstacles to the successful diagnosis and successful treatment of ADHD overall are related to limitations in the diagnosis and treatment of ADHD in African-American patients. While some of these barriers are easier to remove, others may prove more difficult. Some of these barriers are race or ethnicity-related, while others may be at‐ tributable to limited access to healthcare or insurance coverage, low socioeconomic status of African-American patients and a dearth of culturally-competent mental healthcare provid‐ ers. Bussing et al. (2003) found that African American children were less than half as likely to be assessed, diagnosed, and treated for ADHD as Caucasians. Their research survey among African American parents to determine common barriers to help seeking for their children with symptoms of ADHD found that across race, the most commonly cited barriers are system barriers, no perceived need and negative expectations of treatment outcomes.

The Impact of Attention Deficit/Hyperactivity Disorder in African-Americans…

http://dx.doi.org/10.5772/54276

197

It has been reported that during clinician-patient encounter, negative social stereotypes are known to shape behaviors and influence decisions made by healthcare providers. Race and ethnicity is known to adversely influence the medical care provided for other medical conditions. Minority patients with ADHD are likely to be affected by this prac‐ tice as well. Historically, there has been a disproportionate pattern of diagnosis among minority populations in the category of disability. While some of this pattern of diagno‐ sis may be related to minorities being disproportionately exposed to risk factors and psychosocial stressors and are more likely to be economically disadvantaged, the com‐ monly used instruments of assessment which could provide misleading or invalid re‐ sults when used alone to assess patients from various cultural backgrounds may explain the this phenomenon. Frequently, the quality of healthcare delivered is compromised when healthcare providers are culturally insensitive to patients. There are important cul‐ tural differences among individuals of diverse ethnic backgrounds pertaining to their at‐ titudes and beliefs of illness, choice of care, access to care, and degree of trust toward authority figures or institutions and tolerances for certain behaviors. Investigators may have to use culturally sensitive diagnostic tools to assist them in uncovering important

aspects about ADHD that may be unique to the African-American population.

Humans have the inclination to perceive or label other people or things based on their initial impressions or due to harboring elements of discrimination and stigma. Health‐ care workers and physicians who care for mental health patients are not exonerated from this attribute. Eack and colleagues (2008) reported that African-Americans were three times more likely as whites to receive a diagnosis of schizophrenia based on the physician perception of the truthfulness, suspicion of symptom denial, poor insight or "uncooperativeness" of their African-American patients. Without a good understanding of cultural nuances that may provide clues about other possible diagnoses and the stig‐ ma associated with a diagnosis of mental illness among the Black community, white

In addition, pressures from family and friends to refrain from seeking treatment, fear of jeopardizing future employment or ability to serve in the military, concerns that parental skills will be questioned, and fear of the unknown are other factors that have been described by patient and families and these are thought to impact the diagnosis and treatment of ADHD. The African-American population fear of the unknown may be related in part to the consequences of the Tuskegee Experiment, which caused many in the community to lose trust in the field of medical research. However, African American health professionals were even found to be less likely to diagnose ADHD or prescribe stimulant medication treatment due to their social and culturally constructed views of the disorder.

It has also been demonstrated from studies that a substantial proportion of children from all races who are at a high risk for ADHD drop out of care, and that adolescent perceived stig‐ ma about ADHD is influential, above and beyond the perspectives of parents.


**Table 1.** Most prominent difference between African-American and white respondents in perceptions and attitudes about ADHD

#### **2.2. Health system/clinician-driven barriers**

The stigma of ADHD and lack of information about ADHD were found to be significant bar‐ riers to treatment of ADHD among African Americans [Table 1]. In their survey study, Omolara and colleagues (2007) found evidence of racial concerns about the stigma of ADHD diagnosis among African American participants. While some believe that a diagnosis of ADHD "gives children a label for the rest of their lives', others viewed that medicalization

In addition, pressures from family and friends to refrain from seeking treatment, fear of jeopardizing future employment or ability to serve in the military, concerns that parental skills will be questioned, and fear of the unknown are other factors that have been described by patient and families and these are thought to impact the diagnosis and treatment of ADHD. The African-American population fear of the unknown may be related in part to the consequences of the Tuskegee Experiment, which caused many in the community to lose trust in the field of medical research. However, African American health professionals were even found to be less likely to diagnose ADHD or prescribe stimulant medication treatment

It has also been demonstrated from studies that a substantial proportion of children from all races who are at a high risk for ADHD drop out of care, and that adolescent perceived stig‐

**Table 1.** Most prominent difference between African-American and white respondents in perceptions and attitudes

about ADHD

as a form of social control with historical roots.

196 Attention Deficit Hyperactivity Disorder in Children and Adolescents

due to their social and culturally constructed views of the disorder.

ma about ADHD is influential, above and beyond the perspectives of parents.

A substantial number of obstacles to the successful diagnosis and successful treatment of ADHD overall are related to limitations in the diagnosis and treatment of ADHD in African-American patients. While some of these barriers are easier to remove, others may prove more difficult. Some of these barriers are race or ethnicity-related, while others may be at‐ tributable to limited access to healthcare or insurance coverage, low socioeconomic status of African-American patients and a dearth of culturally-competent mental healthcare provid‐ ers. Bussing et al. (2003) found that African American children were less than half as likely to be assessed, diagnosed, and treated for ADHD as Caucasians. Their research survey among African American parents to determine common barriers to help seeking for their children with symptoms of ADHD found that across race, the most commonly cited barriers are system barriers, no perceived need and negative expectations of treatment outcomes.

#### *2.2.1. Lack of culturally competent healthcare providers*

It has been reported that during clinician-patient encounter, negative social stereotypes are known to shape behaviors and influence decisions made by healthcare providers. Race and ethnicity is known to adversely influence the medical care provided for other medical conditions. Minority patients with ADHD are likely to be affected by this prac‐ tice as well. Historically, there has been a disproportionate pattern of diagnosis among minority populations in the category of disability. While some of this pattern of diagno‐ sis may be related to minorities being disproportionately exposed to risk factors and psychosocial stressors and are more likely to be economically disadvantaged, the com‐ monly used instruments of assessment which could provide misleading or invalid re‐ sults when used alone to assess patients from various cultural backgrounds may explain the this phenomenon. Frequently, the quality of healthcare delivered is compromised when healthcare providers are culturally insensitive to patients. There are important cul‐ tural differences among individuals of diverse ethnic backgrounds pertaining to their at‐ titudes and beliefs of illness, choice of care, access to care, and degree of trust toward authority figures or institutions and tolerances for certain behaviors. Investigators may have to use culturally sensitive diagnostic tools to assist them in uncovering important aspects about ADHD that may be unique to the African-American population.

#### *2.2.2. Healthcare provider/teacher bias or prejudice*

Humans have the inclination to perceive or label other people or things based on their initial impressions or due to harboring elements of discrimination and stigma. Health‐ care workers and physicians who care for mental health patients are not exonerated from this attribute. Eack and colleagues (2008) reported that African-Americans were three times more likely as whites to receive a diagnosis of schizophrenia based on the physician perception of the truthfulness, suspicion of symptom denial, poor insight or "uncooperativeness" of their African-American patients. Without a good understanding of cultural nuances that may provide clues about other possible diagnoses and the stig‐ ma associated with a diagnosis of mental illness among the Black community, white physicians may view black patients with suspicion which may color or affect their clini‐ cal judgment. Interestingly, the same study reported that this disparity did not appear to affect other US minority groups, such as Hispanics.

*2.2.4. Limited access to mental health care*

Total physicians by race/ethnicity – 2008

**3. Impact of ADHD in African-Americans**

(Total physicians = 954,224)

African-American families are less likely than their white counterparts to have access to the healthcare system. This may partly be due to the lower socioeconomic class and higher pov‐ erty levels among African-Americans. African-Americans tend to lack insurance coverage for psychiatric or psychological evaluations, behavior modification programs, school consul‐ tations, parent management training, and other specialized program. Substantial costs barri‐ ers exist resulting in out-of-pocket costs. Pastor and Reuben reported a significantly wide and long-standing gap in the rate of the diagnosis of ADHD based on the type of health in‐ surance coverage. They reported that those with Medicaid insurance are most likely to be diagnosed with ADHD, followed by those with private insurance coverage, while those without insurance ended at a distant third. Even when they have insurance, the capitation imposed by the State Mental Health Services further makes access to care very difficult or inadequate, especially, for African Americans and other minority populations. Low income African American caregivers are often frustrated and feel helpless while trying to navigate the maze of the care system. There is no funded special education category specifically for ADHD. This limited access to healthcare system will contribute to less diagnosis of ADHD

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**Race/Ethnicity Number Percentage**

**Table 2.** Source: Physician Characteristics and Distribution in the US, 2010 Edition. American Medical Association.

Comorbidities associated with ADHD include Conduct Disorders, Opposition Defiant Dis‐ orders (ODD), Depressive Disorders, Anxiety disorders, Learning disabilities and Alcohol and Drug addiction. Samuel and colleagues (1999) stated that African-American children with ADHD have higher levels of comorbid psychopathology (Opposition Defiant Disorder, Severe Major Depression, Bipolar Depression, and Separation Anxiety) than in African-American controls. They also reported that when compared to their Caucasian counterparts,

White 519,840 54.5 Black 33,781 3.5 Hispanic 46,507 4.9 Asian 116,412 12.2 American Native/Alaska Native 1,594 .16 Other 13,019 1.3 Unknown 223,071 23.4

Conscious (Explicit) or unconscious (Implicit) bias or prejudices held by healthcare pro‐ viders and sometimes racially-motivated discrimination by mental healthcare personnel can cause the cross-cultural diagnosis of ADHD to be challenging. In addition, biases ex‐ pressed by the evaluators, interviewers or the researcher may influence the outcomes of scoring the behavioral expressions of African-American children. Depending on this held biases or cultural expectations of what constitutes "normal behaviors", non-African American evaluators may rate American-American children with higher levels of hyper‐ active or disruptive behaviors even when the behavior is normal within the context of cultural expectations. It is not uncommon for parents and patients of ethnic minorities to report discrimination in receiving health care. Gingerich and colleagues (1998) reviewed several comparative studies in the 1970 which used teachers' ratings to compare the prevalence of hyperactivity, a component of ADHD among ethnic minorities and white children. They reported one large study conducted using 1700 elementary school chil‐ dren from rural and urban Texan locations in which African-American children were rated as more hyperactive than expected based on their representative population when compared with schools located in white, middle-class neighborhoods where they found that the frequency of hyperactivity was consistent across all ethnic groups. The biases held by health care workers or mental health service providers can result in either un‐ der or over-diagnosis of ADHD in African-American children.

#### *2.2.3. Dearth of African-America healthcare providers*

This factor may prevent the optimal care of Africa-American children with ADHD. More minority clinicians are needed to alleviate the intercultural issues of trust and communica‐ tions that often arise. In 1985, out of the 30,000 Psychiatrists registered to practice in Ameri‐ can, only about 600 were Black (Bell, Fayen & Mattox, 1998). In spite of the efforts and progress made in promoting diversity of healthcare professionals among the physician workforce, the concern about a lack of diversity continues to be an impediment to access and care, especially in the minority populations. Thus, despite some initial progress, African Americans, Latinos/Hispanics, and Native Americans continue to be underrepresented in the U.S. physician workforce. The American Medical Association Council on Medical Edu‐ cation Report 7 (2007) put the total number of US physicians involved in patient care in 2006 as 723,118. When categorized into Race/Ethnicity, 71.4% of these physicians were white, 15.8% were Asian, 6.4% were Hispanic, and 4.5% were Black/African-Americans. The Amer‐ ican Medical Association report in 2012 puts the total number of Black physicians in the workforce at 3.5%, indicating a decline (Table 2). Complicating access to care, most of these physicians set up their practices in urban areas to the detriment of rural communities.

#### *2.2.4. Limited access to mental health care*

physicians may view black patients with suspicion which may color or affect their clini‐ cal judgment. Interestingly, the same study reported that this disparity did not appear

Conscious (Explicit) or unconscious (Implicit) bias or prejudices held by healthcare pro‐ viders and sometimes racially-motivated discrimination by mental healthcare personnel can cause the cross-cultural diagnosis of ADHD to be challenging. In addition, biases ex‐ pressed by the evaluators, interviewers or the researcher may influence the outcomes of scoring the behavioral expressions of African-American children. Depending on this held biases or cultural expectations of what constitutes "normal behaviors", non-African American evaluators may rate American-American children with higher levels of hyper‐ active or disruptive behaviors even when the behavior is normal within the context of cultural expectations. It is not uncommon for parents and patients of ethnic minorities to report discrimination in receiving health care. Gingerich and colleagues (1998) reviewed several comparative studies in the 1970 which used teachers' ratings to compare the prevalence of hyperactivity, a component of ADHD among ethnic minorities and white children. They reported one large study conducted using 1700 elementary school chil‐ dren from rural and urban Texan locations in which African-American children were rated as more hyperactive than expected based on their representative population when compared with schools located in white, middle-class neighborhoods where they found that the frequency of hyperactivity was consistent across all ethnic groups. The biases held by health care workers or mental health service providers can result in either un‐

This factor may prevent the optimal care of Africa-American children with ADHD. More minority clinicians are needed to alleviate the intercultural issues of trust and communica‐ tions that often arise. In 1985, out of the 30,000 Psychiatrists registered to practice in Ameri‐ can, only about 600 were Black (Bell, Fayen & Mattox, 1998). In spite of the efforts and progress made in promoting diversity of healthcare professionals among the physician workforce, the concern about a lack of diversity continues to be an impediment to access and care, especially in the minority populations. Thus, despite some initial progress, African Americans, Latinos/Hispanics, and Native Americans continue to be underrepresented in the U.S. physician workforce. The American Medical Association Council on Medical Edu‐ cation Report 7 (2007) put the total number of US physicians involved in patient care in 2006 as 723,118. When categorized into Race/Ethnicity, 71.4% of these physicians were white, 15.8% were Asian, 6.4% were Hispanic, and 4.5% were Black/African-Americans. The Amer‐ ican Medical Association report in 2012 puts the total number of Black physicians in the workforce at 3.5%, indicating a decline (Table 2). Complicating access to care, most of these

physicians set up their practices in urban areas to the detriment of rural communities.

to affect other US minority groups, such as Hispanics.

198 Attention Deficit Hyperactivity Disorder in Children and Adolescents

der or over-diagnosis of ADHD in African-American children.

*2.2.3. Dearth of African-America healthcare providers*

African-American families are less likely than their white counterparts to have access to the healthcare system. This may partly be due to the lower socioeconomic class and higher pov‐ erty levels among African-Americans. African-Americans tend to lack insurance coverage for psychiatric or psychological evaluations, behavior modification programs, school consul‐ tations, parent management training, and other specialized program. Substantial costs barri‐ ers exist resulting in out-of-pocket costs. Pastor and Reuben reported a significantly wide and long-standing gap in the rate of the diagnosis of ADHD based on the type of health in‐ surance coverage. They reported that those with Medicaid insurance are most likely to be diagnosed with ADHD, followed by those with private insurance coverage, while those without insurance ended at a distant third. Even when they have insurance, the capitation imposed by the State Mental Health Services further makes access to care very difficult or inadequate, especially, for African Americans and other minority populations. Low income African American caregivers are often frustrated and feel helpless while trying to navigate the maze of the care system. There is no funded special education category specifically for ADHD. This limited access to healthcare system will contribute to less diagnosis of ADHD


(Total physicians = 954,224)

**Table 2.** Source: Physician Characteristics and Distribution in the US, 2010 Edition. American Medical Association.

#### **3. Impact of ADHD in African-Americans**

Comorbidities associated with ADHD include Conduct Disorders, Opposition Defiant Dis‐ orders (ODD), Depressive Disorders, Anxiety disorders, Learning disabilities and Alcohol and Drug addiction. Samuel and colleagues (1999) stated that African-American children with ADHD have higher levels of comorbid psychopathology (Opposition Defiant Disorder, Severe Major Depression, Bipolar Depression, and Separation Anxiety) than in African-American controls. They also reported that when compared to their Caucasian counterparts, African-American youths have a tendency to be more resistant or unable to seek treatment, only doing so when their symptoms are more severe. This may be responsible for a broader spectrum of the severity of ADHD symptoms in African-American youths. Epstein (2005) at‐ tributed the exhibition of more ADHD symptoms in African-American youths to fact that they are exposed to more ADHD-related risk factors. This concept was supported by Stein and colleagues (2002) who reported that African-American youth may be exposed to these risk factors at higher rates other than other youth, which may account for the higher preva‐ lence of ADHD in African-Americans. In the general population, some of the risk factors as‐ sociated with the development of ADHD and related pathology include low socioeconomic status (SES), juvenile detainee status, prenatal marijuana exposure and exposure to environ‐ mental toxins. Lead, one of the most thoroughly studied environmental toxins, is linked to impaired attention, hyperactivity, and aggression even at low levels of exposure. Bazargan and colleagues (2005) found that African-Americans living in Public Housing reportedly have higher incidence of ADHD than in the general population as a whole (19%) as com‐ pared to the pooled rate of 5%. The increased exposure resulted from paints used in housing before 1950s which contained a high percentage of lead. Other risk factors attributable to higher incidence of ADHD in African-Americans include low socioeconomic status, lack of access to healthcare (Kendall & Hatton, 2002) and high incidence of low birth weight (Bre‐ slau & Chilcoat, 2000). The higher incidence and symptomatology of ADHD in African-Americans has its consequences some of which will be further elucidated.

ly to have antisocial and borderline personality disorders. To reduce the impact of ADHD on the rate of incarceration of African-American youth, they recommended that Prison Ad‐ ministrators be trained to recognize the symptoms of ADHD and recommend offenders for

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**Figure 2.** Source: Justice Policy Institute Report: The Punishing Decade, & U.S. bureau of Justice Statistics Bulletin.

further intensive screening rather than commitment to prisons first.

**Figure 1.** Source: www.prisonerhealth.org

NCJ219416. Prisoners in 2006.

#### **3.1. ADHD among African-American youth and the criminal justice system**

There appears to be an epidemic of incarceration, especially of African-American males in the United States of America. Compared to the rest of the industrialized world, America has the highest rate of incarceration, currently at about 738 per 100,000. The Justice Department reports that there are about 2.3 million inmates incarcerated in America. In 2010, Dick and Sharon Kyle, a pair of citizen journalists and information activists reported (www.LAProg‐ ressive.com) in an article titled "More Black Men in Prison than Were Enslaved II" that by race, Black males continued to be incarcerated at an extraordinary rate. They pointed out that Black males make up 35.4 percent of the jail and prison population, even though they make up less than 10 percent of the overall U.S population. They also observed that four percent of U.S. black males were in jail or prison in 2009, compared to 1.7 percent of Hispan‐ ic males and 0.7 percent of white males. This translated to black males being locked up at almost six times the rate of their white counterparts.

Black and colleagues (2010) reported that although Attention Deficit/Hyperactivity Disorder (ADHD) is associated with comorbid psychiatric diagnoses and antisocial behavior that con‐ tribute to criminality, yet studies of ADHD in offenders are few. Out of the 319 offenders they evaluated using the Mini International Neuropsychiatric Interview and Medical Out‐ come Health Survey; ADHD was present in 68 (21.3%) subjects. Offenders with ADHD were more likely to report problems with emotional and social functioning and to have a higher suicide risk scores. Other psychopathologies identified in offenders with ADHD include higher rates of mood, anxiety, psychotic and somatoform disorders. They are also more like‐ ly to have antisocial and borderline personality disorders. To reduce the impact of ADHD on the rate of incarceration of African-American youth, they recommended that Prison Ad‐ ministrators be trained to recognize the symptoms of ADHD and recommend offenders for further intensive screening rather than commitment to prisons first.

**Figure 1.** Source: www.prisonerhealth.org

African-American youths have a tendency to be more resistant or unable to seek treatment, only doing so when their symptoms are more severe. This may be responsible for a broader spectrum of the severity of ADHD symptoms in African-American youths. Epstein (2005) at‐ tributed the exhibition of more ADHD symptoms in African-American youths to fact that they are exposed to more ADHD-related risk factors. This concept was supported by Stein and colleagues (2002) who reported that African-American youth may be exposed to these risk factors at higher rates other than other youth, which may account for the higher preva‐ lence of ADHD in African-Americans. In the general population, some of the risk factors as‐ sociated with the development of ADHD and related pathology include low socioeconomic status (SES), juvenile detainee status, prenatal marijuana exposure and exposure to environ‐ mental toxins. Lead, one of the most thoroughly studied environmental toxins, is linked to impaired attention, hyperactivity, and aggression even at low levels of exposure. Bazargan and colleagues (2005) found that African-Americans living in Public Housing reportedly have higher incidence of ADHD than in the general population as a whole (19%) as com‐ pared to the pooled rate of 5%. The increased exposure resulted from paints used in housing before 1950s which contained a high percentage of lead. Other risk factors attributable to higher incidence of ADHD in African-Americans include low socioeconomic status, lack of access to healthcare (Kendall & Hatton, 2002) and high incidence of low birth weight (Bre‐ slau & Chilcoat, 2000). The higher incidence and symptomatology of ADHD in African-

200 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Americans has its consequences some of which will be further elucidated.

almost six times the rate of their white counterparts.

**3.1. ADHD among African-American youth and the criminal justice system**

There appears to be an epidemic of incarceration, especially of African-American males in the United States of America. Compared to the rest of the industrialized world, America has the highest rate of incarceration, currently at about 738 per 100,000. The Justice Department reports that there are about 2.3 million inmates incarcerated in America. In 2010, Dick and Sharon Kyle, a pair of citizen journalists and information activists reported (www.LAProg‐ ressive.com) in an article titled "More Black Men in Prison than Were Enslaved II" that by race, Black males continued to be incarcerated at an extraordinary rate. They pointed out that Black males make up 35.4 percent of the jail and prison population, even though they make up less than 10 percent of the overall U.S population. They also observed that four percent of U.S. black males were in jail or prison in 2009, compared to 1.7 percent of Hispan‐ ic males and 0.7 percent of white males. This translated to black males being locked up at

Black and colleagues (2010) reported that although Attention Deficit/Hyperactivity Disorder (ADHD) is associated with comorbid psychiatric diagnoses and antisocial behavior that con‐ tribute to criminality, yet studies of ADHD in offenders are few. Out of the 319 offenders they evaluated using the Mini International Neuropsychiatric Interview and Medical Out‐ come Health Survey; ADHD was present in 68 (21.3%) subjects. Offenders with ADHD were more likely to report problems with emotional and social functioning and to have a higher suicide risk scores. Other psychopathologies identified in offenders with ADHD include higher rates of mood, anxiety, psychotic and somatoform disorders. They are also more like‐

**Figure 2.** Source: Justice Policy Institute Report: The Punishing Decade, & U.S. bureau of Justice Statistics Bulletin. NCJ219416. Prisoners in 2006.

#### **3.2. ADHD and substance abuse disorder in African-Americans**

Records show that many American youth are caught up in our juvenile justice system. Sig‐ nificant proportions of the arrests are due to either possession of or use of substances, partic‐ ularly marijuana and crack cocaine. The United States Department of Justice puts the estimate of yearly arrest of juveniles at 2.5 million with approximately over a 100,000 youth under the age of 18 years incarcerated daily. Minority youth in the African-America and Hispanic population are overrepresented, accounting for more than 60% of juvenile offend‐ ers in the juvenile justice system. Interestingly, many of these detained youth have psychiat‐ ric disorders and are housed in detention facilities that lack mental health services, thereby compounding the problem.

only 15% of the US population in 2001, they were overrepresented in specific learning disa‐ bilities (18%), mental retardation (34%) and are more likely to be emotionally disturbed (28%). The National Center for Education Statistics (2001) documented that African-Ameri‐ can males make up the majority of students described as "emotionally disturbed" and are more likely to be suspended, expelled from school or subjected to corporal punishment than their white or female peers. In addition to living in extreme poverty and other social dys‐ functions, it has been suggested that ADHD may be contributory to the high rates of school

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There is evidence that ADHD places a substantial economic burden on patients, their fami‐ lies and third-party payers. Pelham and his colleagues (2007) projected that the economic impact of education and medical services for children diagnosed with ADHD as at 2005 was conservatively estimated at \$36-\$52 billion per year, which makes ADHD an important eco‐ nomic and social issue. It is also true that most African-American families live in poverty and are less likely to be insured or have access to mental health services. ADHD leads to increased costs in healthcare and other domains, which is likely to have economic implica‐ tions for African-American families, their children with ADHD diagnosis and the society in general. Das and colleagues documented a correlation between ADHD, employment status and financial stress in middle-age individuals with ADHD. They also reported significant

The economic implications of ADHD on African-America families may include the costs re‐ lated to common psychiatric and medical comorbidities of ADHD, the indirect costs associ‐ ated with work loss among adults with ADHD, the costs of managing accidents among individuals with ADHD and the costs associated with the legal issues engendered by the criminality and deviant behaviors among individuals with ADHD. Chow and colleagues (2003) reported that the economic difficulties imposed on African-Americans due to poverty and lack of health insurance makes it more likely that African-Americans resort to the use of

**3.5. ADHD and the risk of sexually transmitted diseases among African-Americans**

A comparative study on self-reported risky sexual behaviors was conducted by Flory and colleagues (2006) in young adults (ages 18 to 26) with and without childhood attention defi‐ cit/hyperactivity disorder diagnosis. Among the participants were 175 males with a Pitts‐ burg Longitudinal Study (PALS) diagnosis of childhood ADHD. The controls were 111 demographically similar males without childhood ADHD diagnosis. The conclusion drawn from this study is that childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. Although they pointed out that childhood conduct problems did contribute significantly to risky sexu‐ al behaviors among participants with ADHD, they also observed an independent contribu‐ tion of ADHD, which suggested that the characteristic deficits of the disorder or other associated features may be useful childhood markers of later vulnerability. White and col‐

drop-out among African-American youth

**3.4. The economic impacts of ADHD on African-American families**

impairment in health, personal and social domains in their study group.

emergency services when they receive mental health care.

Individuals with substance abuse disorders exhibit hyperactivity, inattention and impulsivi‐ ty which are core symptoms of ADHD. These symptoms may promote antisocial behaviors which may contribute or exacerbate substance use or abuse. Conversely, substance use could worsen the symptoms of ADHD.

Studies of substance abusers and delinquents revealed a higher prevalence of ADHD co‐ morbidity. ADHD is associated with an earlier onset of psychoactive substance use dis‐ orders, independent of psychiatric comorbidities. Retz et al. (2007) stated that children with ADHD show higher levels of substance use disorder comorbidity, particularly when it is associated with social maladaptation and antisocial behavior. Addicted delin‐ quents with ADHD showed worse social environment and a higher degree of psychopa‐ thology, including internalizing and externalizing behaviors, when compared to addicted delinquents without ADHD. Retz and coworkers (2007) systematically examined 129 young male prison inmates for ADHD and substance use disorder. They found that 64.3% showed harmful alcohol consumption and 67.4% fulfilled DSM-IV criteria for any drug abuse or dependence. Further analysis showed that 28.8% of the participants had a diagnosis of ADHD combined type and 52.1% showed ADHD residual type. The out‐ come of these results should suggest adequate therapeutic interventions for addicted young prison inmates, considering the ADHD comorbidity, which is associated with ad‐ ditional psychopathology and social problems.

#### **3.3. ADHD, African-American children/youth, and the school system**

The core symptoms of ADHD, hyperactivity, inattention and impulsivity, are associated with poor developments in several areas of normal functioning. This may be reflected in Af‐ rican-American children with ADHD as poor academic achievements and comportment at school. Biederman and other investigators found that while hyperactivity declines over the course of the disorder, inattention symptoms persist into adulthood. Currie and Stabile, (2006) stated that this persistence of the inattention component of ADHD may be associated with numerous functional deficits, including educational failure. ADHD symptoms affect social functioning, interactions with teachers, peers, siblings and overall quality of life. Non-African-American teachers are more likely to rate African-American children as more hy‐ peractive and disruptive in class than children from other ethnic backgrounds. The Office of Special Education Report (2005) revealed that although African-American children represent only 15% of the US population in 2001, they were overrepresented in specific learning disa‐ bilities (18%), mental retardation (34%) and are more likely to be emotionally disturbed (28%). The National Center for Education Statistics (2001) documented that African-Ameri‐ can males make up the majority of students described as "emotionally disturbed" and are more likely to be suspended, expelled from school or subjected to corporal punishment than their white or female peers. In addition to living in extreme poverty and other social dys‐ functions, it has been suggested that ADHD may be contributory to the high rates of school drop-out among African-American youth

#### **3.4. The economic impacts of ADHD on African-American families**

**3.2. ADHD and substance abuse disorder in African-Americans**

202 Attention Deficit Hyperactivity Disorder in Children and Adolescents

compounding the problem.

could worsen the symptoms of ADHD.

ditional psychopathology and social problems.

**3.3. ADHD, African-American children/youth, and the school system**

Records show that many American youth are caught up in our juvenile justice system. Sig‐ nificant proportions of the arrests are due to either possession of or use of substances, partic‐ ularly marijuana and crack cocaine. The United States Department of Justice puts the estimate of yearly arrest of juveniles at 2.5 million with approximately over a 100,000 youth under the age of 18 years incarcerated daily. Minority youth in the African-America and Hispanic population are overrepresented, accounting for more than 60% of juvenile offend‐ ers in the juvenile justice system. Interestingly, many of these detained youth have psychiat‐ ric disorders and are housed in detention facilities that lack mental health services, thereby

Individuals with substance abuse disorders exhibit hyperactivity, inattention and impulsivi‐ ty which are core symptoms of ADHD. These symptoms may promote antisocial behaviors which may contribute or exacerbate substance use or abuse. Conversely, substance use

Studies of substance abusers and delinquents revealed a higher prevalence of ADHD co‐ morbidity. ADHD is associated with an earlier onset of psychoactive substance use dis‐ orders, independent of psychiatric comorbidities. Retz et al. (2007) stated that children with ADHD show higher levels of substance use disorder comorbidity, particularly when it is associated with social maladaptation and antisocial behavior. Addicted delin‐ quents with ADHD showed worse social environment and a higher degree of psychopa‐ thology, including internalizing and externalizing behaviors, when compared to addicted delinquents without ADHD. Retz and coworkers (2007) systematically examined 129 young male prison inmates for ADHD and substance use disorder. They found that 64.3% showed harmful alcohol consumption and 67.4% fulfilled DSM-IV criteria for any drug abuse or dependence. Further analysis showed that 28.8% of the participants had a diagnosis of ADHD combined type and 52.1% showed ADHD residual type. The out‐ come of these results should suggest adequate therapeutic interventions for addicted young prison inmates, considering the ADHD comorbidity, which is associated with ad‐

The core symptoms of ADHD, hyperactivity, inattention and impulsivity, are associated with poor developments in several areas of normal functioning. This may be reflected in Af‐ rican-American children with ADHD as poor academic achievements and comportment at school. Biederman and other investigators found that while hyperactivity declines over the course of the disorder, inattention symptoms persist into adulthood. Currie and Stabile, (2006) stated that this persistence of the inattention component of ADHD may be associated with numerous functional deficits, including educational failure. ADHD symptoms affect social functioning, interactions with teachers, peers, siblings and overall quality of life. Non-African-American teachers are more likely to rate African-American children as more hy‐ peractive and disruptive in class than children from other ethnic backgrounds. The Office of Special Education Report (2005) revealed that although African-American children represent

There is evidence that ADHD places a substantial economic burden on patients, their fami‐ lies and third-party payers. Pelham and his colleagues (2007) projected that the economic impact of education and medical services for children diagnosed with ADHD as at 2005 was conservatively estimated at \$36-\$52 billion per year, which makes ADHD an important eco‐ nomic and social issue. It is also true that most African-American families live in poverty and are less likely to be insured or have access to mental health services. ADHD leads to increased costs in healthcare and other domains, which is likely to have economic implica‐ tions for African-American families, their children with ADHD diagnosis and the society in general. Das and colleagues documented a correlation between ADHD, employment status and financial stress in middle-age individuals with ADHD. They also reported significant impairment in health, personal and social domains in their study group.

The economic implications of ADHD on African-America families may include the costs re‐ lated to common psychiatric and medical comorbidities of ADHD, the indirect costs associ‐ ated with work loss among adults with ADHD, the costs of managing accidents among individuals with ADHD and the costs associated with the legal issues engendered by the criminality and deviant behaviors among individuals with ADHD. Chow and colleagues (2003) reported that the economic difficulties imposed on African-Americans due to poverty and lack of health insurance makes it more likely that African-Americans resort to the use of emergency services when they receive mental health care.

#### **3.5. ADHD and the risk of sexually transmitted diseases among African-Americans**

A comparative study on self-reported risky sexual behaviors was conducted by Flory and colleagues (2006) in young adults (ages 18 to 26) with and without childhood attention defi‐ cit/hyperactivity disorder diagnosis. Among the participants were 175 males with a Pitts‐ burg Longitudinal Study (PALS) diagnosis of childhood ADHD. The controls were 111 demographically similar males without childhood ADHD diagnosis. The conclusion drawn from this study is that childhood ADHD predicted earlier initiation of sexual activity and intercourse, more sexual partners, more casual sex, and more partner pregnancies. Although they pointed out that childhood conduct problems did contribute significantly to risky sexu‐ al behaviors among participants with ADHD, they also observed an independent contribu‐ tion of ADHD, which suggested that the characteristic deficits of the disorder or other associated features may be useful childhood markers of later vulnerability. White and col‐ leagues (2012) reported that ADHD symptoms were associated with greater sexual victimi‐ zation during adolescence and engagement in risky sexual behaviors. The same study also found a strong association between ADHD symptoms, sexual victimization as well as risky sexual behaviors which is stronger for black women than their white counterparts. Risky sexual behaviors result in increased incidence of Sexually Transmitted Diseases (STDs), HIV/AIDS and unplanned teen pregnancies among African-American youth. Currently, The Center for Disease Control and Prevention (CDC) ranks African-American males as leading other races and gender groups in incarceration rates, new HIV infections, homicide deaths, poverty rates, and diagnosed learning disorders. In addition, the 2011 CDC Report on "Afri‐ can Americans and sexually Transmitted Diseases" showed that STDs take an especially heavy toll on African Americans, particularly young African American women and men. Al‐ though African Americans represent just 14 percent of the U.S. population, yet they account for approximately half of all reported chlamydia and syphilis cases and almost three-quar‐ ters of all reported gonorrhea cases.

sis and treatment of ADHD, increasing awareness about ADHD, removing the stigma of mental illness, elimination of healthcare disparities, enabling access to healthcare and teach‐ ing the benefits of ADHD treatment. The importance of early diagnosis and prompt treat‐ ment cannot be overemphasized. Instead of using one-size-fits-all or the traditional diagnostic parameters, clinicians should incorporate ethnically-sensitive structured parent questionnaires or rating scales to aid in the diagnosis of ADHD in African American chil‐ dren. It is also suggested that care be tailored to suit the needs of African-American children with ADHD and their care-givers. This may engender more corporation and acceptance of a diagnosis of ADHD in their children and compliance with treatment programs. It is impor‐ tant to have an integrated health care system where patients and their families can have greater access to culturally sensitive materials or programs that will educate them about the symptoms of ADHD and the benefits of proper treatment that will improve behaviors. Pa‐ rents, caregivers and mental health counselors should be involved in all the stages of diag‐ nosis and treatment planning of African-American children with ADHD. This strategy will enable them to become partners in their own care and secure their cooperation as much as possible. This will also decrease the rate of discontinuity of care since management of ADHD of ADHD requires adherence to treatment regimens and medical appointments.

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Odom and colleagues evaluated and demonstrated the usefulness of increasing aware‐ ness of ADHD through educational intervention in mothers, predominantly African Americans and reported increase in parental confidence and satisfaction among those who were taught about ADHD; since these qualities are needed in coping with this chronic illness. Same education and training should be provided to teachers who serve

As earlier stated, clinicians may consider using ethnically sensitive, structured question‐ naires or rating scales to aid in the diagnosis of ADHD in African Americans. Obtaining a thorough medical history, conducting a thorough physical examination and utilization of guidelines on the diagnosis and evaluation of ADHD is imperative rather than relying too

Substantial strides at improving outcomes can be made by clinicians and healthcare provid‐ ers by initiating pilot programs that will track the efficacy of a longitudinal care model whereby primary care physicians will collaborate with mental healthcare professionals. Fur‐ thermore, schools, primary care providers and service agents should be incorporated into this collaborative effort to monitor symptoms of ADHD and the response to treatment since a successful management of ADHD is contingent on cooperation and open communication among these caretakers. It is very important that adequate numbers of minority healthcare providers be accessible in schools, clinics and hospitals to address the potential issues of cross-cultural bias and mistrust. Thus, healthcare organizations must recruit and retain a di‐

verse staff whose demographic characteristics are representative of the service area

Healthcare institutions must consider ways of offering improved access to medical services and raising the level of awareness in the community. For example, community events, churches and day care centers could be used to disseminate information and teach about

the African American populations.

heavily on questionnaires for the diagnosis of ADHD.

#### **3.6. Impact of ADHD on family structure and cohesion among African-Americans**

Das and colleagues reported that inattention symptoms associated with ADHD significantly affects multiple life domains in mid-life. Marriages, spousal relationships, social interactions and health-related quality of life are all negatively impacted by ADHD symptoms. The fami‐ lies of children with ADHD have to contend with a greater number of behavioral, develop‐ mental and educational disturbances which often requires that more time, commitment, logistics and energy be spent. ADHD can put a strain on family relationships, especially for partners that have different views on discipline and parenting styles. The stress may be ele‐ vated if either parent feels they are bearing the burden of dealing with the child with ADHD, like taking time off to deal with behavioral problems, school attendance, medical consultations or meeting as part of ADHD management. Parents can feel overwhelmed or find it challenging to cope with their child's disruptive behaviors. Parents may feel socially isolated if they start avoiding social events or family gatherings in hope of avoiding behav‐ ioral problems associated with their child's diagnosis. The child with ADHD may uninten‐ tionally hurt other kids or their siblings during plays or damage property, thereby causing strained relationships. Spousal relationships may be strained. There is the danger of both or either parents spending so much time on the child with ADHD that they do not spend enough time cementing their relationship as couples. This may lead to domestic conflicts, vi‐ olence and sometimes divorce. The level of attention paid by parents to the child with ADHD may engender sibling jealousy and rival with the family

#### **4. Conclusion**

#### **Strategies and interventions**

A number of strategies and interventions have been suggested to improve outcomes and re‐ duce the impact of ADHD in African-Americans. These should be targeted at early diagno‐ sis and treatment of ADHD, increasing awareness about ADHD, removing the stigma of mental illness, elimination of healthcare disparities, enabling access to healthcare and teach‐ ing the benefits of ADHD treatment. The importance of early diagnosis and prompt treat‐ ment cannot be overemphasized. Instead of using one-size-fits-all or the traditional diagnostic parameters, clinicians should incorporate ethnically-sensitive structured parent questionnaires or rating scales to aid in the diagnosis of ADHD in African American chil‐ dren. It is also suggested that care be tailored to suit the needs of African-American children with ADHD and their care-givers. This may engender more corporation and acceptance of a diagnosis of ADHD in their children and compliance with treatment programs. It is impor‐ tant to have an integrated health care system where patients and their families can have greater access to culturally sensitive materials or programs that will educate them about the symptoms of ADHD and the benefits of proper treatment that will improve behaviors. Pa‐ rents, caregivers and mental health counselors should be involved in all the stages of diag‐ nosis and treatment planning of African-American children with ADHD. This strategy will enable them to become partners in their own care and secure their cooperation as much as possible. This will also decrease the rate of discontinuity of care since management of ADHD of ADHD requires adherence to treatment regimens and medical appointments.

leagues (2012) reported that ADHD symptoms were associated with greater sexual victimi‐ zation during adolescence and engagement in risky sexual behaviors. The same study also found a strong association between ADHD symptoms, sexual victimization as well as risky sexual behaviors which is stronger for black women than their white counterparts. Risky sexual behaviors result in increased incidence of Sexually Transmitted Diseases (STDs), HIV/AIDS and unplanned teen pregnancies among African-American youth. Currently, The Center for Disease Control and Prevention (CDC) ranks African-American males as leading other races and gender groups in incarceration rates, new HIV infections, homicide deaths, poverty rates, and diagnosed learning disorders. In addition, the 2011 CDC Report on "Afri‐ can Americans and sexually Transmitted Diseases" showed that STDs take an especially heavy toll on African Americans, particularly young African American women and men. Al‐ though African Americans represent just 14 percent of the U.S. population, yet they account for approximately half of all reported chlamydia and syphilis cases and almost three-quar‐

**3.6. Impact of ADHD on family structure and cohesion among African-Americans**

ADHD may engender sibling jealousy and rival with the family

Das and colleagues reported that inattention symptoms associated with ADHD significantly affects multiple life domains in mid-life. Marriages, spousal relationships, social interactions and health-related quality of life are all negatively impacted by ADHD symptoms. The fami‐ lies of children with ADHD have to contend with a greater number of behavioral, develop‐ mental and educational disturbances which often requires that more time, commitment, logistics and energy be spent. ADHD can put a strain on family relationships, especially for partners that have different views on discipline and parenting styles. The stress may be ele‐ vated if either parent feels they are bearing the burden of dealing with the child with ADHD, like taking time off to deal with behavioral problems, school attendance, medical consultations or meeting as part of ADHD management. Parents can feel overwhelmed or find it challenging to cope with their child's disruptive behaviors. Parents may feel socially isolated if they start avoiding social events or family gatherings in hope of avoiding behav‐ ioral problems associated with their child's diagnosis. The child with ADHD may uninten‐ tionally hurt other kids or their siblings during plays or damage property, thereby causing strained relationships. Spousal relationships may be strained. There is the danger of both or either parents spending so much time on the child with ADHD that they do not spend enough time cementing their relationship as couples. This may lead to domestic conflicts, vi‐ olence and sometimes divorce. The level of attention paid by parents to the child with

A number of strategies and interventions have been suggested to improve outcomes and re‐ duce the impact of ADHD in African-Americans. These should be targeted at early diagno‐

ters of all reported gonorrhea cases.

204 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**4. Conclusion**

**Strategies and interventions**

Odom and colleagues evaluated and demonstrated the usefulness of increasing aware‐ ness of ADHD through educational intervention in mothers, predominantly African Americans and reported increase in parental confidence and satisfaction among those who were taught about ADHD; since these qualities are needed in coping with this chronic illness. Same education and training should be provided to teachers who serve the African American populations.

As earlier stated, clinicians may consider using ethnically sensitive, structured question‐ naires or rating scales to aid in the diagnosis of ADHD in African Americans. Obtaining a thorough medical history, conducting a thorough physical examination and utilization of guidelines on the diagnosis and evaluation of ADHD is imperative rather than relying too heavily on questionnaires for the diagnosis of ADHD.

Substantial strides at improving outcomes can be made by clinicians and healthcare provid‐ ers by initiating pilot programs that will track the efficacy of a longitudinal care model whereby primary care physicians will collaborate with mental healthcare professionals. Fur‐ thermore, schools, primary care providers and service agents should be incorporated into this collaborative effort to monitor symptoms of ADHD and the response to treatment since a successful management of ADHD is contingent on cooperation and open communication among these caretakers. It is very important that adequate numbers of minority healthcare providers be accessible in schools, clinics and hospitals to address the potential issues of cross-cultural bias and mistrust. Thus, healthcare organizations must recruit and retain a di‐ verse staff whose demographic characteristics are representative of the service area

Healthcare institutions must consider ways of offering improved access to medical services and raising the level of awareness in the community. For example, community events, churches and day care centers could be used to disseminate information and teach about ADHD in order to raise awareness regarding the importance of treatment and to lessen fears of stigmatization in the community.

[5] Anonymous.National Institutes of Health Consensus Development Conference State‐ ment: diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). J

The Impact of Attention Deficit/Hyperactivity Disorder in African-Americans…

http://dx.doi.org/10.5772/54276

207

[6] Ayalon, L., & Alvidrez, J. The experience of Black consumers in the mental health system: Identifying barriers to and facilators of mental health treatment using the consumer's perspective ((2007). Issues in Mental Health Nursing, , 28, 1323-1340. [7] Bach PB, Cramer LD, Warren JL, et al.Racial differences in the treatment of early-

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[10] Bussing, R., Gary, F. A., Mills, T. L., et al. Parental explanatory models of ADHD: gender and cultural variations. Soc Psychiatr Epidemiol. (2003). , 38, 563-575.

[11] Bussing, R., Schoenberg, N. E., & Perwien, A. R. Knowledge and information about ADHD: Evidence of cultural differences among African-American and white parents.

[12] Bussing, R., Zima, B., Garry, E., & Garvan, C. (2003). Barriers to detection, help-seek‐ ing, and service use for children with Attention deficit Hyperactivity symptoms.

[13] Bussing, R., Zima, B. T., Mason, D. M., Porter, P. C., & Garvin, C. W. Receiving treat‐ ment for Attention Deficit Hyperactivity Disorder: Do the Perspectives of Adoles‐

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[15] Casangrande SS, Gary TL, LaVeist TA, Gaskin DJ, Cooper LA.Perceived discrimina‐ tion and adherence to medical care I a racially integrated community. J. Gen Intern

[16] Center for Disease Control and Prevention(2006). Racial and Ethnic Disparities in the Diagnosis of HIV/AIDS…33 States, 2001-2004. Morbidity and Mortality Week Re‐

[17] Center for Disease Control and Prevention (CDC).African Americans and Sexually

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cents Matter? Journal of Adolescent Health. (2012). , 49(2012), 7-14.

Group of families in the United States. Cult Med Psychiatry ((2009).

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It is important that care be tailored to suit the needs of various ethnic groups, such the Afri‐ can American community. Culturally competent medical care ensures that all patients will receive care that is compatible with their cultural beliefs and practices. The need to increase cultural competence in healthcare is described in detail in "Healthy People 2010", which is a statement of national health objectives that are designed to identify the most significant pre‐ ventable threats to health and to establish national goals to reduce these threats. The crimi‐ nal code of sentencing and guidelines for African-Americans with a diagnosis of ADHD needs to be reviewed with a view to the elimination of the zero tolerance policy. Instead of confining African American youths to the prison In conclusion, healthcare providers must be diligent in their commitment to reduce or remove barriers to the proper diagnosis and treatment of ADHD in African Americans. There is the need to increase awareness in the African American community regarding the symptoms of ADHD and its treatment, and to improve cultural awareness and sensitivity towards African-American patients among clini‐ cians to reduce the challenges involved in the cross-cultural diagnosis.

#### **Author details**

Rahn Kennedy Bailey\* and Ejike Kingsley Ofoemezie

\*Address all correspondence to: rkbailey@mmc.edu; kofoemezie@mmc.edu; ofoeme‐ zie@msn.com

Department of Psychiatry & Behavioural Sciences, Meharry Medical College, Nashville, Tennessee, U.S.A.

#### **References**


[5] Anonymous.National Institutes of Health Consensus Development Conference State‐ ment: diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD). J Am Acad Child Adolesc Psychiatry. (2000).

ADHD in order to raise awareness regarding the importance of treatment and to lessen fears

It is important that care be tailored to suit the needs of various ethnic groups, such the Afri‐ can American community. Culturally competent medical care ensures that all patients will receive care that is compatible with their cultural beliefs and practices. The need to increase cultural competence in healthcare is described in detail in "Healthy People 2010", which is a statement of national health objectives that are designed to identify the most significant pre‐ ventable threats to health and to establish national goals to reduce these threats. The crimi‐ nal code of sentencing and guidelines for African-Americans with a diagnosis of ADHD needs to be reviewed with a view to the elimination of the zero tolerance policy. Instead of confining African American youths to the prison In conclusion, healthcare providers must be diligent in their commitment to reduce or remove barriers to the proper diagnosis and treatment of ADHD in African Americans. There is the need to increase awareness in the African American community regarding the symptoms of ADHD and its treatment, and to improve cultural awareness and sensitivity towards African-American patients among clini‐

cians to reduce the challenges involved in the cross-cultural diagnosis.

and Ejike Kingsley Ofoemezie

\*Address all correspondence to: rkbailey@mmc.edu; kofoemezie@mmc.edu; ofoeme‐

Department of Psychiatry & Behavioural Sciences, Meharry Medical College, Nashville,

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**Author details**

zie@msn.com

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**Section 5**

**Outcome**

**Section 5**

### **Outcome**

**Chapter 11**

**Attention-Deficit/Hyperactivity Disorder (ADHD) as a**

**African Context: The Perspective of Teachers**

Zaytoon Amod, Adri Vorster and Kim Lazarus

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53784

**1. Introduction**

**Barrier to Learning and Development within the South**

Attention-Deficit/Hyperactivity Disorder (ADHD) is a universal condition transcending cultural, socio-economic and racial barriers. It is considered to be the most common psychiatric disorder amongst children in the United States and Europe, with an estimated 3-10% of children being affected [1]. The situation in Africa does not appear to be much different and although there is a lack of knowledge with regards to ADHD on the African continent, it is believed that the disorder is as prevalent as it is in Western countries [1]. In South Africa specifically it is considered to be the most prevalent psychiatric disorder amongst children with a prevalence rate of approximately 10% [2]. As this has not been confirmed officially, it raises issues relating to possible over-identification of the disorder in South Africa. However, it is feasible that children present with comorbid attention difficulties, when taking into consideration the huge backlog in the education system and the high incidence of learning

The South African education system is still struggling with the aftermath of Apartheid, which promoted exclusion in schools, not only based on race, gender, class, and ethnic background, but also on disability. This lead to the creation of a dual education system and learners, who did not meet the requirements of mainstream education, were placed in special education when educationalists considered it to be in the best interest of the learner [3]. With the abolition of Apartheid and the advent of the Constitution of the Republic of South Africa, Act No. 108 of 1996 [4], respect for the rights of all children regardless of variables such as race, gender, ethniticity, religion and ability was emphasised. This lead to the adaption of a new South African Education Policy, embedded in the philosophy of inclusive education and with its

> © 2013 Amod et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

disorders and language difficulties as additional barriers to learning.

## **Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the South African Context: The Perspective of Teachers**

Zaytoon Amod, Adri Vorster and Kim Lazarus

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53784

#### **1. Introduction**

Attention-Deficit/Hyperactivity Disorder (ADHD) is a universal condition transcending cultural, socio-economic and racial barriers. It is considered to be the most common psychiatric disorder amongst children in the United States and Europe, with an estimated 3-10% of children being affected [1]. The situation in Africa does not appear to be much different and although there is a lack of knowledge with regards to ADHD on the African continent, it is believed that the disorder is as prevalent as it is in Western countries [1]. In South Africa specifically it is considered to be the most prevalent psychiatric disorder amongst children with a prevalence rate of approximately 10% [2]. As this has not been confirmed officially, it raises issues relating to possible over-identification of the disorder in South Africa. However, it is feasible that children present with comorbid attention difficulties, when taking into consideration the huge backlog in the education system and the high incidence of learning disorders and language difficulties as additional barriers to learning.

The South African education system is still struggling with the aftermath of Apartheid, which promoted exclusion in schools, not only based on race, gender, class, and ethnic background, but also on disability. This lead to the creation of a dual education system and learners, who did not meet the requirements of mainstream education, were placed in special education when educationalists considered it to be in the best interest of the learner [3]. With the abolition of Apartheid and the advent of the Constitution of the Republic of South Africa, Act No. 108 of 1996 [4], respect for the rights of all children regardless of variables such as race, gender, ethniticity, religion and ability was emphasised. This lead to the adaption of a new South African Education Policy, embedded in the philosophy of inclusive education and with its

© 2013 Amod et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

primary focus on "meeting the needs of all learners and actualising the full potential of all learners" [5, p.344].

levels of the person's social context are linked in dynamic, interacting, and interdependent

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

http://dx.doi.org/10.5772/53784

217

Therefore, on the one hand the eco-systemic perspective emphasises the importance of the impact that a person's physical environment can have on the development of the person. On the other hand, systems theory examines the multiple levels and groupings of a person's social context that function interdependently so that the whole is reliant upon the interaction of the parts and can only be understood if the different parts are examined. Furthermore, as the different levels of a person's social context is linked in every-changing, interacting and interdependent relationships; a shift in one system will impact the whole in a cyclical fashion. Applied to ADHD within the South African context, the eco-systemic theory assists us in understanding how environmental factors such as lead poisoning [11], which are prevalent in the South African context [12-13], can have on the development of the disorder. Other environmental factors that are of particular importance in the development of ADHD [11] and prevalent in the South African context [14], include poverty and insufficient living conditions. In addition, the eco-systemic theory also assists us in understanding how the child's micro-, meso-, exo-, macro-, and chronosystems [10] can have on the developmental course of ADHD. Here factors such as family discord, a maternal history of psychiatric disorders and a particular parenting style, are of importance [11]. Therefore, applied to ADHD, the eco-systemic perspective helps us to understand that children cannot be viewed in isolation, but as part of the bigger whole and in a reciprocal relationship with it. Taking this into consideration, one of the major challenges in effectively addressing ADHD within the South African context is to understand the complexity of the disorder as seen in a particular context and environment [9].

