Attention-Deficit/Hyperactivity Disorder (ADHD): Interaction between socioeconomic status and parental history of ADHD determines prevalence.

BACKGROUND: Many studies have reported a higher prevalence of Attention-Deficit/Hyperactivity Disorder (ADHD) among disadvantaged populations, but few have considered how parental history of ADHD might modify that relationship. We evaluated whether the prevalence of ADHD varies by socioeconomic status (SES) and parental history of ADHD in a population-sample of elementary school children age 6-14 years. METHODS: We screened all children in grades 1-5 in 17 schools in one North Carolina (U.S.) county for ADHD using teacher rating scales and 1,160 parent interviews, including an ADHD structured interview (DISC). We combined parent and teacher ratings to determine DSM-IV ADHD status. Data analysis was restricted to 967 children with information about parental history of ADHD. SES was measured by family income and respondent education. RESULTS: We found an interaction between family income and parental history of ADHD diagnosis (p = .016). The SES gradient was stronger in families without a parental history and weaker among children with a parental history. Among children without a parental history of ADHD diagnosis, low income children had 6.2 times the odds of ADHD (95% CI 3.4-11.3) as high income children after adjusting for covariates. Among children with a parental history, all had over 10 times the odds of ADHD as high income children without a parental history but the SES gradient between high and low income children was less pronounced [odds ratio (OR) = 1.4, 95% CI 0.6-3.5]. CONCLUSIONS: Socioeconomic status and parental history of ADHD are each strong risk factors for ADHD that interact to determine prevalence. More research is needed to dissect the components of SES that contribute to risk of ADHD. Future ADHD research should evaluate whether the strength of other environmental risk factors vary by parental history. Early identification and interventions for children with low SES or parental histories of ADHD should be explored.

Stimulant prescription cautions: addressing misuse, diversion and malingering.

As prescriptions for stimulant medication to treat ADHD have increased, so have concerns about the nonmedical use and diversion of stimulant medication, especially among college students. There is also growing concern about young adults feigning ADHD in order to receive a prescription for stimulant medication. This paper summarizes recent research on the nonmedical use and diversion of stimulant medication with a focus on the prevalence of these behaviors, motivations for nonmedical use, factors associated with nonmedical use, and the consequences of such use. Research on the medical misuse of prescribed medication and malingering to obtain a diagnosis of ADHD is also discussed.

The misuse and diversion of prescribed ADHD medications by college students.

OBJECTIVE: This study assesses the misuse and diversion of prescribed attention-deficit/hyperactivity disorder (ADHD) medications. METHOD: One hundred fifteen students, attending two universities, with prescriptions for ADHD medications completed a Web survey in spring 2007. RESULTS: Eighty-nine of 115 students (69%) used their ADHD medications as prescribed, whereas 36 (31%) had misused during college by taking larger or more frequent doses than prescribed or by using someone else's medication. Nine students (8%) reported intranasal use during the previous 6 months, and 30 (26%) had diverted medications to peers. Misuse was associated with impulsivity and with other substance use. Enhancing the ability to study outside of class was students' primary motive for misuse, but nonacademic reasons were also reported. Students who misused ADHD medications generally felt that doing so was helpful. CONCLUSIONS: Although most students use their ADHD medication as prescribed, misuse and diversion is not uncommon. Because enhancing academic performance was the primary motive for misuse, the results raise questions about whether undergraduates with ADHD perceive their treatment as adequate and the extent to which physicians and students communicate about issues related to medication adjustments.

The shifting subtypes of ADHD: classification depends on how symptom reports are combined.

Research on the correlates of ADHD subtypes has yielded inconsistent findings, perhaps because the procedures used to define subtypes vary across studies. We examined this possibility by investigating whether the ADHD subtype distribution in a community sample was sensitive to different methods for combining informant data. We conducted a study to screen all children in grades 1-5 (N = 7847) in a North Carolina County for ADHD. Teachers completed a DSM-IV behavior rating scale and parents completed a structured telephone interview. We found substantial differences in the distribution of ADHD subtypes depending on whether one or both sources were used to define the subtypes. When parent and teacher data were combined, the procedures used substantially influenced subtype distribution. We conclude the ADHD subtype distribution is sensitive to how symptom information is combined and that standardization of the subtyping process is required to advance our understanding of the correlates of different ADHD subtypes.

Adjustment to college in students with ADHD.

