Journal of Attention Disorders
Current Literature in ADHD
Abikoff, H., McGough, J., Vitiello, B., McCracken, J., less access to print media than their nonreferred peers.
Davies, M., Walkup, J., et al. (2005). Sequential Nonreferred children whose homes had the same type of pharmacotherapy for children with comorbid atten- media environment as children with ADHD watched as tion deficit/hyperactivity and anxiety disorders.
much television as these children. The authors discussed a Journal of the American Academy of Child and number of possible hypotheses to explain these differences, Adolescent Psychiatry, 44, 418-427.
note that thus far there has yet to be a well-controlledstudy examining whether television viewing causes ADHD, A recent pilot study examined sequential treatment and also suggest the popular understanding “of the relation with methylphenidate with the later addition of between television and ADHD has been unduly influenced Fluvoxamine, an SSRI antidepressant. Children with by simplistic explanations of available data” (p. 10).
ADHD and anxiety were first titrated to an effective doseof methylphenidate. Those who responded favorablywere then treated with Fluvoxamine. A total of 81% ofparticipants responded to the methylphenidate, suggest- Barkley, R. A., & Fischer, M. (2005). Suicidality in ing that children with this combined comorbidity do in children with ADHD, grown-up. ADHD Report, fact respond to ADHD treatments. The benefits of adding Fluvoxamine were less clear than in prior studies as theresponse rate to the Fluvoxamine placebo was higher The potential association of suicidality with medica- than expected. Fluvoxamine treatment in this study did tions used to treat ADHD necessitates investigation of not cause exacerbation of anxiety or physical symptoms.
this question. These authors used data from their longi- These results suggest that stimulants are as effective and tudinal study of 158 hyperactive and 81 control children safe in children with ADHD and comorbid anxiety as in followed for more than 13 years. Twelve questions deal- ing with the topic of suicidality were asked of this sam-ple. Six of the questions dealt with these issues duringhigh school, and the same six were repeated again forfunctioning since leaving high school. The authors report Acevedo-Polakovich, I. D., Lourch, E. P., & Milich, R.
that children growing up with hyperactivity/ADHD were (2005). TV or not TV: Questions and answers regard- significantly more likely to consider, attempt, and be ing television and ADHD. ADHD Report, 13(6), 6-11.
hospitalized for suicidality during high school and weremore likely to consider suicide after high school than Although television habits are often ascribed as cause children in the control group. When risk factors were for and consequence of ADHD, most studies used to examined individually, lifetime major depressive disor- support these positions were conducted on samples of der, conduct disorder in adolescence, severity of ADHD children without the disorder. These authors set out to during the teenage years, and adult follow-up and being address this question specifically in a population of treated with stimulant medication in high school for children with ADHD. The authors conclude that their ADHD increased the likelihood of suicidal ideation and research suggests that children with ADHD watch more attempts in high school. However, when these variables television than their nonreferred peers but that a child’s were examined jointly controlling for the others, the risk home media environment may be a strong factor driving of suicidal ideation in the hyperactive group, both during these differences. According to parent reports, children high school and after high school, was significantly with ADHD had greater access to electronic media and predicted only by presence of lifetime major depressive disorder. Nonetheless, the authors also noted that stimu- The authors conclude that by their young adult years, lant treatment remained marginally associated with sui- youth with ADHD were at high risk for a wide range of cidal ideation, even after controlling for the substantial adverse psychiatric outcomes, including marketing ele- contribution of major depressive disorder and the mar- vated risks of antisocial, addictive, mood, and anxiety ginally significant association with severity of teenage disorders. The authors suggest that their findings provide ADHD. The authors suggested these findings warrant further evidence for the high morbidity associated with further examination in larger studies.
Bauermeister, J. J. (2005). Comparison of the DSM-IV Carpenter, E. M., Frankel, F., Marina, M., Duan, N., combined and inattentive types of ADHD in a & Smalley, S. L. (2004). Internet treatment delivery school-based sample of Latino/Hispanic children.
of parent-adolescent conflict training for families Journal of Child Psychology and Psychiatry, 46, with an ADHD teen: A feasibility study. Family Behavior Therapy, 2026, 1-20.