Although the predominant paradigm in understanding learning barriers such as ADHD, used to be the medical-deficit model, a more social-ecological approach is applicable when intro‐ ducing inclusive education into an education system as it shifts attention from viewing psychiatric disorders as caused by or located within the individual, to viewing the child as being part of a broader system that contains many risk and protective factors that either contribute to the development and maintenance of a particular difficulty, or the prevention thereof. The World Health Organisation [15] defines environmental factors such as poor socioeconomic status and high crime rates that can increase the risk of the developmental of externalising difficulties such as ADHD, as risk factors. In contrast, factors such as supportive parenting styles and educational support that moderate the effects of ADHD and assist in the appropriate adaptation of children with this to the school environment, are seen as protective

In adopting a more socio-ecological paradigm, there will therefore be a shift from using labels such as special needs to applying terminology such as risk and protective factors, or as it is noted in the South African policy documentation; barriers to learning and development [16]. Barriers to learning and development are defined as all factors that can impact upon learning

relationships.

factors.

**3. Barriers to learning and development**

Inclusive education is not uniquely South African and emerged as a key international policy when UNESCO's Salamanca Statement was adopted in 1994, at the World Conference on Special Needs Education in Salamanca, Spain [6]. The emphasis at the Salamanca Conference was on the development of an inclusive education system that would

...accommodate all children, regardless of their physical, intellectual, social, emotional, linguistic or other conditions. This should include disabled and gifted children, street and working children, children from remote or nomadic populations, children from linguistic, ethnic, or cultural minorities and children from other disadvantaged or marginalised areas or groups. [7]

It was further noted that inclusive education systems, must not only recognise and respond to the diverse needs of learners, but also make room for different learning styles and rates. In addition, it is important that education systems ensure the quality of education through the design of appropriate curricula and teaching strategies, whilst also using and involving appropriate community and other resources. [7]

Although inclusive education therefore has a universal philosophy and universal practices, in the South African context it needed to be indigenised to meet the needs of the South African education system. This was done partially through the adoption of an eco-systemic framework in viewing barriers to learning and development.

#### **2. Eco-systemic framework**

Seen in different contexts, human nature, which I had previously thought of as a singular noun, became plural and pluralistic; for the different environments were producing discernible differences, not only across, but also within societies, in talent, temperament, human relations, and particularly in the ways in which the culture, or subculture, brought up its next generation. (Bronfenbrenner, 1979:p.xiii as cited in [8])

Urie Bronfenbrenner is widely known for his development of the eco-systemic theory which looks at the manner in which different environments and social contexts, including political, socio-economical, and cultural patterns, produce distinct differences in the way in which children develop. He argues that to truly understand a child, as well as his/her developmental difficulties, one must view the child holistically within his/her context [9]. The eco-systemic theory, which forms part of the broader social ecological model to understanding learning barriers and more recently titled the bio-ecological perspective [10], amalgamates ecological and systems theories to exemplify how a person's physical environment and the different levels of the person's social context are linked in dynamic, interacting, and interdependent relationships.

Therefore, on the one hand the eco-systemic perspective emphasises the importance of the impact that a person's physical environment can have on the development of the person. On the other hand, systems theory examines the multiple levels and groupings of a person's social context that function interdependently so that the whole is reliant upon the interaction of the parts and can only be understood if the different parts are examined. Furthermore, as the different levels of a person's social context is linked in every-changing, interacting and interdependent relationships; a shift in one system will impact the whole in a cyclical fashion.

Applied to ADHD within the South African context, the eco-systemic theory assists us in understanding how environmental factors such as lead poisoning [11], which are prevalent in the South African context [12-13], can have on the development of the disorder. Other environmental factors that are of particular importance in the development of ADHD [11] and prevalent in the South African context [14], include poverty and insufficient living conditions. In addition, the eco-systemic theory also assists us in understanding how the child's micro-, meso-, exo-, macro-, and chronosystems [10] can have on the developmental course of ADHD. Here factors such as family discord, a maternal history of psychiatric disorders and a particular parenting style, are of importance [11]. Therefore, applied to ADHD, the eco-systemic perspective helps us to understand that children cannot be viewed in isolation, but as part of the bigger whole and in a reciprocal relationship with it. Taking this into consideration, one of the major challenges in effectively addressing ADHD within the South African context is to understand the complexity of the disorder as seen in a particular context and environment [9].

#### **3. Barriers to learning and development**

primary focus on "meeting the needs of all learners and actualising the full potential of all

Inclusive education is not uniquely South African and emerged as a key international policy when UNESCO's Salamanca Statement was adopted in 1994, at the World Conference on Special Needs Education in Salamanca, Spain [6]. The emphasis at the Salamanca Conference

...accommodate all children, regardless of their physical, intellectual, social, emotional, linguistic or other conditions. This should include disabled and gifted children, street and working children, children from remote or nomadic populations, children from linguistic, ethnic, or cultural minorities and children from other disadvantaged or marginalised areas or

It was further noted that inclusive education systems, must not only recognise and respond to the diverse needs of learners, but also make room for different learning styles and rates. In addition, it is important that education systems ensure the quality of education through the design of appropriate curricula and teaching strategies, whilst also using and involving

Although inclusive education therefore has a universal philosophy and universal practices, in the South African context it needed to be indigenised to meet the needs of the South African education system. This was done partially through the adoption of an eco-systemic framework

Seen in different contexts, human nature, which I had previously thought of as a singular noun, became plural and pluralistic; for the different environments were producing discernible differences, not only across, but also within societies, in talent, temperament, human relations, and particularly in the ways in which the culture, or subculture, brought up its next generation.

Urie Bronfenbrenner is widely known for his development of the eco-systemic theory which looks at the manner in which different environments and social contexts, including political, socio-economical, and cultural patterns, produce distinct differences in the way in which children develop. He argues that to truly understand a child, as well as his/her developmental difficulties, one must view the child holistically within his/her context [9]. The eco-systemic theory, which forms part of the broader social ecological model to understanding learning barriers and more recently titled the bio-ecological perspective [10], amalgamates ecological and systems theories to exemplify how a person's physical environment and the different

was on the development of an inclusive education system that would

appropriate community and other resources. [7]

216 Attention Deficit Hyperactivity Disorder in Children and Adolescents

in viewing barriers to learning and development.

**2. Eco-systemic framework**

(Bronfenbrenner, 1979:p.xiii as cited in [8])

learners" [5, p.344].

groups. [7]

Although the predominant paradigm in understanding learning barriers such as ADHD, used to be the medical-deficit model, a more social-ecological approach is applicable when intro‐ ducing inclusive education into an education system as it shifts attention from viewing psychiatric disorders as caused by or located within the individual, to viewing the child as being part of a broader system that contains many risk and protective factors that either contribute to the development and maintenance of a particular difficulty, or the prevention thereof. The World Health Organisation [15] defines environmental factors such as poor socioeconomic status and high crime rates that can increase the risk of the developmental of externalising difficulties such as ADHD, as risk factors. In contrast, factors such as supportive parenting styles and educational support that moderate the effects of ADHD and assist in the appropriate adaptation of children with this to the school environment, are seen as protective factors.

In adopting a more socio-ecological paradigm, there will therefore be a shift from using labels such as special needs to applying terminology such as risk and protective factors, or as it is noted in the South African policy documentation; barriers to learning and development [16]. Barriers to learning and development are defined as all factors that can impact upon learning [17]. These barriers can occur within all levels of the eco-system and can be placed on a continuum; from intrinsic barriers that can be found within the individual, to extrinsic barriers which refer to factors outside the individual [17]. Some of the most prominent extrinsic barriers within the South African context include socio-economic barriers, negative attitudes towards difference and psychiatric disorders, inflexible curricula, inaccessible and unsafe building environments and schools, inappropriate and inadequate provision of support services, lack of enabling and protective legislation and policy, lack of parental recognition and involvement, and lack of human resource development strategies [16]. Some of the most prominent intrinsic barriers include language and communication difficulties, health difficulties such as HIV and tuberculosis, sensory impairments, intellectual and learning difficulties, and pervasive developmental disorders [17].

parenting and a lack of parental supervision [22]. It is essential to understand that if teachers have an incorrect understanding of ADHD and its causes and symptoms, it may lead them to actually support the presence of behaviours associated with ADHD, which can lead to

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Over the past decade, many research studies have been done on teachers' perceptions and knowledge of ADHD. In the United States, a sample of primary school teachers watched a video of a student displaying ADHD-like behaviours as well as those behaviours that are characteristic and unique to Oppositional Defiant Disorder (ODD). When examined, teachers were accurate in their evaluations of ADHD-like symptoms such as inattention and hyperac‐ tivity. However, when students displayed behaviours that belong solely to the domain of ODD, such as opposition and non-compliance, teachers automatically assumed that these behaviours were indicative of ADHD. Thus, teachers mistakenly assumed that children who displayed only ODD-like behaviours also exhibited ADHD-like behaviours [23]. A study conducted in Australia likewise revealed that teachers often provide parents and professionals with incorrect and inappropriate advice and information regarding the child who is displaying ADHD-like symptoms [21]. A study conducted in South Africa by [24] revealed that teachers are actually over identifying children with ADHD, as in the study 11.9% of the learners actually had ADHD, whilst teachers identified 15.4% of the learners to have ADHD. Thus, misunder‐ standings and misperceptions held by teachers may lead to inaccurate information being passed onto professionals, who carry out the task of making an actual ADHD diagnosis.

In support of these findings, further evidence reveals that teacher knowledge of ADHD tends to be very narrow and limited and even incorrect [21]. Three studies, as discussed in [21] were conducted in Australia over the last decade, which explored this area. One of the studies revealed that the teachers in the selected sample group were able to answer 60.7% of items in a questionnaire on ADHD. In a different study, the researchers administered the Knowledge of Attention Deficit Disorders Scale (KADDS) to a group of teachers. The findings of this study reflected that teachers knew more about the causes of ADHD, but possessed less information

In South Africa, a study conducted in the peripheral areas of the Cape Town Metropole in the Western Cape, also employed the KADDS to assess 552 teachers' knowledge of ADHD [2]. Their study revealed that the participants did not have an adequate understanding of ADHD. An overall score of correct responses of 42,6% was obtained. An overall percentage of 35.4%

These above results are consistent with a study conducted by [25]. In this South African study teachers' perceptions of their ability to identify and manage learners diagnosed with ADHD were investigated. Four out of five teachers did not consider themselves able to adequately manage ADHD symptoms, and some of the teachers misidentified and misunderstood certain symptoms of this condition. In a further study, [26] revealed that teachers do not have a sound understanding of the symptoms of ADHD, and the majority of teachers in the sample were unable to distinguish between inattention and ADHD. According to Venter (2011, as cited in [27]), teachers from poor black communities that teach at rural South African schools are the

was gathered for "don't know" responses, and 22% for incorrect responses [2].

regarding treatment interventions for ADHD [21].

inaccurate diagnosis [23].

ADHD would be considered an intrinsic barrier as research has shown that genetic and biological factors such as an imbalance in the neurotransmitters noradrenalin and dopamine play an important role in the development of the disorder. It is however important to also take cognisance of the role that extrinsic barriers such as those noted above, as well as poor socioeconomic circumstances, high crime rates, repeated trauma, parenting styles and parent-child interactions play in the maintenance and further developmental course of the disorder [15].

#### **4. Teachers: A pivotal part of the eco-system**

From an eco-systemic perspective, teachers can act as extrinsic barriers to learning and development when they act as risk factors in the developmental course of ADHD in particular learners in their classrooms. Likewise, teachers can also act as protective factors when their understanding of ADHD and support offered to the learners in their classrooms, positively impact on the developmental course of the disorder.

Teachers are often the primary source of identification and play a pivotal role in the diagnosis, management and intervention of ADHD. They have firsthand experience of the learner in the classroom situation; a setting which requires the learner to sit still, pay attention, adhere to instructions and interact with peers and adults in an appropriate manner. Teachers' knowledge and understanding will determine how they engage with and manage learners experiencing ADHD. Furthermore, their attitudes towards different forms of ADHD intervention would affect their support of these treatment methods and the learners in their classrooms. Early identification and intervention by teachers is vital, especially as a large percentage of individ‐ uals continue to have symptoms in adolescence and adulthood [18], which can impede their future wellbeing. It is important to take cognisance of the manner in which teachers' percep‐ tions, knowledge and attitudes are influenced by contextual and socio-cultural factors, as shown in previous studies [1, 19-20].

It has however been found that teachers' understanding of ADHD is often based on myths and false beliefs. It has been reported that some teachers believe that ADHD is a direct cause of the intake of certain food additives and eating too many sweets [21]. Others are of the idea that ADHD is mainly as a result of biological abnormalities [11], or as a direct result of bad parenting and a lack of parental supervision [22]. It is essential to understand that if teachers have an incorrect understanding of ADHD and its causes and symptoms, it may lead them to actually support the presence of behaviours associated with ADHD, which can lead to inaccurate diagnosis [23].

[17]. These barriers can occur within all levels of the eco-system and can be placed on a continuum; from intrinsic barriers that can be found within the individual, to extrinsic barriers which refer to factors outside the individual [17]. Some of the most prominent extrinsic barriers within the South African context include socio-economic barriers, negative attitudes towards difference and psychiatric disorders, inflexible curricula, inaccessible and unsafe building environments and schools, inappropriate and inadequate provision of support services, lack of enabling and protective legislation and policy, lack of parental recognition and involvement, and lack of human resource development strategies [16]. Some of the most prominent intrinsic barriers include language and communication difficulties, health difficulties such as HIV and tuberculosis, sensory impairments, intellectual and learning difficulties, and pervasive

ADHD would be considered an intrinsic barrier as research has shown that genetic and biological factors such as an imbalance in the neurotransmitters noradrenalin and dopamine play an important role in the development of the disorder. It is however important to also take cognisance of the role that extrinsic barriers such as those noted above, as well as poor socioeconomic circumstances, high crime rates, repeated trauma, parenting styles and parent-child interactions play in the maintenance and further developmental course of the disorder [15].

From an eco-systemic perspective, teachers can act as extrinsic barriers to learning and development when they act as risk factors in the developmental course of ADHD in particular learners in their classrooms. Likewise, teachers can also act as protective factors when their understanding of ADHD and support offered to the learners in their classrooms, positively

Teachers are often the primary source of identification and play a pivotal role in the diagnosis, management and intervention of ADHD. They have firsthand experience of the learner in the classroom situation; a setting which requires the learner to sit still, pay attention, adhere to instructions and interact with peers and adults in an appropriate manner. Teachers' knowledge and understanding will determine how they engage with and manage learners experiencing ADHD. Furthermore, their attitudes towards different forms of ADHD intervention would affect their support of these treatment methods and the learners in their classrooms. Early identification and intervention by teachers is vital, especially as a large percentage of individ‐ uals continue to have symptoms in adolescence and adulthood [18], which can impede their future wellbeing. It is important to take cognisance of the manner in which teachers' percep‐ tions, knowledge and attitudes are influenced by contextual and socio-cultural factors, as

It has however been found that teachers' understanding of ADHD is often based on myths and false beliefs. It has been reported that some teachers believe that ADHD is a direct cause of the intake of certain food additives and eating too many sweets [21]. Others are of the idea that ADHD is mainly as a result of biological abnormalities [11], or as a direct result of bad

developmental disorders [17].

218 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**4. Teachers: A pivotal part of the eco-system**

impact on the developmental course of the disorder.

shown in previous studies [1, 19-20].

Over the past decade, many research studies have been done on teachers' perceptions and knowledge of ADHD. In the United States, a sample of primary school teachers watched a video of a student displaying ADHD-like behaviours as well as those behaviours that are characteristic and unique to Oppositional Defiant Disorder (ODD). When examined, teachers were accurate in their evaluations of ADHD-like symptoms such as inattention and hyperac‐ tivity. However, when students displayed behaviours that belong solely to the domain of ODD, such as opposition and non-compliance, teachers automatically assumed that these behaviours were indicative of ADHD. Thus, teachers mistakenly assumed that children who displayed only ODD-like behaviours also exhibited ADHD-like behaviours [23]. A study conducted in Australia likewise revealed that teachers often provide parents and professionals with incorrect and inappropriate advice and information regarding the child who is displaying ADHD-like symptoms [21]. A study conducted in South Africa by [24] revealed that teachers are actually over identifying children with ADHD, as in the study 11.9% of the learners actually had ADHD, whilst teachers identified 15.4% of the learners to have ADHD. Thus, misunder‐ standings and misperceptions held by teachers may lead to inaccurate information being passed onto professionals, who carry out the task of making an actual ADHD diagnosis.

In support of these findings, further evidence reveals that teacher knowledge of ADHD tends to be very narrow and limited and even incorrect [21]. Three studies, as discussed in [21] were conducted in Australia over the last decade, which explored this area. One of the studies revealed that the teachers in the selected sample group were able to answer 60.7% of items in a questionnaire on ADHD. In a different study, the researchers administered the Knowledge of Attention Deficit Disorders Scale (KADDS) to a group of teachers. The findings of this study reflected that teachers knew more about the causes of ADHD, but possessed less information regarding treatment interventions for ADHD [21].

In South Africa, a study conducted in the peripheral areas of the Cape Town Metropole in the Western Cape, also employed the KADDS to assess 552 teachers' knowledge of ADHD [2]. Their study revealed that the participants did not have an adequate understanding of ADHD. An overall score of correct responses of 42,6% was obtained. An overall percentage of 35.4% was gathered for "don't know" responses, and 22% for incorrect responses [2].

These above results are consistent with a study conducted by [25]. In this South African study teachers' perceptions of their ability to identify and manage learners diagnosed with ADHD were investigated. Four out of five teachers did not consider themselves able to adequately manage ADHD symptoms, and some of the teachers misidentified and misunderstood certain symptoms of this condition. In a further study, [26] revealed that teachers do not have a sound understanding of the symptoms of ADHD, and the majority of teachers in the sample were unable to distinguish between inattention and ADHD. According to Venter (2011, as cited in [27]), teachers from poor black communities that teach at rural South African schools are the ones who possess the most limited knowledge on the condition. Consequently, these children are physically and verbally punished as a result of their ADHD behaviour.

of ADHD. In the study by [2], teachers' exposure to ADHD, which includes the number of workshops attended as well as the number of articles read was positively correlated to their

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In the study by [29] older teachers were more likely to attend workshops and engage in ADHD training than the younger teachers. Teaching experience and exposure to ADHD also increased the likelihood of teachers attending workshops. The more workshops the teachers attended, the more knowledge they had on the disorder, compared to the teachers who did not attend workshops. This was confirmed by the South African study conducted by [2]. Teachers' confidence levels in their ability to teach and deal with a child with ADHD was positively related to their overall knowledge of this condition. As every teacher will experience at least one learner with ADHD per year, it may become essential for teachers to receive pre-service

**5. Knowledge and perceptions of ADHD held by a sample of South African**

Whilst understanding the pivotal role that teachers' knowledge and perceptions play in the identification and treatment of ADHD, this chapter aims to integrate the information from the studies above, with one particular South African study [36] that focussed on the knowledge and perceptions held by a sample of South African Foundation Phase township teachers.

A range of mainstream and special education schools exist in South Africa, which include private and government funded schools. Of the government funded schools, formally white schools were better funded and resourced in comparison to the black township, rural and informal settlement schools. There is no previous documented research on township teachers' perceptions of ADHD in South Africa, which prompted the current study. The study was conducted in Alexandra Township in Gauteng, which is one of the oldest townships in South Africa. It was proclaimed as a township for black persons in 1912, by the Apartheid regime which classified South Africans into four racial groups. Alexandra Township, with a popula‐ tion of about 350 000 people, covers an area of over 800 hectares of land. It consists of persons of different cultures and varying degrees of income and education and has a history of poverty,

The overall aim of this study was to explore and assess the knowledge and perceptions of ADHD held by a sample of Foundation Phase (Reception year to Grade 3) teachers within a township setting. More specifically, the research aimed at exploring the teachers' general knowledge as well as their inadequate knowledge and misconceptions regarding ADHD, with emphasis paid to its' associated features, symptoms/diagnosis and treatment. Teachers'

knowledge of ADHD was also investigated in relation to their demographic group.

In fulfilling the aim of the study, the following research questions were posed:

overcrowding as well as high levels of unemployment and crime.

overall knowledge and understanding of the condition.

training in the area of ADHD [35].

**5.1. Aim of the study**

**foundation phase township teachers**

Conversely, a South African study conducted by [28], which included five schools situated in economically deprived areas and three school situated in economically affluent areas, showed different results to those yielded by [2]. It was revealed that the majority of teachers in this sample group in fact had in-depth knowledge and understanding of ADHD, and were acutely aware of the symptoms of ADHD. The teachers believed that their role in the classroom was crucial to the management of the condition. Furthermore, teachers in this study were very eager to learn and gain more information on the condition. However, this study consisted of a very small sample group and the results garnered appear to be more of an exception and stronger evidence exists for the fact that teachers generally have a poor understanding and lack of knowledge on the condition [2].

Research in the past decade, has explored if older teachers and those teachers who have had more years of teaching experience have better knowledge and understanding of ADHD. An Australian study conducted by [29], where 120 teachers completed a survey on what they thought and knew about ADHD, showed that teachers with more years of teaching experience perceived themselves to have greater knowledge on the condition than the less experienced teachers. However, the number of years of teaching experience of these teachers was not related to their actual levels of knowledge. The age of the teachers was also not linked to the teachers' level of knowledge and understandings of the condition. These results are confirmed by the findings by [2].

However, other research [30] reported that in fact younger teachers know more about ADHD than older ones, a finding which is confirmed by [31]. One explanation for this may be the fact that younger teachers notice the condition more in their classrooms compared to their older counterparts who have developed effective classroom behaviour management strategies. One researcher [32] believes that older teachers are much more rigid and set in their ways as compared to younger teachers, who are willing to be open, honest and adaptable to the needs of ADHD learners.

The question arises as to whether a teacher, who has obtained a more advanced level of education, consequently knows more about ADHD. A study [33] conducted in the United States, which aimed to investigate preschool teachers' past educational practices and their knowledge and understanding of ADHD, revealed that those teachers that obtained higher levels of academic training, such as a university education, performed on a superior level and obtained higher scores on the administered questionnaire than those teachers that only obtained a high school level of education.

The study by [29] also indicated that having taught a student with ADHD is related to that teacher's actual knowledge of the condition. Then the question arises as to whether training and exposure in the area, such as the reading of articles on the topic and the attendance of workshops, contributes to a teacher's level of understanding and knowledge on ADHD. A study by [34], answers this question in the affirmative, and revealed that the attendance of workshops on ADHD has a positive relationship with teacher knowledge and understanding of ADHD. In the study by [2], teachers' exposure to ADHD, which includes the number of workshops attended as well as the number of articles read was positively correlated to their overall knowledge and understanding of the condition.

In the study by [29] older teachers were more likely to attend workshops and engage in ADHD training than the younger teachers. Teaching experience and exposure to ADHD also increased the likelihood of teachers attending workshops. The more workshops the teachers attended, the more knowledge they had on the disorder, compared to the teachers who did not attend workshops. This was confirmed by the South African study conducted by [2]. Teachers' confidence levels in their ability to teach and deal with a child with ADHD was positively related to their overall knowledge of this condition. As every teacher will experience at least one learner with ADHD per year, it may become essential for teachers to receive pre-service training in the area of ADHD [35].

### **5. Knowledge and perceptions of ADHD held by a sample of South African foundation phase township teachers**

Whilst understanding the pivotal role that teachers' knowledge and perceptions play in the identification and treatment of ADHD, this chapter aims to integrate the information from the studies above, with one particular South African study [36] that focussed on the knowledge and perceptions held by a sample of South African Foundation Phase township teachers.

A range of mainstream and special education schools exist in South Africa, which include private and government funded schools. Of the government funded schools, formally white schools were better funded and resourced in comparison to the black township, rural and informal settlement schools. There is no previous documented research on township teachers' perceptions of ADHD in South Africa, which prompted the current study. The study was conducted in Alexandra Township in Gauteng, which is one of the oldest townships in South Africa. It was proclaimed as a township for black persons in 1912, by the Apartheid regime which classified South Africans into four racial groups. Alexandra Township, with a popula‐ tion of about 350 000 people, covers an area of over 800 hectares of land. It consists of persons of different cultures and varying degrees of income and education and has a history of poverty, overcrowding as well as high levels of unemployment and crime.

#### **5.1. Aim of the study**

ones who possess the most limited knowledge on the condition. Consequently, these children

Conversely, a South African study conducted by [28], which included five schools situated in economically deprived areas and three school situated in economically affluent areas, showed different results to those yielded by [2]. It was revealed that the majority of teachers in this sample group in fact had in-depth knowledge and understanding of ADHD, and were acutely aware of the symptoms of ADHD. The teachers believed that their role in the classroom was crucial to the management of the condition. Furthermore, teachers in this study were very eager to learn and gain more information on the condition. However, this study consisted of a very small sample group and the results garnered appear to be more of an exception and stronger evidence exists for the fact that teachers generally have a poor understanding and

Research in the past decade, has explored if older teachers and those teachers who have had more years of teaching experience have better knowledge and understanding of ADHD. An Australian study conducted by [29], where 120 teachers completed a survey on what they thought and knew about ADHD, showed that teachers with more years of teaching experience perceived themselves to have greater knowledge on the condition than the less experienced teachers. However, the number of years of teaching experience of these teachers was not related to their actual levels of knowledge. The age of the teachers was also not linked to the teachers' level of knowledge and understandings of the condition. These results are confirmed

However, other research [30] reported that in fact younger teachers know more about ADHD than older ones, a finding which is confirmed by [31]. One explanation for this may be the fact that younger teachers notice the condition more in their classrooms compared to their older counterparts who have developed effective classroom behaviour management strategies. One researcher [32] believes that older teachers are much more rigid and set in their ways as compared to younger teachers, who are willing to be open, honest and adaptable to the needs

The question arises as to whether a teacher, who has obtained a more advanced level of education, consequently knows more about ADHD. A study [33] conducted in the United States, which aimed to investigate preschool teachers' past educational practices and their knowledge and understanding of ADHD, revealed that those teachers that obtained higher levels of academic training, such as a university education, performed on a superior level and obtained higher scores on the administered questionnaire than those teachers that only

The study by [29] also indicated that having taught a student with ADHD is related to that teacher's actual knowledge of the condition. Then the question arises as to whether training and exposure in the area, such as the reading of articles on the topic and the attendance of workshops, contributes to a teacher's level of understanding and knowledge on ADHD. A study by [34], answers this question in the affirmative, and revealed that the attendance of workshops on ADHD has a positive relationship with teacher knowledge and understanding

are physically and verbally punished as a result of their ADHD behaviour.

lack of knowledge on the condition [2].

220 Attention Deficit Hyperactivity Disorder in Children and Adolescents

by the findings by [2].

of ADHD learners.

obtained a high school level of education.

The overall aim of this study was to explore and assess the knowledge and perceptions of ADHD held by a sample of Foundation Phase (Reception year to Grade 3) teachers within a township setting. More specifically, the research aimed at exploring the teachers' general knowledge as well as their inadequate knowledge and misconceptions regarding ADHD, with emphasis paid to its' associated features, symptoms/diagnosis and treatment. Teachers' knowledge of ADHD was also investigated in relation to their demographic group.

In fulfilling the aim of the study, the following research questions were posed:

	- **◦** Associated Features
	- **◦** Symptoms/Diagnosis
	- **◦** Treatment

were also asked to provide the number of hours of ADHD training that they had received (if any), as well as the number of evaluations and assessments that they had requested for children in their classes that they thought may have ADHD. Teachers were required to indicate the number of children that they had taught with a medical diagnosis of ADHD, how many workshops that they had attended on the topic as well as the number of articles that they had read on the condition. The teachers were also asked to rate their confidence levels to teach a child with ADHD. Lastly, teachers were required to indicate whether they had been asked for feedback by a professional, such as a doctor or psychologist, regarding a child in their class with ADHD in order to assess the child's medication. These questions were based on a questionnaire that was administered in the previously reported South African

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The second section of the questionnaire consisted of the Knowledge of Attention Deficit Disorder Scale (KADDS). This scale was developed by [31] and was previously used in similar studies in South Africa, see [2] and Australia, see [40]. It was designed and consequently published to assess teachers' knowledge, of the symptoms, associated features and treatment of ADHD. The KADDS is a 39 item rating scale which elicits true and correct answers (T), false, incorrect and misperceived answers (F) and don't know answers (DK). Previous research conducted on the internal consistency of the KADDS total score, based on the original 36 items that constituted this scale, revealed high internal consistency ranging from.81 to.86 [31,41-42]. A similarly high internal consistency for the KADDS was found in the present study, with the Cronbach's alpha for the total score being.88. In terms of validity, KADDS scores are sensitive to teacher characteristics such as exposure to and interaction with a child with ADHD and

The last section of the questionnaire contained open- ended questions, where participants were given the opportunity to provide any additional comments or ideas that they had regarding ADHD. This information served to substantiate and support the quantitative results garnered by the research. In research terms, this method of using multiple sources of data to strengthen

Descriptive and inferential statistics and graphs were used to describe the sample respondents and the measurement scales, and to address the aims of the research study. In order to investigate the areas of inadequate knowledge and misconceptions held by teachers, summary statistics for the central tendency, variability and shape were computed at the item level of the KADDS subscales. These results were tabulated using a robot- type colour coding scheme whereby higher mean scores were shaded in deep green and shades of yellow through to red were used for relatively lower and low means respectively. Furthermore, the responses to each item were categorised as "don't know", incorrect responses or misconceptions, and correct responses, thereby enabling the examination of the extent of teachers' misconceptions versus poor knowledge at the item level of each of the subscales. This analysis was depicted graphi‐ cally in the form of a stacked bar graph for the items of each subscale of the KADDS. In order to address the teachers' general knowledge of ADHD content areas in terms of their demo‐

the trustworthiness of the data, is referred to as the triangulation of data [43].

study conducted by [2].

prior training on this condition [31].

**5.3. Data analysis**

	- **◦** Associated Features
	- **◦** Symptoms/Diagnosis
	- **◦** Treatment

#### **5.2. Research design and methodology**

This research was exploratory in nature as there is very limited documented research on ADHD in South Africa. The study garnered both qualitative and quantitative material which was analysed using numerical and descriptive statistics. For logistical and practical reasons, nine primary schools situated within the Alexandra Township were selected. Non probability, convenience sampling was employed as participation by the teachers depended on their availability and willingness to respond. As a result, the final sample of 100 female teachers who consented to participate in the study was not random in nature [37-38]. Foundation Phase teachers were chosen as the sample for this study due to the fact that they play an integral and primary role when it comes to the identification and recognition of ADHD-like symptoms [39]. Permission to undertake the investigation was sought from the Gauteng Department of Education and the ethics committee at the University of the Witwatersrand. A detailed information sheet detailing issues of anonymity and confidentiality regarding the particulars of the study was distributed to the principals of the schools and their teachers.

Clear instructions were given to the respondents during administration of the instrument and assistance was provided if they did not understand what was required. A questionnaire was chosen as the preferred instrument as it allowed for administration to a large group of subjects [38]. The questionnaire which was administered to the 100 participants was threefold in nature. It included; demographic/biographical questions, the Knowledge of Attention Deficit Disor‐ ders Scale (KADDS), as well as open-ended questions. Permission to use the KADDS measure was obtained from Professor Mark Sciutto.

In the first section of the questionnaire teachers were asked demographic questions such as their gender, age, educational level and number of years of teaching experience. Teachers were also asked to provide the number of hours of ADHD training that they had received (if any), as well as the number of evaluations and assessments that they had requested for children in their classes that they thought may have ADHD. Teachers were required to indicate the number of children that they had taught with a medical diagnosis of ADHD, how many workshops that they had attended on the topic as well as the number of articles that they had read on the condition. The teachers were also asked to rate their confidence levels to teach a child with ADHD. Lastly, teachers were required to indicate whether they had been asked for feedback by a professional, such as a doctor or psychologist, regarding a child in their class with ADHD in order to assess the child's medication. These questions were based on a questionnaire that was administered in the previously reported South African study conducted by [2].

The second section of the questionnaire consisted of the Knowledge of Attention Deficit Disorder Scale (KADDS). This scale was developed by [31] and was previously used in similar studies in South Africa, see [2] and Australia, see [40]. It was designed and consequently published to assess teachers' knowledge, of the symptoms, associated features and treatment of ADHD. The KADDS is a 39 item rating scale which elicits true and correct answers (T), false, incorrect and misperceived answers (F) and don't know answers (DK). Previous research conducted on the internal consistency of the KADDS total score, based on the original 36 items that constituted this scale, revealed high internal consistency ranging from.81 to.86 [31,41-42]. A similarly high internal consistency for the KADDS was found in the present study, with the Cronbach's alpha for the total score being.88. In terms of validity, KADDS scores are sensitive to teacher characteristics such as exposure to and interaction with a child with ADHD and prior training on this condition [31].

The last section of the questionnaire contained open- ended questions, where participants were given the opportunity to provide any additional comments or ideas that they had regarding ADHD. This information served to substantiate and support the quantitative results garnered by the research. In research terms, this method of using multiple sources of data to strengthen the trustworthiness of the data, is referred to as the triangulation of data [43].

#### **5.3. Data analysis**

**•** What is the teachers' general knowledge of the content areas of ADHD in terms of:

**•** What are teachers' specific areas of inadequate knowledge and misconceptions in the

**•** Is teachers' knowledge of the ADHD content areas different by demographic group in terms

This research was exploratory in nature as there is very limited documented research on ADHD in South Africa. The study garnered both qualitative and quantitative material which was analysed using numerical and descriptive statistics. For logistical and practical reasons, nine primary schools situated within the Alexandra Township were selected. Non probability, convenience sampling was employed as participation by the teachers depended on their availability and willingness to respond. As a result, the final sample of 100 female teachers who consented to participate in the study was not random in nature [37-38]. Foundation Phase teachers were chosen as the sample for this study due to the fact that they play an integral and primary role when it comes to the identification and recognition of ADHD-like symptoms [39]. Permission to undertake the investigation was sought from the Gauteng Department of Education and the ethics committee at the University of the Witwatersrand. A detailed information sheet detailing issues of anonymity and confidentiality regarding the particulars

of the study was distributed to the principals of the schools and their teachers.

Clear instructions were given to the respondents during administration of the instrument and assistance was provided if they did not understand what was required. A questionnaire was chosen as the preferred instrument as it allowed for administration to a large group of subjects [38]. The questionnaire which was administered to the 100 participants was threefold in nature. It included; demographic/biographical questions, the Knowledge of Attention Deficit Disor‐ ders Scale (KADDS), as well as open-ended questions. Permission to use the KADDS measure

In the first section of the questionnaire teachers were asked demographic questions such as their gender, age, educational level and number of years of teaching experience. Teachers

**◦** Associated Features **◦** Symptoms/Diagnosis

222 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**◦** Treatment

**◦** Treatment

**◦** Treatment

of:

content areas of:

**◦** Associated Features **◦** Symptoms/Diagnosis

**◦** Associated Features **◦** Symptoms/Diagnosis

**5.2. Research design and methodology**

was obtained from Professor Mark Sciutto.

Descriptive and inferential statistics and graphs were used to describe the sample respondents and the measurement scales, and to address the aims of the research study. In order to investigate the areas of inadequate knowledge and misconceptions held by teachers, summary statistics for the central tendency, variability and shape were computed at the item level of the KADDS subscales. These results were tabulated using a robot- type colour coding scheme whereby higher mean scores were shaded in deep green and shades of yellow through to red were used for relatively lower and low means respectively. Furthermore, the responses to each item were categorised as "don't know", incorrect responses or misconceptions, and correct responses, thereby enabling the examination of the extent of teachers' misconceptions versus poor knowledge at the item level of each of the subscales. This analysis was depicted graphi‐ cally in the form of a stacked bar graph for the items of each subscale of the KADDS. In order to address the teachers' general knowledge of ADHD content areas in terms of their demo‐ graphic group, a 1-way Analysis of Variance (ANOVA) was used. This was used to compare the mean responses of the respondents across the levels within each demographic variable on the three KADDS subscales. Line graphs were used to portray the differences between means in the case of significant ANOVA comparisons. Furthermore, the post hoc Scheffe test was used to indicate pairwise significances for significant analyses of demographic variables with more than two levels. In view of the non-normality of the score distributions, the parametric ANOVA tests were validated using the non-parametric equivalent Kruskal-Wallis test. Finally, the Chi squared test was used to compare the demographic characteristics of the respondents who opted versus those who did not opt for a future workshop on ADHD and profile line graphs were plotted to describe the two groups of these demographic variables. In addition, the t-test was used to compare the mean knowledge scores on the three KADDS subscales of these two groups. These analyses were complemented by the researcher's thematic analysis of the qualitative responses.

Regarding the teachers' knowledge in terms of the Associated Features subscale, a mean score of 30.4% was garnered which was lower than the overall scale score of 34.9%, and based on the median score reflected in Table 1, half of the respondents answered fewer than 31.3% of these items correctly. The minimum scores of zero on the Associated Features subscale show 10 teachers who either did not know and/or who answered all the items of the subscale incorrectly. Of the three subscales, the highest mean (percentage correctly answered items) is for Symptoms/Diagnosis (47.9%). Even on this subscale, the average respondent answered approximately half of the items incorrectly. Nine of the 100 teachers scored zero on this Symptoms/Diagnosis subscale. The mean score of 30.6% on the Treatment subscale is compa‐ rably low in relation to the mean score on the Associated Features subscale which was lower than the overall KADDS score of 34.9%. The minimum scores of zero on this subscale show 15 teachers who either did not know and/or who answered all the items of the subscale incor‐

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

http://dx.doi.org/10.5772/53784

225

In order to determine the specific areas of poor knowledge and misconceptions of the content areas of ADHD, the scores of the educator respondents were examined at the item level for the three KADDS subscales. The low internal consistency reliability and low average interitem correlation for the Associated Features subscale (Table 2) imply that some items of the subscale were answered correctly by teachers who answered other items incorrectly, and thus some items would be expected to have vastly different means from others. To reflect the items on which low and poor correct responses were obtained, a robot-type colour coding system was used whereby lower means were shaded red and highest means were shaded dark green with shades of orange for items in between. Item 1, which suggests that ADHD occurs in approximately 15% of school age children, item 27, which states that children with ADHD generally experience more problems in novel situations rather than familiar ones, item 30, which states that the problem behaviours in children with ADHD are distinctly different from the behaviours of non-ADHD children and item 39, which states that children with ADHD display an inflexible adherence to routine, all have very low percentage correct responses with means between 4% and 12%. These percentages are particularly low compared to items 13, which states that it is possible for an adult to have ADHD, item 31, which refers to the idea that children with ADHD are more distinguishable from normal children in a classroom setting as opposed to a free play situation and item 32, which states that the majority of children with ADHD evidence some degree of poor school performance during their early school years, which all have relatively high percentage correct responses with means between 60% and 62%. Apart from these three items, the mean score on the rest of the items of this subscale were all below 42%, and thus the standard deviations were low on these items and as a result on the whole subscale. This low response variability would have impacted negatively on the internal consistency reliability as Cronbach's alpha was dependent on the variability in the responses. In order to investigate the low item scores, a distinction was made between misconceptions, i.e., incorrect responses, versus "don't know" responses. This distinction is displayed graph‐ ically for the Associated Features items in Figure 1 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. Figure 1 shows that teachers have the greatest extent of misconception of ADHD on items 27, 1, 39 and 24, which states that a diagnosis of ADHD by itself makes a child eligible for

rectly.

#### **5.4. Findings**

All of the 100 respondents, who agreed to participate in this study, were female. The average learner to teacher ratio in the schools include in the schools, were 50:1. Almost two-thirds of the teachers in the sample were older than 40years, with a negligible number of them in the 20-25 year category. Consistent with the age distribution of the teacher respondents, the majority (60%) had more than 11 years of teaching experience, 20% had 6-10 years teach‐ ing experience and 20% had 5 years or less. Almost a quarter of the sample had a universi‐ ty level of education, while the remaining individuals had college level training. Over half of the respondents expressed no confidence in their ability to teach children with ADHD. Regarding their knowledge of ADHD, two thirds of the teachers had received no ADHD training. Over half of the respondents (52%) claimed that they had taught children diag‐ nosed with ADHD and had assisted with ADHD evaluations (59%). Almost 40% claimed that they had been asked for feedback by a doctor regarding a child with ADHD in their classroom.

The overall results of the KADDS questionnaire revealed that there is a substantial lack of knowledge about ADHD amongst the participants. Based on the results of Table 1 the overall percentage of correct responses to the 39 KADDS items was 34.9%. Nine of the 100 educator respondents scored zero on all 39 items of the scale.


**Table 1.** Summary descriptive statistics of the three content areas of ADHD

Regarding the teachers' knowledge in terms of the Associated Features subscale, a mean score of 30.4% was garnered which was lower than the overall scale score of 34.9%, and based on the median score reflected in Table 1, half of the respondents answered fewer than 31.3% of these items correctly. The minimum scores of zero on the Associated Features subscale show 10 teachers who either did not know and/or who answered all the items of the subscale incorrectly. Of the three subscales, the highest mean (percentage correctly answered items) is for Symptoms/Diagnosis (47.9%). Even on this subscale, the average respondent answered approximately half of the items incorrectly. Nine of the 100 teachers scored zero on this Symptoms/Diagnosis subscale. The mean score of 30.6% on the Treatment subscale is compa‐ rably low in relation to the mean score on the Associated Features subscale which was lower than the overall KADDS score of 34.9%. The minimum scores of zero on this subscale show 15 teachers who either did not know and/or who answered all the items of the subscale incor‐ rectly.

graphic group, a 1-way Analysis of Variance (ANOVA) was used. This was used to compare the mean responses of the respondents across the levels within each demographic variable on the three KADDS subscales. Line graphs were used to portray the differences between means in the case of significant ANOVA comparisons. Furthermore, the post hoc Scheffe test was used to indicate pairwise significances for significant analyses of demographic variables with more than two levels. In view of the non-normality of the score distributions, the parametric ANOVA tests were validated using the non-parametric equivalent Kruskal-Wallis test. Finally, the Chi squared test was used to compare the demographic characteristics of the respondents who opted versus those who did not opt for a future workshop on ADHD and profile line graphs were plotted to describe the two groups of these demographic variables. In addition, the t-test was used to compare the mean knowledge scores on the three KADDS subscales of these two groups. These analyses were complemented by the researcher's thematic analysis

All of the 100 respondents, who agreed to participate in this study, were female. The average learner to teacher ratio in the schools include in the schools, were 50:1. Almost two-thirds of the teachers in the sample were older than 40years, with a negligible number of them in the 20-25 year category. Consistent with the age distribution of the teacher respondents, the majority (60%) had more than 11 years of teaching experience, 20% had 6-10 years teach‐ ing experience and 20% had 5 years or less. Almost a quarter of the sample had a universi‐ ty level of education, while the remaining individuals had college level training. Over half of the respondents expressed no confidence in their ability to teach children with ADHD. Regarding their knowledge of ADHD, two thirds of the teachers had received no ADHD training. Over half of the respondents (52%) claimed that they had taught children diag‐ nosed with ADHD and had assisted with ADHD evaluations (59%). Almost 40% claimed that they had been asked for feedback by a doctor regarding a child with ADHD in their

The overall results of the KADDS questionnaire revealed that there is a substantial lack of knowledge about ADHD amongst the participants. Based on the results of Table 1 the overall percentage of correct responses to the 39 KADDS items was 34.9%. Nine of the 100 educator

**Mean 95% Confidence Interval for**

Associated features 30.4% 27.0% 33.8% 31.3% 17.2% -0.21 Symptoms/ Diagnosis 47.9% 43.3% 52.5% 50.0% 23.3% -0.51 Treatment 30.6% 26.5% 34.8% 30.8% 20.9% 0.10 Overall 34.9% 31.3% 38.6% 37.2% 18.2% -0.33

**Median Standard**

**deviation**

**Skew Ness**

**mean**

respondents scored zero on all 39 items of the scale.

**Table 1.** Summary descriptive statistics of the three content areas of ADHD

of the qualitative responses.

224 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**5.4. Findings**

classroom.

In order to determine the specific areas of poor knowledge and misconceptions of the content areas of ADHD, the scores of the educator respondents were examined at the item level for the three KADDS subscales. The low internal consistency reliability and low average interitem correlation for the Associated Features subscale (Table 2) imply that some items of the subscale were answered correctly by teachers who answered other items incorrectly, and thus some items would be expected to have vastly different means from others. To reflect the items on which low and poor correct responses were obtained, a robot-type colour coding system was used whereby lower means were shaded red and highest means were shaded dark green with shades of orange for items in between. Item 1, which suggests that ADHD occurs in approximately 15% of school age children, item 27, which states that children with ADHD generally experience more problems in novel situations rather than familiar ones, item 30, which states that the problem behaviours in children with ADHD are distinctly different from the behaviours of non-ADHD children and item 39, which states that children with ADHD display an inflexible adherence to routine, all have very low percentage correct responses with means between 4% and 12%. These percentages are particularly low compared to items 13, which states that it is possible for an adult to have ADHD, item 31, which refers to the idea that children with ADHD are more distinguishable from normal children in a classroom setting as opposed to a free play situation and item 32, which states that the majority of children with ADHD evidence some degree of poor school performance during their early school years, which all have relatively high percentage correct responses with means between 60% and 62%. Apart from these three items, the mean score on the rest of the items of this subscale were all below 42%, and thus the standard deviations were low on these items and as a result on the whole subscale. This low response variability would have impacted negatively on the internal consistency reliability as Cronbach's alpha was dependent on the variability in the responses.

In order to investigate the low item scores, a distinction was made between misconceptions, i.e., incorrect responses, versus "don't know" responses. This distinction is displayed graph‐ ically for the Associated Features items in Figure 1 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. Figure 1 shows that teachers have the greatest extent of misconception of ADHD on items 27, 1, 39 and 24, which states that a diagnosis of ADHD by itself makes a child eligible for placement in special education. These items arranged in decreasing order of incorrect re‐ sponses from 53% to 40% and the least extent on items 31, 13 and 32 (these items similarly arranged in decreasing order of incorrect responses from 14% to 11%).

**Items Mean Median**

32: The majority of ADHD children evidence some degree of poor school performance in the elementary school

33: Symptoms of ADHD are often seen in non-ADHD children who come from inadequate and chaotic home

39: Children with ADHD generally display an inflexible

Associated Features item statistics

**Table 2.** Associated Features item statistics 39: Children with ADHD generally display an

42 44 45 45

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

27: ADHD children experience more problems in novel

situations than familar ones

1: Most estimates suggest that ADHD occurs in 15% of

children

30: The behaviours of ADHD children are different from

behaviours of non-ADHD children

39: Children with ADHD generally display an inflexible

adherance to specific routines or rituals

24: A diagnosis of ADHD makes a child eligible for

placement in special education

22: If an ADHD child can sustain attention to TV for an

hour, he can sustain attention for an hour in class

4: ADHD children are more compliant with their fathers

than their mothers

28: Physical features can be identified by doctors to make

a diagnosis of ADHD

19: ADHD children "outgrow" their symptoms by puberty

and function normally in adulthood

33: ADHD symptoms are often seen in non-ADHD

children who come from chaotic home environments

29: In school-age children, the prevalence of ADHD in

males and females is equivalent

6: ADHD is more common in biological relatives of

children with ADHD than in the general population

17: Symptoms of depression are found more frequently in

ADHD children than non-ADHD children

31: ADHD children are distinguishable from other children

in a classroom than in a free play situation

13: It is possible for an adult to be diagnosed with ADHD

32: ADHD children show some poor school performance

in the elementary school years

<sup>53</sup> <sup>52</sup> <sup>45</sup> <sup>43</sup>

<sup>5</sup> <sup>4</sup> <sup>10</sup> <sup>12</sup>

<sup>28</sup> <sup>32</sup>

<sup>40</sup> <sup>36</sup>

32 32

31 27

Categorised responses to Associated Features items

**Figure 1.** Categorised responses to Associated Features items

adherence to specific routines or rituals.

years.

environments.

**Std.D ev**

66% 100% 48% 42% 55% -0.69

28% 0% 45% 40% 52% 0.99

12% 0% 33% 29% 38% 2.37

15

41

<sup>26</sup> <sup>27</sup> <sup>23</sup>

<sup>60</sup> <sup>62</sup> <sup>66</sup>

11

14 11

inflexible adherence to specific routines or rituals. 12% 0% 33% 29% 38% 2.37

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

No response/ don't know Incorrect response Correct

<sup>22</sup> <sup>20</sup> <sup>25</sup> <sup>28</sup> <sup>33</sup> <sup>34</sup>

<sup>47</sup> <sup>53</sup> <sup>49</sup> <sup>47</sup> <sup>46</sup> <sup>47</sup> <sup>44</sup>

<sup>26</sup> <sup>25</sup> 21 19

In line with the relatively higher mean score of the Symptoms/Diagnosis subscale compared to the other subscales (Table 1), the item means presented in Table 3 for this subscale are generally higher than those of the Associated Features subscale. The items that the teachers found most difficult were 11, which state that it is common for ADHD children to have an inflated sense of selfesteem or grandiosity and 38, which states that if a child responds to stimulant medications then they probably have ADHD, as the mean correct responses obtained were 18% and 23%, respectively. More than two-thirds of the teachers scored the following items correctly: item 3, which states that ADHD children are frequently distracted by extraneous stimuli; item 9, which states that ADHD children often fidget or squirm in their seats; item 21, which states that a child must present with symptoms in two or more settings to obtain an ADHD diagnosis and item 26 which states that ADHD children often have difficulties organising tasks and activities. Once again, in order to investigate the low item scores for Symptoms/Diagnosis, a distinction was made between misconceptions, that is, incorrect responses, versus "don't know" responses. This distinction is displayed graphically for the Symptoms/Diagnosis items in Figure 2 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. The figure shows that teachers have the greatest extent of misconceptions of ADHD Symptoms/ Diagnosis on item 7, which states that one of the symptoms displayed by ADHD children is that they are cruel to other people and item 14, which states that ADHD children often have a history of stealing or destroying other peoples' things (48% and 47% misconceptions respectively). Figure 2 also shows that teachers have the least extent of misconceptions on items 21 and 16; which states that two

clusters of symptoms exist for ADHD, and items 3, 9 and 26 have between 9% and 5% misconceptions.

**95% Confidence Interval for mean**

http://dx.doi.org/10.5772/53784

**Skewness**

227


Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the… http://dx.doi.org/10.5772/53784 227


**Table 2.** Associated Features item statistics 39: Children with ADHD generally display an inflexible adherence to specific routines or rituals. 12% 0% 33% 29% 38% 2.37

Associated Features item statistics

placement in special education. These items arranged in decreasing order of incorrect re‐ sponses from 53% to 40% and the least extent on items 31, 13 and 32 (these items similarly

13: It is possible for an adult to be diagnosed with ADHD. 62% 100% 49% 43% 57% -0.50

**Std.D ev**

4% 0% 20% 17% 23% 4.77

22% 0% 42% 37% 48% 1.37

34% 0% 48% 42% 55% 0.69

41% 0% 49% 43% 57% 0.37

25% 0% 44% 38% 51% 1.17

32% 0% 47% 41% 54% 0.78

32% 0% 47% 41% 54% 0.78

5% 0% 22% 19% 25% 4.19

20% 0% 40% 35% 47% 1.52

33% 0% 47% 41% 55% 0.73

10% 0% 30% 26% 35% 2.71

60% 100% 49% 43% 57% -0.41

**95% Confidence Interval for mean**

**Skewness**

arranged in decreasing order of incorrect responses from 14% to 11%).

**Items Mean Median**

1: Most estimates suggest that ADHD occurs in approximately 15% of school age children.

fathers than with their mothers.

the general population.

adulthood.

or homework.

children.

situation.

placement in special education.

a definitive diagnosis of ADHD.

males and females is equivalent.

novel situations than in familiar situations.

