Integration of soft signs in academically normal and academically at-risk children.

The development of motor and sensory proficiency and the integration of soft signs were analyzed for 38 children with average achievement and 29 children achieving below grade level. Motor coordination, speed, and inhibition, as well as the development of sensory function, were evaluated at the time of entrance to kindergarten and again during the first grade. The performance of both groups progressed on tasks measuring motor speed and coordination as well as tactile integration. Although the children achieving below grade level continued to perform the majority of tasks poorly in comparison with the children performing at grade level, on most of the measures they evidenced definite catch-up or greater gain than the children performing at grade level. Their progress on the motor speed and coordination tasks supports the hypothesis of a developmental lag in these areas. Results of tests of motor inhibition were notable for an absence of progression. That children achieving below grade level did not advance in this area would argue against the hypothesis of a developmental lag for all soft signs. Although results of this longitudinal study are preliminary, findings to date would allow for the possibility that both deficits and lags are responsible for the differences between the academically normal and academically at-risk children.

Disorders of attention and activity level in a referral population.

Of 614 children referred for an evaluation of hyperactivity and inattention, the 422 (68.7%) who qualified for a diagnosis of attention deficit disorder (ADD) were compared with the 192 (31.3%) who did not. The children with ADD had significantly higher full-scale IQ scores, verbal scores, and parental educational levels. They also had a significantly higher incidence of specific learning disabilities (73.7%). The absence of hyperactivity in children with ADD further exaggerated the differences in learning disability between the two groups. Cognitive limitation, severe parental psychopathology, and child neglect/abuse were significantly higher in the group without ADD. The two groups did not differ in the incidence of parental or child depressive symptomatology, motor diagnoses, language disorders, conduct disorders, and psychosomatic complaints. That only 29 children in whom ADD was absent (4.7% of all referrals) had been given a trial of stimulant medication does not support the presence of a major abuse of such drugs in the community.

Methylphenidate dosing: twice daily versus three times daily.

OBJECTIVE: To evaluate the short-term efficacy and side effects associated with two methylphenidate hydrochloride (MPH) dosing patterns. METHODS: Twenty-five boys with attention deficit hyperactivity disorder (ADHD) participated in a 5-week, triple-blind, placebo-controlled, crossover evaluation of MPH administered twice (b.i.d.) versus thrice (t.i.d.) per day (mean dose = 8.8 +/- 5 mg, .30 +/- .1 mg/kg/dose). Four dosing conditions (placebo, titration [gradual increase to target dose], b.i.d., and t.i.d.) were used. Dependent measures obtained on a weekly basis included: parent and teacher ratings of child behavior, parent-child conflicts, parent report of stimulant side effects, child self-report of mood symptoms, a sleep log, laboratory measures of attention, and actigraphic recording of sleep activity. RESULTS: All dosing conditions resulted in significant effects on ADHD symptoms when compared with baseline. Relative to placebo, t.i.d. dosing was characterized by improvement on the greatest number of behavioral measures, and both b.i.d. and t.i.d. were generally more effective than titration. Direct comparisons of b.i.d. and t.i.d. dosing revealed that t.i.d. was associated with greater improvement on the Conners Parent Rating Scale Impulsivity/Hyperactivity factor, with a similar marginally significant effect for the ADD-H Teacher Rating Scale Hyperactivity factor. The analysis of clinically significant change favored a three-times-a-day dosing schedule over placebo on both parent and teacher ratings of impulsivity/hyperactivity and attention. Compared with placebo, appetite suppression was rated, on average, as more severe in the t.i.d. and titration conditions, but not in the b.i.d. condition. However, the number of subjects who exhibited any or severe appetite suppression did not differ significantly between the b.i.d. and t.i.d. schedules. Although there was no difference in sleep duration for children on b.i.d. and t.i.d. schedules, total sleep time appeared to decrease slightly on t.i.d. relative to placebo according to both parent ratings and actigraphic assessment. There were no significant differences between b.i.d. and t.i.d. on any other side effects or sleep variables. CONCLUSIONS: For many children with ADHD, t.i.d. dosing may be optimal. There are few differences in acute side effects between b.i.d. and t.i.d. MPH dosing. The dosing schedule should be selected according to the severity and time course of ADHD symptoms rather than in anticipation of dosing schedule-related side effects.

