Interferon-gamma release assays piloted as a latent tuberculous infection screening tool in Canadian federal inmates.

BACKGROUND: Interferon-gamma release assays (IGRAs) may be useful in diagnosing latent tuberculous infection (LTBI) in inmates; however, published experience in these settings is limited. OBJECTIVE: To identify variables associated with IGRA positivity among Canadian federal inmates with positive tuberculin skin test (TST) results. DESIGN: On intake, TST-positive (≥10 mm) inmates were offered an IGRA (QuantiFERON(®)-TB Gold), and demographic and historical data were collected. IGRA-positive and -negative inmates were compared using the χ(2) test and multivariable logistic regression; the final model's goodness of fit was assessed using Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUC). RESULTS: Of 96 TST-positive inmates, 31 (32.3%) were IGRA-positive. Variables associated with positive IGRA were age >45 years (11/20 vs. 20/75, P = 0.016) and previous LTBI treatment (9/20 vs. 13/55, P = 0.032) in univariate analysis, and being from a country with a moderate or high estimated tuberculosis (TB) incidence (OR 3.5, 95%CI 1.3-9.4, P = 0.013) and absence of bacille Calmette-Guérin (BCG) vaccination (OR 3.3, 95%CI 1.2-9.0, P = 0.017) in multivariable analysis. The data fit the model well, classifying the group better than chance alone (AUC 0.67, P = 0.007). CONCLUSION: High discordance with TST, particularly among BCG-vaccinated inmates and those from low TB incidence countries, suggest that IGRA may be useful in Canadian federal penitentiary screening programmes.

[Advances in the diagnosis and subtyping of attention deficit hyperactivity disorder: what may lie ahead for DSM-V]. / Avances en el diagnóstico y la subclasificación del trastorno por déficit de atención/hiperactividad: qué puede pasar en el futuro respecto al DSM-V.

INTRODUCTION AND AIMS: A number of problems have been identified through research and clinical practice with the current DSM-IV criteria for the diagnosis of attention deficit hyperactivity disorder (ADHD). This paper reviews some of these issues along with possible solutions for consideration in the construction of the criteria for DSM-V. DEVELOPMENT: Issues related to the length of symptom lists and how best to conceptualize the neuropsychological constructs they represent, differing developmental thresholds for diagnosis for adults vs. children and teens, the criterion for age of onset, problems related to the current approach to subtyping, and the development of new items for the adult stage of the disorder are discussed along with other issues pertinent to the continuing effort to test and revise the DSM criteria for ADHD as a function of ongoing empirical research. CONCLUSIONS: The present paper has briefly raised a number of issues that require some attention by the various workgroups charged with creating the DSM-V diagnostic criteria for ADHD.

Time perception and reproduction in young adults with attention deficit hyperactivity disorder.

Adults with attention deficit hyperactivity disorder (ADHD; n = 104) were compared with a control group (n = 64) on time estimation and reproduction tasks. Results were unaffected by ADHD subtype or gender. The ADHD group provided larger time estimations than the control group, particularly at long intervals. This became nonsignificant after controlling for IQ. The ADHD group made shorter reproductions than did the control group (15- and 60-s intervals) and greater reproduction errors (12-, 45-, 60-s durations). These differences remained after controlling for IQ and comorbid oppositional defiant disorder, depression, and anxiety. Only the level of anxiety contributed to errors (at 12-s duration) beyond the level of ADHD. Results extended findings on time perception in ADHD children to adults and ruled out comorbidity as the basis of the errors.

The executive functions and self-regulation: an evolutionary neuropsychological perspective.

Neuropsychology has customarily taken a molecular and myopic view of executive functioning, concentrating largely on those proximal processes of which it may be comprised. Although commendable as a starting point, such an approach can never answer the question, "Why executive functioning?" The present paper encourages neuropsychologists to contemplate the longer-term, functional nature of the executive functions (EFs), using an evolutionary perspective. For purely illustrative purposes, a previously developed model of the EFs is briefly presented and is then examined from an evolutionary perspective. That model views the EFs as forms of behavior-to-the-self that evolved from overt (public) to covert (private) responses as a means of self-regulation. That was necessary given the interpersonal competition that arises within this group-living species. The EFs serve to shift the control of behavior from the immediate context, social others, and the temporal now to self-regulation by internal representations regarding the hypothetical social future. The EFs seem to meet the requirements of a biological adaptation, being an improbable complex design for a purpose that exists universally in humans. Discovering the adaptive problems that the EFs evolved to solve offers an invaluable research agenda for neuropsychology lest that agenda be resolved first by other scientific disciplines. Some adaptive problems that the EFs may have evolved to solve are then considered, among them being social exchange (reciprocal altruism or selfish cooperation), imitation and vicarious learning as types of experiential theft, mimetic skill (private behavioral rehearsal) and gestural communication, and social self-defense against such theft and interpersonal manipulation. Although clearly speculative at the moment, these proposals demonstrate the merit of considering the larger adaptive problems that the EFs evolved to solve. Taking the evolutionary stance toward the EFs would achieve not only greater insight into their nature, but also into their assessment and into those larger adaptive capacities that may be diminished through injury or developmental impairment toward that system.