4: ADHD children are typically more compliant with their

226 Attention Deficit Hyperactivity Disorder in Children and Adolescents

6: ADHD is more common in the 1st degree biological relatives (i.e. mother, father) of children with ADHD than in

17: Symptoms of depression are found more frequently in

19: Most ADHD children "outgrow" their symptoms by the onset of puberty and subsequently function normally in

22: If an ADHD child is able to demonstrate sustained attention to video games or TV for over an hour, that child is also able to sustain attention for at least an hour of class

24: A diagnosis of ADHD by itself makes a child eligible for

27: ADHD children generally experience more problems in

28: There are specific physical features which can be identified by medical doctors (e.g. paediatrician) in making

29: In school age children, the prevalence of ADHD in

30: In very young children (less than 4 years old), the problem behaviours of ADHD children are distinctly different from age-appropriate behaviours of non-ADHD

31: Children with ADHD are more distinguishable from normal children in a classroom setting than in a free play

ADHD children than in non- ADHD children.

In line with the relatively higher mean score of the Symptoms/Diagnosis subscale compared to the other subscales (Table 1), the item means presented in Table 3 for this subscale are generally higher than those of the Associated Features subscale. The items that the teachers found most difficult were 11, which state that it is common for ADHD children to have an inflated sense of selfesteem or grandiosity and 38, which states that if a child responds to stimulant medications then they probably have ADHD, as the mean correct responses obtained were 18% and 23%, respectively. More than two-thirds of the teachers scored the following items correctly: item 3, which states that ADHD children are frequently distracted by extraneous stimuli; item 9, which states that ADHD children often fidget or squirm in their seats; item 21, which states that a child must present with symptoms in two or more settings to obtain an ADHD diagnosis and item 26 which states that ADHD children often have difficulties organising tasks and activities. Once again, in order to investigate the low item scores for Symptoms/Diagnosis, a distinction was made between misconceptions, that is, incorrect responses, versus "don't know" responses. This distinction is displayed graphically for the Symptoms/Diagnosis items in Figure 2 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. The figure shows that teachers have the greatest extent of misconceptions of ADHD Symptoms/ Diagnosis on item 7, which states that one of the symptoms displayed by ADHD children is that they are cruel to other people and item 14, which states that ADHD children often have a history of stealing or destroying other peoples' things (48% and 47% misconceptions respectively). Figure 2 also shows that teachers have the least extent of misconceptions on items 21 and 16; which states that two

clusters of symptoms exist for ADHD, and items 3, 9 and 26 have between 9% and 5% misconceptions.

**Figure 1.** Categorised responses to Associated Features items

Categorised responses to Associated Features items

In line with the relatively higher mean score of the Symptoms/Diagnosis subscale compared to the other subscales (Table 1), the item means presented in Table 3 for this subscale are generally higher than those of the Associated Features subscale. The items that the teachers found most difficult were 11, which state that it is common for ADHD children to have an inflated sense of self-esteem or grandiosity and 38, which states that if a child responds to stimulant medications then they probably have ADHD, as the mean correct responses obtained were 18% and 23%, respectively. More than two-thirds of the teachers scored the following items correctly: item 3, which states that ADHD children are frequently distracted by extra‐ neous stimuli; item 9, which states that ADHD children often fidget or squirm in their seats; item 21, which states that a child must present with symptoms in two or more settings to obtain an ADHD diagnosis and item 26 which states that ADHD children often have difficulties organising tasks and activities.

**Items Mean Median**

3: ADHD children are frequently distracted by

7: One symptom of ADHD children is that they

9: ADHD children often fidget or squirm in their

11: It is common for ADHD children to have an

16: Current wisdom about ADHD suggests two clusters of symptoms: One of inattention and another consisting of hyperactivity/impulsivity.

21: In order to be diagnosed as ADHD, a child must exhibit relevant symptoms in two or more

38: If a child responds to stimulant medications

55 51

<sup>18</sup> <sup>23</sup>

26

27

26: ADHD children often have difficulties

settings (e.g., home, school).

14: ADHD children often have a history of

5: In order to be diagnosed with ADHD, the child's symptoms must have been present

**Items Mean Median Std.** 

extraneous stimuli. 70% 100% 46% 40% 54% -0.89

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

have been physically cruel to other people. 31% 0% 46% 41% 54% 0.83

seats. 78% 100% 42% 37% 48% -1.37

inflated sense of self-esteem or grandiosity. 18% 0% 39% 34% 45% 1.69

stealing or destroying other people's things 21% 0% 41% 36% 48% 1.45

organizing tasks and activities. 77% 100% 42% 37% 49% -1.30

(e.g., Ritalin), then they probably have ADHD. 23% 0% 42% 37% 49% 1.30

No response/ don't know Incorrect response Correct

As for the Associated Features subscale, the knowledge level on the treatment subscale was poor (Table 4), with 14% or fewer of the teachers responding correctly to item 23, which states that the reduction of sugar intake leads to the reduction of ADHD symptoms; item 34, which states that behavioural interventions for children with ADHD focus primarily on the child's problems with inattention; item 35, which states that Electroconvulsive Therapy has been found to be an effective treatment for severe cases

23

9

68

37

6

6

57

<sup>24</sup> <sup>16</sup> <sup>18</sup>

9: ADHD children often fidget or squirm in

their seats.

26: ADHD children often have difficulties

organizing tasks and activities.

<sup>70</sup> <sup>78</sup> <sup>77</sup>

6 5

16: Current wisdom about ADHD suggests two clusters of symptoms: One of inattention and another consisting

before age 7.

21: In order to be diagnosed as ADHD, a child must exhibit relevant symptoms in two or more settings (e.g.,

26: ADHD children often have difficulties organizing

38: If a child responds to stimulant medications (e.g.,

Categorised responses to Symptoms/ Diagnosis items

**Figure 2.** Categorised responses to Symptoms/ Diagnosis items

32 36

28

36

47

21

Ritalin), then they probably have ADHD.

**Table 3.** Symptoms/Diagnosis item statistics

Symptoms/Diagnosis item statistics

21

7: One symptom of ADHD children is that

they have been physically cruel to other

people.

14: ADHD children often have a history of

stealing or destroying other people's things

.

5: In order to be diagnosed with ADHD, the

child's symptoms must have been present

before age 7.

11: It is common for ADHD children to have

an inflated sense of self-esteem or

grandiosity.

38: If a child responds to stimulant

medications (e.g., Ritalin), then they

probably have

21: In order to be diagnosed as ADHD, a

child must exhibit relevant symptoms in two

or more settings (e.g., home, school).

16: ADHD has two clusters of symptoms:

One of inattention and another of

hyperactivity/impulsivity.

3: ADHD children are frequently distracted

by extraneous stimuli.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

48

31

of hyperactivity/impulsivity.

home, school).

tasks and activities.

**Std. Dev.**

57% 100% 50% 44% 58% -0.29

68% 100% 47% 41% 54% -0.78

77% 100% 42% 37% 49% -1.30

57% 100% 50% 44% 58% -0.29

68% 100% 47% 41% 54% -0.78

23% 0% 42% 37% 49% 1.30

**95% Confidence Interval for mean**

**95% Confidence Interval for mean** 

**Dev.** 

36% 0% 48% 42% 56% 0.59

**Skewness**

229

**Skewness** 

http://dx.doi.org/10.5772/53784

Once again, in order to investigate the low item scores for Symptoms/Diagnosis, a distinction was made between misconceptions, that is, incorrect responses, versus "don't know" respons‐ es. This distinction is displayed graphically for the Symptoms/Diagnosis items in Figure 2 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. The figure shows that teachers have the greatest extent of misconceptions of ADHD Symptoms/ Diagnosis on item 7, which states that one of the symptoms displayed by ADHD children is that they are cruel to other people and item 14, which states that ADHD children often have a history of stealing or destroying other peoples' things (48% and 47% misconceptions respectively). Figure 2 also shows that teachers have the least extent of misconceptions on items 21 and 16; which states that two clusters of symptoms exist for ADHD, and items 3, 9 and 26 have between 9% and 5% misconceptions.


Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the… http://dx.doi.org/10.5772/53784 229

**95%** 


**Table 3.** Symptoms/Diagnosis item statistics 38: If a child responds to stimulant medications (e.g., Ritalin), then they probably have ADHD. 23% 0% 42% 37% 49% 1.30 Symptoms/Diagnosis item statistics

In line with the relatively higher mean score of the Symptoms/Diagnosis subscale compared to the other subscales (Table 1), the item means presented in Table 3 for this subscale are generally higher than those of the Associated Features subscale. The items that the teachers found most difficult were 11, which state that it is common for ADHD children to have an inflated sense of self-esteem or grandiosity and 38, which states that if a child responds to stimulant medications then they probably have ADHD, as the mean correct responses obtained were 18% and 23%, respectively. More than two-thirds of the teachers scored the following items correctly: item 3, which states that ADHD children are frequently distracted by extra‐ neous stimuli; item 9, which states that ADHD children often fidget or squirm in their seats; item 21, which states that a child must present with symptoms in two or more settings to obtain an ADHD diagnosis and item 26 which states that ADHD children often have difficulties

Once again, in order to investigate the low item scores for Symptoms/Diagnosis, a distinction was made between misconceptions, that is, incorrect responses, versus "don't know" respons‐ es. This distinction is displayed graphically for the Symptoms/Diagnosis items in Figure 2 where bars shaded in blue indicate the percentage of misconceptions and bars shaded in red indicate incorrect responses for each item. The figure shows that teachers have the greatest extent of misconceptions of ADHD Symptoms/ Diagnosis on item 7, which states that one of the symptoms displayed by ADHD children is that they are cruel to other people and item 14, which states that ADHD children often have a history of stealing or destroying other peoples' things (48% and 47% misconceptions respectively). Figure 2 also shows that teachers have the least extent of misconceptions on items 21 and 16; which states that two clusters of symptoms

exist for ADHD, and items 3, 9 and 26 have between 9% and 5% misconceptions.

9: ADHD children often fidget or squirm in their seats. 78% 100% 42% 37% 48% -1.37

**Std. Dev.**

70% 100% 46% 40% 54% -0.89

36% 0% 48% 42% 56% 0.59

31% 0% 46% 41% 54% 0.83

18% 0% 39% 34% 45% 1.69

21% 0% 41% 36% 48% 1.45

**95% Confidence Interval for mean**

**Skewness**

**Items Mean Median**

3: ADHD children are frequently distracted by

5: In order to be diagnosed with ADHD, the child's symptoms must have been present before age 7.

7: One symptom of ADHD children is that they have

11: It is common for ADHD children to have an inflated

14: ADHD children often have a history of stealing or

been physically cruel to other people.

sense of self-esteem or grandiosity.

destroying other people's things

extraneous stimuli.

organising tasks and activities.

228 Attention Deficit Hyperactivity Disorder in Children and Adolescents

As for the Associated Features subscale, the knowledge level on the treatment subscale was poor (Table 4), with 14% or fewer of the teachers responding correctly to item 23, which states that the reduction of sugar intake leads to the reduction of ADHD symptoms; item 34, which states that behavioural interventions for children with ADHD focus primarily on the child's problems with inattention; item 35, which states that Electroconvulsive Therapy has been found to be an effective treatment for severe cases

Categorised responses to Symptoms/ Diagnosis items **Figure 2.** Categorised responses to Symptoms/ Diagnosis items

As fortheAssociatedFeatures subscale,theknowledge levelonthe treatment subscalewaspoor (Table 4), with 14% orfewer ofthe teachers responding correctly to item23, which states thatthe reduction of sugar intake leads to the reduction of ADHD symptoms; item 34, which states that behaviouralinterventions for childrenwithADHDfocusprimarilyonthe child'sproblemswith inattention;item35,whichstatesthatElectroconvulsiveTherapyhasbeenfoundtobeaneffective treatment for severe cases of ADHD and item 37, which states that research has shown that the prolongeduse ofmedications leads to increasedaddictioninadulthood.Only onitem10,which states thatparent andteachertraining inmanaginganADHDchildaregenerallyeffectivewhen combined with medication, did the majority of the teachers answer correctly.

**Items Mean Median**

34: Behavioral/Psychological interventions for children with ADHD focus primarily on the child's problems with

35: Electroconvulsive Therapy (i.e. shock treatment) has been found to be an effective treatment for severe

36: Treatments for ADHD which focus primarily on punishment have been found to be the most effective

37: Research has shown that prolonged use of stimulant medications leads to increased addiction (i.e.,

Categorised responses to Treatment items

<sup>38</sup> <sup>41</sup> <sup>33</sup>

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

23: Reducing sugar intake is effective in reducing the

**Figure 3.** Categorised responses to Treatment items

symptoms of ADHD.

34: Behavioral/Psychological interventions focus primarily

on the child's problems with inattention.

2: Research suggests that ADHD is largely the result of

ineffective parenting skills.

37: Prolonged use of stimulant medications leads to

increased addiction (i.e., drug, alcohol) in adulthood.

18: Individual psychotherapy is usually sufficient for the

treatment of most ADHD children.

8: Antidepressant drugs have been effective in reducing

symptoms for many ADHD

12: When treatment of an ADHD child is terminated, it is

rare for the child's symptoms to return.

25: Stimulant drugs are the most common type of drug

used to treat children with ADHD

35: Electroconvulsive Therapy has been found to be an

effective treatment for severe cases of ADHD.

15: Side effects of stimulants used for treatment of ADHD

include mild insomnia and appetite reduction.

20: In severe cases of ADHD, medication is used before

other behavior modification techniques.

10: Parent and teacher training for an ADHD child are

effective when combined with medication.

36: Punishment has been found to be the most effective

in reducing the symptoms of ADHD.

30

37

55 47

<sup>7</sup> <sup>12</sup>

<sup>63</sup> <sup>57</sup>

25 24

<sup>12</sup> <sup>19</sup>

40

14

46

<sup>61</sup> <sup>54</sup>

13 12

No response/ don't know Incorrect response Correct

<sup>26</sup> <sup>34</sup>

76

10

14

<sup>48</sup> <sup>55</sup>

<sup>43</sup> <sup>36</sup>

9 9

29

6

65

47

6

47

variables (Table 5) using 1- way Analysis of Variance (ANOVA).

4. Number of years of teaching experience

5. Hours of ADHD training received

ADHD

ADHD

6. Evaluations/ assessments of children you thought may be

7. Number of children taught with a medical diagnosis of ADHD

9. Number of articles read on

10. Confidence to teach a child with ADHD

11. Teachers asked by a DR to assess the medication of a child

8. Number of workshops attended on ADHD

 **df Associated** 

In order to investigate whether the teachers' general knowledge of the content areas of ADHD differed in terms of their demographic group ,their scores on the three ADHD content areas were compared across the levels of each of the demographic

> **Associated Features - p**

**Symptoms /Diagnosis - F** 

2 9.035 \*\*\* 8.521 \*\*\* 15.924 \*\*\*

1 11.508 \*\* 13.928 \*\*\* 20.087 \*\*\*

2 6.538 \*\* 18.290 \*\*\* 20.170 \*\*\*

3 3.275 \* 8.298 \*\*\* 5.629 \*\*

1 12.506 \*\*\* 21.961 \*\*\* 16.809 \*\*\*

2 1.485 1.174 0.092

1 0.071 0.432 0.059

1 0.347 0.919 1.431

**Symptoms /Diagnosis – p** 

**Treatment - F** 

**Treatment – p** 

**Features – F** 

2. Age group 2 2.114 2.126 2.674 3. Education level 1 15.780 \*\*\* 13.919 \*\*\* 6.409 \*

in reducing the symptoms of ADHD.

drug, alcohol) in adulthood.

**Table 4.** Treatment item statistics

inattention.

cases of ADHD.

**Std. Dev.**

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

12% 0% 33% 29% 38% 2.37

14% 0% 35% 31% 41% 2.11

47% 0% 50% 44% 58% 0.12

12% 0% 33% 29% 38% 2.37

**95% Confidence Interval for mean**

**Skewness**

231

http://dx.doi.org/10.5772/53784

Once again, the categorised responses of "don't know" versus misconceptions and correct responses are displayed in Figure 3 for Treatment items. This figure shows greatest miscon‐ ceptions for items 23 and 34, which relate to dietary intake and ADHD and behavioural/ psychological interventions for children with ADHD (53% and 47% incorrect responses respectively), and fewest misconceptions on item 35; which relates to electroconvulsive therapy as a treatment approach for ADHD and item 20, which states that medication is often used before other behaviour modification techniques are attempted.


Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the… http://dx.doi.org/10.5772/53784 231


**Table 4.** Treatment item statistics

As fortheAssociatedFeatures subscale,theknowledge levelonthe treatment subscalewaspoor (Table 4), with 14% orfewer ofthe teachers responding correctly to item23, which states thatthe reduction of sugar intake leads to the reduction of ADHD symptoms; item 34, which states that behaviouralinterventions for childrenwithADHDfocusprimarilyonthe child'sproblemswith inattention;item35,whichstatesthatElectroconvulsiveTherapyhasbeenfoundtobeaneffective treatment for severe cases of ADHD and item 37, which states that research has shown that the prolongeduse ofmedications leads to increasedaddictioninadulthood.Only onitem10,which states thatparent andteachertraininginmanaginganADHDchildaregenerallyeffectivewhen

Once again, the categorised responses of "don't know" versus misconceptions and correct responses are displayed in Figure 3 for Treatment items. This figure shows greatest miscon‐ ceptions for items 23 and 34, which relate to dietary intake and ADHD and behavioural/ psychological interventions for children with ADHD (53% and 47% incorrect responses respectively), and fewest misconceptions on item 35; which relates to electroconvulsive therapy as a treatment approach for ADHD and item 20, which states that medication is often

> **Std. Dev.**

37% 0% 49% 43% 56% 0.55

46% 0% 50% 44% 58% 0.16

65% 100% 48% 42% 56% -0.64

26% 0% 44% 39% 51% 1.11

43% 0% 50% 44% 58% 0.29

19% 0% 39% 35% 46% 1.60

36% 0% 48% 42% 56% 0.59

7% 0% 26% 23% 30% 3.42

34% 0% 48% 42% 55% 0.69

**95% Confidence Interval for mean**

**Skewness**

combined with medication, did the majority of the teachers answer correctly.

used before other behaviour modification techniques are attempted.

**Items Mean Median**

2: Current research suggests that ADHD is largely the

230 Attention Deficit Hyperactivity Disorder in Children and Adolescents

8: Antidepressant drugs have been effective in reducing

10: Parent and teacher training in managing an ADHD child are generally effective when combined with

12: When treatment of an ADHD child is terminated, it

15: Side effects of stimulant drugs used for treatment of ADHD may include mild insomnia and appetite

18: Individual psychotherapy is usually sufficient for the

20: In severe cases of ADHD, medication is often used before other behavior modification techniques are

23: Reducing dietary intake of sugar or food additives is generally effective in reducing the symptoms of ADHD.

25: Stimulant drugs are the most common type of drug

is rare for the child's symptoms to return.

treatment of most ADHD children.

used to treat children with ADHD

result of ineffective parenting skills.

symptoms for many ADHD

medication treatment.

reduction.

attempted.

demographic group ,their scores on the three ADHD content areas were compared across the levels of each of the demographic

**Associated Features - p** **Symptoms /Diagnosis - F** 

2 9.035 \*\*\* 8.521 \*\*\* 15.924 \*\*\*

1 11.508 \*\* 13.928 \*\*\* 20.087 \*\*\*

2 6.538 \*\* 18.290 \*\*\* 20.170 \*\*\*

3 3.275 \* 8.298 \*\*\* 5.629 \*\*

1 12.506 \*\*\* 21.961 \*\*\* 16.809 \*\*\*

2 1.485 1.174 0.092

1 0.071 0.432 0.059

1 0.347 0.919 1.431

**Symptoms /Diagnosis – p** 

**Treatment - F** 

**Treatment – p** 

**Features – F** 

2. Age group 2 2.114 2.126 2.674 3. Education level 1 15.780 \*\*\* 13.919 \*\*\* 6.409 \*

In order to investigate whether the teachers' general knowledge of the content areas of ADHD differed in terms of their **Figure 3.** Categorised responses to Treatment items

Categorised responses to Treatment items

variables (Table 5) using 1- way Analysis of Variance (ANOVA).

4. Number of years of teaching experience

5. Hours of ADHD training received

ADHD

ADHD

6. Evaluations/ assessments of children you thought may be

7. Number of children taught with a medical diagnosis of ADHD

9. Number of articles read on

10. Confidence to teach a child with ADHD

11. Teachers asked by a DR to assess the medication of a child

8. Number of workshops attended on ADHD

 **df Associated** 

In order to investigate whether the teachers' general knowledge of the content areas of ADHD differed in terms of their demographic group,their scores on the three ADHD content areas were compared across the levels of each of the demographic variables (Table 5) using 1- way Analysis of Variance (ANOVA).

teachers with none or few hours, [(F (1; 93) = 9. 035, p < 0.001; F (1; 93) = 8.521, p< 0.001; and F (1; 93) = 15. 924, p <0.05]. Those teachers that have attended ADHD workshops score higher than those who have not [(F (2; 93) = 11. 508, p < 0.001; F (2; 93) = 13. 928, p< 0.001; and F (1; 93) = 20. 087, p <0.05]. Those teachers who have read more than five ADHD articles score higher than those who have not read any ADHD articles [(F (2; 93) = 6. 538, p < 0.001; F (2; 93) = 18. 290, p< 0.001; and F (2; 93) = 20. 170, p <0.05]. In addition, those teachers who have been asked by a doctor to assess medication of a child with ADHD, and those who feel more confident to teach children with ADHD have significantly higher scores on the three ADHD content areas than other teachers (F (3; 93)= 3.275, p < 0.001; F (3; 93) = 8.298, p < 0.001 and F(3; 93) = 5.629, p< 0.05) and (F (1; 93)= 12. 506, p < 0.001; F (1; 93) = 21. 961, p < 0.001 and F(1; 93) = 16. 809, p< 0.05). Finally, it should be noted for all the significant comparisons of the demographic variables, knowledge levels on the Symptoms/ Diagnosis content area were significantly higher than on the Associated Features and Treatment content areas. The qualitative results from the questionnaire revealed that teachers are willing and eager to participate in workshops on ADHD, substantiated by 73% of the sample group indicating that they were in favour of this. Interestingly, the 27% of teachers who did not opt to attend the workshop tended to be older, less confident (Pearson Chi-square(3) = 6.41, p<0.10), tended to have attended fewer ADHD workshops, read fewer ADHD articles and had been less often asked by a doctor to assess the medication of a child with ADHD (Pearson Chisquare(1) = 5.00, p<0.05). However, although the mean scores on the three content areas of ADHD of the respondents who opted for the workshops were marginally higher than those

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

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233

Teachers were given the opportunity to provide additional comments at the end of the questionnaire. Four teachers commented that there exists a lack of resources at the disposal of teachers and that schools should have special classes for children with ADHD, and that schools have a dire need for psychologists to help identify the children who are displaying ADHD like symptoms as soon and early on as possible. Some of the teachers explained that there is often a misdiagnosis of ADHD; and often an over diagnosis made by teachers of this condition. Teachers expressed that they would like to learn more about the identification, treatment and

This study sought to investigate the knowledge and perceptions of ADHD held by Foundation Phase teachers within a township setting in South Africa. The results of the study suggested that there exists a substantial lack of knowledge about ADHD among this sample group. These findings are consistent with the body of literature which states that teachers generally lack knowledge and hold certain misconceptions in the area of ADHD [21]. Teachers in the present study were the most knowledgeable about the symptoms of ADHD, less knowledgeable about the associated features and the least knowledgeable about treatment for this condition; which

Teachers' generally good understanding of the symptoms of ADHD which was shown in this research study, is supported by several other South African studies which were conducted

who did not opt to attend, these differences were not significant.

possible classroom interventions for learners with ADHD children.

supported the results reported in an Australian study [21].

**5.5. Discussion**


**Table 5.** ADHD content areas compared across levels of demographic variables

Education and training is the common theme underlying these items reflecting significant differences on knowledge levels of the three ADHD content areas. Based on the direction of the means and the Scheffe post hoc tests for the significant ANOVA comparisons, the general trend of the means is that the more educated and trained teachers are more knowledgea‐ ble in each of the three ADHD content areas than are the less educated and trained teach‐ ers. Specifically, teachers with a university education score significantly higher than those with a college education [F (1;93) = 15. 780, p < 0.001; F(1; 93) = 13.919, p < 0.001; and F (1;93) = 6.409, p < 0.05], teachers with more than ten hours of ADHD training score higher than teachers with none or few hours, [(F (1; 93) = 9. 035, p < 0.001; F (1; 93) = 8.521, p< 0.001; and F (1; 93) = 15. 924, p <0.05]. Those teachers that have attended ADHD workshops score higher than those who have not [(F (2; 93) = 11. 508, p < 0.001; F (2; 93) = 13. 928, p< 0.001; and F (1; 93) = 20. 087, p <0.05]. Those teachers who have read more than five ADHD articles score higher than those who have not read any ADHD articles [(F (2; 93) = 6. 538, p < 0.001; F (2; 93) = 18. 290, p< 0.001; and F (2; 93) = 20. 170, p <0.05]. In addition, those teachers who have been asked by a doctor to assess medication of a child with ADHD, and those who feel more confident to teach children with ADHD have significantly higher scores on the three ADHD content areas than other teachers (F (3; 93)= 3.275, p < 0.001; F (3; 93) = 8.298, p < 0.001 and F(3; 93) = 5.629, p< 0.05) and (F (1; 93)= 12. 506, p < 0.001; F (1; 93) = 21. 961, p < 0.001 and F(1; 93) = 16. 809, p< 0.05). Finally, it should be noted for all the significant comparisons of the demographic variables, knowledge levels on the Symptoms/ Diagnosis content area were significantly higher than on the Associated Features and Treatment content areas. The qualitative results from the questionnaire revealed that teachers are willing and eager to participate in workshops on ADHD, substantiated by 73% of the sample group indicating that they were in favour of this. Interestingly, the 27% of teachers who did not opt to attend the workshop tended to be older, less confident (Pearson Chi-square(3) = 6.41, p<0.10), tended to have attended fewer ADHD workshops, read fewer ADHD articles and had been less often asked by a doctor to assess the medication of a child with ADHD (Pearson Chisquare(1) = 5.00, p<0.05). However, although the mean scores on the three content areas of ADHD of the respondents who opted for the workshops were marginally higher than those who did not opt to attend, these differences were not significant.

Teachers were given the opportunity to provide additional comments at the end of the questionnaire. Four teachers commented that there exists a lack of resources at the disposal of teachers and that schools should have special classes for children with ADHD, and that schools have a dire need for psychologists to help identify the children who are displaying ADHD like symptoms as soon and early on as possible. Some of the teachers explained that there is often a misdiagnosis of ADHD; and often an over diagnosis made by teachers of this condition. Teachers expressed that they would like to learn more about the identification, treatment and possible classroom interventions for learners with ADHD children.

#### **5.5. Discussion**

In order to investigate whether the teachers' general knowledge of the content areas of ADHD differed in terms of their demographic group,their scores on the three ADHD content areas were compared across the levels of each of the demographic variables (Table 5) using 1- way

> **Associated Features - p**

**Symptoms/ Diagnosis -**

**Symptoms/ Diagnosis –**

**Treatment -**

**Treatment –**

**p**

**F**

**p**

**F**

2 1.485 1.174 0.092

1 0.071 0.432 0.059

1 0.347 0.919 1.431

2 9.035 \*\*\* 8.521 \*\*\* 15.924 \*\*\*

1 11.508 \*\* 13.928 \*\*\* 20.087 \*\*\*

2 6.538 \*\* 18.290 \*\*\* 20.170 \*\*\*

3 3.275 \* 8.298 \*\*\* 5.629 \*\*

1 12.506 \*\*\* 21.961 \*\*\* 16.809 \*\*\*

Education and training is the common theme underlying these items reflecting significant differences on knowledge levels of the three ADHD content areas. Based on the direction of the means and the Scheffe post hoc tests for the significant ANOVA comparisons, the general trend of the means is that the more educated and trained teachers are more knowledgea‐ ble in each of the three ADHD content areas than are the less educated and trained teach‐ ers. Specifically, teachers with a university education score significantly higher than those with a college education [F (1;93) = 15. 780, p < 0.001; F(1; 93) = 13.919, p < 0.001; and F (1;93) = 6.409, p < 0.05], teachers with more than ten hours of ADHD training score higher than

**df Associated Features – F**

**Table 5.** ADHD content areas compared across levels of demographic variables

2. Age group 2 2.114 2.126 2.674

3. Education level 1 15.780 \*\*\* 13.919 \*\*\* 6.409 \*

Analysis of Variance (ANOVA).

232 Attention Deficit Hyperactivity Disorder in Children and Adolescents

4. Number of years of teaching

5. Hours of ADHD training

6. Evaluations/ assessments of children you thought may be

7. Number of children taught with a medical diagnosis of

8. Number of workshops attended on ADHD

9. Number of articles read on

10. Confidence to teach a child

11. Teachers asked by a DR to assess the medication of a child

experience

received

ADHD

ADHD

ADHD

with ADHD

with ADHD

This study sought to investigate the knowledge and perceptions of ADHD held by Foundation Phase teachers within a township setting in South Africa. The results of the study suggested that there exists a substantial lack of knowledge about ADHD among this sample group. These findings are consistent with the body of literature which states that teachers generally lack knowledge and hold certain misconceptions in the area of ADHD [21]. Teachers in the present study were the most knowledgeable about the symptoms of ADHD, less knowledgeable about the associated features and the least knowledgeable about treatment for this condition; which supported the results reported in an Australian study [21].

Teachers' generally good understanding of the symptoms of ADHD which was shown in this research study, is supported by several other South African studies which were conducted using a range of different teacher and school samples [2, 26, 28, 44]. Even though teachers in this study obtained the highest percentage of correct responses for the symptoms/diagnosis subscale of the KADDS, there were two specific items which resulted in the greatest extent of teacher misperception. Physical cruelty to other people and a history of stealing and destroying other people's things were perceived by the teachers as features of ADHD. The behaviours included in these two items are those that are characteristic of a Conduct Disorder and suggestive of an Oppositional Defiant Disorder [45], which the teachers in the present study may not have been aware of. These findings are consistent with the results of a study that was conducted in America [23].

of education, the more knowledge they possessed on ADHD, possibly as a result greater exposure to this condition. Unlike the findings of [31], teachers' knowledge of ADHD was unrelated to their number of years of teaching experience in this study. An important finding for school administrators is the result that teachers who previously attended training pro‐ grammes and workshops and those that were exposed to ADHD by means of written articles, all knew more about the condition than those teachers with less training and exposure in the area. Furthermore, teachers who felt more confident to teach a child with ADHD obtained higher scores on the KADDS, and thus knew more about the condition. This finding supports the results of studies conducted by [2, 31], where the more confident teachers had more

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235

It was noted in this study, that it was the younger, more confident, more experienced teachers who wanted to participate in workshops on ADHD. The teachers also suggested that the workshops include a section on treatment, which is an area where knowledge is seemingly lacking. The older, more inexperienced teachers were those who were reluctant and disinter‐ ested to partake in workshops. One reason for this may be because the older teachers are more

The finding may be related to what Martin Seligman calls learned helplessness. This is once an "individual learns that he or she is not in control, the motivation to seek control may be shut down, even when control later becomes possible [47, p.252]. Due to the lack of resources within the townships in South Africa and the possible lack of options that some of these teachers are faced with, they may have come to learn that they are not in control of the situation, and often what they do is to no avail. Thus, when a workshop is offered to them, they may have learned that they are not in control, and consequently they do not believe that the

Results of the study imply that South African Foundation Phase teachers do not have adequate knowledge or sufficient understanding of ADHD. Teachers seem to have some information on the symptoms of ADHD, and less on the associated features and treatment for the condition. It is therefore important that training programmes or workshops address these gaps in the teachers' knowledge regarding the condition. Overall, the majority of teachers in this study expressed willingness to participate in workshops and training programmes on ADHD. Teachers also indicated that there is a lack of resources at the township schools to aid in the recognition and management of the condition. It is essential that the South African Department of Education becomes aware of these issues and provides teachers with the necessary training and ongoing support to facilitate the learning and schooling experience and holistic develop‐ ment of children with ADHD. This is of particular importance if inclusive education is to be

The following were some of the limitations of the present research study:

set in their ways, and are thus more reluctant to engage in and learn new material.

workshop will be of assistance and benefit to them.

**5.6. Implications of the research**

implemented successfully.

**5.7. Limitations of the study**

knowledge on ADHD.

In the present study, teachers were less knowledgeable about the associated features of ADHD, than they were about the symptoms, as half of the respondents answered less than 31% of the items on this subscale correctly. However, teachers obtained the lowest scores on the treatment subscale. Teachers in the present study possessed very poor and even incorrect knowledge regarding the treatment of ADHD. This finding has an important implication for teacher preservice and in-service training, as teachers play an important role in the identification, management and treatment of ADHD [21]. Teachers in this study seemed to possess limited and even incorrect knowledge on the after effects of medication, and many of them believed that stimulant medications lead to drug and alcohol addictions in adulthood. Nevertheless, the majority of the teachers in the current study were aware that parent and teacher training in managing a child diagnosed with ADHD combined with medical treatment, was generally an effective and preferable method of treatment for this condition.

In line with the results of a number of other studies [2, 46], a large number of teachers in the present study incorrectly believed that the alteration of diet and the reduction of sugars and food additives would lead to the alleviation of ADHD symptoms. Few studies have supported the idea that the alteration of one's diet alleviates symptoms of ADHD, and in fact labels this belief as a common myth [15].

Among the sample group in this study, there existed a clear lack of knowledge on the epi‐ demiology of ADHD, as a very low percentage of correct responses was obtained for the item which stated that most estimates suggest that ADHD occurs in approximately 15% of school age children. As pointed out by the study conducted by [23], if teachers are unaware of how many students in their classrooms have ADHD, it may lead to the condition being overlooked and unidentified, or conversely, it may lead to the teacher attributing many of a child's unruly and uncharacteristic behaviours to ADHD resulting in incorrect referrals [2].

Poor academic performance is often considered as one of the most prominent factors associated with ADHD, and students with ADHD are at an increased risk for grade retention and school failure [15]. Teachers in the present study seemed to be aware of this, and results revealed a large number of correct responses for the questionnaire item which looked at the idea that the majority of ADHD children evidence some degree of poor school performance in the elemen‐ tary school years.

In this study, while the age of the teachers was unrelated to their overall level of ADHD knowledge, their educational level was positively related to this variable. The higher their level of education, the more knowledge they possessed on ADHD, possibly as a result greater exposure to this condition. Unlike the findings of [31], teachers' knowledge of ADHD was unrelated to their number of years of teaching experience in this study. An important finding for school administrators is the result that teachers who previously attended training pro‐ grammes and workshops and those that were exposed to ADHD by means of written articles, all knew more about the condition than those teachers with less training and exposure in the area. Furthermore, teachers who felt more confident to teach a child with ADHD obtained higher scores on the KADDS, and thus knew more about the condition. This finding supports the results of studies conducted by [2, 31], where the more confident teachers had more knowledge on ADHD.

It was noted in this study, that it was the younger, more confident, more experienced teachers who wanted to participate in workshops on ADHD. The teachers also suggested that the workshops include a section on treatment, which is an area where knowledge is seemingly lacking. The older, more inexperienced teachers were those who were reluctant and disinter‐ ested to partake in workshops. One reason for this may be because the older teachers are more set in their ways, and are thus more reluctant to engage in and learn new material.

The finding may be related to what Martin Seligman calls learned helplessness. This is once an "individual learns that he or she is not in control, the motivation to seek control may be shut down, even when control later becomes possible [47, p.252]. Due to the lack of resources within the townships in South Africa and the possible lack of options that some of these teachers are faced with, they may have come to learn that they are not in control of the situation, and often what they do is to no avail. Thus, when a workshop is offered to them, they may have learned that they are not in control, and consequently they do not believe that the workshop will be of assistance and benefit to them.

#### **5.6. Implications of the research**

using a range of different teacher and school samples [2, 26, 28, 44]. Even though teachers in this study obtained the highest percentage of correct responses for the symptoms/diagnosis subscale of the KADDS, there were two specific items which resulted in the greatest extent of teacher misperception. Physical cruelty to other people and a history of stealing and destroying other people's things were perceived by the teachers as features of ADHD. The behaviours included in these two items are those that are characteristic of a Conduct Disorder and suggestive of an Oppositional Defiant Disorder [45], which the teachers in the present study may not have been aware of. These findings are consistent with the results of a study that was

In the present study, teachers were less knowledgeable about the associated features of ADHD, than they were about the symptoms, as half of the respondents answered less than 31% of the items on this subscale correctly. However, teachers obtained the lowest scores on the treatment subscale. Teachers in the present study possessed very poor and even incorrect knowledge regarding the treatment of ADHD. This finding has an important implication for teacher preservice and in-service training, as teachers play an important role in the identification, management and treatment of ADHD [21]. Teachers in this study seemed to possess limited and even incorrect knowledge on the after effects of medication, and many of them believed that stimulant medications lead to drug and alcohol addictions in adulthood. Nevertheless, the majority of the teachers in the current study were aware that parent and teacher training in managing a child diagnosed with ADHD combined with medical treatment, was generally

In line with the results of a number of other studies [2, 46], a large number of teachers in the present study incorrectly believed that the alteration of diet and the reduction of sugars and food additives would lead to the alleviation of ADHD symptoms. Few studies have supported the idea that the alteration of one's diet alleviates symptoms of ADHD, and in fact labels this

Among the sample group in this study, there existed a clear lack of knowledge on the epi‐ demiology of ADHD, as a very low percentage of correct responses was obtained for the item which stated that most estimates suggest that ADHD occurs in approximately 15% of school age children. As pointed out by the study conducted by [23], if teachers are unaware of how many students in their classrooms have ADHD, it may lead to the condition being overlooked and unidentified, or conversely, it may lead to the teacher attributing many of a child's unruly

Poor academic performance is often considered as one of the most prominent factors associated with ADHD, and students with ADHD are at an increased risk for grade retention and school failure [15]. Teachers in the present study seemed to be aware of this, and results revealed a large number of correct responses for the questionnaire item which looked at the idea that the majority of ADHD children evidence some degree of poor school performance in the elemen‐

In this study, while the age of the teachers was unrelated to their overall level of ADHD knowledge, their educational level was positively related to this variable. The higher their level

and uncharacteristic behaviours to ADHD resulting in incorrect referrals [2].

an effective and preferable method of treatment for this condition.

conducted in America [23].

234 Attention Deficit Hyperactivity Disorder in Children and Adolescents

belief as a common myth [15].

tary school years.

Results of the study imply that South African Foundation Phase teachers do not have adequate knowledge or sufficient understanding of ADHD. Teachers seem to have some information on the symptoms of ADHD, and less on the associated features and treatment for the condition. It is therefore important that training programmes or workshops address these gaps in the teachers' knowledge regarding the condition. Overall, the majority of teachers in this study expressed willingness to participate in workshops and training programmes on ADHD. Teachers also indicated that there is a lack of resources at the township schools to aid in the recognition and management of the condition. It is essential that the South African Department of Education becomes aware of these issues and provides teachers with the necessary training and ongoing support to facilitate the learning and schooling experience and holistic develop‐ ment of children with ADHD. This is of particular importance if inclusive education is to be implemented successfully.

#### **5.7. Limitations of the study**

The following were some of the limitations of the present research study:

**•** The sample for the study was obtained on a strict voluntary basis; using a purposive, non probability sampling method. The current sample is not representative of the entire population of Foundation Phase township teachers. Responses to the questionnaire were very much dependent on the teachers' availability and willingness to participate in the study. A sample of 100 teachers from a specific geographic location was obtained, and there were no male participants. Thus, the sample used in the study was small and narrow. For these reasons, issues with generalisability arose and therefore widespread conclusions from the results cannot be drawn.

research conducted in the last decade. After an in depth analysis of the results of the study and other research conducted, the chapter highlighted that the lack of knowledge that teachers has, as well as the misperceptions they hold regarding ADHD, need to be addressed as teachers play a vital role in the identification, diagnosis, referral and treatment process of ADHD. Inaccurate information about ADHD can lead to inaccurate referrals, resulting in the incorrect information being relayed to parents and doctors, which in itself has negative effects and consequences for individuals' diagnosed with the condition. In addition the chapter also noted the need for more workshops and programmes to become available to teachers to aid them in the recognition and management of ADHD in their classrooms. Overall, the chapter high‐ lighted the need for more research to be conducted in the area of ADHD in South Africa, in order for every learner to maximise his or her potential and to succeed within the South African

Attention-Deficit/Hyperactivity Disorder (ADHD) as a Barrier to Learning and Development within the…

http://dx.doi.org/10.5772/53784

237

and Kim Lazarus2

1 Department of Psychology, University of the Witwatersrand, Johannesburg, South Africa

[1] Meyer A. Cross-cultural issues in ADHD research. Journal of Psychology in Africa

[2] Perold M., Louw C., Kleynhans S. Primary school teachers' knowledge and misper‐ ceptions of attention deficit hyperactivity disorder (ADHD). South African Journal of

[3] Naicker SM. From Apartheid education to inclusive education. International Educa‐

[4] South African Government. Constitution of the Republic of South Africa, Act No. 108

[5] Prinsloo E. Working towards inclusive education in South African classrooms. South

[6] Engelbrecht P., Green, L. Responding to the challenges of inclusive education in

tion Summit for a Democratic Society, 26-28 June 2000, Detroit, Michigan.

of 1996. Pretoria: South African Government; 1996.

African Journal of Education 2001;21(4) 344-348.

southern-Africa. Pretoria: Van Schaik Publishers; 2011.

inclusive education classroom environment.

, Adri Vorster1

\*Address all correspondence to: adri.vorster@wits.ac.za

2 Epworth Children's Village, Johannesburg, South Africa

**Author details**

Zaytoon Amod1

**References**

2005;10 101-106.

Education 2010;30 457-473.


#### **5.8. Suggestions for future research**

The following suggestions are made for future research:


#### **6. Conclusion**

This chapter primarily focused on one particular South African study [36] that sought to investigate the knowledge and perceptions of ADHD held by Foundation Phase teachers in a township in Gauteng. The results of the study were compared to local and international research conducted in the last decade. After an in depth analysis of the results of the study and other research conducted, the chapter highlighted that the lack of knowledge that teachers has, as well as the misperceptions they hold regarding ADHD, need to be addressed as teachers play a vital role in the identification, diagnosis, referral and treatment process of ADHD. Inaccurate information about ADHD can lead to inaccurate referrals, resulting in the incorrect information being relayed to parents and doctors, which in itself has negative effects and consequences for individuals' diagnosed with the condition. In addition the chapter also noted the need for more workshops and programmes to become available to teachers to aid them in the recognition and management of ADHD in their classrooms. Overall, the chapter high‐ lighted the need for more research to be conducted in the area of ADHD in South Africa, in order for every learner to maximise his or her potential and to succeed within the South African inclusive education classroom environment.

#### **Author details**

**•** The sample for the study was obtained on a strict voluntary basis; using a purposive, non probability sampling method. The current sample is not representative of the entire population of Foundation Phase township teachers. Responses to the questionnaire were very much dependent on the teachers' availability and willingness to participate in the study. A sample of 100 teachers from a specific geographic location was obtained, and there were no male participants. Thus, the sample used in the study was small and narrow. For these reasons, issues with generalisability arose and therefore widespread conclusions from

**•** English is not a first language for many of the teachers that participated in the research study. It is unknown to what extent the teachers' responses to the questionnaire were hampered by language related issues, which similar research studies conducted in the future would have to consider. The construct validity of the measuring instrument used was

**•** There is limited local literature and research on ADHD. Further work is necessary to develop and contextualize international developments in relation to the unique South African

**•** The majority of teachers in this study were willing to participate in workshops related to ADHD training. Future researchers could focus on creating and providing training pro‐ grammes that would bridge the gaps in knowledge about ADHD and its causes, symptoms

**•** After the implementation of teacher training and workshops, follow up programme evaluation studies and longitudinal research would be beneficial. This research could serve as a springboard for future workshops and educational programs to be implemented at

**•** Broader teacher samples from public, private, rural and township schools need to be

**•** Future research could focus on creating awareness and gathering resources to aid in the recognition and management of the condition at schools. It is essential that teachers receive the necessary training and ongoing support to facilitate the learning and schooling experi‐

This chapter primarily focused on one particular South African study [36] that sought to investigate the knowledge and perceptions of ADHD held by Foundation Phase teachers in a township in Gauteng. The results of the study were compared to local and international

the results cannot be drawn.

**5.8. Suggestions for future research**

context.

and treatment.

**6. Conclusion**

schools at a national level.

ence of children with ADHD.

considered in future ADHD studies.

therefore a possible limitation of the study.

236 Attention Deficit Hyperactivity Disorder in Children and Adolescents

The following suggestions are made for future research:

Zaytoon Amod1 , Adri Vorster1 and Kim Lazarus2

\*Address all correspondence to: adri.vorster@wits.ac.za

1 Department of Psychology, University of the Witwatersrand, Johannesburg, South Africa

2 Epworth Children's Village, Johannesburg, South Africa

#### **References**


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**Chapter 12**

**ADHD Children's Emotion Regulation in FACE© –**

**Emotion): Theory, Research and Practice**

Smadar Celestin-Westreich and

view of ADHD children's functioning.

Additional information is available at the end of the chapter

Leon-Patrice Celestin

http://dx.doi.org/10.5772/54422

**1. Introduction**

**Perspective (Facilitating Adjustment of Cognition and**

Children with ADHD are known to display primary features of impulsivity, inattention and/or hyperactivity [1]. They also constitute a diverse group, encompassing predominantly inattentive (ADHD-I), hyperactive/impulsive (ADHD-HI) and combined (ADHD-C) sub‐ types with multiple comorbidities and developmental paths [2]. ADHD children's cognitive functioning and outcomes have been investigated extensively. Remarkably, much less re‐ search and prevention efforts have been devoted to their emotional processes and outcomes [2-4]. Consistent with a surge in research placing emotions at the centre of various psycho‐ pathologies over the past decade, a start has been made toward gaining a more balanced

This chapter discusses why emotion research is important for ADHD children (§2), presents the FACE©-model (Facilitating the Adjustment of Cognition and Emotion, [5, 6]) (§3) as a comprehensive framework through which to identify the major components and levels of emotional and associated cognitive functioning covered by the broad concept of emotion regulation (ER) (§4) and critically reviews which of these issues have been investigated in the context of ADHD (§5). The chapter pursues with identifying cautions and conditions for translating research into practice and reformulating these into a resiliency perspective on ADHD children's emotional functioning, after which implications are drawn from the evi‐ dence-base to inform intervention and prevention efforts with ADHD youth and their fami‐ lies (§6). The chapter briefly rounds out by outlining a strengths-based perspective on

and reproduction in any medium, provided the original work is properly cited.

© 2013 Celestin-Westreich and Celestin; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

further emotion-oriented research and practice with ADHD youth (§7).

properly cited.

## **ADHD Children's Emotion Regulation in FACE© – Perspective (Facilitating Adjustment of Cognition and Emotion): Theory, Research and Practice**

Smadar Celestin-Westreich and Leon-Patrice Celestin

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54422

#### **1. Introduction**

Children with ADHD are known to display primary features of impulsivity, inattention and/or hyperactivity [1]. They also constitute a diverse group, encompassing predominantly inattentive (ADHD-I), hyperactive/impulsive (ADHD-HI) and combined (ADHD-C) sub‐ types with multiple comorbidities and developmental paths [2]. ADHD children's cognitive functioning and outcomes have been investigated extensively. Remarkably, much less re‐ search and prevention efforts have been devoted to their emotional processes and outcomes [2-4]. Consistent with a surge in research placing emotions at the centre of various psycho‐ pathologies over the past decade, a start has been made toward gaining a more balanced view of ADHD children's functioning.

This chapter discusses why emotion research is important for ADHD children (§2), presents the FACE©-model (Facilitating the Adjustment of Cognition and Emotion, [5, 6]) (§3) as a comprehensive framework through which to identify the major components and levels of emotional and associated cognitive functioning covered by the broad concept of emotion regulation (ER) (§4) and critically reviews which of these issues have been investigated in the context of ADHD (§5). The chapter pursues with identifying cautions and conditions for translating research into practice and reformulating these into a resiliency perspective on ADHD children's emotional functioning, after which implications are drawn from the evi‐ dence-base to inform intervention and prevention efforts with ADHD youth and their fami‐ lies (§6). The chapter briefly rounds out by outlining a strengths-based perspective on further emotion-oriented research and practice with ADHD youth (§7).

properly cited.

© 2013 Celestin-Westreich and Celestin; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **2. Why emotional functioning matters in children with ADHD**

ADHD children's frequent learning and academic difficulties have received ample attention [1,2]. Programs destined at helping children with ADHD typically focus on alleviating the behavioural components that contribute to such difficulties in order to facilitate their school and subsequent professional curriculum. Less extensively investigated yet widely docu‐ mented is ADHD children's often complicated social, relational and family functioning [7-9]. Children with ADHD are known, for example, to have more negative peer relationships [10], be subject to bullying [11], engage in risk-taking and antisocial behaviour [12], and ex‐ perience family difficulties [4, 13, 14]. While these risk factors have led to underscoring the importance of social skills training for children with ADHD, relatively few studies to date have investigated these issues from an emotion perspective that may shed light on their un‐ derlying mechanisms.

Children with ADHD are also diagnosed more often than not with comorbid disorders [1], such as conduct disorder (CD) and oppositional defiant disorder (ODD) in 40 to 60% of cas‐ es [15-17], as well as anxiety and depression (including suicide risks) [17-20]. Attachment problems [21, 22] and posttraumatic stress symptoms/disorder are also frequently associated with ADHD [12, 23]. Furthermore, Bipolar Disorder (BD) constitutes a major possible co‐ morbidity with emotional implications for ADHD children [5, 24-26]. Pointing to yet another line of potential deficits in emotion processing, it is also increasingly acknowledged that children may concurrently present with ADHD and autism spectrum symptoms or disorder (ASS/D) [27-29].

When evaluating the impact of ADHD on children's developmental course, research there‐ fore typically grapples with the issue of disentangling to what extent their relational and so‐ cial problems are a mere consequence of their core behaviour regulation difficulties, or whether and when these problems reflect more fundamental facets of their emotional func‐ tioning. In addition, the pervasiveness of emotion-related difficulties throughout the spec‐ trum of ADHD subtypes and comorbidities questions the extent to which such difficulties are ADHD (subtype) specific or represent overarching mechanisms of emotional dysregula‐ tion that broadly put children at risk for experiencing clinical problem behaviour.

**Figure 1.** ADHD Children's Functioning in FACE©-perspective, at Cognitive-Emotional Micro-level and at Biopsychoso‐

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

245

The FACE©-model thus posits that in order to constructively apprehend and act upon ADHD children's behavioural and relational challenges, it is necessary to gain insight into their cognitive-emotional adjustment processes within the ecological context of their experi‐ enced allostatic load [30]. Importantly, systematically accounting for the risk and resiliency balance operating in the ADHD child's life should also contribute to a strengths-based ap‐ proach that fosters the 'positive faces' of ADHD and thereby pave the way for effective pre‐ vention and intervention programs [4, 31, 32]. Figure 1 illustrates this model at micro-level

[6, 25, 33-35] and at macro-level [4, 6, 30], as discussed hereafter.

**3.1. The role of reciprocal cognitive and emotional adjustments on a micro-level**

tal to adaptive behaviour has been increasingly recognised over the past decade.

The notion that successful coordination of cognitive control and emotion regulation is pivo‐

cial Macro-level

### **3. ADHD children's behaviour in FACE©-perspective: Cognitive and emotional adjustments within a risk-resiliency context**

While diverse areas of research address the above-cited issues separately, there is a need to move toward a comprehensive, integrated view of ADHD children's cognitive and emotion‐ al functioning, so as to inform research as well as prevention and intervention efforts in this context. Stated in a nutshell and schematized in Figure 1, the FACE©-model aims to respond to this need by focusing on ADHD children's reciprocal adjustments of cognitive control and emotion regulation on a micro-level, while accounting for biopsychosocial risk and re‐ siliency dynamics on a macro-level [4-6].

**2. Why emotional functioning matters in children with ADHD**

244 Attention Deficit Hyperactivity Disorder in Children and Adolescents

derlying mechanisms.

(ASS/D) [27-29].

