Mark L. Wolraich

Comparison of diagnostic criteria for attention-deficit hyperactivity disorder in a county-wide sample

OBJECTIVE To examine teacher-reported prevalence rates for attention-deficit hyperactivity disorder (ADHD) based on DSM-III-R and DSM-IV in the same population. METHOD Teachers completed questionnaires in which they rated all their students on all DSM-III-R and DSM-IV symptoms for disruptive behavior disorders except for seven conduct disorder symptoms but including seven symptoms screening for anxiety or depression. This constituted all children in kindergarten through fifth grade in a middle Tennessee county during the 1993-1994 academic year (16 schools, 398 teachers, and 8,258 children). Also included were questions about the childrens diagnosis of ADHD, treatment with stimulants, and the presence of behavior or academic problems. RESULTS The prevalence rates were 7.3% for ADHD (DSM-III-R); 11.4% for ADHD, total (TOT); 5.4% for ADHD, inattentive type (AD); 2.4% for ADHD, hyperactive-impulsive type (HI); and 3.6% for ADHD, combined type (CT). Factor analysis identified five factors: opposition/defiance-conduct, inattention, hyperactivity/impulsivity, anxiety/depression, and stealing-truancy. The rates of problems differed mostly between ADHD-AD and ADHD-HI (40% versus 80%) for behavior and (75% versus 23%) for academics. Few (15% to 40%) had an ADHD diagnosis or stimulant treatment (21% to 32%). CONCLUSION DSM-IV criteria are likely to increase the prevalence of this disorder in comparison with DSM-III-R rates, but they may better characterize its heterogeneity.

Examination of DSM-IV criteria for attention deficit/hyperactivity disorder in a county-wide sample.

&NA; This study replicated, in the subsequent academic year, teacher‐reported prevalence rates for attention deficit/hyperactivity disorder (ADHD) based on DSM‐IV. Teachers in grades K‐5 in a Tennessee county (10 schools, 214 teachers, and 4323 children) completed questionnaires on all their students consisting of the DSM‐IV symptoms for disruptive behavior disorders, except for eight conduct disorder symptoms, seven symptoms screening for anxiety or depression, ratings of performance, and questions about the presence of ADHD, stimulant medication treatment, and behavioral or academic problems. The prevalence rates were 16.1% for ADHD‐all types, 8.8% for ADHD‐inattentive type (AD), 2.6% for ADHD‐hyperactive/impulsive type (HI), and 4.7% for ADHD‐combined type and 6.8, 3.2, 0.6, and 2.9%, respectively, when impairment was taken into consideration. The rates of problems differed mostly between ADHD‐AD and ADHD‐HI (30% vs. 68%) for behavior and (56% vs. 16%) for academics. Few (11‐33%) had an ADHD diagnosis or were treated with stimulant treatment (8‐26%). DSM‐IV criteria are likely to increase the prevalence but may better characterize the heterogeneity of this disorder.

Assessing the impact of parent and teacher agreement on diagnosing attention-deficit hyperactivity disorder

This study examines the impact of interrater reliability on the diagnosis of attention-deficit hyperactivity disorder (ADHD). A screening of 6171 elementary school children identified 1573 children with a high risk for ADHD according to teacher rating. Follow-up parent interviews and information from teachers were collected on 243 children. Before screening, health care professionals had diagnosed ADHD in 40% of the identified children. There was low agreement between the parent and teacher reports of ADHD symptoms according to DSM-IV–based questionnaires: Inattentive (r = .34, κ = 0.27), Hyperactive/Impulsive (r = .27, κ = 0.22), and Performance Impairment (r = .31, κ = 0.07). When the two-setting requirement was strictly enforced, poor interrater agreement decreased diagnostic rates for all three types of ADHD in this clinical sample: Inattentive (15%–5%), Hyperactive/Impulsive (11%–3%), and Combined (23%–7%). Parent and teacher agreement was low concerning ADHD symptoms and performance. The recommendation of multiple informants significantly decreased the prevalence. Allowing for observer disagreement by using more lenient core symptom scores could reduce the effect.

