Improve Listening Skills in ADHD Children

How To Conquer Add / Adhd

Number 1 Guide On How To Cope With Attention Deficit Disorder, Add Adhd. Inside this research collection, you will: Learn about Add / Adhd in Laymens Terms and find out more about the Keys to Success in dealing with the disorder. Cut to the chase reading. No wasting your time, your money and your patience. Arm yourself with knowledge about the causes and symptoms of Add / Adhd, in children and in adults. And find out where to go for testing and a diagnosis. Take action now to get started on the Success Path instead of plodding along on the Ignorance Trail. Uncover specific ways to help children (yours or someone elses) who have been diagnosed with Add / Adhd. Use our handy resources, network, learn more ways and get more help. Tailor strategies that work for Both you and the child. Read overviews about many successful treatment strategies along with detailed information about how to pinpoint specific options available in Your area (i.e. where You live). No more waiting to find out who can help or where to go. Print out our basic questions to ask when you are trying to learn more about Add / Adhd so that you can keep a journal of handy information for follow up reference and quick help along the way. Save money, time, aggravation, stress, hair from being pulled out, and much moreby Printing out and using our, How to Set Up and Use Organizer & Filing Systems, step-by-step action plan. Fill your notebook with your own planner sheets downloaded from our resource section and use them Now! No more waiting for a better day. Its here and its time to get organized. Read more here...

How To Conquer Add Adhd Summary

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Neuropsychological characterization of ADHD

Neuropsychological research studies of pediatric ADHD frequently dichotomize cognitive performance into higher-order executive functions and lower-order non-executive functions . Other terms used to describe this dichotomy include top-down vs. bottom-up , and effortful vs. automatic . Higherorder executive functions broadly encompass atten-tional control, working memory, response inhibition, cognitive flexibility, planning, organization, and set-shifting. In contrast, lower-order functions include state regulation, activation arousal, processing speed, and basic language processing, as well as long-term memory and basic sensory and motor functions. As detailed below, recent findings have cast doubt on whether ADHD constitutes a pure disorder of executive function given that many children with ADHD perform poorly on both higher-order and lower-order measures 7 . Neuropsychological profiles of preschool children with ADHD Despite the fact that the symptoms of ADHD frequently have their...

Epidemiology of ADHD in adults

The incidence of ADHD is approximately 3 to 9 for children and around 4 to 5 for adults 4 . Familial studies have found that parents of children with ADHD have a significantly increased risk of being diagnosed with ADHD 5 . Fathers of children with ADHD show a 24 incidence of also having ADHD, while the incidence is 7 for control families. Furthermore, mothers of children with ADHD show a prevalence rate of 15 , while mothers of control children have an incidence of 3 . In addition, relatives of adults with ADHD were found to show prevalence rates of 49 compared to 2.5 of adults without ADHD 6 . It has been estimated that approximately 60 of childhood diagnosed ADHD cases continue to show a sufficient number of symptoms into late adolescence and adulthood that are considered to be clinically significant 7, 8 . These symptoms have been also found to be a risk factor for lower levels of employment and academic attainment, marital problems, substance abuse, higher levels of automobile...

Gender differences in adult ADHD

In children the ratio of males to females diagnosed with ADHD ranges from 2 1 to 9 1 29 . Studies with adults have found a more balanced ratio and some have pointed to this difference between adults and children as evidence that many adults are inaccurately identified with ADHD 30 . Others have suggested that this imbalance is due to females showing fewer disruptive behaviors and not being referred for assistance until entering college or work positions that require sustained attention 31 . Biederman et al. 32 sought to evaluate whether the clinical presentation of ADHD in women differs from that in men and whether this difference in expression of symptoms accounts for the later referral of women for evaluation. A previous study by this group found that women with ADHD have higher rates of mood disorders, conduct problems, learning problems, and neuropsychological deficits compared to normally functioning women 31 . Others studies have found similar rates of higher levels of...

Cognitive remediation strategies for children with ADHD

Although both pharmacological and psychosocial interventions provide acute benefits with respect to symptom reduction and impairment (e.g. parent-child relationships), these interventions seldom result in sustained benefits once the intervention has been discontinued 48 nor do they yield long-term improvements in psychosocial functioning 71 . Limitations of these evidence-based interventions have consequently spurred the development of alternative interventions for ADHD, particularly those that target either attention 72, 73 or working memory 74,75 .

Etiological mechanisms in ADHD

Data from numerous studies indicate that both genetic and environmental factors interact to produce the diverse constellation of behavioral characteristics that define ADHD. However, results from family, twin, and adoption studies have shown that ADHD tends to cluster in families and that genetic factors alone reportedly explain up to 80 of the variance in the ADHD pheno-type 32 . Beyond general heritability, molecular genetic studies have focused primarily on genetic alterations that may interfere with proper functioning of brain catechol-amines dopamine and norepinephrine. Dopamine and norepinephrine neurons are functionally expressed in many interconnected brain pathways involved in top-down (e.g. prefrontal cortex) and bottom-up (e.g. locus coeruleus) cognitive control, respectively. Further, the majority of effective pharmacological treatments for ADHD (e.g. stimulants and nonstimulants) interact with dopamine and norepinephrine systems to dramatically improve the core symptoms...

Neuropsychology of pediatric ADHD across development

Initially conceptualized as a condition largely confined to boys who were hyperactive or hyperkinetic, the role of attentional dysfunction in ADHD was introduced by Douglas in 1972 6 , who examined vigilance deficits in these children. Research characterizing the precise nature of attentional dysfunction, as well as cognitive correlates of hyperactivity and impulsivity, has since increased. Neuropsychological research of ADHD has informed modern clinical practice and contemporary models of underlying pathophysiology, and guided neuroimaging approaches. However, only recently have investigators begun to appreciate the limitations of time-locked snapshots of neuropsycho-logical functioning in ADHD and the importance of developmental factors (e.g. age, symptom stability, environmental changes) that have the potential to confound concurrent estimates of neurocognitive dysfunction in youth with ADHD. As such, current knowledge about the developmental trajectory of neu-rocognitive...

Treatment for adults with ADHD

For children with ADHD, pharmacotherapy and psychotherapy are treatment options that are used frequently. There is also a rich literature on how best to adjust the environment for children with ADHD, as well as guidance for parents and teachers on behavioral management (refer to the previous chapter for an extended discussion of this literature). In general, the treatment focus for children tends to be on the child's surrounding adult system. For adults with ADHD, environmental modification options are often more limited. Few job supervisors are willing to provide interventions that are frequently used for children, for example, color-coded folders, timers, frequent breaks, or tangible immediate rewards and post-task check-ups multiple times per day. While the research on adult therapies is less substantive than for children, some studies on pharmacological management and psychotherapies have been conducted. Overall, the treatment options for adults fall into three categories...