ADHD children's frequent learning and academic difficulties have received ample attention [1,2]. Programs destined at helping children with ADHD typically focus on alleviating the behavioural components that contribute to such difficulties in order to facilitate their school and subsequent professional curriculum. Less extensively investigated yet widely docu‐ mented is ADHD children's often complicated social, relational and family functioning [7-9]. Children with ADHD are known, for example, to have more negative peer relationships [10], be subject to bullying [11], engage in risk-taking and antisocial behaviour [12], and ex‐ perience family difficulties [4, 13, 14]. While these risk factors have led to underscoring the importance of social skills training for children with ADHD, relatively few studies to date have investigated these issues from an emotion perspective that may shed light on their un‐

Children with ADHD are also diagnosed more often than not with comorbid disorders [1], such as conduct disorder (CD) and oppositional defiant disorder (ODD) in 40 to 60% of cas‐ es [15-17], as well as anxiety and depression (including suicide risks) [17-20]. Attachment problems [21, 22] and posttraumatic stress symptoms/disorder are also frequently associated with ADHD [12, 23]. Furthermore, Bipolar Disorder (BD) constitutes a major possible co‐ morbidity with emotional implications for ADHD children [5, 24-26]. Pointing to yet another line of potential deficits in emotion processing, it is also increasingly acknowledged that children may concurrently present with ADHD and autism spectrum symptoms or disorder

When evaluating the impact of ADHD on children's developmental course, research there‐ fore typically grapples with the issue of disentangling to what extent their relational and so‐ cial problems are a mere consequence of their core behaviour regulation difficulties, or whether and when these problems reflect more fundamental facets of their emotional func‐ tioning. In addition, the pervasiveness of emotion-related difficulties throughout the spec‐ trum of ADHD subtypes and comorbidities questions the extent to which such difficulties are ADHD (subtype) specific or represent overarching mechanisms of emotional dysregula‐

tion that broadly put children at risk for experiencing clinical problem behaviour.

**emotional adjustments within a risk-resiliency context**

siliency dynamics on a macro-level [4-6].

**3. ADHD children's behaviour in FACE©-perspective: Cognitive and**

While diverse areas of research address the above-cited issues separately, there is a need to move toward a comprehensive, integrated view of ADHD children's cognitive and emotion‐ al functioning, so as to inform research as well as prevention and intervention efforts in this context. Stated in a nutshell and schematized in Figure 1, the FACE©-model aims to respond to this need by focusing on ADHD children's reciprocal adjustments of cognitive control and emotion regulation on a micro-level, while accounting for biopsychosocial risk and re‐

**Figure 1.** ADHD Children's Functioning in FACE©-perspective, at Cognitive-Emotional Micro-level and at Biopsychoso‐ cial Macro-level

The FACE©-model thus posits that in order to constructively apprehend and act upon ADHD children's behavioural and relational challenges, it is necessary to gain insight into their cognitive-emotional adjustment processes within the ecological context of their experi‐ enced allostatic load [30]. Importantly, systematically accounting for the risk and resiliency balance operating in the ADHD child's life should also contribute to a strengths-based ap‐ proach that fosters the 'positive faces' of ADHD and thereby pave the way for effective pre‐ vention and intervention programs [4, 31, 32]. Figure 1 illustrates this model at micro-level [6, 25, 33-35] and at macro-level [4, 6, 30], as discussed hereafter.

#### **3.1. The role of reciprocal cognitive and emotional adjustments on a micro-level**

The notion that successful coordination of cognitive control and emotion regulation is pivo‐ tal to adaptive behaviour has been increasingly recognised over the past decade.

From a predominantly *cognitive* perspective, ADHD's cardinal characteristics of impaired sustained attention and impulsiveness provide grounds per se for expecting so-called topdown disturbances of emotional functioning. Attentional fluctuations for example may in‐ terfere with how and when the child notices emotional cues, both internal and interpersonal [36-39]. Similarly, poor behavioural control and planning typical of ADHD are likely to hamper, amongst others, the child's ability to postpone emotional responses or to adequate‐ ly modulate their form and intensity [40-43]. High-order cognitive processes such as behav‐ ioural inhibition, sustained attention, attention allocation and cognitive switching indeed are critical to flexibly responding to emotional interactions in everyday life. Neuroscience studies have allowed to quite consistently link ADHD children's problems with these proc‐ esses to distinct underactivation of inferior frontal cortex (IFC) and dorsolateral prefrontal cortex (DLPFC) circuitries. In comparison, evidence suggests that conduct disordered chil‐ dren display underactivation of paralimbic system areas and bipolar children of ventral frontostriatal circuitry [44, 45].

through primary disturbances in an intrinsically integrated 'emotional-with-cognitive com‐ ponents' circuitry. This intricacy of reciprocal emotion and cognitive processing provides a basis for neural understanding of the different emotion regulation levels detailed further on.

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Several fields of study, such as developmental psychopathology, trauma and stress-related as well as neurobiological investigations, converge to demonstrate that children's dysfunc‐ tional behaviour, cognition and emotion do not occur in isolation but relative to an immedi‐ ate and larger environment [7, 31, 53]. Children's direct and long-term outcomes are determined by a dynamic balance of risks versus resources across several domains through‐

Children with ADHD are known to be at increased risk of confronting additional stressors that even further diminish their perceived resources, notably as regards their parents' (e.g. ADHD, substance abuse, stress, anxiety) and siblings' functioning (e.g. ADHD or behaviou‐ ral problems) [13, 54, 55], along with the quality of their parenting (e.g. harsh or inconsis‐ tent) [56, 57] and family environments (e.g. high levels of negative expressed emotions) [14, 58, 59] as well as school or leisure context (e.g. peer rejection) [10, 11, 60]. In other words, assessing ADHD children's emotional functioning without considering the scope of stres‐ sors versus resources operating in their immediate and larger environment will generate on‐

Investigating this risk-resiliency load furthermore may be particularly pertinent to under‐ standing ADHD children's emotional functioning given their peculiar arousal balance. Children with ADHD are indeed documented to struggle simultaneously with being overburdened and under-challenged when processing information [2]. While these fea‐ tures have been demonstrated in predominantly cognitive situations, and while clinical accounts do tend to reflect issues with emotional overburdening in ADHD children's day-to-day interpersonal functioning [4, 61, 62], there is a need for empirical evidence to

*In short,* ADHD children's emotion regulation skills may be extra challenged given the po‐ tential level of additional stressors that they tend to face. Their emotional functioning there‐ fore deserves to be examined against the broader backdrop of cumulative *risks* operating in their lives. Inversely, assessing the impact of contextual *resources* on ADHD children's emo‐ tion regulation skills is likely to provide precious leads for enhancing intervention and pre‐

Taking into account these conceptual foundations, the FACE©-model hereafter first more specifically guides our focus on the emotional and associated cognitive components im‐ plied in the emotion regulation process (§4). The evidence-base with regard to how these components present in children with ADHD is then primarily discussed on a micro-level (§5, 5.1-5.3). Macro-level parenting and family influences on ADHD children's emotional functioning are briefly reviewed in relation to their cognitive-emotional adjustments

**3.2. The role of the biopsychosocial risk and resiliency balance on a macro-level**

out their development, as illustrated in Figure 1 [6].

ly a limited understanding of the processes at hand.

this regard.

vention efforts.

(§5.4).

Even within this top-down perspective, the reciprocal directions of cognitive and emotional effects in behavioural (dis)adjustments need to be underscored. For example, in a five-year follow-up of preadolescent girls with ADHD, the association between childhood executive functioning skills such as planning and adolescent internalising and externalising comorbid‐ ity was partially mediated by social functioning in adolescence, and vice versa [46]. Studies in this vein yet still focus on behavioural manifestations of interpersonal functioning rather than on underlying emotional processes. Moreover, although the above predominant 'cogni‐ tive-toward-emotional' pathways have been only partially investigated to date, it has be‐ come apparent that they do not suffice to fully explain the range of emotional dysfunction and comorbidity in children with ADHD [47, 48].

More recently, ADHD theories have therefore turned to including an *emotion-centred* per‐ spective. This perspective is supported by brain functioning studies on how underlying emotional mechanisms may be disrupted in their own right in the context of ADHD [47, 49]. Neuroimaging studies indeed demonstrate the complexity of the neurobiological circuitry of emotion regulation, which requires continuous adjustments and integration of limbic and prefrontal brain systems [19, 45, 50, 51]. The dorsolateral, orbitofrontal and anterior cingu‐ late cortex in fact are part of complex interrelated networks that mediate emotional and cog‐ nitive information processing in relation with striatal, cerebellar, and parietal regions along with the amygdala and hippocampus [44, 45, 48, 51, 52]. More specifically, ADHD disrup‐ tions in IFC and DLPFC regions are found to be associated with prominent structural defi‐ cits in basal ganglia, deficient connectivity with reduced amygdala along with (possibly compensatory) enlarged hippocampus, all of which mediate emotion processing [44, 49]. Ex‐ pectations of central emotional disruptions in ADHD children's functioning hereby are fur‐ ther supported by the convergence of certain early-onset ADHD manifestations and the developmental precedence of the emotional brain systems compared to a comparatively late maturing cognitive circuitry [37, 44].

*In short,* from a micro-level perspective, children with ADHD may be vulnerable to emotion dysregulation through predominant 'cognitive-toward-emotional' pathways as well as through primary disturbances in an intrinsically integrated 'emotional-with-cognitive com‐ ponents' circuitry. This intricacy of reciprocal emotion and cognitive processing provides a basis for neural understanding of the different emotion regulation levels detailed further on.

#### **3.2. The role of the biopsychosocial risk and resiliency balance on a macro-level**

From a predominantly *cognitive* perspective, ADHD's cardinal characteristics of impaired sustained attention and impulsiveness provide grounds per se for expecting so-called topdown disturbances of emotional functioning. Attentional fluctuations for example may in‐ terfere with how and when the child notices emotional cues, both internal and interpersonal [36-39]. Similarly, poor behavioural control and planning typical of ADHD are likely to hamper, amongst others, the child's ability to postpone emotional responses or to adequate‐ ly modulate their form and intensity [40-43]. High-order cognitive processes such as behav‐ ioural inhibition, sustained attention, attention allocation and cognitive switching indeed are critical to flexibly responding to emotional interactions in everyday life. Neuroscience studies have allowed to quite consistently link ADHD children's problems with these proc‐ esses to distinct underactivation of inferior frontal cortex (IFC) and dorsolateral prefrontal cortex (DLPFC) circuitries. In comparison, evidence suggests that conduct disordered chil‐ dren display underactivation of paralimbic system areas and bipolar children of ventral

Even within this top-down perspective, the reciprocal directions of cognitive and emotional effects in behavioural (dis)adjustments need to be underscored. For example, in a five-year follow-up of preadolescent girls with ADHD, the association between childhood executive functioning skills such as planning and adolescent internalising and externalising comorbid‐ ity was partially mediated by social functioning in adolescence, and vice versa [46]. Studies in this vein yet still focus on behavioural manifestations of interpersonal functioning rather than on underlying emotional processes. Moreover, although the above predominant 'cogni‐ tive-toward-emotional' pathways have been only partially investigated to date, it has be‐ come apparent that they do not suffice to fully explain the range of emotional dysfunction

More recently, ADHD theories have therefore turned to including an *emotion-centred* per‐ spective. This perspective is supported by brain functioning studies on how underlying emotional mechanisms may be disrupted in their own right in the context of ADHD [47, 49]. Neuroimaging studies indeed demonstrate the complexity of the neurobiological circuitry of emotion regulation, which requires continuous adjustments and integration of limbic and prefrontal brain systems [19, 45, 50, 51]. The dorsolateral, orbitofrontal and anterior cingu‐ late cortex in fact are part of complex interrelated networks that mediate emotional and cog‐ nitive information processing in relation with striatal, cerebellar, and parietal regions along with the amygdala and hippocampus [44, 45, 48, 51, 52]. More specifically, ADHD disrup‐ tions in IFC and DLPFC regions are found to be associated with prominent structural defi‐ cits in basal ganglia, deficient connectivity with reduced amygdala along with (possibly compensatory) enlarged hippocampus, all of which mediate emotion processing [44, 49]. Ex‐ pectations of central emotional disruptions in ADHD children's functioning hereby are fur‐ ther supported by the convergence of certain early-onset ADHD manifestations and the developmental precedence of the emotional brain systems compared to a comparatively late

*In short,* from a micro-level perspective, children with ADHD may be vulnerable to emotion dysregulation through predominant 'cognitive-toward-emotional' pathways as well as

frontostriatal circuitry [44, 45].

and comorbidity in children with ADHD [47, 48].

246 Attention Deficit Hyperactivity Disorder in Children and Adolescents

maturing cognitive circuitry [37, 44].

Several fields of study, such as developmental psychopathology, trauma and stress-related as well as neurobiological investigations, converge to demonstrate that children's dysfunc‐ tional behaviour, cognition and emotion do not occur in isolation but relative to an immedi‐ ate and larger environment [7, 31, 53]. Children's direct and long-term outcomes are determined by a dynamic balance of risks versus resources across several domains through‐ out their development, as illustrated in Figure 1 [6].

Children with ADHD are known to be at increased risk of confronting additional stressors that even further diminish their perceived resources, notably as regards their parents' (e.g. ADHD, substance abuse, stress, anxiety) and siblings' functioning (e.g. ADHD or behaviou‐ ral problems) [13, 54, 55], along with the quality of their parenting (e.g. harsh or inconsis‐ tent) [56, 57] and family environments (e.g. high levels of negative expressed emotions) [14, 58, 59] as well as school or leisure context (e.g. peer rejection) [10, 11, 60]. In other words, assessing ADHD children's emotional functioning without considering the scope of stres‐ sors versus resources operating in their immediate and larger environment will generate on‐ ly a limited understanding of the processes at hand.

Investigating this risk-resiliency load furthermore may be particularly pertinent to under‐ standing ADHD children's emotional functioning given their peculiar arousal balance. Children with ADHD are indeed documented to struggle simultaneously with being overburdened and under-challenged when processing information [2]. While these fea‐ tures have been demonstrated in predominantly cognitive situations, and while clinical accounts do tend to reflect issues with emotional overburdening in ADHD children's day-to-day interpersonal functioning [4, 61, 62], there is a need for empirical evidence to this regard.

*In short,* ADHD children's emotion regulation skills may be extra challenged given the po‐ tential level of additional stressors that they tend to face. Their emotional functioning there‐ fore deserves to be examined against the broader backdrop of cumulative *risks* operating in their lives. Inversely, assessing the impact of contextual *resources* on ADHD children's emo‐ tion regulation skills is likely to provide precious leads for enhancing intervention and pre‐ vention efforts.

Taking into account these conceptual foundations, the FACE©-model hereafter first more specifically guides our focus on the emotional and associated cognitive components im‐ plied in the emotion regulation process (§4). The evidence-base with regard to how these components present in children with ADHD is then primarily discussed on a micro-level (§5, 5.1-5.3). Macro-level parenting and family influences on ADHD children's emotional functioning are briefly reviewed in relation to their cognitive-emotional adjustments (§5.4).

### **4. Which aspects of emotion regulation merit investigation in ADHD children and why?**

The field of emotion regulation research is unwieldy and potentially confusing as illustrated hereafter (§4.1). To clarify the evidence-base regarding ADHD children's emotion regula‐ tion, the next paragraphs first disentangle its major operational components (§4.2) and then integrate these in the micro-level of the model introduced with Figure 1 (§4.3).

50, 63, 64, 66]. Cognitive and emotional processes are intricately interwoven in these compo‐ nents. This is the case, for instance, as thoughts and feelings jointly constitute the subjective experience accompanying a child's initial physiological reactions (appraisal); or as memory intervenes along with emotional reactivity in how the child regulates emotional intensity (modulation); or as attention allocation, planning and attributed feeling reciprocally deter‐

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249

Third and in line with the above, a more detailed working definition of the *process of emotion regulation* has been proposed by Eisenberg and Spinrad (2004) as consisting of "initiating, avoiding, inhibiting, maintaining, or modulating the occurrence, form, intensity, or duration of internal feeling states, emotion-related physiological, attentional processes, motivational states, and/or the behavioural concomitants of emotion in the service of accomplishing af‐ fect-related biological or social adaptation or achieving individual goals" [67, p.338]. This definition further highlights the important range of processes at work in emotion regulation. Taking into account this working definition, ADHD children's important levels of external‐ ising (CD, ODD, BD) as well as internalising comorbidity (anxiety, depression, BD) imply that their emotional arousal, appraisal and expression might carry both 'hot' and 'cold', as

Closing in on the micro-level of the FACE©-model allows summarising the aforementioned multiple facets and levels of emotional, and associated cognitive, functioning covered by the

mine the behaviour through which the child exhibits an emotion (expression).

well as 'approach' and 'avoidance' features as detailed further on [60].

**4.3. ADHD children's emotion regulation conceptually revisited**

concept of emotion regulation, as visualised in figure 2.

**Figure 2.** ADHD children's cognitive, emotional and behavioural ER components

#### **4.1. Investigating ADHD children's emotion regulation: A complex issue**

The adequate recognition and expression of emotions is fundamental to a child's develop‐ ment, and emotion regulation is instrumental to the personal and relational as well as the cognitive fulfilment of the child [42, 63]. Despite this knowledge, few empirical studies among children with ADHD (or adults for that matter) are specifically dedicated to their emotion regulation skills. It has not helped that emotion regulation tends to be approached in a broad variety of ways, regardless of the investigated population. The focus of ER re‐ search with ADHD children notably ranges from physiological mechanisms and neurobio‐ logical circuits to questionnaire-based and observational behavioural measures; and from laboratory to ecologically pertinent studies. Furthermore, emotional functioning consists of autonomic, automated and implicit responses [16, 48, 50] as well as deliberate, effortful reg‐ ulation [20, 37], which adds to the investigation range [42]. In fact, the transient, elusive and subjective nature of emotions has complicated the process of generating an encompassing and yet precise definition of emotion since centuries, and has probably contributed to em‐ pirical research shying away from the subject [51, 64]. The conceptualisation history of ADHD thus has moved away during the second half of the 20th century from emotional fea‐ tures that were previously included in its core descriptions, only to return to addressing their pervasiveness in the contemporary literature [47]. In recent years, a more pragmatic approach involves focussing on the typical or core features of ER that allow setting a frame‐ work with working definitions to guide emotion research [63].

#### **4.2. Major operational components and levels of emotion regulation**

Three operational specifications of emotion regulation appear particularly pertinent to the present purpose of clarifying the investigation of emotional processes in children with ADHD.

First, *emotions* are bio-psycho-social phenomena that consist of (unconscious, autonomic) physiological reactions, which are accompanied by subjective experiences and behavioural expressions within a given context [48, 63, 65]. Emotion research with ADHD children there‐ fore deserves to include at least three levels of interest, namely a biological, an (introspec‐ tive) experiential and a behavioural-interpersonal level.

Second, competent *emotional functioning*, which appears to be challenged in children with ADHD, consequently comprises at least three core, interconnected components that merit examination, namely the adequate appraisal, modulation and expression of emotions [42, 50, 63, 64, 66]. Cognitive and emotional processes are intricately interwoven in these compo‐ nents. This is the case, for instance, as thoughts and feelings jointly constitute the subjective experience accompanying a child's initial physiological reactions (appraisal); or as memory intervenes along with emotional reactivity in how the child regulates emotional intensity (modulation); or as attention allocation, planning and attributed feeling reciprocally deter‐ mine the behaviour through which the child exhibits an emotion (expression).

Third and in line with the above, a more detailed working definition of the *process of emotion regulation* has been proposed by Eisenberg and Spinrad (2004) as consisting of "initiating, avoiding, inhibiting, maintaining, or modulating the occurrence, form, intensity, or duration of internal feeling states, emotion-related physiological, attentional processes, motivational states, and/or the behavioural concomitants of emotion in the service of accomplishing af‐ fect-related biological or social adaptation or achieving individual goals" [67, p.338]. This definition further highlights the important range of processes at work in emotion regulation. Taking into account this working definition, ADHD children's important levels of external‐ ising (CD, ODD, BD) as well as internalising comorbidity (anxiety, depression, BD) imply that their emotional arousal, appraisal and expression might carry both 'hot' and 'cold', as well as 'approach' and 'avoidance' features as detailed further on [60].

#### **4.3. ADHD children's emotion regulation conceptually revisited**

**4. Which aspects of emotion regulation merit investigation in ADHD**

integrate these in the micro-level of the model introduced with Figure 1 (§4.3).

**4.1. Investigating ADHD children's emotion regulation: A complex issue**

work with working definitions to guide emotion research [63].

tive) experiential and a behavioural-interpersonal level.

**4.2. Major operational components and levels of emotion regulation**

Three operational specifications of emotion regulation appear particularly pertinent to the present purpose of clarifying the investigation of emotional processes in children with

First, *emotions* are bio-psycho-social phenomena that consist of (unconscious, autonomic) physiological reactions, which are accompanied by subjective experiences and behavioural expressions within a given context [48, 63, 65]. Emotion research with ADHD children there‐ fore deserves to include at least three levels of interest, namely a biological, an (introspec‐

Second, competent *emotional functioning*, which appears to be challenged in children with ADHD, consequently comprises at least three core, interconnected components that merit examination, namely the adequate appraisal, modulation and expression of emotions [42,

The field of emotion regulation research is unwieldy and potentially confusing as illustrated hereafter (§4.1). To clarify the evidence-base regarding ADHD children's emotion regula‐ tion, the next paragraphs first disentangle its major operational components (§4.2) and then

The adequate recognition and expression of emotions is fundamental to a child's develop‐ ment, and emotion regulation is instrumental to the personal and relational as well as the cognitive fulfilment of the child [42, 63]. Despite this knowledge, few empirical studies among children with ADHD (or adults for that matter) are specifically dedicated to their emotion regulation skills. It has not helped that emotion regulation tends to be approached in a broad variety of ways, regardless of the investigated population. The focus of ER re‐ search with ADHD children notably ranges from physiological mechanisms and neurobio‐ logical circuits to questionnaire-based and observational behavioural measures; and from laboratory to ecologically pertinent studies. Furthermore, emotional functioning consists of autonomic, automated and implicit responses [16, 48, 50] as well as deliberate, effortful reg‐ ulation [20, 37], which adds to the investigation range [42]. In fact, the transient, elusive and subjective nature of emotions has complicated the process of generating an encompassing and yet precise definition of emotion since centuries, and has probably contributed to em‐ pirical research shying away from the subject [51, 64]. The conceptualisation history of ADHD thus has moved away during the second half of the 20th century from emotional fea‐ tures that were previously included in its core descriptions, only to return to addressing their pervasiveness in the contemporary literature [47]. In recent years, a more pragmatic approach involves focussing on the typical or core features of ER that allow setting a frame‐

**children and why?**

248 Attention Deficit Hyperactivity Disorder in Children and Adolescents

ADHD.

Closing in on the micro-level of the FACE©-model allows summarising the aforementioned multiple facets and levels of emotional, and associated cognitive, functioning covered by the concept of emotion regulation, as visualised in figure 2.

**Figure 2.** ADHD children's cognitive, emotional and behavioural ER components

Given this broadness of the emotion regulation concept, it could be argued that much re‐ search has in fact touched upon ADHD children's emotional functioning in one way or an‐ other. Diverse perspectives, such as parent- and self-reported accounts of affective lability and comorbidities, social information processing or temperament can be conceived as ques‐ tioning the role of emotions in ADHD children's outcomes [3, 11, 68]. However, only a limit‐ ed number of studies to date have effectively investigated the emotion-centred theory in children with ADHD as a means of understanding underlying mechanisms of their behav‐ ioural expressions [69, 70].

which puts the body in basic 'approach/fight' versus 'avoidance/flight' readiness. The *regu‐ lation* of emotional arousal additionally involves activation of the parasympathetic nervous system, either unconsciously or through deliberate efforts. Emotional reactivity therefore is often operationalised by confronting children with emotionally evocative material, such as pictures, stories or movies and measuring their changes from baseline in heart rate (HR), blood pressure (BP) or skin conductance (SC) levels [48, 65, 71, 72]. Blood pressure and skin conductance levels hereby provide information about sympathetic activity, whereas heart rate is linked to both sympathetic arousal and parasympathetic physiological inhibition [65, 71, 72]. Furthermore, to obtain a dynamic assessment of effortful emotion regulation, re‐ search may present children with emotional challenging tasks while measuring their recip‐

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

251

Only a handful of studies to date have directly examined the first component of emotional impulsiveness, namely ADHD children's autonomic nervous system reactivity [48, 65, 71, 73-76]. Most of these studies, moreover, were not emotion-driven, but pertained to physical positional changes [76], cognitively challenging tasks [71, 72] or daily routine conditions [74, 75]. Only one published study appears to have addressed the issue in an explicit emotion

The findings regarding ADHD children's autonomic reactivity have remained inconclusive so far, depending on comorbidity, selected physiological measures and laboratory para‐ digms [74-76]. For instance, a naturalistic study of circadian arousal variations revealed heightened diurnal and nocturnal heart rate levels in primary school age children with ADHD compared to non-clinical controls [75]. In contrast, a laboratory study examined whether school-aged children with ADHD had lower autonomic functioning and reactivity relative to those with an anxiety disorder. This was tested during and after a cognitively challenging task requiring mental arithmetic, as indexed by alteration of SC and HR levels [71]. ADHD children's skin conductance did not differ from anxious ones in baseline, stress or recovery conditions. Their heart rate yet showed a decreased response when recovering after the cognitively challenging task. These findings suggest a relative parasympathetic dominance in children with ADHD that was even more pronounced in those without co‐

Moreover, one early study by Beauchaine et al (2001) used a two-phase paradigm with (indi‐ rect) emotional elements, namely a reward and extinction based repetitive response task, that was followed by the viewing of a two minute video portraying escalating conflict be‐ tween peers [73]. Skin conductance, cardiac pre-ejection periods (PEP) and respiratory sinus arrhythmia (RSA) were investigated as respective indices of sympathetic and parasympa‐ thetic responses in adolescents aged 12 to 17 with ADHD (n=17) and ADHD with CD (n=20) compared to non-clinical controls (n=20). Although both ADHD groups displayed lower SC than controls during baseline, no differences emerged during the reward/extinction condi‐ tion. However, the comorbid ADHD children exhibited more sympathetic reactivity (PEP) compared to the ADHD and control groups at baseline, and relative to the controls only during the reward/extinction phase. They also showed lower baseline parasympathetic ac‐ tivity (RSA) relative to the ADHD-only and control children, but the groups did not differ in

rocal adjustments of sympathetic and parasympathetic responses (see below).

regulation context as detailed further on [48].

morbid CD or ODD [71].

In what follows, our focus consequently will be on studies that have explicitly undertaken to test hypotheses about ADHD children's functioning through the lens of emotion regulation. Given our focus, the discussion will more specifically highlight the fields of ADHD chil‐ dren's emotional functioning that have remained relatively neglected to date, namely their physiological reactivity, basic and contextual emotional appraisal skills, along with, to a lesser extent, deliberate emotion regulation efforts.

#### **5. Emotion regulation in ADHD children according to the evidence-base**

Consistent with the aforementioned facets of emotion regulation (see figure 2), the review of the evidence-base hereafter is organised into arousal, basic appraisal and expression re‐ search. Thus, we focus primarily and successively on studies examining how children with ADHD physiologically regulate emotions (§5.1), how they process basic or contextualised emotional cues, mainly in facial expressions (§5.2), and how they deliberately modulate emotional experience and expression (§5.3); this with a priority on recent findings.

#### **5.1. Physiological emotional reactivity and regulation in children with ADHD**

Children with ADHD's hyperactivity and impulsivity have been posited from an emo‐ tion perspective to reflect a basic hyper-arousal tendency, apart from later maturing cog‐ nitive control [47]. This tendency has been called emotional impulsiveness, notably by Barkley (2010), and considered to constitute in its own right a core feature of children with ADHD [42, 47, 48]. Emotional impulsiveness is specifically conceived, relative to its cognitive equivalent, as consisting of heightened emotional reactivity along with lessened inhibition of emotional expression [47, 61]. Children with ADHD thus may be expected to show increased physiological reactivity when confronted with affective stimuli com‐ pared to non-clinical children. On the other hand, research relative to externalizing disor‐ ders, which are often concomitant with ADHD, has suggested that children with antisocial, oppositional-defiant and conduct disordered behaviour present an underaroused autonomic nervous system in general baseline [65, 71] as well as in physical or emotion‐ al change conditions [16, 48]. ADHD children's emotional reactivity may therefore also be expected to vary according to the nature of their comorbidities.

On a physiological level, *emotional arousal* reflects in sympathetic nervous system mobilisa‐ tion, for example through increased heart rate, sweating, muscular tightening and so forth, which puts the body in basic 'approach/fight' versus 'avoidance/flight' readiness. The *regu‐ lation* of emotional arousal additionally involves activation of the parasympathetic nervous system, either unconsciously or through deliberate efforts. Emotional reactivity therefore is often operationalised by confronting children with emotionally evocative material, such as pictures, stories or movies and measuring their changes from baseline in heart rate (HR), blood pressure (BP) or skin conductance (SC) levels [48, 65, 71, 72]. Blood pressure and skin conductance levels hereby provide information about sympathetic activity, whereas heart rate is linked to both sympathetic arousal and parasympathetic physiological inhibition [65, 71, 72]. Furthermore, to obtain a dynamic assessment of effortful emotion regulation, re‐ search may present children with emotional challenging tasks while measuring their recip‐ rocal adjustments of sympathetic and parasympathetic responses (see below).

Given this broadness of the emotion regulation concept, it could be argued that much re‐ search has in fact touched upon ADHD children's emotional functioning in one way or an‐ other. Diverse perspectives, such as parent- and self-reported accounts of affective lability and comorbidities, social information processing or temperament can be conceived as ques‐ tioning the role of emotions in ADHD children's outcomes [3, 11, 68]. However, only a limit‐ ed number of studies to date have effectively investigated the emotion-centred theory in children with ADHD as a means of understanding underlying mechanisms of their behav‐

In what follows, our focus consequently will be on studies that have explicitly undertaken to test hypotheses about ADHD children's functioning through the lens of emotion regulation. Given our focus, the discussion will more specifically highlight the fields of ADHD chil‐ dren's emotional functioning that have remained relatively neglected to date, namely their physiological reactivity, basic and contextual emotional appraisal skills, along with, to a

**5. Emotion regulation in ADHD children according to the evidence-base**

Consistent with the aforementioned facets of emotion regulation (see figure 2), the review of the evidence-base hereafter is organised into arousal, basic appraisal and expression re‐ search. Thus, we focus primarily and successively on studies examining how children with ADHD physiologically regulate emotions (§5.1), how they process basic or contextualised emotional cues, mainly in facial expressions (§5.2), and how they deliberately modulate

Children with ADHD's hyperactivity and impulsivity have been posited from an emo‐ tion perspective to reflect a basic hyper-arousal tendency, apart from later maturing cog‐ nitive control [47]. This tendency has been called emotional impulsiveness, notably by Barkley (2010), and considered to constitute in its own right a core feature of children with ADHD [42, 47, 48]. Emotional impulsiveness is specifically conceived, relative to its cognitive equivalent, as consisting of heightened emotional reactivity along with lessened inhibition of emotional expression [47, 61]. Children with ADHD thus may be expected to show increased physiological reactivity when confronted with affective stimuli com‐ pared to non-clinical children. On the other hand, research relative to externalizing disor‐ ders, which are often concomitant with ADHD, has suggested that children with antisocial, oppositional-defiant and conduct disordered behaviour present an underaroused autonomic nervous system in general baseline [65, 71] as well as in physical or emotion‐ al change conditions [16, 48]. ADHD children's emotional reactivity may therefore also

On a physiological level, *emotional arousal* reflects in sympathetic nervous system mobilisa‐ tion, for example through increased heart rate, sweating, muscular tightening and so forth,

emotional experience and expression (§5.3); this with a priority on recent findings.

**5.1. Physiological emotional reactivity and regulation in children with ADHD**

be expected to vary according to the nature of their comorbidities.

ioural expressions [69, 70].

lesser extent, deliberate emotion regulation efforts.

250 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Only a handful of studies to date have directly examined the first component of emotional impulsiveness, namely ADHD children's autonomic nervous system reactivity [48, 65, 71, 73-76]. Most of these studies, moreover, were not emotion-driven, but pertained to physical positional changes [76], cognitively challenging tasks [71, 72] or daily routine conditions [74, 75]. Only one published study appears to have addressed the issue in an explicit emotion regulation context as detailed further on [48].

The findings regarding ADHD children's autonomic reactivity have remained inconclusive so far, depending on comorbidity, selected physiological measures and laboratory para‐ digms [74-76]. For instance, a naturalistic study of circadian arousal variations revealed heightened diurnal and nocturnal heart rate levels in primary school age children with ADHD compared to non-clinical controls [75]. In contrast, a laboratory study examined whether school-aged children with ADHD had lower autonomic functioning and reactivity relative to those with an anxiety disorder. This was tested during and after a cognitively challenging task requiring mental arithmetic, as indexed by alteration of SC and HR levels [71]. ADHD children's skin conductance did not differ from anxious ones in baseline, stress or recovery conditions. Their heart rate yet showed a decreased response when recovering after the cognitively challenging task. These findings suggest a relative parasympathetic dominance in children with ADHD that was even more pronounced in those without co‐ morbid CD or ODD [71].

Moreover, one early study by Beauchaine et al (2001) used a two-phase paradigm with (indi‐ rect) emotional elements, namely a reward and extinction based repetitive response task, that was followed by the viewing of a two minute video portraying escalating conflict be‐ tween peers [73]. Skin conductance, cardiac pre-ejection periods (PEP) and respiratory sinus arrhythmia (RSA) were investigated as respective indices of sympathetic and parasympa‐ thetic responses in adolescents aged 12 to 17 with ADHD (n=17) and ADHD with CD (n=20) compared to non-clinical controls (n=20). Although both ADHD groups displayed lower SC than controls during baseline, no differences emerged during the reward/extinction condi‐ tion. However, the comorbid ADHD children exhibited more sympathetic reactivity (PEP) compared to the ADHD and control groups at baseline, and relative to the controls only during the reward/extinction phase. They also showed lower baseline parasympathetic ac‐ tivity (RSA) relative to the ADHD-only and control children, but the groups did not differ in RSA during the video condition. The SC and PEP findings of this study were essentially re‐ plicated in a more recent investigation with four to six year old preschoolers at risk for hav‐ ing ADHD and ODD (n=18) [77]. Changes in at-risk preschoolers' heart rate in this study further pointed to a predominance of parasympathetic mediation of their autonomic re‐ sponses in behavioural reward/extinction conditions.

*Taken together,* findings remain mixed as regards several aspects of ADHD children's auto‐ nomic reactivity. The earlier indications of a heightened sympathetic responsiveness in co‐ morbid ADHD and CD children in a reward-based condition contrast with both underarousal expectations and with ADHD-only children's similar-to-control sympathetic reactivity in an active emotion induction/suppression context. A convergent tendency yet appears to come forward regarding ADHD children's inadaptive parasympathetic respons‐ es across different investigation contexts (deliberate emotion induction/suppression versus spontaneous responses to cognitively challenging tasks). This tendency would lend support to behavioural observations that children with ADHD especially have difficulty adequately adjusting their emotional responses [42, 61]. Moreover, ADHD children tend to show altered HPA-functioning, as evidenced in blunted versus intensified cortisol reactivity in respective‐ ly externalising (ADHD-C and conduct disorder comorbidity) and internalising (ADHD-I and anxious comorbidity) children. Thus, ADHD children's cortisol reactivity might medi‐ ate their emotional responses in emotionally challenging situations. Evidently, however, given the scant number of available studies, further specific examination is required of ADHD children's physiological arousal in emotional conditions. Variations herein according to ADHD comorbidities and subtypes merit further clarification, with the latter remaining largely unaddressed as regards sympathetic and parasympathetic physiological regulation.

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Emotion research in children with ADHD has emerged in part through a select number of 'early' studies examining their facial emotion recognition (FER) skills. Research on FER questions the ability of the child to adequately process or appraise basic emotional cues, a skill that is instrumental to its survival and interactions with others [40, 41, 81]. Although such cues can be verbal as well as non-verbal, especially the latter are recognised to be force‐ ful communication elements and this early-on in development [82]. FER research paradigms thus generally consist of recording children's proficiency in labelling facial emotions, which

Given the discussion so far, at least four basic questions apply to ADHD children's FER, namely 1) are ADHD children's FER skills compromised compared to those without ADHD?, 2) if so, for which emotions is this the case?, 3) are ADHD children's FER skills linked to their (interpersonal) behavioural functioning?, and 4) which underlying mecha‐

Altogether, fourteen published studies were identified from 1998 on in Pubmed and through further reviewing of references that have directly addressed (facial) emotion rec‐ ognition and understanding in children diagnosed with ADHD, besides one study on 'atrisk' children [83] and an ongoing study by our FACE©-ADHD program [30, 84]. As summarised in Table 1 and discussed in paragraph 5.2.1, two-third of these studies [28, 36, 39, 40, 85-89] have focused on simple FER and mostly pointed toward ADHD chil‐ dren experiencing significantly more FER difficulties compared to non-clinical controls. The investigated samples however remain relatively small and diverse in terms of con‐ text and comorbidity. Furthermore, precise indications regarding which facial emotions

**5.2. ADHD children's processing of basic (facial) emotional cues**

are either viewed in isolation or within a broader visual or verbal context.

nisms may explain ADHD children's FER difficulties?

In all, one published study could be identified that explicitly investigated whether children with ADHD display a particular sympathetic and/or parasympathetic reactivity in manifest emotional conditions and whether this differs according to emotions. In a rare laboratory paradigm using active emotion induction and suppression conditions, Musser et al. (2011) indeed examined 66, seven to nine-year old, ADHD and non-clinical control children's auto‐ nomic responses [48]. Children were first instructed to facially mimic emotions of a main character viewed in a developmentally appropriate film clip (active emotion induction), and subsequently to imagine the main characters' feelings yet while not expressing any facial emotion (active emotion suppression). The children's sympathetic cardiac PEP and para‐ sympathetic RSA were recorded throughout positive and negative emotion induction and suppression conditions. ADHD and control children's autonomic responses did not differ in baseline or neutral conditions. No significant group differences emerged either in children's sympathetic (PEP) responses. However, ADHD children exhibited a slight yet significant parasympathetic augmentation (RSA), and this inflexibly across all emotional conditions (positive and negative, induction and suppression). Moreover, when expressing deliberate positive facial emotion, the ADHD group responded with a more pronounced ineffective parasympathetic increase in contrast to control children's RSA decrease, suggesting an ina‐ daptive emotional approach response.

ADHD children's physiological reactivity has furthermore been investigated along an addi‐ tional line of questioning concerning alterations in their hypothalamic-pituitary-adrenocorti‐ cal (HPA) axis. Consistent with the initially outlined expectations, ADHD children have been expected to show blunted cortisol responses to stress [78-80]. Again, studies in this re‐ spect have as yet seldom focused specifically on emotional contexts and have yielded mixed results across ADHD heterogeneity. In essence, predicted blunted cortisol responses are evi‐ denced in children with ADHD and comorbid disruptive behaviour disorders. However, children with ADHD and comorbid anxiety disorders tend to show increased cortisol reac‐ tivity [78, 79]. Furthermore, one study compared cortisol responses during a public speaking situation among children with ADHD-C (n=52), ADHD-I (n=23) and non-clinical controls (n=25) [80]. In this more manifest psychosocial stress condition, ADHD children's HPA functioning showed subtype distinctions along similar externalising versus internalising lines as above, with ADHD-C children displaying blunted and ADHD-I increased cortisol responses. Finally, one study explicitly examined whether ADHD children's oppositional behaviour would be mediated by their cortisol reactivity to expressed emotions during a family emotion provocation task [58]. High levels of parental negative expressed emotion were indeed associated with both oppositional behaviour and increased cortisol responses in children with ADHD. Cortisol reactivity hereby mediated the emotion-to-behaviour path‐ way in all children.

*Taken together,* findings remain mixed as regards several aspects of ADHD children's auto‐ nomic reactivity. The earlier indications of a heightened sympathetic responsiveness in co‐ morbid ADHD and CD children in a reward-based condition contrast with both underarousal expectations and with ADHD-only children's similar-to-control sympathetic reactivity in an active emotion induction/suppression context. A convergent tendency yet appears to come forward regarding ADHD children's inadaptive parasympathetic respons‐ es across different investigation contexts (deliberate emotion induction/suppression versus spontaneous responses to cognitively challenging tasks). This tendency would lend support to behavioural observations that children with ADHD especially have difficulty adequately adjusting their emotional responses [42, 61]. Moreover, ADHD children tend to show altered HPA-functioning, as evidenced in blunted versus intensified cortisol reactivity in respective‐ ly externalising (ADHD-C and conduct disorder comorbidity) and internalising (ADHD-I and anxious comorbidity) children. Thus, ADHD children's cortisol reactivity might medi‐ ate their emotional responses in emotionally challenging situations. Evidently, however, given the scant number of available studies, further specific examination is required of ADHD children's physiological arousal in emotional conditions. Variations herein according to ADHD comorbidities and subtypes merit further clarification, with the latter remaining largely unaddressed as regards sympathetic and parasympathetic physiological regulation.

#### **5.2. ADHD children's processing of basic (facial) emotional cues**

RSA during the video condition. The SC and PEP findings of this study were essentially re‐ plicated in a more recent investigation with four to six year old preschoolers at risk for hav‐ ing ADHD and ODD (n=18) [77]. Changes in at-risk preschoolers' heart rate in this study further pointed to a predominance of parasympathetic mediation of their autonomic re‐

In all, one published study could be identified that explicitly investigated whether children with ADHD display a particular sympathetic and/or parasympathetic reactivity in manifest emotional conditions and whether this differs according to emotions. In a rare laboratory paradigm using active emotion induction and suppression conditions, Musser et al. (2011) indeed examined 66, seven to nine-year old, ADHD and non-clinical control children's auto‐ nomic responses [48]. Children were first instructed to facially mimic emotions of a main character viewed in a developmentally appropriate film clip (active emotion induction), and subsequently to imagine the main characters' feelings yet while not expressing any facial emotion (active emotion suppression). The children's sympathetic cardiac PEP and para‐ sympathetic RSA were recorded throughout positive and negative emotion induction and suppression conditions. ADHD and control children's autonomic responses did not differ in baseline or neutral conditions. No significant group differences emerged either in children's sympathetic (PEP) responses. However, ADHD children exhibited a slight yet significant parasympathetic augmentation (RSA), and this inflexibly across all emotional conditions (positive and negative, induction and suppression). Moreover, when expressing deliberate positive facial emotion, the ADHD group responded with a more pronounced ineffective parasympathetic increase in contrast to control children's RSA decrease, suggesting an ina‐

ADHD children's physiological reactivity has furthermore been investigated along an addi‐ tional line of questioning concerning alterations in their hypothalamic-pituitary-adrenocorti‐ cal (HPA) axis. Consistent with the initially outlined expectations, ADHD children have been expected to show blunted cortisol responses to stress [78-80]. Again, studies in this re‐ spect have as yet seldom focused specifically on emotional contexts and have yielded mixed results across ADHD heterogeneity. In essence, predicted blunted cortisol responses are evi‐ denced in children with ADHD and comorbid disruptive behaviour disorders. However, children with ADHD and comorbid anxiety disorders tend to show increased cortisol reac‐ tivity [78, 79]. Furthermore, one study compared cortisol responses during a public speaking situation among children with ADHD-C (n=52), ADHD-I (n=23) and non-clinical controls (n=25) [80]. In this more manifest psychosocial stress condition, ADHD children's HPA functioning showed subtype distinctions along similar externalising versus internalising lines as above, with ADHD-C children displaying blunted and ADHD-I increased cortisol responses. Finally, one study explicitly examined whether ADHD children's oppositional behaviour would be mediated by their cortisol reactivity to expressed emotions during a family emotion provocation task [58]. High levels of parental negative expressed emotion were indeed associated with both oppositional behaviour and increased cortisol responses in children with ADHD. Cortisol reactivity hereby mediated the emotion-to-behaviour path‐

sponses in behavioural reward/extinction conditions.

252 Attention Deficit Hyperactivity Disorder in Children and Adolescents

daptive emotional approach response.

way in all children.

Emotion research in children with ADHD has emerged in part through a select number of 'early' studies examining their facial emotion recognition (FER) skills. Research on FER questions the ability of the child to adequately process or appraise basic emotional cues, a skill that is instrumental to its survival and interactions with others [40, 41, 81]. Although such cues can be verbal as well as non-verbal, especially the latter are recognised to be force‐ ful communication elements and this early-on in development [82]. FER research paradigms thus generally consist of recording children's proficiency in labelling facial emotions, which are either viewed in isolation or within a broader visual or verbal context.

Given the discussion so far, at least four basic questions apply to ADHD children's FER, namely 1) are ADHD children's FER skills compromised compared to those without ADHD?, 2) if so, for which emotions is this the case?, 3) are ADHD children's FER skills linked to their (interpersonal) behavioural functioning?, and 4) which underlying mecha‐ nisms may explain ADHD children's FER difficulties?

Altogether, fourteen published studies were identified from 1998 on in Pubmed and through further reviewing of references that have directly addressed (facial) emotion rec‐ ognition and understanding in children diagnosed with ADHD, besides one study on 'atrisk' children [83] and an ongoing study by our FACE©-ADHD program [30, 84]. As summarised in Table 1 and discussed in paragraph 5.2.1, two-third of these studies [28, 36, 39, 40, 85-89] have focused on simple FER and mostly pointed toward ADHD chil‐ dren experiencing significantly more FER difficulties compared to non-clinical controls. The investigated samples however remain relatively small and diverse in terms of con‐ text and comorbidity. Furthermore, precise indications regarding which facial emotions are more challenging for ADHD children to process remain inconsistent. As reviewed in Table 2 and discussed in paragraph 5.2.2, six studies also focused on emotion under‐ standing in context and/or simultaneously compared ADHD children's simple versus contextualised emotion recognition [39, 41, 81, 90-92].

**Authors1,2 Year Country**

> Pelc 2006 Belgium

> > Shin 2009 Korea

Sinzig 2008 Germany

Williams 2008 Australia

ADHD+CD children

**ADHD Comparison Age Sex**

30 ? 30 NC 7-12 Boys / Girls

42a / 95b A 6-10 a / 6-15 b 27 NC Boys

21 auti+ADHD 19 autism 30 A / 29 NC 6-18 Boys / Girls

51 A / 51 NC 8-17 Boys

**Type Comorbidity Medication Setting**

> HI no no

? no no clinical

I / C CDD/ODD no clinical

I / C Opp/Anx/Dep no(T1) / yes(T2) clinical

**Table 1.** Published studies on basic FER skills in children with DSM-IV diagnosed ADHD

a

**Measures (primary)**

Ekman, morphed intensities happy, angry, sad, disgust 7-point rating difficulty (7point)

 ERT: pos / neg; context matching; b attention

FEFA: FER, eye pairs Happy, angry, sad, fear, disgust, surprise, neutral Sustained attention, Inhibition, Set shifting

FER Happy, angry, sad, fear, disgust, neutral ERP during 2nd FER naturalistic open design, pre-/post MPH

1 First author, see references for full author list | 2 Legend: ? = unspecified, A = ADHD, NC = Non-clinical controls, BD = Bipolar Disorder, SMD = Severe Mood Dysregulation, CP = Conduct problems, CD = Conduct Disorder, ODD = Opposi‐ tional Defiant Disorder, Anx = anxiety, Dep = deptression, SA = separation anxiety, SP = social phobia, opp = opposi‐ tional; I = ADHD Inattentive subtype, C = ADHD Combined subtype, HI = ADHD Hyperactive-Impulsive subtype; MPH = Methylphenidate; RT = reaction times; DANVA = Diagnostic Analysis of Nonverbal Accuracy; ERT = Emotion Recogni‐ tion Test; ;JACFEE = Japanese & Caucasian Facial Expressions of Emotion | 3 Sample comprising 18 ADHD, 7 CD, 10

**Findings**

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255

ADHD general deficit & specific difficulties for anger (high intensity) & sadness (all intensities), not for happiness & disgust poor awareness errors for anger and disgust ADHD FER errors inversely linked to interpersonal problems

 sample 1, b sample 2 No difference in pooled positive (happy, surprise) or negative (angry, sad, fear, disgust) FER between ADHD and controls See table 2

Autism+ADHD and ADHD poorer facial & eye pair recognition than autism and controls Joy, surprise: ADHD < Autism+ADHD < controls and autism FER linked with sustained attention and inhibition deficits in ADHD children

ADHD(anx/dep) poorer FER anger & fear than controls; no ADHD subtype effects reduced initial occipital activity, followed by exaggeration, & reduced temporal activity during contextual processing After MPH normalized brain activity but no mood changes

a

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#### ADHD Children's Emotion Regulation in FACE© – Perspective… http://dx.doi.org/10.5772/54422 255


are more challenging for ADHD children to process remain inconsistent. As reviewed in

Table 2 and discussed in paragraph 5.2.2, six studies also focused on emotion under‐

standing in context and/or simultaneously compared ADHD children's simple versus

**Measures (primary)**

(initial) visual orientation to negative-neutral face pairs

fear, hostility, & nose-width ratings in happy, angry, fearful, & neutral faces; RT amygdala fMRI

DANVA facial & oral happy, angry, sad, fear

DANVA n° errors labelling happy, angry, sad, fear

IAPS, 50% neutral, 25% neg, 25% pos immediate recognition & memory (new / old picture)

**Findings**

no group differences in initial attention allocation expected orientation tendency to negative emotions in controls

Fear: BD & SMD more fear ratings neutral faces:ADHD no difference Hostility, nose-width: no differences ADHD left amygdala hyperactivation vs SMD hypoactivation for fear – nosewidth contrasts

Controls; ADHD+CP least errors Fear errors: ADHD+CP 23% vs NC 27% Sadness errors: ADHD+CP 33% vs NC 29% ADHD mostly random errors ADHD; CP more errors, sig for sad, marginal for happy & fear; not for anger ADHD vs CP similar (CP more sad errors)

Most errors by BD and SMD patients All: errors angry > fear > sad > happy Happy: ADHD+CD more errors than controls, less than BD and SMD Angry, sad, fear: ADHD+CD least errors compared to clinical groups and NC

All: faster response to positive pictures All: memory negative > positive > neutral ADHD neutral pictures memory < controls (unengaged when no salience) ADHD+CD+ODD memory positive pics lower than controls & ADHDonly

contextualised emotion recognition [39, 41, 81, 90-92].

254 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**Type Comorbidity Medication Setting**

> ? ? no school

? ?(SA,SP) no clinical

? (ODD) no clinical

? CD yes clinical

? 16 ODD/CD 40% ?

**ADHD Comparison Age Sex**

35 A / 31 NC 6-11 Boys

18 A / 37 NC 43 BD / 29 SMD 8-17 Boys

68 A / 27 NC 63 ADHD+CP 24 CP 7-13 Boys / Girls

35 A 3 / 92 NC 42 BD / 39 SMD 44 Anx-Dep 7-18 Boys / Girls

30 A / 25 NC 12-15 Boys

**Authors1,2 Year Country**

> Ahmadi 2011 Iran

Brotman 2010 USA

Cadesky 2000 USA

> Guyer 2007 USA

Krauel 2009 Germany 1 First author, see references for full author list | 2 Legend: ? = unspecified, A = ADHD, NC = Non-clinical controls, BD = Bipolar Disorder, SMD = Severe Mood Dysregulation, CP = Conduct problems, CD = Conduct Disorder, ODD = Opposi‐ tional Defiant Disorder, Anx = anxiety, Dep = deptression, SA = separation anxiety, SP = social phobia, opp = opposi‐ tional; I = ADHD Inattentive subtype, C = ADHD Combined subtype, HI = ADHD Hyperactive-Impulsive subtype; MPH = Methylphenidate; RT = reaction times; DANVA = Diagnostic Analysis of Nonverbal Accuracy; ERT = Emotion Recogni‐ tion Test; ;JACFEE = Japanese & Caucasian Facial Expressions of Emotion | 3 Sample comprising 18 ADHD, 7 CD, 10 ADHD+CD children

**Table 1.** Published studies on basic FER skills in children with DSM-IV diagnosed ADHD


**Authors1,2 Year Country**

> Shin 2009 Korea

Yuill 2007 England

**Groups Comparison Age Gender**

42a / 95b 27 NC 6-10a

19 a / 17 b 5-11 a / 5-6 b Boys

 / 6-15b Boys

> ? ?ODD no clinical

**Type Comorbidity Medication Setting**

> ? no no clinical

a

a

sentence

<sup>1</sup> First author, see references for full author list. | 2 Legend: ? = unspecified, A = ADHD, NC = Non-clinical controls, CD = Conduct Disorder, ODD = Oppositional Defiant Disorder, C = ADHD Combined subtype, HI = ADHD Hyperactive-Impul‐ sive subtype; RT = reaction times; JACFEE = Japanese & Caucasian Facial Expressions of Emotion | 3 Summer program

Children generally are able to identify basic facial emotions (happiness, anger, sadness and fear) by early childhood and gain in accuracy to accomplish fuller emotion classification by middle childhood [86]. In children with ADHD, brain imaging studies have documented (posterior) right hemispheric specificities, such as an enlarged right hemisphere structure and hypofused functioning, along with possibly reduced amygdala and compensatory en‐ larged hippocampus [44, 49]. Since such deficits are profoundly linked to impairments in evaluating emotional stimuli, children with ADHD may be expected to have difficulties in adequately perceiving or processing emotions at an appraisal level [41]. Additionally, ADHD children's fluctuating attentional deployment raises questions as to whether im‐ paired sustained attention also contributes to difficulties in processing affective cues [83].