Executive functioning and olfactory identification in young adults with attention deficit-hyperactivity disorder.

Young adults with attention deficit-hyperactivity disorder (ADHD; N = 105) were compared with a control group (N = 64) on 14 measures of executive function and olfactory identification using a 2 (group) X 2 (sex) design. The ADHD group performed significantly worse on 11 measures. No Group X Sex interaction was found on any measures. No differences were found in the ADHD group as a function of ADHD subtype or comorbid oppositional defiant disorder. Comorbid depression influenced the results of only 1 test (Digit Symbol). After IQ was controlled for, some group differences in verbal working memory, attention, and odor identification were no longer significant, whereas those in inhibition, interference control, nonverbal working memory, and other facets of attention remained so. Executive function deficits found in childhood ADHD exist in young adults with ADHD and are largely not influenced by comorbidity but may be partly a function of low intelligence.

Executive functioning, temporal discounting, and sense of time in adolescents with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD).

Clinic-referred teens (ages 12-19) with ADHD and ODD (N = 101) were compared to community control (CC) teens, equated for age and sex, (N = 39) on a variety of psychological tasks assessing executive functioning (EF), temporal reward discounting, and time estimation and reproduction. A factor analysis reduced the EF measures to three dimensions, representing CPF Inattention, Working Memory, and CPT Inhibition. Results indicated that the ADHD group had significantly more CPT Inattention than the CC group. No differences were found for Working Memory or CPT Inhibition. The ADHD group displayed significantly greater temporal discounting of delayed hypothetical monetary rewards relative to immediate ones and manifested more impaired time reproduction, but not time estimation, than did the CC group. Main effects for level of IQ were found only on the Working Memory factor and largely did not interact with the group factor otherwise. The group differences in CPT Inattention, temporal discounting, and time reproduction were not a function of level of comorbid oppositional defiant disorder, delinquency, or anxiety-depression. Results are reasonably consistent with past research on EF and sense of time in children with ADHD and extend these findings to the adolescent age group. Problems with working memory and CPT inhibition found in prior studies of children with ADHD, however, were not evident here, perhaps owing to age-related improvements or insufficient task difficulty.

Parent-adolescent conflict in teenagers with ADHD and ODD.

Eighty-seven male teens (ages 12-18 years) with ADHD/ODD and their parents were compared to 32 male teens and their parents in a community control (CC) group on mother, father, and teen ratings of parent-teen conflict and communication quality, parental self-reports of psychological adjustment, and direct observations of parent-teen problem-solving interactions during a neutral and conflict discussion. Parents and teens in the ADHD/ODD group rated themselves as having significantly more issues involving parent-teen conflict, more anger during these conflict discussions, and more negative communication generally, and used more aggressive conflict tactics with each other than did parents and teens in the CC group. During a neutral discussion, only the ADHD/ODD teens demonstrated more negative behavior. During the conflict discussion, however, the mothers, fathers, and teens in the ADHD/ODD group displayed more negative behavior, and the mothers and teens showed less positive behavior than did participants in the CC group. Differences in conflicts related to sex of parent were evident on only a few measures. Both mother and father self-rated hostility contributed to the level of mother-teen conflict whereas father self-rated hostility and anxiety contributed to father-teen conflict beyond the contribution made by level of teen ODD and ADHD symptoms. Results replicated past studies of mother-child interactions in ADHD/ODD children, extended these results to teens with these disorders, showed that greater conflict also occurs in father-teen interactions, and found that degree of parental hostility, but not ADHD symptoms, further contributed to levels of parent-teen conflict beyond the contribution made by severity of teen ADHD and ODD symptoms.

The efficacy of problem-solving communication training alone, behavior management training alone, and their combination for parent-adolescent conflict in teenagers with ADHD and ODD.

Two family therapies were compared using teens with attention-deficit/hyperactivity disorder. Ninety-seven families were assigned to either 18 sessions of problem-solving communication training (PSCT) alone or behavior management training (BMT) for 9 sessions followed by PSCT for 9 sessions (BMT/PSCT). Both treatments demonstrated significant improvement in ratings of parent-teen conflicts at the midpoint but did not differ. By posttreatment, both produced improvement on ratings and observations but did not differ. Significantly more families dropped out of PSCT alone than out of BMT/PSCT. At most, 23% of families showed reliable change either by midpoint or by posttreatment, with no differences between therapies. Yet 31%-70% of families were normalized. Group-level change and normalization rates support treatment efficacy, whereas indices of reliable change are less impressive.