This study examined the validity and distinctiveness These authors examined the feasibility of Internet of ADHD subtypes within school-based sample of delivery of a parent-adolescent conflict training program Latino/Hispanic children, ages 6 to 11, identified by for families with a teenager suffering from ADHD. The classroom teachers and subsequently undergoing a com- authors attempted to ascertain the willingness of families prehensive diagnostic assessment. When comparing the to participate in a Web-based study, identify relevant subtypes with each other, the inattentive subtype was issues related to confidentiality of Internet data collec- associated with later onset of inattentive symptoms and tion, and determine participant satisfaction with this higher rates of sluggish cognitive tempo. This group was treatment protocol. Six families participated and four also less assertive socially and had fewer externalizing were compliant with participation requirements. A series symptoms than the combined type group. Both the inat- of single subject linear aggressions revealed that all but tentive and combined type groups exhibited lower acad- one participant maintained a steady log-in rate over time.
emic achievement and more ADHD type behaviors Treatment compliant results, according to these authors, during tasks than their non-ADHD counterparts. They were rated as “promising.” Participants provided high also exhibited more internalizing symptoms. Parents of ratings of the security of the Web site and satisfaction inattentive subtype children reported less parenting scale scores were also above neutral.
stress. These children also exhibited lower levels ofadaptive functioning.
Dickstein, D. P., Garvey, M., Pradella, A. G.,Greenstein, D. K., Sharp, W. S., Castellanos, F. X., Biederman, J., Monuteaux, M. C., Mick, E., et al. (2005). Neurologic examination of abnormal- Spencer, T., Wilens, T. E., Silva, J. M., et al. (2006).
ities in children with Bipolar Disorder or ADHD.
Young adult outcome of ADHD: A controlled ten- Biological Psychiatry, 58, 517-524.
year follow-up study. Psychological Medicine, 36,167-179.
ADHD and bipolar disorder in children were evalu- ated through an examination of neurologic abnormalities A case controlled, 10-year prospective study of 140 in this study. The authors performed the Revised youth without ADHD and 120 with ADHD between the Physical and Neurological Exam for Soft Signs in groups ages of 6 and 18 was ascertained from psychiatric and of children with ADHD, bipolar disorder, and controls.
pediatric sources. At the 10-year follow-up, 112 (80%) Then, a blind rater evaluated motor performance. Results and 105 (88%) of the ADHD and controls, respectively, were analyzed using multiple analyses of covariance.
were reassessed (mean age = 22 years). The lifetime Participants with ADHD were impaired on repetitive prevalence for disorders including mood, anxiety, antiso- task reaction time. In contrast, pediatric bipolar partici- cial, developmental, and substance were significantly pants, both with and without comorbid ADHD, were greater in ADHD young adults compared to controls.
impaired on sequential task reaction time. The authors conclude that this differential pattern of soft signs by students’ on-task and spelling study behaviors. Although diagnosis suggested pathophysiologic differences improvement in on-task behavior was comparable across between ADHD and bipolar disorder in children. They the two interventions, self-monitoring of attention had pro- hypothesize that repetitive motor performance requires duced substantially higher gains in spelling study behavior inhibition of nonrelevant movements. As such, ADHD among four of the six students. This is the first study in participants’ impairment in this domain supports the which differential effects of these two interventions have hypothesis that ADHD involves a core deficit of fronto- been investigated among students with ADHD.
striatal-basal ganglia neurocircuitry. In contrast, partici-pants with bipolar disorder caused by their impairmentin sequential and motor performance appeared to reflectimpaired attentional set shifting and reversal learning Huang-Pollock, C. L., Nigg, J. T., & Carr, T. H.
suggesting a different pathophysiology.