**Table 2.** Published studies on contextual emotion understanding by DSM-IV ADHD-children

*5.2.1. ADHD children's simple facial emotion recognition skills*

**Measures (primary)**

to be linked with emotion stories comprising target emotion word

 Study 1, ERT: see table 1; Match situational cartoon to facial picture b Study 2, Attention: ADS continuous performance target / non-target (omission, commission errors, RT, RT variability)

 Study 1, Match facial expression to emotional situation sentence; match object picture to nonemotional situation

b Study 2, Same task, with inhibitory scaffolding (impulsive inhibition)

**Findings**

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257

ADHD Children's Emotion Regulation in FACE© – Perspective…

Confusions: fear-surprise, angerdisgust

FER: See table 1 (no differences) ADHD lower contextual understanding (face to situation match) than controls Only omission attentional errors account significantly for ADHD children's contextual understanding (not verified in controls)

All: non-emotion task easier than

ADHD overall poorer performances; Emotional: 30-40% correct (21% for suprise) vs 79-95% in controls; Non-emotional: mostly 40-50% correct vs 94-100% in controls No age effects; no ODD effects

emotion task


<sup>1</sup> First author, see references for full author list. | 2 Legend: ? = unspecified, A = ADHD, NC = Non-clinical controls, CD = Conduct Disorder, ODD = Oppositional Defiant Disorder, C = ADHD Combined subtype, HI = ADHD Hyperactive-Impul‐ sive subtype; RT = reaction times; JACFEE = Japanese & Caucasian Facial Expressions of Emotion | 3 Summer program

**Table 2.** Published studies on contextual emotion understanding by DSM-IV ADHD-children

#### *5.2.1. ADHD children's simple facial emotion recognition skills*

**Authors1,2 Year Country**

> Corbett 2000 USA

Braaten 2000 USA

Da Fonseca 2008 France

> Singh 1998 USA

**Groups Comparison Age Gender**

256 Attention Deficit Hyperactivity Disorder in Children and Adolescents

37 A / 37 NC 6-12 Boys / Girls

24 A/ 19 NC 6-12 Boys

27 A / 27 NC 5-15 Boys / Girls

> 50 - 34 boys 16 girls

**Type Comorbidity Medication Setting**

> C no no clinical

HI C ? no community

> C 6ODD 1CD no clinical

> > ? ? no SP3

**Measures (primary)**

JACFEE: happy, angry, sad, fear, disgust, surprise, neutral Prosody Test (identify happy, angry, sad, neutral from speech intonation) Inhibition: Go No-Go Task (verbal); Matching Familiar Figures Test (nonverbal) Attention: Memory for Sentences (verbal); Knox Cube Test (nonverbal)

Empathy to fictitious story with positive vs negative and simple vs complex feelings (match between labelling characters' emotion and labelling own emotion; explaining characters' emotion) Parent-reported emotional behaviour Self-reported emotional intensity and reactivity to reward / punishment situations

(1) Magazine pictures (face / body) (2) Similar pictures, masked face (emotional) or object (non-emotional) Happy, angry, sad, fear Non-verbal labelling (Smiley)

JACFEE: happy, angry, sad, fear, disgust, surprise;

**Findings**

ADHD children significantly less proficient than controls on all measures (visual and verbal emotion recognition, verbal & nonverbal attention, and impulse control with non-verbal stimuli), except for the Go No-Go task where they scored better. FER skills explain 85% of variance in discriminating ADHD from control children.

ADHD children less match between characters' and own emotion than controls ADHD less character-centred explanations of characters' emotions than controls More parent-reported emotional behaviour in ADHD children than controls No sign. differences in childreported emotional intensity and contingency reactivity

ADHD children less efficient in recognising simple and contextualised emotions than controls, no emotion specificity ADHD no significant difficulties in recognising objects in context All: FER happy, angry > fear, sad

74% mean correct identification for ADHD Errors: Fear>Anger/ Surprise>Disgust>Sad>Happy

Children generally are able to identify basic facial emotions (happiness, anger, sadness and fear) by early childhood and gain in accuracy to accomplish fuller emotion classification by middle childhood [86]. In children with ADHD, brain imaging studies have documented (posterior) right hemispheric specificities, such as an enlarged right hemisphere structure and hypofused functioning, along with possibly reduced amygdala and compensatory en‐ larged hippocampus [44, 49]. Since such deficits are profoundly linked to impairments in evaluating emotional stimuli, children with ADHD may be expected to have difficulties in adequately perceiving or processing emotions at an appraisal level [41]. Additionally, ADHD children's fluctuating attentional deployment raises questions as to whether im‐ paired sustained attention also contributes to difficulties in processing affective cues [83].

More precise expectations about differential emotion recognition difficulties have been diffi‐ cult to formulate. For instance, joy and surprise tend to be more easily recognised by chil‐ dren overall compared to fear, sadness and disgust [86]. Yet, negative facial expressions compared to neutral ones are also documented to mobilise typically developing children's attention; a tendency that is understood as an adaptive response toward potential danger [36, 15]. Children with CD/ODD, which are frequent ADHD comorbidities, for their part seem to display a marked increased bias toward processing negative emotional information in social situations. At the same time, CD/ODD children also appear less aroused by nega‐ tive emotional stimuli [15, 85]. Thus, detailed expectations about ADHD children's FER skills may depend on their clinical constellation including their comorbidities.

tualising emotions, especially anxiety, during a verbal recognition task, as well as in Theory of Mind (also see §5.2.2). For all children, happiness was best recognised facially, followed

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The aforementioned less expected difficulties with the recognition of the *positive emotion* happiness were also found in children with ADHD and comorbid CD [86], as well as in a comparison among children (ages 6-18) with autism, autism and ADHD, and ADHD-only [28] (see Table 1). In the latter study, both groups with ADHD, namely ADHD-only and co‐ morbid autism and ADHD, were less proficient in recognising happiness as well as surprise

In contrast, ADHD appears to be associated with *more* successful FER in some instances, as comes forward from a detailed analysis of studies examining whether FER patterns are dis‐ tinct or cut across clinical conditions. This was the case, for example, in a rare study compar‐ ing FER among children and adolescents with BD, severe mood dysregulation (SMD), ADHD and/or CD, anxiety and/or depression and controls [86]. Markedly, the ADHD with CD group appeared to make least errors in angry, sad and fearful FER compared to all other groups, including non-clinical controls. Similarly, another study compared FER among chil‐ dren with ADHD, ADHD with conduct problems (CP) or CP (all with comorbid ODD), and controls. Along with controls, the comorbid ADHD with CP children also exhibited least er‐

on faces and on eye pairs, relative to autism-only and non-clinical children [28].

rors except for sadness, while ADHD-only children mostly displayed random errors.

who made more FER errors also exhibited higher interpersonal problems [88].

Findings tend to be clearer regarding the *behavioural and relational impact* of children's FER skills *(question 3)*. When this is examined, studies indeed report significant associations be‐ tween ADHD children's FER skills and daily-life outcomes. For instance, in the pilot study of the FACE©-research, ADHD children's FER skills were inversely proportional to parent and teacher rated ADHD-specific (hyperactivity, inattention, impulsivity) and non-specific (oppositional and aggressive) problem behaviour [30, 84]. Similarly, the above-cited hyper‐ active/impulsive ADHD children without comorbidities investigated by Pelc et al. (2006)

Finally, some studies attempted to shed light on the neural basis of ADHD children's FER skills *(question 4)* (see table 2). One study examined contrasted amygdala responses when rating emotional cues (fear and hostility) versus non-emotional ones (nose-width) in happy, angry, fearful or neutral faces, and this among youth with BD, SMD, ADHD and non-clini‐ cal controls [85]. Interestingly, although ADHD youth did not differ from the other groups in fear, hostility or nose-width ratings, they manifested left-amygdala hyperactivation in fear – nose-width contrasts compared to healthy controls, bipolar and SMD children. Anoth‐ er study, by Williams et al. (2008), recorded ADHD youth's event-related potentials during a second presentation of facial emotion labelling, before and after methylphenidate (MPH) treatment in an open label trial spanning four weeks [89]. ADHD boys showed a pattern of reduced occipital activity during initial perceptual analysis that was associated with their disrupted FER and mood. This was followed by flow-on difficulties in emotion processing, such as an exaggerated structural encoding activity and finally reduced temporal contextual activity. In short, these findings lend further support to possible (compensatory) amygdala responses and specific temporal-occipital pathways in mood processing linked to ADHD.

by anger, and fear (sample 1) or sadness (sample 2) [4, 5, 30, 84].

Overall, the reviewed studies point to statistically significant *differences* in basic FER skills between children with ADHD and non-clinical controls or other clinical groups, as illustrat‐ ed in Table 1 *(question 1)*. However, depending on comorbidity and comparison groups, dif‐ ferences are not necessarily to the disadvantage of the ADHD population and/or tend to vary widely as regards which emotions elicit more recognition difficulties *(question 2)*. More‐ over, whenever performance percentages are specified, a majority of ADHD children (60% and up) still appear to exhibit accurate FER.

Thus, the right hemisphere hypothesis has been supported at least partially as several stud‐ ies document children with ADHD to be less efficient at identifying *negative facial cues* com‐ pared to non-clinical controls [36, 40, 83, 84, 88, 89]. Specific negative FER difficulties, however, vary across studies and children's clinical status, with no clear pattern coming for‐ ward. For example, an expected dampened detection of anger and fear was found compared to non-clinical controls in a sample of 51 adolescent boys with ADHD and associated oppo‐ sitional behaviour along with depressed and anxious mood [89]. This was also the case for anger and sadness, but not for fear, in a sample of hyperactive/impulsive ADHD children without comorbidities [88].

These findings partially converge with pilot results from an ongoing multi-method, multiinformant research that operationalises the above FACE©-model. In this research, a natural‐ istic group of medicated ADHD children in a special school setting is compared with gender- and age-matched non-referred children (ages 7-12, mean age 10, 80% boys) on corre‐ lates of emotion regulation [30, 84]. On a micro-level, children are examined on emotional components of ER (basic FER, emotion recognition in context, and self-reported experience) along with cognitive (Theory-Of-Mind), attentional (simple and modified emotional Simon tasks), and behavioural ones (multi-informant reports of problem behaviour including ag‐ gression and anxiety). Children's developmental risk-resiliency load is furthermore regis‐ tered on a macro-level. Compared to controls (n=13), a preliminary sample of ADHD children (n=15) with comorbid learning problems and autism spectrum symptoms (ASS) (re‐ spectively 66% and 33%) made significantly more FER errors than controls (t (26) = -2,578, p = 0,016) and doubted more their choices (t (26) = -2,147, p = 0,041). These comorbid ADHD children were in particular marginally less efficient at identifying happiness and anger. A second subsample of ADHD children (n=20), also with mainly learning problems but no ASS, did not differ in basic FER compared to controls (n=20) but was less efficient in contex‐ tualising emotions, especially anxiety, during a verbal recognition task, as well as in Theory of Mind (also see §5.2.2). For all children, happiness was best recognised facially, followed by anger, and fear (sample 1) or sadness (sample 2) [4, 5, 30, 84].

More precise expectations about differential emotion recognition difficulties have been diffi‐ cult to formulate. For instance, joy and surprise tend to be more easily recognised by chil‐ dren overall compared to fear, sadness and disgust [86]. Yet, negative facial expressions compared to neutral ones are also documented to mobilise typically developing children's attention; a tendency that is understood as an adaptive response toward potential danger [36, 15]. Children with CD/ODD, which are frequent ADHD comorbidities, for their part seem to display a marked increased bias toward processing negative emotional information in social situations. At the same time, CD/ODD children also appear less aroused by nega‐ tive emotional stimuli [15, 85]. Thus, detailed expectations about ADHD children's FER

Overall, the reviewed studies point to statistically significant *differences* in basic FER skills between children with ADHD and non-clinical controls or other clinical groups, as illustrat‐ ed in Table 1 *(question 1)*. However, depending on comorbidity and comparison groups, dif‐ ferences are not necessarily to the disadvantage of the ADHD population and/or tend to vary widely as regards which emotions elicit more recognition difficulties *(question 2)*. More‐ over, whenever performance percentages are specified, a majority of ADHD children (60%

Thus, the right hemisphere hypothesis has been supported at least partially as several stud‐ ies document children with ADHD to be less efficient at identifying *negative facial cues* com‐ pared to non-clinical controls [36, 40, 83, 84, 88, 89]. Specific negative FER difficulties, however, vary across studies and children's clinical status, with no clear pattern coming for‐ ward. For example, an expected dampened detection of anger and fear was found compared to non-clinical controls in a sample of 51 adolescent boys with ADHD and associated oppo‐ sitional behaviour along with depressed and anxious mood [89]. This was also the case for anger and sadness, but not for fear, in a sample of hyperactive/impulsive ADHD children

These findings partially converge with pilot results from an ongoing multi-method, multiinformant research that operationalises the above FACE©-model. In this research, a natural‐ istic group of medicated ADHD children in a special school setting is compared with gender- and age-matched non-referred children (ages 7-12, mean age 10, 80% boys) on corre‐ lates of emotion regulation [30, 84]. On a micro-level, children are examined on emotional components of ER (basic FER, emotion recognition in context, and self-reported experience) along with cognitive (Theory-Of-Mind), attentional (simple and modified emotional Simon tasks), and behavioural ones (multi-informant reports of problem behaviour including ag‐ gression and anxiety). Children's developmental risk-resiliency load is furthermore regis‐ tered on a macro-level. Compared to controls (n=13), a preliminary sample of ADHD children (n=15) with comorbid learning problems and autism spectrum symptoms (ASS) (re‐ spectively 66% and 33%) made significantly more FER errors than controls (t (26) = -2,578, p = 0,016) and doubted more their choices (t (26) = -2,147, p = 0,041). These comorbid ADHD children were in particular marginally less efficient at identifying happiness and anger. A second subsample of ADHD children (n=20), also with mainly learning problems but no ASS, did not differ in basic FER compared to controls (n=20) but was less efficient in contex‐

skills may depend on their clinical constellation including their comorbidities.

and up) still appear to exhibit accurate FER.

258 Attention Deficit Hyperactivity Disorder in Children and Adolescents

without comorbidities [88].

The aforementioned less expected difficulties with the recognition of the *positive emotion* happiness were also found in children with ADHD and comorbid CD [86], as well as in a comparison among children (ages 6-18) with autism, autism and ADHD, and ADHD-only [28] (see Table 1). In the latter study, both groups with ADHD, namely ADHD-only and co‐ morbid autism and ADHD, were less proficient in recognising happiness as well as surprise on faces and on eye pairs, relative to autism-only and non-clinical children [28].

In contrast, ADHD appears to be associated with *more* successful FER in some instances, as comes forward from a detailed analysis of studies examining whether FER patterns are dis‐ tinct or cut across clinical conditions. This was the case, for example, in a rare study compar‐ ing FER among children and adolescents with BD, severe mood dysregulation (SMD), ADHD and/or CD, anxiety and/or depression and controls [86]. Markedly, the ADHD with CD group appeared to make least errors in angry, sad and fearful FER compared to all other groups, including non-clinical controls. Similarly, another study compared FER among chil‐ dren with ADHD, ADHD with conduct problems (CP) or CP (all with comorbid ODD), and controls. Along with controls, the comorbid ADHD with CP children also exhibited least er‐ rors except for sadness, while ADHD-only children mostly displayed random errors.

Findings tend to be clearer regarding the *behavioural and relational impact* of children's FER skills *(question 3)*. When this is examined, studies indeed report significant associations be‐ tween ADHD children's FER skills and daily-life outcomes. For instance, in the pilot study of the FACE©-research, ADHD children's FER skills were inversely proportional to parent and teacher rated ADHD-specific (hyperactivity, inattention, impulsivity) and non-specific (oppositional and aggressive) problem behaviour [30, 84]. Similarly, the above-cited hyper‐ active/impulsive ADHD children without comorbidities investigated by Pelc et al. (2006) who made more FER errors also exhibited higher interpersonal problems [88].

Finally, some studies attempted to shed light on the neural basis of ADHD children's FER skills *(question 4)* (see table 2). One study examined contrasted amygdala responses when rating emotional cues (fear and hostility) versus non-emotional ones (nose-width) in happy, angry, fearful or neutral faces, and this among youth with BD, SMD, ADHD and non-clini‐ cal controls [85]. Interestingly, although ADHD youth did not differ from the other groups in fear, hostility or nose-width ratings, they manifested left-amygdala hyperactivation in fear – nose-width contrasts compared to healthy controls, bipolar and SMD children. Anoth‐ er study, by Williams et al. (2008), recorded ADHD youth's event-related potentials during a second presentation of facial emotion labelling, before and after methylphenidate (MPH) treatment in an open label trial spanning four weeks [89]. ADHD boys showed a pattern of reduced occipital activity during initial perceptual analysis that was associated with their disrupted FER and mood. This was followed by flow-on difficulties in emotion processing, such as an exaggerated structural encoding activity and finally reduced temporal contextual activity. In short, these findings lend further support to possible (compensatory) amygdala responses and specific temporal-occipital pathways in mood processing linked to ADHD.

#### *5.2.2. Understanding of emotions in context by children with ADHD*

While identifying simple facial emotions represents the most basic form of emotion recogni‐ tion, real-life communication seldom consists of isolated facial expressions. Facial expres‐ sions are mostly if not always situationally embedded. From their earliest interactions, children learn to modulate their appraisal of facial emotions according to the context [66]. As experience develops, this skill increasingly involves (episodic) memory and associated hippocampal functions through which emotional stimuli are linked to (the remembrance of) contextual cues. Specifically, given disruptions in right hemispheric functioning and in the IFC/DLPFC to amygdala circuitry reported for children with ADHD, they may be expected to display difficulties in contextualising emotions over and above their simple FER difficul‐ ties [44, 49]. A next level in emotional assessment therefore consists of examining the child's ability to appropriately link facial expressions and (social) situations or to understand emo‐ tional cues in their context (e.g. in stories) [42, 64].

jects in their context, confirming an emotional rather than solely perceptual nature of their matching errors [91]. A study addressing the link between ADHD boys' continuous atten‐ tional performance furthermore found only omission errors to account significantly for ADHD children's matching of facial emotional expressions to situational cartoons [39]. Also, in an early yet thorough study involving FER, along with prosody, verbal and nonverbal impulse inhibition and attention tasks, ADHD children's significantly poorer performances

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Still, findings on ADHD children's contextual emotion recognition seem to remain quite task and/or stimulus dependent. For instance, one study involved the matching of facial expres‐ sions to specifically designed emotion-situation sentences, and object pictures to non-emo‐ tional sentences [92]. In this case, ADHD boys exhibited exceptionally poor performances with only 20 to 40% of correct emotional and 40 to 50% non-emotional matchings. Control children, in turn, achieved 79 to 100% correct matchings across conditions. These findings contrast with a sensibly higher overall mean of 74% of correct contextual emotion identifica‐ tion by ADHD children documented in Singh's early study [81]. In the same line of stimu‐ lus-dependent ER variations, a condition of contextualised emotion recognition in verbal material yielded anger to be least well identified by both control and ADHD children, as op‐

Of note, studies comparing contextual emotion recognition among children with ADHD and *other clinical conditions* or different *subtypes* are still lacking. Simple or contextualised proc‐ essing of *prosody* also has hardly been investigated in children with ADHD [15, 93]. In adults, emotional semantic processing has been found to be enhanced compared to controls, possibly through compensatory mobilisation of cognitive resources [94]. Similar investiga‐

Overall, ADHD children as a group do appear to display specificities in FER skills that tend to set them apart from non-referred controls and children with other clinical conditions. In addition, the ADHD child and adolescent population also does seem to exhibit more diffi‐ culties in matching facial emotions to contextual clues, or recognising emotions in verbal

The pattern of these basic and contextualised (facial) emotion recognition specificities yet re‐ mains unclear to date. ADHD children with or without comorbidities are diversely found to be less efficient in recognising simple negative as well as positive facial emotions compared to non-clinical controls and possibly also to children with different clinical conditions. How‐ ever, the opposite occurs in some instances, with some large comparison studies document‐ ing better FER skills in (comorbid) ADHD children relative to other clinical and non-clinical groups. Comorbidity or medication statuses do not appear to provide sufficient leads for ex‐ plaining these contrasting outcomes. Potential influences of maturation (age) and ADHD heterogeneity (subtypes) still require further clarification given that half of the studies span child through adolescent populations, and that the majority leaves ADHD subtypes unspe‐ cified. Also needed are studies that address potential gender effects on simple or contextual‐

on all tasks relative to controls where explained for 85% by their FER skills [41].

posed to being second-best recognised in a condition of FER [84].

tions are needed in children with ADHD.

context, compared to non-clinical controls.

*5.2.3. Summary*

All six reviewed published studies (see Table 2) provide evidence that children with ADHD are less successful in reciprocally matching (facial) emotions and interpersonal situations than non-clinical controls *(question 1)* [39, 41, 81, 90-92]. Furthermore, as mentioned above (§5.2.1), the subsample of ADHD children with learning problems of the ongoing FACE©- ADHD research was significantly less efficient than non-clinical controls in identifying emo‐ tions in verbally presented stories [84]. Along the same line of thought, an early study by Braaten et al. (2000) stands somewhat apart by addressing a more sophisticated level of emotional understanding. Here, children's ER was further probed by assessing their ability to recognise characters' emotions in a story and to relate these to their own feelings [90]. Children with ADHD were less likely than controls to match their own feelings with those of the child in the story and to interpret the latter according to the characters' context.

Again, however, no clear pattern emerges as to whether ADHD children have more difficul‐ ty contextualising specific emotions *(question 2)*. For example, an early study with five to 13 year old ADHD boys and girls enrolled in a summer camp, using Ekman's facial affect pictures, suggested a mixed pattern of negative emotions as well as surprise to elicit more contextualisation errors than happiness [81]. Another mixed pattern of better contextualis‐ ing of happy and angry, than fearful and sad feelings occurred for both ADHD-combined subtype and control children when asked to link symbolic facial expressions (Smiley's) to masked faces of people in popular magazine pictures [91].

Apparently, few of these studies furthermore examined the link between ADHD children's contextualised emotion recognition and their behavioural outcomes *(question 3)*. In our on‐ going research, children's emotion recognition (and Theory-of-Mind) were found to be in‐ versely related to reports of their externalizing and internalizing problem behaviour in both subsamples regardless of type of ADHD comorbidity [30, 84].

Some studies finally addressed possible underlying mechanisms of ADHD children's diffi‐ culties in contextualising emotions *(question 4)*. For instance, Da Fonseca et al's (2008) study also included the matching of objects to situational magazine pictures. In contrast to the emotional matching, ADHD children displayed no significant difficulties in replacing ob‐ jects in their context, confirming an emotional rather than solely perceptual nature of their matching errors [91]. A study addressing the link between ADHD boys' continuous atten‐ tional performance furthermore found only omission errors to account significantly for ADHD children's matching of facial emotional expressions to situational cartoons [39]. Also, in an early yet thorough study involving FER, along with prosody, verbal and nonverbal impulse inhibition and attention tasks, ADHD children's significantly poorer performances on all tasks relative to controls where explained for 85% by their FER skills [41].

Still, findings on ADHD children's contextual emotion recognition seem to remain quite task and/or stimulus dependent. For instance, one study involved the matching of facial expres‐ sions to specifically designed emotion-situation sentences, and object pictures to non-emo‐ tional sentences [92]. In this case, ADHD boys exhibited exceptionally poor performances with only 20 to 40% of correct emotional and 40 to 50% non-emotional matchings. Control children, in turn, achieved 79 to 100% correct matchings across conditions. These findings contrast with a sensibly higher overall mean of 74% of correct contextual emotion identifica‐ tion by ADHD children documented in Singh's early study [81]. In the same line of stimu‐ lus-dependent ER variations, a condition of contextualised emotion recognition in verbal material yielded anger to be least well identified by both control and ADHD children, as op‐ posed to being second-best recognised in a condition of FER [84].

Of note, studies comparing contextual emotion recognition among children with ADHD and *other clinical conditions* or different *subtypes* are still lacking. Simple or contextualised proc‐ essing of *prosody* also has hardly been investigated in children with ADHD [15, 93]. In adults, emotional semantic processing has been found to be enhanced compared to controls, possibly through compensatory mobilisation of cognitive resources [94]. Similar investiga‐ tions are needed in children with ADHD.

#### *5.2.3. Summary*

*5.2.2. Understanding of emotions in context by children with ADHD*

260 Attention Deficit Hyperactivity Disorder in Children and Adolescents

tional cues in their context (e.g. in stories) [42, 64].

masked faces of people in popular magazine pictures [91].

subsamples regardless of type of ADHD comorbidity [30, 84].

While identifying simple facial emotions represents the most basic form of emotion recogni‐ tion, real-life communication seldom consists of isolated facial expressions. Facial expres‐ sions are mostly if not always situationally embedded. From their earliest interactions, children learn to modulate their appraisal of facial emotions according to the context [66]. As experience develops, this skill increasingly involves (episodic) memory and associated hippocampal functions through which emotional stimuli are linked to (the remembrance of) contextual cues. Specifically, given disruptions in right hemispheric functioning and in the IFC/DLPFC to amygdala circuitry reported for children with ADHD, they may be expected to display difficulties in contextualising emotions over and above their simple FER difficul‐ ties [44, 49]. A next level in emotional assessment therefore consists of examining the child's ability to appropriately link facial expressions and (social) situations or to understand emo‐

All six reviewed published studies (see Table 2) provide evidence that children with ADHD are less successful in reciprocally matching (facial) emotions and interpersonal situations than non-clinical controls *(question 1)* [39, 41, 81, 90-92]. Furthermore, as mentioned above (§5.2.1), the subsample of ADHD children with learning problems of the ongoing FACE©- ADHD research was significantly less efficient than non-clinical controls in identifying emo‐ tions in verbally presented stories [84]. Along the same line of thought, an early study by Braaten et al. (2000) stands somewhat apart by addressing a more sophisticated level of emotional understanding. Here, children's ER was further probed by assessing their ability to recognise characters' emotions in a story and to relate these to their own feelings [90]. Children with ADHD were less likely than controls to match their own feelings with those of the child in the story and to interpret the latter according to the characters' context.

Again, however, no clear pattern emerges as to whether ADHD children have more difficul‐ ty contextualising specific emotions *(question 2)*. For example, an early study with five to 13 year old ADHD boys and girls enrolled in a summer camp, using Ekman's facial affect pictures, suggested a mixed pattern of negative emotions as well as surprise to elicit more contextualisation errors than happiness [81]. Another mixed pattern of better contextualis‐ ing of happy and angry, than fearful and sad feelings occurred for both ADHD-combined subtype and control children when asked to link symbolic facial expressions (Smiley's) to

Apparently, few of these studies furthermore examined the link between ADHD children's contextualised emotion recognition and their behavioural outcomes *(question 3)*. In our on‐ going research, children's emotion recognition (and Theory-of-Mind) were found to be in‐ versely related to reports of their externalizing and internalizing problem behaviour in both

Some studies finally addressed possible underlying mechanisms of ADHD children's diffi‐ culties in contextualising emotions *(question 4)*. For instance, Da Fonseca et al's (2008) study also included the matching of objects to situational magazine pictures. In contrast to the emotional matching, ADHD children displayed no significant difficulties in replacing ob‐ Overall, ADHD children as a group do appear to display specificities in FER skills that tend to set them apart from non-referred controls and children with other clinical conditions. In addition, the ADHD child and adolescent population also does seem to exhibit more diffi‐ culties in matching facial emotions to contextual clues, or recognising emotions in verbal context, compared to non-clinical controls.

The pattern of these basic and contextualised (facial) emotion recognition specificities yet re‐ mains unclear to date. ADHD children with or without comorbidities are diversely found to be less efficient in recognising simple negative as well as positive facial emotions compared to non-clinical controls and possibly also to children with different clinical conditions. How‐ ever, the opposite occurs in some instances, with some large comparison studies document‐ ing better FER skills in (comorbid) ADHD children relative to other clinical and non-clinical groups. Comorbidity or medication statuses do not appear to provide sufficient leads for ex‐ plaining these contrasting outcomes. Potential influences of maturation (age) and ADHD heterogeneity (subtypes) still require further clarification given that half of the studies span child through adolescent populations, and that the majority leaves ADHD subtypes unspe‐ cified. Also needed are studies that address potential gender effects on simple or contextual‐ ised emotion recognition with sufficient participation of girls with ADHD. The effects of verbal versus non-verbal stimulus modes as yet remain underexplored too.

Study paradigms consequently generally consist of manipulating children's reward expect‐ ancy and registering their self-reported and/or behaviourally observed emotional responses. Most studies have confirmed children with ADHD to experience heightened frustration lev‐ els in association with persistence and behavioural control problems, this both in cognitive task conditions [66, 95, 82] and in less investigated emotional contexts [9]. Detailed accounts of their task-related emotional experiences however provide important nuance regarding

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For instance, an early study compared how seven to nine year old, clinically-referred ADHD children (n=22) and non-referred controls (n=20) compared on performance, study-time, selfrated persistence (namely how much did the child feel like continuing), and facially record‐ ed frustration levels during a nonsense word learning task [82]. Children were assigned to either a predetermined continuous reinforcement (CRF) or partial reinforcement (PRF) con‐ dition. The CRF and PRF conditions both consist of an acquisition phase followed by a nonreward extinction phase, yet PRF involves random instead of continuous reward during acquisition. Importantly, reinforcement pertained to persistence rather than task correctness in this study. As expected, learning occurred in both phases for both groups. Children with ADHD yet made more errors, expressed more frustration and felt less like persisting overall. Interestingly, especially the random reward (PRF) condition yielded three-fold frustration levels in ADHD children during the acquisition phase along with a persistence deficit. In turn, only children with ADHD (and not controls) in the CRF condition spent more studytime over the acquisition course [82]. Thus, children with ADHD displayed a marked diffi‐ culty habituating to initial frustration, while investing considerable effort in a consistent

In the same vein, self-reported frustration was studied in medicated children with ADHD (n=21; mostly combined subtype) compared to non-clinical controls (n=43) using a blindfold‐ ed puzzle task [66]. This study moreover recorded detailed accounts of children's emotions, such as their self-reported mood after the task, general persistence and frustration tendency (likeliness of quitting and getting frustrated compared to peers), insight in the accompany‐ ing physical, emotional, or cognitive sensations of their frustration and how they dealt with it. Children additionally completed a structured emotional competence self-report measure, along with a mathematics task. Consistent with the previous findings, the present ADHD children were less persistent overall but invested as much time as control children in the tasks. This yielded them mixed results: they were more likely to quit the puzzle task and completed less mathematic problems than their peers, but the ones they completed were ac‐ curate. Of special interest for the present focus, the children with ADHD were likelier to re‐ port suffering frustration and give up compared to other children, were able to identify signs of their frustration and knew about ways of dealing with it. However, they were sig‐

nificantly less effective at acting upon this emotional understanding than controls.

Children with ADHD have also been demonstrated to have difficulty deliberately masking their emotions in an elicited frustration situation [95]. One study for instance examined ADHD boys' (n=26, ages 6 to 11) observed emotion regulation compared to that of controls (n=23), by explicitly asking them to hide their feelings even if they became upset during a

ADHD children's emotional understanding and process insight [66, 82].

reward condition.

Furthermore, when FER difficulties are documented in ADHD children, these appear to be linked to adverse behavioural and interpersonal outcomes. Similar links remain to be fur‐ ther established for ADHD children's contextual emotion recognition.

Finally, there are some indications that ADHD children's basic and contextual emotion rec‐ ognition skills are related to specificities in right hemispheric emotion-processing and (left) amygdala hyperactivity, while attentional impacts remain less well established. The intrica‐ cy of cognitive and emotional systems hereby points to the need of considering multiple pathways of underlying mechanisms instead of mutually exclusive ones, whereby probable compensatory functioning may contribute to explaining the absence of observed emotion processing deficits in some instances.

In sum, the heterogeneity of the population of youth with ADHD, the relative scarcity of current studies directly addressing their emotion recognition skills, and the contrasting out‐ comes so far all call for a research agenda that would more systematically examine the ex‐ tent to which gender, age, ADHD subtypes, comorbidities and stimulus type account for variability in ADHD children's basic and contextualised emotion recognition skills.

#### **5.3. How do children with ADHD (deliberately) modulate subjective experiences and behavioural expressions of emotional reactivity?**

As defined previously, emotional impulsiveness consists of diminished inhibition of emo‐ tional expression besides heightened emotional reactivity (cf.§5.1) [47, 61]. ADHD children's difficulties with modulating their emotional expressions have been mostly documented in‐ directly through a vast literature attesting to their externalising problem behaviour. Specific examination of the behavioural component of ADHD children's emotional impulsiveness to date has mainly concerned their management of frustration, and this principally in cognitive task-interference contexts [61, 83].

On a behavioural level, children with ADHD are inclined to favour situations that provide immediate reward. They also tend to have difficulty persisting when gratification is de‐ layed. This tendency has been described under the delay-aversion hypothesis [66]. Still, the question arises what makes it more difficult for children with ADHD than for their peers to delay reward and persist when positive reinforcement remains uncertain? From an emotioncentred perspective, ADHD children's difficulties with persisting under delayed reward conditions are thought to be mediated by the challenge of regulating negative emotions, and especially frustration.

Several studies have therefore explicitly investigated how children with ADHD modulate their emotional experience and expression in constrained task conditions that elicit frustra‐ tion. Frustration is defined here as the emotion resulting from an absence of reward when such reward is expected [82]. Persistence can thus be conceived as the ability to adjust or modulate frustration perception so as to maintain task-oriented behavioural continuity. Study paradigms consequently generally consist of manipulating children's reward expect‐ ancy and registering their self-reported and/or behaviourally observed emotional responses.

ised emotion recognition with sufficient participation of girls with ADHD. The effects of

Furthermore, when FER difficulties are documented in ADHD children, these appear to be linked to adverse behavioural and interpersonal outcomes. Similar links remain to be fur‐

Finally, there are some indications that ADHD children's basic and contextual emotion rec‐ ognition skills are related to specificities in right hemispheric emotion-processing and (left) amygdala hyperactivity, while attentional impacts remain less well established. The intrica‐ cy of cognitive and emotional systems hereby points to the need of considering multiple pathways of underlying mechanisms instead of mutually exclusive ones, whereby probable compensatory functioning may contribute to explaining the absence of observed emotion

In sum, the heterogeneity of the population of youth with ADHD, the relative scarcity of current studies directly addressing their emotion recognition skills, and the contrasting out‐ comes so far all call for a research agenda that would more systematically examine the ex‐ tent to which gender, age, ADHD subtypes, comorbidities and stimulus type account for

variability in ADHD children's basic and contextualised emotion recognition skills.

**5.3. How do children with ADHD (deliberately) modulate subjective experiences and**

As defined previously, emotional impulsiveness consists of diminished inhibition of emo‐ tional expression besides heightened emotional reactivity (cf.§5.1) [47, 61]. ADHD children's difficulties with modulating their emotional expressions have been mostly documented in‐ directly through a vast literature attesting to their externalising problem behaviour. Specific examination of the behavioural component of ADHD children's emotional impulsiveness to date has mainly concerned their management of frustration, and this principally in cognitive

On a behavioural level, children with ADHD are inclined to favour situations that provide immediate reward. They also tend to have difficulty persisting when gratification is de‐ layed. This tendency has been described under the delay-aversion hypothesis [66]. Still, the question arises what makes it more difficult for children with ADHD than for their peers to delay reward and persist when positive reinforcement remains uncertain? From an emotioncentred perspective, ADHD children's difficulties with persisting under delayed reward conditions are thought to be mediated by the challenge of regulating negative emotions, and

Several studies have therefore explicitly investigated how children with ADHD modulate their emotional experience and expression in constrained task conditions that elicit frustra‐ tion. Frustration is defined here as the emotion resulting from an absence of reward when such reward is expected [82]. Persistence can thus be conceived as the ability to adjust or modulate frustration perception so as to maintain task-oriented behavioural continuity.

verbal versus non-verbal stimulus modes as yet remain underexplored too.

ther established for ADHD children's contextual emotion recognition.

processing deficits in some instances.

262 Attention Deficit Hyperactivity Disorder in Children and Adolescents

task-interference contexts [61, 83].

especially frustration.

**behavioural expressions of emotional reactivity?**

Most studies have confirmed children with ADHD to experience heightened frustration lev‐ els in association with persistence and behavioural control problems, this both in cognitive task conditions [66, 95, 82] and in less investigated emotional contexts [9]. Detailed accounts of their task-related emotional experiences however provide important nuance regarding ADHD children's emotional understanding and process insight [66, 82].

For instance, an early study compared how seven to nine year old, clinically-referred ADHD children (n=22) and non-referred controls (n=20) compared on performance, study-time, selfrated persistence (namely how much did the child feel like continuing), and facially record‐ ed frustration levels during a nonsense word learning task [82]. Children were assigned to either a predetermined continuous reinforcement (CRF) or partial reinforcement (PRF) con‐ dition. The CRF and PRF conditions both consist of an acquisition phase followed by a nonreward extinction phase, yet PRF involves random instead of continuous reward during acquisition. Importantly, reinforcement pertained to persistence rather than task correctness in this study. As expected, learning occurred in both phases for both groups. Children with ADHD yet made more errors, expressed more frustration and felt less like persisting overall. Interestingly, especially the random reward (PRF) condition yielded three-fold frustration levels in ADHD children during the acquisition phase along with a persistence deficit. In turn, only children with ADHD (and not controls) in the CRF condition spent more studytime over the acquisition course [82]. Thus, children with ADHD displayed a marked diffi‐ culty habituating to initial frustration, while investing considerable effort in a consistent reward condition.

In the same vein, self-reported frustration was studied in medicated children with ADHD (n=21; mostly combined subtype) compared to non-clinical controls (n=43) using a blindfold‐ ed puzzle task [66]. This study moreover recorded detailed accounts of children's emotions, such as their self-reported mood after the task, general persistence and frustration tendency (likeliness of quitting and getting frustrated compared to peers), insight in the accompany‐ ing physical, emotional, or cognitive sensations of their frustration and how they dealt with it. Children additionally completed a structured emotional competence self-report measure, along with a mathematics task. Consistent with the previous findings, the present ADHD children were less persistent overall but invested as much time as control children in the tasks. This yielded them mixed results: they were more likely to quit the puzzle task and completed less mathematic problems than their peers, but the ones they completed were ac‐ curate. Of special interest for the present focus, the children with ADHD were likelier to re‐ port suffering frustration and give up compared to other children, were able to identify signs of their frustration and knew about ways of dealing with it. However, they were sig‐ nificantly less effective at acting upon this emotional understanding than controls.

Children with ADHD have also been demonstrated to have difficulty deliberately masking their emotions in an elicited frustration situation [95]. One study for instance examined ADHD boys' (n=26, ages 6 to 11) observed emotion regulation compared to that of controls (n=23), by explicitly asking them to hide their feelings even if they became upset during a competitive Stop Signal Task with peers. The boys with ADHD not only had more difficulty with regulating their emotions compared to their non-clinical peers, they were also less suc‐ cessful at hiding their emotions despite knowing that they were expected to do so [95].

tionally assessed children's emotional behaviours, intensity and reactions to contingencies using reported responses to hypothetical reward and punishment situations instead of live laboratory paradigms [90]. The use of these formats yielded parent-reports of more manifest signs of sadness, anger and guilt in ADHD boys but no self-reported differences in emotion‐

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265

Finally, the chronic and pervasive impact of emotional impulsiveness is documented in a rare longitudinal study that followed up on hyperactive (n=158) and community control (n=81) children, currently 27 years of age [47]. Participants reported on emotional impulsive‐ ness (such as impatient, irascible, easily excited, frustrated, annoyed and emotionally over‐ reactive behaviour) and were interviewed on multiple domains of functioning (e.g., home life and responsibilities, marital life, social interactions and leisure activities, occupation, and so forth). Emotional impulsiveness was highly correlated with the interrelated dimen‐ sions of inattention and hyperactivity-impulsivity in participants with persistent ADHD. The severity of emotional impulsiveness furthermore contributed uniquely to participants'

*Taken together,* these studies' findings lend credence to the emotion-centred expectations that ADHD children's (cognitive) abilities may become masked, not only by task modalities, but significantly so too by difficulties in modulating their emotional responses across tasks and situational demands. They also indicate that children with ADHD may especially benefit from support in translating mood- and mood-repair-knowledge into action. Still, there is ample room for further investigation of ADHD children's deliberate modulation of emotion‐ al responses in emotional contexts. The small number of studies and limited investigation scope leave more open questions than answers for the time being, notably regarding wheth‐ er and to what extent children with ADHD experience differential emotion regulation diffi‐ culties depending on the type of emotions, their intensity, the interaction styles and the involved relational contexts, to name but a few. The longitudinal findings on the unique life‐ long impact of emotional impulsiveness underline the importance of uncovering early inter‐ vention leads for supporting youth with ADHD to behaviourally modulate their emotions.

**5.4. ADHD children's emotion regulation in the context of parenting and family risks and**

The reviewed evidence-base suggests that children with ADHD differ from other children in their processing of facial affective clues, are less effective at matching (facial) affect and con‐ text, experience higher frustration levels in (cognitively) challenging situations and experi‐ ence more difficulty habituating to negative feelings and/or modulating these by acting upon mood-repair techniques, despite some degree of insight into internal emotion-related signals. Importantly, these difficulties occur even though children with ADHD appear to in‐

From a theoretical viewpoint (see paragraph 3.2), these observations raise questions about contextual effects, and especially parenting and family ones, on ADHD children's emotion regulation skills. Several macro-level pathways may indeed influence the development of ER skills in children with ADHD, both directly and indirectly, as illustrated by the arrows in

vest considerable effort into 'doing well' and complying with external instructions.

al intensity or reactivity compared to controls.

**resources**

overall impairment and multiple domain-specific adverse outcomes.

Of note, the previous studies examined ADHD children's emotional expression in cognitive‐ ly challenging contexts. Two other studies did so too in more explicitly emotion-related in‐ terpersonal contexts. One study used a prize paradigm with 8 to 11-year-old medicated children with ADHD-combined (ADHD-C, n=16) and inattentive (ADHD-I, n=14) subtypes (12 boys, 9 girls) compared to controls (n=17) [9]. Children's emotional responses were re‐ corded in disappointing versus non-disappointing conditions, namely receiving an unwant‐ ed versus a desired prize, after they had been asked to rank prizes in order of desirability and told they would receive prizes for helping another examiner. Emotion-focused meas‐ ures included children's facial and non-verbal reactions (classified as positive, negative, so‐ cial monitoring or tension behaviour), along with self-rated affect (how they felt about the prize, how frustrated they felt and how they liked the prize). As expected, all children gen‐ erally displayed condition-congruent behaviour, along with more intense self-reported af‐ fect following disappointment and more interest and effective ER in the non-disappointing condition. Children with ADHD-C additionally showed a trend toward more negatively be‐ having after disappointment, experiencing more prize interest and affect intensity as well as poorer ER than inattentive and control peers. Remarkably, children with ADHD-C also showed significantly more positive behaviour overall (regardless of condition) than their in‐ attentive and control peers [9]. These findings concord with evidence stemming from phys‐ iological reactivity research (cf. §5.1), suggesting that children with ADHD, and among them mainly those with the combined subtype, experience difficulties in adjusting their emotions and related behaviours across shifting situational demands.

A study by Melnick & Hinshaw (2000) employed a more ecologically valid approach by us‐ ing a videotaped frustrating family task to examine emotional reactivity and regulation among six to twelve year old, low aggressive (n=23) and high aggressive (n=25) ADHD boys compared to non-clinical controls and their parents (see §5.4 for the latter) [60]. Frustration, or negative emotion, was elicited by asking the child to complete a construction model with parental help while two building pieces were lacking. Children's behaviour was coded as regards the intensity of their emotional ventilation (or reactivity) and the appropriateness of their emotion modulation strategies (such as problem solving, seeking help, accommodat‐ ing, negative focussing or shutting down). Interestingly, no generalised ER difficulty could be demonstrated for these ADHD children. Observer-rated aggression was also not related to children's emotion regulation strategies overall, nor was emotional reactivity a significant predictor of their behavioural and social (peer) outcomes in this study. However, withinpopulation distinctions emerged whereby high-aggressive ADHD boys exhibited expected overreactive emotions and impaired problem solving, whereas low-aggressive ADHD boys showed either normal range or underresponsive emotional reactions [60].

It should be noted that, similar to (facial) emotion recognition evidence, findings on ADHD children's emotional intensity and behaviour may present measure-dependent variations. For instance, the early empathy study by Braaten et al. (2000) cited in paragraph 5.2.2 addi‐ tionally assessed children's emotional behaviours, intensity and reactions to contingencies using reported responses to hypothetical reward and punishment situations instead of live laboratory paradigms [90]. The use of these formats yielded parent-reports of more manifest signs of sadness, anger and guilt in ADHD boys but no self-reported differences in emotion‐ al intensity or reactivity compared to controls.

competitive Stop Signal Task with peers. The boys with ADHD not only had more difficulty with regulating their emotions compared to their non-clinical peers, they were also less suc‐ cessful at hiding their emotions despite knowing that they were expected to do so [95].

264 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Of note, the previous studies examined ADHD children's emotional expression in cognitive‐ ly challenging contexts. Two other studies did so too in more explicitly emotion-related in‐ terpersonal contexts. One study used a prize paradigm with 8 to 11-year-old medicated children with ADHD-combined (ADHD-C, n=16) and inattentive (ADHD-I, n=14) subtypes (12 boys, 9 girls) compared to controls (n=17) [9]. Children's emotional responses were re‐ corded in disappointing versus non-disappointing conditions, namely receiving an unwant‐ ed versus a desired prize, after they had been asked to rank prizes in order of desirability and told they would receive prizes for helping another examiner. Emotion-focused meas‐ ures included children's facial and non-verbal reactions (classified as positive, negative, so‐ cial monitoring or tension behaviour), along with self-rated affect (how they felt about the prize, how frustrated they felt and how they liked the prize). As expected, all children gen‐ erally displayed condition-congruent behaviour, along with more intense self-reported af‐ fect following disappointment and more interest and effective ER in the non-disappointing condition. Children with ADHD-C additionally showed a trend toward more negatively be‐ having after disappointment, experiencing more prize interest and affect intensity as well as poorer ER than inattentive and control peers. Remarkably, children with ADHD-C also showed significantly more positive behaviour overall (regardless of condition) than their in‐ attentive and control peers [9]. These findings concord with evidence stemming from phys‐ iological reactivity research (cf. §5.1), suggesting that children with ADHD, and among them mainly those with the combined subtype, experience difficulties in adjusting their

emotions and related behaviours across shifting situational demands.

showed either normal range or underresponsive emotional reactions [60].

A study by Melnick & Hinshaw (2000) employed a more ecologically valid approach by us‐ ing a videotaped frustrating family task to examine emotional reactivity and regulation among six to twelve year old, low aggressive (n=23) and high aggressive (n=25) ADHD boys compared to non-clinical controls and their parents (see §5.4 for the latter) [60]. Frustration, or negative emotion, was elicited by asking the child to complete a construction model with parental help while two building pieces were lacking. Children's behaviour was coded as regards the intensity of their emotional ventilation (or reactivity) and the appropriateness of their emotion modulation strategies (such as problem solving, seeking help, accommodat‐ ing, negative focussing or shutting down). Interestingly, no generalised ER difficulty could be demonstrated for these ADHD children. Observer-rated aggression was also not related to children's emotion regulation strategies overall, nor was emotional reactivity a significant predictor of their behavioural and social (peer) outcomes in this study. However, withinpopulation distinctions emerged whereby high-aggressive ADHD boys exhibited expected overreactive emotions and impaired problem solving, whereas low-aggressive ADHD boys

It should be noted that, similar to (facial) emotion recognition evidence, findings on ADHD children's emotional intensity and behaviour may present measure-dependent variations. For instance, the early empathy study by Braaten et al. (2000) cited in paragraph 5.2.2 addi‐ Finally, the chronic and pervasive impact of emotional impulsiveness is documented in a rare longitudinal study that followed up on hyperactive (n=158) and community control (n=81) children, currently 27 years of age [47]. Participants reported on emotional impulsive‐ ness (such as impatient, irascible, easily excited, frustrated, annoyed and emotionally over‐ reactive behaviour) and were interviewed on multiple domains of functioning (e.g., home life and responsibilities, marital life, social interactions and leisure activities, occupation, and so forth). Emotional impulsiveness was highly correlated with the interrelated dimen‐ sions of inattention and hyperactivity-impulsivity in participants with persistent ADHD. The severity of emotional impulsiveness furthermore contributed uniquely to participants' overall impairment and multiple domain-specific adverse outcomes.

*Taken together,* these studies' findings lend credence to the emotion-centred expectations that ADHD children's (cognitive) abilities may become masked, not only by task modalities, but significantly so too by difficulties in modulating their emotional responses across tasks and situational demands. They also indicate that children with ADHD may especially benefit from support in translating mood- and mood-repair-knowledge into action. Still, there is ample room for further investigation of ADHD children's deliberate modulation of emotion‐ al responses in emotional contexts. The small number of studies and limited investigation scope leave more open questions than answers for the time being, notably regarding wheth‐ er and to what extent children with ADHD experience differential emotion regulation diffi‐ culties depending on the type of emotions, their intensity, the interaction styles and the involved relational contexts, to name but a few. The longitudinal findings on the unique life‐ long impact of emotional impulsiveness underline the importance of uncovering early inter‐ vention leads for supporting youth with ADHD to behaviourally modulate their emotions.

#### **5.4. ADHD children's emotion regulation in the context of parenting and family risks and resources**

The reviewed evidence-base suggests that children with ADHD differ from other children in their processing of facial affective clues, are less effective at matching (facial) affect and con‐ text, experience higher frustration levels in (cognitively) challenging situations and experi‐ ence more difficulty habituating to negative feelings and/or modulating these by acting upon mood-repair techniques, despite some degree of insight into internal emotion-related signals. Importantly, these difficulties occur even though children with ADHD appear to in‐ vest considerable effort into 'doing well' and complying with external instructions.

From a theoretical viewpoint (see paragraph 3.2), these observations raise questions about contextual effects, and especially parenting and family ones, on ADHD children's emotion regulation skills. Several macro-level pathways may indeed influence the development of ER skills in children with ADHD, both directly and indirectly, as illustrated by the arrows in Figure 1. Exploring these contextual pathways seems all the more pertinent given the ob‐ served discrepancies of ER findings within the ADHD youth population and apparently in‐ sufficient explanatory value of subtype, comorbidity or medication-statuses.

nomenon, described as the positive illusory bias, was investigated in one study as regards its link with parental emotional expression among families with seven to ten year old chil‐ dren with ADHD compared to controls (N=56) [99]. Parental criticism was indeed associated with greater positive illusory bias, and parental warmth with lower bias regarding social functioning in children with ADHD. Such findings call for the investigation of comparable parenting effects on ER aspects such as ADHD children's physiological reactivity, basic or

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

267

Regarding behavioural modulation, a retrospective study for instance examined whether re‐ called parental ADHD and parenting behaviour related to current emotion regulation among adults with persistent ADHD (n=73, mean age 40, half combined/half inattentive subtypes) [21]. The ADHD adults whose mother possibly had ADHD recalled more mater‐ nal rejection and punishment, less paternal rejection and punishment, along with more emo‐ tional warmth. These retrospectively identified maternal parenting characteristics, as well as recalled maternal ADHD symptoms, were linked to current insecure emotional functioning and interpersonal relationships. ADHD adults' current attachment and emotion processing patterns were not similarly linked to recalled paternal ADHD and fathering characteristics.

