Dennis K. Norman

Comorbidity between ADDH and Learning Disability: A Review and Report in a Clinically Referred Sample

A widely variable overlap ranging from 10 to 92% has been reported in the literature between attention deficit disorder with hyperactivity (ADDH) and learning disability (LD), most likely a result of inconsistencies in the criteria used to define LD in different studies. The following study seeks to more accurately determine rates of LD in clinically referred children. Using a psychometrically reliable methodological approach, it was expected that the rate of LD in ADDH children would be far more modest than previously reported. Subjects were referred children with ADDH (N = 60), children with academic problems (N = 30), and normal controls (N = 36) of both sexes with available psychological and achievement testing. Using a liberal definition of LD, significant differences were found between the groups (ADDH = 38% versus academic problems = 43% versus normals = 8%; p = 0.002). In contrast, more modest rates were found using two more stringent methods of assessment (23 and 17%; 10 and 3%; 2 and 0%, respectively; p = 0.02). Arithmetic-based LD appears to be equally identified by both stringent methods, whereas the liberal definition overidentified children in all three groups. These findings show that a liberal definition of LD overidentifies LD not only in ADDH children but also in normal children.

INTELLECTUAL PERFORMANCE AND SCHOOL FAILURE IN CHILDREN WITH ATTENTION DEFICIT HYPERACTIVITY DISORDER AND IN THEIR SIBLINGS.

We made psychiatric and intellectual assessments of 140 children with attention deficit hyperactivity disorder (ADHD), 120 normal controls, and their 303 siblings. The index children were white, non-Hispanic boys. ADHD children were more likely to have had learning disabilities, repeated grades, been placed in special classes, and received academic tutoring. They also did worse on the Wechsler Intelligence Scale for Children--Revised (WISC-R). Among ADHD probands, comorbid conduct, major depressive, and anxiety disorders predicted school placement more than school failure or WISC-R scores. However, the neuropsychological disability of all ADHD children could not be attributed to comorbid disorders because those without comorbidity had more school failure and lower WISC-R scores than normal controls. Intellectual impairment was also increased among siblings of ADHD children. This provides converging evidence that the ADHD syndrome is familial.

Effects of Family History and Comorbidity on the Neuropsychological Performance of Children with ADHD: Preliminary Findings

OBJECTIVE Because ADHD is heterogeneous with respect to psychiatric comorbidity, familiality, and learning disabilities, it was hypothesized that such features might influence the severity and pattern of neuropsychological function in ADHD. METHOD Subjects were 9- to 20-year-old males with DSM-III-R ADHD (n = 65) and normal controls (n = 45). Information on neuropsychological performance was obtained in a standardized manner, blind to the probands clinical status. RESULTS ADHD probands were significantly impaired on neuropsychological functions compared with controls irrespective of composite psychiatric comorbidity status, and those with a family history of ADHD were most impaired. ADHD probands with learning disabilities showed a pattern suggestive of reduced motor dominance and extremely slow reading speed. CONCLUSIONS These results indicate that neuropsychological performance in ADHD is significantly affected by familial status and presence of learning disabilities. The similarity of findings between ADHD children with and without comorbid psychiatric disorders suggests that the neuropsychological impairments in our sample were associated with ADHD. These findings raise the possibility of alterations of cerebral dominance and of frontal networks in ADHD. Further research is needed to replicate these findings in larger samples, to clarify the role of specific comorbid psychiatric disorders, and to assess directly cerebral functioning in subjects with ADHD.

Diagnosed intellectual and emotional impairment among parents who seriously mistreat their children: prevalence, type, and outcome in a court sample

A substantial body of research evidence over the past three decades has indicated that intellectual and emotional impairment among parents is a factor contributing to child abuse and neglect. This study examined the court records of 206 seriously abused or neglected children and their families in a large urban area and found that in over half the records a parent had been diagnosed as having an emotional disorder and/or low IQ, with a majority of these diagnoses indicating significant impairment. Although type of impairment (emotional, low IQ, and a subsample of substance abusers) did not predict type of mistreatment, higher predicted risk for continued mistreatment, or greater likelihood of permanent removal of the child by the court, low IQ parents revealed significantly less prior court involvement and greater acceptance of court-ordered services. Parents diagnosed with serious emotional disorders were significantly more likely than less disturbed parents to have their children permanently removed despite findings of no significant differences in risk or compliance factors.

Quality of life assessment in adults with type 1 Gaucher disease

The effect of enzyme replacement therapy on health-related quality of life in 25 adults with type 1 Gaucher disease was investigated over a 2-year period. Quality of life was assessed using the SF-36 Health Survey (SF-36). Psychological functioning was assessed using the Symptom Checklist-90R. The results indicated significant improvement in 7 of 8 SF scale scores beginning at 18 months of therapy (P<0.05 to 0.001). The SF scale showing improvement first was Vitality (energy level and fatigue) at 6 months of therapy (P<0.01). The SF-36 scales showing the largest improvements were Role-Physical and Social Functioning (P<0.001). Compared to the general US adult population, the study populations health profile was significantly lower prior to starting therapy but by 24 months of therapy there were no differences between the two. No differences were found in psychological functioning compared to a US adult normative group at the start of therapy. However, within the study population there was significant improvement in mood and global functioning and fewer psychological symptoms reported at 24 months of therapy. The findings indicate that enzyme replacement therapy for type 1 Gaucher disease has a positive impact on health-related quality of life from the patients perspective.

