Sharon Milberger

ADHD Is Associated With Early Initiation of Cigarette Smoking in Children and Adolescents

OBJECTIVE The association between attention-deficit hyperactivity disorder (ADHD) and cigarette smoking in children and adolescents was evaluated. METHOD Subjects were 6- to 17-year-old boys with DSM-III-R ADHD (n = 128) and non-ADHD comparison boys (n = 109) followed prospectively for 4 years into mid-adolescence. Information on cigarette smoking was obtained in a standardized manner blind to the probands clinical status. Cox proportional hazard models were used to predict cigarette smoking at follow-up using baseline characteristics as predictors. RESULTS ADHD was a significant predictor of cigarette smoking at follow-up into mid-adolescence. Our findings also revealed that ADHD was associated with an early initiation of cigarette smoking. This was the case even after controlling for socioeconomic status, IQ, and psychiatric comorbidity. In addition, among children with ADHD, there was a significant positive association between cigarette smoking and conduct, major depressive, and anxiety disorders. CONCLUSIONS ADHD, particularly the comorbid subtype, is a significant risk factor for early initiation of cigarette smoking in children and adolescents. Considering the prevalence and early childhood onset of ADHD, these findings highlight the importance of smoking prevention and cessation programs for children and adolescents with ADHD.

Predictors of Persistence and Remission of ADHD into Adolescence: Results from a Four-Year Prospective Follow-up Study

OBJECTIVE To evaluate the predictors of persistence and the timing of remission of attention-deficit hyperactivity disorder (ADHD). METHOD Subjects were 6- to 17-year old Caucasian, non-Hispanic boys with and without ADHD. DSM-III-R structured diagnostic interviews and blind raters were used to examine psychiatric diagnoses, cognitive achievement, social, school, and family functioning at a 4-year follow-up assessment. RESULTS At the 4-year follow-up assessment, 85% of children with ADHD continued to have the disorder and 15% remitted. Of those who remitted, half did so in childhood and the other half in adolescence. Predictors of persistence were familiality of ADHD, psychosocial adversity, and comorbidity with conduct, mood, and anxiety disorders. CONCLUSIONS The findings prospectively confirm that the majority of children with ADHD will continue to express the disorder 4 years later. For a minority of children, ADHD was a transient disorder that remits early in development. In addition, we have shown that persistence of ADHD is predictable. Familiality, adversity, and psychiatric comorbidity may be clinically useful predictors of which children with ADHD are at risk for a persistent disorder.

Is childhood oppositional defiant disorder a precursor to adolescent conduct disorder? Findings from a four-year follow-up study of children with ADHD.

OBJECTIVE To evaluate the overlap between attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), addressing whether ODD is subsyndromal form of conduct disorder (CD) and, if so, whether it is a precursor or prodrome syndrome of CD. METHOD Assessments from multiple domains were used to examine 140 children with ADHD and 120 normal controls at baseline and 4 years later. RESULTS Of children who had ADHD at baseline, 65% had comorbid ODD and 22% had CD. Among those with ODD, 32% had comorbid CD. All but one child with CD also had ODD that preceded the onset of CD by several years. ODD+CD children had more severe symptoms of ODD, more comorbid psychiatric disorders, lower Global Assessment of Functioning Scale scores, more bipolar disorder, and more abnormal Child Behavior Checklist clinical scale scores compared with ADHD children with non-CD ODD and those without ODD or CD. In addition, ODD without CD at baseline assessment in childhood did not increase the risk for CD at the 4-year follow-up, by midadolescence. CONCLUSIONS Two subtypes of ODD associated with ADHD were identified: one that is prodromal to CD and another that is subsyndromal to CD but not likely to progress into CD in later years. These ODD subtypes have different correlates, course, and outcome.

Genetic heterogeneity in attention-deficit hyperactivity disorder (ADHD): gender, psychiatric comorbidity, and maternal ADHD

The authors examined the siblings of 140 attention-deficit hyperactivity disorder (ADHD) and 120 control probands and classified families as antisocial if the proband had conduct disorder or a parent had antisocial personality. Partial support was found for the hypothesis that the ADHD gender effect would be limited to antisocial families. Boys had an increased risk for ADHD compared with girls, but only among siblings from antisocial families. The effect size for predicting ADHD in siblings of probands was greater for maternal compared with paternal ADHD, but only for families exhibiting antisocial disorders. Strong support was found for the hypothesis that, compared with siblings from nonantisocial families, those from antisocial families would have more psychopathology (ADHD, depression, substance use, and conduct disorders). The presence of antisocial disorders signals a distinct subtype of ADHD.