Adaptive functioning in children with attention-deficit hyperactivity disorder.

OBJECTIVE: To evaluate the utility of the Vineland Social Adaptive Scale (Vineland) in measuring social adaptive functioning in children with attention-deficit hyperactivity disorder (ADHD). DESIGN: Cross-sectional group comparison. SETTING: Multidisciplinary hyperactivity and learning problem clinic at a tertiary referral center in Chicago, Ill. PARTICIPANTS: One hundred four school-age children with ADHD. INTERVENTION: None. MEASUREMENTS/MAIN RESULTS: The Vineland was administered to the study population. Despite average full-scale IQ scores (mean [+/- SD], 101 +/- 6), the children with ADHD had Vineland standard scores in the borderline to low-average range (73 +/- 14). The discrepancy between the Vineland standard scores and the full-scale IQ scores increased with increasing age and IQ. CONCLUSIONS: Children with ADHD referred to a tertiary attention problem clinic displayed significant social adaptive dysfunctioning on the Vineland. The evaluation of children with ADHD should include assessment of adaptive skills, and treatment planning for children with ADHD should include the identification of social and adaptive deficiencies when therapeutic goals are established.

Psychiatric and developmental disorders in families of children with attention-deficit hyperactivity disorder.

OBJECTIVE: To evaluate whether a pediatric family history obtained via a brief parent interview would reveal a high prevalence of psychiatric and developmental disorders in the family members of children with attention-deficit hyperactivity disorder (ADHD) compared with a group of children with another chronic developmental disability, Down syndrome (DS). DESIGN: A controlled cross-sectional group comparison study. SETTING: An interdisciplinary hyperactivity and learning problem clinic and a DS clinic located in a large, urban tertiary care teaching hospital in Chicago, Ill. PARTICIPANTS: A total of 140 children with ADHD and 163 children with DS of comparable socioeconomic status. MEASURES: Using a screening questionnaire and parent interview, the development pediatricians obtained a family history. RESULTS: By parent report, children with ADHD were significantly more likely than the control children with DS to have a parent affected by alcoholism (P = .007), other drug abuse (P < .001), depression (P < .001), delinquency (P < .001), learning disabilities (P < .001), and ADHD (P < .001). Similar patterns were evidenced in other first- and second-degree relatives. CONCLUSIONS: The high reported frequency of psychiatric and developmental disorders in the families of children with ADHD requires that the treating clinician explore the area of family psychiatric and developmental history and use the findings to formulate a comprehensive treatment plan that includes anticipatory guidance and psychosocial intervention.

Early maturation of motor-delayed children at school age.

Children underwent motor and sensory testing during each of 3 consecutive years beginning at kindergarten entrance. Children were assigned to either a motor-normal or motor-delayed group based on results from testing during the 1st year of the study. Motor-normal subjects (n = 17) had standard scores on a global motor-sensory test that fell within one standard deviation of the mean. Motor-delayed subjects (n = 12) had a global motor-sensory test standard score indicating greater than one standard deviation of motor delay and, in addition, were delayed by a minimum of one standard deviation on four of five of the motor-sensory test subtests. At the conclusion of the 3-year study, the mean standard score of the motor-delayed group remained greater than one standard deviation below the performance of the motor-normal group as measured by the global motor-sensory test. Statistical analysis using repeated measures analysis of variance indicated that the motor-delayed group made gains but did not close the gap between themselves and the motor-normal group during the 3-year study. Group x time interaction effects showed that during the study, significant gain was made by the motor-delayed group on the motor coordination subtest of the motor-sensory test. The study supports the conclusion that motor-delayed children without early intervention fail to outgrow their motor delays by age 8 years.

Motor disorders and attention-deficit/hyperactivity disorder.