(2005). Deficient attention is hard to find: Applyingthe perceptual load model of selective attention toADHD subtypes. Journal of Child Psychology andPsychiatry, 46, 1211-1218.
Faraone, S. V., Biederman, J., & Mick, E. (2006).
The age dependent decline of ADHD: A meta- These authors sought to determine whether selective analysis of follow-up studies. Psychological attention is a primary deficit in childhood ADHD. A per- Medicine, 36, 159-165.
ceptual load paradigm was used to examine both earlyand late selective attention problems in children with Through a meta-analysis, these authors analyzed data inattentive and combined subtypes of ADHD. No evi- from published follow-up studies of ADHD. A regres- dence emerged for selective attention deficits in either sion model was used to separately assess the syndro- of the subtypes. However, sluggish cognitive tempo was matic and symptomatic persistence of ADHD. When associated with abnormal early selection. The authors only those meeting full criteria for ADHD were defined concluded that at least some and possibly most children as having “persistent ADHD,” the rate of persistence was with DSM-IV–diagnosed ADHD have normal selective low, approximately 15% at 25 years of age. But when attention. They suggested their results supported a move cases were consistent with DSM-IV’s current definition away from theories of attention dysfunction as primary of ADHD in partial remission, the rate of persistence was in combined type ADHD. They also note that children much higher, approximately 65%. The authors conclude with ADHD who demonstrate sluggish cognitive tempo their results demonstrate that estimates of ADHD’s per- warrant further study for possible early selective atten- sistence rely heavily on definition. Regardless of definition, however, evidence for ADHD lessens with age accordingto these data.
Evans, S. W., Allen, J., Moore, S., & Strauss, E.
(2005). Measuring symptoms in functioning of Harris, K. R., Friedlander, D. B., Sadler, B., youth with ADHD in middle schools. Journal of Frizzelle, R., & Graham, S. (2005). Self-monitoring Abnormal Child Psychology, 33, 695-706.
of attention versus self-monitoring of academic per-formance: Effects among students with ADHD in This study examined the interrater agreement of the general education classroom. Journal of Special teacher ratings and the relationship between ratings and Education, 39, 145-156.
observation data for ADHD symptoms in a middleschool setting. Teacher ratings and observational data In a counterbalanced, multiple baseline across- were collected regularly during the course of 2 academic subjects design, attention and performance monitoring years for middle school students diagnosed with ADHD.
were evaluated to determine potential differential effects Findings indicated low rates of interrater agreement as on the on-task and spelling study behavior of six ele- well as low rates of agreement between teachers and mentary students with ADHD in a general education observational data and between observational data col- classroom. Low self-monitoring of attention and self- lected in different classrooms. The interrater agreement monitoring of performance had positive effects on was lowest in late fall and gradually increased during the second half of the year. The authors discuss implications between the ages of 7 and 10 were examined. Two for conducting treatment outcome evaluations of school- assessment measures were used, including the coding of based treatment programs and diagnostic evaluations.
causal attributions as mothers watch their children’s As it relates to ADHD, these data reinforce the need to behavior. Mothers of boys with ADHD plus ODD rated collect behavioral samples across multiple classes and the causes of oppositional and inattentive-impulsive child behaviors as more stable and global than didmothers of nonproblem boys in identifying causes oftheir children’s failure on laboratory tasks. Mothers ofboys with ADHD plus ODD provided more child nega- Grizenko, N., Kobacina, B., Amoral, B., Schwartz, G., tive attributional causes than did mothers of eitherADHD only or nonproblem boys. The authors discuss Ter-Stepanian, M., & Joober, R. (2006). Relationship implications for assessing and understanding attributions between response to methylphenidate treatment in in families of children with ADHD and ODD.
children with ADHD and psychopathology in theirfamilies. Journal of the American Academy of Childand Adolescent Psychiatry, 45, 47-53.
