Ernest S. L. Luk

Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children.

BACKGROUND Executive function deficits have been reported repeatedly in children with Attention Deficit Hyperactivity Disorder (ADHD). Stimulant medication has been shown to be effective in improving cognitive performance on most executive function tasks, but neuropsychological tests of executive function in this population have yielded inconsistent results. Methodological limitations may explain these inconsistencies. This study aimed to measure executive function in medicated and non-medicated children with ADHD by using a computerized battery, the Cambridge Neuropsychological Test Automated Battery (CANTAB), which is sensitive to executive function deficits in older patients with frontostriatal neurological impairments. METHODS Executive function was assessed in 30 children with ADHD: 15 were stimulant medication naive and 15 were treated with stimulant medication. These two groups were compared to 15 age, sex and IQ matched controls. RESULTS The unmedicated children with ADHD displayed specific cognitive impairments on executive function tasks of spatial short-term memory, spatial working memory, set-shifting ability and planning ability. Impairments were also seen on spatial recognition memory and delayed matching to sample, while pattern recognition memory remained intact. The medicated children with ADHD were not impaired on any of the above executive function tasks except for deficits in spatial recognition memory. CONCLUSIONS ADHD is associated with deficits in executive function. Stimulant medication is associated with better executive function performance. Prospective follow-up studies are required to examine these effects.

Abnormal executive function in attention deficit hyperactivity disorder: the effect of stimulant medication and age on spatial working memory

OBJECTIVE This study sought to examine the factors associated with spatial working memory and the use of strategies to impairments in spatial working memory in children with attention deficit hyperactivity disorder (ADHD). The developmental trajectories for spatial working memory in medicated and medication naïve children with ADHD were investigated. In addition, the effect of psychostimulant medication on deficits in spatial working memory was examined. METHOD A cross-sectional study compared performance between 21 psychostimulant medicated children with ADHD, 27 medication naïve children with ADHD and 26 matched control subjects on computerized tests of spatial memory and spatial working memory. RESULTS Compared with the controls, performance in medication naïve children with ADHD was significantly worse on the spatial working memory task. There was no difference in performance between the medicated children with ADHD and the control subjects on this same task, despite the ongoing symptoms of ADHD in the former group. The pattern of normal and abnormal performance in the ADHD groups was age-independent. CONCLUSIONS Deficits in executive functions related to spatial working memory do occur in children with ADHD, although the magnitude of these deficits is not related to the childs age or the level of ADHD symptoms. These deficits were not present in the current sample of children who were receiving psychostimulant medication.

Routine outcome measurement in a child and adolescent mental health service: an evaluation of HoNOSCA

Objective: This paper evaluates a range of properties for a clinician-based instrument designed for routine use in a child and adolescent mental health service (CAMHS). Method: The Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) is a new outcome measure with great promise. Case vignettes were used to examine interrater reliability. HoNOSCA was implemented for routine outpatient use by multidisciplinary staff with a return rate of 84%. The 305 ratings obtained at assessment were analysed by age, gender and diagnosis. Asample of 145 paired ratings with a 3-month interval were examined for the measurement of change over time. Results: Interrater reliability of the total score indicates moderate reliability if absolute scores are used and good reliability if the total score is used for relative comparisons. Most scales have good to very good reliability. The scales discriminated between age and gender in the expected way. HoNOSCA correlated with clinicians’ views of change and was sensitive to change over a 3-month period. The total score seemed a proxy for severity. Conclusion: Routine outcome instruments must be explored in settings where they will be used and with realistic training. HoNOSCA appears to be of value in routine outcome measurement and although questions remain about reliability and validity, the results strongly support further investigation.

Children with persistent conduct problems who dropout of treatment.

Abstract Dropout of treatment is one of the key issues in outcome in a child and adolescent mental health service. We report two studies focusing on the treatment process and the dropout rate of children with persistent conduct problems presenting to a community mental health service, using a prospective design. The first study included 32 children and used a randomised controlled treatment design comparing a CBT approach with conjoint family therapy and an eclectic approach. The overall dropout rate was 36%. Dropout occurred significantly less frequently in the CBT group. The dropout group was associated with mothers who were younger and less educated, a poorer rating by the clinicians at the last meeting, parental dissatisfaction with the treatment service and perception that the treatment was less organised and having less behavioural tasks. In the second study we used a naturalistic follow-up design. Forty-six children were included. The overall dropout rate was 48%. Again, the children who defaulted were rated by clinicians as less likely to have improved and dropout was also significantly associated with parental perception of a less organised treatment. In both studies dropout usually occurred after assessment and at the early phase of treatment.

The Development of a Screening Questionnaire for Childhood Cruelty to Animals

Childhood cruelty to animals may be a marker of poor prognosis amongst conduct disordered children. However, other than semistructured interviews with parents or children, there are no screening instruments for this behavior. The aim of this study was to develop such an instrument. In the first phase of the study, a parent-report questionnaire, Childrens Attitudes and Behaviors Towards Animals (CABTA) was designed and piloted on 360 elementary school children, enabling community norms and a factor structure for the instrument to be derived. In the second phase, the questionnaire was completed by the parents of a small sample of children (N = 17) to establish its test-retest reliability. In the third phase of the study, the CABTA was completed by the parents of 19 children who had been diagnosed with either a Disruptive Behavioral Disorder or Attention Deficit Hyperactivity Disorder, and the results were compared with the outcome of a semistructured interview with parents regarding their childs behavior toward animals. The results of the various phases of the study indicated that the CABTA consists of two factors. Typical and Malicious Cruelty to animals, and is a reliable and valid tool for detecting childhood cruelty to animals. Possible use and adaptations of the CABTA as a screening instrument in clinical and community samples are discussed.