OBJECTIVE: To examine college adjustment in students reporting an ADHD diagnosis and the effect of medication treatment on students' adjustment. METHOD: 1,648 first-semester freshmen attending a public and a private university completed a Web-based survey to examine their adjustment to college. RESULTS: Compared with 200 randomly selected control students, 68 students with ADHD reported more academic concerns and depressive symptoms. This was explained by higher rates of inattentive symptoms among students with ADHD and was unrelated to hyperactive-impulsive symptoms. Among students with ADHD, medication treatment was not related to better adjustment or diminished ADHD symptoms. The contribution of inattention to academic concerns and depressive symptoms remained significant when controlling for personality traits. CONCLUSION: Students with ADHD experience greater academic performance concerns and depressive symptoms during the transition to college. Medication treatment did not appear to diminish ADHD symptoms nor enhance students' adjustment.

Investigating teacher and student effects of the Incredible Years Classroom Management Program in early elementary school.

The present paper reports on the results of a cluster randomized trial of the Incredible Years® Teacher Classroom Management Program (IY-TCM) and its effects on early elementary teachers' management strategies, classroom climate, and students' emotion regulation, attention, and academic competence. IY-TCM was implemented in 11 rural and semi-rural schools with K-2 teachers and a diverse student sample. Outcomes were compared for 45 teachers who participated in five full day training workshops and brief classroom consultation and 46 control teachers; these 91 teachers had a total of 1192 students. A high level of teacher satisfaction was found and specific aspects of the training considered most valuable for early elementary teachers were identified. Hierarchical linear modeling indicated a statistically significant intervention effect on Positive Climate in the classroom (d=0.45) that did not sustain into the next school year. No main effects on student outcomes were observed, although a priori moderator analyses indicated that students with elevated social-behavioral difficulties benefitted with regard to prosocial behavior (d=0.54) and inattention (d=-0.34). Results highlight potential benefits and limitations of a universal teacher training program for elementary students, and suggest strategies for future delivery of the IY-TCM program and areas for future research.

Attention Problems and Academic Achievement: Do Persistent and Earlier-Emerging Problems Have More Adverse Long-Term Effects?

OBJECTIVE: This study examined whether the negative association between children's attention difficulties and their academic functioning is largely confined to children whose attention problems persist across early grades and whether it depends on when attention problems emerge in children's schooling. METHOD: Children from the normative sample of the Fast Track study were classified into four attention problem groups based on the presence versus absence of attention problems in first and second grade. RESULTS: Those with attention problems in both grades showed a decline in reading and math achievement during the K-5 interval relative to children with attention problems in first grade only. Both groups of inattentive first graders also performed worse than comparison children. In contrast, children whose attention problems emerged in second grade did not differ from comparison children on any achievement outcome performed significantly better than inattentive first graders. CONCLUSION: The implications of these findings are discussed.

The Prevalence of ADHD in a Population-Based Sample.

OBJECTIVE: Few studies of ADHD prevalence have used population-based samples, multiple informants, and Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) criteria. Moreover, children who are asymptomatic while receiving ADHD medication often have been misclassified. Therefore, we conducted a population-based study to estimate the prevalence of ADHD in elementary school children using DSM-IV criteria. METHOD: We screened 7,587 children for ADHD. Teachers of 81% of the children completed a DSM-IV checklist. We then interviewed parents using a structured interview (DISC). Of these, 72% participated. Parent and teacher ratings were combined to determine ADHD status. We also estimated the proportion of cases attributable to other conditions. RESULTS: Overall, 15.5% of our sample met DSM- (4th ed.; text rev., DSM-IV-TR) criteria for ADHD (95% CI [14.6%, 16.4%]); 42% of cases reported no previous diagnosis. With additional information, other conditions explained 9% of cases. CONCLUSION: The prevalence of ADHD in this population-based sample was considerably higher than 3% to 7%. To compare study results, the DSM criteria need standardization.

Community-Based multiple family groups to prevent and reduce violent and aggressive behavior: the GREAT Families Program.

This paper describes the targeted intervention component of GREAT Schools and Families. The intervention-GREAT Families-is composed of 15 weekly multiple family group meetings (e.g., 4-6 families per group) and addresses parenting practices (discipline, monitoring), family relationship characteristics (communication, support, cohesion), parental involvement and investment in their child's schooling, parent and school relationship building, and planning for the future. High-risk youth and their families-students identified by teachers as aggressive and socially influential among their peers-were targeted for inclusion in the intervention. The paper describes the theoretical model and development of the intervention. Approaches to recruitment, engagement, staff training, and sociocultural sensitivity in work with families in predominantly poor and challenging settings are described. The data being collected throughout the program will aid in examining the theoretical and program processes that can potentially mediate and moderate effects on families. This work can inform us about necessary approaches and procedures to engage and support families in efforts to reduce individual and school grade-level violence and aggression.

