Barry D. Garfinkel

Comorbidity of ADHD and reading disability among clinic-referred children

Of a consecutive series of 115 boys diagnosed in a university outpatient clinic as ADHD, 39% also demonstrated a specific reading disability. Pure ADHD patients were compared with mixed ADHD + RD and normal controls on a battery of cognitive and attentional measures. The aim was to determine whether a distinct pattern of deficits would distinguish the groups. Both ADHD subgroups performed significantly worse than controls on measures of sequential memory and attentional tasks involving impulse control andplanful organization. Only ADHD+RD boys differed from controls on measures or rapid word naming and vocabulary. The reuslts are discussed within the framework of an automatic versus effortful information-processing model.

Behavioral and Cognitive Subtypes of ADHD

Attention-deficit hyperactivity symptoms are observed by teachers in 9.2% of a nonreferred elementary school population. Two subtypes of attention-deficit hyperactivity disorder (ADHD), a cognitive form and a behavioral form, are identified. The behavioral subtype includes about 80% of those identified and is characterized by distinct clinical phenomenology of inattention, impulsivity, and hyperactivity. These children can be described on a continuum of severity, with the most severe showing behavioral features indistinguishable from conduct disorder. Children with behavioral subtypes of ADHD do not exhibit the specific skill deficits on neuropsychological tests that are characteristic of reading disabled children. There is a second, less prevalent type of cognitive attention-deficit hyperactivity disorder constituting approximately 20% of ADHD children that includes severe academic underachievement along with inattention, impulsivity, and overactivity. Children with the cognitive subtype exhibit information processing deficits that involve inadequate encoding and retrieval of linguistic information, characteristic of reading disabilities.

School phobia: the overlap of affective and anxiety disorders

In a group of 26 early adolescent, chronic school refusers, 69% met DSM-III criteria for affective disorder (depression), 62% met criteria for anxiety disorder, and 50% had both depressive and anxiety disorders. Patients with both disorders were more severely symptomatic as indicated by higher scores on rating scales for anxiety and depression. While children and adolescents with depressive disorders frequently reported anxiety symptoms, in general those with anxiety disorders did not commonly describe depression. However, those patients with severe anxiety symptoms reported specific depressive symptomatology, indicating that severe anxiety disorders in children and adolescents may be clinically indistinguishable from depression.

Comparative Studies of Pharmacotherapy for School Refusal

Two studies compared alprazolam and imipramine in the treatment of school refusal. In an open label study (N = 17), two-thirds of the subjects completing a trial in both the alprazolam and imipramine groups showed moderate to marked global improvement in symptoms of anxiety and depression. In the double-blind, placebo-controlled study (N = 24), posttreatment scores calculated as change from baseline on the Anxiety Rating for Children were significantly different (p = .03) among the three treatment groups, with the active medication groups showing the most improvement. Additionally, on all depression rating scales, similar trends were evident with the alprazolam and imipramine groups demonstrating greater improvement than the placebo group. However, analyses of covariance (with pretreatment scores as the covariates) showed no significant differences among the three treatment groups on change in anxiety and depression scales. Thus, additional research is needed to determine whether trends in this study are explained by drug effect or baseline differences on rating scales.

The computerized continuous performance task: a new measure of inattention.

Attentional performance was measured using a computerized continuous performance task, several psychometric tasks, and ratings of classroom behavior. Subjects were 51 children in the inpatient and day hospital programs of a psychiatric hospital. The relationship between performance on the computerized task and all other measures was examined. Results indicated that the continuous performance task significantly correlated with several other psychometric measures of inattention, ratings of inattention, impulsivity, and hyperactivity. The CPT had slightly better sensitivity and the same specificity as the Conners Teacher Rating Scale in identifying Conduct and Attention Deficit Disordered children. Implications for the use of the computerized continuous performance task as a screening measure for attentional difficulties is discussed.