Motor and perceptual output problems were associated with hyperactivity before ADHD was described in North America. Many European pediatricians continue to consider these deficits along with inattention and hyperactivity to be part of one disorder. Motor deficits are an associated neurodevelopmental deficit in a substantial number of ADHD patients. In order for the patients' need to be addressed, pediatricians must be able to recognize motor coordination deficits and make appropriate recommendations to the patients' caregivers.

Neuropsychological skills with motor dysfunctional and motor normal children.

A group of 40 children was selected from a larger sample based on their performance on motor coordination, motor speed, and motor inhibition tasks. Twenty of the children were classified as Motor Dysfunctional (MD) and 20 were classified as Motor Normal (MN). The groups were compared on several neuropsychological measures. The results indicated the MD children were significantly lower on a number of measures, particularly those requiring sensory integration. There were not significant differences on several of the tasks, including those more complex in nature. The results are discussed in relation to developmental models of neuropsychological functioning.

Longitudinal assessment of motor and sensory skills in academically disabled and control children.

Motor and tactile integration skills were sequentially assessed with academically average (N = 28) and academically disabled children (N = 17) over a 3-year period. The initial results demonstrated considerable differences between the groups. Analysis of variance and visual inspection of trends in the longitudinal data for the academically disabled group revealed a mixed pattern with catch-up in the motor areas and persistent delays in sensory areas. The results suggest different developmental patterns depending on the skill and group assessed. Right hand advantages were found across groups with motor speed whereas a left hand advantage was demonstrated on a stereognosis task. These right-left differences suggest an important developmental role for corpus callosum myelinization. The interpretation of soft neurological signs needs to be refined to allow for these sensory-motor, right-left parameters.

Evaluation of changes made to an infant home apnea monitoring program in response to findings from a national consensus panel.

A comparison was made of two different management methods that were developed to help follow high-risk infants on home apnea or bradycardia monitors. With the first method (group 1), used before 1986, decisions were based partly on home pneumogram results. The second method (group 2), based partly on suggestions about monitoring from a national consensus panel, mainly uses clinical history to assist with making decisions. Comparisons were made between the two groups of infants in a retrospective clinical analysis. The infants in group 2, on the average, had significantly fewer days on a monitor than group 1 (174 vs 324) and had much fewer pneumogram tests (0.3 vs 1.6). Several advantages in using a specific monitoring follow-up procedure were noted, including the benefits to the parents from using a consistent plan for management.

Measures of attention deficit. Part I: Questionnaires.

Despite much progress in the diagnosis and management of children with attentional problems, hyperactivity, and learning difficulties, current diagnostic techniques remain inadequate to readily distinguish a primary attentional disorder from a more complex secondary problem. Developmental and behavioral questionnaires to supplement office evaluation of hyperactivity, neuromaturation, and selected cognitive processes continue to be improved. These measures suffer from different biases, focus on different childhood characteristics and associated problems, and approach childhood interaction with the environment differently. Several are psychometrically more sound, and several provide the physician with developmental and social information that may help improve the habilitative prescription. The general pediatrician can use these questionnaires to complement his or her evaluation and follow-up of children who present with learning and behavioral problems. Prior to choosing an instrument, the clinician should review the advantages of each and choose the one most suited to his or her practice.

Measures of attention deficit. Part II: Clinical perspectives and test interpretation.

After a detailed behavioral and developmental history has been supplemented by the use of formal questionnaires, the diagnosis of an attentional disorder can be further clarified by the judicious selection of psychoeducational and pediatric physical and neurodevelopmental examinations. The most common difficulty in the interpretation of psychoeducational test subscores and profiles is the significant overlap between the patterns generated by attentional deficits and those associated with memory-based learning disabilities. Certain other medical and behavioral conditions need to receive careful consideration prior to finalizing the diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). A thorough but focused general examination coupled with the pediatric neurodevelopmental examination can contribute to this differentiation.

Ophthalmic disorders in children with Down syndrome.