To conclude on potential contextual influences on ADHD children's emotion regulation, it is noteworthy that the cultural component hereof has drawn little attention so far. While basic FER is considered to be relatively universal, this assumption is far less evident for the con‐ textual embedment of emotions and for their behavioural correlates. One study for instance found parenting strategies among children with ADHD to differ by ethnicity, although this did not moderate treatment outcomes [100]. Potential effects of ethnicity and culture on

*In sum,* the frequent cumulative presence of ADHD among family members by itself forms a considerable risk burden that may increase emotion dysregulation in children with ADHD or constitute critical obstacles toward their learning of effective emotion reg‐ ulation. While these risks of parental ADHD, negative parenting and family interactions are easily conceived, there is a lack of empirical research that investigates when and how such cumulative risks versus resources specifically operate in the ADHD child's acquisi‐

Behavioural observations, neurobiological and brain imaging data have led to postulate that children with ADHD may experience disrupted emotion regulation. More specifically, ADHD children are expected to exhibit right hemispheric- and attention-related emotion recognition difficulties along with emotional impulsiveness, including heightened physio‐ logical reactivity and lessened control of behavioural emotional expression, as synthesised at micro-level of the FACE-model. ADHD children's emotion regulation consequently mer‐ its investigation as regards their physiological arousal levels, basic and contextualised ap‐

praisal of (facial) emotional cues and modulation of emotional behaviour.

ADHD children's appraisal and expression of emotions thus deserve examination.

tion of emotion regulation skills.

**5.5. Summary**

contextualised emotion appraisal and behavioural modulation.

The most *direct* contextual effects on ADHD children's ER skills concern the way in which parents raise their children and run the family as regards these skills. Mediating and moder‐ ating effects of, for instance, parental depression, marital conflict, and critical and harsh pa‐ renting indeed already have been documented in general developmental studies and in research regarding predictors of early-onset conduct problems [53, 96, 97]. With the in‐ creased recognition of adult persistence of ADHD, many children with ADHD are acknowl‐ edged to grow up in families with at least one parent with ADHD [8, 43] and possibly siblings too [55, 96]. Emotional impairments in children with ADHD therefore are expected to be reciprocally shaped by their personal neurobiological predispositions and parentingand family-related disruptions in emotion regulation [8, 14, 43, 57, 97, 98]. ER disruptions also involve *less direct* effects, such as ADHD children's observational, modelled learning of emotion expression through their parents and possibly siblings. Moreover, structural and functional contextual risks and resources are known to operate through *cumulative and rela‐ tive principles*, also described as psychological allostatic load [7, 13, 30, 35, 53]. For example, an accumulation of family members with ADHD, internalising or externalising comorbidity, family conflict and an adverse school climate would expectedly culminate in mutually un‐ dermining effects on the ADHD child's ER skills. Conversely, the presence, for example, of family members with strong emotion regulation skills and a supportive school climate would constitute cumulative resources that stimulate the ADHD child's emotion regulation skills, or at least counterbalance its personal liabilities to this regard.

Unfortunately, to what extent parental, parenting and family ER difficulties affect specific ER components in ADHD offspring has hardly been empirically examined. A Pubmed search with the key-words 'ADHD', 'emotion regulation' and 'parenting' yields a mere five published articles, among which only the above-cited study of Melnick et al. (2000) directly tackled the subject (see §5.3) [60]. In this previously described videotaped frustrating family task, asides from child ER, parental behaviour was also observed as regards positive versus negative parenting (e.g. situational advice, warmth, structuring and empathy versus nega‐ tivity, intrusiveness, withdrawal), along with personal (global) emotion regulation (e.g. anxiety, maintenance of focus on and interaction with the child). Mean levels of parenting behaviour did not differ significantly among the ADHD (sub)groups and control children. However, parental anxiety/nervousness and mother's negativity were significantly associat‐ ed with child global emotion regulation difficulties overall; whereas father's global ER and advice-giving were marginally linked with child positive coping behaviour.

These findings are consonant with several other research reports linking parental negativity, sometimes in association with parental ADHD, to (self-reported) adverse outcomes on emo‐ tion regulation in ADHD offspring and this throughout the life span [21, 47, 99].

For instance, in the broader literature children with ADHD have been described to resort to overestimation of their social, behavioural or family-related self-perceptions, probably as a compensation mechanism for excessive emotionally negative interactions [98, 99]. This phe‐ nomenon, described as the positive illusory bias, was investigated in one study as regards its link with parental emotional expression among families with seven to ten year old chil‐ dren with ADHD compared to controls (N=56) [99]. Parental criticism was indeed associated with greater positive illusory bias, and parental warmth with lower bias regarding social functioning in children with ADHD. Such findings call for the investigation of comparable parenting effects on ER aspects such as ADHD children's physiological reactivity, basic or contextualised emotion appraisal and behavioural modulation.

Regarding behavioural modulation, a retrospective study for instance examined whether re‐ called parental ADHD and parenting behaviour related to current emotion regulation among adults with persistent ADHD (n=73, mean age 40, half combined/half inattentive subtypes) [21]. The ADHD adults whose mother possibly had ADHD recalled more mater‐ nal rejection and punishment, less paternal rejection and punishment, along with more emo‐ tional warmth. These retrospectively identified maternal parenting characteristics, as well as recalled maternal ADHD symptoms, were linked to current insecure emotional functioning and interpersonal relationships. ADHD adults' current attachment and emotion processing patterns were not similarly linked to recalled paternal ADHD and fathering characteristics.

To conclude on potential contextual influences on ADHD children's emotion regulation, it is noteworthy that the cultural component hereof has drawn little attention so far. While basic FER is considered to be relatively universal, this assumption is far less evident for the con‐ textual embedment of emotions and for their behavioural correlates. One study for instance found parenting strategies among children with ADHD to differ by ethnicity, although this did not moderate treatment outcomes [100]. Potential effects of ethnicity and culture on ADHD children's appraisal and expression of emotions thus deserve examination.

*In sum,* the frequent cumulative presence of ADHD among family members by itself forms a considerable risk burden that may increase emotion dysregulation in children with ADHD or constitute critical obstacles toward their learning of effective emotion reg‐ ulation. While these risks of parental ADHD, negative parenting and family interactions are easily conceived, there is a lack of empirical research that investigates when and how such cumulative risks versus resources specifically operate in the ADHD child's acquisi‐ tion of emotion regulation skills.

#### **5.5. Summary**

Figure 1. Exploring these contextual pathways seems all the more pertinent given the ob‐ served discrepancies of ER findings within the ADHD youth population and apparently in‐

The most *direct* contextual effects on ADHD children's ER skills concern the way in which parents raise their children and run the family as regards these skills. Mediating and moder‐ ating effects of, for instance, parental depression, marital conflict, and critical and harsh pa‐ renting indeed already have been documented in general developmental studies and in research regarding predictors of early-onset conduct problems [53, 96, 97]. With the in‐ creased recognition of adult persistence of ADHD, many children with ADHD are acknowl‐ edged to grow up in families with at least one parent with ADHD [8, 43] and possibly siblings too [55, 96]. Emotional impairments in children with ADHD therefore are expected to be reciprocally shaped by their personal neurobiological predispositions and parentingand family-related disruptions in emotion regulation [8, 14, 43, 57, 97, 98]. ER disruptions also involve *less direct* effects, such as ADHD children's observational, modelled learning of emotion expression through their parents and possibly siblings. Moreover, structural and functional contextual risks and resources are known to operate through *cumulative and rela‐ tive principles*, also described as psychological allostatic load [7, 13, 30, 35, 53]. For example, an accumulation of family members with ADHD, internalising or externalising comorbidity, family conflict and an adverse school climate would expectedly culminate in mutually un‐ dermining effects on the ADHD child's ER skills. Conversely, the presence, for example, of family members with strong emotion regulation skills and a supportive school climate would constitute cumulative resources that stimulate the ADHD child's emotion regulation

Unfortunately, to what extent parental, parenting and family ER difficulties affect specific ER components in ADHD offspring has hardly been empirically examined. A Pubmed search with the key-words 'ADHD', 'emotion regulation' and 'parenting' yields a mere five published articles, among which only the above-cited study of Melnick et al. (2000) directly tackled the subject (see §5.3) [60]. In this previously described videotaped frustrating family task, asides from child ER, parental behaviour was also observed as regards positive versus negative parenting (e.g. situational advice, warmth, structuring and empathy versus nega‐ tivity, intrusiveness, withdrawal), along with personal (global) emotion regulation (e.g. anxiety, maintenance of focus on and interaction with the child). Mean levels of parenting behaviour did not differ significantly among the ADHD (sub)groups and control children. However, parental anxiety/nervousness and mother's negativity were significantly associat‐ ed with child global emotion regulation difficulties overall; whereas father's global ER and

These findings are consonant with several other research reports linking parental negativity, sometimes in association with parental ADHD, to (self-reported) adverse outcomes on emo‐

For instance, in the broader literature children with ADHD have been described to resort to overestimation of their social, behavioural or family-related self-perceptions, probably as a compensation mechanism for excessive emotionally negative interactions [98, 99]. This phe‐

sufficient explanatory value of subtype, comorbidity or medication-statuses.

266 Attention Deficit Hyperactivity Disorder in Children and Adolescents

skills, or at least counterbalance its personal liabilities to this regard.

advice-giving were marginally linked with child positive coping behaviour.

tion regulation in ADHD offspring and this throughout the life span [21, 47, 99].

Behavioural observations, neurobiological and brain imaging data have led to postulate that children with ADHD may experience disrupted emotion regulation. More specifically, ADHD children are expected to exhibit right hemispheric- and attention-related emotion recognition difficulties along with emotional impulsiveness, including heightened physio‐ logical reactivity and lessened control of behavioural emotional expression, as synthesised at micro-level of the FACE-model. ADHD children's emotion regulation consequently mer‐ its investigation as regards their physiological arousal levels, basic and contextualised ap‐ praisal of (facial) emotional cues and modulation of emotional behaviour.

Our review of the current evidence-base concerning ADHD children's emotion regulation reveals a still emerging field that involves a wide scope of ER components and operationali‐ sations, which have only been investigated to a limited extent to date. This state-of-the-art prohibits drawing definite conclusions on the extent to which the ADHD youth population exhibits the expected ER difficulties, and the degree to which these apply to its heterogene‐ ous subgroups as regards subtypes and comorbidities. Further empirical evidence is re‐ quired too regarding how, precisely, parental, parenting and family dynamics hamper versus foster specific aspects of ADHD children's emotion regulation.

groups are more particularly concerned by specific ER difficulties [ 19, 28, 37, 46]. Moreover, cross-sectional research, which is currently dominant, informs little to none about children's personal trajectories, while understanding these trajectories is crucial to guiding prevention

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

269

A *second*, related challenge consists of clarifying the proportions of children with ADHD who are vulnerable to exhibiting ER difficulties. Percentages of ADHD versus control chil‐ dren concerned by the observed ER differences indeed are not systematically provided in many studies. A clear view of the proportion of the investigated ADHD children facing emotion regulation challenges consequently does not automatically emerge from the evi‐ dence-base. Closer analysis nevertheless reveals that oftentimes only a minority or a sub‐ group among the children with ADHD presents deficits in the investigated emotion regulation components, while a majority successfully accomplishes the tasks at hand. Prac‐ tice relevance would consequently be enhanced if empirical research were oriented to a larg‐ er extent on identifying the subsets of ADHD children who account for the differences in

A *third* challenge concerns the clinical relevance of statistical findings. Group-level *statistical‐ ly* significant differences or correlations do not naturally equal *clinically* significant levels of emotion dysregulation in (all) children with ADHD [6]. When studies report statistical ER differences between groups of controls and children with ADHD, it therefore still remains to be specified to what extent these *differences* correspond to clinically relevant functional *im‐ pairments* in the latter. This challenge is compounded by the inherent chiasm between, on the one hand, striving toward as 'pure' as possible research conditions, and on the other hand, obtaining ecologically valid insights of how ADHD children's emotion regulation ef‐ forts unfold when cognitive, emotional and behavioural stimulus input and output occur si‐

Additionally, and contrasting with a voluminous parenting literature and demand, very lit‐ tle empirical research has been devoted to the potential emotional strengths that may come with ADHD [13]. A growing resiliency-oriented literature yet suggests that the aim of help‐ ing ADHD children better deal with their personal and interpersonal challenges may be more difficult to attain when weighing in on 'what goes wrong' without simultaneously try‐ ing to understand 'what goes right' [102]. The macro-level of the FACE-model indeed re‐ minds that solely assessing ADHD children's emotion-related problems does not provide a valid view of day-to-day dynamics. Importantly, it creates the risk of overlooking child- and family strengths that contribute to compensating, alleviating or avoiding negative emotional outcomes in the ADHD child's development [31]. This omission of strengths, or of at least a balanced risk-resiliency assessment, may contribute to accounting, for instance, for the pro‐ portions of children with diagnosed ADHD in which no significant emotion regulation defi‐

Altogether these factors add to necessary caution when linking empirical data to real-life im‐ plications for ADHD children and their families. Given a generalised tendency to overgener‐ alisation, evidence-based practice would benefit from studies adding more ecologically valid indices in their conclusions regarding the profiles of ADHD children to which ob‐

and intervention efforts with individual ADHD children and their families.

emotion regulation observed between investigated groups.

multaneously in a continuous loop of adjustment processes.

cits are found in the discussed studies.

Taken together, the available studies nevertheless suggest that children with ADHD tend to differ from other children in their processing of facial affective clues and are at-risk for being less effective at adequately adapting their physiological arousal to situational demands, and at matching (facial) affect and context. Children with ADHD also appear vulnerable to expe‐ riencing higher frustration levels in (cognitively) challenging situations, and having more difficulties with behaviourally habituating to negative feelings and modulating these by act‐ ing upon mood-repair techniques. This happens despite indications that children with ADHD do demonstrate some degree of insight into internal emotion-related signals. Per‐ haps even more importantly, it appears that children with ADHD invest considerable effort into 'doing well' and attempting to control their negative emotions when requested to do so, yet these efforts are seldom acknowledged and/or accompanied by the expected results. The prevention and intervention implications hereof are discussed hereafter.

#### **6. From studying to facilitating ADHD children's emotion regulation**

Translating research into practice remains an important challenge for designing, implement‐ ing and evaluating ADHD prevention and intervention programs [6, 18, 57, 101]. Several characteristics of the extant ER research yet call for caution when attempting to move from the evidence-base toward one-on-one practice with ADHD children. We therefore first ana‐ lyse conditions for a cautious interpretation of the evidence-base that also foster a strengthsbased approach, this along three related lines pertaining to the individual, the proportional and the clinical relevance of the empirical findings (§6.1). Several potential implications of the ER evidence-base for emotion-oriented intervention with ADHD children and their fam‐ ilies are considered subsequently (§6.2).

#### **6.1. Cautions and conditions for an evidence-based, resiliency-oriented practice**

A *first* and fundamental challenge when relying on the evidence-base for practice consists of deciphering its potential relevance for the individual child with ADHD and its family. Em‐ pirical research indeed mostly reports on statistically significant differences between groups of children with and without ADHD; or on *group-level* correlations between the ADHD sta‐ tus and several emotion regulation aspects. Such mean differences or group-wise correla‐ tions evidently do not concern all investigated ADHD children. Most of the current research data thus critically leave open questions as to which children within the investigated ADHD groups are more particularly concerned by specific ER difficulties [ 19, 28, 37, 46]. Moreover, cross-sectional research, which is currently dominant, informs little to none about children's personal trajectories, while understanding these trajectories is crucial to guiding prevention and intervention efforts with individual ADHD children and their families.

Our review of the current evidence-base concerning ADHD children's emotion regulation reveals a still emerging field that involves a wide scope of ER components and operationali‐ sations, which have only been investigated to a limited extent to date. This state-of-the-art prohibits drawing definite conclusions on the extent to which the ADHD youth population exhibits the expected ER difficulties, and the degree to which these apply to its heterogene‐ ous subgroups as regards subtypes and comorbidities. Further empirical evidence is re‐ quired too regarding how, precisely, parental, parenting and family dynamics hamper

Taken together, the available studies nevertheless suggest that children with ADHD tend to differ from other children in their processing of facial affective clues and are at-risk for being less effective at adequately adapting their physiological arousal to situational demands, and at matching (facial) affect and context. Children with ADHD also appear vulnerable to expe‐ riencing higher frustration levels in (cognitively) challenging situations, and having more difficulties with behaviourally habituating to negative feelings and modulating these by act‐ ing upon mood-repair techniques. This happens despite indications that children with ADHD do demonstrate some degree of insight into internal emotion-related signals. Per‐ haps even more importantly, it appears that children with ADHD invest considerable effort into 'doing well' and attempting to control their negative emotions when requested to do so, yet these efforts are seldom acknowledged and/or accompanied by the expected results. The

versus foster specific aspects of ADHD children's emotion regulation.

268 Attention Deficit Hyperactivity Disorder in Children and Adolescents

prevention and intervention implications hereof are discussed hereafter.

ilies are considered subsequently (§6.2).

**6. From studying to facilitating ADHD children's emotion regulation**

**6.1. Cautions and conditions for an evidence-based, resiliency-oriented practice**

A *first* and fundamental challenge when relying on the evidence-base for practice consists of deciphering its potential relevance for the individual child with ADHD and its family. Em‐ pirical research indeed mostly reports on statistically significant differences between groups of children with and without ADHD; or on *group-level* correlations between the ADHD sta‐ tus and several emotion regulation aspects. Such mean differences or group-wise correla‐ tions evidently do not concern all investigated ADHD children. Most of the current research data thus critically leave open questions as to which children within the investigated ADHD

Translating research into practice remains an important challenge for designing, implement‐ ing and evaluating ADHD prevention and intervention programs [6, 18, 57, 101]. Several characteristics of the extant ER research yet call for caution when attempting to move from the evidence-base toward one-on-one practice with ADHD children. We therefore first ana‐ lyse conditions for a cautious interpretation of the evidence-base that also foster a strengthsbased approach, this along three related lines pertaining to the individual, the proportional and the clinical relevance of the empirical findings (§6.1). Several potential implications of the ER evidence-base for emotion-oriented intervention with ADHD children and their fam‐

A *second*, related challenge consists of clarifying the proportions of children with ADHD who are vulnerable to exhibiting ER difficulties. Percentages of ADHD versus control chil‐ dren concerned by the observed ER differences indeed are not systematically provided in many studies. A clear view of the proportion of the investigated ADHD children facing emotion regulation challenges consequently does not automatically emerge from the evi‐ dence-base. Closer analysis nevertheless reveals that oftentimes only a minority or a sub‐ group among the children with ADHD presents deficits in the investigated emotion regulation components, while a majority successfully accomplishes the tasks at hand. Prac‐ tice relevance would consequently be enhanced if empirical research were oriented to a larg‐ er extent on identifying the subsets of ADHD children who account for the differences in emotion regulation observed between investigated groups.

A *third* challenge concerns the clinical relevance of statistical findings. Group-level *statistical‐ ly* significant differences or correlations do not naturally equal *clinically* significant levels of emotion dysregulation in (all) children with ADHD [6]. When studies report statistical ER differences between groups of controls and children with ADHD, it therefore still remains to be specified to what extent these *differences* correspond to clinically relevant functional *im‐ pairments* in the latter. This challenge is compounded by the inherent chiasm between, on the one hand, striving toward as 'pure' as possible research conditions, and on the other hand, obtaining ecologically valid insights of how ADHD children's emotion regulation ef‐ forts unfold when cognitive, emotional and behavioural stimulus input and output occur si‐ multaneously in a continuous loop of adjustment processes.

Additionally, and contrasting with a voluminous parenting literature and demand, very lit‐ tle empirical research has been devoted to the potential emotional strengths that may come with ADHD [13]. A growing resiliency-oriented literature yet suggests that the aim of help‐ ing ADHD children better deal with their personal and interpersonal challenges may be more difficult to attain when weighing in on 'what goes wrong' without simultaneously try‐ ing to understand 'what goes right' [102]. The macro-level of the FACE-model indeed re‐ minds that solely assessing ADHD children's emotion-related problems does not provide a valid view of day-to-day dynamics. Importantly, it creates the risk of overlooking child- and family strengths that contribute to compensating, alleviating or avoiding negative emotional outcomes in the ADHD child's development [31]. This omission of strengths, or of at least a balanced risk-resiliency assessment, may contribute to accounting, for instance, for the pro‐ portions of children with diagnosed ADHD in which no significant emotion regulation defi‐ cits are found in the discussed studies.

Altogether these factors add to necessary caution when linking empirical data to real-life im‐ plications for ADHD children and their families. Given a generalised tendency to overgener‐ alisation, evidence-based practice would benefit from studies adding more ecologically valid indices in their conclusions regarding the profiles of ADHD children to which ob‐ served emotion processing and regulation characteristics apply, and to which degree these correspond to clinically relevant impairments [6, 19]. Even when considering that emotion regulation training probably constitutes a valuable asset to any prevention and intervention effort, the main preoccupation for children with ADHD still consists of tailoring such efforts as closely as possible to their particular ER challenges. The current knowledgebase hereby points to potentially relevant prevention/intervention avenues that merit individual tailor‐ ing when addressing ADHD children's emotional functioning in practice.

pre- versus posttest improvements in child- and parent-reported experiential and behaviou‐ ral outcomes after program completion [4, 5, 30]. The FACE©-program hereby also involves stimulating the transfer of clinic-based activities through home activities during which pa‐ rents and children use self-report versions of the FACE'ogram© illustrated in Figure 1 to map perceived stressors and resources. Micro-challenges in daily adjustments are also moni‐ tored through the use of a cognitive-emotional diary (FACE©-CEM) [6]. Similar diary meth‐

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

271

Despite a growing range of evidence-based interventions for ADHD children and their fami‐ lies, emotion-centred insights yet still remain sparsely applied in this context [104]. To date, many of these interventions also have more broadly concerned children with oppositional behaviour and conduct problems, whereby ADHD symptoms may be involved but not nec‐ essarily amount to formal ADHD diagnoses. Most interventions thus still tend to focus pri‐ marily on behavioural and/or cognitive modification techniques, even if emotion-related management is more or less implicitly involved in parent-training intervention components [56, 104-106]. A recent meta-analysis of 40 ADHD-oriented parent-intervention studies here‐ by showed parenting competence to be the only parent-intervention outcome with a largeto-moderate effect from immediate assessment to follow-up, among otherwise generally moderate-to-small outcome effects [104]. Training outcomes seem to follow comparable tra‐ jectories for mothers and fathers, consisting of immediate efficacy followed by limited gen‐ eralisation and waning longer term effects, although it should be noted that fathers typically

Interestingly, two interventions that do include a more explicit emotion-centred focus, one of which was aimed at ADHD children, are reported to yield firmer long-term outcomes. Thus, one study assessed whether limiting negative emotional control through the training of parental positive behaviour in a family-centred intervention would amend the growth of children's early behaviour problems [107]. An effortful increase in proactive parenting was indeed significantly associated with lower levels of toddlers' general behavioural problems through age two to four. Another study more specifically evaluated the efficacy of the In‐ credible Years (IY) interventions for children with a primary ADHD diagnosis [108]. The IY interventions involve emotion-focused techniques, besides more traditional child and parent behaviour modification and parenting support, and have been found effective in reducing negative parenting and externalising behaviour among children with ODD and CD in a ser‐ ies of randomized control group studies [96, 108]. An updated program version was used to more precisely examine IY efficacy with four to six-year-old ADHD children (n=49) and their parents who participated in six intervention months. Emotion-focused targets included emotional coaching and teaching of ER strategies, reducing parental depression and anger and increasing family support. Statistically and clinically significant post-treatment effects were found for most outcome variables; including parent-reported and observed parenting, child social, externalising and ADHD-specific behaviours. Significantly, ADHD children's

Finally and for the sake of exhaustiveness, it deserves to be noted that, given space-con‐ straints, the present discussion did not extensively review medication effects on ADHD chil‐

ods have been found useful for identifying ADHD families' daily challenges [103].

have been less implicated and thus less investigated [106].

treatment progress was maintained after one year [108].

#### **6.2. How to face emotion regulation in children with ADHD and their families: Prevention and intervention keys**

Bearing the discussed cautions in mind, an integrated theory-grounded, evidence-based and strengths-oriented approach offers several instrumental leads for accompanying children and their parents towards facing emotionally disruptive facets of ADHD and equipping them with emotion regulation strengths.

On a *micro-level*, it appears key to help at-risk ADHD children with adjusting their emotion‐ al reactivity, with appraising how emotions relate to particular contexts, with recognising negative emotions, and with acquiring problem solving, mood-adjustment knowledge and techniques to act upon this knowledge.

On a *macro-level*, parents with ADHD are likely to find solace in the same focuses, while pa‐ rents of ADHD children in general may benefit from psychoeducation about the aforemen‐ tioned ER specificities in their children (and partners) and from tailoring emotion regulation and problem solving techniques to these specificities.

Given the most directly influential impact of parenting on the child's life, it appears particu‐ larly important for practice to identify parental ADHD as well as parental emotional resour‐ ces. Indeed, adults who suffer emotional disruptions themselves confront a significant parenting burden when rearing one or more children with ADHD. Parents with ADHD, but also with other affective issues such as depression, may be particularly vulnerable toward disrupted emotion regulation [43]. Conversely, since not all parents of ADHD children present with ADHD and not all ADHD parents suffer (the same extent of) emotional impair‐ ments, recognising ER resources in parents represents a valuable asset for building resilien‐ cy in their children. Identifying the ER strategies acquired by parents with ADHD hereby especially offers added value because this simultaneously allows drawing on experiencetested insights, promoting empathy with the ADHD child and engaging in uncovering exist‐ ing strengths in the family.

An illustration of these principles can be found and is currently evaluated in the ongoing FACE©-ADHD program, which consists of thirteen weekly, 2-hour sessions combining child and parent intervention [4, 5, 30]. Sessions evolve from psychoeducation through problemsolving activities and cognitive-oriented parenting support, toward more specific targeting of (negative) emotions, building emotional skills and training in emotion regulation so as to reduce negative and increase positive experiences and interactions by and among ADHD children and their parents. In a preliminary evaluation, this approach yielded significant pre- versus posttest improvements in child- and parent-reported experiential and behaviou‐ ral outcomes after program completion [4, 5, 30]. The FACE©-program hereby also involves stimulating the transfer of clinic-based activities through home activities during which pa‐ rents and children use self-report versions of the FACE'ogram© illustrated in Figure 1 to map perceived stressors and resources. Micro-challenges in daily adjustments are also moni‐ tored through the use of a cognitive-emotional diary (FACE©-CEM) [6]. Similar diary meth‐ ods have been found useful for identifying ADHD families' daily challenges [103].

served emotion processing and regulation characteristics apply, and to which degree these correspond to clinically relevant impairments [6, 19]. Even when considering that emotion regulation training probably constitutes a valuable asset to any prevention and intervention effort, the main preoccupation for children with ADHD still consists of tailoring such efforts as closely as possible to their particular ER challenges. The current knowledgebase hereby points to potentially relevant prevention/intervention avenues that merit individual tailor‐

Bearing the discussed cautions in mind, an integrated theory-grounded, evidence-based and strengths-oriented approach offers several instrumental leads for accompanying children and their parents towards facing emotionally disruptive facets of ADHD and equipping

On a *micro-level*, it appears key to help at-risk ADHD children with adjusting their emotion‐ al reactivity, with appraising how emotions relate to particular contexts, with recognising negative emotions, and with acquiring problem solving, mood-adjustment knowledge and

On a *macro-level*, parents with ADHD are likely to find solace in the same focuses, while pa‐ rents of ADHD children in general may benefit from psychoeducation about the aforemen‐ tioned ER specificities in their children (and partners) and from tailoring emotion regulation

Given the most directly influential impact of parenting on the child's life, it appears particu‐ larly important for practice to identify parental ADHD as well as parental emotional resour‐ ces. Indeed, adults who suffer emotional disruptions themselves confront a significant parenting burden when rearing one or more children with ADHD. Parents with ADHD, but also with other affective issues such as depression, may be particularly vulnerable toward disrupted emotion regulation [43]. Conversely, since not all parents of ADHD children present with ADHD and not all ADHD parents suffer (the same extent of) emotional impair‐ ments, recognising ER resources in parents represents a valuable asset for building resilien‐ cy in their children. Identifying the ER strategies acquired by parents with ADHD hereby especially offers added value because this simultaneously allows drawing on experiencetested insights, promoting empathy with the ADHD child and engaging in uncovering exist‐

An illustration of these principles can be found and is currently evaluated in the ongoing FACE©-ADHD program, which consists of thirteen weekly, 2-hour sessions combining child and parent intervention [4, 5, 30]. Sessions evolve from psychoeducation through problemsolving activities and cognitive-oriented parenting support, toward more specific targeting of (negative) emotions, building emotional skills and training in emotion regulation so as to reduce negative and increase positive experiences and interactions by and among ADHD children and their parents. In a preliminary evaluation, this approach yielded significant

ing when addressing ADHD children's emotional functioning in practice.

**Prevention and intervention keys**

them with emotion regulation strengths.

270 Attention Deficit Hyperactivity Disorder in Children and Adolescents

techniques to act upon this knowledge.

ing strengths in the family.

and problem solving techniques to these specificities.

**6.2. How to face emotion regulation in children with ADHD and their families:**

Despite a growing range of evidence-based interventions for ADHD children and their fami‐ lies, emotion-centred insights yet still remain sparsely applied in this context [104]. To date, many of these interventions also have more broadly concerned children with oppositional behaviour and conduct problems, whereby ADHD symptoms may be involved but not nec‐ essarily amount to formal ADHD diagnoses. Most interventions thus still tend to focus pri‐ marily on behavioural and/or cognitive modification techniques, even if emotion-related management is more or less implicitly involved in parent-training intervention components [56, 104-106]. A recent meta-analysis of 40 ADHD-oriented parent-intervention studies here‐ by showed parenting competence to be the only parent-intervention outcome with a largeto-moderate effect from immediate assessment to follow-up, among otherwise generally moderate-to-small outcome effects [104]. Training outcomes seem to follow comparable tra‐ jectories for mothers and fathers, consisting of immediate efficacy followed by limited gen‐ eralisation and waning longer term effects, although it should be noted that fathers typically have been less implicated and thus less investigated [106].

Interestingly, two interventions that do include a more explicit emotion-centred focus, one of which was aimed at ADHD children, are reported to yield firmer long-term outcomes. Thus, one study assessed whether limiting negative emotional control through the training of parental positive behaviour in a family-centred intervention would amend the growth of children's early behaviour problems [107]. An effortful increase in proactive parenting was indeed significantly associated with lower levels of toddlers' general behavioural problems through age two to four. Another study more specifically evaluated the efficacy of the In‐ credible Years (IY) interventions for children with a primary ADHD diagnosis [108]. The IY interventions involve emotion-focused techniques, besides more traditional child and parent behaviour modification and parenting support, and have been found effective in reducing negative parenting and externalising behaviour among children with ODD and CD in a ser‐ ies of randomized control group studies [96, 108]. An updated program version was used to more precisely examine IY efficacy with four to six-year-old ADHD children (n=49) and their parents who participated in six intervention months. Emotion-focused targets included emotional coaching and teaching of ER strategies, reducing parental depression and anger and increasing family support. Statistically and clinically significant post-treatment effects were found for most outcome variables; including parent-reported and observed parenting, child social, externalising and ADHD-specific behaviours. Significantly, ADHD children's treatment progress was maintained after one year [108].

Finally and for the sake of exhaustiveness, it deserves to be noted that, given space-con‐ straints, the present discussion did not extensively review medication effects on ADHD chil‐ dren's emotion regulation. Briefly considered, the additive value of combining medication and psychosocial treatments has been demonstrated especially for children with intense ADHD symptomatology [2, 105, 108]. It is therefore likely that medication may benefit the efficacy of emotion-focused interventions with these children too, albeit because a normali‐ sation of behavioural activity levels is expected to improve learning conditions and family communication [38]. For instance, a study on 43 elementary-school-age children with ADHD documents the positive impact of amphetamine medication on child and family dy‐ namics [59]. Furthermore, Williams' et al.'s study (2008) on youth's event-related potentials before and after MPH treatment [89], evoked in paragraph 5.2.1, specifically showed that improved brain activity after MPH treatment predicted diminution of emotional lability al‐ though not of negative mood. Medication has however also been reported to result in blunt‐ ed, flattened, restricted and dysphoric emotional expression along with passive and even submissive behaviour among children with ADHD [109]. Optimising medication doses may therefore be crucial, as evidenced by one study reporting curvilinear MPH dose effects on ADHD children's visual focusing and variability of facially expressed emotions [38]. Subop‐ timal medication protocols might in turn interfere with the process of training ADHD chil‐ dren's emotion regulation skills. Investigating the impact of ADHD medication on emotioncentred intervention outcomes and its differential effects according to symptom intensity, comorbidity and medication dosage is therefore recommended.

emotions differently compared to peers so that they are in need of extra support in the skill of emotionally adjusting to habitual contextual demands. Throughout the diverse outcomes for this heterogeneous population, it seems that especially children with an externalising pattern of functioning, namely those with the combined ADHD subtype and/or comorbid conduct problems, are most at-risk for demonstrating emotion regulation difficulties at physiological, experiential and behavioural levels. Although as yet scarcely investigated, pa‐ rental expressed negativity furthermore appears to adversely weigh in on ADHD children's

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

273

Given that the research to date predominantly has investigated ADHD children's emotion regulation in cognitive (challenging) situations, findings hereby primarily underscore the importance of considering the impact of ADHD children's emotional functioning on (cogni‐ tive) task accomplishments and of acknowledging their non-apparent regulation efforts. These insights call for incorporating mood-management support for children with ADHD in learning conditions. They also call for a paradigm shift so as to value ADHD children's ef‐ forts instead of sole outcomes to a much larger extent than is generally the case in academic

Importantly, the observation that large proportions of investigated children with ADHD do not exhibit the expected emotion regulation difficulties still tends to go unnoticed. This leaves unexploited critical leads for gaining a refined understanding of the impact of ADHD on a child's life and of the resources that may be more or less naturally present in some fam‐ ilies to mend its expected adverse effects. Emerging intervention-outcome evidence also points to promising resiliency-building opportunities through the integration of emotion regulation, problem solving, behaviour modification and positive parenting training for

The complex field of ADHD children's emotion regulation thus still remains under-explored empirically on several aspects with practical relevance. Children's physiological reactivity, appraisal of emotional cues and modulation of emotional experience and expression hardly have been examined in inherently emotion-driven contexts, such as during parent-child and family interactions. More ecologically valid indices are therefore needed as to which emo‐ tion regulation processes underlie ADHD children's observed emotional disruptions in the

In a theory-grounded research utopia, each of the emotion regulation components specified at the micro-level of the FACE©-model would be investigated longitudinally as they develop in children with ADHD while taking into account probable mediating and moderating ef‐ fects of their macro-level risk and resiliency balance, especially as regards their parenting and family environment. As an added value, ADHD children's emotion regulation trajecto‐

In an evidence-based practice utopia, research would systematically inform about the pro‐ portions and specificities of children with ADHD concerned by clinically relevant emotion dysregulation processes. Even more fundamentally, empirical findings would predictively outline the constellation of cognitive-emotional (micro-level) and family environmental

those children with ADHD and their parents who confront emotion dysregulation.

daily life situations where they matter most in their early years.

ries would be compared with those of children with other clinical conditions.

emotion regulation skills at parenting and family-functioning levels.

contexts.

*Taken together,* an integration of the nascent empirical evidence-base with the outlined con‐ ceptual foundations suggests the importance of incorporating techniques for adjusting emo‐ tional reactivity, appraisal and behavioural modulation of emotions when intervening with children with ADHD and their parents, whereby relative focuses merit to be tailored to the specificities of the individual family's risk-resiliency balance and challenges. Research-wise there still is a critical need for prospective, follow-up as well as qualitative studies to move towards more fine-grained evidence-based insights into how and under which conditions emotion regulation training with ADHD children and their parents bears fruit.

#### **7. Conclusion**

Drawing on the FACE©-model, this chapter has examined ADHD children's emotion regula‐ tion skills on a cognitive-emotional adjustment and behavioural expression micro-level, along with parenting and family risks and resources herein on a contextual macro-level. Emotion regulation hereby was operationally conceived as the autonomic and effortful modulation of the transient physiological reactions, the basic and contextualised appraisal, the subjective experience and the overt behavioural expressions involved in emotions.

As far as the extant evidence-base allows concluding, children with ADHD appear vulnera‐ ble to some extent to difficulties in modulating each of these emotion regulation compo‐ nents, from adaptively accommodating physiological reactivity through adequately appraising emotions in their context to flexibly modulating experience and behavioural ex‐ pression of emotions. At the least, children with ADHD as a group seem inclined to process emotions differently compared to peers so that they are in need of extra support in the skill of emotionally adjusting to habitual contextual demands. Throughout the diverse outcomes for this heterogeneous population, it seems that especially children with an externalising pattern of functioning, namely those with the combined ADHD subtype and/or comorbid conduct problems, are most at-risk for demonstrating emotion regulation difficulties at physiological, experiential and behavioural levels. Although as yet scarcely investigated, pa‐ rental expressed negativity furthermore appears to adversely weigh in on ADHD children's emotion regulation skills at parenting and family-functioning levels.

dren's emotion regulation. Briefly considered, the additive value of combining medication and psychosocial treatments has been demonstrated especially for children with intense ADHD symptomatology [2, 105, 108]. It is therefore likely that medication may benefit the efficacy of emotion-focused interventions with these children too, albeit because a normali‐ sation of behavioural activity levels is expected to improve learning conditions and family communication [38]. For instance, a study on 43 elementary-school-age children with ADHD documents the positive impact of amphetamine medication on child and family dy‐ namics [59]. Furthermore, Williams' et al.'s study (2008) on youth's event-related potentials before and after MPH treatment [89], evoked in paragraph 5.2.1, specifically showed that improved brain activity after MPH treatment predicted diminution of emotional lability al‐ though not of negative mood. Medication has however also been reported to result in blunt‐ ed, flattened, restricted and dysphoric emotional expression along with passive and even submissive behaviour among children with ADHD [109]. Optimising medication doses may therefore be crucial, as evidenced by one study reporting curvilinear MPH dose effects on ADHD children's visual focusing and variability of facially expressed emotions [38]. Subop‐ timal medication protocols might in turn interfere with the process of training ADHD chil‐ dren's emotion regulation skills. Investigating the impact of ADHD medication on emotioncentred intervention outcomes and its differential effects according to symptom intensity,

*Taken together,* an integration of the nascent empirical evidence-base with the outlined con‐ ceptual foundations suggests the importance of incorporating techniques for adjusting emo‐ tional reactivity, appraisal and behavioural modulation of emotions when intervening with children with ADHD and their parents, whereby relative focuses merit to be tailored to the specificities of the individual family's risk-resiliency balance and challenges. Research-wise there still is a critical need for prospective, follow-up as well as qualitative studies to move towards more fine-grained evidence-based insights into how and under which conditions

Drawing on the FACE©-model, this chapter has examined ADHD children's emotion regula‐ tion skills on a cognitive-emotional adjustment and behavioural expression micro-level, along with parenting and family risks and resources herein on a contextual macro-level. Emotion regulation hereby was operationally conceived as the autonomic and effortful modulation of the transient physiological reactions, the basic and contextualised appraisal, the subjective experience and the overt behavioural expressions involved in emotions.

As far as the extant evidence-base allows concluding, children with ADHD appear vulnera‐ ble to some extent to difficulties in modulating each of these emotion regulation compo‐ nents, from adaptively accommodating physiological reactivity through adequately appraising emotions in their context to flexibly modulating experience and behavioural ex‐ pression of emotions. At the least, children with ADHD as a group seem inclined to process

emotion regulation training with ADHD children and their parents bears fruit.

comorbidity and medication dosage is therefore recommended.

272 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**7. Conclusion**

Given that the research to date predominantly has investigated ADHD children's emotion regulation in cognitive (challenging) situations, findings hereby primarily underscore the importance of considering the impact of ADHD children's emotional functioning on (cogni‐ tive) task accomplishments and of acknowledging their non-apparent regulation efforts. These insights call for incorporating mood-management support for children with ADHD in learning conditions. They also call for a paradigm shift so as to value ADHD children's ef‐ forts instead of sole outcomes to a much larger extent than is generally the case in academic contexts.

Importantly, the observation that large proportions of investigated children with ADHD do not exhibit the expected emotion regulation difficulties still tends to go unnoticed. This leaves unexploited critical leads for gaining a refined understanding of the impact of ADHD on a child's life and of the resources that may be more or less naturally present in some fam‐ ilies to mend its expected adverse effects. Emerging intervention-outcome evidence also points to promising resiliency-building opportunities through the integration of emotion regulation, problem solving, behaviour modification and positive parenting training for those children with ADHD and their parents who confront emotion dysregulation.

The complex field of ADHD children's emotion regulation thus still remains under-explored empirically on several aspects with practical relevance. Children's physiological reactivity, appraisal of emotional cues and modulation of emotional experience and expression hardly have been examined in inherently emotion-driven contexts, such as during parent-child and family interactions. More ecologically valid indices are therefore needed as to which emo‐ tion regulation processes underlie ADHD children's observed emotional disruptions in the daily life situations where they matter most in their early years.

In a theory-grounded research utopia, each of the emotion regulation components specified at the micro-level of the FACE©-model would be investigated longitudinally as they develop in children with ADHD while taking into account probable mediating and moderating ef‐ fects of their macro-level risk and resiliency balance, especially as regards their parenting and family environment. As an added value, ADHD children's emotion regulation trajecto‐ ries would be compared with those of children with other clinical conditions.

In an evidence-based practice utopia, research would systematically inform about the pro‐ portions and specificities of children with ADHD concerned by clinically relevant emotion dysregulation processes. Even more fundamentally, empirical findings would predictively outline the constellation of cognitive-emotional (micro-level) and family environmental (macro-level) characteristics of those ADHD children who are most at-risk for emotion dys‐ regulation so as to direct prevention or intervention efforts toward these children.

[3] Anastopoulos AD, Smith TF, Garrett ME, Morrissey-Kane E, Schatz NK, Sommer JL, et al. Self-Regulation of Emotion, Functional Impairment, and Comorbidity Among

ADHD Children's Emotion Regulation in FACE© – Perspective…

http://dx.doi.org/10.5772/54422

275

[4] Celestin-Westreich S, Celestin LP. [Families' Cognitive-Emotional Adjustments when Facing Attention Deficit Hyperactivity Disorder]. Ann Med Psychol 2008;166(5):

[5] Celestin LP, Celestin-Westreich S. The FACE© program: cognitive-emotional adjust‐ ment training for children and families with ADHD and Bipolar Disorder. In Stress & Anxiety Research Society ([STAR] Ed.), 26th International Conference of the Stress

[6] Celestin-Westreich S, Celestin LP. [Child, Parenting and Family Assessment in

[7] Buschgens CJ, van Aken MA, Swinkels SH, Altink ME, Fliers EA, Rommelse NN, et al. Differential family and peer environmental factors are related to severity and co‐

[8] Kepley HO, Ostrander R. Family characteristics of anxious ADHD children: prelimi‐

[9] Maedgen JW, Carlson CL. Social functioning and emotional regulation in the atten‐ tion deficit hyperactivity disorder subtypes. J Clin Child Psychol 2000;29(1):30-42.

[10] Mrug S, Molina BS, Hoza B, Gerdes AC, Hinshaw SP, Hechtman L, et al. Peer rejec‐ tion and friendships in children with Attention-Deficit/Hyperactivity Disorder: con‐

tributions to long-term outcomes. J Abnorm Child Psychol 2012;40(6):1013-26.

[11] Bacchini D, Affuso G, Trotta T. Temperament, ADHD and peer relations among schoolchildren: the mediating role of school bullying. Aggress Behav 2008;34(5):

[12] Malmberg K, Edbom T, Wargelius HL, Larsson JO. Psychiatric problems associated with subthreshold ADHD and disruptive behaviour diagnoses in teenagers. Acta

[13] Corwin M, Mulsow M, Feng D. Perceived family resources based on number of

[14] Peris TS, Hinshaw SP. Family dynamics and preadolescent girls with ADHD: the re‐ lationship between expressed emotion, ADHD symptomatology, and comorbid dis‐

[15] Krauel K, Duzel E, Hinrichs H, Rellum T, Santel S, Baving L. Emotional memory in ADHD patients with and without comorbid ODD/CD. J Neural Transm 2009;116(1):

members with ADHD. J Atten Disord. 2012;16(6):517-29.

ruptive behavior. J Child Psychol Psychiatry 2003;44(8):1177-90.

and Anxiety Research Society (pp.60-61). Halle, Germany: STAR;2005.

FACE©-perspective]. Leuven/Den Haag: Acco;2010a. [Book in Dutch]

morbidity in children with ADHD. J Neural Transm 2008;115(2):177-86.

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343-49. [Article in French]

447-59.

117-20.

Paediatr 2011;100(11):1468-75.

While patiently building the empirical evidence-base and advocating shifts toward sus‐ tained research policies that stimulate large-scale longitudinal investigations, remembering the final aim of ADHD emotion research may facilitate moving toward the outlined practice utopia. This aim would expectedly consist of significantly contributing to ameliorating ADHD children's outcomes. A strengths-oriented evidence-base consequently deserves to integrate research that also focuses on gaining an understanding of the conditions under which children with ADHD do manage to regulate their emotions in functional ways. The current chapter allows concluding that combining the search for dysfunctional emotion areas with the discovery of individual and contextual characteristics of children with ADHD who fare best emotionally despite their vulnerabilities, offers the strongest leads for durably building ADHD children's resilience.

#### **Acknowledgements**

The ongoing research on children with ADHD according to the FACE©-model and -pro‐ gram is supported in part by the OZR VUB Research Grant OZR1075 "ADHD and Bipolar Disorder in Youth". The authors would also like to thank the students who participated in the data collection for the ongoing FACE-ADHD research during the completion of their master thesis.

#### **Author details**

Smadar Celestin-Westreich1\* and Leon-Patrice Celestin2

\*Address all correspondence to: Smadar.Westreich@vub.ac.be

1 Dept. Clinical & Life Span Psychology, Vrije Universiteit Brussels, Brussels, Belgium

2 Hospital Practitioner Psychiatry & FACE©-program, Paris, France

#### **References**


[3] Anastopoulos AD, Smith TF, Garrett ME, Morrissey-Kane E, Schatz NK, Sommer JL, et al. Self-Regulation of Emotion, Functional Impairment, and Comorbidity Among ChildrenWith AD/HD. J Atten Disord 2011;15(7):583-92.

(macro-level) characteristics of those ADHD children who are most at-risk for emotion dys‐

While patiently building the empirical evidence-base and advocating shifts toward sus‐ tained research policies that stimulate large-scale longitudinal investigations, remembering the final aim of ADHD emotion research may facilitate moving toward the outlined practice utopia. This aim would expectedly consist of significantly contributing to ameliorating ADHD children's outcomes. A strengths-oriented evidence-base consequently deserves to integrate research that also focuses on gaining an understanding of the conditions under which children with ADHD do manage to regulate their emotions in functional ways. The current chapter allows concluding that combining the search for dysfunctional emotion areas with the discovery of individual and contextual characteristics of children with ADHD who fare best emotionally despite their vulnerabilities, offers the strongest leads for durably

The ongoing research on children with ADHD according to the FACE©-model and -pro‐ gram is supported in part by the OZR VUB Research Grant OZR1075 "ADHD and Bipolar Disorder in Youth". The authors would also like to thank the students who participated in the data collection for the ongoing FACE-ADHD research during the completion of their

1 Dept. Clinical & Life Span Psychology, Vrije Universiteit Brussels, Brussels, Belgium

[1] American Psychiatric Association. Rationale for Changes in ADHD in DSM-5. From the ADHD and Disruptive Behavior Disorders Workgroup. 2012. Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=383# [2] Barkley RA. Attention-Deficit Hyperactivity Disorder. A handbook for diagnosis and

regulation so as to direct prevention or intervention efforts toward these children.

building ADHD children's resilience.

274 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Smadar Celestin-Westreich1\* and Leon-Patrice Celestin2

\*Address all correspondence to: Smadar.Westreich@vub.ac.be

2 Hospital Practitioner Psychiatry & FACE©-program, Paris, France

treatment. Third Edition. New York: The Guilford Press;2006.

**Acknowledgements**

master thesis.

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**Author details**


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[34] Celestin LP, Celestin-Westreich S. [How to FACE© Bipolar Disorder in the Elderly]. In: Ferrero F, Aubry JM, eds. Traitements psychologiques des troubles bipolaires; Médecine et psychothérapies. Paris: Elsevier/Masson, 2009:177-90. [Chapter in

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**Chapter 13**

**A Comparison Between Life Quality and Weight-Height**

Attention Deficit and Hyperactivity Disorder (ADHD) comprises a disorder which is charac‐ terized with inattention, hyperactivity and impulsivity, seen in 3-7% of school-age children Boys are two to nine times more often affected than girls [1]. Twin, adoption, and molecular genetic studies show ADHD to be highly heritable. Evidence from animal and human studies implicates the dysregulation of frontal-subcortical-cerebellar catecholaminergic circuits in the pathophysiology of ADHD. Imaging studies suggest that abnormalities of the dopaminergic

The main course of ADHD is a persistent pattern of inattention and/or hyperactivityimpulsivity that may be seen more frequently and/or severely compared to individuals with the same level of development. Its pathophysiology appears to involve different alterations in dopaminergic and noradrenergic pathways related to the control of atten‐

ADHD is associated with important deterioration at numerous fields such as developmental, cognitive, emotional, social and academical, and also associated with personal time for parents because of affecting several health risks and academic performance. Deterioration in these fields based on basic sypmtoms of ADHD: hyperactivity, inattention and impulsivity [5]. In case of ADHD, as a result of inadequacies any time in the life of the child, reduction in selfconfidence, misery, failure and thus reduced quality of life; deterioration of interpersonal and

and reproduction in any medium, provided the original work is properly cited.

© 2013 Demirci et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

and adrenergic transmitter systems lead to impaired neurotransmission [2]

**Measurements of Patients, Under Stimulant and Non-**

**Stimulant Treatment due to Attention-Deficit and**

**Hyperactivity Disorder, and Healthy Population**

Esra Ozdemir Demirci, Merve Cikili Uytun, Rabia Durmus and Didem Behice Oztop

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53790

tion and impulsivity [1,3,4].

**1. Introduction**

## **A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and Non-Stimulant Treatment due to Attention-Deficit and Hyperactivity Disorder, and Healthy Population**

Esra Ozdemir Demirci, Merve Cikili Uytun, Rabia Durmus and Didem Behice Oztop

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53790

**1. Introduction**

Attention Deficit and Hyperactivity Disorder (ADHD) comprises a disorder which is charac‐ terized with inattention, hyperactivity and impulsivity, seen in 3-7% of school-age children Boys are two to nine times more often affected than girls [1]. Twin, adoption, and molecular genetic studies show ADHD to be highly heritable. Evidence from animal and human studies implicates the dysregulation of frontal-subcortical-cerebellar catecholaminergic circuits in the pathophysiology of ADHD. Imaging studies suggest that abnormalities of the dopaminergic and adrenergic transmitter systems lead to impaired neurotransmission [2]

The main course of ADHD is a persistent pattern of inattention and/or hyperactivityimpulsivity that may be seen more frequently and/or severely compared to individuals with the same level of development. Its pathophysiology appears to involve different alterations in dopaminergic and noradrenergic pathways related to the control of atten‐ tion and impulsivity [1,3,4].

ADHD is associated with important deterioration at numerous fields such as developmental, cognitive, emotional, social and academical, and also associated with personal time for parents because of affecting several health risks and academic performance. Deterioration in these fields based on basic sypmtoms of ADHD: hyperactivity, inattention and impulsivity [5]. In case of ADHD, as a result of inadequacies any time in the life of the child, reduction in selfconfidence, misery, failure and thus reduced quality of life; deterioration of interpersonal and

© 2013 Demirci et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

intra-family relations, being affected adversely of psychological well-being could be seen. Therefore, it is reported that "psychosocial dimension" gains importance gradually besides clinical parameters in multidimensional monitoring of disease and adequacy and inadequacy in this dimension could be explained with "life quality" concept [6]. Because of difficulties in academical, social and emotional fields, the effects of deterioration over life quality came into discussion in the context of the recent literature [7,8,9]. This level of interest is not surprising due to the complexity of the relationships; QoL(Quality of life) is not only influenced by the disorder itself, but also by many proximal (i.e. family, friendship) and distal (socioeconomic and cultural) factors. In addition to its core symptoms of attention deficit, hyperactivity and impulsivity, ADHD is associated with numerous developmental, cognitive, emotional, social and academic impairments [10,11].