Familial aggregation of psychopatholgy in children Moore, C. M., Biederman, J., Wozniak, J., Mick, E., with ADHD who are good responders to methylphenidate Aleardi, M., Wardrop, M., et al. (2006). Differences was compared to those who were poor responders. A in brain chemistry in children and adolescents with total of 118 clinically referred children 6 to 12 years of ADHD with and without comorbid bipolar disorder: age participated in a double-blind, placebo-controlled, A proton magnetic resonance spectroscope study.
randomized, 2-week crossover trial of methylphenidate American Journal of Psychiatry, 163, 316-318.
from 1999 to 2004. Information was collected on 342first-degree and 1,151 second-degree relatives of The brain chemistry in the anterior cingulate cortex children with ADHD. Forty-four participants showed of children and adolescents with ADHD alone, children mild or no improvement, and 74 showed moderate or with ADHD plus bipolar disorder, and children with no very much improvement on methylphenidate over Axis I DSM-IV condition were evaluated using proton placebo. First-degree relatives of good responders were spectra analysis. Children with ADHD had a significantly at significantly higher risk of ADHD than the relatives higher ratio of glutamine to myo-inositol-containing of poor responders. Second-degree relatives of good compounds than children with ADHD plus bipolar dis- responders were at significantly higher risk of antisocial order and unaffected children. The authors suggest that personality disorder compared to the relatives of poor an understanding of these brain chemistry differences responders. The authors conclude that the significantly may provide information about the action of antimanic higher presence of ADHD in the first-degree relatives treatments such as lithium. They also suggest that these and of antisocial personality in the second-degree rela- chemical differences may also reflect changes in sero- tives of good Ritalin responders suggest that this group may at least partially be distinct from the poor respondergroup on the basis of genetic determinants.
Pelham, W. E., Manos, M., Ezzell, C., Tresco, K. E.,Gnagy, E., Hoffman, N., et al. (2005). A dose-rang- Johnston, C., Chen, M., & Ohan, J. (2006). Mothers’ ing study of methylphenidate transdermal system in attribution for behavior in non-problem boys, boys children with ADHD. Journal of the American with ADHD and boys with ADHD and oppositional Academy of Child and Adolescent Psychiatry, 44, defiant disorder. Journal of Clinical Child and Adolescent Psychology, 35, 60-71.
This recent study continued a series of studies being Attributions for child behavior among mothers of 38 conducted as part of a Food and Drug Administration appli- nonproblem boys, 26 boys with ADHD, and 25 boys cation for methylphenidate patch. This study evaluated with ADHD and oppositional defiant disorder (ODD) the efficacy of a range of doses on a variety of outcome measures for children attending a summer treatment pro- (2005). Behavior differences in drivers with ADHD: gram. Thirty-seven children ages 6 to 13 in this program The driving behavior questionnaire. Accident Analysis were administered three doses of methylphenidate via and Prevention, 37, 996-1004.
the patch. The patch was applied either 6 through 120min before the start of the program each day, and each ADHD has been linked to an increased number of dri- condition was compared to placebo. The magnitude of ving citations, particularly for speeding and a fourfold dose was related to the number of points children earned increase in accident risk. Using three factors—errors, on their daily report cards and in the classroom and lapses, and violations—these authors used regression through observational ratings of behavior in the class- analysis to explore the impact of ADHD status, gender, room. More negative behavior was observed when the and age. Results indicated that ADHD status is positively patch was applied 120 min before the program regardless and significantly related to driving errors, lapses, and vio- of whether it was medication or placebo. These studies lation scores. Older participants with ADHD did not differ are consistent with other stimulant studies suggesting statistically from controls relative to errors and violations.
that increased dosages yields increased effectiveness.
There were no significant effects of age on error, lapse, or However, small doses of stimulants produced effects that violation scores for control participants. Consistent with were fairly comparable to larger ones.
other research, gender was significantly related to viola-tion scores but not to errors or lapses such that the maleswere more likely than females to report higher violationscores controlling for ADHD status and age.