Frequency of bulimic behaviors and associated social maladjustment in female graduate students

A questionnaire survey of 550 female medical, business and law students revealed that 12% met criteria for bulimia. The bulimic students reported significantly more social maladjustment than their non-eating disordered peers. Frequency of binging and purging was associated with the degree of social impairment, with significant social dysfunction being noted on the overall scale at a minimum binging/purging frequency of once weekly. This finding suggests that the proposed DSM-III frequency criterion may be too restrictive.

Eating disorders and social maladjustment in female medical students.

A survey of eating disorders in female medical students showed that 15% had a lifetime history of bulimia or anorexia nervosa. On the work, social/leisure, and overall subscales of the Social Adjustment Scale Self-Report, those medical students who had current or previous eating disorders reported greater social maladjustment then medical students who did not have eating disorders.

Postprandial insulin profiles with implantable pump therapy may explain decreased frequency of severe hypoglycemia, compared with intensive subcutaneous regimens, in insulin-dependent diabetes mellitus patients**

PURPOSE To examine the mechanism of the decreased frequency of severe hypoglycemia with implantable pump therapy compared with subcutaneous intensive therapy. PATIENTS AND METHODS Eight subjects with insulin-dependent diabetes mellitus (IDDM), enrolled in an implantable insulin pump study, were admitted to the General Clinical Research Center and on 2 separate days were given either a dose of preprandial insulin chosen to maintain normoglycemia for a standard (450 kcal, 50% carbohydrate) breakfast or 1.75 times the dose. The two doses were administered subcutaneously (by syringe or with an external pump) during one inpatient admission and by implantable pump (intraperitoneally, n=6; or intravenously, n=2) during a separate admission. Blood glucose, plasma-free insulin, and neurocognitive function were measured for 4 hours after the meal. RESULTS Subcutaneous administration resulted in 7 episodes of hypoglycemia (2 with the usual dose and 5 with the 1.75-fold dose), defined as blood glucose less than 50 mg/dL; implantable pump treatment resulted in only 2 episodes, both with the 1.75-fold dose (P <0.05, Fishers two-tailed test for implantable versus subcutaneous). Compared with subcutaneous delivery, implantable pump therapy provided significantly lower insulin levels during the final 2 hours after administration of the usual dose and the 1.75-fold dose (P <0.005). In addition to the decreased frequency of hypoglycemia, implantable pump therapy resulted in significantly lower area under the glycemia curve during the first 120 minutes with the 1.75-fold dose compared with subcutaneous administration. CONCLUSIONS The lower frequency of severe hypoglycemia with intensive therapy administered by implantable pump therapy is explained by the more rapid clearance of insulin delivered intraperitoneally or intravenously compared with intensive subcutaneous injection regimens. The lower frequency of severe hypoglycemia with implantable pump therapy compared with subcutaneous therapy demonstrated in clinical trials is confirmed by this study, in which we attempted to induce hypoglycemia.

Personality functioning in normal weight bulimia

This study examined the personality organization and functioning of 57 normal weight bulimic women as assessed by the Rorschach and compared their performance to that of comparable groups of nonpatient and outpatient depressed women. In contrast to nonpatients, the bulimic and depressed groups were similar in their overall level of dysphoric affect, emotional lability and impulsivity, avoidance of affective stimulation, state of emotional overload, relatively poor perceptual accuracy, lower interest in other people, and lack of set coping style. The bulimic group, however, displayed greater egocentricity, narcissism, anger, and negativity and was more underincorporative than the depressed, who were more introspective but also more arbitrary in their perceptions than the bulimics.

An empirical study of the DSM-IV defensive functioning scale in personality disordered patients

The inclusion of the Defensive Functioning Scale (DFS) in the DSM-IV provides clinicians with the opportunity to incorporate psychodynamic information into their descriptive diagnoses. The DFS contains 27 specific defenses covering six levels of defensive functioning ranging from psychotic to normal. This study undertook an initial empirical evaluation of the DFS. A sample of 100 clinicians completed a questionnaire containing both the personality disorder (PD) symptoms and the DFS defenses of PD patients known to them, DFS ratings were not related to clinician orientation. Patient gender was related to only one defense level, with women being assigned significantly more action level defenses than men. Multiple regression analyses revealed unique and meaningful patterns of association between the defense levels and PD symptoms. Additionally, the DFS ratings provided unique information regarding level of impairment and treatment success. These results provide initial empirical support for the clinical application and relevance of the proposed DFS system.