Consequently, methylphenidate for stimulant group and atomoxetine for nonstimulant group are in primer use for ADHD treatment. The use of these medications becomes widespread gradually. It is reported that both medications are effective on treatment of ADHD's basic symptoms in children and adolescents. Thus, significant improvement could be seen in life quality [9,17,18]. When comparing with normal population, difficulties in academical, social

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

http://dx.doi.org/10.5772/53790

287

The side effects on weight and height of these medications which are used considerably in child psychiatry are in discussion over a long time. Although a few studies defend inefficiency over weight and height, some studies show arrest in height development and shortness in ultimate height [19]. Current studies in this content on children and adolescents are subjects

In our study, we aimed to compare the effect of long acting methylphenidatefor and/or atomoxetine usage due to ADHD, weight-height measurements, and comparison of life quality

This study was conducted in Department of Child and Adolescent Pscyhiatry, Erciyes University Faculty of Medicine in the period from September 2011 to May 2012. Study population consists of 52 patients with ADHD based on DSM-IV and these patients were pharmacologically treated for at least 12 months and sypmtom severity is consistent with Scanning and Evaluation Scale based on DSM-IV for Behavioral Disorders in Children and Adolescents. Coexisting psychiatric disorders were accepted as exclusion criteria. Children with no previous history of psychopharmalogical treatment except ADHD and simultaneously no previous history of epilepsy and other medical disease was examined. Control group was selected randomly between patients of social pediatric clinical and specified as 25 healthy children in physical and psychological way. Smilarity between control and patient group from the point of gender and age avaragewas noticed. Parents of children with ADHD filled sociodemographic data form, The Pediatric Quality of Life Inventory(PedsQL), Atilla Turgay Scanning and Evaluation Scale based on DSM-IV for Behavioral Disorders in Children and Adolescents. Weight and height measurements were performed by our nurse specialist. Parents of control group also filled the same tests. Parents of both group signed informed

The Pediatric Quality of Life Inventory(PedsQL): Developed for psychosocial and physcial life quality measurement of children and adolescent between 2-18 age interval by Varni and et all. and adapted into Turkish for 8-18 age interval was carried out by Çakın Memik et al. [21,22]. It is obtained that Cronbach Alfa coefficients vary between 0.80 and 0.88. PedsQL between the

and emotional fields could be developed more frequently.

between children and adolescents, and healthy population.

consent and ethics committee approval was obtained.

**3. Scales used in this study**

of only a few studies specially in our country [20].

**2. Material and methods**

The psychostimulants (e.g., methylphenidate) are considered the first-line of therapy for ADHD, relieving symptoms by increasing intrasynaptic dopamine, norepinephrine, and serotonin [12]. Nevertheless, some patients fail to respond to stimulants or are unable to tolerate them, and the stimulants such as methylphenidate are contraindicated for some children and adolescents including those with Tourette's disorder. Nonstimulant agents used in ADHD include tricyclic antidepressants, bupropion, clonidine, guanfacine, selective serotonin reuptake inhibitors, and newer atypical antidepressants [13,14]. But their current use is limited, because these agents do not improve impulsive behavior and cognitive impairments and also they have serious adverse effects [15].

On the other hand, atomoxetine, a highly selective inhibitor of the noradrenergic transporter, is the first non-psychostimulant agent approved by the Food and Drug Administration (FDA) for ADHD. Compared to its effect on the norepinephrine transporter, atomoxetine has very little affinity for the dopamine or serotonin transpoter. As a result of the central role of CYP2D6 in metabolism of atomoxetine, the activity of this enzyme plays a significant role in its pharmachokinetics. The majority of people ([90%), who metabolise atomoxetine and other CYP2D6 substrates relatively rapidly, are designed as CYP2D6 extensive metaboliser. Its efficacy in children with ADHD has been demonstrated in three double-blind, placebocontrolled trials [16].


Commonly used drugs for ADHD are shown in table 1.

**Table 1.** Commonly used drugs for ADHD

Consequently, methylphenidate for stimulant group and atomoxetine for nonstimulant group are in primer use for ADHD treatment. The use of these medications becomes widespread gradually. It is reported that both medications are effective on treatment of ADHD's basic symptoms in children and adolescents. Thus, significant improvement could be seen in life quality [9,17,18]. When comparing with normal population, difficulties in academical, social and emotional fields could be developed more frequently.

The side effects on weight and height of these medications which are used considerably in child psychiatry are in discussion over a long time. Although a few studies defend inefficiency over weight and height, some studies show arrest in height development and shortness in ultimate height [19]. Current studies in this content on children and adolescents are subjects of only a few studies specially in our country [20].

In our study, we aimed to compare the effect of long acting methylphenidatefor and/or atomoxetine usage due to ADHD, weight-height measurements, and comparison of life quality between children and adolescents, and healthy population.

#### **2. Material and methods**

intra-family relations, being affected adversely of psychological well-being could be seen. Therefore, it is reported that "psychosocial dimension" gains importance gradually besides clinical parameters in multidimensional monitoring of disease and adequacy and inadequacy in this dimension could be explained with "life quality" concept [6]. Because of difficulties in academical, social and emotional fields, the effects of deterioration over life quality came into discussion in the context of the recent literature [7,8,9]. This level of interest is not surprising due to the complexity of the relationships; QoL(Quality of life) is not only influenced by the disorder itself, but also by many proximal (i.e. family, friendship) and distal (socioeconomic and cultural) factors. In addition to its core symptoms of attention deficit, hyperactivity and impulsivity, ADHD is associated with numerous developmental, cognitive, emotional, social

The psychostimulants (e.g., methylphenidate) are considered the first-line of therapy for ADHD, relieving symptoms by increasing intrasynaptic dopamine, norepinephrine, and serotonin [12]. Nevertheless, some patients fail to respond to stimulants or are unable to tolerate them, and the stimulants such as methylphenidate are contraindicated for some children and adolescents including those with Tourette's disorder. Nonstimulant agents used in ADHD include tricyclic antidepressants, bupropion, clonidine, guanfacine, selective serotonin reuptake inhibitors, and newer atypical antidepressants [13,14]. But their current use is limited, because these agents do not improve impulsive behavior and cognitive impairments

On the other hand, atomoxetine, a highly selective inhibitor of the noradrenergic transporter, is the first non-psychostimulant agent approved by the Food and Drug Administration (FDA) for ADHD. Compared to its effect on the norepinephrine transporter, atomoxetine has very little affinity for the dopamine or serotonin transpoter. As a result of the central role of CYP2D6 in metabolism of atomoxetine, the activity of this enzyme plays a significant role in its pharmachokinetics. The majority of people ([90%), who metabolise atomoxetine and other CYP2D6 substrates relatively rapidly, are designed as CYP2D6 extensive metaboliser. Its efficacy in children with ADHD has been demonstrated in three double-blind, placebo-

**Drug Dosage Dosage range Time of Maximum plasma**

Concerta 18,27,36,54,72 18-72 8 2000 Metadate CD 10,20,30 20-60 5 2001 Ritalin LA 10,20,30,40 20-60 5 2002 Adderall XR 10,20,30 10-40 1-4 2001 Ritalin 5,10,20 10-60 0.3-4 2000 Atomoksetin 10,18,25,40,60 10-60 1-2,3-4 2002

**concentraiton (hour) FDA approval year**

and academic impairments [10,11].

286 Attention Deficit Hyperactivity Disorder in Children and Adolescents

and also they have serious adverse effects [15].

Commonly used drugs for ADHD are shown in table 1.

controlled trials [16].

**Table 1.** Commonly used drugs for ADHD

This study was conducted in Department of Child and Adolescent Pscyhiatry, Erciyes University Faculty of Medicine in the period from September 2011 to May 2012. Study population consists of 52 patients with ADHD based on DSM-IV and these patients were pharmacologically treated for at least 12 months and sypmtom severity is consistent with Scanning and Evaluation Scale based on DSM-IV for Behavioral Disorders in Children and Adolescents. Coexisting psychiatric disorders were accepted as exclusion criteria. Children with no previous history of psychopharmalogical treatment except ADHD and simultaneously no previous history of epilepsy and other medical disease was examined. Control group was selected randomly between patients of social pediatric clinical and specified as 25 healthy children in physical and psychological way. Smilarity between control and patient group from the point of gender and age avaragewas noticed. Parents of children with ADHD filled sociodemographic data form, The Pediatric Quality of Life Inventory(PedsQL), Atilla Turgay Scanning and Evaluation Scale based on DSM-IV for Behavioral Disorders in Children and Adolescents. Weight and height measurements were performed by our nurse specialist. Parents of control group also filled the same tests. Parents of both group signed informed consent and ethics committee approval was obtained.

#### **3. Scales used in this study**

The Pediatric Quality of Life Inventory(PedsQL): Developed for psychosocial and physcial life quality measurement of children and adolescent between 2-18 age interval by Varni and et all. and adapted into Turkish for 8-18 age interval was carried out by Çakın Memik et al. [21,22]. It is obtained that Cronbach Alfa coefficients vary between 0.80 and 0.88. PedsQL between the ages of 8-18 children / adolescents, there are forms for both self-report and parent and consists of 23 articles. The scale of physical health, emotional functioning, social functioning, and school functioning challenged areas. Scoring, scale total score (CAP), physical health score (FSTP), emotional, social and school functioning scores evaluating the substance of the calculation of the total score of psychosocial health (PSTP) to be carried out in three areas. This is the last month of children and adolescents with the scale in question. Substances "never", "rarely", "sometimes", "often" or "always" in the form of, and in turn responded, 100, 75, 50, 25, 0 points are given. Points total score is obtained by dividing the number of items collected and replenished. As a result the higher the PedsQL total score, the better the perceived healthrelated quality of life [20].

group in terms of avarage age and sex ratio. Socio- demographic characteristics of the group with ADHD and the control group are shown in tables (Table 2 and table 3). Socio-demographic

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

**Age** 10,57 2,17

**Mother's Educational level n %**

36,03 40,44 n 32 20 n 46 3

> 16 11 3

**Monthly Income n %**

**Mean Standart deviation/Percent**

5,87 6,16 % 61,5 38,5 % 93,9 6,1

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289

3,8 38,5 7,7 30,8 19,2

% 0 28,8 11,5 26,9 32,7

% 82,7 5,8 9,6 1,9

34,6 51,9 11,5 1,9 **%**

30,8 21,2 5,8

differences between the two groups are outstanding.

Mother age Father Age Education The First 5 years 6th-10th.years Number of siblings 2 and under 2 2- 4 siblings

Not education Primary school Secondary high school High school University

**Father'sEducational level** Not education Primary school Secondary high school High school University

> Location Metropolitan City Town Village

Under 1000 TL 1000-3000 TL 4000-10000 TL up to 10000 **Father Occupation**

> Employee Civil servant Tradesman

Thus fields of physical health, emotional functioning, social functioning and shcool function‐ ing as features of well-being, identified by WHO, was examined.

Turgay DSM-IV Based Child and Adolescent Behavior Disorders Screening and Rating Scale: This scale was developed by Turgay [23], based on DSM-IV diagnosis criteria. This scale consists of 41 questions; 9 of them for attention deficit, 9 of them for mobility and impulsivity, 8 of them for comorbid oppositional defiant disorder (ODD), and 15 of them for behavioral disorder. Each question has 4 choices: 0 for strongly disagree, 1 for somewhat, 2 for agree, 3 for strongly agree. For ADHD diagnosis, min 6 of 9 questions that examine attention deficit should have 2 or 3 scoring, min 6 of 9 questions that examine hyperactivity or impulsivity should have 2 or 3 scoring. For ODD, min 4 of 8 questions should have 2 or 3 scoring; for BD diagnosis, min 2 of 25 questions should exist for 6 months or 1 year. Confidence validity test was conducted by Ercan et al. in Turkey [24].

#### **4. Statistical evaluation**

The statistics software SPSS 17.0 is utilized in this study. The data obtained through measure‐ ment is indicated as arithmetic mean (X) and standard deviation (SD); the data obtained through census is indicated as percentages (%).The significance level in the evaluations is determined as p<0.05. One- Sample Kolmogorov- Smirnov Test is used for control if variables are normal distribution or not. The grading differences between the groups (childrenadolescents with ADHD diagnoses and healthy children-adolescents) are compared by using the "Student t test" for the measuremental variables that conform to the normal distribution and "Mann Whitney-U test" for the measuremental variables that do not conform to the normal distribution. Tukey and Dunnett post hoc tests are also used for varyans analyze. Sperman correlation test is used for showing correlations.

#### **5. Results**

Fourty two of patients who admitted into study were men (80.8%) and ten were women (19.2%). The avarage age of children was 10.42 ±2.136. Control group was smilar to patient group in terms of avarage age and sex ratio. Socio- demographic characteristics of the group with ADHD and the control group are shown in tables (Table 2 and table 3). Socio-demographic differences between the two groups are outstanding.

ages of 8-18 children / adolescents, there are forms for both self-report and parent and consists of 23 articles. The scale of physical health, emotional functioning, social functioning, and school functioning challenged areas. Scoring, scale total score (CAP), physical health score (FSTP), emotional, social and school functioning scores evaluating the substance of the calculation of the total score of psychosocial health (PSTP) to be carried out in three areas. This is the last month of children and adolescents with the scale in question. Substances "never", "rarely", "sometimes", "often" or "always" in the form of, and in turn responded, 100, 75, 50, 25, 0 points are given. Points total score is obtained by dividing the number of items collected and replenished. As a result the higher the PedsQL total score, the better the perceived health-

Thus fields of physical health, emotional functioning, social functioning and shcool function‐

Turgay DSM-IV Based Child and Adolescent Behavior Disorders Screening and Rating Scale: This scale was developed by Turgay [23], based on DSM-IV diagnosis criteria. This scale consists of 41 questions; 9 of them for attention deficit, 9 of them for mobility and impulsivity, 8 of them for comorbid oppositional defiant disorder (ODD), and 15 of them for behavioral disorder. Each question has 4 choices: 0 for strongly disagree, 1 for somewhat, 2 for agree, 3 for strongly agree. For ADHD diagnosis, min 6 of 9 questions that examine attention deficit should have 2 or 3 scoring, min 6 of 9 questions that examine hyperactivity or impulsivity should have 2 or 3 scoring. For ODD, min 4 of 8 questions should have 2 or 3 scoring; for BD diagnosis, min 2 of 25 questions should exist for 6 months or 1 year. Confidence validity test

The statistics software SPSS 17.0 is utilized in this study. The data obtained through measure‐ ment is indicated as arithmetic mean (X) and standard deviation (SD); the data obtained through census is indicated as percentages (%).The significance level in the evaluations is determined as p<0.05. One- Sample Kolmogorov- Smirnov Test is used for control if variables are normal distribution or not. The grading differences between the groups (childrenadolescents with ADHD diagnoses and healthy children-adolescents) are compared by using the "Student t test" for the measuremental variables that conform to the normal distribution and "Mann Whitney-U test" for the measuremental variables that do not conform to the normal distribution. Tukey and Dunnett post hoc tests are also used for varyans analyze. Sperman

Fourty two of patients who admitted into study were men (80.8%) and ten were women (19.2%). The avarage age of children was 10.42 ±2.136. Control group was smilar to patient

ing as features of well-being, identified by WHO, was examined.

was conducted by Ercan et al. in Turkey [24].

288 Attention Deficit Hyperactivity Disorder in Children and Adolescents

correlation test is used for showing correlations.

**4. Statistical evaluation**

**5. Results**

related quality of life [20].



**Mean Standart deviation/Percent**

8 0

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291

2 0

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

33 of patients (63.5%) were under long acting methylphenidate (OROS-MPH) therapy and 19 (36.5%) were under atomoxetine therapy. The medication use duration of first group was 18.54±15.43 months and second group was 18.3±14.8 months. No significant difference was

Dose rate for OROS-MPH was averagely 29,4±7,88 mg and for atomexetine was averagely

Height average in patient group was 141,4±13,8 cm, weight average was 37,07±11,17 kg and height average for control group was 145,6±17,9cm, weight average was41,1±15,5 kg (p=0,251). In terms of weight and height, there is no significant difference between atomexetine users,

When considered sub-group of life quality scale in patient group, phsycal sub-group was found as 80,8 ±15,27, while emotianol sub-group was 66,05±18,26, life quality social was 76,15±22,28 and sub-group associated with school was 66,25±18,86. In control group, physcal sub-group was found as 96,37±7,02, while emotional sub-group was 90,2±13,5, life quality social 97,4±7,92 and sub-group associated with school was 91,6±10,19. There is significant

found between these two groups in terms of duration (p=0,958, t=0,52).

**Monthly Income n %**

**Mother Occupation n %**

Town Village

Under 1000 TL 1000-3000 TL 4000-10000 TL up to 10000 **Father Occupation**

> Employee Civil servant Tradesman Retired Other

Housewife Civil servant Nurse Other Psychopathology in family Psychopathology in mother Psychopathology in father Psychopathology in siblings

45,42±12,36 mg.

**Table 3.** Socio-demographic characteristics of the control group

MPH-OROS users and control group (Table 4 and 5).

**Table 2.** Socio-demographic characteristics of the group with ADHD




**Table 3.** Socio-demographic characteristics of the control group

**Mean Standart deviation/Percent**

**Mean Standart deviation/Percent**

9,6 32,7 % 78,8 11,6 3,8 5,8 % 5,7 5,7 9,6

5,28 6,79 % 60 40 % 88 12

> % 88 4

5 17 n 41 6 2 3 n 3(ADHD,depression) 3(ADHD,depression ,psychotic disorder) 5(DEHB)

**Age** 10,4 2,66

**Mother's Educational level n %**

**Father'sEducational level** n %

37,7 41,8 n 15 10 n 22 3

> n 22 1

Retired Other Mother Occupation Housewife Civil servant Nurse Other Psychopathology in family Psychopathology in mother Psychopathology in father Psychopathology in siblings

290 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Mother age Father Age Education The First 5 years 6th-10th.years Number of siblings 2 and under 2 2- 4 siblings

Not education Primary school Secondary high school High school University

Not education Primary school Secondary high school High school University

> Location Metropolitan City

**Table 2.** Socio-demographic characteristics of the group with ADHD

33 of patients (63.5%) were under long acting methylphenidate (OROS-MPH) therapy and 19 (36.5%) were under atomoxetine therapy. The medication use duration of first group was 18.54±15.43 months and second group was 18.3±14.8 months. No significant difference was found between these two groups in terms of duration (p=0,958, t=0,52).

Dose rate for OROS-MPH was averagely 29,4±7,88 mg and for atomexetine was averagely 45,42±12,36 mg.

Height average in patient group was 141,4±13,8 cm, weight average was 37,07±11,17 kg and height average for control group was 145,6±17,9cm, weight average was41,1±15,5 kg (p=0,251). In terms of weight and height, there is no significant difference between atomexetine users, MPH-OROS users and control group (Table 4 and 5).

When considered sub-group of life quality scale in patient group, phsycal sub-group was found as 80,8 ±15,27, while emotianol sub-group was 66,05±18,26, life quality social was 76,15±22,28 and sub-group associated with school was 66,25±18,86. In control group, physcal sub-group was found as 96,37±7,02, while emotional sub-group was 90,2±13,5, life quality social 97,4±7,92 and sub-group associated with school was 91,6±10,19. There is significant difference between all fields of life quality in both groups (p<0.001\*). When comparing life quality of atomexetine and MPH users, no significant difference was found. But when comparing long acting MPH users and atomexetine users with control group individually, significant difference was examined in life quality sub-groups between control group and other two groups (Table 4).


anxiety side effects could be showed with the use of OROS MPH. The side effects of somnolence

**Table 5.** Comparement of patients under OROS-MPH, atomoxetine treatment with each others and control group

**Comparement of patients under OROS-MPH treatment with atomoxetine treatment**

Mean of ages p= 0,586 p= 0,933 p= 0,806 Mean of height p= 0,294 p= 0,336 p= 1,00 Mean of weight p= 0,475 p= 0,225 p= 0,937

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

Non effective 11 4 1

Insomnia 2 - -

Loss of appetite 2 - -

Nervoussness 2 - -

Hyperactivity 1 - -

Increase in anxiety 1 - -

Somnolence - 1 -

Non compliance of treatment - 1 -

**MPH Atomoxetine Risperidone**

**Comparement of patients under OROS-MPH with control group**

p= 0,991 p<0,001\* p<0,005\*

p= 1,00 p<0,001\* p<0,001\*

p= 0,821 p<0,001\* p<0,005\*

p= 0,683 p<0,001\* p<0,001\*

**Comparement of patients under atomoxetine treatment with control group**

293

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and non-compliance with the development of atomoxetine (Table 6).

**Table 6.** Reason of finishing first treatment and relationship between drugs

**Reason of finishing first treatment / First treatment**

Mean of physical health field in PedsQL

MMean of emotional functioning field in PPedsQL

MMean of , social functioning field in PedsQL

MMean of shcool functioning field in PedsQL

(p<0,05\*)

**Table 4.** Comparement of Socialdemographic datas and life quality

In OROS-MPH user group, while score between age and life quality in school field was found significantly correlated; (p<0.05\*, r=0.443) in atomexetine user group, no correlation was found. When considering changes in hand-writing and drug use, 20 patients of 52 parents showed recovery in hand writing after drug intake.

26 patients (50%) were applied before any other treatment of ADHD. However, several side effects, and due to non compliance of previously treatment patients couldn't maintain previous treatment is observed. 16 patients of the 26 patients, (20.8%), inability to benefit from treatment, 2 patients (2.6%), insomnia, and 2 (2.6%), loss of appetite, and 2 (2.6%), nervousness, 1 'patients (1.3%) hyperactivity, and 1 (1.3%), treatment noncompliance, and 1 (1.3%) increase in anxiety, and 1 (1.3%) were somnolence. The relationship between these side effects, drugs, the treat‐ ment of patients do not benefit from atomoxetine before 4 out, 11 patients are used long-or short-acting MPH, that 1 learned that used risperidone treatment. Insomnia, loss of appetite, and nervousness side effects was seen with all the OROS MPH. Increase in hyperactivity and


difference between all fields of life quality in both groups (p<0.001\*). When comparing life quality of atomexetine and MPH users, no significant difference was found. But when comparing long acting MPH users and atomexetine users with control group individually, significant difference was examined in life quality sub-groups between control group and

Mean of ages 10,42 ±2,136 10,4±2,66 p= 0,970

Mean of height 141,63 ±14,19 145,6±17,9 p= 0,296

Mean of weight 37,07±11,17 41,12±15,5 p= 0,251

PedsQL 80,8 ±15,27 96,37±7,02 p< 0,001\*

field in PedsQL 66,05±18,26 90,2±13,5 p< 0,001\*

PedsQL 76,15±22,28 97,4±7,92 p<0,001\*

In OROS-MPH user group, while score between age and life quality in school field was found significantly correlated; (p<0.05\*, r=0.443) in atomexetine user group, no correlation was found. When considering changes in hand-writing and drug use, 20 patients of 52 parents showed

26 patients (50%) were applied before any other treatment of ADHD. However, several side effects, and due to non compliance of previously treatment patients couldn't maintain previous treatment is observed. 16 patients of the 26 patients, (20.8%), inability to benefit from treatment, 2 patients (2.6%), insomnia, and 2 (2.6%), loss of appetite, and 2 (2.6%), nervousness, 1 'patients (1.3%) hyperactivity, and 1 (1.3%), treatment noncompliance, and 1 (1.3%) increase in anxiety, and 1 (1.3%) were somnolence. The relationship between these side effects, drugs, the treat‐ ment of patients do not benefit from atomoxetine before 4 out, 11 patients are used long-or short-acting MPH, that 1 learned that used risperidone treatment. Insomnia, loss of appetite, and nervousness side effects was seen with all the OROS MPH. Increase in hyperactivity and

PedsQL 66,25±18,86 91,6±10,19

**Table 4.** Comparement of Socialdemographic datas and life quality

recovery in hand writing after drug intake.

**Patient group Control group Comparement of groups**

t= 0,041

t= 1,051

t= 1,166

z= 4,845

t= 5,867

z=5,155

P<0,001\* t= 7,668

other two groups (Table 4).

292 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Mean of physical health field in

Mean of emotional functioning

Mean of , social functioning field in

Mean of shcool functioning field in

(p<0,05\*)

**Table 5.** Comparement of patients under OROS-MPH, atomoxetine treatment with each others and control group

anxiety side effects could be showed with the use of OROS MPH. The side effects of somnolence and non-compliance with the development of atomoxetine (Table 6).


**Table 6.** Reason of finishing first treatment and relationship between drugs

#### **6. Discussion — conclusions**

Life quality measurement is a method that gains gradually importance in children and adolescent, mental health surveys and clinical practice. Investigators and practioners sup‐ posed that important deterioration in psychosocial fields associated with ADHD based on basic symptoms of ADHD.

mood disorders. Comorbidity of attention-deficit disorder or disruptive behavior disorder with other psychiatric diagnoses did not influence overall Quality of Life. Also ıt had been found that children with ADHD were more limited in schoolwork and social functioning[32]. Danckaerts M. et al. showed that a robust negative effect on QoL was reported by the parents

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

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295

Because of difficulties in academical, social and emotional fields, the adverse effect of ADHD on life quality is in evidence in current studies. Numerous studies have shown significant recovery in life quality with medication use in case of ADHD [6,7,8]. The results of studies carried out in this content showed adverse effect on all fields of children with ADHD diagnosis and therapy requirement. Also, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life [34]. In line with previous studies, our study showed that there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment [6,7,8]. Among this, when comparing all sub-fields of life quality scale, there is no significant difference between atomexetine and OROS-MPH users. This result is consistent with Leo Bastiaens's study [35] conducted in 75 children between 6-12 age interval, comparing the effects of atomexetine and stimulant therapy over life quality, and there are further studies that suggests efficiency of OROS-MPH on life quality [36]. Also in another study of Leo Bastiaens, 84 patients (atomoxetine n = 39/stimulants n = 45), between the ages of 5 and18, were treated for approximately 8 months. At end point, there were no significant

However an interesting study is that; 977 Male and female patients aged 6-17 years seeking treatment for symptoms of ADHD were assessed,they were grouped according to wheth‐ er they were prescribed psycho- and/or pharmacotherapy (treatment) or not (no/'other' treatment) Although both treatment and no/'other' treatment cohorts showed improve‐ ments in mean Quality of Life over 12 months, the difference was small and not statistical‐

In our study, we found that confounding result, although patients with ADHD tent to show a decrease in school success with increase in age, patients who take OROS-MPH treatment show an increase in life quality school sub-score. This increase could be due to enhancement in OROS-MPH usage dose with age. Higher dose levels in OROS-MPH could be asserted as more effective for increase in academical success. Compared with the control group, decrease of life quality sub-areas is supported the view of pharmacotherapy alone not enough. How‐

İn this point; V A Harpin showed that the primary school children with ADHD frequently begins to be seen as being different as classmates start to develop the skills and maturity that enable them to learn successfully in school. ADHD to succeed, more frequently the child experiences academic failure, rejection by peers, and low self esteem. And This study sug‐ gested that assessment by an educational psychologist may help to unravel learning strengths

50 children and adolescents with ADHD diagnosis, 30 control group and both of their parents are examined. Rosenberg Self-Esteem Scale and Children's Quality of Life Scale are used. The

of children with ADHD across a broad range of psychopathology symptoms [33].

differences in improvements of quality of life between the two groups [37].

ever, further studies are needed to obtain certain data.

and difficulties, and advise on necessary support in the classroom [39].

ly significant [38].

Children and adolescent with ADHD are at increased risk of academic failure, dropping out of school or college, teenage pregnancy, alcohol and substance use and criminal behaviour. Driving poses an additional risk. The emotional impairments of children and adolescents with ADHD may include poor self-regulation of emotion, greater excessive emotional expression, especially anger and aggression, greater problems coping with frustration, reduced empathy, and decreased arousal to stimulation [25]. Children and adolescents with ADHD have problems with peer relationships lack friendships, or have limitations in their activities with friends if they do have friends. More than half of these children and adolescents have serious problems with peer relationships [26]. Relationships and activities within the family can be impaired and in some cases family relationships can break down, bringing additional social and financial difficulties causing children to feel sad or show oppositional or aggressive behavior [27].

Specific academic difficulties noted in children with ADHD include slower reading fluency weaker reading comprehension (Ghelani and poor penmanship. Mastery of academic skills can also be hampered by the secondary effects (impulsivity, inattention, and disorganization) that ADHD can have upon a child's ability to practice newly learned skills or study recently presented material in the homework setting [28,29].

ADHD affects not only on the child, but also on parents and siblings, causing disturbances to family and marital functioning, increased healthcare costs for patients and their family. Children and their families changes from the preschool years to primary school and adoles‐ cence, with varying aspects of the disorder being more prominent at different stages. Also, ADHD had more parent-reported problems in terms of emotional-behavioral role function, behavior, mental health, and self-esteem. In addition, the problems of children with ADHD had a significant impact on the parents' emotional health and parents' time to meet their own needs, and they interfered with family activities and family cohesion[30].

ADHD is one of the most common psychiatric conditions estimated to affect 5-10% of all children and ADHD predisposes children to impaired academic, familial, social, vocational and emotional functioning if untreated. ADHD does not remit with the onset of puberty alone and teenagers and adults continue to have symptoms of the disorder that cause significant problems in their lives[31].

Children with attention-deficit and disruptive behavior disorder had, according to parent ratings, a better emotional functioning score than children with anxiety disorders. Their academic performance was significantly lower than for children with anxiety disorders and other disorders, but school functioning was reported as equal. Clinicians reported more problems in behavior toward others for this group compared to children with anxiety and mood disorders. Comorbidity of attention-deficit disorder or disruptive behavior disorder with other psychiatric diagnoses did not influence overall Quality of Life. Also ıt had been found that children with ADHD were more limited in schoolwork and social functioning[32]. Danckaerts M. et al. showed that a robust negative effect on QoL was reported by the parents of children with ADHD across a broad range of psychopathology symptoms [33].

**6. Discussion — conclusions**

294 Attention Deficit Hyperactivity Disorder in Children and Adolescents

presented material in the homework setting [28,29].

basic symptoms of ADHD.

behavior [27].

problems in their lives[31].

Life quality measurement is a method that gains gradually importance in children and adolescent, mental health surveys and clinical practice. Investigators and practioners sup‐ posed that important deterioration in psychosocial fields associated with ADHD based on

Children and adolescent with ADHD are at increased risk of academic failure, dropping out of school or college, teenage pregnancy, alcohol and substance use and criminal behaviour. Driving poses an additional risk. The emotional impairments of children and adolescents with ADHD may include poor self-regulation of emotion, greater excessive emotional expression, especially anger and aggression, greater problems coping with frustration, reduced empathy, and decreased arousal to stimulation [25]. Children and adolescents with ADHD have problems with peer relationships lack friendships, or have limitations in their activities with friends if they do have friends. More than half of these children and adolescents have serious problems with peer relationships [26]. Relationships and activities within the family can be impaired and in some cases family relationships can break down, bringing additional social and financial difficulties causing children to feel sad or show oppositional or aggressive

Specific academic difficulties noted in children with ADHD include slower reading fluency weaker reading comprehension (Ghelani and poor penmanship. Mastery of academic skills can also be hampered by the secondary effects (impulsivity, inattention, and disorganization) that ADHD can have upon a child's ability to practice newly learned skills or study recently

ADHD affects not only on the child, but also on parents and siblings, causing disturbances to family and marital functioning, increased healthcare costs for patients and their family. Children and their families changes from the preschool years to primary school and adoles‐ cence, with varying aspects of the disorder being more prominent at different stages. Also, ADHD had more parent-reported problems in terms of emotional-behavioral role function, behavior, mental health, and self-esteem. In addition, the problems of children with ADHD had a significant impact on the parents' emotional health and parents' time to meet their own

ADHD is one of the most common psychiatric conditions estimated to affect 5-10% of all children and ADHD predisposes children to impaired academic, familial, social, vocational and emotional functioning if untreated. ADHD does not remit with the onset of puberty alone and teenagers and adults continue to have symptoms of the disorder that cause significant

Children with attention-deficit and disruptive behavior disorder had, according to parent ratings, a better emotional functioning score than children with anxiety disorders. Their academic performance was significantly lower than for children with anxiety disorders and other disorders, but school functioning was reported as equal. Clinicians reported more problems in behavior toward others for this group compared to children with anxiety and

needs, and they interfered with family activities and family cohesion[30].

Because of difficulties in academical, social and emotional fields, the adverse effect of ADHD on life quality is in evidence in current studies. Numerous studies have shown significant recovery in life quality with medication use in case of ADHD [6,7,8]. The results of studies carried out in this content showed adverse effect on all fields of children with ADHD diagnosis and therapy requirement. Also, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life [34]. In line with previous studies, our study showed that there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment [6,7,8]. Among this, when comparing all sub-fields of life quality scale, there is no significant difference between atomexetine and OROS-MPH users. This result is consistent with Leo Bastiaens's study [35] conducted in 75 children between 6-12 age interval, comparing the effects of atomexetine and stimulant therapy over life quality, and there are further studies that suggests efficiency of OROS-MPH on life quality [36]. Also in another study of Leo Bastiaens, 84 patients (atomoxetine n = 39/stimulants n = 45), between the ages of 5 and18, were treated for approximately 8 months. At end point, there were no significant differences in improvements of quality of life between the two groups [37].

However an interesting study is that; 977 Male and female patients aged 6-17 years seeking treatment for symptoms of ADHD were assessed,they were grouped according to wheth‐ er they were prescribed psycho- and/or pharmacotherapy (treatment) or not (no/'other' treatment) Although both treatment and no/'other' treatment cohorts showed improve‐ ments in mean Quality of Life over 12 months, the difference was small and not statistical‐ ly significant [38].

In our study, we found that confounding result, although patients with ADHD tent to show a decrease in school success with increase in age, patients who take OROS-MPH treatment show an increase in life quality school sub-score. This increase could be due to enhancement in OROS-MPH usage dose with age. Higher dose levels in OROS-MPH could be asserted as more effective for increase in academical success. Compared with the control group, decrease of life quality sub-areas is supported the view of pharmacotherapy alone not enough. How‐ ever, further studies are needed to obtain certain data.

İn this point; V A Harpin showed that the primary school children with ADHD frequently begins to be seen as being different as classmates start to develop the skills and maturity that enable them to learn successfully in school. ADHD to succeed, more frequently the child experiences academic failure, rejection by peers, and low self esteem. And This study sug‐ gested that assessment by an educational psychologist may help to unravel learning strengths and difficulties, and advise on necessary support in the classroom [39].

50 children and adolescents with ADHD diagnosis, 30 control group and both of their parents are examined. Rosenberg Self-Esteem Scale and Children's Quality of Life Scale are used. The over 12 months, the difference was small and not statistically significant [38].

[33].

with treatment [41].

results of this study suggest that self-esteem in the children and adolescents with ADHD is not significantly high and that their quality of life is significantly low. This is noticeable for it draws attention to the psycho-social dimension in the clinical evaluation of the children with ADHD [40]. İn this way, social support and motivational therapy may needed. pharmacotherapy alone not enough. However, further studies are needed to obtain certain data. İn this point; V A Harpin showed that the primary school children with ADHD frequently begins to be seen as being different as classmates start to develop the skills and maturity that enable them to learn successfully in school. ADHD to succeed, more frequently the child experiences academic failure, rejection by peers, and low self esteem. And This study suggested that assessment by an educational psychologist may help to unravel learning strengths and difficulties, and advise on necessary support in the classroom [39].

negative effect on QoL was reported by the parents of children with ADHD across a broad range of psychopathology symptoms

Because of difficulties in academical, social and emotional fields, the adverse effect of ADHD on life quality is in evidence in current studies. Numerous studies have shown significant recovery in life quality with medication use in case of ADHD [6,7,8]. The results of studies carried out in this content showed adverse effect on all fields of children with ADHD diagnosis and therapy requirement. Also, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life [34]. In line with previous studies, our study showed that there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment [6,7,8]. Among this, when comparing all sub-fields of life quality scale, there is no significant difference between atomexetine and OROS-MPH users. This result is consistent with Leo Bastiaens's study [35] conducted in 75 children between 6-12 age interval, comparing the effects of atomexetine and stimulant therapy over life quality, and there are further studies that suggests efficiency of OROS-MPH on life quality [36]. Also in another study of Leo Bastiaens , 84 patients (atomoxetine n = 39/stimulants n = 45), between the ages of 5 and18, were treated for approximately 8 months. At end

 However an interesting study is that; 977 Male and female patients aged 6-17 years seeking treatment for symptoms of ADHD were assessed ,they were grouped according to whether they were prescribed psycho- and/or pharmacotherapy (treatment) or not (no/'other' treatment) Although both treatment and no/'other' treatment cohorts showed improvements in mean Quality of Life

due to enhancement in OROS-MPH usage dose with age. Higher dose levels in OROS-MPH could be asserted as more effective for increase in academical success. Compared with the control group, decrease of life quality sub-areas is supported the view of

> effects was seen with all the OROS MPH. Increase in hyperactivity and anxiety side effects could be showed with the use of OROS MPH. The side effects of somnolence and noncompliance with the development of atomoxetine. But our datas are limited about relation‐ ship of side effects and life quality. Further studies are needed side effects of OROS-MPH

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

http://dx.doi.org/10.5772/53790

297

Long-term effects of methylphenidate and atomoxsetine on growth rates of children with ADHD are the other size of the treatment which also effect the Quality of life. The effect of OROS-MPH and atomoxsetine over weight and height is still a subject of discussion. The final results, as to children with attention deficit who take stimulant medication grow slower than children with no treatment, verify the results of previous studies in 1972-1973. Recent study showed a decrease in expected weight and height growing in children who take stimulant therapy. In treatments continuing 2-3 years, the growing speed shows

İn the one of the review about effects of stimulants on height and weight; the quantitative analyses showed that treatment with stimulant medication led to statistically significant delays in height and weight. Treatment with stimulants in childhood reduced expected height and weight. This review also found statistically significant evidence of attenuation of these deficits over time. The qualitative review suggested that growth deficits may be dose dependent. Some

Prolonged medication (data evaluated at 6 months - 5 years) with short-acting MPH has shown to have minimal impact on height only at the first 6 months; however, catch up growth was detected during adolescent period in 96 cases wo were treated with short-acting MPH 0.41-0.49 mg/kg/day [46]. İn another research about the potential negative influence of methylphenidate on growth; mean value of height was lower than expected mean height for age by 0.42 cm at diagnosis. This difference increased to 2.69 cm (at 30 months of treatment), but it subsequently decreased to 0.83 cm (at 48 months of treatment). The relationship between nutritional status and the negative effects on the height curve in those patients would require nutritional

Two new researches was performed on the effect of amoxetine on growing patients with 5 year follow-up and long- time efficiency and reliability of atomoxetine. After a 5 year followup, it is suggested that while atomoxetine has no or a little effect on growing, in some cases could cause reduction in growing. Especially in 18 months, growing could be affected a little, however normal development could proceed in a period of 2-3 years [43,44]. Spenc‐ er et al present findings from an ongoing 5-year study of the efficacy and safety of treatment with atomoxetine. After 1 month's treatment,they found patients weighed less than expected from their starting percentiles relative to population norms, with a maximum shortfall at 15 months and a return to expected weight by 36 months. Patients were slightly shorter than expected after 12 months, reaching a maximum shortfall at 18 months and returning to expected height by 24 months. Patients in the top quartile for body mass index (BMI) or weight at baseline, and those in the third quartile for height, showed 5-year decreases from

data suggest that ultimate adult growth parameters are not affected [45].

optimization to return anthropometric variables to normal [47].

and atomoxetine on life quality.

normalization tendency [43,44].

point, there were no significant differences in improvements of quality of life between the two groups [37].

From anoher study Figure 1 shows benefit (dark green bars) or no benefit (light green bars) by outcome group in treated participants with attention deficit hyperactivity disorder (ADHD) versus untreated ADHD. Improvement was reported most often in studies of driving and obesity outcomes (left side), with a greater proportion of outcomes reported to exhibit no benefit following treatment compared with no treatment in studies of occupation (right side). An intermediate proportion of studies of self-esteem, social function, academic, drug use/ addictive behavior,antisocial behavior, and services use outcomes reported benefit with treatment [41]. 50 children and adolescents with ADHD diagnosis, 30 control group and both of their parents are examined. Rosenberg Self-Esteem Scale and Children's Quality of Life Scale are used. The results of this study suggest that self-esteem in the children and adolescents with ADHD is not significantly high and that their quality of life is significantly low. This is noticeable for it draws attention to the psycho-social dimension in the clinical evaluation of the children with ADHD [40]. İn this way, social support and motivational therapy may needed. From anoher study Figure 1 shows benefit (dark green bars) or no benefit (light green bars) by outcome group in treated participants with attention deficit hyperactivity disorder (ADHD) versus untreated ADHD. Improvement was reported most often in studies of driving and obesity outcomes (left side), with a greater proportion of outcomes reported to exhibit no benefit following treatment compared with no treatment in studies of occupation (right side). An intermediate proportion of studies of

self-esteem, social function, academic, drug use/addictive behavior,antisocial behavior, and services use outcomes reported benefit

Figure 1. Figure 1. Benefit and no benefit with treatment by outcome group \*This figure is taken from" A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: \*This figure is taken from" A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: effects of treatment and non-treatment "

effects of treatment and non-treatment " **Figure 1.** Benefit and no benefit with treatment by outcome group

Treatment with OROS-MPH and atomoxsetine also have side effects. Evidence shows that ADHD medications are safe and effective for children ages 6 and older. For children over the age of 6, long-term effectiveness and adverse effects are not well studied. More studies showed that psychostimulants and atomoxetine may cause insomnia, appetite loss, tiredness, social withdrawal, and abdominal pain. Psychostimulants and atomoxetine may also cause a modest increase in average blood pressure and average heart rate in some children and adolescents. Children or adolescents taking atomoxetine may be more likely to think about suicide than children who do not take it. More adverse effects were report‐ ed in preschoolers than in elementary school children. Moodiness and irritability often led to discontinuation of treatment with MPH. [42] In our study; 26 patients were applied before any other treatment of ADHD. However, several side effects, and due to non compliance of previously treatment patients couldn't maintain previous treatment is observed. İnsom‐ nia, loss of appetite, nervousness, hyperactivity, increase in anxiety, and somnolence areside effect which cause to stop first treatment. Insomnia, loss of appetite, and nervousness side effects was seen with all the OROS MPH. Increase in hyperactivity and anxiety side effects could be showed with the use of OROS MPH. The side effects of somnolence and noncompliance with the development of atomoxetine. But our datas are limited about relation‐ ship of side effects and life quality. Further studies are needed side effects of OROS-MPH and atomoxetine on life quality.

results of this study suggest that self-esteem in the children and adolescents with ADHD is not significantly high and that their quality of life is significantly low. This is noticeable for it draws attention to the psycho-social dimension in the clinical evaluation of the children with

İn this point; V A Harpin showed that the primary school children with ADHD frequently begins to be seen as being different as classmates start to develop the skills and maturity that enable them to learn successfully in school. ADHD to succeed, more frequently the child experiences academic failure, rejection by peers, and low self esteem. And This study suggested that assessment by an educational psychologist may help to unravel learning strengths and difficulties, and advise on necessary

negative effect on QoL was reported by the parents of children with ADHD across a broad range of psychopathology symptoms

Because of difficulties in academical, social and emotional fields, the adverse effect of ADHD on life quality is in evidence in current studies. Numerous studies have shown significant recovery in life quality with medication use in case of ADHD [6,7,8]. The results of studies carried out in this content showed adverse effect on all fields of children with ADHD diagnosis and therapy requirement. Also, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life [34]. In line with previous studies, our study showed that there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment [6,7,8]. Among this, when comparing all sub-fields of life quality scale, there is no significant difference between atomexetine and OROS-MPH users. This result is consistent with Leo Bastiaens's study [35] conducted in 75 children between 6-12 age interval, comparing the effects of atomexetine and stimulant therapy over life quality, and there are further studies that suggests efficiency of OROS-MPH on life quality [36]. Also in another study of Leo Bastiaens , 84 patients (atomoxetine n = 39/stimulants n = 45), between the ages of 5 and18, were treated for approximately 8 months. At end

 However an interesting study is that; 977 Male and female patients aged 6-17 years seeking treatment for symptoms of ADHD were assessed ,they were grouped according to whether they were prescribed psycho- and/or pharmacotherapy (treatment) or not (no/'other' treatment) Although both treatment and no/'other' treatment cohorts showed improvements in mean Quality of Life

In our study, we found that confounding result, although patients with ADHD tent to show a decrease in school success with increase in age, patients who take OROS-MPH treatment show an increase in life quality school sub-score. This increase could be due to enhancement in OROS-MPH usage dose with age. Higher dose levels in OROS-MPH could be asserted as more effective for increase in academical success. Compared with the control group, decrease of life quality sub-areas is supported the view of

From anoher study Figure 1 shows benefit (dark green bars) or no benefit (light green bars) by outcome group in treated participants with attention deficit hyperactivity disorder (ADHD) versus untreated ADHD. Improvement was reported most often in studies of driving and obesity outcomes (left side), with a greater proportion of outcomes reported to exhibit no benefit following treatment compared with no treatment in studies of occupation (right side). An intermediate proportion of studies of self-esteem, social function, academic, drug use/ addictive behavior,antisocial behavior, and services use outcomes reported benefit with

50 children and adolescents with ADHD diagnosis, 30 control group and both of their parents are examined. Rosenberg Self-Esteem Scale and Children's Quality of Life Scale are used. The results of this study suggest that self-esteem in the children and adolescents with ADHD is not significantly high and that their quality of life is significantly low. This is noticeable for it draws attention to the psycho-social dimension in the clinical evaluation of the children with ADHD [40]. İn this way, social support and

From anoher study Figure 1 shows benefit (dark green bars) or no benefit (light green bars) by outcome group in treated participants with attention deficit hyperactivity disorder (ADHD) versus untreated ADHD. Improvement was reported most often in studies of driving and obesity outcomes (left side), with a greater proportion of outcomes reported to exhibit no benefit following treatment compared with no treatment in studies of occupation (right side). An intermediate proportion of studies of self-esteem, social function, academic, drug use/addictive behavior,antisocial behavior, and services use outcomes reported benefit

\*This figure is taken from" A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder:

\*This figure is taken from" A systematic review and analysis of long-term outcomes in attention deficit hyperactivity

Treatment with OROS-MPH and atomoxsetine also have side effects. Evidence shows that ADHD medications are safe and effective for children ages 6 and older. For children over the age of 6, long-term effectiveness and adverse effects are not well studied. More studies showed that psychostimulants and atomoxetine may cause insomnia, appetite loss, tiredness, social withdrawal, and abdominal pain. Psychostimulants and atomoxetine may also cause a modest increase in average blood pressure and average heart rate in some children and adolescents. Children or adolescents taking atomoxetine may be more likely to think about suicide than children who do not take it. More adverse effects were report‐ ed in preschoolers than in elementary school children. Moodiness and irritability often led to discontinuation of treatment with MPH. [42] In our study; 26 patients were applied before any other treatment of ADHD. However, several side effects, and due to non compliance of previously treatment patients couldn't maintain previous treatment is observed. İnsom‐ nia, loss of appetite, nervousness, hyperactivity, increase in anxiety, and somnolence areside effect which cause to stop first treatment. Insomnia, loss of appetite, and nervousness side

No Benefit Benefit

ADHD [40]. İn this way, social support and motivational therapy may needed.

pharmacotherapy alone not enough. However, further studies are needed to obtain certain data.

point, there were no significant differences in improvements of quality of life between the two groups [37].

over 12 months, the difference was small and not statistically significant [38].

296 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Figure 1. Figure 1. Benefit and no benefit with treatment by outcome group

**Figure 1.** Benefit and no benefit with treatment by outcome group

effects of treatment and non-treatment "

disorder: effects of treatment and non-treatment "

treatment [41].

with treatment [41].

0% 20% 40% 60% 80% 100%

support in the classroom [39].

motivational therapy may needed.

[33].

Long-term effects of methylphenidate and atomoxsetine on growth rates of children with ADHD are the other size of the treatment which also effect the Quality of life. The effect of OROS-MPH and atomoxsetine over weight and height is still a subject of discussion. The final results, as to children with attention deficit who take stimulant medication grow slower than children with no treatment, verify the results of previous studies in 1972-1973. Recent study showed a decrease in expected weight and height growing in children who take stimulant therapy. In treatments continuing 2-3 years, the growing speed shows normalization tendency [43,44].

İn the one of the review about effects of stimulants on height and weight; the quantitative analyses showed that treatment with stimulant medication led to statistically significant delays in height and weight. Treatment with stimulants in childhood reduced expected height and weight. This review also found statistically significant evidence of attenuation of these deficits over time. The qualitative review suggested that growth deficits may be dose dependent. Some data suggest that ultimate adult growth parameters are not affected [45].

Prolonged medication (data evaluated at 6 months - 5 years) with short-acting MPH has shown to have minimal impact on height only at the first 6 months; however, catch up growth was detected during adolescent period in 96 cases wo were treated with short-acting MPH 0.41-0.49 mg/kg/day [46]. İn another research about the potential negative influence of methylphenidate on growth; mean value of height was lower than expected mean height for age by 0.42 cm at diagnosis. This difference increased to 2.69 cm (at 30 months of treatment), but it subsequently decreased to 0.83 cm (at 48 months of treatment). The relationship between nutritional status and the negative effects on the height curve in those patients would require nutritional optimization to return anthropometric variables to normal [47].

Two new researches was performed on the effect of amoxetine on growing patients with 5 year follow-up and long- time efficiency and reliability of atomoxetine. After a 5 year followup, it is suggested that while atomoxetine has no or a little effect on growing, in some cases could cause reduction in growing. Especially in 18 months, growing could be affected a little, however normal development could proceed in a period of 2-3 years [43,44]. Spenc‐ er et al present findings from an ongoing 5-year study of the efficacy and safety of treatment with atomoxetine. After 1 month's treatment,they found patients weighed less than expected from their starting percentiles relative to population norms, with a maximum shortfall at 15 months and a return to expected weight by 36 months. Patients were slightly shorter than expected after 12 months, reaching a maximum shortfall at 18 months and returning to expected height by 24 months. Patients in the top quartile for body mass index (BMI) or weight at baseline, and those in the third quartile for height, showed 5-year decreases from expected values. Those below median height at baseline showed increases relative to expected values.[43]

ADHD-related difficulties, improved with time on atomoxetine The sexes did not differ significantly in mean GIPD total scores.and also improvement in ADHD-related difficulties did not differ significantly between boys and girls [52]. In the second step of our study; we aimed to compare effects of sex differences on response of treatment with both atomoxetine

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

http://dx.doi.org/10.5772/53790

299

Consequently, ADHD, which is a chronic neuropsychiatric disorder, is known as negative‐ ly effective on life quality perception in reports about children and it is suggested that evaluation of life quality in follow-up and treatment stages of ADHD and efficiency of pharmacological treatment on life quality of this patients could be a guide for determin‐ ing the fields that children have difficulty on. Besides, when comparing with normal population, the difficulties in academical, social and emotional fields could be seen more frequently. Medical treatment of attention deficit and hyperactivity disorder alone could cause increasing in conseptualization tendency of problems and nondevelopment on problem solving skills. Therefore, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life. Karabekiroğlu K. et al found that more than half of the teachers denoted that the medication used for ADHD would have serious side effects and even with treatment ADHD would not sufficiently improve, and the children diagnosed with ADHD or autism should be trained at separate classes. So that the parents and teachers may benefit from structured educative programs inorder to get

One of the importent point is that further study is needed to understand the social and psychological processes that underlie stigmatization, how parents balance perceived benefits of treatment with mental health stigma concerns, and to determine how stigmatization effects

Although in our study, patients with ADHD tent to show a decrease in school success with increase in age, patients who take OROS-MPH treatment show an increase in life quality school sub-score. This information could be a guide for examining of detailed determining of OROS-

Limitaton of our study are number of patients and time of treatments. Our datas are not enough effects of socio-demographic differences, side effects, gender and stigma on life quality. Measurement of quality of life in attention-deficit-hyperactivity disorder (ADHD) gives a more complete picture of day-to-day functioning and treatment effects than behavioural rating alone. Quality of life is effected from numerous factors so that new measurement parameters

In conclusion; there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment. Tretment is increase life quality of ADHD patients but only medical treatment is not enought.There is no significant difference between weight and height when comparing between control groups of OROS-MPH and atomexetine. Further studies are needed to support the effects of OROS-MPH and atomoxetine on life quality and

and OROS-MPH, also correlation with life quality, ıt is our limitation of this study.

rid of wrong assumptions and stigma [53].

quality of life children with ADHD.

MPH effects.

should be developed.

weight-height.

In our study, we found no significant difference between both control group of OROS-MHP and atomoxetine in terms of weight and height. And also no significant difference were between treatment under OROS-MHP and atomoxetine. This result could be associated with time limitation. Further studies are needed if there are difference effects of between OROS-MPH and atomoxetine treatment on weight-height.