Theoretical conceptualizations of ADHD

Theoretical characterizations of what we now call ADHD have evolved considerably throughout the past century, from what was originally conceptualized as a moral defect 7 , to a disorder that was primarily behavioral in nature and related to hyperkinesis and or impulse control deficits, to more of a cognitive disorder of attention, to one of higher-order executive functions 8 . Yet it is notable that, unlike many psychiatric disorders, throughout most of its history ADHD has been conceptualized as a disorder of neurological dysfunction rather than a condition of primarily psychogenic origin. Scientific consensus has clearly and consistently rallied around the point that ADHD is not caused by bad parents or teachers. This is not to say that the symptom expression and behavioral functioning of individuals with ADHD are not influenced substantially by environmental factors and that an array of environmental factors clearly affect neural development and behavior. However, a core...

Pdults with adhd who hL a morbid diaggnosisCore symptoms attention and impulsivity

May experience more significant deficits in cognition In adults, the two core symptoms of ADHD are children, hyperactivity is clinically uncommon in adults, although restlessness is often reported. When inattention is the primary symptom, the diagnosis is ADHD predominantly inattentive (ADHD PI). This subtype of ADHD is characterized by problems with attention regulation, without significant symptoms of impulsivity or hyperactivity. Even when adults do have symptoms of hyperactivity, it is still the problems related to inattention and disorganization that have the greatest effect on daily life, according to recent research on the relative contributions of specific executive functions to adaptive functioning 36 . Among the most common direct measures of sustained attention are the computerized continuous performance tests (CPTs). Two of the most widely used are the Conners' CPT and the Test of Variables of Attention (TOVA). For these measures, the patient is asked to distinguish...

Diagnostic issues in adult ADHD

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) 11 identifies three subtypes of ADHD -predominately inattentive, hyperactive-impulsive, and combined. DSM-IV-TR does not address diagnosis of ADHD in adults except to state that hyper-activity may decrease over time, and become internal restlessness in older adolescents and adults. Thus, diagnosis of ADHD in adulthood generally presumes a previous diagnosis of ADHD in childhood. Several studies have supported the occurrence of ADHD in adults as well as the concordance between childhood and adult ADHD symptomatology 12 . Notably as well, newly diagnosed adults tend to be those diagnosed with ADHD predominately inattentive subtype, rather than the combined subtype 13 . While clinicians and researchers generally accept the presence of ADHD in adults, there is controversy about the timing of diagnosis. An initial diagnosis of ADHD that occurs in adulthood requires the report of symptoms...

Neuropsychological measurement of adult ADHD

Measures of inhibition and sustained attention appear to be most universally reliable in the research literature on adult ADHD, mirroring findings in child research. Other neuropsychological measures of purported symptoms of ADHD are less reliable, suggesting broad heterogeneity and imperfect mapping of neuro-psychological tasks onto real-world symptoms. Moreover, while group differences between people with and without ADHD may be seen on some measures, often the differences are too small to be clinically useful. Many research papers with significant findings reveal differences that may nonetheless be within the average range of functioning. Table 5b.1 shows the areas of functioning usually assessed, along with some current tests used for clinical evaluation. Recently, more attention has been given to the possibility that executive functions may be divided into hot and cool processes, a concept first suggested by Zelazo and colleagues 53 . Cool executive functions are those of...

Comorbidity profiles in children with ADHD

Upwards of two-thirds of children and adolescents with the disorder meet criteria for one or more comorbid psychiatric conditions. In particular, approximately 5060 meet criteria for oppositional defiant disorder (ODD), 30-50 meet criteria for conduct disorder (CD), 25 meet criteria for one or more anxiety disorders, and 15-25 have a comorbid mood disorder 4 . Relative to same-aged peers, children with ADHD are also at heightened risk for tic disorders, learning disabilities, and substance use disorders 4 . The high prevalence of psychiatric comorbidity among youth with ADHD may reflect common etiological mechanisms and or temperamental features (e.g. impulsivity), as well as associated psychosocial consequences of the disorder (e.g. demoralization stemming from impaired social functioning). ADHD is also considered a significant risk factor for adverse outcomes during adolescence and adulthood 5 however, the relative contributions of ADHD vs. psychiatric comorbidity to subsequent...

Frontal lobe activation in adults with ADHD

With the advent of fMRI the frontal lobes remain an area of interest. Studies with adult participants have found that right frontal regions show less activation in adults with ADHD compared to controls on tasks that evaluate inhibition and working memory this difference is evident even when no difference is found behav-iorally 57 . It may well be that the areas that are involved in higher-order reasoning do not coordinate well with executive functioning, organization, and planning capacities of the frontal lobes, thus resulting in poorer performance in participants with ADHD. Moreover, widespread activity may result in inefficient processing of information. A regional cerebral blood flow (rCBF) study supports this conclusion. Findings from this study indicated that blood flow changes in women and men with ADHD differed from typical adults in that activation was more widespread and generally in the occipital regions. In contrast, the participants without ADHD showed higher levels of...

Developmental heterogeneity of ADHD and psychiatric comorbidities

From a treatment perspective, ADHD is still often viewed as a relatively homogeneous disorder, with only minimal evidence of tailoring treatments to individuals. Nevertheless, from a phenomenological, neuropsychological, genetic and developmental perspective, variation abounds and is well described in the extant literature. Heterogeneity with regard to psychiatric comorbidity has been extensively studied. Unfortunately, comorbid disorders are often conceptualized as independent conditions that co-occur with ADHD (e.g. like a sore throat and a broken leg). This may make sense from a medical or treatment perspective (e.g. treat the ADHD and treat the depression), but is extremely unlikely to be true from an etiological perspective rates of overlap are far too high for this to be possible. Several thoughtful reviews 25 have proposed potential explanations for the high comor-bidity rates, which include similar risk factors for multiple disorders, one disorder increasing risk for another,...

ADHD Phenomenology

Attention deficit hyperactivity disorder (ADHD) is a complex psychiatric syndrome characterized by devel-opmentally excessive manifestations of inattention, hyperactivity, and impulsivity which have their onset prior to age 7 and are associated with impairments in at least two domains of psychosocial functioning (e.g. scholastic achievement, family interactions, peer relations) 1 . Widely considered to be the most common psychiatric disorder of childhood, ADHD affects approximately 5 of school-aged children worldwide 2 , with diagnostic rates in males exceeding those of females by 4 1 in non-referred investigations and 9 1 in clinically referred samples 3 .