Reich, W., Neuman, R., Volk, H. E., Joiner, C. A., &Todd, R. (2005). Comorbidity between ADHD andsymptoms of bipolar disorder in a community sam-ple of children and adolescents. Twin Research and Saudino, K. J., Ronald, A., & Plomin, R. (2005).
Human Genetics, 8, 459-466.
The etiology of behavior problems in 7-year-oldtwins. Substantial genetic influence and negligible The prevalence and frequency of comorbidity of bipolar shared environmental influence for parent disorder was examined with ADHD in a nonreferred pop- ratings and ratings by same and different teachers.
ulation of twins. Children and adolescents ages 7 to 18 Journal of Abnormal Child Psychology, 33, 113-131.
with a history of manic symptoms were identified from apopulation-based twin sample obtained from state birth This study examined the relative contributions to teacher records. The sample was enriched for ADHD, however ratings made by genetic influences in twins rated by same there was also a random control sample that allowed the and different teachers. Parents and teachers rated nearly authors to examine population prevalence of the 4,000 7-year-old identical and fraternal twin pairs on the disorder. Juveniles with threshold or below threshold Strengths and Differences Questionnaire. Individual differ- manic episodes were further assessed for comorbidity. The ences as measured by all three raters in hyperactivity, peer authors found the population prevalence of broadly defined problems, conduct problems, emotional symptoms, total mania in the random sample was 0.2%. The possible manic behavior problems, and prosocial behavior were found to be episode showed significant comorbidity with population- substantially heritable. Shared environmental influences defined severe combined and inattentive ADHD subtypes.
were often small, with the influence of nonshared environ- The authors concluded that there is a significant associa- ments making more substantial contributions. Parents tion of bipolar symptoms with two population-defined sub- tended to contrast their children with each other when types of ADHD. Episodes of possible bipolar disorder as making hyperactivity ratings, leading to greater differences defined by DSM-IV were uncommon in the nonreferred between nonidentical siblings than predicted by genetic sample. Finally, the authors conclude that children and influences, while teachers displayed no such contrast adolescents with ADHD appear to be only modestly at effects. The authors conclude that although parents have a increased risk for bipolar disorder.
more intimate knowledge of their child as an individual,they also have a narrower context to make judgments aboutbehavior, whereas teachers have greater expertise withchildren and observe them in a structured context. Ratings Reimer, B., D’ambrosio, L. A., Gilbert, J., from both sources, however, did in fact yield consistent Coughlin, J. F., Biederman, J., Surman, C., et al.
results regarding the causes of behavior problems.
Snyder, J., Prichard, J., Schrepferman, L., Patrick, selecting atomoxetine therapy for children with M. R., & Stoolmiller, N. (2004). Child impulsiveness- ADHD. Pharmacotherapy, 25, 1541-1549.
inattention, early peer experiences and the develop-ment of early onset conduct problems. Journal of In this survey of more than 40,000 patients, atomoxe- Abnormal Child Psychology, 32, 579-594.
tine therapy was found to systematically be preferred forpatients with psychiatric comorbidities. In the time frame This longitudinal study examined the relationship of between April and December 2003, individuals were 1.5 the development of conduct problems from both trait and times more likely to begin medication therapy with atom- experiential perspectives. Two hundred and sixty-seven oxetine than stimulants. It is interesting that frequent use males and females were assessed at kindergarten entry of behavioral health care services led to predisposal to and again at three time points, ending at the conclusion start treatment with atomoxetine relative to a stimulant but of second grade. Assessment of inattentive/impulsive not for individuals with obesity. Alcohol dependence but traits were based on parent and teacher report as well as not drug dependence or drug abuse was predictive of the classroom observations and measures of working mem- selection of atomoxetine over a short-acting stimulant.
ory. Peer measures included playground observationsand sociometric ratings. Using linear growth models,conduct problems at entry and progression during a 2-yearperiod were significantly predicted by trait/symptom Whalen, C., Henker, B., Ishikawa, S. S., Jamner, L.
assessments made by parents and teachers. For boys, D., Floro, J. N., Johnston, J. A., et al. (2006). An peer rejection and negative interactions mediated initial electronic diary study of contextual triggers and levels and growth of conduct problems for parent ratings.