Although one of the research children with ADHD who performed poorly on the neuropsy‐ chological battery had greater BMI z-scores, and were more likely to be classified as over‐ weight/obese compared with children with ADHD who performed better on the neuropsychological battery. In addition, children with ADHD who were taking a stimulant medication had significantly lower BMI z-scores compared with children with ADHD who were not taking medication or who were taking a non-stimulant medication. They claimed that EF (Executive Function) is more impaired among children with ADHD and co-occurring weight problems, highlighting the importance of self-regulation as a link between pediatric obesity and ADHD [48].

An intresting point is that last studies reported an association between overweight and ADHD. Although a higher prevalence of overweight/obesity was reported in clinical samples of patients with ADHD, longitudinal studies are needed to better understand the mechanisms underlying the association between ADHD and overweight/obesity [49].

Current data suggests an association between growing and medical effect of stimulants. Also normal growing speeds have been shown in children who take no treatment with attention deficit hyperactivity disorder. Therefore, further studies should focus on fields as detailed definition of growing and development effects of stimulants in children with different ages, determining the growing deficiency mechanism up to stimulant [50].

Gender differences is another variability that may affect the quality of life. Children with high levels of ADHD symptoms have many associated behaviour problems, even in pre-school years, and boys with high levels of ADHD symptoms are more severely affected compared with girls. Datas of researches are not enough in this field.

Data from 5 clinical atomoxetine trials (4 from Europe and 1 from Canada) with similar inclusion and exclusion criteria and similar durations (8- to 12-week follow-up) were included in the pooled analysis. 136 girls and 658 boys were treated with atomoxetine. Atomoxetine was effective in improving some aspects of health-related quality of life (HR-QoL) in both genders without any significant differences across genders.Also, ıt was found that correlations between core symptoms of ADHD and HR-QoL were low to moderate in both boys and girls [51].

Also 6-17 aged of patients were treated with atomoxetine in two studies. ADHD-related difficulties were assessed after 8 and 24 weeks using the Global Impression of Perceived Difficulties (GIPD) instrument, which can be taken to reflect the patient's QoL from the three perspectives. The GIPD scores over time suggest that patients' QoL, as reflected by perceived ADHD-related difficulties, improved with time on atomoxetine The sexes did not differ significantly in mean GIPD total scores.and also improvement in ADHD-related difficulties did not differ significantly between boys and girls [52]. In the second step of our study; we aimed to compare effects of sex differences on response of treatment with both atomoxetine and OROS-MPH, also correlation with life quality, ıt is our limitation of this study.

expected values. Those below median height at baseline showed increases relative to

In our study, we found no significant difference between both control group of OROS-MHP and atomoxetine in terms of weight and height. And also no significant difference were between treatment under OROS-MHP and atomoxetine. This result could be associated with time limitation. Further studies are needed if there are difference effects of between OROS-

Although one of the research children with ADHD who performed poorly on the neuropsy‐ chological battery had greater BMI z-scores, and were more likely to be classified as over‐ weight/obese compared with children with ADHD who performed better on the neuropsychological battery. In addition, children with ADHD who were taking a stimulant medication had significantly lower BMI z-scores compared with children with ADHD who were not taking medication or who were taking a non-stimulant medication. They claimed that EF (Executive Function) is more impaired among children with ADHD and co-occurring weight problems, highlighting the importance of self-regulation as a link between pediatric

An intresting point is that last studies reported an association between overweight and ADHD. Although a higher prevalence of overweight/obesity was reported in clinical samples of patients with ADHD, longitudinal studies are needed to better understand the mechanisms

Current data suggests an association between growing and medical effect of stimulants. Also normal growing speeds have been shown in children who take no treatment with attention deficit hyperactivity disorder. Therefore, further studies should focus on fields as detailed definition of growing and development effects of stimulants in children with different ages,

Gender differences is another variability that may affect the quality of life. Children with high levels of ADHD symptoms have many associated behaviour problems, even in pre-school years, and boys with high levels of ADHD symptoms are more severely affected compared

Data from 5 clinical atomoxetine trials (4 from Europe and 1 from Canada) with similar inclusion and exclusion criteria and similar durations (8- to 12-week follow-up) were included in the pooled analysis. 136 girls and 658 boys were treated with atomoxetine. Atomoxetine was effective in improving some aspects of health-related quality of life (HR-QoL) in both genders without any significant differences across genders.Also, ıt was found that correlations between core symptoms of ADHD and HR-QoL were low to moderate in

Also 6-17 aged of patients were treated with atomoxetine in two studies. ADHD-related difficulties were assessed after 8 and 24 weeks using the Global Impression of Perceived Difficulties (GIPD) instrument, which can be taken to reflect the patient's QoL from the three perspectives. The GIPD scores over time suggest that patients' QoL, as reflected by perceived

underlying the association between ADHD and overweight/obesity [49].

determining the growing deficiency mechanism up to stimulant [50].

with girls. Datas of researches are not enough in this field.

expected values.[43]

obesity and ADHD [48].

both boys and girls [51].

MPH and atomoxetine treatment on weight-height.

298 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Consequently, ADHD, which is a chronic neuropsychiatric disorder, is known as negative‐ ly effective on life quality perception in reports about children and it is suggested that evaluation of life quality in follow-up and treatment stages of ADHD and efficiency of pharmacological treatment on life quality of this patients could be a guide for determin‐ ing the fields that children have difficulty on. Besides, when comparing with normal population, the difficulties in academical, social and emotional fields could be seen more frequently. Medical treatment of attention deficit and hyperactivity disorder alone could cause increasing in conseptualization tendency of problems and nondevelopment on problem solving skills. Therefore, it is suggested that recovery attempts for children with ADHD diagnosis should include all fields of life. Karabekiroğlu K. et al found that more than half of the teachers denoted that the medication used for ADHD would have serious side effects and even with treatment ADHD would not sufficiently improve, and the children diagnosed with ADHD or autism should be trained at separate classes. So that the parents and teachers may benefit from structured educative programs inorder to get rid of wrong assumptions and stigma [53].

One of the importent point is that further study is needed to understand the social and psychological processes that underlie stigmatization, how parents balance perceived benefits of treatment with mental health stigma concerns, and to determine how stigmatization effects quality of life children with ADHD.

Although in our study, patients with ADHD tent to show a decrease in school success with increase in age, patients who take OROS-MPH treatment show an increase in life quality school sub-score. This information could be a guide for examining of detailed determining of OROS-MPH effects.

Limitaton of our study are number of patients and time of treatments. Our datas are not enough effects of socio-demographic differences, side effects, gender and stigma on life quality. Measurement of quality of life in attention-deficit-hyperactivity disorder (ADHD) gives a more complete picture of day-to-day functioning and treatment effects than behavioural rating alone. Quality of life is effected from numerous factors so that new measurement parameters should be developed.

In conclusion; there is significantly difference in all sub-fields of life quality scale between control group and under ADHD treatment. Tretment is increase life quality of ADHD patients but only medical treatment is not enought.There is no significant difference between weight and height when comparing between control groups of OROS-MPH and atomexetine. Further studies are needed to support the effects of OROS-MPH and atomoxetine on life quality and weight-height.

#### **Acknowledgements**

PubChem chemical substance (submitted) records that are classified under the same Medical Subject Headings (MeSH) controlled vocabulary as the current articles.

[10] Raggi VL, Chronis AM (2006) Interventions to address the academic impairment of children and adolescents with ADHD. Clin Child Fam Psychol Rev 9:85–111

A Comparison Between Life Quality and Weight-Height Measurements of Patients, Under Stimulant and…

http://dx.doi.org/10.5772/53790

301

[11] Wehmeier PM, Schacht A, Barkley RA (2010) Social and emotional impairment in children and adolescents with ADHD and the impact on quality of life. J Adolesc Health

[12] Popper CW (2000) Pharmacological alternatives to psychostimulants for the treatment of attention deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 9:605–

[13] Scahill L, Chappell PB, Kim YS, Katsovich L, Sheperd E et al (2001) A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit

[14] Silver LB (1999) Alternative (nonstimulant) medications in the treatment of attentiondeficit/hyperactivity disorder in children. Pediatr Clin North Am 46:965–975

[15] Wilens TE, Biederman J, Baldessarini RJ, Geller B, Schleifer D, Spencer TJ et al (1996) Cardiovascular effects of therapeutic doses of tricyclic antidepressants in children and

[16] Sauer JM, Ponsler GD, Mattiuz EL, Long AJ, Witcher JW, Thomasson HR et al (2003) Disposition and metabolic fate of atomoxetine hydrochloride: the role of CYP2D6 in

[17] Hechtman A, Abikoff H, Klein RG, et al. Academic achievement and emotional status of children with ADHD treated with long-term methylphenidate and multimodal

[18] Banaschewski T, Coghill D, Santosh P, et al. Long-acting medications for the hyperki‐ netic disorders. A systematic review and European treatment guidelines. Eur Child

[19] Zhang H, Du M, Zhuang S. Impact of long-term Treatment of Methylphenidate on Height and Weight of School Age Children with ADHD. Neuropediatrics 2010;41:55-59

[20] Yıldız Ö, , Ağaoğlu B., , Karakaya I,Şahika G, Şişmanlar ŞG, Çakın Memik N, Efficiency and tolerability of OROS-methylphenidate in Turkish children and adolescents with attention-deficit/hyperactivity disorder, Anatolian Journal of Psychiatry, 2010; 11:44-50

[21] Çakın Memik N, Ağaoğlu B, Coşkun A, et al. The validity and reliability of pediatric quality of life inventory in 8-12 year old turkısh children. . Turkish Journal of Child

[22] Çakın Memik N, Ağaoğlu B, Coşkun A ve ark. The validity and reliability of pediatric quality of life inventory in 13-18 year old turkısh adolescents. Turkish Journal of

[23] Turgay A. Turgay DSM-IV Based Child and Adolescent Behavior Disorders Screening

and Rating Scale, Integrative Therapy Institude Toronto, Kanada 1995.

psychosocial treatment. J Am Acad Child Adolesc Psychiatry 2004;43:812–9.

hyperactivity disorder. Am J Psychiatry 158:1067–1074

Adolesc Psychiatry 2006;15:476–95.

Adolesc Psychiatry 2008; 15:87-98.

Psychiatry 2007; 18:353-63

adolescents. J Am Acad Child Adolesc Psychiatry 35:1491–1501

human disposition and metabolism. Drug Metab Dispos 31:98–107

46:209–217

646

#### **Author details**

Esra Ozdemir Demirci, Merve Cikili Uytun, Rabia Durmus and Didem Behice Oztop

Department of Child and Adolescent Psychiatry, Erciyes University Medical Faculty, Kay‐ seri, Turkey

#### **References**


[10] Raggi VL, Chronis AM (2006) Interventions to address the academic impairment of children and adolescents with ADHD. Clin Child Fam Psychol Rev 9:85–111

**Acknowledgements**

300 Attention Deficit Hyperactivity Disorder in Children and Adolescents

**Author details**

seri, Turkey

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Esra Ozdemir Demirci, Merve Cikili Uytun, Rabia Durmus and Didem Behice Oztop

Department of Child and Adolescent Psychiatry, Erciyes University Medical Faculty, Kay‐

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[40] Zeynep Göker\*, Evrim Aktepe\*\*, Sema Kandil Self-esteem and Quality of Life in Children and Adolescents with Attention Deficit Hyperactivity Disorder New/Yeni

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[43] Spencer TJ., Kratochvil JC, Sangal RB, Saylor KE, Bailey CE, Dunn DW, Geller DA, Casat CD, Lipetz RS, Jain R, Newcorn JH, Ruff DD, Feldman PD, Furr JA, and Allen JA. Effects of Atomoxetine on growth in children with Attention Deficit/hyperactivity disorder following up to five years of treatment. J Child Adolesc Psychopharmacol 17

[44] Kratochvil JC, Wilens ET, Greenhill LL ve ark (2006) Effects of long term Atomoxetine treatment for young children with Attention Deficit/hyperactivity disorder. J Child

[45] Faraone VS,Biederman J, Morley PC, Thomas. Spencer JT, Effect of Stimulants on Height and Weight: A Review of the Literature J. Am. Acad. Child Adolesc. Psychiatry,

[46] Moungnoi P, Maipang P. Long-term effects of short-acting methylphenidate on growth rates of children with attention deficit hyperactivity disorder at Queen Sirikit National

[47] Durá-Travé T, Yoldi-Petri ME, Gallinas-Victoriano F, Zardoya-Santos P Effects of osmotic-release methylphenidate on height and weight in children with attentiondeficit hyperactivity disorder (ADHD) following up to four years of treatment. J Child

[48] Graziano PA, Bagner DM, Waxmonsky JG, Reid A, McNamara JP, Geffken GR Cooccurring weight problems among children with attention deficit/hyperactivity disorder: the role of executive functioning. Int J Obes (Lond). 2012 Apr;36(4):567-72.

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[24] Ercan ES, Amado S, Somer O, et al. Development of A Test Battery for the Assessment of Attention Deficit Hyperactivity Disorder. Turkish Journal of Child Adolesc Psychia‐

[25] Barkley RA. Attention-Deficit/Hyperactivity Disorder: A Handbook for Diagnosis and

[26] Escobar R, Soutullo CA,Hervas A, et al.Worse quality of life for children with newly diagnosed attention-deficit/hyperactivity disorder, compared with asthmatic and

[27] Schreyer I, Hampel P. (ADHD among boys in childhood: quality of life and parenting behavior)(Article in German). Z Kinder Jugendpsychiatr Psychother 2009;37:69–75.

[28] Ghelani K, Sidhu R, Jain U, Tannock R: Reading comprehension and reading related abilities in adolescents with reading disabilities and attention-deficit/hyperactivity

[29] Racine MB, Majnemer A, Shevell M, Snider L: Handwriting performance in children with attention deficit hyperactivity disorder (ADHD). J Child Neurol 23:399–406, 2008.

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**Section 6**

**Ethical Issues**


**Section 6**

### **Ethical Issues**

[49] Erhart M, Herpertz-Dahlmann B, Wille N, Sawitzky-Rose B, Hölling H, Ravens-Sieberer U.Examining the relationship between attention-deficit/hyperactivity disor‐ der and overweight in children and adolescents. Eur Child Adolesc Psychiatry. 2012

[50] Poulton A. Growth and maturation in children and adolescents with attention deficit hyperactivity disorder Current Opinion in Pediatrics turkish edition, Vol 1, No 4, 2006.

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[52] Wehmeier PM, Schacht A, Dittmann RW, Banaschewski T. Minor differences in ADHDrelated difficulties between boys and girls treated with atomoxetine for attentiondeficit/hyperactivity disorder. Atten Defic Hyperact Disord. 2010 Jun;2(2):73-85

[53] Karabekiroðlu K, Memik NC, Özel ÖÖ, Toros F, Öztop D, Özbaran B et all.. Stigmati‐ zation and Misinterpretations on ADHD andAutism: A Multi-Central Study with

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Jan;21(1):39-49. Epub 2011 Nov 26

304 Attention Deficit Hyperactivity Disorder in Children and Adolescents

Defic Hyperact Disord. 2012 Mar;4(1):25-35.

**Chapter 14**

**Ethical Concerns Raised by Neuroscience, Labeling, and**

Take a moment to consider how individuals with Attention Deficit Hyperactivity Disorder (ADHD) are described. When people talked about these individuals what do they say about their behaviors, bodies, and minds? Do these descriptions vary across individuals, contexts, and time? Now compare your reflections as to how individuals with ADHD are often descri‐

These descriptions are common and, as a matter of fact, most of them were drawn from

My point for using this activity to open this chapter is to make you aware of your personal theories and how the symptoms of ADHD, who has it, and what happens as a result is influenced by our perspectives. Let me clarify what I mean a bit more with a boy name Michael and a role-play for you. Imagine that you are a teacher and Michael is a student in your classroom. You enjoy Michael's humor but he is showing uneven academic progress and is

> © 2013 Zambo; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

**•** delay or deterioration in their cognitive, social, and emotional functioning.

**•** universal condition transcending culture, socio-economic, and race.

**Intervening in the Lives of Individuals with ADHD**

Additional information is available at the end of the chapter

bed. In today's world ADHD is described as a:

**•** chronic condition with life-span implications.

**•** heterogeneous developmental disorder.

Debby Zambo

**1. Introduction**

**•** disorder/dysfunction.

**•** brain difference.

chapters in this book.

**•** social and emotional burden.

http://dx.doi.org/10.5772/53004

**Chapter 14**

### **Ethical Concerns Raised by Neuroscience, Labeling, and Intervening in the Lives of Individuals with ADHD**

Debby Zambo

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/53004

**1. Introduction**

Take a moment to consider how individuals with Attention Deficit Hyperactivity Disorder (ADHD) are described. When people talked about these individuals what do they say about their behaviors, bodies, and minds? Do these descriptions vary across individuals, contexts, and time? Now compare your reflections as to how individuals with ADHD are often descri‐ bed. In today's world ADHD is described as a:


These descriptions are common and, as a matter of fact, most of them were drawn from chapters in this book.

My point for using this activity to open this chapter is to make you aware of your personal theories and how the symptoms of ADHD, who has it, and what happens as a result is influenced by our perspectives. Let me clarify what I mean a bit more with a boy name Michael and a role-play for you. Imagine that you are a teacher and Michael is a student in your classroom. You enjoy Michael's humor but he is showing uneven academic progress and is

constantly fidgety and out of his seat. Take a few minutes to answer these questions: From where is Michael's lack of progress stemming? Why is he so fidgety and out of his seat? What would you do to help Michael?

Data from the two conditions (neuroscience and medical science) showed some differences. Participants who saw the fMRI image and read information suggesting ADHD was a biological disorder believed that neuroscience would be useful to them. These participants believed information from neuroscience would help them identify students with ADHD, understand how their brain works, and understand why they behave in certain ways. Participants in the neuroscience condition also thought neuroscience would help them teach these students. They thought neuroscience would show them how to create learning environments and lessons

Ethical Concerns Raised by Neuroscience, Labeling, and Intervening in the Lives of Individuals with ADHD

http://dx.doi.org/10.5772/53004

309

In comparison, participants in the medical science condition, who saw the image of the premature infant and read information from medical science also saw it as useful but had different theories about its use. Participants in this group thought medical science would help them understand the cause, signs, and symptoms of ADHD, the importance of medication, and how to manage students' behaviors. Different conditions lead to different perspectives of

I hope these results help you realize that each of us operates from our own vantage point, or the theories that we construct as we go about our daily lives. The theories we build, in this sense, are not like the grand ideas tested by researchers (e.g., behaviorism, information processing, psychoanalysis) but the mental models or internal maps we use to navigate and make sense of our world and the things and individuals in it. We each construct our own theories based on our observations, but we also build theories based on what we hear or read. Social relationships matter and through dialogue and other means collective theories get built, spread, and get used to determine good and bad and normal and abnormal (Gergen, 2009). Collective theories gain momentum when they are turned into the stories that we tell. Stories become cultural artifacts and when they are repeated they become the norm and influence our values and behaviors. This includes our perceptions of disorders, who has them, and what this means. Consider the following example in which another culture, in this case the Maori of New Zealand, were seen as different simply because of their culture and its' traditions.

Psychology…has created the mass abnormalization of the Maori people by virtue of the fact the Maori people have been…recipients of defined labels and treatments…Clinical psychology is a form of social control…and offers no more "truth" about the realities of the Maori people's lives than a regular reading of a horoscope page in the local newspaper (Lawson-Te, Ano, 1993)

Foucault (1978; 1979) a proponent of helping people to understand their subjugation revealed the power of taken for granted practices. To Foucault, power is a coordinated cluster of relations and the specialized language a discipline develops creates binaries and divides. Instead of being seen as an individual we get placed into categories such as normal or abnormal. Disciplines also produce certain research procedures that privilege certain kinds of methodologies and scrutinize and classify us along their disciplinary lines. In other words, we become the labels that get assigned to us and the labels we acquire are used to control us. Disciplines gain power and influence public policy. Given this, let's look at mental disorders,

conducive to these students' needs.

like ADHD from a historical perspective.

students with ADHD.

Now, let's consider some common answers. If you thought Michael's uneven progress and fidgetiness stemmed from his family's lack of discipline you would likely direct Michael and his family to a counselor, who in turn might place them in some sort of counseling or therapy. If you thought Michael's uneven progress and fidgetiness came from a brain difference you would likely refer Michael to the school psychologist, who in turn might refer him to a physician, who might place Michael on medication. If you thought Michael's uneven progress and fidgetiness stemmed from his environment (your classroom) you might decide to differentiate his instruction and restructure the activities he was given so he could get up and move. Three varied perspectives of Michael with three different outcomes. No perspective was neutral and each set Michael on a different path.

To take the idea of teachers' perspectives about boys like Michael one step further let me explain a study conducted by two colleagues and myself (Zambo, Zambo & Sidlik) in 2009. We wanted to understand what teachers thought about individuals with ADHD and if neuroscience was useful to them so we based on the work of McCabe and Castel (2008) and Weisberg, Keil, Goodstein, Rawson, and Gray (2008). These researchers manipulated infor‐ mation and used an fMRI image, a graph, or no image to understand if neuroscience was persuasive and they found it was both persuasive and misleading. These researchers conclud‐ ed that fMRI images were persuasive because they appealed to their participants' intuitive reductionist notions of learning and confirmed theories and biases they already possessed (learning boils down to brightly lit areas captured in fMRIs). Instead of thinking of learning as a complex process unable to be reduced to biological functions alone, participants believed colorful images proved learning had occurred.

Based on this work, we set out to understand what a group of preservice teachers knew about ADHD, where they learned this information, and what they thought about medical science and neuroscience being useful to them to educate students with attention challenges. We used a general questionnaire but manipulated the type of information participants received. Half of our participants saw an fMRI image and read about ADHD from a neuroscience perspective (e.g., caused by faulty neuroreceptors responding to the neurotransmitter dopamine) and the other half saw an image of a premature infant and read about ADHD from a medical per‐ spective (e.g., infants being born prematurely and weighing less than 3.3 pounds often develop ADHD).

We found that the participants in both groups knew a lot about the behaviors of students with ADHD. They knew, or at had theories that, students with ADHD were hyperactive, excitable, impulsive, irritable, and seldom tired. They also believed that these characteristics inhibit students' learning and social life. They believed that children with attention challenges were distractible, struggle with concentration, get off task easily, and have social and family problems. When asked where they learned this information they said they had friends or family members with it, heard celebrities on television talk about it, and discussed it in their courses (especially special education courses).

Data from the two conditions (neuroscience and medical science) showed some differences. Participants who saw the fMRI image and read information suggesting ADHD was a biological disorder believed that neuroscience would be useful to them. These participants believed information from neuroscience would help them identify students with ADHD, understand how their brain works, and understand why they behave in certain ways. Participants in the neuroscience condition also thought neuroscience would help them teach these students. They thought neuroscience would show them how to create learning environments and lessons conducive to these students' needs.

constantly fidgety and out of his seat. Take a few minutes to answer these questions: From where is Michael's lack of progress stemming? Why is he so fidgety and out of his seat? What

Now, let's consider some common answers. If you thought Michael's uneven progress and fidgetiness stemmed from his family's lack of discipline you would likely direct Michael and his family to a counselor, who in turn might place them in some sort of counseling or therapy. If you thought Michael's uneven progress and fidgetiness came from a brain difference you would likely refer Michael to the school psychologist, who in turn might refer him to a physician, who might place Michael on medication. If you thought Michael's uneven progress and fidgetiness stemmed from his environment (your classroom) you might decide to differentiate his instruction and restructure the activities he was given so he could get up and move. Three varied perspectives of Michael with three different outcomes. No perspective was

To take the idea of teachers' perspectives about boys like Michael one step further let me explain a study conducted by two colleagues and myself (Zambo, Zambo & Sidlik) in 2009. We wanted to understand what teachers thought about individuals with ADHD and if neuroscience was useful to them so we based on the work of McCabe and Castel (2008) and Weisberg, Keil, Goodstein, Rawson, and Gray (2008). These researchers manipulated infor‐ mation and used an fMRI image, a graph, or no image to understand if neuroscience was persuasive and they found it was both persuasive and misleading. These researchers conclud‐ ed that fMRI images were persuasive because they appealed to their participants' intuitive reductionist notions of learning and confirmed theories and biases they already possessed (learning boils down to brightly lit areas captured in fMRIs). Instead of thinking of learning as a complex process unable to be reduced to biological functions alone, participants believed

Based on this work, we set out to understand what a group of preservice teachers knew about ADHD, where they learned this information, and what they thought about medical science and neuroscience being useful to them to educate students with attention challenges. We used a general questionnaire but manipulated the type of information participants received. Half of our participants saw an fMRI image and read about ADHD from a neuroscience perspective (e.g., caused by faulty neuroreceptors responding to the neurotransmitter dopamine) and the other half saw an image of a premature infant and read about ADHD from a medical per‐ spective (e.g., infants being born prematurely and weighing less than 3.3 pounds often develop

We found that the participants in both groups knew a lot about the behaviors of students with ADHD. They knew, or at had theories that, students with ADHD were hyperactive, excitable, impulsive, irritable, and seldom tired. They also believed that these characteristics inhibit students' learning and social life. They believed that children with attention challenges were distractible, struggle with concentration, get off task easily, and have social and family problems. When asked where they learned this information they said they had friends or family members with it, heard celebrities on television talk about it, and discussed it in their

would you do to help Michael?

neutral and each set Michael on a different path.

308 Attention Deficit Hyperactivity Disorder in Children and Adolescents

colorful images proved learning had occurred.

courses (especially special education courses).

ADHD).

In comparison, participants in the medical science condition, who saw the image of the premature infant and read information from medical science also saw it as useful but had different theories about its use. Participants in this group thought medical science would help them understand the cause, signs, and symptoms of ADHD, the importance of medication, and how to manage students' behaviors. Different conditions lead to different perspectives of students with ADHD.

I hope these results help you realize that each of us operates from our own vantage point, or the theories that we construct as we go about our daily lives. The theories we build, in this sense, are not like the grand ideas tested by researchers (e.g., behaviorism, information processing, psychoanalysis) but the mental models or internal maps we use to navigate and make sense of our world and the things and individuals in it. We each construct our own theories based on our observations, but we also build theories based on what we hear or read. Social relationships matter and through dialogue and other means collective theories get built, spread, and get used to determine good and bad and normal and abnormal (Gergen, 2009). Collective theories gain momentum when they are turned into the stories that we tell. Stories become cultural artifacts and when they are repeated they become the norm and influence our values and behaviors. This includes our perceptions of disorders, who has them, and what this means. Consider the following example in which another culture, in this case the Maori of New Zealand, were seen as different simply because of their culture and its' traditions.

Psychology…has created the mass abnormalization of the Maori people by virtue of the fact the Maori people have been…recipients of defined labels and treatments…Clinical psychology is a form of social control…and offers no more "truth" about the realities of the Maori people's lives than a regular reading of a horoscope page in the local newspaper (Lawson-Te, Ano, 1993)

Foucault (1978; 1979) a proponent of helping people to understand their subjugation revealed the power of taken for granted practices. To Foucault, power is a coordinated cluster of relations and the specialized language a discipline develops creates binaries and divides. Instead of being seen as an individual we get placed into categories such as normal or abnormal. Disciplines also produce certain research procedures that privilege certain kinds of methodologies and scrutinize and classify us along their disciplinary lines. In other words, we become the labels that get assigned to us and the labels we acquire are used to control us. Disciplines gain power and influence public policy. Given this, let's look at mental disorders, like ADHD from a historical perspective.

In the United States, the first classification of a mental disorder occurred in 1840 and given its newness there were only a handful of distinctions. In 1930 psychiatry emerged and the perceptions of mental disorders began to grow. By 1938 the number of disturbances rose to approximately forty and since then, the number of disorders has risen to over three hundred and drug treatments have grown into a multi-billion dollar industry. If an individual has ADHD symptoms it is likely that he/she will be offered medication (Gergen, 2009).

amine (Adderall) slow the reuptake of dopamine in the brain and decrease the impulsivity and agitation of ADHD in 70-90% of cases. This quick and easy removal of symptoms is leading to more and more children at younger ages, and more and more adolescents and adults to be prescribed medication. But too often, medication is the only treatment many individuals receive despite the fact that absolute proof of its benefits is not available and little is known about its long-term effects (Farah, 2005). While there is no doubt medication helps many individuals with ADHD there is also no doubt that, for some, there are unintended conse‐ quences and side effects like weight loss, sleeplessness, and cloudy minds (Chau, 2007). Neuroscientists, physicians, psychiatrists, psychologists, and social workers warn that medication needs to be coupled with behavioral, social, and emotional support because alone it is not enough. In other words, medicine is a part of the puzzle but it is not a panacea. Locating an attention problem solely in an individual's brain and treating her/his brain with medication gets results but it does not offer a cure or help an individual truly understand him/herself. Medication focuses on changing behaviors. It does not increase self-awareness or heal a body

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or mind (Farah, 2005; Morse, 2006; Stein, della Chiesa, Hinton, & Fischer, 2010).

down and become aware of our beliefs we will miss ethical questions like:

these?

and fit into the world?

motivation)? Will an individual on medication be robbed of his/her identity?

**•** Does the label of ADHD promote standardized, quick and easy treatments?

**•** How can we better the lives and learning of individuals with ADHD?

**•** Is the label of ADHD promoting biases and stereotypes?

**•** How might the use of this stimulant cause psychological harm (e.g., lower esteem and

**•** When it comes to medication, what responsibilities are there and who is accountable for

**•** How can individuals with ADHD be supported so they know how to compensate, navigate,

Medicating children can also lead to misuse of medication if they are not instructed as to its proper use. Current sales figures indicate that Ritalin and Adderall are not only being used by individuals with ADHD but by high school and college students without it. A survey by McCabe, Knight, Teter, and Wechsler (2005) discovered that as many as 10% of high school students and 20% of college students say that they have used prescription stimulant medications to increase their performance on a test and this use varies by eth‐ nicity, gender, achievement, and location. White males who receive low grades, and are going to Ivy League colleges in the northeast with high standards, are the most likely to abuse stimulant medication. Interestingly, the stimulants they abuse often come from their peers who have been diagnosed with ADHD. Purchasing Ritalin is so prevalent among young adults it is referred as " kiddy coke" and "study buddies." While my in‐ tent is not to criticize or condone the use of medication, I realize medication helps many individuals, but I want to once again point out that of we do not slow our thinking

Psychiatry has influence but another discipline neuroscience, has also come into play. In today's disorder-focused society neuroscience is influencing perspectives and this trend is likely to continue to grow (Maxwell, 2004). The past fifty years has seen an explosion of information about the brain offered to laypersons (Stamm, 2007; Stein, della Chiesa, Hin‐ ton, & Fischer, 2010). More findings are leading to more interest, more treatments, and as these get normalized and incorporated into policies and beliefs, fewer calls for restraint. When it comes to a disorder like ADHD more findings from are leading to more biologi‐ cal theories of it and more standardized treatments aimed at this cause. Neuroscientists are helping us understand how the brain of individuals with ADHD function but like McCabe and Castel (2008) and Weisberg, Keil, Goodstein, Rawson, and Gray (2008) showed these findings can be persuasive and misleading because they are new, diminu‐ tive, and alluring even though much of it is being overextended, misinterpreted, and simplified. If interpreted literally, and in isolation, findings from neuroscience will reduce learning, behavior, and emotions to biological processes alone. There are treatments, cur‐ ricula, and products that purport to utilize findings from neuroscience to promote the learning and behavior of individuals with ADHD without any scientific backing.

Neuroscience is providing new and important information but if we are not careful it can also produce simplified and detached views of individuals, including those with ADHD. A Pygmalion Effect, or self-fulfilling prophecy is a groundless expectation that leads to behaviors that the make the original expectation come true (Merton, 1948). In other words, we see what we expect and expect what we want to see. Remember the opening exercise where you recalled various perspectives of individuals with ADHD and the Maori people who were perceived to be abnormal and defined and perceived as such. Just because a characterization, or label becomes common does not mean it is right, fair, ethical, or just.

#### **2. The ethics of ADHD**

Considering ethical questions that arise when an individual is labeled ADHD is important because five million children (most of whom are boys) between the ages of 3 and 17 years and 8 million adults are diagnosed with it and this number is growing each year (U.S. Department of Health and Human Services, 2010). Thanks to better diagnosis and the spread of information, more and more children, adolescents, and adults are being diagnosed and as a result of identification more and more are being treated with pharmaceutical, social, and behavioral interventions (Barkley, 2005). Unfortunately, and too often, medication is often the only treatment many individuals receive. Medications like methyphenidate (Ritalin) and amphet‐ amine (Adderall) slow the reuptake of dopamine in the brain and decrease the impulsivity and agitation of ADHD in 70-90% of cases. This quick and easy removal of symptoms is leading to more and more children at younger ages, and more and more adolescents and adults to be prescribed medication. But too often, medication is the only treatment many individuals receive despite the fact that absolute proof of its benefits is not available and little is known about its long-term effects (Farah, 2005). While there is no doubt medication helps many individuals with ADHD there is also no doubt that, for some, there are unintended conse‐ quences and side effects like weight loss, sleeplessness, and cloudy minds (Chau, 2007). Neuroscientists, physicians, psychiatrists, psychologists, and social workers warn that medication needs to be coupled with behavioral, social, and emotional support because alone it is not enough. In other words, medicine is a part of the puzzle but it is not a panacea. Locating an attention problem solely in an individual's brain and treating her/his brain with medication gets results but it does not offer a cure or help an individual truly understand him/herself. Medication focuses on changing behaviors. It does not increase self-awareness or heal a body or mind (Farah, 2005; Morse, 2006; Stein, della Chiesa, Hinton, & Fischer, 2010).

In the United States, the first classification of a mental disorder occurred in 1840 and given its newness there were only a handful of distinctions. In 1930 psychiatry emerged and the perceptions of mental disorders began to grow. By 1938 the number of disturbances rose to approximately forty and since then, the number of disorders has risen to over three hundred and drug treatments have grown into a multi-billion dollar industry. If an individual has

Psychiatry has influence but another discipline neuroscience, has also come into play. In today's disorder-focused society neuroscience is influencing perspectives and this trend is likely to continue to grow (Maxwell, 2004). The past fifty years has seen an explosion of information about the brain offered to laypersons (Stamm, 2007; Stein, della Chiesa, Hin‐ ton, & Fischer, 2010). More findings are leading to more interest, more treatments, and as these get normalized and incorporated into policies and beliefs, fewer calls for restraint. When it comes to a disorder like ADHD more findings from are leading to more biologi‐ cal theories of it and more standardized treatments aimed at this cause. Neuroscientists are helping us understand how the brain of individuals with ADHD function but like McCabe and Castel (2008) and Weisberg, Keil, Goodstein, Rawson, and Gray (2008) showed these findings can be persuasive and misleading because they are new, diminu‐ tive, and alluring even though much of it is being overextended, misinterpreted, and simplified. If interpreted literally, and in isolation, findings from neuroscience will reduce learning, behavior, and emotions to biological processes alone. There are treatments, cur‐ ricula, and products that purport to utilize findings from neuroscience to promote the

ADHD symptoms it is likely that he/she will be offered medication (Gergen, 2009).

310 Attention Deficit Hyperactivity Disorder in Children and Adolescents

learning and behavior of individuals with ADHD without any scientific backing.

becomes common does not mean it is right, fair, ethical, or just.

**2. The ethics of ADHD**

Neuroscience is providing new and important information but if we are not careful it can also produce simplified and detached views of individuals, including those with ADHD. A Pygmalion Effect, or self-fulfilling prophecy is a groundless expectation that leads to behaviors that the make the original expectation come true (Merton, 1948). In other words, we see what we expect and expect what we want to see. Remember the opening exercise where you recalled various perspectives of individuals with ADHD and the Maori people who were perceived to be abnormal and defined and perceived as such. Just because a characterization, or label

Considering ethical questions that arise when an individual is labeled ADHD is important because five million children (most of whom are boys) between the ages of 3 and 17 years and 8 million adults are diagnosed with it and this number is growing each year (U.S. Department of Health and Human Services, 2010). Thanks to better diagnosis and the spread of information, more and more children, adolescents, and adults are being diagnosed and as a result of identification more and more are being treated with pharmaceutical, social, and behavioral interventions (Barkley, 2005). Unfortunately, and too often, medication is often the only treatment many individuals receive. Medications like methyphenidate (Ritalin) and amphet‐

Medicating children can also lead to misuse of medication if they are not instructed as to its proper use. Current sales figures indicate that Ritalin and Adderall are not only being used by individuals with ADHD but by high school and college students without it. A survey by McCabe, Knight, Teter, and Wechsler (2005) discovered that as many as 10% of high school students and 20% of college students say that they have used prescription stimulant medications to increase their performance on a test and this use varies by eth‐ nicity, gender, achievement, and location. White males who receive low grades, and are going to Ivy League colleges in the northeast with high standards, are the most likely to abuse stimulant medication. Interestingly, the stimulants they abuse often come from their peers who have been diagnosed with ADHD. Purchasing Ritalin is so prevalent among young adults it is referred as " kiddy coke" and "study buddies." While my in‐ tent is not to criticize or condone the use of medication, I realize medication helps many individuals, but I want to once again point out that of we do not slow our thinking down and become aware of our beliefs we will miss ethical questions like:


**•** Do individuals with ADHD really need to change? How can characteristics and relational styles be respected rather than modified? How can individuals with ADHD become their own advocates?

focuses on the right and wrong, good and bad treatment of, perfection of, or unwelcome invasion of and worrisome manipulation of the human brain. Gazzaniga (2005, 2011) furthered this idea to include "the examination of how we as humans, want to deal with the social issues of disease, normality, mortality, lifestyle, and the philosophy of living informed by our understanding of underlying brain mechanisms." To Gazzaniga, neuroscience should help everyone develop a brain-based philosophy of life. But this is not easy because we tend to focus on ideas that align with our beliefs and allow our beliefs and emotions to cloud our judgment. To develop a brain-based philosophy we will need valid information and time for deep and reflective thought. Beliefs are not easy to change and neuroscience and ethics do not mix easily. Some findings from neuroscience are difficult to understand because they make us question the very fabric of who we are, who we can become, and how is best to live our lives. Moral questions have been around for centuries and after years of debate a human rights approach focuses on ensuring that everyone, including individuals with ADHD receive truthful information, a voice in their lives, the right not to be harmed, and the right to develop and grow. Now look back at the questions posed in the previous section and consider how these

Ethical Concerns Raised by Neuroscience, Labeling, and Intervening in the Lives of Individuals with ADHD

http://dx.doi.org/10.5772/53004

313

In closing. I hope this chapter has made you reflect on your beliefs and ask questions as to how findings from neuroscience, medical science, psychiatry, and all of the other disciplines used to influence the lives of individuals with ADHD can be used fairly, for their good, and for the betterment of individuals with ADHD. Reason (1988) used the term "critical subjectivity" to explain the balance we should strive to achieve. To him we should critically reflect on what we learn and disregard what seems harmful and unjust. Gergan (2009) makes a similar point and reminds us to consider how beliefs stem from dominant disciplines, become obvious, bestow power, and cause some voices to be silenced. Kahneman (2011) notes the importance of slowing down and reflecting on our thinking and how information we focus on influences our thoughts and behaviors. Realizing that neuroscience can be persuasive and influence our beliefs opens the door for us to re-interpret and re-envision our perspectives of it. Moral questions arise when science's findings are applied to lives and we need to examine and change

Questioning, of course, does not always provide automatic answers to moral issues but it does bring into focus the need to seek valid information and keep a critical eye on the facts we receive and trust. Findings and treatments from neuroscience can have positive or negative effects. Interventions can help individuals focus and behave. But if we are not careful they can also place stars on their bellies and rob individuals of their identities (Racine & Illes, 2006). The limits of methodology and the complexity of relations between research and practice take

Progress is being made as the many chapters in this volume note, but we have much work ahead. To use neuroscience appropriately a causal chain of evidence needs to be clear and it is important to realize that when it comes to labeling, treating, and caring for individuals with

**•** The best information from neuroscience is gathered with reliable and valid tools, replicated,

center stage in the challenges we face (Stein, della Chiesa, Hinton, & Fischer, 2010).

our theories, methodologies, and beliefs if they are wrong (Gopnik, 2009).

positions relate to individuals with ADHD.

ADHD we must realize:

and combined with personal insights.

Habermas (2003) notes that the careless use of biomedical advances can undermine the behaviors and passions of individuals, or change individuals so much they lose the ability to understand and take responsibility for their own lives. In the wake of neuroscience and biotechnologies it is important to step back, reflect, make good ethical decisions, and take action to ensure that individuals with ADHD are allowed to be themselves and have a voice in their development and lives (Stein, della Chiesa, Hinton, & Fischer, 2010).

#### **3. Making ethical decisions**

*Now, the Star-Bell Sneetches had bellies with stars. The Plain-Belly Sneetches had none upon thars. Those stars weren't so big. They were really so small. You might think such a thing wouldn't matter at all. But, because they had stars, all the Star-Belly Sneetches Would brag, "We're the best kind of Sneetch on the beaches." With their snoots in the air, they would sniff and they'd snort "We'll have nothing to do with the Plain-Belly sort!" And, whenever they met some, when they were out walking, They'd hike right on past them without even talking.* Dr. Seuss (1961)

The quote from *The Sneeches* by Dr. Seuss (1961) was written to oppose anti-Semitism and remind us about discrimination. As science moves forward the ethical challenges we will face will continue to grow and change. Neuroscience is seeping into all of our lives and changing what we know and think, including what we think about ADHD. However, making ethical decisions is often perplexing and sometimes stars on bellies become so common we fail to see them. When it comes to neuroscience how do we decide what to believe? How do we know what is right and wrong, what is just and unfair? Where can we find reliable information? Who's ideas matter? Neuroethics brings questions like these into focus and this is important because of the power of our beliefs. Neuroethics sits at the intersection between neuroscience and the ethical, legal and social implications it brings. To Racine and Illes (2006), neuroethics focuses on the right and wrong, good and bad treatment of, perfection of, or unwelcome invasion of and worrisome manipulation of the human brain. Gazzaniga (2005, 2011) furthered this idea to include "the examination of how we as humans, want to deal with the social issues of disease, normality, mortality, lifestyle, and the philosophy of living informed by our understanding of underlying brain mechanisms." To Gazzaniga, neuroscience should help everyone develop a brain-based philosophy of life. But this is not easy because we tend to focus on ideas that align with our beliefs and allow our beliefs and emotions to cloud our judgment. To develop a brain-based philosophy we will need valid information and time for deep and reflective thought. Beliefs are not easy to change and neuroscience and ethics do not mix easily. Some findings from neuroscience are difficult to understand because they make us question the very fabric of who we are, who we can become, and how is best to live our lives. Moral questions have been around for centuries and after years of debate a human rights approach focuses on ensuring that everyone, including individuals with ADHD receive truthful information, a voice in their lives, the right not to be harmed, and the right to develop and grow. Now look back at the questions posed in the previous section and consider how these positions relate to individuals with ADHD.

**•** Do individuals with ADHD really need to change? How can characteristics and relational styles be respected rather than modified? How can individuals with ADHD become their

Habermas (2003) notes that the careless use of biomedical advances can undermine the behaviors and passions of individuals, or change individuals so much they lose the ability to understand and take responsibility for their own lives. In the wake of neuroscience and biotechnologies it is important to step back, reflect, make good ethical decisions, and take action to ensure that individuals with ADHD are allowed to be themselves and have a voice

The quote from *The Sneeches* by Dr. Seuss (1961) was written to oppose anti-Semitism and remind us about discrimination. As science moves forward the ethical challenges we will face will continue to grow and change. Neuroscience is seeping into all of our lives and changing what we know and think, including what we think about ADHD. However, making ethical decisions is often perplexing and sometimes stars on bellies become so common we fail to see them. When it comes to neuroscience how do we decide what to believe? How do we know what is right and wrong, what is just and unfair? Where can we find reliable information? Who's ideas matter? Neuroethics brings questions like these into focus and this is important because of the power of our beliefs. Neuroethics sits at the intersection between neuroscience and the ethical, legal and social implications it brings. To Racine and Illes (2006), neuroethics

in their development and lives (Stein, della Chiesa, Hinton, & Fischer, 2010).

own advocates?

**3. Making ethical decisions**

312 Attention Deficit Hyperactivity Disorder in Children and Adolescents

*Now, the Star-Bell Sneetches had bellies with stars.*

*Those stars weren't so big. They were really so small.*

*You might think such a thing wouldn't matter at all.*

*But, because they had stars, all the Star-Belly Sneetches*

*"We'll have nothing to do with the Plain-Belly sort!"*

*They'd hike right on past them without even talking.*

Dr. Seuss (1961)

*Would brag, "We're the best kind of Sneetch on the beaches."*

*With their snoots in the air, they would sniff and they'd snort*

*And, whenever they met some, when they were out walking,*

*The Plain-Belly Sneetches had none upon thars.*

In closing. I hope this chapter has made you reflect on your beliefs and ask questions as to how findings from neuroscience, medical science, psychiatry, and all of the other disciplines used to influence the lives of individuals with ADHD can be used fairly, for their good, and for the betterment of individuals with ADHD. Reason (1988) used the term "critical subjectivity" to explain the balance we should strive to achieve. To him we should critically reflect on what we learn and disregard what seems harmful and unjust. Gergan (2009) makes a similar point and reminds us to consider how beliefs stem from dominant disciplines, become obvious, bestow power, and cause some voices to be silenced. Kahneman (2011) notes the importance of slowing down and reflecting on our thinking and how information we focus on influences our thoughts and behaviors. Realizing that neuroscience can be persuasive and influence our beliefs opens the door for us to re-interpret and re-envision our perspectives of it. Moral questions arise when science's findings are applied to lives and we need to examine and change our theories, methodologies, and beliefs if they are wrong (Gopnik, 2009).

Questioning, of course, does not always provide automatic answers to moral issues but it does bring into focus the need to seek valid information and keep a critical eye on the facts we receive and trust. Findings and treatments from neuroscience can have positive or negative effects. Interventions can help individuals focus and behave. But if we are not careful they can also place stars on their bellies and rob individuals of their identities (Racine & Illes, 2006). The limits of methodology and the complexity of relations between research and practice take center stage in the challenges we face (Stein, della Chiesa, Hinton, & Fischer, 2010).

Progress is being made as the many chapters in this volume note, but we have much work ahead. To use neuroscience appropriately a causal chain of evidence needs to be clear and it is important to realize that when it comes to labeling, treating, and caring for individuals with ADHD we must realize:

**•** The best information from neuroscience is gathered with reliable and valid tools, replicated, and combined with personal insights.


[3] Farah, M. (2005). Neuroethics: The practical and the philosophical. *Trends in Cognitive*

Ethical Concerns Raised by Neuroscience, Labeling, and Intervening in the Lives of Individuals with ADHD

http://dx.doi.org/10.5772/53004

315

[5] Gazzaniga, M.S. (2011). *Who's in charge: Free will and the science of the brain.* New York:

[6] Gergen, K.J. (2009). *An invitation to social construction* (2nd ed.). Los Angeles, CA: Sage.

[9] Kahneman, D. (2011). *Thinking fast and slow.* New York, NY" Farrar, Strauss, and

[10] Lawson-Te, A. (1993). The socially constructed nature of psychology and the abnor‐

[11] McCabe, D.P., & Castel, A.D. (2008). Seeing is believing: The effect of brain images on judgments of scientific reasoning. *Cognition, 107*(1), 343-352. doi:10.1016/j.cognition.

[12] McCabe, S.E., Knight, J.R., Teter, C.J., & Wechsler, H. (2005). Non-medical use of pre‐ scription stimulants among US college students: prevalence and correlates from a na‐

[14] Morse, S. (2006). Moral and legal responsibility and the new neuroscience. In Illes, J. (Ed.), *Neuroethics: Defining the issues in theory, practice, and policy* (51-61). New York:

[15] Reason, P. (1988). Introduction. In P. Reason (Ed.), *Human inquiry in action: Develop‐*

[17] Stamm, J. (2007). *Bright from the start: The simple science-backed way to nurture your*

[18] Stein, Z., della Chiesa, B. Hinton, C., Fischer, K.W. (f2010). Ethical issues in educa‐ tional neuroscience: Raising children in a brave new world (p 1-32). *Boston, Oxford*

[19] U.S. Department of Health and Human Services, (2010). *Summary health statistics for U.S. children: National health interview survey.* Washington, DC: U.S. Government

[20] Weisberg, D.S., Keil, F.C., Goodstein, E.R., Rawson, & Gray, J.R. (2008). The seductive allure of neuroscience explanations. *Journal of Cognitive Neuroscience, 20*(3), 470-477.

[7] Gopnik, A. (2009). *The philosophical baby*. New York: Farrar, Straus and Giroux.

[8] Habermas, J. (2003). *The future of human nature*. (Cambridge, UK: Polity Press).

mation of the Maori, New Zealand Psychological Bulletin, 76, 25030.

[13] Merton, R.K. (1948). The self-fulfilling prophecy. *Antioch Review,* 8, 193-210.

*ments in new paradigm research* (pp. 1–17). Newbury Park, CA: Sage.

[16] Seuss, Dr. (1961). *The Sneeeches and other stories*. New York: Random House.

*child's developing mind, from birth to age 3.* New York: Gotham Books.

[4] Gazzania, M. (2005): *The ethical brain*. New York: Dana Press.

*Science, 9*, 34-40.

Harper Collins.

Giroux.

2007.07.017

tional survey. *Addiction, 100*, 96-106.

Oxford University Press.

University Press.

Printing Office.


This chapter is full of questions, perhaps more than answers, but this is where I see us. Gains are being made and beliefs are being formed. Fortunately the Sneetches came to realize they were wrong.

*But Mc Bean was quite wrong. I'm quite happy to say That the Sneetches got really quite smart on that day, The day they decided that Sneetches are Sneetches.*

*And no kind of Sneetch is best on the beaches, that day all the Sneetches forgot about the stars. And whether they had one, or not, upon thars.* Dr. Seuss (1961)

### **Author details**

#### Debby Zambo

Mary Lou Fulton Teachers College, Arizona State University, Phoenix

#### **References**


**•** We need to become better consumers of information from neuroscience.

314 Attention Deficit Hyperactivity Disorder in Children and Adolescents

and useable terms.

tions that work.

were wrong.

Dr. Seuss (1961)

**Author details**

Debby Zambo

**References**

*that Sneetches are Sneetches.*

*And whether they had one, or not, upon thars.*

*Neuroscience, 1*(1), 18-20.

**•** We need to understand that the tools neuroscientists use are new, popular, rapidly chang‐ ing, and persuasive. We need to understand these tools, the level of analysis they are able to perform, the reliability/validity of results, and what this all means to us in understandable

**•** Neuroscience cannot tell us how to treat individuals. However, it can be used to confirm, enrich, and refine theories and models of learning and behavior. Different vantage points or a consilience of disciplines (e.g., human development, cognitive science, neuroscience, behavioral science) are best (Wilson, 1998). A multi-voiced perspective leads to interven‐

**•** Even though information from neuroscience has grown, given insight, and become part of daily conversations we must not lose sight of the fact that it is an evolving and quickly

This chapter is full of questions, perhaps more than answers, but this is where I see us. Gains are being made and beliefs are being formed. Fortunately the Sneetches came to realize they

*But Mc Bean was quite wrong. I'm quite happy to say That the Sneetches got really quite smart on that day, The day they decided*

[1] Barkley, R. A. (2001). The executive functions and self-regulation: An evolutionary

[2] Chau, V. (2007). Popping pills to study: Neuroethics in education, *Stanford Journal of*

neuropsychological perspective. *Neuropsychology Review, 11*, 1-29.

changing field. We need to be fascinated but remain skeptical at the same time.

*And no kind of Sneetch is best on the beaches, that day all the Sneetches forgot about the stars.*

Mary Lou Fulton Teachers College, Arizona State University, Phoenix


[21] Wilson, E.O. (1998). Consilience: The unity of knowledge. New York: Random House.

[21] Wilson, E.O. (1998). Consilience: The unity of knowledge. New York: Random

House.

316 Attention Deficit Hyperactivity Disorder in Children and Adolescents

*Edited by Somnath Banerjee*

ADHD in children and adolescents is a neurodevelopmental disorder, which is recognized by the clinicians all over the world. ADHD is a clinical diagnosis based on reliable history, reports from home and school and a physical examination to rule out any other underlying medical conditions. ADHD can cause low self-esteem in the child and impair quality of life for the child and the family. It is known that ADHD is a chronic illness and that clinicians needed to use chronic illness principles in treating it. The last 10 years have seen an increase in the number of medications that have been approved for the treatment of ADHD. This book has tried to address some of the issues in ADHD.

Photo by umesh chandra / iStock

Attention Deficit Hyperactivity Disorder in Children and Adolescents

Attention Deficit

Hyperactivity Disorder in

Children and Adolescents