The impact of tutoring on early reading achievement for children with and without attention problems.

This study examined whether the benefits of reading tutoring in first grade were moderated by children's level of attention problems. Participants were 581 children from the intervention and control samples of Fast Track, a longitudinal multisite investigation of the development and prevention of conduct problems. Standardized reading achievement measures were administered after kindergarten and 1st grade, and teacher ratings of attention problems were obtained during 1st grade. During 1st grade, intervention participants received three 30-min tutoring sessions per week to promote the development of initial reading skills. Results replicated prior findings that attention problems predict reduced 1st grade reading achievement, even after controlling for IQ and earlier reading ability. Intervention was associated with modest reading achievement benefits for inattentive children without early reading difficulties, and substantial benefits for children with early reading difficulties who were not inattentive. It had no discernible impact, however, for children who were both inattentive and poor early readers. Results underscore the need to develop effective academic interventions for inattentive children, particularly for those with co-occurring reading difficulties.

What do we really know about ADHD in college students?

Research on ADHD in college students began in the 1990s and has been steadily increasing in recent years. Because young adults with ADHD who attend college have experienced greater academic success during high school than many peers with the disorder, which is likely to be associated with better overall functioning, the degree to which they experience similar patterns of adjustment difficulties was not initially known. Accumulating research suggests that college students with ADHD experience less academic success and greater psychological and emotional difficulties than other students and use alcohol and drugs at higher rates. However, conclusions to be drawn from this research are limited by the use of small samples that may not be representative of the wider population of students with ADHD, and a lack of diagnostic rigor in identifying students with ADHD to be included in such research. Studies of the effectiveness of psychosocial treatments, medication treatment, and academic accommodations are extremely limited or nonexistent. Issues particularly germane to college students include feigning ADHD and the misuse and diversion of stimulant medication. Given that at least 25 % of college students with disabilities are diagnosed with ADHD, methodologically sound investigations are clearly needed in order to better understand the impact of ADHD on college students' adjustment and to develop and implement interventions that can enhance students' success.

Teacher management practices for first graders with attention problems.

OBJECTIVE: To examine whether teacher reports of accommodations and interventions for inattentive first graders are consistent with best practice guidelines. METHOD: A total of 36 teachers completed the Teacher Management Questionnaire (TMQ) for 92 students in five predominantly low-income, minority schools. The TMQ is a newly developed measure designed to assess the frequency with which teachers implement a variety of accommodations and interventions with individual students. Additional teacher and student background data were collected on the inattentive sample, including behavior ratings and academic testing. RESULTS: Teachers reported variable implementation of different management strategies, with more frequent use of class-wide structure and organizational interventions, and less frequent assignment modifications and individual behavior plans. Greater use of some strategies was reported for inattentive students and those with additional risk characteristics such as oppositional behavior and school-based referrals. CONCLUSION: Teachers appear to differentiate some management strategies based on the presence of attention problems, although their self-reported implementation is not well aligned with best practice guidelines.

A randomized trial of two promising computer-based interventions for students with attention difficulties.

Few studies have examined whether attention can be improved with training, even though attention difficulties adversely affect academic achievement. The present study was a randomized-controlled trial evaluating the impact of Computerized Attention Training (CAT) and Computer Assisted Instruction (CAI) on attention and academic performance in 77 inattentive first graders. Students receiving either intervention were more likely than controls to show a moderate decline in teacher rated attention problems in first grade. Students receiving CAI also showed gains in reading fluency and in teacher ratings of academic performance. Intervention effects for attention were absent by second grade largely because attention problems declined in all groups. However, post hoc analyses indicated potential longer-term benefits for children with 6 or more inattentive symptoms at baseline. Persistent attention problems were associated with poorer academic performance in multiple domains. Results provide initial evidence that CAT and CAI can improve children's attention in the classroom - and support additional studies to determine whether more clinically significant benefits are attainable.

Predictors of nonmedical ADHD medication use by college students.