Effects of Diets High in Sucrose or Aspartame on The Behavior and Cognitive Performance of Children

BACKGROUND Both dietary sucrose and the sweetener aspartame have been reported to produce hyperactivity and other behavioral problems in children. METHODS We conducted a double-blind controlled trial with two groups of children: 25 normal preschool children (3 to 5 years of age), and 23 school-age children (6 to 10 years) described by their parents as sensitive to sugar. The children and their families followed a different diet for each of three consecutive three-week periods. One diet was high in sucrose with no artificial sweeteners, another was low in sucrose and contained aspartame as a sweetener, and the third was low in sucrose and contained saccharin (placebo) as a sweetener. All the diets were essentially free of additives, artificial food coloring, and preservatives. The childrens behavior and cognitive performance were evaluated weekly. RESULTS The preschool children ingested a mean (+/- SD) of 5600 +/- 2100 mg of sucrose per kilogram of body weight per day while on the sucrose diet, 38 +/- 13 mg of aspartame per kilogram per day while on the aspartame diet, and 12 +/- 4.5 mg of saccharin per kilogram per day while on the saccharin diet. The school-age children considered to be sensitive to sugar ingested 4500 +/- 1200 mg of sucrose per kilogram, 32 +/- 8.9 mg of aspartame per kilogram, and 9.9 +/- 3.9 mg of saccharin per kilogram, respectively. For the children described as sugar-sensitive, there were no significant differences among the three diets in any of 39 behavioral and cognitive variables. For the preschool children, only 4 of the 31 measures differed significantly among the three diets, and there was no consistent pattern in the differences that were observed. CONCLUSIONS Even when intake exceeds typical dietary levels, neither dietary sucrose nor aspartame affects childrens behavior or cognitive function.

Obtaining Systematic Teacher Reports of Disruptive Behavior Disorders Utilizing DSM-IV

This study examines the psychometric properties of the Vanderbilt AD/HD Diagnostic Teacher Rating Scale (VADTRS) and provides preliminary normative data from a large, geographically defined population. The VADTRS consists of the complete list of DSM-IV AD/HD symptoms, a screen for other disruptive behavior disorders, anxiety and depression, and ratings of academic and classroom behavior performance. Teachers in one suburban county completed the scale for their students during 2 consecutive years. Statistical methods included (a) exploratory and confirmatory latent variable analyses of item data, (b) evaluation of the internal consistency of the latent dimensions, (c) evaluation of latent structure concordance between school year samples, and (d) preliminary evaluation of criterion-related validity. The instrument comprises four behavioral dimensions and two performance dimensions. The behavioral dimensions were concordant between school years and were consistent with a priori DSM-IV diagnostic criteria. Correlations between latent dimensions and relevant, known disorders or problems varied from .25 to .66.

Teachers' screening for attention deficit/hyperactivity disorder: comparing multinational samples on teacher ratings of ADHD.

This study evaluates a measurement model for Attention Deficit/Hyperactivity Disorder (ADHD). The DSM-IV divides 18 symptoms into two groups, inattentive and hyperactive/impulsive. Elementary school teachers rated 21,161 children in 4 locations: Spain, Germany, urban US, and suburban US. Confirmatory factor analysis suggested that the 2-factor model (inattention, hyperactivity/impulsivity) shows the best fit. A third factor, impulsivity, was too slight to stand-alone. Children with academic performance problems were distinguished by inattention, but children with behavior problems typically had elevations in inattention, hyperactivity, and impulsivity. Between-site differences were statistically significant, but so small that we conclude that same measurement model fits all 4 samples in 2 continents.

Stimulant Medication Therapy in the Treatment of Children with Attention Deficit Hyperactivity Disorder

Despite the tremendous research advances that have increased our knowledge regarding the pharmacodynamics, clinical pharmacology, pharmacokinetics, and adverse effects of stimulant medications in the treatment of children with ADHD, our knowledge is yet incomplete. Perhaps the most central unresolved issue concerns our understanding of the pathogenesis, pathophysiology, and diagnosis of ADHD. This review has touched briefly on the controversy and confusion surrounding this issue. Although our understanding of the use of stimulant medications in this disorder is similarly incomplete, a review of the literature does allow certain conclusions to be made that are helpful to the practitioner. 1. Stimulant medications are an effective treatment modality for most children with ADHD. Short-term efficacy is well documented, and long-term outcome may be improved when stimulants are used with other therapeutic strategies. Stimulants in and of themselves are not a panacea. 2. It is impossible to predict which children will have a favorable response to stimulant medications and which children may have a placebo response. The use of individual single-blind medication trials is a practical solution to this problem and should be considered for all children who are candidates for stimulant therapy as a means for preventing overuse or inappropriate use of these medications. 3. The precise mechanism of action of stimulants is not yet completely understood, but stimulants appear to exert their therapeutic effects through their influence on multiple neurotransmitters in the catecholamine, dopamine, norepinephrine axis in the central nervous system. 4. The three major stimulants--methylphenidate, dextroamphetamine, and pemoline--appear to be equally efficacious, although methylphenidate has emerged as the most commonly used and most studied drug. Because of its potential for causing liver toxicity, pemoline has remained a second-line medication. 5. The three major stimulants appear to have somewhat different mechanisms of action so that failure of a patient to respond to one medication does not mean that he or she will not respond to another. 6. The recommended starting doses for the stimulants are 0.3 mg per kg of methylphenidate, 0.15 mg per kg of dextroamphetamine, and 37.5 mg of pemoline. There is a great deal of individual variability in dose response, so doses must be titrated for optimal effects in each child. Sustained release preparations are much more expensive than regular preparations and may be less effective. 7. There is no evidence that stimulants have any effect on ultimate adult height. 8. Although relatively uncommon, motor tics have been observed in children on stimulants, and all children on stimulants need to be carefully monitored for the development of tics. (ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetic Considerations in the Treatment of Attention-Deficit Hyperactivity Disorder with Methylphenidate