Sources of phenotypic variability across the lifespan

That preschoolers, school-age children, adolescents and adults with ADHD appear different is well described in the scientific and clinical literature. In general, these developmental changes occur gradually, in a dimensional fashion, rather than as abrupt all-or-none phenomena. Patterns of extreme hyperactivity, which are characteristic of the preschool years, generally diminish over time, while symptoms falling more within the realm of the inattention domain become more prominent and impairing with increasing age 13 . The degree to which impulsiveness has large developmental variation is less clear, as it is a source of considerable impairment associated with both younger and older manifestations of the disorder. Not surprisingly, developmental variations in clinical presentation result in age-related differences in diagnosis, particularly as related to DSM-IV-based ADHD subtypes. ADHD-HI is most commonly diagnosed in early childhood, ADHD-C is most commonly diagnosed in clinical...

Pharmacological treatments

Following the substantial literature on child ADHD medication treatment, stimulant treatment for adults with ADHD has been the primary model of care. In early studies of adult response to stimulants, an unexplained difference in response rate between adults and children to stimulants was found. Controlled studies on children reported a 70 response rate, while the adult response was lower, at about 50 60 . More recent studies, however, have demonstrated outcomes consistent with the child research. Spencer et al. 60 suggest that earlier studies were characterized by doses that were too low, around 0.6 mg kg per day. In a study of methylphenidate (MPH) including a double-blind placebo-controlled design, Spencer et al. used a target dose of 1 mg kg per day and found a 78 response rate. Of the stimulant medications, methylphenidate (MPH) has been identified as the preferred treatment for most adults with ADHD. One of the biggest risks of medication for ADHD is appetite suppression loss....

Diffusion tensor imaging DTI

To less efficient processing of information. Thus, these differences also serve to support the idea that fewer connections across (front to back) the brains of people with ADHD contribute to a disconnect between reasoning skills and those involved in association and previous learning. Both of these difficulties are present in ADHD and appear to be active throughout adolescence and adulthood.

Overall cognitive functioning

Comorbid attention deficit hyperactivity disorder (ADHD) 21 , perform significantly worse on cognitive measures than patients with less severe neuropathology. Several studies have indicated that patients with earlier age of onset perform worse than patients with later age of onset 19, 20, 22 whereas other studies have yielded no relationship between age of onset and cognitive functioning 14,16 . Gender is not related to cognitive functioning 14, 19 .

Neuropsychological functioning

In late-onset disease, frontal dementia is identified after diagnosis with psychiatric disorders ranging from ADHD to schizophrenia. In 11 patients, ages 10 From a neuropsychological standpoint, this disease illustrates a point that the timing of disease onset in development alters the phenotype. While all patients have the same biochemical abnormality, and most show frontal demyelination, the phenotype varies from age to age motor symptoms predominate in young children, ADHD symptoms in older children, and psychiatric disorders in adolescents and adults. We do not know whether this relates to the particular pathways that are functional at different ages or the particular mutations associated with early and late onset that may alter pathophysiology.

Medication and imaging

A new area of investigation is the use of fMRI to evaluate the effects of medication on performance. Current research has suggested that catecholamine dysregulation, particularly with dopamine, is associated with the frontostriatal deficits seen in ADHD. These deficits include problems with activity level as well as difficulties in reward-seeking behaviors. Studies using PET imaging to compare adults with ADHD with those without ADHD have found a relation between the structures associated with the regulation of dopamine and brain differences in participants with ADHD, particularly in the right caudate. In addition, the caudate reacts differentially in people with ADHD when methylphenidate is administered 59 .

Sexlinked single gene

Inactivated because it contains a large number of repeats, and therefore does not effectively produce a critical FMR1 protein 25, 26 . As the X chromosome is affected, males are more strongly impacted than females and show poorer abilities. The physical features associated with Fragile-X include distinctive facial features, including long faces and prominent ears 27 , and connective tissue abnormalities 28 . The median range of intellectual abilities for males is in the moderate impairment range, with median intellectual abilities in the low average range for females 29 . Articulation difficulties 30 and pragmatic difficulties (e.g. echolalia, stereotyped language) are often reported and sequential processing and spatial reasoning are also areas of weakness. Relative strengths in expressive and receptive vocabulary have been observed 31, 32 . While a relative strength in early reading and spelling skills has been reported 31, 33 , academic difficulties include poor math and abstract...

Nonprofit Clinical Trials

In his excellent article Understanding Clinical Trials, Justin A. Zivin focuses on drugs and medical procedures. But diet therapy and lifestyle changes can also treat certain conditions, with fewer side effects. To date, only a handful of dietary regimens have been tested rigorously, and most of these relate to heart disease. I am treating two ADHD children with diet therapy because, for them, this is more effective than drugs. Is this an anomaly, or does it represent a trend If diet therapy helps even 3 percent of the millions of children on Ritalin, we need to establish

Pharmacological intervention

In recent years attention has been given to developing evidence-based guidelines for the use of psychophar-macological agents in managing the neurobehavioral consequences of TBI in adults. In children, the treatment of TBI-related problems with psychotropic medication is not at all well studied, despite common use in practice. Psychostimulants are the most researched agent, probably because of the frequency of attention regulatory problems after TBI and the success of stimulants in treating developmentally based ADHD. However, even with stimulants, results of TBI-focused studies have been mixed. Existing studies suggest that treatment effects on behavior (hyperactivity, impulsiv-ity) may be greater than on cognition, but that effects overall may be less apparent than those seen in developmental ADHD populations 85 .

Differential diagnosis

The DSM-IV-TR indicates that prior to making a formal diagnosis of a reading disorder, a clinician must differentiate learning concerns from normal variation in academic attainment, and from scholastic difficulties due to a lack of opportunity, poor teaching, or cultural factors 9 . It is fairly common for children with a reading disorder to have a comorbid learning disorder affecting mathematics and written expression 15 . There also exists a high comorbidity between Reading Disorder and Attention Deficit Hyperactivity Disorder (ADHD) 16 . Additionally, it is fairly common for children with a reading disorder to demonstrate deficits with their social and emotional functioning and often exhibit symptoms of depression and anxiety 7 .

Behavioral interventions

Behavioral parent training (BPT) has been a well-studied intervention for various childhood mental health disorders including ADHD 48 . BPT is a treatment approach wherein parents are taught how to manipulate antecedents (e.g. rules, commands) and consequences (e.g. rewards, time out) of their child's behavior (e.g. aggression, noncompliance) in order to improve behavior. Although effects of BPT on core ADHD symptoms have been reported 49 , it appears that the primary evidence for BPT as an intervention for ADHD is founded on the effects of BPT on co-occurring opposi-tional problems and impairment in children versus improvements in the core symptoms of ADHD per se 50 . Given that children with ADHD often present with comorbid ODD, the effect of BPT on ODD is noteworthy. Lastly, BPT for families of children with ADHD has also demonstrated improvements in parental functioning 49 . Thus, the evidence for BPT for ADHD suggests that BPT improves co-occurring oppositional defiant behavior,...