OBJECTIVE: To identify the predictors of nonmedical ADHD medication use by college students. PARTICIPANTS: A total of 843 undergraduates attending one public or one private university in southeastern United States. METHOD: Students completed a Web-based survey inquiring about ADHD medication use during the first semester freshman of their year and a second time during the second semester of their sophomore year. RESULTS: A total of 45 participants (5.3%) reported the onset of nonmedical ADHD use between the two survey administrations. The majority of these students were high substance users as freshman. Attention difficulties also predicted the onset of nonmedical use, especially in the absence of excessive substance use. Compared with other nonmedical users of ADHD medication, those reporting attention difficulties had lower GPAs, greater academic concerns, and higher levels of depressive symptoms. CONCLUSION: Attention difficulties contribute to the onset of nonmedical ADHD medication use in a significant minority of nonmedical users. These students may begin using ADHD medication to address attention problems they experience as undermining their academic success.

Instability in teacher ratings of children's inattentive symptoms: implications for the assessment of ADHD.

OBJECTIVE: To examine the cross-grade stability of clinically elevated teacher ratings of inattentive symptoms in 3 samples of elementary schoolchildren. PARTICIPANTS AND METHODS: Samples 1 and 2 included 27 first graders and 24 fourth graders, respectively, identified based on clinically elevated teacher ratings of inattentive symptoms. The third sample included 28 children in grades 1 to 4 from the Multimodal Treatment Study of attention-deficit hyperactivity disorder (Multimodal Treatment Study of Children with attention-deficit hyperactivity disorder Study) with a confirmed attention-deficit hyperactivity disorder diagnosis. Teacher ratings of inattentive symptoms were completed an average of 12 to 14 months apart so that cross-grade stability of elevated ratings could be computed for each sample. RESULTS: In all 3 samples, clinically elevated ratings persisted for less than 50% of children and between 25% and 50% had ratings that declined to within the normative range. The decline in attention difficulties was not related to hyperactivity, oppositional behavior, or anxiety at baseline, nor was it explained by children beginning medication treatment. CONCLUSIONS: Many elementary-aged children rated by their teachers as highly inattentive are not considered to demonstrate these problems the following year, even children with a confirmed attention-deficit hyperactivity disorder diagnosis. The instability in clinically elevated teacher ratings found across 3 independent samples highlights the importance of annual reevaluations to avoid treating children for problems that may no longer be present.

Motives and perceived consequences of nonmedical ADHD medication use by college students: are students treating themselves for attention problems?

OBJECTIVE: This study examines why college students without a prescription take ADHD medication, what they perceive the consequences of this to be, and whether attention problems are associated with this behavior. METHOD: More than 3,400 undergraduates attending one public and one private university in the southeastern United States completed a Web-based survey. RESULTS: Nonmedical ADHD medication use in the prior 6 months was reported by 5.4% of respondents and was positively associated with self-reported attention difficulties. Enhancing the ability to study was the most frequent motive reported; nonacademic motives were less common. Students perceived nonmedical use to be beneficial despite frequent reports of adverse reactions. CONCLUSION: Students without prescriptions use ADHD medication primarily to enhance academic performance and may do so to ameliorate attention problems that they experience as undermining their academic success. The academic, social, and biomedical consequences of illicit ADHD medication use among college students should be researched further.

Self-reported ADHD and adjustment in college: cross-sectional and longitudinal findings.

OBJECTIVE: To examine the association between self-reported ADHD and college adjustment. PARTICIPANTS: Study 1 included nearly 3400 undergraduates attending a public and private university. Study 2 included 846 students who participated during freshman and sophomore year. METHOD: Students completed a web-based survey that assessed diagnostic status and adjustment in multiple domains. RESULTS: Relative to other students, those with self-reported ADHD had lower GPAs and reported more academic concerns, depressive symptoms, social concerns, emotional instability, and substance use. Overall, however, most were making satisfactory adjustments in these domains. Benefits of medication treatment were not found. Freshman year ADHD predicted lower GPA, increased academic concerns and alcohol use, and smoking initiation. CONCLUSION: Students with ADHD struggled relative to peers but most were adjusting reasonably well across multiple domains. Future research should move beyond the use of self-reported diagnosis and more carefully examine the impact of medication treatment in this population.

Returning to roots: on social information processing and moral development.

Social information processing theory has been posited as a description of how mental operations affect behavioral responding in social situations. Arsenio and Lemerise (this issue) proposed that consideration of concepts and methods from moral domain models could enhance this description. This paper agrees with their proposition, although it suggests that numerous additional concepts about the nature of latent mental structures (e.g., working models, schemas, scripts, object relations, classical conditioning) provide equally compelling refinements to processing theory. Furthermore, theoretical and methodological challenges in integrating latent mental structures into processing theory remain.