ADHD: Get ready, get set, get mad. Journal of the For teacher ratings, the mediation relationship was American Academy of Child and Adolescent significant only for growth. Outcome for girls was more Psychiatry, 45, 166-174.
complex, with social factors alone mediating symptoms/trait impact for conduct problems. Overall, peer prob- Across 7 days, mothers and 25 children with ADHD lems continued to have strong additive effects on the taking stimulant medication, and mothers and 25 children severity of conduct problems. The authors suggest that without ADHD between the ages of 7 and 12 years were trait-like problems could be used to identify children provided electronic diary reports approximately every 30 who may require intervention, whereas social interac- min between nonschool hours. The child and maternal tions could be a target for such interventions.
perceptions of behaviors, moods, and interaction qualityduring prepatory and transitional activities were comparedwith those during other activities. Maternal reportsrevealed that child symptomatic behaviors and negative Stevenson, J., Asherson, P., Hay, D., Levy, F., moods, maternal negative moods, and parent-child dis- Swanson, J., Thapar, A., et al. (2005). Characterizing agreement were elevated in the ADHD but not in the com- the ADHD phenotype for genetic studies. Develop- parison group while getting ready versus other activities.
mental Science, 8, 115-121.
Children’s self-ratings also revealed situational effectsindicating that school-age children with ADHD can pro- This article provides an excellent overview of advances vide meaningful self-reports using carefully structured in research on the association between ADHD symptoms electronic diaries. Even when children with ADHD are and genetics. The review focuses on methods to accurately receiving stimulant pharmacotherapy, these data suggest define ADHD symptoms predicted by genetic variation.
that preparatory tasks of daily living are especially chal- The article reviews categorical and dimensional lenging and disproportionately linked to child behavior approaches, the need for multiple reporters of children’s problems, parent negative affect, and contentious interac- behavior, and most important, a system to sort out genetic tions. These data provide support for the need for com- causes of common comorbidities with ADHD.
bined medical and psychosocial treatments in ADHD.
Van Brunt, D. L., Johnston, J. A., Ye, W., Pohl, G. M., Wilens, T., Kratochvil, C., Newcorn, J., & Gao, H.
Sun, P. J., Sterling, K. L., et al. (2005). Predictors of (2006). Do children and adolescents with ADHD respond differently to atomoxetine? Journal of the end point on a number of rating scales. There were no sta- American Academy of Child and Adolescent tistically significant differences in the overall effects on Psychiatry, 45, 149-157.
ADHD symptoms, response rates, or time to responsebetween age groups. Children but not adolescents had a These authors report data contrasting the efficacy and higher rate of somnolence and headache relative to placebo.
tolerability of atomoxetine between children and adoles- No other clinically meaningful treatment differences were cents with ADHD. Efficacy measures included response seen in adverse event rates, vital signs, weight, height, lab- rate, times to response, and mean changes from baseline to oratory values, or ECG between children and adolescents.

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Highlights of prescribing information

HIGHLIGHTS OF PRESCRIBING INFORMATION These highlights do not include all the information needed to use ----------------------------- ADVERSE REACTIONS -------------------------------------- GRALISE safely and effectively. See full prescribing information for The most common adverse reaction (greater than or equal to 5% and twice GRALISE. GRALISE® (gabapentin) tablets I

Medtronic synchromed infusion system (med08)

SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE DATE: 02/91 REVIEWED: 3/13 PAGES: 1 of 4 RESPONSIBILITY: PURPOSE: To provide information on the Medtronic SynchroMed Infusion DEFINITION: Medtronic SynchroMed infusion system – an implantable system designed to contain and to administer parenteral drugs intrathecally. The system consists of an implantable programmab

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