Structural magnetic resonance imaging

Studies conducted to date have demonstrated overall reductions in total cortical volume in children with ADHD relative to age- and sex-matched controls through age 19 by approximately 3 overall and 3-5 in the right hemisphere 35 . Abnormal morphology (bilateral volumetric reduction) has been documented in virtually all areas of the frontal cortex. In contrast, prominent increases in grey matter have been reported in the posterior temporal and inferior parietal cortices bilaterally in ADHD 36 . In limbic regions, larger bilateral hippocampus as well as reduced bilateral amygdala over the area of the basolateral complex have been reported in ADHD 37 . The basal ganglia have been implicated in the pathophysiology of ADHD due to their input-output role as a mediator of frontal-subcortical communication and catecholamine modulation of motor and cognitive functions. Subtle caudate nucleus volume and symmetry differences have been reported in ADHD in childhood however, caudate normalization...

Pharmacological interventions

Stimulant medications are the first-line pharmacological intervention for ADHD 57 and include short- and long-acting preparations of methylphenidate and amphetamine salts. The literature on stimulant medication for ADHD has demonstrated acute benefits on multiple behavioral outcomes (see ref. 58 for reviews), including improvements in core symptoms of ADHD, compliance, aggression, and academic productivity. Although a dose-dependent response to stimulant medication has been cited in the literature 59 , such increases may also be accompanied by the emergence and or exacerbation of adverse events. In addition, several studies have noted that the dose of stimulant medication can be reduced substantially if a combined approach is taken whereby both stimulant medication and behavioral interventions are in place 60 . The opposite is also true that is, the intensity of behavioral interventions can be substantially reduced if concurrent stimulant medication is provided. Given the noted side...

Enhancement of executive function development

As we close this section on cognitive interventions, one recent study is worth noting. Although it is not directly aimed at children with ADHD, Diamond and colleagues 76 evaluated Tools of the Mind , a comprehensive preschool curriculum designed to enhance executive function development, which is particularly relevant to ADHD given reported impairments in time management and organizational skills in children with ADHD 15 . Tools of the Mind is grounded in established developmental theory and was developed based on Luria's Thus, while the aforementioned studies have notable limitations, considerable progress has been made on how to ameliorate patterns of neurocognitive dysfunction of children with ADHD. Contrary to existing methods, such techniques may improve both the acute difficulties children with ADHD experience as well as the long-term outcomes for these children. Although many questions remain, several clear directions exist for future work in this area (e.g. comparison and or...

Neuropsychological stability relative to symptom stability

To date, few studies have investigated the extent to which neuropsychological functioning has paralleled ADHD symptom stability or remission over development. Such analyses are critical to understanding the centrality (or lack thereof) of neuropsychological dysfunction to ADHD. Kalff et al. examined the neuro-cognitive profiles of 5- and 6-year-old children who were diagnosed as either having ADHD or subthres-hold ADHD 18 months later, as well as typically developing children without ADHD symptoms 29 . Poorer performance on measures of visuomotor integration, verbal working memory, and visual attention at baseline were predictive of ADHD 18 months later. Further, the performance of subthreshold ADHD children 18 months prior generally fell between that of ADHD children and controls 29 . Recently, our group found that executive and nonexecutive skills correlated with the presence or absence of childhood ADHD at early adult follow-up 30 . Specifically, when divided into subgroups of ADHD...

Summary conclusions and directions for future endeavors

ADHD is a highly prevalent, early emerging neuro-developmental disorder that results in considerable personal suffering and impairment throughout life for many afflicted individuals. Considerable research, as documented by thousands of scientific publications throughout the past several decades, has focused on issues related to classification, neuropsychology, neurobiology, and treatment. Clearly, this body of research has documented the importance of heredity in the etiology of ADHD, has provided important clues regarding the neurocognitive and neurobiologi-cal substrates of the disorder, and has, from a public health perspective, increased awareness ofthe disorder and provided clinicians with treatment guidelines for helping patients that have greater empirical support. Among the more important advances is the now well-accepted notion of ADHD as a disorder with lifetime consequences as opposed to a temporary disorder limited to childhood. This, in turn, has resulted in a substantial...

Neuropsychological heterogeneity

ADHD is also characterized by considerable neuro-psychological heterogeneity. Several meta-analyses provide clear documentation that, on the group level, children 32-34 and adults 35, 36 with ADHD differ significantly from non-ADHD comparison groups on a wide array of neuropsychological measures. However, in general, effect sizes have been modest and too small to suggest that any single type of neuropsychological deficit could account for or be accounted for by ADHD alone. As such, the practice of using neuro-psychological tests to make the diagnosis of ADHD is quite problematic and such data should be used cautiously and always interpreted within the context of a more complete psychological or psychiatric evaluation. For example, among a small battery of executive function tests, Nigg et al. 37 found that the Stop-Signal Task had the greatest sensitivity to ADHD, yet only 51 of diagnosed individuals performed poorly on that measure. Identification of individuals with ADHD increased...

Advanced PET techniques

Several other PET tracers have been developed for AD pathology as well, including 18F-FDDNP and 18F-AV-45. Various tracers have also been used to demonstrate changes in brain metabolic patterns following drug treatment that correlate with clinical status in AD 69-75 . In healthy participants, PET data suggest that dopamine D2 receptor activity in the hippocampus shows a relationship to cognitive performance in memory and other domains, suggesting a potential target for pharmacological agents to treat memory disorders 76 . Similarly, in chronic TBI Kraus et al. found improvements in executive functions following amantadine treatment that correlated with increased left prefrontal glucose metabolism 77 . Forssberg and colleagues have noted regional abnormalities in dopaminergic function in adolescents with ADHD which correlated with attentional and hyperactivity symptoms, offering a potential method for monitoring treatment response or targeted pharmacotherapeutics 78, 79 ....

Psychological functioning and comorbidities

Prevalence rates of ADHD have been documented at 31 for inattention and 31 for hyperactivity-impulsivity 41, 42 . The prevalence rate of behavioral problems has not been directly studied however, in pediatric patients with comorbid epilepsy and ADHD, 31 of the sample also had comorbid oppositional defiant disorder (ODD) 24 . Rates for depressive disorders range from 5 to 33 in children and adolescents with epilepsy 13, 43 . Rates of anxiety disorders range between 16 and 48 43, 44 .

Functional magnetic resonance imaging

Functional MRI studies have consistently implicated connectivity among the prefrontal cortex, basal ganglia, thalamus, and cerebellum in the pathophysiology of pediatric ADHD. Yet specific neural substrates have not been identified, as both hypoactivation and hyper-activation within this connectivity have been observed. A series of studies have examined response inhibition in ADHD with mixed results. Schulz et al. prospectively examined response inhibition in adolescents diagnosed with ADHD during childhood compared to adolescents with no history of ADHD 41 . Adolescents with childhood ADHD exhibited markedly greater activation of frontal regions, while controls activated a distinct neural network including temporal, cerebellar, and hippocam-pal regions. Activation of the anterior cingulate gyrus was inversely related to performance, with greater activation in individuals who had more difficulty inhibiting the prepotent response 41 . Rubia et al. examined inhibition and...