Characteristics of parent‐ and child‐reported anxiety in psychostimulant medication naïve, clinically referred children with attention deficit hyperactivity disorder, combined type (ADHD‐CT)

Objective: Anxiety is a frequent comorbid condition in referred primary school-age children with attention deficit hyperactivity disorder, combined type (ADHD-CT), yet there has been relatively little systematic research of the nature of this comorbid anxiety. We describe the characteristics of parent-reported child anxiety disorders and child-reported anxiety disorders in primary school-age children with ADHD-CT. Method: A cross-sectional study of 75 clinically-referred psychostimulant medication naïve children with ADHD-CT examining separately parent and child reports of anxiety, defined categorically and dimensionally. A two-year follow up of 12 children with parent-reported child anxiety and 12 children with child-reported anxiety was also completed. Results: There was no significant association between the child and parent reports of anxiety. Generalized anxiety disorder (GAD), separation anxiety disorder (SAD), specific phobia (SpPh) and social phobia (SoPh) were the most common anxiety disorder diagnoses reported by parents and children. Two-year follow-up data revealed no decrease in the parent report but a significant decrease in the child report of anxiety disorders. Conclusions: The dissonance between the parent report of child anxiety and the child report of anxiety, emphasizes the importance of careful and thorough clinical assessment of the childs perspective. The nature of parent-reported child anxiety and childrens self-report of anxiety requires further systematic research.

Attention deficit hyperactivity disorder: current progress and controversies

Objective: Attention deficit hyperactivity disorder (ADHD) is a common chronic and disabling condition in children. This paper reviews the taxonomic issues and the major comorbid conditions, neurobiological correlates, treatment and public health issues associated with ADHD. Method: Pertinent recent papers are reviewed from the psychological and psychiatric literature. Results: The two major taxonomies now define a similar group of children with ADHD of a combined type/hyperkinetic disorder. Advances in the understanding and treatment of ADHD demonstrate the complex multidimensional links between neurobiology, psychology and behaviour. Careful assessment of individual factors in treatment planning and ongoing monitoring of psychostimulant medication treatment in the longer term are recommended. Conclusions: There is much still to learn about ADHD, and increased levels of clinical research and treatment resources are required.

Parent group treatments for children with Oppositional Defiant Disorder

Abstract This study compared two group intervention strategies aimed at parents of primary school-aged children with Oppositional Defiant Disorder. One group focused on parent management training; the second used a cognitive approach, which focused on parental stress and problem solving skills. Both interventions were effective with a clinic-referred sample showing overall improvements in post-treatment child behaviours and parenting stress levels. Parents who attended the parent management training reported the larger reduction in conduct problems in their children, whereas parents who attended the parenting stress group showed a reduction in their reported level of stress. The results emphasise the importance of specifically targeted interventions.

Attention Deficit Hyperactivity Disorder and Comorbid Anxiety: Practitioner Problems in Treatment Planning

Attention Deficit Hyperactivity Disorder, combined type, and anxiety have been shown to co-occur in children but specific treatments tailored to suit this combination of diagnoses have not yet been reported. This paper addresses the problem from the perspective of clinical practice with a focus on treatment planning and evaluation. Existing work in the published literature is examined. A pilot study designed to explore the suitability of a cognitive-behavioural family-based intervention for use in a child mental health service is presented. The results of the intervention revealed high levels of parent and child satisfaction although there was no change in the level of symptoms. The implications for treatment planning and for future group interventions are discussed with regard to parent psychopathology and the difficulty in generalising research findings to day-to-day clinical practice.

Attention deficit hyperactivity disorder: anxiety phenomena in children treated with psychostimulant medication for 6 months or more

Objective: The intermediate- to long-term use of psychostimulant medication has unclear benefits on the core symptoms of attention deficit hyperactivity disorder (ADHD) and delayed onset affective symptom side effects which can mimic these core ADHD symptoms. ‘ADHD and anxiety’ has also been associated with a poor response to short-term psychostimulant medication treatment. In addition, it is unclear whether ‘ADHD and anxiety’ should be defined from the childs and/or the parents perspective. We propose that anxiety will be increased in children with ADHD who are treated with psychostimulant medication in the intermediate- to long-term who are identified by clinicians as poor responders. Method: Twenty children with ADHD who were medicated for 6 months or more and who had ongoing core symptoms of ADHD were compared to 20 age- and IQ-matched children with ADHD who were medication-naive. Chi-squared tests were performed on the categorical dependent variables and independent t-tests on the dependent continuous variables. Results: Anxiety is significantly increased in children with ADHD treated with psychostimulant medication in the intermediate- to long-term who are noted by clinicians to have ongoing core symptoms of ADHD. This statistically significant finding is evident with both categorical and dimensional measures of anxiety from the childs perspective. Conclusions: The recognition of anxiety and its management in children with ADHD is generally poorly understood. In this particular group of children with ADHD, anxiety may be a side effect of intermediate- to long-term psychostimulant medication and/or a potential marker for a poor response to intermediate- to long-term psychostimulant medication treatment.