Methylphenidate is commonly used for the treatment of attention-deficit hyperactivity disorder (ADHD). Its efficacy in improving the core symptoms of ADHD, as well as some of the aggressive and oppositional behaviours, is well documented, based on a large volume of research. Methylphenidate has a wide margin of safety and relatively mild adverse effects, most commonly appetite suppression and insomnia.Methylphenidate is a rapidly absorbed medication that, in its d-isomer form, readily penetrates the CNS, particularly the striatum. It appears to function by blocking the reuptake of dopamine.Both the plasma concentrations and behavioural effects of methylphenidate demonstrate a time to maximum of between 1 and 3 hours, with the maximum behavioural effects occurring when the plasma concentrations are increasing. Because of the rapid onset of action, the effects of methylphenidate can be dramatic but usually last only about 4 hours with the immediate-release formulation. The behavioural responses of individuals are also highly variable, so that it is necessary to start treatment at a low dosage and increase up to a maximally effective dosage (usually starting at 10–15 mg/day with increases of 10–15mg at weekly intervals to a maximum dosage of 60 mg/day, irrespective of formulation). Because of the variability in behavioural responses, assessment of plasma concentrations is not clinically useful nor does weight help in deciding an appropriate dosage. The difficulties in administering methylphenidate multiple times a day, particularly during the school day, have been alleviated in the past few years by the development of extended-release preparations with varying behavioural effects lasting 8–12 hours. The 8-hour preparations (Metadate® CD and Ritalin® LA) utilise a microbead technology, while the 12-hour preparation (Concerta®) utilises an osmotic pump system. All extended-release formulations effectively control the symptoms of ADHD. While pharmacokinetic differences appear to exist between some of these new formulations, there are currently no clinical data available to demonstrate clinical efficacy differences between them.

Pediatricians' reported practices in the assessment and treatment of attention deficit disorders.

This study examined, in a national survey, the assessment and treatment practices of pediatricians who care for children with attention deficit disorders (ADD). A questionnaire was sent to randomly selected members of the American Academy of Pediatrics (AAP), stratified by state. Of 417 (52%) responses returned, there were 290 (38%) completed questionnaires. It was found that most pediatricians did not utilize specific DSM-III criteria for ADD; however, they do rely on symptoms of distractibility, overactivity, and impulsivity, which are the behaviors central to the DSM-III diagnosis. In addition, learning difficulties were felt to be contributory. Parents were the most frequently reported sources of information about a childs behavior, but the histories provided by teachers, and psychoeducational reports, also were sought frequently. Many pediatricians still use diagnostic procedures that have recently come under question, such as soft neuroligic signs, activity level in the office, and response to stimulant medication. Methylphenidate and behavior modification were the most frequent therapies employed. Over half of the respondents use periodic reevaluation with rating scales to determine medication efficacy, but very few use placebo trials. More recently trained pediatricians tended to rely more on behavioral treatments than did earlier trained physicians. J Dev Behav Pediatr 8:191–197, 1987. Index terms: attention deficit disorder.

Treatment of attention deficit hyperactivity disorder in children and adolescents : Safety considerations

Despite a large body of evidence for both the validity of the diagnosis of attention deficit hyperactivity disorder (ADHD) and the efficacy of its treatment with medication, there is an equally long history of controversy. This article focuses on presenting safety information for medications approved by the US FDA for the treatment of individuals with ADHD.Stimulant medications are generally safe and effective. The common adverse effects of stimulant medications, including appetite suppression and insomnia, are usually of mild severity and manageable without stopping the medication. The more severe adverse effects such as tics or bizarre behaviours occur with low frequency and usually resolve when the medication is stopped. The possible impact on growth requires careful monitoring. Several rare but potentially severe adverse effects including sudden cardiac death and cancer following long-term treatment have been reported; however, these effects have not been adequately demonstrated to be of significant concern at this time. Atomoxetine also has a mild adverse effect profile in terms of severity and frequency although the numbers of studies and years of clinical experience is considerably less with this drug than for the stimulant medications.When the risks are juxtaposed to the clear efficacy in significantly reducing dysfunctional symptoms of ADHD, benefit-risk analyses support the continued use of these pharmacological treatments for patients with ADHD.