Repeated testing and practice effects

A related issue is lack of valid results due to intra-individual variation. Salthouse and Berish 10 have found in demented adults that within-person variability may increase with neurological compromise and that repeated measurements may be necessary to obtain a true measurement of ability. Intra-individual variation in adult patients is an important characteristic in conditions as diverse as chronic fatigue syndrome 11 , malingering 12 , and dementia 13 . Further work has indicated that intra-individual variability may be an indicator of neurological integrity 14 . However, little work has been done in this area with children. It has been noted that children with ADHD show marked intra-individual variation 15 however, no work could be found in children with neurological disease. In children with neurodegenerative diseases, intra-individual variability may pose a significant problem as the confounding effects of physical illness and declining mental ability may render a single testing...

Current treatments and new directions

The chapters on childhood (Marks et al.) and adult (Semrud-Clikeman and Fine) ADHD provide excellent reviews regarding the benefits of empirically validated treatments for ADHD as well as their shortcomings. Taken together, data clearly indicate that behavioral interventions and stimulant medication improve the functioning of school-age children with ADHD, although for adults the benefits of non-pharmacological interventions are less clear. More limited data are available regarding empirically validated treatments for preschool children with ADHD. Some studies of parent management training for preschoolers with ADHD have shown promise 57 , but other studies have shown more limited benefits. Effect sizes for stimulant medication in preschoolers appear somewhat smaller than those reported for school-age children and rates of side effects may be somewhat higher 58 . There are also several notable limitations to current evidence-based interventions. Many parents prefer not to use...

Phenotypic variability

Disease onset of late infantile MLD is characterized by rapid motor deterioration with tremor and weakness. This is often misdiagnosed as cerebral palsy. Soon after motor symptoms, neurocognitive impairments appear and the children are often bedridden within months after diagnosis. The children can survive for years in a vegetative state. Juvenile and adult phenotypes differ from early-onset forms by the first indicator being neurobehavioral symptoms. The disease then shows variable progression of motor disability. In the juvenile form children often show symptoms of ADHD and are treated for years with psychostimulants with poor results. In adolescents and adults, neurobehavioral symptoms are depression, psychosis, and conduct difficulties 76, 77 . In particular, signs of executive dysfunction are prominent with symptoms such as trouble with the law, promiscuous behavior, and credit-card debt. In others, depression and psychotic symptoms are manifest. These psychiatric presentations...

Universal assessment issues

Higher incidence of ADHD than in generalpopulation pharmacologicaltreatment may be beneficial. Riskfor depression comparable to that of generalpopulation, with decreased risk in individuals with lower intellect. Socialrisks across the lifespan include less frequent socialcontact and lower quality friendships

Diagnostic utility of neuropsychological measures

Although clearly beneficial for elucidating neurocogni-tive substrates, approximately 50 of pediatric ADHD cohorts perform in the normal range on any given neurocognitive measure, suggesting poor sensitivity 31 . Further, the absence of an impaired score on neuropsychological tasks seldom rules out the presence of ADHD, contributing to reduced specificity 31 . Despite these limitations, neuropsychological assessment in pediatric ADHD remains important, particularly with respect to issues of differential diagnosis and or psychiatric comorbidity (e.g. learning disabilities, language and or pervasive developmental disorders), identification of individual learning styles (e.g. reconciliation of speed vs. accuracy), and establishment of home- and or school-based interventions

Summary and future directions

ADHD is a heterogeneous psychiatric disorder characterized by clinically significant manifestations of inattention, hyperactivity, and impulsivity, which persist in a significant subset of affected individuals and portend risk for a number of adverse psychosocial outcomes. Within the past several decades, a variety of models have been proposed identifying various core cognitive deficits in children with ADHD, based on the suspicion that deficient neuropsycholog-ical functioning underlies the diverse array of behavioral difficulties associated with the disorder. Although numerous theoretical models have emphasized frontally-mediated executive functions with regard to the underlying pathophysiology and resulting symptomatic expression 80 , recent reviews and meta-analyses 15 have suggested that executive function deficiencies do not account for most of the variance in ADHD symptoms, discounting the clinical utility of such measures in diagnostic assessment. Yet the apparent schism...

Developing vs mature neural systems

Recent longitudinal MRI studies have demonstrated substantial neuroanatomic differences in pediatric ADHD that fluctuate dynamically. The first study to examine neural changes over time followed a large sample of individuals with ADHD and age-matched healthy controls (age range 4.5-19 years) using a mixture of longitudinal and cross-sectional MRI analytical methods 38 . At baseline, healthy controls had significantly greater total cerebral volume than ADHD patients, as well as larger frontal grey and white matter. However, after adjustment for total cerebral volume, no significant difference in frontal volume remained between the two groups. Further, analysis of a subset of follow-up scans 2-3 years later demonstrated no disparity in frontal morphometry in ADHD rather, the frontal lobes had the smallest effect sizes of any anatomical region. Baseline differences in cerebellar volume persisted, with a nonsignificant tendency for this difference to increase over time 38 . Longitudinal...

Cognitive functioning

Cognitive functioning in adults with ADHD has generated controversy in the literature. Some findings suggest that cognitive functioning is similar across groups with ADHD and control comparisons (e.g. ref. 34), while others indicate no substantial differences between the populations (e.g. ref. 35). A meta-analysis that included methodological variables indicated that the differences in research findings were related to how the groups were diagnosed, the use of DSM-based criteria, and the presence of comorbid disorders, all of which affected the level of ability seen across samples. The type of IQ estimate used also influences research outcomes on cognitive functioning. Differences between ADHD and non-ADHD groups are likely to be wider when IQ tests include tasks for short-term memory and processing speed. Another factor that may influence studies of adult ADHD is that children with ADHD who become adults with ADHD may have a more severe form of the disorder. Variability in research...

Remediation of attentional functioning

Two studies have been conducted that focus on improving attention in children with ADHD through intensive, targeted attention-focused training programs. Kerns et al. 72 evaluated the program, Pay Attention , which includes materials designed to enhance sustained, selective, alternating, and divided attention through both visual and auditory activities. Results indicated that, compared to those who were engaged in computer-based activities (e.g. games and puzzles), ADHD probands who participated in Pay Attention improved their performance on several neurocognitive tests as well as measures of academic achievement. Parent reports of ADHD symptoms did not improve as a function of treatment however, a trend toward improvement in teacher-reported inattention and impulsivity was reported for children in the Pay Attention condition. Recently, a computerized progressive attentional training (CPAT) program was evaluated in a sample of children with ADHD it includes four training tasks designed...