Commentary on the multimodal treatment study of children with ADHD.

The multimodal treatment study of attention deficit hyperactivity disorder (MTA Study) constitutes a landmark in the history of treatment research in child psychopathology, being the largest single study of its kind ever undertaken. Important findings have emerged from this project, as the papers in the present volume will attest. This commentary focuses on several concerns about the assumptions that appear to have guided the design of the MTA study, particularly its psychosocial treatment component, as well as the manner in which treatment results have been presented to date. In particular, no explicit theory of ADHD appears to have guided the construction of the treatment components, relying instead on implicit theories associated with those treatments, such as the notion that the symptoms of ADHD arise through faulty learning and defective contingencies of reinforcement. Future articles from this study will need to address these and other concerns if the results of the study are to be properly interpreted and the scientific and clinical yield is to be maximized.

Multimethod psychoeducational intervention for preschool children with disruptive behavior: two-year post-treatment follow-up.

This paper describes the 2-year post-treatment follow-up of preschool children identified as having high levels of disruptive behavior at kindergarten entry. They were assigned to four treatment conditions: A no-treatment group, parent-training only, treatment classroom only, and the combination of parent training with the treatment classroom. Interventions lasted the entire kindergarten academic year. Initial post-treatment results reported previously indicated no effects for the parent-training program but some efficacy for the classroom intervention program. For this report, the disruptive behavior (DB) children were subdivided into those who did (n = 74) and did not (n = 77) receive the treatment classroom. Two-year post-treatment follow-up results indicated no differences between the classroom treated and untreated DB groups. These groups also failed to differ in the percentage of children using available treatments across the follow-up period. The DB children in both groups had significantly more symptoms of ADHD and ODD than a community control group (N = 47) at follow-up. They also received higher ratings of externalizing problems on the parent Child Behavior Checklist, more severe ratings of behavior problems at home, and ratings of more pervasive behavior problems at school, and had poorer academic skills. Results suggested that early intervention classrooms for DB children may not produce enduring effects once treatment is withdrawn, and that better approaches are needed for identifying those DB children at greatest risk for later maladjustment.

Multi-method psycho-educational intervention for preschool children with disruptive behavior: preliminary results at post-treatment.

Annual screenings of preschool children at kindergarten registration identified 158 children having high levels of aggressive, hyperactive, impulsive, and inattentive behavior. These "disruptive" children were randomly assigned to four treatment conditions lasting the kindergarten school year: no treatment, parent training only, full-day treatment classroom only, and the combination of parent training with the classroom treatment. Results showed that parent training produced no significant treatment effects, probably owing largely to poor attendance. The classroom treatment produced improvement in multiple domains: parent ratings of adaptive behavior, teacher ratings of attention, aggression, self-control, and social skills, as well as direct observations of externalizing behavior in the classroom. Neither treatment improved academic achievement skills or parent ratings of home behavior problems, nor were effects evident on any lab measures of attention, impulse control, or mother-child interactions. It is concluded that when parent training is offered at school registration to parents of disruptive children identified through a brief school registration screening, it may not be a useful approach to treating the home and community behavioral problems of such children. The kindergarten classroom intervention was far more effective in reducing the perceived behavioral problems and impaired social skills of these children. Even so, most treatment effects were specific to the school environment and did not affect achievement skills. These findings must be viewed as tentative until follow-up evaluations can be done to determine the long-term outcomes of these interventions.

A pilot study of methylphenidate, clonidine, or the combination in ADHD comorbid with aggressive oppositional defiant or conduct disorder.

A pilot comparison of the safety and efficacy of methylphenidate (MPH) combined with clonidine, clonidine monotherapy, or MPH monotherapy in 6- to 16-year-old children diagnosed with attention deficit hyperactivity disorder (ADHD) and comorbid aggressive oppositional defiant disorder or conduct disorder was completed. Study design was a 3-month, randomized, blinded, group comparison with eight subjects per group. No placebo comparison was used. All three treatment groups showed significant improvements in attention deficits, impulsivity, oppositional, and conduct disordered symptoms as assessed by parent and teacher rating scales and laboratory measures. Significant differences among treatment groups were found only on a few measures. Only the clonidine monotherapy group showed significantly decreased fine motor speed. These results suggest the safety and efficacy of clonidine alone or in combination with MPH for the treatment of ADHD and aggressive oppositional and conduct disorders.

Early androgen treatment decreases cognitive function and catecholamine innervation in an animal model of ADHD.