Tricyclic Antidepressant and Methylphenidate Treatment of Attention Deficit Disorder in Children

Twelve boys with attention deficit disorder (ADD) were treated in a double-blind placebo controlled crossover experiment with methylphenidate, clomipramine (CMI) and desipramine (DMI). A Latin square design was followed to control for the order of presentation of the drugs. Behavioral ratings by teachers and child care workers indicated methylphenidate had a greater efficacy than the other drugs. The therapeutic action of the short-acting sympathomimetic agent diminished by evening, whereas the tricyclic antidepressants (TCAs) have a longer half-life and therefore continued to be effective. The TCAs were more effective with affective symptoms and less likely to disturb sleep. The present study underscores the need to understand better the amelioration of various ADD symptoms by different medications.

Clinical effect of buspirone in autistic children

Buspirone is a novel antianxiety agent with no chemical similarity to other psychotropic medications. Pharmacological effects include inhibition of serotonin neurons, decrease of striatal levels of serotonin and metabolites, and reduction in serotonin binding sites. Buspirone also has effects on dopamine, norepinephrine, and the GABA systems. To pursue an antiserotonergic treatment rationale for autistic disorder, an open-blind 4-week trial comparing buspirone to fenfluramine or methylphenidate was conducted. Hyperactivity was a target symptom in three children with improvement noted in two with buspirone. Behavioral toxicity was encountered in one of two autistic subjects treated with methylphenidate and very mild improvement in another subject on fenfluramine. An autistic child with obsessive ideation was unchanged. No adverse reaction to buspirone was encountered. Further investigation in a double-blind trial of buspirone is warranted for treatment of symptoms of autism, especially aggression and hyperactivity.

The Occurrence of Behavior Disorders in Children: The Interdependence of Attention Deficit Disorder and Conduct Disorder

A nonreferred elementary school population of 315 children participated in a screening for behavioral problems. The prevalence of inattentive-overactive symptoms suggestive of Attention Deficit Disorder (ADD) was determined to be 2.3%; 3.6% of the children had aggressive/oppositional symptoms suggestive of Conduct Disorder (CD). Another 3.0% showed both ADD and CD symptoms. Index children comprise 8.9% of the school population and were more likely to come from broken homes and had more remedial education. They also had higher scores on the ADD Interview (DICA) and were more impulsive and disorganized on a computerized attentional battery. There were no symptoms or characteristics that differentiated the inattentive-overactive (ADD) from the aggressive/oppositional (CD) child. Multivariate statistical techniques indicated a different relative importance of individual symptoms in the two groups. These results suggest the interdepencence of symptoms commonly associated with ADD and CD diagnoses.

School Phobia: Patterns of Family Functioning

Seventy-six families of children with school phobia were evaluated with the Family Assessment Measure. Mothers and fathers, as separate groups, rated clinically significant dysfunction in the parent-child relationship in the areas of role performance and values and norms. There were no significant differences between intact and single-parent families on ratings of family dysfunction. There was significantly less family dysfunction as rated by mothers and by children if the child had a diagnosis of pure anxiety disorder compared to families of school phobic children in other diagnostic categories.

Depression and Symptoms of Attention Deficit Disorder with Hyperactivity

Abstract Thirty-five boys, classified as major depressive disorder (MDD, N = 12), attention deficit disorder with hyperactivity (ADDH, N = 12), or normal (NL, N = 11) on the basis of structured clinical interviews were evaluated using the Child Depression Rating Scale (CDRS), Connors Parent Questionnaire (CPQ), and Jesness Inventory Manifest Aggression Scale (JIMAS). The MDD group scored significantly higher than the NL group on the CPQ indicating a higher than normal rate of externalizing behavioral symptoms for the MDD boys. Item analyses of JIMAS revealed that the MDD group positively endorsed criteria showing poor impulse control and stress intolerance significantly more often than the other two groups. Boys with MDD did not have features of ADDH, but may have oppositional disorder, whereas boys with ADDH may have dysthymia.