Chapter premise and objectives

Mechanisms associated with ADHD, based on the assumption that deficient neuropsychological processes underlie the heterogeneous array of behavioral difficulties associated with the disorder. Although technological and methodological advances have ushered in a flurry of scientific exploration and helped to resolve numerous ambiguities, such investigations have also raised additional questions, and, with a few exceptions, have neglected to approach the search for constituent deficiencies from a developmental perspective. In the current chapter, specific emphasis has been placed on reviewing (i) neuropsychological profiles of ADHD in children and adolescents (ii) the stability of neuropsychological functioning across the aforementioned developmental periods in youth with ADHD (including relationships between the stability of neuro-psychological functioning and the continuity persistence of ADHD symptoms) (iii) potential moderators of neuropsychological functioning (iv) patterns of...

Infants and children

Children with SB have also shown increased psychosocial and behavioral comorbidities, including attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD) 36 . Better coping mechanisms are associated with improved behavioral outcomes in children and positive family psychosocial characteristics 34, 37 .

Coping strategiesenvironmental modification

There is no research documenting whether individual coaching or workplace accommodations are effective for adults with ADHD. Barkley et al. 63 have outlined theoretical principles for supporting adults through these approaches, based on both child evidence of effective behavioral treatments and areas of failure to which clinicians should pay attention. They recommend, first, that identification of and attention to comorbid disorders such as substance abuse and depression occur such difficulties should be identified and treated. Educational and occupational impairments are likely to be present, requiring knowledge of the applicability of the Americans with Disabilities Act in order to design accommodations for problematic environments. Financial management assistance is another area in which adults with ADHD are often suggested to need assistance similarly, health management may be an area of focus, as well. Taking a hint from child studies, Barkley et al. 63 recommend that tangible...

Additional executive functions

Tower of London, Tower of Hanoi, Delis-Kaplan Executive Function System Tower Task) are typically used to assess planning. In this task, colored beads or disks are stacked in specific configurations on three pegs. Following specific rules, the patient must move the pegs to make a target configuration. In a study of young adults with average or better cognitive ability, The Tower of London-Drexel Edition was not found to distinguish between ADHD and control groups, or to strongly correlate with other executive functioning variables except processing speed 45 . Although planning and organization has been widely recognized clinically as an area of difficulty for those with ADHD, tests that measure it do not seem to be effective in discriminating symptoms of ADHD. Previous work with children has suggested that mental flexibility, or the ability to shift easily and effectively from one task to another, is compromised in persons who have ADHD. Unprompted word retrieval,...

Emotional social and behavioral assessment

TBI is also associated with a high rate of emotional and behavioral problems in adulthood including increased anxiety, depression and poor coping skills 60-62 . Maladaptive behaviors are related to the psychiatric sequelae of pediatric TBI, which have become an important focus of the evaluation of TBI outcomes in the long term. Although some patients suffer from lifetime psychiatric disorders, there is also evidence for the emergence of novel disorders, particularly following severe injury during childhood. Bloom and colleagues 63 reported that attention deficit hyperactivity disorder and depression are the most common novel diagnoses, though a variety of psychiatric diagnoses may be present, with 74 of disorders persisting in 48 of injured children. Post-injury personality disorders have also been identified in a high proportion of TBI survivors (66 ), though there does not appear to be a TBI-specific personality syndrome given that common post-TBI disorders range between borderline,...

Epidemiology of mathematics disorder

Mathematics disorder is often comorbid with ADHD, with a prevalence ranging from 15 to 44 36 . Researchers have examined comorbidity prevalence rates between LDs and other genetically based psychopathology, such as bipolar disorder, ADHD combined type, autism, and spina bifida they found that 60 to 79 of children with these primary disorders also had a co-occurring learning disorder, whether mathematics, reading, or written language specific 37 . The presence of a math disorder ranged from 21 to 33 in the various groups.

Neurocognitive outcomes

These differences in outcome studies raise questions of sample representation and individual variability. Recruitment strategies focused on samples of convenience (e.g. patients who show up in the long-term survivor clinic) may result in over-representation of pathology. Those patients lost to follow-up may not experience the same degree of problems as those seeking medical evaluations. Unfortunately, many studies do not include sufficient data to determine whether the results can generalize to the patient population. When more representative samples are included, the impact of chemotherapy-only treatment is often more localized to specific processes (i.e. sustained attention, cognitive fluency) or to a specific subset of patients at higher risk due to treatment intensity or genetic predispositions. For example, we recently reported data suggesting that the elevated rates of ADHD in long-term survivors of pediatric leukemia are related to individual genetic polymorphisms 36 . In a...

Neuropsychological aspects of psychopathology across the lifespan a synthesis

As evident in the previous two chapters, the understanding of psychopathology and its associated neuro-psychological deficits across the lifespan is complicated by the uneven investigation of pediatric and adult disorders 1, 2 . In particular, as Sivan 2 emphasizes, while select disorders that impact developmental functioning are considered in the pediatric neuropsychol-ogy literature (i.e. the comorbidity of attention deficit hyperactivity disorder (ADHD) with other mood and behavioral disorders 3 also see Marks et al. and Halperin et al., this volume), examination of mood disorders and other forms of developmental psycho-pathology, and their associated neuropsychological markers, is less frequent. This has led to these disorders being less clearly understood with regard to their neuropsychological profiles and impact across childhood. At the same time, this situation contrasts significantly with our understanding of adult psycho-pathology. Schizophrenia, bipolar disorder, and the...

Psychotherapy and psychoeducation

While medication can alleviate symptoms of ADHD, it does not provide guidance on the coping skills and strategies needed for adults with ADHD to be successful in daily functioning. Adults with ADHD experience much higher rates of failure in relationships, work, and academic environments, which suggests that such strategies are needed to improve their long-term outcomes. Moreover, the high rates of comorbidity with mood and anxiety disorders, conduct problems, and substance abuse call for treatment that addresses highly complex clinical presentations. Although psychoeducation may play an important role in treating ADHD, particularly for clinic-referred adults who were not treated or identified in childhood, Barkley et al. 63 caution that ADHD leads primarily to deficits in performance, not knowledge. A person with ADHD may not behave appropriately even though they clearly understand, for example, that they should not drink and drive, blow up at the boss, or defer an important task for...

Remediation of working memory

This software-based training program was developed to improve working memory abilities, particularly in children with ADHD or severe attention problems. The training is implemented with a software product (RoboMemo from Cogmed Cognitive Medical Systems AB, Stockholm, Sweden) and includes a set ofcomputerized visual-spatial and auditory-verbal working memory tasks. All tasks involve (a) maintenance of simultaneous mental representations of multiple stimuli (b) unique sequencing of stimulus order in each trial and (c) progressive adaptation of difficulty level as a function of individual performance. Training plans are individualized and are modified according to performance however, the typical plan includes 13 tasks, with 15 trials of eight tasks each day. In two clinical trials, the Cogmed intervention was compared to an identical computer program using low working memory load tasks that were not adjusted based on child performance. In the initial,...