The spontaneously hypertensive rat (SHR) has been used as an animal model of attention deficit hyperactivity disorder (ADHD). The present study was designed to determine whether exposure to elevated androgen levels early in development demonstrated impairments in cognitive functioning, neuroendocrine control, and brain development parallel to those seen in ADHD children. The animals (SHR and Wistar (WKY) controls) were implanted with testosterone on postnatal day 10 and tested for behavior in a spatial cognition paradigm on postnatal day 45. Plasma samples were collected for determination of adrenocorticotrophin hormone (ACTH) and corticosterone levels as indicators of the basal tone of the pituitary-adrenal neuroendocrine axis. In addition, the density of tyrosine hydroxylase-immunoreactive fibers (an indicator of catecholamine innervation) in the frontal cortex was compared between animals. The current data show that early testosterone treatment in SHR animals resulted in additional deficits in spatial memory in the water maze, but was ineffective in altering the response of WKY animals. Furthermore, SHR rats had high basal ACTH and low corticosterone levels that may indicate a dysfunctional stress axis similar to other reports in humans with persistent ADHD. Finally, there was a further suppression of tyrosine hydroxylase-immunoreactivity in the frontal cortex of androgen-treated SHR rats. These results support the hypothesis that early androgen treatment may support the neurobiology of animals with genetic predisposition to hyperactivity, impulsivity and inattention in a manner consistent with the enhanced expression of ADHD-like behaviors.

Predictive power of frontal lobe tests in the diagnosis of attention deficit hyperactivity disorder.

A battery of tests presumed to assess various frontal lobe functions in children was evaluated for the accuracy of the tests in classifying children as having attention deficit hyperactivity disorder (ADHD). Two groups of children were tested: (1) 66 children, ages 6-11 years, with ADHD, and (2) a normal community control group of 64 children of the same age. Results indicated good positive predictive power (PPP) for seven of the tests (ranging from 80 to 90%), suggesting that abnormal scores on these tests may be indicative of the presence of ADHD. However, the rates of negative predictive power (NPP) even for these seven tests were modest (ranging from 50 to 66%). Sensitivity was also poor (ranging from 5 to 43%) as were the levels of false negatives (averaging 40%) creating fair-to-poor overall classification rates for all tests (49 to 70%). It is concluded that while these neuropsychological tests may have some value in clinical evaluations of children's psychological abilities, they may not be useful as the sole criteria for the diagnostic classification of children as ADHD.

Attention-deficit hyperactivity disorder and the stress response.

BACKGROUND: Attention-deficit hyperactivity disorder (ADHD) is a developmental disorder whose three main symptoms are impulsiveness, inattention, and hyperactivity. Researchers have proposed that the central deficit in ADHD is one of poor response inhibition. The present studies were designed to look at the functioning of the hypothalamic-pituitary-adrenal (HPA) axis in response to mental stress in aggressive ADHD subjects participating in a longitudinal study of various psychosocial treatments. METHODS: Pretest and posttest morning salivary samples for cortisol determination were collected from subjects given a battery of tests. RESULTS: The study shows that ADHD subjects who maintained their diagnosis over the first year of the study had a blunted response to the stressor in comparison to those ADHD subjects who no longer retained the disorder 1 year later. CONCLUSIONS: The data suggest that an impaired response to stress may be a marker for the more developmentally persistent form of the disorder.

Solid-phase microextraction with temperature-programmed desorption for the analysis of iodination disinfection byproducts.

An analytical approach for the determination of chlorination and iodination disinfection byproducts based on solid-phase microextraction (SPME) was developed. Solid-phase microextraction presents a simple, rapid, sensitive, and solvent-free approach to sample preparation in which analytes in either air or water matrixes are extracted into the polymeric coating of an optical fiber. Analytes are subsequently thermally desorbed in the injection port of a gas chromatograph for separation, detection, and quantitation. Thermal degradation of iodoform was observed during desorption from a polyacrylate fiber in initial GC/MS and GC/ECD experiments. Experiments were designed to determine SPME conditions that would allow quantification without significant degradation of analytes. Isothermal and temperature-programmed thermal desorptions were evaluated for efficacy in transferring analytes with wide-ranging volatilities and thermal stabilities into chromatographic analysis columns. A temperature-programmed desorption (TPD) (120-200 degrees C at 5 degrees C/min with an on-column injection port or 150-200 degrees C at 25 degrees C/min with a split/splitless injection port) was able to efficiently remove analytes with wide-ranging volatilities without causing thermal degradation. The SPME-TPD method was linear over 2-3 orders of magnitude with an electron capture detector and detection limits were in the submicrogram per liter range. Precision and detection limits for selected trihalomethanes were comparable to those of EPA method 551. Extraction efficiencies were not affected by the presence of 10 mg/L soap, 15 mg/L sodium iodide, and 6000 mg/L sodium thiosulfate. The SPME-TPD technique was applied to the determination of iodination disinfection byproducts from individual precursor compounds using GC/MS and to the quantitation of iodoform at trace levels in a water recycle system using GC/ECD.