The goal of this study was to determine the frequency of ophthalmic disorders in a group of young children with Down syndrome who were unselected for ophthalmic abnormalities, and to determine whether examination by a pediatric ophthalmologist should become standard practice. Of 77 children referred to a Down syndrome clinic at a teaching hospital and evaluated by a pediatric ophthalmologist, 61 per cent had ophthalmic disorders needing treatment and monitoring. Furthermore, the percentage of children with ophthalmic disorders increased with age, from 38 per cent in the two- to 12-month-old group to 80 per cent in the five- to 12-year-old group. The authors conclude that children with Down syndrome should be evaluated by a pediatric ophthalmologist in the first six months of life and annually thereafter.

Hearing loss in children with Down syndrome.

Conventional behavioral testing of hearing shows that children with Down syndrome have a high prevalence of hearing deficits. However, most young (< 3.5 years of age) children with Down syndrome are unable to cooperate in this type of testing. We evaluated auditory brain-stem responses of 47 unselected patients 2 months to 3 1/2 years of age. Thirty-four percent had normal hearing, 28% had unilateral loss, and 38% had bilateral loss. Type of loss was conductive in 19 ears, mixed in 14, and sensorineural in 16. Degree of loss was mild in 33 ears, moderate in 13, and severe to profound in 3. Language quotients and degree of hearing loss were compared and an association was not found. Because of the high prevalence of hearing loss in children with Down syndrome, we recommend evaluation of auditory brain-stem responses in the first 6 months of life.

Adaptive skills dysfunction in ADD and ADHD children.

Adaptive functioning was examined in children with Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD), and a psychiatric comparison group of children with pervasive developmental disorders or mild mental retardation (PDD/MR). As assessed with the Vineland Adaptive Behavior Scales, adaptive functioning was well below average for all three clinic groups. (The PDD/MR group had the lowest adaptive functioning scores, although not statistically different from the other groups). However, the level of adaptive functioning relative to IQ in the areas of Socialization, Communication and Daily Living was significantly lower for the ADD and ADHD groups. These deficits in adaptive functioning that characterize children with ADHD and ADD may help explain the poor long-term prognosis of ADHD, suggesting that increased attention should be paid to the assessment and treatment of adaptive functioning in individuals with ADHD and ADD.

Asperger syndrome associated with Steinert's myotonic dystrophy.

Steinert's myotonic dystrophy was diagnosed in a 10-year-old girl with Asperger syndrome. This form of myotonic dystrophy is one of a growing list of genetic diseases that can be diagnosed by analysis of a gene with trinucleotide repeats that may expand. The patient has the largest such expansion known within her pedigree. She has many of the psychological deficits that have been reported in adult-onset myotonic dystrophy. This is the first known report of an association of this disorder with Asperger syndrome. Recently Moebius syndrome has been found in association with disorders of the autistic spectrum; physicians practicing developmental medicine should now also consider Steinert's myotonic dystrophy when evaluating children with facial diplegia.

Psychometric characteristics of the Wender Utah Rating Scale (WURS): reliability and factor structure for men and women.

The goals of this study were to examine the factor structure of the Wender Utah Rating Scale (WURS), to evaluate potential gender differences in factor composition, and to assess the reliability of the scale. The WURS was completed by 310 fathers and 305 mothers of children referred for evaluation of Attention-Deficit Hyperactivity Disorder (ADHD). For males, a five-factor solution (Conduct Problems, Learning Problems, Stress Intolerance, Attention Problems, Poor Social Skills/Awkward) accounted for 72 percent of the variance. There was also a five-factor solution for females (Dysphoria, Impulsive/Conduct, Learning Problems, Attention and Organizational Problems, Unpopular) which accounted for 71 percent of the variance. Symptoms of inattention and impulsivity loaded on separate factors for both men and for women. Test-retest reliability was examined with a different sample of 57 adults who completed the WURS on two separate occasions, 1 month apart. The WURS demonstrated satisfactory internal consistency and temporal stability, and it may be a useful tool for the study of ADHD in adults.