Conclusion

Studies of neuropsychological functioning in adults with ADHD confirm that the core deficits in this disorder are attention and inhibition. These problems can be identified though assessment. The impact on executive functions, while theoretically persuasive, is not well documented empirically, specifically with the measurement tools that are available for assessment. It appears to be of primary importance to assess the daily functioning of adults with ADHD, and to consider the many other difficulties that this population brings to the clinical environment, such as problems with mood, conduct, and substance use abuse, when considering factors contributing to distress. When reviewing the research literature, it is important to be aware of which specific ADHD populations the findings may apply to and whether the differences seen between groups are large enough to be clinically meaningful. There is much work to be done in the adult ADHD population to better understand how this childhood...

Research directions

Friendships and perhaps increasing isolation in adulthood. At this point, there is the need for greater emphasis on intervention outcome research including prospective studies of interventions to address social isolation and passivity. Children with disabilities are at great risk for passivity, yet the most commonly used behavioral rating instruments do not assess this aspect of functioning. There is increasing awareness of the prevalence of comorbid ADHD in children with CP, but little is known about the efficacy of pharmacological and behavioral interventions in this population. In addition, current ADHD rating scales were not designed for use in a population with significant motor impairments.

Summary

With regard to psychological functioning, children with epilepsy often exhibit ADHD symptoms and behavioral problems. Differential diagnosis between absence seizures and inattention is important, as children with these diagnoses can present similarly. Additionally, anxiety and depression have been documented at higher rates than in the general population.

Behavior adjustment

Behavioral adjustment is an important issue for children with SB. Fletcher et al. 69 found that hydro-cephalus was related to the presence of behavior adjustment problems in children with SB (5 to 7 years of age). Another study demonstrated that 33 of children with SB met criteria for attention deficit hyperactivity disorder (ADHD) and 13 met the criteria for oppositional defiant disorder 66 .

Comorbidity

LDs have high rates of comorbidity with each other, as well as with other psychiatric and medical conditions. Among LDs, Reading Disorder is often comorbid with Disorder of Written Expression and or Mathematics Disorder. Disorder of Written Expression and Mathematics Disorder are rarely found in isolation. There are also high rates of co-occurrence between LD and other psychiatric disorders, including Attention-Deficit Hyperactivity Disorder (ADHD) and disruptive behavior disorders, mood disorders, anxiety disorders, and substance use disorders 26, 41-43 .

Basal ganglia

That appear in childhood including attention deficit hyperactivity disorder (ADHD) and Tourette syndrome are also associated with abnormalities in the basal ganglia. Recent studies have shown reduced overall caudate volumes and lateralized differences in caudate and globus pallidus volumes (left greater than right) in children diagnosed with ADHD 47 . Further, fractional anisotropy, a measure of apparent white matter integrity using a structural imaging technique called diffusion tensor imaging (DTI), is reduced in ventral prefrontal to caudate pathways in children with ADHD 48 . Behaviorally, this prefrontal caudal circuit is thought to relate to inhibitory control (e.g. a go-no go task). As for etiological factors, there is recent evidence that early diet can influence future caudate volumes and intellectual aptitude 49 , suggesting a potential avenue for environmental factors such as nutrition on neural structure and cognitive behavioral outcome.

Key chapter points

ADHD in adults presents differently from ADHD in children. The primary difficulty is found in attention and executive functioning in adults, while for children overactivity is the prime area of concern, as well as inattention. 2. Age of onset for an ADHD diagnosis is an area of controversy and has not been resolved. Some suggest a cut-off of 12 for symptoms to appear while others adhere to a cut-off of 7. This cut-off appears to differentially affect women compared to men. 3. Neuropsychological testing needs to be comprehensive when evaluating the presence or absence of ADHD. There is currently not a particular profile that definitively diagnoses ADHD, but rather a group of strengths and weaknesses that 4. Neuroimaging is uncovering differences in areas of the brain that are associated with ADHD. These include the caudate, frontal white matter, and anterior cingulate regions. Further study is needed that links these anatomic areas with functional differences in performance and...

Historical data

To fully appreciate the consequences of TBI, the importance of collecting thorough pre-injury historical information cannot be overstated. Brain injuries in children are not randomly distributed in the general population different patterns of pre-injury functioning are associated with increased risk for injury. Inattentive or impulsive children engage in more risky behavior that increases their likelihood of injuries, including head injuries. As discussed previously, the rate of pre-injury ADHD in children who go on to suffer TBI is probably at least twice as high as that seen in the general population. Rates of premorbid cognitive and academic difficulties and familial stressors may also be higher in children who sustain TBI 64 . For the clinician, this means that behaviors attributed to the injury must be scrutinized carefully to determine precisely what is new, changed, or unexpected in the child's post-injury functioning.

Associated features

Attention and executive functioning have been described as problematic for people with LD (e.g. lower TMT-B scores for young adults with LD see 46 ). Given that studies of neuropsychological functioning in adults with LD have focused on achievement test scores for group classification without examining comorbidity, it is possible that these attention and executive deficits are a function of high rates of comorbidity with disorders such as ADHD (cf. 29 ). Memory deficits in LD have been described by some, including reports of short-term and working memory deficits 47 . Again, samples limit use of these findings for example, Isaki and Plante's 47 clinical sample combined adults with a history of LD with adults who had a history of general language deficits. It is probable that problems with remembering are secondary to primary input processes for adults with LD 29,40 . abnormalities in language language association areas and frontal regions. Specific structural atypicalities identified...

Daily functioning

In reviewing the literature on group differences in performance on executive functioning measures, it seems clear that difficulties seen in daily life may not always map onto neuropsychological measures. For example, adults with ADHD are known to have a greater number of automobile accidents 46 , poorer graduation rates and more problems at work 47 , yet neuropsychological measures meant to assess planning, organization, strategy formation, and response to feedback do not seem to be effective discriminatory measures. Research indicates that children and adults with and without problems in executive functioning can have similar levels of primary ADHD symptoms 48 , indicating a lack of specificity of executive functioning deficits for the disorder of ADHD. Moreover, differences observed in neuropsychological functioning with regard to executive functions reveal group differences in ADHD that are generally too small to be clinically significant at the individual level 49 . Clinically, it...

Final thoughts

As research progresses, a link between the neuropsy-chological deficits seen in adults with ADHD, neuro-imaging results, and response to medication is beginning to be forged. Diagnostic issues as well as the existence of comorbid disorders continue to be areas that require further study and clarification. It is also not clear from the research how we may be able to predict which adolescents will be able to sufficiently compensate for their attentional difficulties and no longer require medication. There are few studies that evaluate brain structure and function while controlling for medication response and or treatment history. Studies with children with ADHD with and without a treatment history have found differences both neuropsychologically as well as structurally functionally 45 . These issues need further study and evaluation. Similar to research with children and adolescents with ADHD, there are few studies that evaluate possible differences between subtypes. Most studies use...