Impact of Adversity on Functioning and Comorbidity in Children with Attention-Deficit Hyperactivity Disorder

OBJECTIVE Prior research on risk factors for attention-deficit hyperactivity disorder (ADHD) has shown that familial risk factors play a role in the disorders etiology. This study investigated whether features of the family environment were associated with ADHD. METHOD One hundred forty children with ADHD and 120 normal control probands were studied. Subjects were Caucasian, non-Hispanic males between the ages of 6 and 17 years. Exposure to parental psychopathology and exposure to parental conflict were used as indicators of adversity, and their impact on ADHD and ADHD-related psychopathology and dysfunction in children was assessed. RESULTS Increased levels of environmental adversity were found among ADHD compared with control probands. The analyses showed significant associations between the index of parental conflict and several of the measures of psychopathology and psychosocial functioning in the children. In contrast, the index of exposure to parental psychopathology had a much narrower impact, affecting primarily the childs use of leisure time and externalizing symptoms. CONCLUSIONS A relationship appears to exist between adversity indicators and the risk for ADHD as well as for its associated impairments in multiple domains. These findings confirm previous work and stress the importance of adverse family-environment variables as risk factors for children who have ADHD.

Pregnancy, delivery and infancy complications and attention deficit hyperactivity disorder: Issues of gene-environment interaction

We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit hyperactivity disorder (ADHD) and addressed issues of comorbidity and familiarity by testing multiple hypotheses. Subjects were 6-17-year-old boys with DSM-III-R ADHD (n = 140) and normal controls (n = 120) and their first-degree biologic relatives. Information on PDICs was obtained from mothers in a standardized manner blind to the probands clinical status. Using linear and logistic regression models, a positive association was found between ADHD and PDICs in the probands. Additionally, PDICs were associated with the correlates of ADHD (i.e., impaired cognitive functioning and poor school performance). Moreover, it was those specific complications that reflect chronic exposure, such as maternal bleeding, smoking, family problems, and illicit drug use during pregnancy that accounted for these findings. No interaction between genetic factors and PDICs were found. Our findings add to the literature supporting an association between ADHD and PDICs. Our results may help clinicians focus on particular complications rather than the wide range of possible perinatal complications.

How Reliable Are Maternal Reports of Their Children's Psychopathology? One-Year Recall of Psychiatric Diagnoses of ADHD Children

OBJECTIVE Although childhood psychiatric diagnoses often rely on maternal reports, little is known about their long-term reliability and diagnostic accuracy. Thus, the authors sought to examine these psychometric features in a cohort of ADHD and control children. METHOD The sample consisted of 140 referred children with ADHD and 120 normal controls. The authors compared childhood diagnoses based on maternal reports of their childrens psychopathology at this baseline assessment with those collected 1 year later. RESULTS Both reliability and accuracy were excellent for ADHD. Reliability and specificity were also excellent for conduct disorder, oppositional defiant disorder, major depression, bipolar disorder, separation anxiety, and multiple anxiety disorders. Reliability and sensitivity were relatively low for simple phobia, social phobia, agoraphobia, and overanxious disorder. CONCLUSIONS With some exceptions, maternal reports of their childrens psychopathology provided a reliable and accurate means of assessment. Generally, maternally derived diagnoses were less accurate for internalizing compared with externalizing disorders. However, specificity was high for all diagnoses, suggesting that mothers were not biased to report symptoms that had not occurred.

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.

Further Evidence of an Association Between Attention-Deficit/Hyperactivity Disorder and Cigarette Smoking: Findings from a High-Risk Sample of Siblings

The authors investigated the relationship between attention-deficit/hyperactivity disorder (ADHD) and cigarette smoking in siblings of ADHD and non-ADHD probands. They conducted a 4-year follow-up of siblings from ADHD and control-group families. In the siblings of ADHD probands, ADHD was associated with higher rates and earlier onset of cigarette smoking. There was also a significant positive association between cigarette smoking and conduct disorder, major depression, and drug abuse in the siblings, even after adjusting for confounding variables. Moreover, smoking was found to be familial among ADHD families but not control-group families. Our findings indicate that ADHD is a risk factor for early initiation of cigarette smoking in the high-risk siblings of ADHD probands.

Are perinatal complications relevant to the manifestation of ADD? Issues of comorbidity and familiality.

OBJECTIVE We evaluated the role of pregnancy, delivery, and infancy complications (PDICs) in the etiology of attention deficit disorder (ADD) addressing issues of comorbidity and familiarity by formulating and testing multiple hypotheses. METHOD Subjects were six to 17-year-old boys with DSM-III attention deficit disorder (ADD, N = 73), psychiatric (N = 26), and normal (N = 26) controls and their relatives. Information on PDICs was obtained from the mothers in a standardized manner blind to the probands clinical status. RESULTS Using odds ratio analyses, an association was found between ADD and PDICs that was strongest for the comorbid and nonfamilial subtypes. In contrast, noncomorbid and familial ADD subgroups differed less from normal controls in the risk for PDICs. CONCLUSIONS The increased risk for PDICs in nonfamilial ADD children and the lack of evidence for increased risk among familial ADD patients suggests that PDICs may be part of nongenetic etiologic mechanisms in this disorder, especially for children who have comorbid disorders.