Psychosocial

Pediatric TBI is also associated with a variety of psychiatric symptoms and disorders. Generally speaking, novel disorders occur much less frequently after moderate injuries when traits of the disorder are not present premorbidly. Personality change is a frequent psychiatric consequence of more severe TBI. Changes involving lability, aggression, and disinhibition are most common, whereas apathy and paranoia occur less frequently 29 . Secondary attention-deficit hyperactivity disorder (S-ADHD) has been found to develop in approximately 15-20 of children with TBI who did not display premorbid ADHD 30,31 . TBI also increases the risk for other disruptive

Key clinical trials

Multimodal Treatment Study of Children with ADHD (MTA) who were diagnosed with ADHD, Combined type 63 . The study was developed to compare the most evidence-based interventions for ADHD on multiple outcomes over a 14-month period and to gauge the extent to which the intensive interventions provided through the study fared better than treatments received in the community. Children were randomized to one of four treatment conditions (1) behavioral treatment (BPT, STP, classroom behavior management) (2) medication management (primarily stimulant medication) (3) combined behavioral and medication management or (4) a community comparison condition. The immediate 14-month post-treatment data indicated that medication management alone was as effective as the combined treatment condition in reducing ADHD symptoms, suggesting that there was no incremental benefit of behavioral interventions 64 . However, compared to the medication management condition, the combined treatment condition resulted...

Comorbidity issues

Children with ADHD frequently show additional disorders including higher incidences of learning disabilities, antisocial behaviors, and mood and anxiety disorders. Several studies have found similar rates of psychiatric comorbidity in adults, with elevations in antisocial and substance abuse behaviors 23 . In a follow-up of hyperactive children into adulthood, Fischer et al. 24 studied young adults with ADHD combined-subtype diagnoses, who had a history of ADHD as children, and control young adults without any ADHD symptoms. The ADHD group showed a higher risk for at least one psychiatric disorder compared to the control group. Twenty-six percent of the ADHD group vs. 12 percent of the control group were Additional studies have found increased incidence of bipolar disorder, oppositional defiant disorder, and substance abuse in adults with ADHD combined-subtype diagnoses compared to adults with ADHD predominately inattentive type 25 . Others have found a higher incidence of dysthymia,...

Cerebral ALD

C-ALD is characterized by rapid and devastating demyelination of the brain. If left untreated, boys with C-ALD demonstrate a downhill course affecting all aspects of higher cortical and motor functions, leading to death. The age of the child correlates with the rapidity of deterioration such that younger children have a more rapid downhill course. Approximately 80 of children with C-ALD present with characteristic demyelination of the posterior white matter on MRI with concomitant signs on neuropsychological testing. Early signs of the disease consist of diminished visual processing skills with progression to visual agnosia and eventually cortical blindness. Children with these visual symptoms are often first identified by deteriorating visual motor skills the visual , not the motor, is impaired. In approximately 15-20 of cases, demyelination is frontal (anterior presentation). These children have behavioral dysregulation and executive dysfunction in association with damaged frontal...

MRI findings

Smaller volumes in cortical gray matter, the prefrontal cortex and anterior cingulate volumes in adults with larger volumes in white matter overall and in the gray matter of the nucleus accumbens have been found 54 . Other areas that have been found to be thinner in adults with ADHD include the dorsolateral prefron-tal cortex and the anterior cingulate areas associated with attention and executive functioning 55 . Table 5b.2. Findings from neuroimaging in adults with ADHD. Table 5b.2. Findings from neuroimaging in adults with ADHD. 8 ADHD Ca C ADHD for total brain volume C ADHD in left orbitofrontalcortex volume 24 ADHD C ADHD corticalgray matter C ADHD prefrontalvolume C ADHD ACCb volume C ADHD overallwhite matter volume 24 ADHD C ADHD Rc inferior parietalvolume C ADHD R dorsolateralprefrontalvolume C ADHD R ACC 8 ADHD C ADHD ACC 6 ADHD C ADHD frontaland temporalregions C ADHD widespread activation C ADHD occipitallobe 20 ADHD C ADHD cerebellar and occipitalactivation C ADHD when...

Gender

Gender is also an important issue taken into account with neuropsychological assessment, particularly during the neurobehavioral maturation periods. Boys and girls have been shown to have different rates of development, and as a result differing patterns of cognitive progression. Girls have been shown to often outperform boys on some neuropsychological instruments, particularly ones requiring language and aspects of early executive control 28 . Additionally, Levy and Heller have suggested that lateral asymmetry may be less noticeable in women 32 . Furthermore, differential patterns of aging have been noted women still typically outlive men, and this has an impact on considerations regarding neurological disease process, and its impact on cognition and behavior. Neuropsychological and psychopathological disorders have also been shown to occur differentially with regard to gender. During early development, males are more likely to display and be referred for assessment for externalizing...

Melatonin

Melatonin is the principal hormone secreted by the pineal gland. Melatonin regulates the sleep-wake cycle, as well as sleep, sexual behavior, and immuno-logical function. With aging melatonin levels decline. Across the lifespan, melatonin is typically prescribed for treatment of insomnia, including for sleep disturbance in children with attention-deficit hyperactivity disorder. Melatonin is also sold to treat jet lag. Slowed reaction time has been associated with mela-tonin, but the direct effects of melatonin on cognition appear minimal. Rather, any cognitive effects are likely to be secondary to the indirect effects of melatonin's hypothermic properties and disruption in the sleep-wake cycle. Several studies have shown a relationship between decline of melatonin and symptoms of dementia. However, trials of melatonin for sleep disturbance 101 and cognitive impairment in Alzheimer's disease 102 have been negative.

Memory

Deficits in memory are considered a hallmark of ADHD for both children and adults, as is suggested by the DSM-IV criteria of forgetfulness and difficulty following through with tasks. Research has suggested that there are problems in both visual and verbal working and long-term memory in persons with ADHD. Agreement has largely been found with regard to deficits in verbal memory for adults with ADHD. Tests with more complex demands such as the Wechsler Memory Scales-III Logical Memory subtest (WMS-III) appear to be more sensitive than shorter tests such as the Digit Span subtest of the WAIS III. The Logical Memory subtest requires the patient to recall an entire story, while Digit Span requires immediate recall of number sequences. The numbers of story elements recalled immediately and after 30 minutes for Logical Memory have both been found to be lower for adults with ADHD. In children, the digits backwards condition of the Digit Span subtest has been shown to be more sensitive than...

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